Terms such as ‘taking a knock’ obscure the devastating effects of brain injuries suffered on the pitch. The sport’s culture needs to change
It looks choreographed when you see it slowed down, the way the bodies intertwine; limbs tucked around limbs, bones colliding with bone, flesh pressed against flesh, until they become one mound of man moving in slow motion until, as if shocked by electricity, the players jolt back into play. All but one.
It’s mid-March, England are playing Ireland in the Six Nations. Tighthead prop Kyle Sinckler looks like he is knocked out, if only for a few seconds, lying prone on the ground following an impact. The collision is heavy but quick. He is taken off the field of play and does not return for the second half of the match after failing a head injury assessment.
It’s not the first time.
In 2019, a headline for the UK Independent read: “Kyle Sinckler has no recollection of England’s Rugby World Cup defeat due to concussion”. The article detailed how the England prop had been knocked unconscious in the opening minutes of the final. It had taken him a month to “get over” missing the game due to an “accidental collision”.
It was reported that he was out before he had even hit the ground, having taken an elbow to the head. He was left motionless with his arms straight in the air in what is known as the “fencing response”, which is when a person experiences an impact that is strong enough to cause a traumatic brain injury. This position, usually with the arms extended or flexed in the air, can last up to several seconds after a collision and is a strong indicator that a concussion has occurred. Sinckler was attended to by medics and came round after two or three minutes of care. He was removed from the pitch.
The attitude that has often prevailed is that injury is just the nature of the game.
But fast forward to 2022, following the England vs Ireland game, there is an outcry on social media when Sinckler is named on the bench for England’s match against France days after the captured collision.
I watch it play out in 280-character tirades on Twitter, which is a charged and provocative place at the best of times, something I have become accustomed to over the last six years as I have researched brain injury within sport.
In one corner, there are those staunch in their view that rugby will be ruined or “made soft” by too many rules. In the other are people like former England international Kyran Bracken who posted a video clip of the moment with the words: “Kyle [Sinckler] is unconscious. Any boxer would be banned from action for a long time. Rugby knows better? Play the next week! What the f***”.
The Sinckler incident happened after rugby’s head injury protocols came under fire once again following an England vs Wales match when two Welsh players, Tomas Francis and Owen Watkin, collided with England’s Charlie Ewels. Francis was clearly dazed and displaying ataxia, which is the loss of muscle control or co-ordination of voluntary movements following the collision. He could be seen stumbling, holding his head, and he fell while trying to find his feet. All are clear indications of a concussion and any player with these symptoms should be immediately removed from the game, not to return, according to World Rugby’s protocols.
But Francis played on, although he was substituted in the second half. The lobby group Progressive Rugby, whom I have come to know over the last year, described the protocols as not fit for purpose after Francis was declared fit to face France following his injury. Professor John Fairclough, a former Welsh rugby union team doctor, called the decision to reinstate him just 13 days later a “grave mistake”. In his expert view, “it is beyond any doubt that Tomas Francis had suffered a brain injury”. He added: “As someone who has taken an oath to protect life, I can’t, in all good conscience, fail to highlight that I think him playing the next game puts him at unnecessary risk of serious harm, whether that be now or in the future.”
That future can be fragile. Nobody knows this more than former internationals Alix Popham and 2003 World Cup-winning England hooker Steve Thompson, who are part of a litigation against rugby authorities that was announced in December 2020. Both claim the sport has left them with permanent brain damage along with a diagnosis of early onset dementia and tentative diagnosis of chronic traumatic encephalopathy (CTE), a progressive neurodegenerative syndrome caused by single, episodic or repetitive blunt force impacts to the head.
These blows can be defined as either concussive or subconcussive blows. Concussive blows are the hits to the head that typically cause immediate symptoms: dizziness or black-out. The impact can cause the brain to suddenly shake violently, or bounce around or twist inside the skull, creating chemical changes within it and sometimes stretching and damaging brain cells to the point where they no longer work properly.
A subconcussive blow is defined as a head impact that does not result in a clinical concussion, meaning that there are no immediate symptoms. And yet subconcussive blows are believed to have adverse long-term effects in some individuals, particularly if there are repetitive occurrences. These impacts in sport could include a collision of helmets on the American football field, a fist to the face in boxing, the heading of a ball in soccer or a tackle in rugby.
We have come to think of the brain as powerful, similar to the smartphones we all have, as if neurons are made of sturdy reinforced glass, supposedly unbreakable, engineered to protect against damage and withstand trauma because of its casing within the skull. But the brain tissue itself is extremely soft and extremely delicate.
Imagine an egg. The shell is the skull, the yolk in the middle is the brain. What happens to the yolk when you shake that egg lightly? Now, violently? What happens when you do that over and over again?
From the gladiator arena to the boxing ring, athletes have always forfeited their bodies for sport. Often in front of a live audience for money, sponsorship, adrenaline, glory or, ideally, all of the above. But without correct protocols, severe and irreversible damage is being done and what is being forfeited isn’t just a body, but a mind and ultimately a person’s future.
The early stages of CTE can include difficulty thinking and concentrating (cognitive impairment), as well as headaches. Later stage symptoms can include depression or mood swings, explosivity and short-term memory loss, executive dysfunction, language difficulties, impulsivity and the potential for suicide. Sufferers can develop severe memory loss with dementia. There are still no treatments to stop or slow the diseases that cause dementia.
Two of the most at-risk groups prone to neurodegenerative disease are athletes and soldiers. On the surface, they seem worlds apart but there are many comparisons to be drawn between them. Both enable male camaraderie, bonding and friendship, a heady mix of machismo and brotherhood. Both are aspirational, both follow a set of rules, both require an ability to keep going under severe stress, their successes dictated by a willingness to sacrifice personal glory for the good of the team. But being brave does not protect you from traumatic brain injury, and part of the problem is the culture of sport — and, more to the point, masculinity — that is not only putting professional players in danger but also trickling down to grassroots and schools.
Peter Robinson’s 14-year-old son Benjamin died from second impact syndrome, having sustained multiple brain injuries playing schoolboy rugby in Carrickfergus, Co Antrim, in 2011. He was kept on the pitch despite displaying visible symptoms of his injuries and alerting his mother and team-mates that he didn’t feel right. The referee of the match had said that he thought some of the players were “prima donnas and drama queens” when it came to injury. The decision to keep Benjamin on ultimately meant that a mother and father had to bury their son.
“The culture of sport eats protocol for breakfast,” Peter Robinson told me. “So, in other words, the red mist of the game, that attitude of win at all costs, you know, play injured and all of that. That idea of just ‘get up and get on with it, stop moaning’. That culture still kicks in.”
Language can be an important factor in our understanding and awareness. It determines how seriously brain injury is taken by athletes, the public and those governing the sport itself.
Scientific vocabulary can make the information feel exclusionary. Certainly not on purpose, but by their very nature, the complexity of the words makes them tricky to pronounce, let alone understand. I still stumble on ‘chronic traumatic encephalopathy’, despite having read it and said it countless times over the last six years. It’s not something that slides comfortably off the tongue.
Language can also diminish the severity of an incident with expressions like “taken a knock”, “mild concussion” or, in the case of Sinckler, “accidental collision”. Diminishing phrases like these are dangerous not only to other professionals but also to aspiring amateur players. Nobody wants to appear weak in sport, especially one where defiance and strength are the key components.
We are taught as children that when we get knocked down, we pick ourselves up, we dust ourselves off and we get back out there — both in sport and in life — and sometimes that involves making a sacrifice. And isn’t it a fact universally acknowledged that the payoff in overcoming challenges is almost always worth the pain we’ve been through? That we are stimulated and thrive from our handling of hardship? That without great sacrifice there is no great achievement? That’s why the clichés exist after all; “what doesn’t kill you makes you stronger” — except when it does kill you. And that is the sobering truth of the reality faced by those living with the consequences of concussion and brain injury.
This article was first published in April 2022.
Like Sinckler, Steve Thompson has no recollection of the World Cup final he took part in. He knows what lies ahead and would tell me that there is a guilt that comes with his CTE diagnosis, for his family, for his work, but family mainly. He tells me he has often thought it would be easier if he wasn’t here, though he isn’t emotional about it when he says it. It feels like he has accepted his fate. Perhaps it’s just in his nature — another hit taken, ready to walk it off.
There are those that have argued, and will continue to argue, that injury is a risk that comes with the territory which ultimately makes rugby the game it is. But a love for the game has to include care for the wellbeing of its players, otherwise all that is left is the vicarious thrill of watching people get hurt.
‘A Delicate Game: Brain Injury, Sport and Sacrifice’ by Hana Walker-Brown is published by Hodder Studio