Alan J Pearce and Stephen Townsend
Melbourne, September 8, 2024
In the second quarter of the Western Bulldogs’ last game before the Australian Football League (AFL) finals, the chin of their superstar captain Marcus Bontempelli bounced off the shoulder of an opposing midfielder.
As Bontempelli sat on the bench looking dazed, the television broadcast commentary expressed hope that he had not suffered a concussion because his team ‘might need him to win this game,’ noting that an injury might also hurt his pursuit of the Brownlow Medal awarded to the season’s best and fairest player.
Fortunately for all, there was no problem — Bontempelli returned to the field and helped steer his team to an important victory.
But the immediate concerns about Bontempelli’s medal votes and impact on the final score, rather than of his physical wellbeing, is a harbinger of the many conversations about potential head injuries that will happen in Australia in the coming month as the country’s two biggest national competitions — the AFL and the National Rugby League (NRL) — enter their post-season.
Professional athletes push themselves to their physical limits and that carries risks of bodily harm. Playing through injury is applauded because it embodies the ‘warrior’ ethos that many associate with contact sports.
However, sport is not war, and concussion is causing many to rethink the value of playing through injury, particularly when that injury could result in permanent damage to the body’s most vital organ.
A growing concern
There are 20 top-flight players across Australian rules and Rugby League sitting on the sideline due to concussion — 12 in the NRL, four in the NRL Women’s, and four across the eight teams that qualified for the AFL finals.
Some of these players have been ruled out indefinitely after sustaining multiple concussions in short periods. This year alone, the AFL has had five players retire (and at the time of writing, potentially a sixth) and in the NRL there have been at least two.
These premature retirements, including an 18-year-old who was six months into his professional career — suggest two things.
First, there is increased awareness among athletes that repetitive brain trauma carries life-threatening risks. Second, many Footballers are damaging their brains by returning to play too soon.
What makes concussions special?
We have all heard stories of players who come oh-so-close to playing in a grand final, only to be injured just before the big dance. Whether it be a broken bone or torn muscle, seeing these players watching on mournfully adds a pathos to elite sport that is an essential part of its emotional appeal.
Concussion does not appear to garner the same reaction from fans, players or coaches. There is no pathos, no empathy, just frustration that a talented player could be kept from their footballing destiny by an invisible injury.
The Adelaide Crows experience
During the 2021 AFL Women’s finals series, Adelaide Crows Captain Chelsea Randall was forced to miss the grand final after suffering a concussion in the game prior.
While Randall gracefully accepted the league rules, highlighting her responsibility to send an ‘important message’ to grassroots Footballers about the importance of concussion protocols, others responded differently.
Former St Kilda forward Nick Riewoldt claimed he would ‘go to the Supreme Court’ if he were in Randall’s position.
“If I am feeling okay and they are saying you have got to sit 12 days out, which is an arbitrary number, I am seeking an injunction. I am trying to play,” he said.
But a year later, when the Geelong Cats’ young star Max Holmes suffered a hamstring injury on the cusp of the 2022 grand final, Riewoldt was more sullen than combative, simply saying his ‘heart (went) out’ to Holmes.
The symptoms of concussion manifest differently in every brain — changes to cognition, balance, mood and so forth. Unlike musculoskeletal injuries which are often visible to the naked eye or via medical imaging, concussion can currently only be diagnosed symptomatically.
One injured brain may show immediate signs of disturbance while another may initially appear normal only to regress days or weeks later. It is also possible for athletes to fool concussion tests by hiding or minimising their symptoms.
This is a unique aspect of concussion, which demands a more nuanced discussion around diagnosis and exclusion protocols.
The Finals Fever
These discussions get even trickier when it comes to finals time. The emotion of Finals Football causes players and fans to accept unreasonable risks in the pursuit of trophies.
Stricter exclusion protocols — 12 days for the AFL/AFLW and 11 days for the NRL/NRLW — have been applauded in some circles.
It is still not aligned with available neuroscience research, but these rest periods are an improvement on the bad old days when a Footballer could return to play in the same game after suffering an obvious brain injury.
However, these exclusion periods have also increased the stakes for players, coaches and medical staff when it comes to diagnosing concussion. Under these new rules, a player concussed in a semi- or preliminary final will miss the grand final.
Saving players from themselves
Athletes, elite and otherwise, will often do anything to stay in the game. It’s not just about the pursuit of money or the glory of victory, but the necessity of maintaining their identity as athletes.
An athlete, in the original Greek translation of the term, means ‘one who competes,’ and you cannot compete sitting on the sidelines. Mandatory rest periods for concussion are designed to save players from themselves by taking the decision out of their hands.
After a concussion to the Adelaide Crows’ Izak Rankine, former players-turned-pundits Tim Watson and Garry Lyon supported moving the pre-finals bye week from the end of the regular season to the week before the grand final to give concussed players extra time to recover before the decider.
While this proposal has merit and would reduce some pressure on finals-bound players to hide or minimise their concussions, it is fundamentally unsound because it conforms to the inadequacies of existing exclusion protocols.
We have a growing body of evidence to show that while symptoms resolve within a week, the brain takes longer to recover from a biological basis, somewhere between 20 to 30 days.
This is not new research. The first call for concussed Australian football players to be excluded for “two to four weeks” was published more than 60 years ago.
In response to this body of evidence, the Australian Institute of Sport announced earlier this year a 21-day rest period for recreational players who sustain a concussion.
Protocols not implemented
However, the AFL and NRL have not implemented these protocols. Instead of following recommendations, they argue that the ‘advanced care settings’ available to their athletes mitigate the need for such onerous rest periods.
While it is true that elite athletes are subject to greater monitoring than their recreational counterparts, their brains are the same and are exposed to even greater trauma forces on a more regular basis.
Moreover, the tests used to diagnose concussions are open to the same ambiguity whether they are applied to elite or recreational athletes. The pressure of finals Football increases the opportunities for these ambiguities to be exploited.
The clearest solution for protecting athletes’ brains is to apply the same 21-day exclusion protocol to elite and recreational athletes alike.
The AFL can also act on its proposal to have independent doctors assess concussions, as the NRL and NRLW have done in recent years. Having independent doctors will avoid risks of bias in their diagnosis, removing the potential for club doctors’ decisions to be influenced by a desire to see their team succeed.
Knowingly or unknowingly, making decisions that affect a player’s availability, especially during finals, is a harder decision to make for a doctor who is employed by a Football club.
Where to now?
If concussion orthodoxy prevails, one day soon Australians will no longer tolerate our professional athletes, who push themselves to their limits week in and out, living with brain injuries or brain diseases such as chronic traumatic encephalopathy (CTE).
Elite sporting leagues should implement changes before this becomes a reality. It is too late to make these changes before the 2024 finals series, but 2025 could be different.
If these changes are made, they will be driven not only by Club and League administrators but also by fans and the media. Cultural change is needed alongside a shift in policy change.
Concussion needs to be spoken about as a brain injury, rather than the player receiving a ‘head knock.’
This shift in language more accurately reflects the significant injury a player has suffered which, just like a ruptured ACL or a broken ankle, renders them unequivocally unable to play.
The media too can play its part in changing the culture around concussion.
It is not accurate or appropriate to frame concussion as an injury that players are guaranteed to recover from within a fortnight, treating any case where symptoms last longer as a surprise or aberration.
We must accept that concussion is a brain injury with health consequences that are potentially more severe than a ruptured ACL or torn hamstring.
We should not expect athletes to play in a grand final at the expense of their brain health. In doing so, the AFL in particular will live up to its laudable claim that ‘athlete health and wellbeing is our highest priority.’
Alan J Pearce is a Neurophysiologist, focusing on concussion and CTE research. He is also a Member of the Australian Sports Brain Bank and a Founder of the charity Concussion Legacy Foundation Australia and Co-Editor of the forthcoming book Routledge Handbook of Sport, Concussion and Brain Injury. Stephen Townsend is a historian of Sport and Health at the University of Queensland. He is a Research Fellow at the Queensland Centre for Olympic and Paralympic Studies and Editor of the forthcoming book Head in the Game: Sociocultural Analysis of Brain Trauma in Sport. The above article and photograph, which appeared first on the website of 360info, have been published here under Creative Commons.
