The Growing Controversy over Rugby’s Head Injury Assessment

Jul 21, 2017

Six hundred seconds doesn’t seem like a very long time. To put it in context it took the teams on average 51 seconds to emerge from the tunnel before the final test game in Eden Park. The Hakka prior to kick off took a further 81 seconds. Given that four Hakkas were completed during the tour (one before each of the three test games and one before the Maori game) if they all took on average 81 seconds (and the final Hakka did seem deceptively short) then ceremonial dances would have equated to over half the time used to assess whether, or not, a player had suffered a head injury which may potentially impair them.
The Head Injury Assessment (“HIA”) or “head bin” as it has been termed has long been a source of debate amongst the rugby fraternity. The World Rugby Laws at rule 3.12 provides the procedure by which a temporary substitution is made to allow a HIA be conducted on a player. These rules specifically that a 3.12(a) “If that player is not presented to a match official on the touchline within ten minutes (actual time) of leaving the field of play to undergo the Head Injury Assessment, the replacement will automatically become permanent and the replaced player is not allowed to return to the field of play.” In placing the time limit on the assessment World Rugby are presumably trying to safeguard against a potential “abuse” of the process whereby teams could utilize the time to essentially avail of an additional substitution but what they have in fact done is curtailed the ability of team doctors and management to make a fully informed and objective decision on a player’s fitness to return to the field of play. Now let’s remember that in Eden Park it took the teams 51 seconds to emerge from the changing rooms and run onto the field of play. If a player has taken a blow to the head they will need to leave the field of play and be assessed in the medical room. A player with a potential head injury is unlikely to race from the field with the same vigor and speed as he entered it so assuming that it takes 60 seconds for the player to both leave and return to the field then immediately the time for “assessment” is reduced to eight minutes.
The last Lions Tour in 2013 was marred with the image of George Smith staggering to his feet and struggling to maintain his balance prior to returning to the field following a HIA some 6 minutes later. The actual assessment of Smith couldn’t have taken more than 2 minutes at best given his tentative steps off the field. The Lions Tour of 2017 won’t be marred by one image of player welfare being disregarded but instead a list of names will be needed to put into context the true failing of this system during the competition. Joe Marler and Leigh Halfpenny both suffered “concussive symptoms” in challenge games but were not even removed from the field for the purposes of HIAs. Stuart Hogg left the tour having suffered a facial fracture which, by its’ very nature involved a significant impact to his head. Jared Payne left the tour due to migraines however these were attributed to an “inner ear” issue and not symptomatic of repeated concussions, one can only hope this is the true cause. Dan Bigger and Courtney Laws both failed HIAs during the tour. Anthony Watson left the field in the second test for a HIA which saw him return to the field within minutes, assuming it took two minutes at least to leave and return to the field then we are to assume that a comprehensive assessment was carried out with four minutes or two hundred and forty seconds.
The scene was set for an epic battle to conclude the tour. The tour was level and the Lions were facing into the challenge of trying to overcome the All Blacks in the veritable fortress that is Eden Park. Eden Park had not witnessed an All Blacks defeat since 1994. Kieran Read, the All Black’s captain, lead his team onto the field for his one hundredth cap and it was evident from the Hakka and the cool stare down of the assembled Lions that both teams were exuding passion, drive and determination to emerge as victors. Eighty minutes to make history. Eighty minutes for heroes to be created. The sounds of the Lions supporters chanting “Lions, Lions, Lions” repeatedly drowned out the home support. The Lions were not there to make up the numbers, to add to the list of teams who had fallen short in Eden Park or been overcome by the occasion. What followed was 80 minutes of heroic efforts by both teams, of electric runs, of missed opportunities, of well taken chances but all of that paled in comparison with the farcical application of the HIA procedure.
Alun Wynn Jones, participating in his third Lions tour, was replaced in the 51st minutes after taking a blow to the head from the swinging arm belonging to Jerome Kaino, with the All Black receiving a ten-minute period in the Sin Bin for his actions. The television cameras pan to the sideline and capture what can only be described as dazed and groggy looking Wynn Jones looking on. Sixteen minutes later Lion’s captain Sam Warburton is required to leave the field for a HIA. As Warburton exists the field the crowd present and those viewing from around the world take a collective sharp intake of breath as Wynn Jones returns to the field of play, albeit in a temporary capacity. Warburton apparently passes the HIA to returning to the field within six minutes. The use of Wynn Jones as a temporary substitution either highlighted a complete lack of any assessment of the player’s injuries once he was taken from the field (perhaps with the intention being to carry out a full assessment following the game mistakenly assuming he would not be required to return to play) or worse still, the complete disregard for player welfare of those involved in the Lions management. Warren Gatland, Lions coach, informs the assembled media following the full time whistle that not only had Wynn Jones undergone a HIA but he had passed it.
Fast forward to Warburton’s post match interview and the situation took an even more sinister turn when he admits to not recalling exactly what he had said to referee Romain Poite in the conversation which followed the incident which resulted in his being sent for a HIA. This comment may have been simply Warburton not remembering the exact conversation regarding the ensuing, and somewhat controversial, penalty awarded to the Lions however nevertheless it may display more of an accurate representation of the situation than one would like.
The Lions team doctor, Dr Eanna Falvey, described HIA management during the tour as a “collaborative effort” with the entire backroom team being involved in the “process”. He stated that the “biggest risk was sending a player back for the sake of winning and thus sacrificing the players health”, a statement I would wholeheartedly agree with. Then further acknowledged that a player will always want to return to the field of play and that his/the sideline teams’ role was to “protect the players for themselves”. All the right sentiments, the right attitude and approach but words are meaningless without the correlating actions to back them up and without laying the fault solely at Dr Falvey’s feet there was a clear failing in Eden Park and on some level some portion of the blame must be attributed to the medical team.
The finger of blame may also be pointed at Warren Gatland and whilst no one would question a coach relying on the medical team’s advices and opinions there is the potential for a coach to disregard those advices or cause a borderline decision regarding fitness to return to sway more to one side than another. That is not to say that there is any suggestion that the medical team or indeed Gatland were at fault on this occasion or that they acted in any way improperly however there is the potential for this to happen with the HIA system and it certainly is not unheard of. Rugby fans will be aware of the litany of head injuries sustained by George North for club and country and some of his questionable returns to the field of play at both levels with Gatland coaching the national side. The cynic may question whether the attitude in the backroom may be partly a factor, if not in the actions of the managerial set up but perhaps in the attitude being exuded.
Whilst a cloud now surrounds the final game of the tour one thing that is clear is that the HIA in its current guise is not fit for purpose and arguably could never be modified to be so. World Rugby, as the governing body of the sport, needs to intervene and take action to safeguard its’ greatest asset, the players. As there is clearly no appetite to extend the HIA period or take steps to sanction teams where there is a blatant disregard for player welfare then it is time to introduce the Blue Card system to the elite game. The Blue Card is currently being trialed and youth and non-elite levels in New Zealand and Australia with a similar trial commencing shortly in South Africa with all three countries already leading the way in prioritizing player welfare. A player is given a blue card where there is a suspected head injury and is permanently substituted for the remainder of the game prior to only returning to rugby following a three week period or sooner if medical certification is obtained. There is no explanation as to why this card hasn’t been considered for elite level. Perhaps changes would be needed such as increasing squad sizes to facilitate more substitutions but surely that cannot be considered an impediment in the context of safeguarding players.
The All Blacks side were not without incidents of head injuries, potential concussions and HIAs being utilized but the attitude of their coach was evident when All Black Israel Dagg described his team mate Ben Smith’s decision to pull out of the remainder of the tour following the first game with a head injury as the right decision “because you’ve only got one brain”. Fortunately the injury has been attributed to an inner ear infection but nevertheless the attitude of the players is clear no game is more important than your health. World Rugby, teams and coaches have no right to play games with a player’s health. A player who has suffered a head injury is, by definition, impaired and the decision to return to the field has to be taken out of the player’s hands. The time when supporters look on and commend the valiant efforts of a player clearly persevering through injury for the “good of the team” is gone, replaced by the concerned eyes of those viewing watching hoping they are not witnessing a player play with their life whilst pointing an accusatory finger at those who should know better, those who should be protecting the players as Dr Falvey put it best, “from themselves”.
World Rugby continues to persevere with the HIA despite numerous medical professionals, including the former medical advisor to the IRB (World Rugby in its’ former guise) Dr Barry O’Driscoll, being vocal in their criticism of it and describing it as unfit for purpose. Dr Martin Rafferty, Medical Advisory to World Rugby, in June 2013 acknowledged that “there is no perfect diagnostic test (for concussion)”. Then why does World Rugby persist with the HIA, why is there any need for assessment, if the question even needs to be asked then the player should be removed from the field of play.
Rugby by its very definition is a contact sport. Players will collide, injuries will be sustained and head injuries will never be eliminated from the game. That is the reality of a contact sport were collision is the name of the game. What can be changed is how the game reacts to these injuries, the steps taken to protect the players, to manage head injuries and to educate players and coaches alike on what is at stake. The stakes are too high to take any further chances than those already being taken by the players when they put their bodies on the line for the sake of pride, for the love of the game, for the fans who watch and their profession. The time for deliberation on the HIA or re-evaluation of the procedure has passed. World Rugby in perpetuating this system are killing the Lions tour, the game, the enjoyment of fans and potentially killing their players.
Stop watch on I read through what I have written. Five minutes and seven seconds, three hundred and seven seconds, over half the time allocated by World Rugby for a HIA to be conducted within. Six hundred seconds will never be adequate when the stakes we are gambling with are so high.
Cody is a practising lawyer in Dublin, Ireland. An avid sports enthusiast she is also qualified in Sports Law through the Irish Law Society. She is actively involved in striving to highlight head injuries and concussion in contact sports, particularly Rugby Union.


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