Concussion experts discuss Tua’s medical outlook, what he should do if concussed again
First in a four-part series on the Dolphins’ quarterback situation
The Dolphins’ doctors — and at least one physician involved with the players union — told team management that Tua Tagovailoa is not more likely to sustain another concussion than anybody else.
That’s a big reason the Dolphins remain committed to Tagovailoa as their starter for 2023 even after a season in which he missed 5½ games (including a playoff game) because of concussions.
But what do other concussion experts believe?
Two contacted by the Miami Herald in the past week say there’s not enough evidence to indicate that Tagovailoa is prone to concussions, even though he had two and possibly three this past season.
They say there’s no reason for him to consider retirement.
But one of them cautioned that if Tagovailoa next season sustains concussions from hits that would not typically cause concussions in others, that would be a red flag and warrant at least the consideration of retirement.
Neither of the experts contacted for telephone interviews has examined Tagovailoa’s medical records.
But both of the experts — Robert Cantu and Chris Nowinski — said it’s fine for Tagovailoa to resume playing, provided his symptoms disappear. Multiple Dolphins players said recently Tagovailoa has told them that he feels fine.
“If he had a headache for a year and wasn’t able to exercise, that’s when you start having that conversation about whether it’s worth going back,” Nowinski, co-founder and CEO of the Concussion Legacy Foundation, said by phone. “But if the recovery is in the scope of weeks” and not many months, then there’s no need to step permanently away from the game.
“The odds a doctor would say, ‘You should never return to the field’ are slim,” Nowinski said.
Cantu — one of the founders of the Concussion Legacy Foundation and Medical Director and Director of Clinical Research at the Cantu Concussion Center at Emerson Hospital in Concord, Massachusetts — said there’s no medical need for Tagovailoa to discontinue playing.
“Is it as safe to return as it was before his third concussion? Yes,” said Cantu, who strongly believes Tagovailoa had three concussions this past season based on his wobbliness after the Bills Week 3 hit that was not diagnosed as a concussion.
“It’s a violent game. He’s at risk for head injury and at risk for CTE, which is a later-life issue. Is he at great risk if he plays further? Likely. But I would never say he should not come back and play next year.”
Both doctors said it was wise for Tagovailoa not to play again this past season, even though the Dolphins never formally ruled him out for the season.
“The more concussions you have in a short period of time, the greater risk you have of having a longer recovery and there’s also risks of developing health disorders, things could get in the way of his career,” Nowinski said. “His brain needs and deserves months to recover.
“The best course is to rest until next season. Even though we return players within a week or two of a concussion, the brain doesn’t recover at least until a month. Giving Tua six months to recover hopefully gets him back to the previous baseline when he didn’t have concussions.”
Cantu wrote a “Return to Play” medical guidebook in 1986 that was used by many college football programs.
“When we did that, we indicated that someone who had three concussions in any one given season should be sat down for the rest of that season and another three months to boot once they were asymptomatic,” Cantu said. “With three concussions, I would support him being sat down for the season [even though] there isn’t evidence-based science to definitely state that is necessary to do.”
Is Tagovailoa more likely to have another concussion next season because he had two or three this season?
“There is no statistically proven answer to that question,” Cantu said.
There is medical evidence that suggests people who have one concussion are more likely to have another within a short period of time. But there is no evidence, according to Cantu, that someone who has multiple concussions in a few months is more likely to have another one nearly a year later.
If Tagovailoa sustains another concussion next season, should he be held out longer than a person who sustains his first concussion?
If that happened, Cantu said he would hold Tagovailoa out a bit longer than players who sustained their first concussion, but not appreciably longer.
The concussion clock “starts at zero [for Tagovailoa] next September” presuming he doesn’t have another before then, Cantu said.
“If you put a great deal of months between concussions, you’re much more likely to go back to what your baseline is [before that stretch of concussions]. If he has a fourth [overall] concussion in September, that would still be his first next season.
“I would be a little more conservative next season. I wouldn’t be four or five weeks conservative. There’s not the science to say that you should be two or three weeks more conservative. There is not any scientific basis to holding him out several weeks” if he has a mild concussion next season.
“But common sense would say rest him a little longer [than most in that scenario]. But if you hold him out an inordinate amount of time after a concussion next fall, it would not be based on science.”
Nowinski said if Tagovailoa sustains a concussion next season, “I would probably not consider returning him within one week,” but that he could return without needing to sit out many weeks.
Nowinski added that “concussions tend toward getting more severe with longer recoveries [as they add up], but that’s not the case for everybody and there are examples of people who appeared to have career-ending concussions who returned without problems.
“Tua doesn’t have chronic symptoms, so that’s a good sign. There’s no sign that the next one will [sideline him] six months.”
Cantu said a scenario that should cause Tagovailoa to consider retirement would be this:
“If blows that do not normally produce symptoms now are producing concussion symptoms. If the intensity is considerably less and not expected to produce symptoms and are still producing symptoms, that’s the person at real risk,” Cantu said. “That would be a bad situation and mean your career is over.”
Would the hit that produced a concussion against Green Bay quality as such a hit?
Cantu does not believe it would because Tagovailoa’s head hit the turf on that play. “It was more moderate than mild,” he said.
Cantu said there’s no concussion magic number that exists after which a player should definitely retire.
“I worry more about what seems to be a mild blow that produces concussion symptoms, especially if those symptoms last,” Cantu said. “Concussions are talked about as if they are all the same and they’re not. Concussions with symptoms for 30 minutes or an hour or a day are not the same brain injury as someone who has symptoms for three months or six months.”
Is there concern that Tagovailoa is prone to concussions? Nowinski said that would be unfair to say.
Cantu said “you are not going to know the answer until he resumes play next summer. Certain people are more prone to be concussed than others. The reason for some might be neck structure; some could be about brain [factors] that we don’t know.”
Nowinski was critical of the Dolphins’ handling of Tagovailoa in late September. Even though two doctors said he did not sustain a concussion in Week 3 against Buffalo, Nowinski believes he suffered a head injury that day and that he should never have played five days later against Cincinnati, when he sustained a concussion on a violent tackle that caused his head to bounce off the turf. Tagovailoa missed two games after that before returning for a game against Pittsburgh.
“I would not call this bad luck,” Nowinski said. “I would call this unfortunate medical management. He was never given a chance to recover from the first concussion. Anybody who got hit like the hit he took four days after that [against Cincinnati] is going to be vulnerable for a long time. That’s why I suggested he take the rest of the season off [after the Green Bay concussion]. But calling him concussion prone is not fair.”
An NFL and union investigation absolved the Dolphins of any wrongdoing in the handling of the Buffalo incident; Tagovailoa was ruled to have had a back injury at the time.
The Dolphins and Tagovailoa are expected to give serious thought to Tagovailoa using a helmet with more protection than the one he had been wearing.
“What’s interesting is his helmet is one of the higher-rated helmets,” coach Mike McDaniel said. “It’s in the top two or three, I think, from the NFL rating… for helmet safety.
“I think with every player, that’s a choice that they make. They all like the comfort, feel and whatever, but I think those will be discussions that he’ll have with all of us – equipment, doctors and staff. But it is a very safe helmet in terms of how the NFL has rated helmets.”
Steelers quarterback Kenny Pickett wore a helmet with more padding than Tagovailoa’s after sustaining a concussion this past season. But Nowinski said he has seen no evidence to indicate that those types of helmets — or Q-Collars — significantly reduce the risk of concussion.
“There is going to be no technological solution to prevent this,” he said. “I think back to [Carolina Panthers All Pro linebacker] Luke Kuechley wearing a Q-Collar when he got the concussion that ended his career. It is a verifiable fact that a Q-Collar does not reduce concussion risks.
“There is no strong evidence that position specific helmets would be better for him. The most logical thing to do to reduce future concussion risk is to adjust how he plays to avoid unnecessary” blows to the head.
McDaniel said “we have thoughts of how to help him” slide without putting his head at great risk.
Cantu said wearing a helmet with more padding “slightly decreases the acceleration forces that the brain will [sustain] within that area” but whether it reduces concussions is unknown.
CBS NFL insider Jonathan Jones noted that all three of Tagovailoa’s “hits have been to the back of the head — the occipital area — and the league is developing a quarterback specific helmet with extra padding in the back, since that’s where the majority of quarterback concussions occur.”
But Nowinski said “more studies are needed on that helmet” to determine their effectiveness and added that there’s “always a risk of head injuries with bigger or heavier helmets.”
So the Dolphins move ahead with Tagovailoa, based on the belief that this season’s concussions were not an alarming harbinger.
“Talking with the doctors and consultants and everyone we dealt with, we fully expect him back next year 100 percent ready,” Dolphins general manager Chris Grier said.
This story was originally published January 20, 2023 at 1:18 PM.
