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Concussions in Rugby

Helping to kick and tackle the injury out of the game that

South Africa Loves so much Part 1

Are you a school learner who thinks that a lot of players seem to get hurt or walk off the field injured during rugby matches or training? Are you a parent watching your child playing rugby, scared that they are going to get injured? There is nothing wrong with that, this means you are aware of the risks at hand, with Concussions being a very common one. These can be very serious and unfortunately as we have all been reminded lately can be life threatening.

Stats show that “In South Africa, rugby has the highest incidence of concussion amongst collision team sports. 10 to 15% of high school rugby players will suffer a concussion in any season. Up to 50% of high school rugby players would have suffered a concussion in their high school playing careers” – Sports Concussion SA. This stat sounds scary which is understandable because if they are not identified and managed correctly, concussions can become serious.

The good news is concussions can definitely be “less scary” if we have a very clear understanding of the condition and how to act when they occur, and the injury can definitely be prevented.

The series of three article will help give you a better understanding and clear up that “fogginess” that is common when it comes to comprehensively understanding this condition. They will discuss the injury, how to identify a possible injury, how to manage it and how to prevent it, including how physiotherapists play a role in all of this.

The injury discussed:

Concussions are injuries that include trauma to the brain. They are classified and categorised under the term Mild Traumatic brain injuries. The word “mild” does the seriousness of the injury a disservice. Although classified as mild, concussions are serious no matter how mild or severe. When discussing it in the sports environment concussions are defined as “a mild traumatic brain injury as a result of bio-mechanical forces” (McCroy , et al., 2017) Concussions normally occur when there is a direct blow to the head, however it can also be caused by a blow to any part of the body that results in a whiplash mechanism in the neck (Romeu-Mejia, et al., 2019). During these two scenarios, the head jolts and there is a change in direction. This change of direction results in the brain moving in the skull and contacting the bony surface, commonly it comes back and makes contact with the opposite side of the skull as well, a phenomenon known as Coup-Contrecoup. During this incident there is an acceleration-deceleration scenario that occurs within the brain tissue. There are two main types of tissue in the brain, white matter, and grey matter. These two tissues accelerate and decelerate at different rates, and this creates a shearing force between the two. This results in stretching and tearing of nerve fibres, triggering inflammatory responses, and resulting in an energy crisis in the brain (Romeu-Mejia, et al., 2019). How to identify the injury: Concussions can be easily missed, and the signs and symptoms of concussions can arise straight away or only days later. These symptoms can include headache, nausea, dizziness, loss of consciousness, double vision, blurred vision, foggy sensation, confusion, feeling fatigued, and memory challenges, to name a few. These symptoms can overlap with symptoms of other conditions, and they need to be identified as soon as possible. Research has shown that the most common symptoms that arise with a sports related concussion are headache, feeling foggy/slowed down, fatigued, dizziness and feeling pressure in the head (van Tonder, et al., 2021).

“Boksmart” is a South African rugby organisation and safety initiative, which does extensive coverage on rugby and its medical concerns, focuses a lot on concussion and emphasise that coaches, teammates, parents, and the medical team need to be very aware of the possibility of concussions in rugby. If a player goes down with what seems to be a head injury because of a blow to the head, a heavy tackle or landing on their head/neck for example, a concussion needs to be assessed for. The medical team or most suitable person needs to get to the player and secure the head and neck area (Boksmart , 2019).

Symptoms of concussion needs to be observed and the player, if possible, needs to feedback on what they are feeling. If any of the previous mentioned symptoms such as headache, sense of fogginess, dazed look etc are present, concussion needs to be suspected. If the player presents with or complains of any of the following, they need to be “red flagged” and taken off the field immediately and taken to the hospital for assessment and neuro imaging. Red flags include severe neck pain, deteriorating consciousness, seizures, constant vomiting, increasing confusion, slurred speech, numbness/tingling in the limbs and ongoing double vision (World Rugby, 2021)

Recognise and Remove:

Maddocks Questions are a set of questions that have been created and are used by Boksmart and World Rugby to help identify possible concussions. The individual that is assessing the players asks the injured player these questions. The questions are: “What venue are we at today”, “Who scored last”, “Who are we playing”, “What Half is it”, “Who did you play in the last game”, “Did you win the last game”. The player should be able to answer these questions correctly with no hesitation. The assessor needs to go according to the idea of “Recognise and Remove” (as suggested by Boksmart), which is if there is one symptom present and the player hesitates or answers one question incorrectly, that is enough to take them off the field. If there are no obvious symptoms present and the player can answer the questions correctly, but the assessor is still suspecting a concussion then the player should come off the field. BokSmart suggests “When in doubt, sit them out”.

In the follow-up articles injury treatment and prevention will be covered. Debbie Cameron Physiotherapy is passionate about school sports and specifically in the prevention of injury. To book an appointment, contact Michelle or Chantal on 031 765 8898.


Boksmart , 2019. Referees/Coach's On the Field Concussion Guideline. [Online] Available at: [Accessed April 2022].

Childrens Hospital of Philadelphia , 2022. Return to Learn After a Concussion. [Online] Available at: [Accessed April 2022].

Dekosky, S., Ikonomovic, M. & Gandy, S., 2010. Traumatic Brain Injury — Football, Warfare, and Long-Term Effects. Minnesota Medicine, 93(12), pp. 46-47.

Hislop, M. et al., 2017. Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial. Brittish Journal of Sprts Medicine, 51(15).

Hrysomallis, C., 2016. Neck Muscular Strength, Training, Performance and Sport Injury Risk: A Review. Sports Medicine, 46(8).

Ledreux, A. et al., 2020. Assessment of Long-Term Effects of Sports-Related Concussions: Biological Mechanisms and Exosomal Biomarkers. Frontiers in Neuroscience, Volume 14.

McCroy , P. et al., 2017. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Brittish Journal of Sport medicine, 51(11).

Romeu-Mejia, R., Giza, C. C., Giza, C. C. & Goldman, J., 2019. Concussion Pathophysiology and Injury Biomechanics. Current Reviews in Musculoskeletal Medicine, , 12(2), pp. 105-116.

van Tonder, R. et al., 2021. Presenting features of female collegiate sports-related concussion in South Africa: a descriptive analysis. South African Journal of Sports Medicine, 33(1).

World Rugby, 2019. INNOVATIVE RUGBY WORLD CUP 2019 DRIVES BEST-EVER PLAYER WELFARE OUTCOMES. [Online] Available at: [Accessed April 2022].

World Rugby, 2021. Concussion Guidelines. [Online] Available at: [Accessed April 2022].

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