Miami Dolphins quarterback Tua Tagovailoa has been placed in concussion protocol three times this season.
Miami Dolphins quarterback Tua Tagovailoa is attended to by medical staff after being sacked by Cincinnati Bengals defensive tackle Josh Tupou on Sept. 30. He later returned to the game.
Baseball may have been supplanted by football as America’s favorite pastime over the last half century. However, one metaphor from the diamond permeates Americana: three strikes and you’re out.
It is often the case on the job and in a courtroom. At the typical workplace, miscreants are given a warning for their first offense, suspended the second time around, and shown the door for their figurative strike three. In many jurisdictions, including federal courts, conviction for a third violent felony means a life sentence.
In football and other collision sports, the saying has traditionally applied to concussions. Dr. Thomas Quigley was the team physician for the Harvard University football team for more than 40 years, according to the Boston Globe. Early in his stint there, in 1945, he decided any player who had suffered three concussions should end his career.
Back then, Harvard was still among the elite college football programs in the country. Combined with the reputation of its medical school – still enjoyed today, any such pronouncement from the Cambridge, Mass., institution was as good as gold.
Seven years later, Quigley’s sideline colleague, Dr. Augustus Thorndike published a paper in the New England Journal of Medicine entitled, “Serious Recurrent Injuries of Athletes – Contraindications to Further Competitive Participation.” In it, Thorndike endorsed Quigley’s rule, thus removing any doubt whatsoever among sports medics nationwide.
Unfortunately, neither Quigley nor Thorndike offered a shred of scientific evidence upon which to base their pronouncement. Furthermore, their definition of concussion included being knocked out. Today, we know far fewer than 10% of concussions involve loss of consciousness.
Still, as recently as 2009, the National Athletic Trainers’ Association echoed the rule in its concussion guidelines which read in part, "Because of an increased risk for future concussions, as well as for slowed recovery, athletes with a history of three concussions should be advised that terminating participation in contact sports may be in their best interest."
Interviewed at the time, Bears and Blackhawks neuropsychologist Elizabeth Pieroth, Psy. D., took exception. "I don't like this blanket statement," she said.
Imagine you are a catcher, goalie or linebacker who has had two concussions but no recurrence for several years. Then, during a game or practice, you are briefly stunned by a blow to the head but seemingly feel fine within moments of the play ending. Knowing that your career could very well be over if you report yourself to the athletic trainer, are you going to do so? Pieroth was sure you would not.
Consequently, for that reason and because of better science, concussion specialists have largely abandoned the “three strikes and you’re out” rule. Largely.
Because, when it comes to three concussions all suffered in one season, the consensus remains that, while an athlete’s career in a contact sport is not necessarily over, his or her season should be.
That is precisely the situation faced by Dolphins quarterback Tua Tagovailoa.
Credit Dolphins head coach Mike McDaniel for becoming suspicious while watching film on Monday, a day after his team’s loss to the Packers. However, blame the NFL for a concussion protocol which remains broken and brought Tagovailoa and the Dolphins to the uncomfortable place they are now.
The Dolphins quarterback had landed hard on the back of his head with 2:40 left in the first half but popped up quickly, apparently unscathed. In the wake of a concussion diagnosis a day later, the NFL and NFLPA initiated an investigation. On Saturday, the League and Players Association announced their concussion policy had not been violated because no overt signs of concussion were displayed.
Fair enough – in the immediate moments post-hit – but if the Miami coaching staff noticed something reviewing film, why couldn’t the onsite medical staff – not tasked with coaching – have noticed the same in real time during the second half? Fans on social media did. Prior to the hard hit, the Miami signal caller’s stat line read nine for 12, with 229 yards passing. In the second half, he completed seven of 13 attempts for 81 yards with three interceptions, which occurred on consecutive drives.
Of course, there would be no such controversy if Tagovailoa’s first concussion had been managed differently. And make no mistake, that was a concussion he suffered when he was slammed to the turf and came up wobbly against the Bills on Sept. 25. Strike one.
Had he been placed in the concussion protocol post-game back then, he would not have had time to return four days later against the Bengals. That night, there was no question that it was a concussion which required his exit on a spine board. Strike two.
Without strike two on Sept. 29, last week’s strike three would have only been strike two – if it had taken place at all. A concussion in one football season leaves a victim more vulnerable for the remainder of that season and actually for another full season thereafter. Still, a 2003 study published in the Journal of the American Medical Association showed that more than 90% of second concussions in the same season happened within 10 days of the first. Suffering that second concussion so soon left Tagovailoa’s brain in an even more fragile state.
At this point, his brain needs an extended period for rest and recovery.
A career is in question only when concussions increase in frequency, they become increasingly more severe, they involve longer and longer recoveries, they trigger migraine headaches, and/or a victim ends up with post-concussion syndrome.
The latter is a disaster and is defined as the persistence of concussion symptoms three months following the injury. A study published in the Journal of Neurotrauma in 2016 showed a recovery rate of only 27% and two-thirds of those who did recover, did so in the first year.
So far, apparently, none of this applies to Tagovailoa. Missing the remainder of the season, regardless of the playoff implications, offers the best hope of keeping it that way.
John Doherty
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