Concussion: The Invisible Injury

One of sports’ most dangerous injuries is also one that is hardest to diagnose. There’s a reason why concussion is known as the silent or invisible injury.

Unlike a broken arm or a laceration, we can’t see the damage a concussion can do to the brain. Its long term effects can be felt even decades after the final hit. Dr Barry O’Driscoll, former member of the International Rugby Board’s medical advisory panel, explains what a concussion is.


The symptoms can be dizziness, nausea, balance problems, memory problems, depression, confusion, headaches or blurred vision. A common misunderstanding is that you have to be knocked out to get a concussion. This is not the case.

The issue has become a big talking point in sport, especially in the NFL and rugby. There has been some controversy in the past regarding the long term damage repeated concussions can have on former NFL players. You can tell straight away that these players, running into each other as fast and as hard as they can, are not retiring from the game as healthy as they were at the beginning of their career. Concussion and other play-related brain trauma have been proposed as a cause of player suicides. However, the NFL and its panel of doctors denied this link for years. Even in 2007 Dr Ira Casson, former member of the NFL Medical panel, was denying the link.

Dr Casson left his position on the medical panel in 2009, much to the relief of many concussion advocates.

Christopher Nowinski, a former WWE wrestler and Harvard football defensive lineman, has been an advocate of concussion education in the US for years. Needless to say, he’s been a bit of a thorn in the side of the NFL. He suffered 6 concussions in his 11 years in sports but  it took him years to realise the damage they had done to his health. He had to retire from WWE as a result of post-concussion symptoms. One frightening incident led to him seeking help.

Chris Nowinski in his WWE days. Photo Credit: Wikimedia Commons
Chris Nowinski in his WWE days. Photo Credit: Wikimedia Commons

When researching concussions in sport, Nowinski heard of the death of former Pittsburgh Steeler, Mike Webster. Nicknamed Iron Mike, Webster played in the NFL from 1974 to 1990 and is considered by many as the best centre ever to play the game. However, Mike’s post-football life was anything but easy. He suffered from amnesia, depression and acute muscle pain – classic symptoms of concussion. Mike died in 2002 aged 50. His brain was examined and the coroner, Dr Bennet Omalu, noted that Mike suffered from Chronic Traumatic Encephalopathy (CTE), a disorder usually found in boxers. Mike Webster was the first NFL player to be diagnosed with CTE.

Mike Webster’s case was not an isolated incident. It was followed by Andre ‘Dirty’ Waters and Terry Long, former NFL players that both showed signs of CTE post-mortem. The difference was that Waters and Long took their own lives.

Here’s the science bit…CTE is a progressive degenerative disease of the brain found in athletes and others with a history of repeated brain trauma, including concussions. The trauma triggers degeneration of brain tissue, including the build-up of tau protein.

The symptoms of CTE are much more severe than concussion and it can lead to full blown dementia or Alzheimer’s Disease later in life. In rare cases, it can also cause Amyotrophic Lateral Sclerosis (ALS), otherwise known as Lou Gehrig’s Disease. Interesting fact: it’s now thought that former Yankee Lou Gehrig died as a result of CTE – not the disorder named after him.

2 years ago, The New York Times published images of brain injuries in athletes. In a new study of 85 people who had a history of repeated mild brain trauma, it found that 68 of them had evidence of CTE. I highly recommend you look at the photographs; the damage is quite disturbing. (The accompanying article can be found here.)

In October 2006, Nowinski published Head Games: Football’s Concussion Crisis, which details his career-ending injury and discusses the dangers of concussions in football and other contact sports. The book served as the basis of the documentary, Head Games, which was first released in 2012, followed by an updated version in 2014.

In 2007, Chris Nowinski and Dr Robert Cantu founded Sports Legacy Institute to advance the study, treatment and prevention of the effects of brain trauma in athletes and other at-risk groups. It took a while for the NFL to realise the damage concussions can do to athletes.


Nowinski was named one of the Top 40 under 40 by Hockey News. This was attributed to his ability in getting hockey players to donate their brain tissue after death. Photo Credit: brainstreams
Nowinski was named one of the Top 40 under 40 by Hockey News. This was attributed to his ability in getting hockey players to donate their brain tissue after death. Photo Credit: brainstreams

Last year, a group of over 4,500 former NFL players sued the league for concussion damage and they were given a settlement of $760 million. Many players believe that this is too small considering the NFL generates $10 billion annually. It’s possible that they might refuse this offer for something bigger. However, ailing players and their families need help now and can’t afford to wait.

Over the past year or so, concussion has dominated debate in the rugby world. In the past, the policy in rugby was that if a player is suspected of having a concussion, they can’t return to action for a minimum of a week. The International Rugby Board (IRB) came under fire in 2012 for modifying  their concussion policy and introducing a Pitch-side Suspected Concussion Assessment (PSCA). Under this, if a player is suspected of having a concussion they are to leave the field for 5 minutes and be assessed by a doctor. Players who pass the test can then rejoin the game. This has caused worry among doctors and former players.

George Smith‘s concussion last summer during the Lions test led to widespread criticisms of the new protocols. Smith passed the assessment and was then allowed to return to play. For anyone watching the match, it was clear that he was not fully fit.

With the NFL’s huge pay-out to concussed former players, there is a possibility that the IRB might face the same fate in the future.

Lamont in action for Scotland in 2007. He retired from rugby in 2013. Photo Credit: marcelo schnaidt
Lamont in action for Scotland in 2007. He retired from rugby in 2013. Photo Credit: marcelo schnaidt

Former Scotland and Glasgow Warriors winger, Rory Lamont, was knocked out cold 10 times on the field and had a number of other concussions throughout his career. He was not aware of the damage concussions can do during his playing days and he believes that the rugby governing bodies are still not doing enough to educate players about concussion.


At the Brain and Sports Injury Conference in December, the main message from doctors, former players and others was that education is key in getting the message across to players.

Rugby and American football are brutal, exciting and dangerous sports. Changes need to be made to ensure the safety of the players and governing bodies are taking steps to make the games safer. Player welfare needs to be made the Number 1 priority.

It’s not just rugby and NFL that are at risk. Concussion has also been a hot topic in hockey and soccer. Former NHL players have recently filed a lawsuit against the league, saying that the NHL promoted violence regardless of the health risks. In the first four months of the Premier League season, 3 players were knocked unconscious on the field. One of them was Hugo Lloris who returned to play after the clash; he should have been forced to leave the field.

For more information on concussion and Chronic Traumatic Encephalopathy (CTE), go to the Sports Legacy Institute or the Boston University CTE Center websites. You can also follow Chris Nowinski and Sports Legacy on Twitter.

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