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Repetitive concussions in sport

Repetitive concussions in sport

By Dr Cristina Morganti-Kossmann

Obligations Personal Injuries 


Sport-related concussions (SRCs) comprise a complex medicolegal problem in the context of Australian contact sport. This article discusses current knowledge on sport concussion and continuing developments in the diagnosis and management of sport concussions that have led to substantial changes in sport rules and raised significant legal issues.

Repetitive sport concussion: controversies between medicine and the media

In the last few years, the consequences of SRCs have received extraordinary attention within the sport environment, the research community, the legal sector, schools and colleges, the media and the society at large. The impacts of emerging evidence are such that recently in the United States (US) a professional football offensive lineman announced his retirement in his prime to prevent the development of irreversible brain damage. In the last two years, thousands of young people have not participated in high school football.1

The misconception fuelled by the media each time new scientific investigation is released on chronic traumatic encephalopathy (CTE) in athletes is responsible for spreading panic in our communities, suggesting that sport concussion will inevitably cause CTE and even increase the risk of suicide.2 There is no doubt that sport concussions and the devastating neurodegenerative disease, CTE, are associated with repetitive head trauma. However, there is much more we need to know before we can establish the incidence and predictability of CTE in sport.

Currently, we find ourselves torn between the scientific evidence on CTE based on what some describe as ‘a selfselected group of former athletes’, and the anxiety caused by sensationalist journalism. We seldom read that most athletes recover well from a concussion and do not suffer any longterm defects. Clearly, not every player will develop damaging neurological consequences.

Despite ongoing progress in medical understanding of sport concussion, there is no unequivocal means of establishing whether a concussion has occurred or not. An athlete may experience the first symptoms of a concussion hours or days after the game without recalling a collision event. Scientists are working hard to identify biomarkers (objective measures of brain damage) for use at side-lines to indicate, quickly, whether a player has sustained a concussion, and its severity. There are no prognostic means to determine the enduring consequences of repetitive concussions and predict the impact upon the player’s mental and neurological health decades after their retirement from sport. The individual’s predisposition to mental and neurological diseases must also be considered, which may be unrelated to whether they’ve sustained head injuries.

From dementia pugilistica to chronic traumatic encephalopathy (CTE)

The association of contact sports with brain injuries has been known for decades. Dementia pugilistica was used a century ago to describe the array of cognitive and motor deficits in boxers. In 2005, Dr Omalu, a neuropathologist from the US, first confirmed actual brain neurodegenerative changes upon autopsy of a football player who died of cardiac failure. He coined the term ‘chronic traumatic encephalopathy’ (CTE). The player had been retired for 12 years and prior to death presented symptoms of cognitive impairment, mood disorder, and Parkinson’s-type neurological changes.

These findings were rejected by the National Football League (NFL), which heavily attacked the study and Omalu himself.3 However, despite initial resistance by sport associations, this publication became the stepping stone for the recognition that repeated head trauma may cause long-term neurological impairment in professional football players. Playing any form of contact sport, including soccer, can potentially cause CTE. Recently, accumulating scientific evidence has literally transformed the sports scene, with changes in game rules and guidelines for improved diagnosis, management and prevention of head injuries.

Symptoms of CTE

Sport concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. The symptomatology of CTE includes cognitive decline, aggression, confusion and depression. In 2015, the neuropathological criteria for diagnosing CTE were established by expert neuropathologists and classified as mild or severe, based on strict pathological changes.4 The severity of the condition has been associated with the duration of professional sport engagement and the number of hits to the head received.

Dr Ann McKee of Boston University’s CTE Center has published most data on CTE-related brain changes in American sportsmen. Its most recent work in 2017 sparked another wave of panic across the globe.5 The investigation of over 200 brains, donated by ex-footballers, the largest series ever analysed, revealed CTE in 177 brains of those who had been involved in sport for approximately 15 years. Nearly all NFL players had CTE, with the majority having the severe form correlating with aggravated cognitive impairment, behavioural/mood changes and dementia. These pathological findings were contextualised by lifestyle, neurological and neuropsychological information provided by family and treating physicians. The brain lesions formed by the deposition of the ‘toxic’ proteins, phosphorylated TAU and beta-amyloid, were revealed to be distinct from those found in non-trauma ageing brains. Sadly, mild CTE was often associated with suicide, whereas severe CTE was linked to dramatic neurodegeneration, dementia and Parkinson’s. The authors concluded that risk factors for developing CTE are:

  1. age of first exposure to sport;
  2. duration of sport involvement;
  3. player’s role;
  4. number of blows; and
  5. distinction of linear versus rotational acceleration causing a concussion.

However, this study is somewhat biased, since the brains were provided by individuals who sustained repetitive concussions and presented neurological decline, increasing the likelihood that the clinico-pathological features of CTE would be evident. This cohort does not represent the overall population of NFL players, precluding the possibility of establishing a broad incidence of CTE.

Australia fair

The incidence of hospitalisation for sport concussions in Victoria has steadily increased by an average of 5.4 per cent per year between 2002 and 2011. In 2013, 4,745 people aged 15 or over were hospitalised for SRC. A 60 per cent increase in hospitalisations over nine years included concussions occurring in other activities such as motor sports, horse riding, Australian football, rugby and roller sports.6 The Australian Football League (AFL) has reported a significant increase in the number of concussions requiring players to miss games. This trend should be seen as positive, as it may indicate a growing understanding of the detrimental consequences of concussion among doctors, coaches and players. This awareness is likely to increase the chance that a concussion will be reported and managed as a serious health risk. Yet despite this progress, there is a consensus among sport and medical associations that the majority of concussions remain unreported and untreated.

Australian football has a higher risk and rate of injury compared with other community sports. According to the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), concussion is the fourth most common injury in Australian football,7 but the true number of concussions in AFL and sport in general is difficult to estimate. Under-reporting by players is a problem if/when they fear exclusion from upcoming matches. This tendency emphasises the importance of having a physician available to reliably diagnose any suspected concussions and manage them. A recent concussion audit in the AFL reported six concussions per 1,000 player hours played.8 Analysis of a single AFL team over 14 years showed one concussion every 50 games. The 17.6 concussions per 1,000 player hour match included 12 per cent of affected players suffering loss of consciousness, and 80.7 per cent of those concussed returning to the field on the same day. Although there was no secondary concussion in those returning to play, other studies from the US/Canada reveal an increased reconcussion risk of three to six times in athletes with previous history. The injury surveillance repor by the National Rugby League (NRL) claimed increased headinjury from 210 in 2015 to 276 in 2016, respectively. Among the players removed from the field, 54 per cent returned to play in 2015, compared with 66 per cent in 2016.

Preventing injury and improving accurate diagnosis

International guidelines

In October 2016, the Consensus Statement on Concussion in Sport was established at the 5th International Consensus Conference on Concussion in Sport, held in Berlin.9 The meeting engaged experts from the traumatic brain injury, dementia, imaging and biomarker fields. The following international guidelines were established to improve the diagnosis and management of sport concussions.

Recognise: What is the definition of concussion?

SRC is a traumatic brain injury induced by biomechanical forces. It is caused by a direct blow to the head, or elsewhere in the body, causing an impulsive force that is transmitted to the head. SRC results in rapid onset of short-lived impairment of neurological function that resolves spontaneously. Symptoms evolve over minutes to hours and days. In some cases, symptoms may be prolonged. SRC does not require loss of consciousness. No abnormality is seen on standard structural neuroimaging brain scans. Resolution of the clinical and cognitive deficiencies follows a sequential course.

Side-line evaluation

Because of the difficulty in diagnosing a concussion and the possible evolution of symptoms, players should be removed from the field when a concussion is suspected and then assessed by a physician or licensed healthcare provider. The progress in understanding sport concussion led to a recent update of the Sport Concussion Assessment Tool (SCAT) with SCAT5 for adults10 and Child SCAT5 for those aged 5-12.11 These questionnaires are used to examine the athlete where symptoms are not severe. SCAT5 is a composite of tests to assess consciousness, cognition, memory; physical changes; balance; cervical spine injuries; decision-making; injury advice provided to the healthcare professional; monitoring the athlete; information on rest and rehabilitation; and return to sport or school strategy. Importantly, the new guidelines include the requirement that a professional has performed the SCAT5 and provided clear instructions on how to use the questionnaire. Child SCAT5 requires the participation of parents.


A player should be evaluated by a physician or licensed healthcare provider on site and if this person is absent, the player should be removed from the field. If the outcome of SCAT5 is positive, the player cannot return to play on the day, should not be left alone and should be monitored repeatedly.


A health physician or Emergency Department will reassess and monitor the development of the player’s concussion and recommend further examinations if symptoms worsen.


The duration of rest required remains controversial. Currently, the athlete will rest until symptom-free over the next 24-48 hours, followed by a gradual return to light physical activity before working up to a more strenuous workout, unless the symptoms are aggravated by activity.


This is a new addition to the guidelines. Most individuals recover spontaneously from a concussion within 10-14 days, but some may require psychological, cervical and vestibular rehabilitation in cases where there are balance issues.


Referral for further testing is required for post-concussive symptoms that persist after 14 days.


The recovery process is difficult to confine to fixed rules and timing because each case is different. The majority of athletes recover within a month. However, recovery may take longer depending on psychological factors. Greater severity of acute symptoms increases the likelihood that a longer recovery period will be required. Pre-existing conditions (depression) and hyperactivity or learning disabilities in children are also likely to exacerbate symptoms and recovery periods. Teenagers, particularly girls, seem to be more vulnerable to persistent symptoms.

Return to sport

This is the most challenging aspect. An athlete’s return to sport strictly depends on the age of the athlete and their compliance with medical advice. If they return too soon, they increase the risk of a second concussion, which exacerbates initial brain damage. Once symptom-free, the athlete undergoes a rehabilitation period of at least a week, provided he/she remains symptoms-free when exercising.

Risk reduction

Pre-season evaluation of SRC will identify players at higher risk of concussion and provide them with educational training and behaviour modifications in the field, with the aim of preventing future concussions. Medical history also includes any form of injury sustained outside sport.


The strongest evidence of evolving policy to respond to risks associated with concussion comes from disallowing ‘bodychecking’ (a defensive technique) in ice-hockey in under-13s, which reduced the risk of SRC. Limiting whole body contact (as during a tackle) in youth football practices also reduces the frequency of head contact. In soccer, stricter enforcement of red cards for high elbows in heading duels reduce the risk of concussion.

Players' perception: Are they sticking to the rules?

Some argue that changing sport rules and introducing safer guidelines make things worse. The pressure felt by players increases the risk of under-reporting of possible concussion for fear of being removed from future matches. The AFL puts together lists of players being removed because of a concussion. Professor Caroline Finch, director of the Australian Centre for Research into Injury in Sport and Its Prevention, has suggested developing a national concussion registry to gather sufficient data, improve information and research.

The proposal for AFL players to wear helmets has received mixed responses. Helmets’ effectiveness in reducing a concussion is uncertain because the damage is caused by the sudden movement of the brain within the skull, hitting the cranium, rather than receiving a blow to the head. A helmet, however, prevents head fractures. It has been argued that the protective gear used in American football may increase the aggressiveness of the players because they feel less vulnerable. There have been proposals to introduce cushioned soft helmets in AFL, which absorb the impact, albeit in the absence of proof that they reduce concussions.

The AFL has become harsher in addressing misbehaviour in the field. North Melbourne’s Jarrad Waite and St Kilda midfielder Koby Stevens were each given one-weeksuspensions by the Match Review Panel for ‘reckless tackles that injured their opponents’.12

More success is seen in youth sport, with the total ban of tackling in those under 14 years. The adolescent brain is particularly susceptible to head injuries due to the complex development that the brain is undergoing at this age. Also, a youth needs 7-10 days longer than an adult to recover from a concussion. Thus, an injury may affect the ultimate brain function in the long term.

Because each individual is different, the introduction of a thorough baseline of physiological, neurological and psychological pre-season testing to obtain the player’s abilities when they are unaffected by a concussion could be of benefit. The baseline could then be used to assess any neurological changes whenever a concussion is suspected. The clubs have increasing responsibility to implement the latest guidelines and receive substantial fines if they fail to remove concussed players from play or return them to the field too soon after injury. In fact, in 2014, four NRL clubs were fined $20,000 each for breaching the governing body’s guidelines in this respect.13

Sport-related concussions and the law

United States: The class action against the NFL

In the US, the problem of SRCs was highlighted by the class action against the NFL in January 2017, which resulted in a compensation settlement of over AU$1 billion to 5,000 retired players. The ‘plaintiffs accused the NFL Parties [of being] aware of the evidence and the risks associated with repetitive traumatic brain injuries, but failing to warn and protect players against the long-term risks, and ignoring and concealing this information from players’.14

The first two claims in the NFL’s concussion settlement were announced recently, with $US9 million awarded in benefits.15

The payouts are slowly being provided to former athletes, with US$5 million given for amyotrophic lateral sclerosis (ALS) and US$4 million for CTE, on the condition that each individual played at least five seasons and received a diagnosis under the age of 45. Players diagnosed with Parkinson’s, Alzheimer’s or dementia are also eligible for payments.

Australia: New policies

In mid-2016, the Australian Medical Association and the Australian Institute of Sport released a joint policy on sport concussion: The Concussion in Sport Position Statement.16

Under the heading ‘the potential consequences of concussion’, the Concussion in Sport Position Statement urges children under 14 years to stop sport for at least 14 days after all symptoms have cleared.

This statement coincided with the launch of the federal government website, which ‘ensures that all members of the public have rapid access toinformation to increase their understanding of SRC and to assist in the delivery of best practice medical care’.

AFL players cannot receive compensation from WorkSafe or equivalent state workers’ compensation bodies, but they can claim common law compensation where the player is able to demonstrate negligence by the Club or the AFL, which caused the career-ending injury.

Pressure for legal action against the football and rugby leagues is mounting. Peter Jess, former football agent and concussion campaigner, established a website where players can register if they believe they have suffered brain injuries in contact sport:17 ‘In addition to diagnosing potential medical issues, Concussion Matters will seek to develop a class actionto compensate those people who have been affected.’

A few players have retired because of head injuries in recent years, including Adelaide’s Scott Stevens, Brisbane’s Jonathan Brown, former Saint and Lion Matt McGuire, ex-Demon Sam Blease, North Melbourne’s Leigh Adams and Brisbane’s Justin Clarke. Athletes from both NRL and AFL have launched independent legal action against their respective leagues seeking compensation.

Lawsuits in Australia

James McManus, a renowned rugby player, was the first sportsman to have launched legal action against his club, the

Newcastle Knights, in 2017.18 He claims that he was forced into early retirement in 2015 due to repetitive head blows, particularly in the three years he played for the Knights. Over the course of his career, McManus played 166 games. His claim, filed in the NSW Supreme Court, alleged that the club was liable for ‘permitting or requiring him to continue to be exposed to [Traumatic Brain Injury] when they knew the cumulative effects could create a permanent impairment’.

He suffered from ‘cognitive and memory impairment, mood swings, headaches, anxiety, depression, lethargy and sleep disturbance’. McManus claimed that the club had failed to conduct assessments by specialised medical professionals after concussions. Moreover, the club retired him after a concussion but did not inform him of the possible long-term consequences of repetitive concussions. The club also failed to recommend that he seek his own medical assessment. Despite being diagnosed by a neurologist as suffering from concussion, he was required to play in a match in which he suffered another severe concussion as a result of which he was admitted to a hospital emergency department. The Knights rejected his accusations, claiming that rugby is a ‘dangerous recreational activity’ of which McManus was aware. McManus had consented to the risks of injuries inherent in the sport and ‘waive[d] any claim in respect of loss, injury or damage’. McManus responded that the club’s failure to manage his concussions prevented him from having a successful career in rugby in Australia or overseas, and this included missing opportunities of sponsorship and advertising, thus implying lost monetary earnings in rugby and/or other professional employment. The league claimed it had used established concussion protocols. The lawyers acting for McManus are seeking to obtain medical records from other players (Robbie Rochow and Richie Fa’aoso) to demonstrate a pattern of behaviour that will strengthen their chances of winning the case.

In 2017, another NRL player, Brett Horsnell, lodged the first proceedings against the Parramatta District Rugby League Club, which may later be extended to Gold Coast, South Queensland, the NRL and the Australian Rugby League Commission in Queensland. He showed medical evidence of CTE after 10 years of playing 154 games, in which he suffered over 50 head blows.19

In May 2017, Sam Blease (24 years, Geelong) and Matt Maguire (30 years, Brisbane) were forced to retire due to repeated concussions, and did not receive payouts from the AFL. The claims progressed at the AFL’s grievance tribunal. Finally, both players won compensation from the competition’s governing body over repeated concussions that were deemed to have caused the end of their careers.20 Blease, who suffered two serious concussions, was eligible for 200 per cent of his salary, whereas Maguire only 50 per cent of his salary. The details of their compensation awards are not known.21Justin Clarke received a payout of $700,000 for suffering a severe concussion and was warned by medical experts never to play any contact sports again.22

Heritier Lumumba, another AFL player, is at the centre of a very different case, which might potentially escalate into a legal action against the Melbourne Demons. Instead of accusing the club of lack of attention in relation to his concussions, Lumumba accused the team doctors of not allowing him to play after a concussion when he felt he was fit to play. This prevented him from participating in a sufficient number of games to be included in the fourth season with the Demons.23


Repetitive head injuries undoubtedly lead to cumulative brain damage, possibly culminating in progressive neurodegenerative changes. Athletes, referees, administrators, parents, coaches and healthcare providers must be educated on the detection of SRC, its clinical features, assessment tools available and the criteria of safe return-to-play policies. Web-based resources, educational videos and international outreach programmes are useful. Fair play and respect for opponents are ethical values that should be encouraged in all sports and sporting associations. Similarly, trainers, parents and club managers should ensure that these values are implemented on the field.

Want to find out more? Register for the LIV's Sports Law Insights, 12 March, where Dr Morganti-Kossmann, will join other expert panelists to discuss concussions in sport. Book here.

Dr Cristina Morganti-Kossmann is an Adjunct Associate Professor at the Department of Epidemiology and Preventive Medicine, Monash University, and Director of Lex Medicus Publishing. As a neuroscientist, Dr Morganti-Kossmann has been working on traumatic brain injury for 26 years in Europe and Australia, generating 122 publications. At Lex Medicus, she is responsible for the development of the educational program on musculoskeletal anatomy, pathologies and methods of medical examination. Phone: (03) 8375 540 Email:

This article first appeared in Precedent, the journal of the Australian Lawyers Alliance (ALA), issue 143, published in November/December 2017 (Sydney, Australia, ISSN 1449-7719), pp20-27.  It has been reproduced with the kind permission of the author and the ALA.  For more information about the ALA, please go to:


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19 B Read, ‘Horsnell’s legal team find a staggering 50 head knocks’ The Australian (online), 18 July 2017, <>.

20 K Francis, ‘Will concussion injuries eventually destroy the NRL and AFL in Australia?’, Sporting News (online), 25 July 2017, <>.

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22 N Browning, ‘Justin Clarke and Concussion in the AFL’, The Footy Almanac (online), 28 April 2016, <>.

23 J Ralph, ‘Heritier Lumumba set to retire but launch legal proceedings against Melbourne’, The Herald Sun (online), 24 November 2016, <>.


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