Jamal Adams had to be held back by multiple Seattle Seahawks staffers as he approached an unaffiliated neurotrauma consultant earlier this season. The “Monday Night Football” matchup was Adams’ first game in 386 days following a series of injuries and he had no intention of coming out just nine plays into his return.
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Moments earlier, while trying to tackle New York Giants quarterback Daniel Jones, Adams had taken a knee to the helmet. Following the collision, Adams laid flat and face-down on the field. When he tried to get up on a knee, he lost his balance and fell back on his rear end. By the time he made it to his knee on his second attempt, he was met by the Seahawks’ trainers. When he tried to stand up, he stumbled again. Before Adams even made it to the sideline, it was clear he should not be allowed to continue playing.
Since 2014, each NFL team has been required to have a league-appointed unaffiliated neurotrauma consultant (UNC) — an impartial physician independent from the team — present on the sideline to assist in identifying symptoms of concussions during games, working with team doctors to decide when to evaluate players and helping to do it.
Adams shouted at and angrily stared down this UNC, who, after an evaluation, had determined that the Seahawks safety likely suffered a concussion and needed to go to the locker room for further testing during his team’s Week 4 game against the Giants.
The concussion protocol can be triggered by a trainer, team physician, coach, referee, player or UNC. Once the protocol is initiated, the UNC works through the concussion checklist. It begins with determining whether any of the four “no-go” symptoms — which automatically rule out the player — are present: loss of consciousness, amnesia, confusion or ataxia (which is defined as abnormality of balance/stability, motor coordination or dysfunctional speech caused by a neurological issue).
If the player hasn’t displayed any of the no-go symptoms, the UNC moves on to considering the player’s history of head injuries, asking him a series of rudimentary questions known as “Maddocks Questions.” The video of the play on which the head injury occurred is reviewed and a neurological evaluation is conducted, with an examination of the player’s spine, speech, gait and eye movements. According to the protocol, a player must be escorted to the locker room if any of those elements are “positive, inconclusive or suspicious of concussion.” At some point, the UNC determined Adams fell into that category.
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While Adams being ruled out was a success for the NFL’s concussion protocol, his unwillingness to accept that outcome — which subsequently got him fined — is indicative of an issue that continues to plague the process. Players want to play, and concussions often fall into the category of ailments they’ll attempt to push through to do so.
The day before Adams’ concussion, in fact, New York Jets cornerback D.J. Reed suffered a concussion against the Kansas City Chiefs but concealed it and finished the game. His concussion was diagnosed after the game, and he didn’t clear the protocol for another three weeks. Surely, Reed is not the only player to recognize concussion symptoms yet choose to play through it.
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Others may simply not notice their symptoms. Panthers tight end Hayden Hurst hit his head on the ground against the Bears in Week 10 but passed a concussion evaluation and returned to the game. It wasn’t until the next day that Hurst realized he had suffered post-traumatic amnesia — he couldn’t remember up to four hours after the game — and was placed in the concussion protocol. Ahead of the Week 15 slate of games, Hurst was placed on injured reserve, ending his season.
“Anytime a player is diagnosed after game day with a concussion, we go back and very carefully review all of the facts that go into that and make sure the concussion protocol was properly applied — and also make sure we understand the medical decision-making,” NFL chief medical officer Allen Sills said last week. “I retain an extremely high degree of confidence in the men and women that help us administer our concussion protocol. … We’re not perfect, but I think we’ve set a very high bar and standard for ourselves.”
Still, an indeterminable number of concussions go undetected as a result of symptoms going unreported.
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“I think you have to start this discussion with the understanding that most players will never tell you when they have concussion symptoms,” said Chris Nowinski, a former NFL player who co-founded the Concussion Legacy Foundation in 2007. “The protocol and the education program is meant to say, ‘Please report concussions when you have them,’ but we all understand that’s not going to happen most of the time. And we may not ever be able to change that. Because I believe that players have symptoms so frequently that, if they reported every time they had symptoms, we’d run out of players.”
Stewart Bradley struggled to stand up after his head collided with the hip of Philadelphia Eagles teammate and fellow linebacker Ernie Sims. As Bradley attempted to get to his feet, he lost his balance multiple times. When he finally stood, he stumbled groggily forward before collapsing to the field and sprawling out on his back.
It was 2010, and Bradley was allowed back into the game against the Green Bay Packers for a few plays before he was ruled out due to what should’ve been an easily identifiable concussion. In direct response to the mistake, the NFL instituted its game-day concussion protocol in 2011.
“When we started doing this, most concussions were not diagnosed,” Nowinski said. “Since then, the protocol continues to evolve to try to eliminate embarrassing mistakes for the NFL.”
The NFL says it has made progress when it comes to concussions. In 2015, the league reported 275 concussions between the preseason and regular season. The number has fluctuated since then, but it was down to 213 in 2022, a 22.5 percent difference from 2015.
It can’t be ignored, though, that the number of concussions reported increased year over year. The jump from 187 in 2021 to 213 represents a 13.9 percent increase. And while the total number of concussions reported for 2023 won’t be announced until the season is over, 11.5 percent more concussions were reported in this year’s preseason than last year’s.
“We follow them all,” NFLPA chief medical director Thom Mayer said in September. “The league, obviously, has a little bit of a tendency to celebrate when they go down, but not so much when they go up.”
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The NFL and NFLPA changed the concussion protocol in October 2022 after Miami Dolphins quarterback Tua Tagovailoa took a hit to the head and stumbled before being allowed to return to the game. That resulted in ataxia being added as a “no-go” symptom. The league believes that led to an increase in the number of evaluations, which, in turn, may have contributed to the rise in reported concussions.
“They’re evaluating more players now,” NFL commissioner Roger Goodell told ESPN in September. “I think they’re also — and I think this is a good thing long term — more conservative in their approach. So, you’re going to get more evaluations. As such, you’ll likely get more concussions (diagnosed).”
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According to the NFL, an average of three to four evaluations have been performed for every instance of a diagnosed concussion since at least 2018. The belief is that number will rise.
“The ability to spot and diagnose concussions still relies upon experts,” Jeff Miller, an NFL executive who presides over health and safety initiatives, said in September. “There’s no technology to say yea or nay. And so, a conservative culture around examining players who may have suffered a concussion makes all the sense in the world. … But, regardless, it’s less about the number of concussions we have than it is about identifying players who are in need of an evaluation and making sure they get it.”
The NFL doesn’t want concussions to go up, of course, but the recent rise may very well be a result of the improved responsiveness to the problem. According to the NFLPA, about 50 percent of the NFL’s diagnosed concussions are self-reported or reported by teammates. And, according to the NFL, only 25 percent of players who’ve been concussed this season have returned to play the following week. (The Houston Texans, according to multiple reports, are unlikely to have star quarterback C.J. Stroud under center for the second consecutive week due to his recent concussion.)
“It could represent an increased sensitivity of the combination of players, coaches, team physicians and unaffiliated neurotrauma consultants to the signs and symptoms of concussion,” Mayer said. “We’re going to have to continue to watch it over time to say, ‘What do we think is going on?’”
The league’s original concussion protocol didn’t include independent trainers serving as spotters in the press box, had no requirement for independent UNCs to be involved in the evaluation process and left out ataxia as a no-go symptom. Admittedly, the protocol wasn’t stringent enough and allowed far too many loopholes that enabled players to return to action.
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Over the years, more has been learned about what causes concussions. That knowledge has helped the NFL adapt the protocol, treatment, the designs of equipment and the rules of the game. But the identification of concussions on the fly remains difficult.
“Concussions are kind of like snowflakes: No two are going to be alike,” sports neuroscientist and TBRx co-founder Peter Cummings said. “To diagnose them becomes really tricky.”
There’s no definitive way to determine whether a player has a concussion. That may not be as much of a factor when the symptoms are overt, but it’s not always so obvious.
“And because it’s so difficult to identify in black and white terms — ‘What is a concussion?’ — it leaves opportunity for things to potentially be missed,” former Los Angeles Chargers team physician Dr. Tal David said. “I would say 75 percent of the concussions that I saw and diagnosed on the sideline were reported by the athlete. It was not obvious to the observer, spotter, physician, whoever it is, that they happened.”
Many concussions are caused by subconcussive impacts. Those may produce zero observable external effects and allow players to clear concussion protocol.
“You still have a significant opportunity for traumatic brain injury, scarring and long-term encephalopathy from that,” said Dr. Shawn Evans, an emergency trauma doctor at Scripps Memorial Hospital La Jolla in San Diego, who has treated thousands of concussions. “We’re screening a lot more athletes and we’re more sensitive, but you’re still seeing glaring examples at all levels of field participation of people who’ve been concussed, are clearly concussed, are dizzy and meet those really tall watermarks and are still being left on the field.”
In those types of situations, the onus to identify the concussion largely falls on the player to (1) know he’s not feeling right and (2) come clean about it. Not all players will be in a rush to rule themselves out of a game. It’s easy to imagine a player fighting for a job or new contract attempting to game the system to stay on the field, and many of them are successful.
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For players who want to avoid entering the concussion protocol, it’s not just about missing the rest of the game. To get cleared, they have to pass the NFL’s return-to-participation protocol. There is no set timeline after which they can return to action. It’s a five-phase process. To advance to each phase, players must show that symptoms haven’t returned.
Once they make it to the end, they still have to receive clearance from an independent neurological consultant. That process can take multiple weeks, which can be the difference between a player keeping or losing his job.
“It’s just hard at 24 to think about your life at 54,” former NFL quarterback Jordan Palmer said. “When the system is set up (for a player) to make a lot of money in a short amount of time, it’s hard to get their attention to look 20 and 30 years from now. And so, it’s nothing I think the NFL could solve. I don’t think it’s negligence or anybody doing a bad job. I just think it’s hard to have somebody be so focused on it because every contract, for the most part, is year to year. … It really is a ‘you need to produce right now’ business.”
In late September, Las Vegas Raiders quarterback Jimmy Garoppolo was drilled on a sack by Pittsburgh Steelers safety Minkah Fitzpatrick. Garoppolo was slow to get up, but he didn’t display any outward concussion symptoms and never came out of the game. When he was evaluated after the game, however, it was revealed he had indeed suffered a concussion.
“There is no way to eliminate concussions in a collision sport,” David said. “It can’t happen.”
Eliminating the inherent guesswork in the process, however, is an important goal. That will require time, resources and money for the development of new technologies to identify concussions.
“You’ve just got to understand that science is slow and it happens at its own pace,” Cummings said. “We can measure neurocognitive function now, we can measure neuromotor function now, we can track eye movements now and we can bring all this technology onto the field and not just diagnose concussions more confidently but, more importantly, make sure that a player is ready to go back.
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“It’s finding these … apps and different things that can measure these things and give you real-time data on what’s going on with your athlete and that allow you to protect them. I think that one of the biggest things is finding the right technology that can do that. That can benefit all sports if the NFL can lead the way because they have so much money to put into this kind of research. … If we can start getting some of this tech onto the NFL field, then everybody benefits.”
(Top photo of Tua Tagovailoa: David Santiago / Miami Herald / Tribune News Service via Getty Images)
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