Tagovailoa Should Take a Permanent Timeout

On September 12, 2024, during a Week 2 matchup against the Buffalo Bills, “[t]wo of the most fragile things in the NFL collided[:] Damar Hamlin’s [Buffalo Bills] chest and Tua Tagovailoa’s [Miami Dolphins] head.”[1] This collision sent shockwaves through the sports world for two reasons.

First, it was Hamlin’s chest that made contact with Tagovailoa. During the 2022 NFL season, Hamlin “notably died on the field before being [later] revived [at a hospital,]” after tackling wide receiver Tee Higgins of the Cincinnati Bengals.[2] (emphasis added). During the play, Hamlin had wrapped his arms around Higgins’s shoulders and helmet to bring him to the ground, but Higgins’s right shoulder awkwardly collided into Hamlin’s chest.[3] While many commentators and viewers perceived the tackle as “routine,” Hamlin attempted to stand up, but ultimately passed out and fell backwards.[4] Hamlin was then transported to the University of Cincinnati Medical Center where he suffered cardiac arrest at 1:48am local time.[5] Hamlin was eventually revived and later confirmed that he suffered an episode of “commotio cordis,” an extremely rare condition in which “cardiac rhythm is disrupted by a blow to the chest during a specific 40-millisecond span in the heart’s electrical cycle.”[6]

Second, Tagovailoa has an extensive history of concussions. Not including the concussion Tagovailoa suffered on September 12^th, 2024, the Dolphin’s star quarterback has suffered a total of four known concussions in the last five years. Tagovailoa’s first known concussion occurred “while he was still [the University of] Alabama’s starting quarterback. In a game against Mississippi State during the 2019 season, Tagovailoa suffered a concussion and broken nose when taking a sack in addition to breaking and dislocating his hip.”[7] Tagovailoa’s second known concussion occurred in Week 3 of the 2022 NFL season when “the back of [his] head hit the ground hard after a hit by Matt Milano [of the Buffalo Bills].”[8] Tagovailoa’s third known concussion occurred four days after the 2022 Week 3 game against the Bills, when he “was slammed hard to the turf [by a Cincinnati Bengals defender] and . . . lay[ed] there afterward with his fingers seemingly frozen in the air for several seconds.”[9] Tagovailoa’s fourth known concussion occurred on Christmas day of the 2022 NFL season when he “hit the back of his head against the ground [after being tackled] . . . in the second quarter against [a Green Bay] . . . Packers [defender].”[10] Thus, it has come as no surprise to members of the sports world that many are now calling for Tagovailoa to hang up the helmet once and for all.

But before moving forward with analyzing why Tagovailoa should retire, it is important to review the NFL’s protocol regarding concussions and how a player would return to the game. According to the NFL’s “Concussion Game Day Checklist,” when a player receives an impact to the head, the player goes into “Concussion Protocol” if:

1. The player exhibits or reports symptoms or signs suggestive of a concussion or stinger (a nerve pinch injury); or
2. The team Athletic Trainer, booth ATC spotter, team Physician, NFL game official, coach, teammate, sideline Unaffiliated Neurotrauma Consultant (UNC) or booth UNC initiates the protocol; or
3. A third UNC, who monitors the broadcast video and audio feeds of each game from the spotters’ booth, notifies on-field UNCs of possible head, neck or spine injuries; or
4. The player exhibits defined impact seizure and fencing responses as independent signs of potential loss of consciousness (i.e., listed as “No-Go” criteria under the current Protocol). Players who display either of these signs at any time shall be removed from play and may not return to the game; or
5. If a player is demonstrating ataxia (i.e., abnormality of balance/stability, motor coordination, or dysfunctional speech). A team physician, in consultation with the sideline UNC, will then determine if the instability is neurologically caused, and if the player will be designated a “No-Go” and be unable to return to play.[11]

Moreover, “[o]fficials, teammates, and coaching staffs have been instructed to take an injured player directly to a member of the medical team for appropriate evaluation, including a concussion assessment, if warranted.”[12] Lastly, “all players who undergo any concussion evaluation on game day, are to have a follow-up evaluation conducted the following day by a member of the medical staff.”[13]

After a player is diagnosed with a concussion under the “Concussion Protocol,” in order for that player to return to play in an NFL practice/game, the following five-step “Return-to-Participation Protocol” must be completed:[14]

1. Symptom Limited Activity: The player is prescribed rest, limiting or, if necessary, avoiding activities (both physical and cognitive) which increase or aggravate symptoms. Under athletic training staff supervision, limited stretching and balance training can be introduced, progressing to light aerobic exercise, all as tolerated.
2. Aerobic Exercise: Under direct oversight of the team’s medical staff, the player should begin graduated cardiovascular exercise and may also engage in dynamic stretching and balance training. Neurocognitive and balance testing can be administered after completion of Phase Two and the results should be interpreted as back to baseline.
3. Football Specific Exercise: The player continues with supervised cardiovascular exercises that are increased and may mimic sport-specific activities, and supervised strength training is introduced. The player is allowed to practice with the team in sport-specific exercise for 30 minutes or less with ongoing and careful monitoring.
4. Club-Based Non-Contact Training Drills: The player continues cardiovascular, strength and balance training, team-based sports-specific exercise, and participates in non-contact football activities (e.g., throwing, catching, running, and other position-specific activities). Neurocognitive and balance testing should be completed no later than the end of Phase Four with the results interpreted as back to baseline.
5. Football Activity/Clearance: Upon clearance by the Club physician for full football activity involving contact, the player must be examined by the Independent Neurological Consultant (INC) assigned to his Club. If the INC concurs with the Club physician that the player’s concussion has resolved, he may participate in his Club’s next practice or game.

Hence, even though the NFL’s “Concussion Protocol” and “Return-To-Participation Protocol” are detailed and expansive, once the player has been cleared, it is up to them to decide if they truly want to return to the game. In other words, the NFL cannot prevent a cleared player from continuing to play despite a history of concussions.

In the case at hand, Tagovailoa, who has been placed on the injured reserved with no timetable to return, has said that he has “no plans to retire after suffering his latest concussion . . . .”[15] (emphasis added). However, the science shows that Tagovailoa should retire and prioritize his health over his love for the game. According to a 2008 study conducted by neuropathologist Ann McKee, MD, from the Bedford VA Medical Center and CTE Center at Boston University Medical Center, evidence of “neurodegeneration” was found after “studying the brains of 12 former football players over a 2-year period . . . .”[16]

Specifically, Dr. McKee found that “[e]ach brain showed apparent signs of repeated trauma, the only cause of a condition known as CTE. CTE has been found to lead to depression, loss of judgment, inability to control impulse, rages, and memory loss, and can ultimately result in dementia. What’s worse, these symptoms are not immediately apparent and can emerge up to 10 years after one stops playing football.”[17] (emphasis added). Furthermore, a 2003 prospective study found that “athletes with a history of three or more previous concussions had three times the risk of getting a subsequent concussion than those with no previous history.”[18]

Thus, while it is quite possible that the damage has already been done, and that Tagovailoa may unfortunately experience some of the horrible side effects of his multiple concussions years down the line, he currently has the opportunity to mitigate his chances by choosing to retire now. If he continues to play, then he remains extremely likely to receive another concussion, which would make it more likely that he could develop any number of the horrible side effects found in Dr. McKee’s study. Finally, there would be no shame in Tagovailoa choosing to retire in order to prioritize his health and well-being. In fact, the Miami star would likely be praised for bringing attention to an area of the NFL that still needs much improvement.

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[1] Postrado, Jay, Tua Tagovailoa’s NFL Future: Should Concussion Concerns Force Early Retirement?, Fan Arch (September 16, 2024) https://fanarch.com/blogs/nfl/tua-tagovailoas-nfl-future-should-concussion-concerns-force-early-retirement?srsltid=AfmBOoqxKBnXX2XJtXek8X30pJ8Sslr0PEWS865MBepxVOJ7Rq4jmg-c.

[2] Id.; Nation, Bills’ Damar Hamlin in critical condition after collapse on field, PBS (January 3, 2023) https://www.pbs.org/newshour/nation/bills-damar-hamlin-in-critical-condition-after-collapse-on-field.

[3] Nation, Bills’ Damar Hamlin in critical condition after collapse on field, PBS (January 3, 2023) https://www.pbs.org/newshour/nation/bills-damar-hamlin-in-critical-condition-after-collapse-on-field.

[4] Farmer, Sam, Bills’ Damar Hamlin in critical condition after cardiac arrest on field, ‘MNF’ halted, Los Angeles Times (January 2, 2023) https://www.latimes.com/sports/story/2023-01-02/bills-safety-damar-hamlin-administered-cpr-after-on-field-hit-vs-bengals.

[5] Buffalo Bills X (formally Twitter) account post from January 3, 2023: https://x.com/BuffaloBills/status/1610166228559052801.

[6] Parrino, Matt, Bills’ Damar Hamlin suffered Commotio Cordis after collision, says heart is still in the game, Syracuse.com (April 18, 2023) https://www.syracuse.com/buffalo-bills/2023/04/bills-damar-hamlin-suffered-commotio-cordis-after-collision-says-heart-is-still-in-the-game.html.

[7] McKessy, Jack, Tua Tagovailoa ‘has no plans to retire’ from NFL after latest concussion, per report, USA Today (September 16, 2024) https://www.usatoday.com/story/sports/nfl/dolphins/2024/09/15/tua-tagovailoa-not-retiring-nfl-concussion/75236661007/.

[8] Rorabaugh, Dan, Tua Tagovailoa injury update: How is he after hit, concussion? Will he retire?, USA Today Network – Florida (September 13, 2024) https://www.palmbeachpost.com/story/sports/nfl/dolphins/2024/09/13/tua-tagovailoa-concussion-injury-updates/75206183007/.

[9] Id.

[10] Thames, Alanis, McDaniel: Tua suffered concussion in loss to Packers, Associated Press (December 28, 2022) https://apnews.com/article/sports-health-tua-tagovailoa-head-injuries-nfl-football-c2f033614d09cb691473809c7b86c0d2.

[11] NFL Concussion Protocol & Return-to-Participation Protocol: Overview (October 2022) https://www.nfl.com/playerhealthandsafety/health-and-wellness/player-care/concussion-protocol-return-to-participation-protocol.

[12] Id.

[13] Id.

[14] Id.

[15] Gonzales, Christian, Dolphins QB Tua Tagovailoa has no plans to retire after suffering latest concussion, NFL (September 15, 2024) https://www.nfl.com/news/dolphins-qb-tua-tagovailoa-has-no-plans-to-retire-after-suffering-latest-concussion.

[16] https://med.nyu.edu/departments-institutes/population-health/divisions-sections-centers/medical-ethics/education/high-school-bioethics-project/learning-scenarios/the-nfl-brain-injury; see also, Schwarz, Alan, 12 Athletes Leaving Brains to Concussion Study, The New York Times (September 23, 2008) https://www.nytimes.com/2008/09/24/sports/football/24concussions.html.

[17] Id; see also NFL-LONG Study: Improving life beyond the game, Boston Children’s Hospital (2023) https://www.childrenshospital.org/nfl-long-study/findings.

[18] Graham R, Rivara FP, Ford MA, et al., editors, Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families, Institute of Medicine; National Research Council (February 4, 2014) https://www.ncbi.nlm.nih.gov/books/NBK185336/#:~:text=The%20researchers%20reported%20that%20athletes,those%20with%20no%20previous%20history; see also Bruce, H.J., et al., American Football Play and Parkinson Disease Among Men, National Library of Medicine (2023) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10422187/ (In addition to the other horrible side effects of CTE, this study notes that multiple concussions and CTE injuries lead to an increase in Parkinson Disease among men).