Knowledge of sport-related concussion among referees in youth football in Croatia, Germany, Norway, and Türkiye – a survey-based study

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OBJECTIVES: Sport-related concussions (SRCs), though common in football, remain under-recognized, particularly at youth and amateur levels where medical personnel are rarely present. Referees are key stakeholders in safeguarding player health, yet their knowledge and awareness of SRCs are underexplored. This study assessed referees' knowledge and awareness about SRCs across Europe. DESIGN: Cross-sectional online survey. METHODS: A 19-item questionnaire was distributed by national football associations in Croatia, Germany, Norway, and Türkiye. Items addressed demographics, concussion knowledge, symptom recognition, awareness of assessment tools, and interest in education. A concussion knowledge score (CKS) was calculated. Data were analyzed using Kruskal-Wallis and Wilcoxon rank-sum test, with significance set at p < 0.05. RESULTS: 2722 surveys were analyzed. The overall median CKS was 75% with no significant differences between countries (p = 0.345). In Germany, CKS differed by gender and prior SRC history (significant differences, p < 0.01). Commonly recognized symptoms included dizziness (≥90%) and headache (≥78%), whereas subtler signs like irritability (≤21%) were poorly identified. Eleven percent of referees reported awareness of SRC assessment tools, most citing eye movement tests; only few named formal tools such as Sport Concussion Assessment Tool (SCAT) or Concussion Recognition Tool (CRT). Across all respondents, 73% expressed interest in concussion education. CONCLUSIONS: Referees demonstrated moderate SRC knowledge but notable gaps in recognizing subtle symptoms and awareness of validated assessment tools. Due to the highly uneven sample distribution, between-country comparisons are exploratory. Incorporating concussion education into referee licensing may enhance early identification and promote player safety in youth and amateur football.

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