Jalen Hurts was the MVP of Super Bowl LIX. Prior to defeating the Chiefs in the biggest game of the year, he made headlines after an earlier contest by beating something else. After being sent to the medical tent for a suspected concussion late in the first half of the Eagles’ game against the Commandeers on Nov. 14. Instead of entering the concussion protocol, he returned for the second half of a 26-18 victory.

Interviewed post-game, Hurts said, “I guess I beat the protocol.” His insinuation was clear. 

On Dec. 22, facing the Commanders again, he was either not so fortunate or not so skilled.  Early in the first quarter, he was assisted to his feet by a teammate at the end of a scramble, was obviously unsteady on his feet, and ended up in the tent again. This time, he was not allowed to return and he was placed in the NFL’s concussion protocol. He would miss the Eagles’ final two games of the regular season before being cleared to return just in time for his team’s first playoff game. In all, he missed 21 days.

By comparison, the average time missed by an NFL player following a concussion is only nine days, according to a 2022 study published in the Clinical Journal of Sports Medicine.

Was Hurts’ relatively prolonged recovery the result of playing through concussion symptoms and ‘beating’ the concussion protocol in November? Furthermore, if he did in fact suffer a concussion back then, did that previous episode make December’s more likely.

Tua Tagovailoa’s experience during two events in the same week in 2022 would strongly suggest that the answer is yes on both counts. The Dolphins quarterback’s first episode was somehow re-labeled a back injury, paving the way for what happened four days later, when he left the field in Cincinnati on a stretcher.

The medical literature goes beyond suggestion and offers scientific proof.

A study out of the University of Pittsburgh Medical Center and published in 2016 in Pediatrics, the journal of the American Academy of Pediatrics, demonstrated that staying in a game or practice with concussion symptoms doubled recovery time for athletes, age 12-19, from 22 days to 44.

Hurts, 26, is no teenager. Furthermore, the preponderance of scientific evidence suggests adults take 10-14 days to recover clinically from concussion while teens take closer to a month.

Clinical recovery – the cessation of symptoms — is one thing; the brain’s complete recovery is something altogether different. If the brain is completely recovered — depending on age — in 2-4 weeks, why is it so much more vulnerable to a repeat concussion for much longer than that?

JAMA published a University of North Carolina study in 2003 showing that 92% of second concussions in the same season occurred within 10 days of the first. Nonetheless, any concussion made another more likely and three or more tripled the chance of another.

92% of second concussions in the same season occurred within 10 days of the first.

Along the same lines, another study in Pediatrics, this time out of Boston Children’s Hospital in 2013, found any previous history of concussion resulted in doubling the duration of symptoms from 12 to 24 days. Worth noting is that, given that the subjects were age 12-22, these data applied to younger adults, too. Of greater concern, regardless of age, if the first concussion had occurred any time in the previous year, the second concussion’s symptoms lasted an average of 35 days.

And prolonged symptoms sometimes take on a life of their own.

On May 28, 2023, Yankees first basemen Anthony Rizzo tagged out San Diego Padre Fernando Tatis, Jr., on a pick-off play. Unfortunately, in the process, as he leaned down and forward to snag the pitcher’s toss, Rizzo caught a face full of Tatis’ right hip. After applying the tag, Rizzo staggered away, attempted to make another tag into thin air, and eventually stumbled to the ground.

Removed from the game, with what was described as a “neck injury” — another case of re-labeling — he missed the next three-game series before returning to play. However, just over two months later, on Aug. 3, Rizzo was suddenly put on the injured list with “post-concussion syndrome.”

Perhaps, it was a little soon for that diagnosis because the medical literature describes it as a persistence of symptoms for three months or more, not two.  Ominously, once the diagnosis is made, the recovery rate is only 27% according to a 2016 study from the Journal of Neurotrauma.

Ultimately, though, the diagnosis proved correct because Rizzo was unable to return that season. Prior to the injury, he was hitting .304 with 11 home runs and 32 RBI. Over the ensuing nine weeks, he hit .172 with one home run and nine RBI. In 2024, his stat line read .228, 8 HR, & 35 RBI. Now, an unsigned free agent, at age 35, his career could be over.

How could anyone – particularly a professional athlete – be affected for that long? In 2019, Neurology, the journal of the American Academy of Neurology, published a study that helps provide an answer. Using diffusion tensor imaging (DTI) and functional MRI (fMRI), sophisticated MRI techniques for mapping the brain, the Canadian researchers scanned 24 collegiate athletes three times: immediately after a concussion, upon return to play, and then a year later. Another 122 athletes were checked pre-season and used as controls. The scans showed significant abnormalities at the time of concussion, with little improvement at the time of return to play, when the athletes were apparently asymptomatic. Even a year later, while some measures had returned to normal, others had not or had actually changed for the worse.

Rizzo’s experience is not an isolated one for a big-league hitter. A Northwestern study of concussed MLB players and published by the Orthopaedic Journal of Sports Medicine in 2020 showed, “Batting performance was significantly poorer one year after concussion and over the remainder of the players’ careers.”

Hurts’ history is not an isolated one for the NFL, either.

Surprisingly, on Jan. 30, in the lead-up to the Super Bowl, the League admitted as much when it delivered its annual report on injuries.  Commenting on the report, NFL chief medical officer Dr. Alan Sills acknowledged that only 28% of players evaluated for a concussion on the sideline were diagnosed with one and entered the concussion protocol. Really?

They were evaluated because of the suspicion of a referee, teammate, coach, or member of the medical staff. That suspicion was triggered by behavior consistent with a concussion. Such behavior is the result of the neurological cascade that takes place in the brain once a sufficient blow to the head has triggered that chemical reaction. Once the reaction starts, it must run its course, usually taking 10 days, according to well-established research at UCLA by David Hovda, Ph.D. In short, there is no un-ringing the bell, no matter how normal someone seems minutes later. Knowing that, what ever happened to “when in doubt, sit them out”?

On Oct. 6, Bears safety Jay Brisker was removed from a game and allowed to return. He reported symptoms the next day and was diagnosed with a concussion. Placed on injured reserve a month later, he never returned. He had also been removed from a game and allowed to return both in 2022 and 2023, only to be diagnosed afterwards and miss two games subsequently each time. During the 2022 game, he was actually removed twice but allowed to return after each sideline evaluation.

On Dec. 28, Patriots quarterback Drake Maye was removed from the game after a big hit but missed only one series. A complete evaluation for a suspected concussion takes longer than that. In a post-game interview, he admitted to having his “bell rung.”

On Jan. 18, Lions quarterback Jared Goff threw a pick-six and, during the return, was leveled. He, too, missed only one series while being checked in the tent. Noting his dazed appearance, game broadcasters freely discussed Goff having had his “bell rung,” even as he continued playing and throwing two more interceptions.

At the collegiate level, in the Jan. 9 Orange Bowl game, Notre Dame quarterback Riley Leonard and Penn State tight end Tyler Warren were suspected of having concussions. Leonard was driven to the turf late in the 2nd quarter, immediately grabbed his helmet, needed the help of teammates to stand, was obviously shaky on his feet, and sent off by a referee. In the 4th quarter, Warren landed hard on the back of his head, going out of bounds. Then, as he rolled over, he seemed to posture with his arms as his eyes went back in his head. Medical help was summoned when he was unable to get to his feet.

At least Leonard missed the rest of the half and was apparently evaluated further during half time before returning. Allard missed a total of three plays, returning to the field during the same drive. No word was ever provided in the media about Allard’s condition but Leonard admitted post-game that he was “wobbly” at the time he was hit.

As evidenced by Rizzo’s case, the problem is not isolated to football. In 2015, during the 2nd quarter of Game 4 of the NBA’s Western Conference finals, Steph Curry landed hard on the back of his head. After remaining down for a prolonged period, he arose looking dazed and clearly unsteady on his feet. He ended up missing 12 minutes of game time wrapped around half time but was allowed to return. The team went out of its way afterwards to insist he was not concussed.

One game later, Klay Thompson was kneed in the right ear and collapsed to the floor clutching both sides of his head. He returned, too, but admitted during a post-game interview that he was still dizzy. It wasn’t until the next day, upon the insistence of his father – former Lakers great Mychal Thompson – that he was examined and diagnosed with a concussion but then missed only one game.

These may be “anecdotes” but they indicate a trend where players, motivated to keep playing for a variety of reasons, are able to penetrate the supposed defenses intended to protect them.  A study of CFL football players published in the Clinical Journal of Sports Medicine in 2018 provided solid data rather than anecdotes. It found that nearly a quarter suffered symptoms of a concussion at least once during the 2015 season but fewer than 20% actually self-reported to team medical staff.

A Cleveland Clinic study looked at the financial consequences of concussions in the NFL from 2005 through 2015 and may explain that reluctance on the part of pros to self-report. Published in 2017 in the Clinical Journal of Sports Medicine, it determined that a concussion diagnosis cost a player $300K-$1.3M on his next contract. Furthermore, only 30% of those concussed were still playing three years later but 54% of the un-concussed remained in the game. At the five-year mark, the numbers were 12% and 37%, respectively. 

Only 30% of those concussed were still playing three years later, but 54% of the un-concussed remained in the game.

Jerry Glanville was right. “NFL” does mean “not for long.”

Which is about the time I am able to take seriously the NFL’s claim that the culture has changed and players are self-reporting. Some are but, clearly, many still are not and the higher the stakes the game and the more important the position they play – meaning quarterback, the more likely they are to try to “beat the concussion protocol.” Intentionally or not, those responsible for players’ health are also allowing them to do it by playing the re-labeling game or by ignoring those initial symptoms altogether.

When a player with symptoms denies having them to avoid entering the concussion protocol, he or she risks prolonged recovery and further injury. For teenagers, that includes the very rare but often fatal “Second Impact Syndrome,” where the brain swells uncontrollably. Medical professionals who preach one thing and do another – with cursory sideline checks — lose credibility with players and the public. Younger players who see this type of behavior, then seek to emulate it and attempt to “soldier on” in their own games. Added all together, when someone beats the concussion protocol, everybody loses.

John Doherty is a licensed physical therapist and athletic trainer. This column reflects solely his opinion. Reach him at jdoherty@powershealth.org. Follow him on X (formerly Twitter) @JDohertyATCPT.

You can download a printable concussion symptom checklist here: https://www.go4.io/resource/concussions-symptoms-checklist/

To read the NFL’s concussion protocol overview, click here.