Concussion in sport - more than a head knock
While concussion is often considered part and parcel of playing sport, studies have shown that the risks of head trauma are far greater and potentially longer term than a fuzzy head, staggering or seeing double.
With a new story in the media every week about the impact concussion is having on the health and wellbeing of athletes, how we deal with concussion (or not deal with it) is an emerging threat to the safe sport landscape.
Concussion in sport isn’t just an issue at the elite level, it impacts athletes at all levels.
Lisa White is a Titled Sports and Exercise Physiotherapist who has been working in sport for 22 years. She has worked with Olympians and Paralympians, attended the Commonwealth Games and is across a variety of local sports – from multiple football codes, rowing, triathlon, cycling, martial arts and gymnastics.
As a sideline physio in local sport, White often makes decisions on whether players have been concussed and if they should continue to play and feels that, historically, concussion has been poorly understood.
“General physiotherapy training did not equip me with the skills to make informed decisions regarding their ability to play and the potential serious consequences of concussion,” she says, “So I undertook official studies to be qualified in concussion testing.
“In our clinic alone, our concussion trained physios see several patients a day for concussion rehabilitation,” White explains.
“There is rarely a game of any contact sport that we work at on a weekend that does not require an assessment for a potential concussion at some point, more often in some codes such as rugby.”
Concussions occur regularly in sport at all levels, according to the Australian Institute of Health and Welfare. In 2020-2021 they cited “every four minutes, someone in Australia is hospitalised for a head injury” and “24% of these injuries are from sport”. Cycling has the highest hospital admission rate for head injuries.
According to the Australian Institute of Sport’s Concussion and Brain Health position statement 2024, during the 2019 National Rugby League (NRL) season in Australia, an incidence of 15.4 diagnosed concussions per 1,000 hours of match play was reported.
While these high impact or “collision” sports are well versed in concussion, there are also sports considered "limited-contact" that may be a little behind in policies and procedures around concussion, particularly at the grassroots level.
Malcolm Murta played soccer from the age of five and worked his way through the age groups, through to junior state representative level and into the National Premier League (NPL) until multiple concussions and then a final “king hit” had him hanging up his soccer boots for good.
“I remember one concussion when I was playing youth NPL for under 18s and I got a kick to the face mid-air going for a diving header which pretty much knocked me out instantly,” Murta recalls. “I hit the ground face first. I was definitely concussed but was expected to play the next week. I didn’t, but the expectation was there.”
His story is particularly difficult because many of his concussions went undiagnosed and he continued to hit the field week after week. The roll-on impacts meant that even the slightest head tap might send him into "full head knock hell". It has impacted his life so significantly that he has lost entire periods of time due to memory loss.
“I think the first time I remember my symptoms were really bad was in Under 23s. I got two head knocks in the same game within 10 minutes of each other and then I drove myself home. I wasn’t with it and nobody stopped me from driving.
“I don't remember driving home and I don’t remember from then until a few days later. That was the first time I realised that this was getting pretty real.”
As with any young person making strides in their sporting career, the fear of seeming weak or unsuitable, played heavily on Murta’s mind, particularly since he was making inroads to First Grade.
“At that time I was like, ‘I'll give it one more head knock and then that's it’ because I was like, ‘I don't want to live in fear,’” he says. “Like I want to keep playing. I was going through the ranks and had a future.
“But then I had the big injury. Right at the same time I’d been offered to play with First Grade, I was at training and got hit in the head with a close ball at around 100km an hour. They said it was the equivalent of a king hit.
“This was a Tuesday night in March right before the season kick off,” he recalls. “I don’t remember anything from the Friday beforehand right up until the middle of June.
“I had just started working in real estate and I sold my first house. I don’t remember selling the house, which is a huge milestone and achievement and I don’t remember it.”
There are many things that Murta doesn’t remember during that time, including his 21st birthday. As a result of his concussion and the ongoing cognitive repercussions, he had to give up his job and due to the basic insurances offered in community sport, he couldn’t afford the upkeep in his specialist care.
“Two years after quitting sport, I still suffer vertigo, tinnitus, lack of sleep, anxiety attacks, fatigue and I’ve also had depression.”
When asked about the potential impacts of a concussion on an athlete, White says there are the short-term impacts of symptoms such as headache, visual, vestibular, cognitive, psychological, metabolic and cervical spine issues and the time off sport which can have significant social impacts. As well as mental health and in some cases financial issues with not being able to participate in their sport, attend work or school.
“One of the biggest dangers with a concussion can be sustaining a second head knock before recovering from the first,” she explains. “This can put an athlete at risk of post-concussion syndrome or Chronic Traumatic Encephalopathy (CTE), which includes long term and more significant issues such as career-ending concussions for professional athletes, permanent physical and mental disability, loss of income, mental health issues, social issues and poor academic performance in children and adolescents.”
Having had over 20 significant head knocks in his sporting life, Murta is concerned about CTE.
“Having all these concussions, I mean, I'm not trying to exaggerate, but CTE is a big thing that concerns me,” he says. “And the fact that you don't know you’ve got it until after you passed away is a big scary thing.”
White is hopeful that the recent shift in how concussion is being treated in sport will make it less of a threat for future generations of sports people.
She acknowledges there has been some great research into concussion over the past few years and can see firsthand that a lot of sporting codes are starting to recognise the long-term issues by increasing their mandatory stand down times for post-concussion injuries.
“The recent Senate inquiry into sports-related concussion has made some really helpful recommendations to those working in sport for managing sports-related concussion,” she says. “In conjunction with the position statement by the AIS, concussion management and awareness is heading in the right direction and we will see some really exciting things in the future.”
Although she acknowledges there is still a long way to go with raising awareness and ensuring that all sporting organisations, coaches, parents and athletes appreciate the potentially detrimental impact that concussion can have on an athlete of any level. There is also a way to go in refining concussion protocols across different sporting organisations and ensuring that these are implemented effectively.
“Setting a high standard in concussion management in high performance, professional and representative sport helps to filter down to the grassroots and increase awareness,” she says.
“Just because you cannot see a concussion does not mean it is not serious. Any suspected concussion should be thoroughly assessed by a trained professional and athletes should not be returned to play until they have been appropriately cleared.
“We have had multiple situations of parents arguing when their children are removed from play and refusing to have them assessed until the clubs and coaches insist before letting them to return to play.
“I think this is due to a lack of education and understanding. It’s terrifying to think that their child may suffer a lifelong brain injury for the sake of playing a local game of sport.”
Murta agrees that the most important thing is education and awareness.
“I've never really spoken about my head injury to a lot of people because just for the memories it brings up,” he admits. “But if it can save someone else from getting concussions or sort of look after himself more that's, I guess, the biggest goal is to talk about it.”
Murta has steered clear of sport since the big hit and is now working in a family friendly environment with people who understand the long-term impacts concussion has had on his wellbeing.
How does he feel now, on reflection?
“It was a big turning point in my life and everything, but I mean it’s sort of weird to look at the concussion and think, ‘if that hadn't happened, I wouldn't be where I am today’,” he reflects. “Pretty much in the job I am, I wouldn't have had the opportunities I've had so far if it hadn’t happened, so you’ve got to focus on the positives.”
White’s viewpoint, whether she’s on the sidelines of local or elite level sport, remains the same.
“In my role it can seem challenging to make a decision to remove a significant player in a vital part of an important game as there is a lot of pressure from coaches, players and the crowd and there is significant time pressure,” she says.
However, she is adamant that regardless of the level, the sport or the age of the participant: “If in doubt, sit them out!”
The knock-on effects
In a podcast recorded in 2021, Sport Integrity Australia spoke to former Wallabies player Peter FitzSimons, whose personal crusade against concussion started two decades ago.
“… years ago in reading The New York Times, I became more and more aware of how concussion was a serious issue in sport … there were lots of NFL players particularly that were to use the old terminology ‘punch drunk’ which was like a revelation to many people because a lot of us were naive enough to think that it was only boxers that could suffer damage through concussion.”
At the time of the interview FitzSimons suggested that while “huge progress” within contact sporting codes has been made, the rules were still flaunted each week.
“…When you see someone clearly concussed, clearly gaga, still getting HIA (head injury assessments), which is let’s see if they’re concussed or not, and then so often they come back on the field …. Can you tell us what it was?” he asks. “Professional football codes have to get serious about observing the protocols.”
In the podcast FitzSimons cited America as leading the charge in this space due to concussion problems in the NFL.
“You know in America it was not taken seriously for many years, many decades until I think the first case was $800 million class action … I don't have the figures in front of me … but there was serious money that changed hands … [because] the footballers were quite reasonably saying, ‘You knew what this was doing to our brains and yet you still sent us out there … you put us out there week after week, we suffered brain damage because of what you did’."
One of our most successful Paralympians with six gold, three silver and two bronze medals, Michael Milton, admitted in the same podcast he competed in an era where he often didn’t wear a helmet in downhill skiing and that crashes were all part of the sport.
“[The impacts of those crashes] is certainly a concern going forward,” he admits. “When I start to think about skiing over 6,000 days in my life, averaging a crash at least once a day, you start adding up and thinking there’s probably pretty high numbers of multiple impacts that potentially could have an issue in the future.”
When reflecting on the many sports over and above the obvious concussion sports like football and boxing, Milton suggested that training coaches, medical staff and the athletes themselves in the importance of taking concussion seriously was the key.
“I think certainly the way things are managed have changed over the years, and you know I think it's probably more important for those people involved in the sport to have education and an understanding.”
Associate Professor Alan Pearce, a neurophysiologist said that sports are now starting to take concussion seriously.
“The emerging evidence worldwide is very clear that there are links between repeated head trauma and that's either with repeated concussions or what we call sub-concussions where the brain receives impacts, but you don't see the obvious signs of concussion per se,” he explained. “And what we do see from the international research is that there are links now to a range of diseases and cognitive impairments.”
“It’s all about small steps, it’s all about changing the attitudes of the wider community to concussion or sub-concussions, taking the injury more seriously… We will still keep calling for changes because we know that the long-term welfare will pay off in the end.”
Studies into CTE thanks to the Australia Sports Brain Bank
According to the Concussion and Brain Health Position Statement, 100,000 sport related concussions occur in Australia each year. Most concussions occur in community sport however many are still not documented.
Studies are being undertaken to determine what the long-term impacts of concussion in sport might be. Researchers are studying possible links between sport and Chronic Traumatic Encephalopathy (CTE).
The Australian Sports Brain Bank (ASBB) is an international collaboration committed to researching the long-term effects of regular concussions in Australian sportspeople on the brain, in particular with regards to CTE. There is currently no test available to test for CTE in the living, but the ASBB is hoping to change that.
First found in the sport of boxing, CTE is a condition caused by repeated mild traumatic brain injuries and is now being linked to sports such as American football, Australian Rules football, rugby league and rugby union. No doubt as the ASBB grows in donations, other sports with participants at risk of CTE will come to light.
According to the ASBB, CTE can cause problems with memory, thinking, personality and behavioural changes, aggression and depression.
ASBB international partner, the Concussion Legacy Foundation, publishes up-to-date information about the science of CTE on their website.
For more information head to concussionfoundation.com.au and www.brainbank.org.au
Concussion in Australian Sport website
Concussion affects athletes at all levels and is a growing concern nationally and internationally.
The Concussion in Australian Sport website has resources for athletes, parents and teachers, coaches and support staff, medical practitioners and physiotherapists, to support the Concussion and Brain Health Position Statement.
“There is no such thing as a good concussion, and we need to be concerned about each concussion and manage each concussion seriously,” Dr David Hughes, Australian Institute of Sport Chief Medical Advisor, says.
Concussion in Australian Sport brings together evidence-based information on concussion for the management of sports-related concussion for all Australians, regardless of the sport, location or level of participation.
