Should Tua's season be over? Dr. Chris Nowinski answers top 7 questions on Dolphins QB's concussions

By Dr. Chris Nowinski, Concussion Legacy Foundation co-founder and CEO

Monday, Miami Dolphins head coach Mike McDaniel announced quarterback Tua Tagovailoa was placed in the concussion protocol after he “displayed and admitted to having concussion symptoms” after their loss to the Green Bay Packers on Sunday night.

This is likely Tua’s third concussion of the season, after what appeared, from my perspective, to be an obvious concussion on September 25 that the team refused to call a concussion, followed by a clear concussion on September 29 where Tua was knocked unconscious and showed decorticate posturing. Decorticate posturing is a rare brain injury sign more often seen in stroke victims, suggesting a more serious injury.

What happens next is important for Tua’s career and his life, and it’s an important teaching moment, so I’ve shared some insights below. It’s also a stark reminder of how much work we have ahead of us to continue to change the conversation on concussions.

1. Tua is in the concussion protocol, but does he have a concussion?

• Almost certainly, yes, Tua has a concussion. The team reported Tua “displayed and admitted to having concussion symptoms” on Monday. Self-report of concussion symptoms after a head impact is the gold standard for diagnosis, specifically when the patient has experience with concussions. Unfortunately, Tua knows all too well what a concussion feels like. 

• We also have a clear possible mechanism for concussion. Tua’s concussion was not diagnosed during the game, but looking back at the film there is a clear head to ground impact that preceded a decline in his performance. Finally, he is also displaying signs of concussion. Therefore, it would be nearly impossible for a physician to conclude he did not suffer a concussion.

2. Will the Miami Dolphins diagnose him with a concussion?

• It would seem reasonable if Tua has a concussion, he will be diagnosed with a concussion. However, because there is no objective test for concussion, a diagnosis is not certain. Remember, on September 25, Tua showed 5 unique concussion signs after a head impact:
  • He grabbed his head in pain
  • He stumbled when he stood
  • He "shook off the cobwebs" and moved his head side-to-side (which you only do in the instance of a concussion)
  • He fell
  • He then had to be held up by his teammates

• But after initially calling it a concussion, the team claimed those five signs were somehow caused by a “back injury” earlier in the game and returned him to play. They stuck with this story all week, refusing to put Tua in the formal protocol, yet they also said they tested him for a concussion for three days before the Thursday night game.
• The Dolphins have a poor track record on this, and there are other possible diagnoses teams have made in these situations. Those of us following this field over the last 20 years remember the NFL used to call concussion symptoms a “traumatically-induced migraine” (here is Terry Glenn in 2002) and let players continue to play. Earlier this month, the captain of the England rugby team said his long-term symptoms after a concussion are actually due to nerve injuries in his neck. In both situations, there is no test that can differentiate those injuries with certainty – it’s the doctor’s call. 10 years ago, it wouldn’t surprise me to see one of those two diagnoses reported for Tua. But because the Dolphins are now under a microscope, I cannot imagine they’ll try to give an alternative diagnosis again.

3. How did the NFL spotter miss this?

• In retrospect, it’s easy to suggest the video of Tua’s head hitting the ground is the concussion, but to my knowledge, Tua didn’t show concussion signs after the impact (like stumbling again), so it wouldn’t have triggered a call down and automatic removal. Changing the protocol wouldn’t fix this unless we want everyone to come out of the game when their head hits the ground.

4. Why did Tua wait until Monday to report his symptoms?

• Most likely, he didn’t “wait” until Monday. We should give him the benefit of the doubt and assume he didn’t notice his symptoms until he woke up the next day. If you are hit hard enough to have a concussion, you have been through some serious trauma, which the body can compensate for with a burst of adrenaline or other responses that can mask the subtle symptoms of a concussion. Concussion symptoms are often delayed by a day or two. In addition, we cannot expect players with malfunctioning brains to recognize their brains are malfunctioning. Instead, we should respect Tua for reporting his symptoms. Most concussions show no outward signs, and NFL players often choose to not report their symptoms because they fear that when they are put in the protocol, they might lose their job.

5. Will Tua play again this season?

• Tua should not play again this season. Full stop. But the Dolphins should make the playoffs, which could give Tua enough time to become asymptomatic and clear the concussion protocol. What Tua may not know is that the concussion protocol is imperfect and is not the only variable to consider when deciding whether to return this season. Clinical experience (and my personal experience) suggests that the more concussions one has, and the closer together they are, the longer they take to recover from, and the more likely symptoms are to become permanent. Tua would be further risking his career to return this season, but a doctor may not be willing to tell him that.

• The Dolphins will likely send Tua to multiple doctors around the country for PR reasons as they consider what to do. The doctors that pro teams refer professional athletes to in these situations are often the doctors that are most likely to tell the team what they want to hear – that there is no permanent damage, and it is safe to return. Consider it from the team’s perspective – would you keep sending players to a doctor who often advises them to sit out when have no symptoms if you could send them to many other doctors who will tell them to play? Conservative doctors may stop getting referrals.

6. Is Tua "concussion-prone" and should he retire?

• It’s not fair to Tua to label him as concussion-prone, and he does not have to retire. A cluster of concussions, or even long-term symptoms, does not prevent a successful return or long career. Remember a decade ago when people were predicting Sidney Crosby would need to retire after fighting concussions? He’s still playing. Tua has had multiple concussions this season, but I’d argue his medical management of his September 25 apparent concussion is to blame – Tua’s been playing football a long time and never had issues before. Let’s hope, given proper rest, he doesn’t again.

• However, Tua should receive all the support he needs in his recovery, including mental health support. There is no good data on what happens to athletes after three concussions in three months because it is so rare. The anecdotes, however, are concerning. I recently counselled a professional athlete and connected him to better medical resources after he suffered three concussions in the last year and attempted suicide.

7. What does Tua's experience mean for other athletes?

• No one is being watched more closely for concussions right now than Tua. Yet everyone missed it – the NFL spotters, the team medical staff, the coaches, the announcers, and the players on the field. If we can’t spot Tua’s concussion, what are the chances we do a good job spotting the concussions of youth athletes, who don’t have the benefit of 30 medical professionals at each game, multiple camera angles and replays, coaches and teammates who know what concussions look like, and the experience of having had prior concussions? That’s why we launched our Stop Hitting Kids in the Head Campaign, which encourages parents to choose non-contact sports for their kids before high school. For children, our primary focus should be concussion prevention.