Concussion is arguably the biggest danger facing modern-day rugby players and, although much is being done to try to improve player welfare, it is a very real problem which can and does affect players of all sizes and abilities.

This weekend saw a timely reminder of that as the huge South African lock, Eben Etzebeth, suffered a heavy knock-out after a clash with Billy Vunipola. Etzebeth is probably one of the biggest players in world rugby, at 2.04m tall and 123kg, and was described last week by England player James Haskell as having “the biggest ‘guns’ in the game”. Yet he was felled like a tree at Twickenham on Saturday. He remained motionless with his arms out in front of him for some time but in the end was, fortunately, able to walk off, although clearly dazed. 

It was truly a relief to see him leave the field and not return. There have been too many cases where players who must surely have been concussed have been allowed to play on. Memorably, during the third Lions test in Australia three years ago, George Smith was clearly knocked out following a nasty head clash with Richard Hibbard and, despite stumbling from the field with the help of team physios, re-emerged a mere five minutes later to play on. It was an incident which shocked the rugby world and prompted a refocusing of the Head Injury Assessment (HIA) protocols.

Indeed progress has been made, and World Rugby’s emphasis on “Putting Players First” marks an important stepping stone towards reducing the risks. There are guidelines available online, providing important information about diagnosing concussion, which should be followed during the 10-minute HIA following a suspected head knock, as well as after the game. Meanwhile, World Rugby regulation 10 states that:

“All players diagnosed with concussion during a Game or training must:
(i) be removed from the field of play and not return to play or train on the same day; and
(ii) complete the graduated return to play protocol described in the World Rugby Concussion Guidelines.”

These protocols and thorough guidelines certainly mark a significant improvement in standards. Nonetheless, many have wondered why it has taken so long for World Rugby to react, given that concussion evidence has been available for at least 15 years. In 1997, just two years after the game turned professional, the American Academy of Neurology published a report that warned: “Repeated concussions can cause cumulative brain injury in an individual over months or years”.

Many high-profile players have had concussion trouble in recent seasons, as players continue to get bigger and bigger. England captain Dylan Hartley and full-back Mike Brown, as well as Ireland’s fly-half Jonny Sexton and Wales star George North, have all suffered concussions; Hartley has even openly confessed that his career could be over if he suffers another. 

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Indeed, there is a seemingly ever-growing list of players who have been forced to retire because of their recurring problems, with former Saracens captain Alistair Hargreaves in October being the most recent example. For similar reasons, Irish internationals Nathan White, Kevin McLaughlin and Declan Fitzpatrick have all also called time on their careers over the past two seasons, as did Welsh international stalwart Jonathan Thomas and three former England internationals: Andy Hazell, Michael Lipman and Shontayne Hape.

Hape, in particular, has been vocal about his experiences of repeated concussions, revealing how blows to the head have left him with constant migraines, unable to “bear to listen to music”, and struggling to “even remember [his] PIN number”. He also explained that, having been forced out of the game, he was in denial over the end of his career and had gone into depression. And, though he claimed to be in a much better place now, he outlined his worries about dementia and the other possible long-term effects of concussion.

Chronic traumatic encephalopathy (CTE) is a progressive, degenerative form of dementia only diagnosable after death. Experts have increasingly been it repeated concussions and chronic traumatic encephalopathy (CTE) in various contact sports – especially boxing and NFL. In 2013 for example, Dr Willie Stewart, a Consultant Neuropathologist in Glasgow, confirmed it in the case of a former rugby player. Clearly, such startling scientific developments have begun to hit home for many players, particularly as they consider their life after rugby, and have clearly contributed to decisions to hang up their boots.

It is a positive step, though, that so many players are talking about the condition and are raising awareness of it. In September, Canadian international Jamie Cudmore revealed his struggles with concussion – though he is still playing at 37 – and alleges negligent treatment by his former club, Clermont Auvergne. Indeed, his account is quite shocking: he describes how he was forced to play on in the Champions Cup Final despite having suffered several concussions in the weeks prior to the game, and he was knocked out twice during the final itself. He has also remarked that he was unaware of the real consequences this could have for his health: in fact, second-impact syndrome – suffering two head impacts in quick succession – can kill.

Yet his story is all too common. In 2015, Wales came under heavy scrutiny for their treatment of George North in a game against England: after TV pictures showed that he was twice knocked unconscious, he continued to play on. 

Hape’s account is also illustrative of the attitudes of players and coaches towards concussion. He spoke about his fear of opening up about his problems due to the pressures of wanting to start regularly for his new club, to achieve bonuses and not letting his teammates down. This is perhaps the biggest problem of all; indeed, another former England player, Alex Corbisiero, has described the concussion tests as “laughable”.

Attitudes do seem to be changing, though. The past two seasons have seen a huge awareness drive, along with a great increase in guidance on how to treat concussion. It, therefore, must be hoped that as more and more high-profile players share their experiences, the attitudes revealed by Hape and Cudmore will continue to be broken down.

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Nonetheless, alongside these issues is an interesting legal question surrounding the possibility of players being able to sue their former clubs – or perhaps even World Rugby – for negligence in their handling of the condition. Former Sale Sharks scrum-half Cillian Willis has publically announced that he is pursuing legal action against the club after he was allowed to play on despite suffering concussions. Indeed, given that the US has recently seen a $765m settlement with the NFL for players suffering from the long-term effects of repeated concussions, rugby clubs and sports lawyers alike will be watching how that case develops with great interest.

Finally, it is worth noting that it is not just professional athletes who can be affected by concussion. Speaking to Varsity, Andrew Burnett, a member of the CURUFC 1st XV squad, has opened up about his own troubles with concussion this term following a head-on-head collision.

“I can’t actually remember what happened, but have watched the video of the match,” he said. “I was evidently unsteady on my feet. Despite that, I carried on for another 10 minutes – making four more tackles. The only bit I remember was approaching a lineout and seeing our main jumper upside down. Needless to say, I missed the throw…”

Speaking of the effects of the injury, Burnett said: “After the match, I had a very poor memory for a few hours” and, “for the next two weeks I had horrendous headaches and really struggled to concentrate... Excellent excuses for supervisions but very frustrating nonetheless.” He frankly admits that “I wouldn’t be so bad if I hadn’t played on. Unfortunately, I passed the on-field concussion test.” 

This perhaps suggests, therefore, that there is still more that can be done to train those involved in rugby (players, coaches, and physios alike) at all levels about spotting the signs of concussion early and getting players off the pitch. While concussion can never be eradicated from a full-contact sport like rugby, managing player welfare – both short and long-term – must continue to be of paramount concern.

Fortunately, Andrew is feeling much better than he was and, having taken five weeks off, he is quite realistic about his situation: “I’m having my first run-through tomorrow. If I get through that I’m fine; if not, I’ll have to see the neurosurgeon.” 

A stark reminder then that concussion is, ultimately, a brain injury. And it must be treated as such.