Article Text

Download PDFPDF
Bowing, kneeling and ‘prostration’: athlete's collapse patterns during sudden cardiac arrhythmia/arrest on the field of play
  1. Stanislav Baltsezak
  1. Correspondence to Dr Stanislav Baltsezak, Department of MSK and Sport and Exercise Medicine (DOMSEM), Anglian Community Enterprise, Primary Care Centre, Turner Road, Colchester, UK; stanzhak{at}


Background Sudden cardiac arrest (SCA) on the field of play remains one of the most tragic and challenging events for a team physician. Even with robust regular preparticipation cardiac screening we cannot prevent all cases of SCA. Ability to recognise imminent cardiac arrest occurring on the field of play remains an important step in managing this condition without delay.

Methods You Tube was searched for video clips clearly depicting the sequence of an athlete's collapse of cardiac origin. A pattern of collapse was subsequently analysed.

Results 13 cases were available for public viewing on You Tube and demonstrated the final position of collapse. 12 collapses had full video footage of athlete's fall. All athletes were men. 84.6% (11) cases were from football (soccer). 15.4% (2) of cases were from martial arts. In 10 out of 12 cardiac event cases (83.3%) bowing and/or kneeling were followed by decubitus position. 58.3% (7) of cases demonstrated bowing at the beginning of collapse. 58.3% (7) cases had kneeling as an element of collapse. 61.5% (8 out of 13 cases) of casualties adopted position of ‘prostration’ (ie, prone) as final stage of collapse.

Conclusions When on the field of play, in the absence of head injury, athletes displaying bowing and/or kneeling positions followed by collapse should be assumed to have a life-threatening cardiac event. Final position of ‘prostration’ was adopted in over half of cardiogenic collapses. A sports medicine professional should bear this in mind and target his/her assessment and treatment accordingly. When attending such casualties, a defibrillator must be taken to the collapsed player.

  • arrythmia
  • cardiac arrest
  • death/mortality
  • doctors in PHC
  • prehospital care, doctors in PHC

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


Sudden cardiac death (SCD) although infrequent, remains by far the most challenging and tragic event a sports medicine professional can face. Regular participation in athletic competition is associated with an increased risk for SCD. Relative risk is increased by 2.8 times compared with non-athletes, write Ljungqvist et al.1 However, it is not the sport but combination of intensive physical exercise with underlying cardiovascular disease that can trigger life-threatening arrhythmia leading to SCD.

The data on incidence of SCD varies from one study to another. It rather depends on methods of collecting that data. From the study done by Atkins et al2 on out-of-hospital cardiac arrest, the incidence of sudden cardiac arrest (SCA) due to cardiovascular disease in children and young adults aged 14–24 years was 1:27 000. An Italian study by Corrado et al3 reported incidence of SCD as 1:28 000 for young competitive athletes. Whereas, Harmon et al4 in their study of student-athletes aged 17–23 years, write that in the USA, the incidence of SCD per year was 1:33 134 for male and 1:77 646 for female athletes, respectively.

Preparticipation cardiac screening is aimed at detecting underlying cardiovascular conditions in athletes. Corrado et al5 have demonstrated that adding 12-lead ECG to history and examination results in a substantial increase in the ability to identify potentially lethal heart disorders. However, the debate regarding what constitutes the best cardiac screening in sport is still ongoing. Even in the presence of robust preparticipation cardiac screening (eg, history, examination, ECG and echocardiogram) there is no guarantee that it will prevent all cases of SCD.

Therefore, it is important to identify signs of imminent cardiac arrest on the field of play, so that appropriate assessment and treatment are initiated without delay. From other causes of cardiac arrest both in hospital and in prehospital environment, we know that early recognition and treatment of cardiac arrest improves survival. Drezner et al6 first recommended the assumption of SCA in any collapsed and unresponsive athlete. Nonetheless, it has been observed that a number of recorded SCA events on the field of play demonstrate a repeating pattern of the player’s collapse: a player would often bow, then kneel down, followed by falling forward. The purpose of this study was to more closely characterise the presentation of cardiogenic collapse on the field of play.


Video clips for recorded SCD/SCA cases detailing a player’s collapse were searched for on You Tube. Overall, 13 cases7–23 of cardiogenic collapse were identified (table 1). Twelve of them had whole footage. One case just showed final position of collapse before beginning of the first aid.

Table 1

Sequence of collapse in 13 available recorded cases


All collapsed athletes were men; 84.6% (11) of cases were from football (soccer); 15.4% (2) of cases were from martial arts; 10 sportsmen died following the collapse. One athlete already had an implantable cardioverter defibrillator in situ, and was shocked out of arrhythmia by the device. One athlete recovered spontaneously following the collapse, and one athlete was successfully resuscitated. Both sportsmen had to retire from sport.

There were 58.3% (7 out of 12 collapses) of cases demonstrated bowing (figure 1) at the beginning of collapse; 58.3% (7) cases had kneeling (figures 2 and 3) as an element of collapse; 61.5% (8 out of 13 clips) of cases ended up in the prone position—‘prostration’ sign (figure 4), 15.4% (2) of cases adopted lateral decubitus position and 23.1% (3) collapsed on their back. In 10 out of 12 cardiac event cases (83.3%), bowing and/or kneeling were followed by decubitus position.

Figure 1

First stage of collapse: bowing.

Figure 2

Second stage of collapse: kneeling (a).

Figure 3

Second stage of collapse: kneeling (b).

Figure 4

Final stage of collapse: prostration.


A limited number of available video clips may reflect the fact that SCD is an extremely distressing event and a full video footage of this tragedy is protected from public viewing in the majority of cases. Even though the greatest number of cases was from football (soccer), it does not make this sport the most dangerous activity. It can be explained by football being one of the most popular games in the world and having one of the highest numbers of clips on You Tube. Harmon et al4 observed that the highest number of SCD in student-athletes per year was in basketball with the rate of 1:11 394. She found that sports with the next highest risk were swimming (1:23 488) and lacrosse (1:23 357), followed by American football (1:38 497) and cross-country (1:41 695).

Case 12 video clip8 shows commotio cordis (CC) leading to sportsmen's SCD. CC is a case of SCA which occurs in the absence of structural heart disease. In CC, a chest wall impact over the heart area triggers ventricular fibrillation. Link2,4 stated that ventricular fibrillation was recorded both when automated external defibrillators (AED) were used in early resuscitation of CC and during animal experimental models. In spite of a chest wall strike preceding player's collapse, life-threatening arrhythmia is the main reason for sportsmen's fall. Therefore, we can observe a similar pattern of collapse like in other cases of SCA.

Over half the cases demonstrated bowing and kneeling as initial stages of collapse. The possible pathophysiological rationale for these positions could be to improve blood flow to the brain. In cases of life-threatening arrhythmias, cardiac output is not sufficient enough to maintain adequate brain circulation. By adopting lean forward bow-like position, athlete facilitates blood flow against gravity towards the brain. Falling on one's knees could be a conscious response to do the same. It could also improve cardiac preload as does squatting. Alternatively, it could mean loss of neuromuscular control of lower limbs in the context of life-threatening pulseless arrhythmia. Over half of all cases displayed the ‘prostration’ sign as a final position of collapse. Since running/walking forward is the most frequent direction a player takes on the field of play, falling forward can be a natural impetus for the player at the time of SCA situation.

Random position of a bow as a way of resting is rather commonly adopted by a number of athletes during the game/competition. However, when followed by collapse it may indicate serious cardiac event. A severe head injury can result in an athlete similarly adopting a collapsed position. Attentive observation of the game/sport event will help in excluding head injury as a cause of collapse. It will also assist in identifying cases of traumatic CC.

The small number of recorded cases, as well as 84.6% of cases being from football, may make the observations made in this report difficult to apply to other sports. A thorough analysis of future cardiogenic collapses throughout sports should be undertaken in order to improve our recognition of imminent life-threatening cardiac events on the field of play.


Prompt recognition of SCA in athletes is the first barrier to effective management which includes immediate chest compressions, retrieval and use of an AED. It appears that while on the field of play, in the absence of history of head injury, athletes displaying bowing and kneeling positions followed by collapse should be suspected of potential life-threatening cardiac event. It is likely to be taking place when a collapsed athlete is lying prone. A sports physician should bear this in mind and carry a defibrillator when attending such casualties. Recorded cases of SCA should be made available for the sports medicine community for analysis and study so that future medical professionals can promptly recognise and treat this condition.


The author is very grateful to Baltsezhak ES for providing technical support with photographs.



  • Contributors SB designed the study, performed data analysis and manuscript writing.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.