Rugby has long been seen as the ultimate test of toughness, a sport in which grown men collide with full force, where courage is displayed in every tackle, and where pain is simply shrugged off as “just a knock”. Yet, the landscape of rugby is changing and what was once dismissed as “just a knock” has now become rugby’s deepest existential crisis. The concussion discussion is happening, and it is taking place at the intersection of medicine, law, governance and culture. Former players are suing, scientists are searching for answers, governing bodies are changing the rule book, and parents and fans are asking whether rugby, in its current form, is sustainable.
So, how did we get here? In 2023 evidence with a lawsuit started to emerge, attempting to correlate a group of rugby players’ concussion history and early onset dementia (among other cognitive dysfunctions). The lawsuit, involving former World Cup winners’ Steve Thompson, Mark Regan and 295 other former players, took on World Rugby regarding player safety, specifically the high concussion rates. And there was merit. The injury surveillance review published by World Rugby indicated a rate of one concussion every 1.8 matches in men’s elite rugby and one concussion every 2.7 matches in international men’s matches. With an average of 17-18 days lost due to the concussion on these respective levels. To put this into perspective, if we have two squads (23 each) totalling 46 players, they play each other twice — at least one out of the 46 would have sustained a concussion. This is if the medical team or referee correctly identifies the signs, the players are transparent about their symptoms and they end up leaving the field.
Physiology explained
A concussion is a type of mild traumatic brain injury that occurs when the brain experiences sudden acceleration-deceleration forces, or rotational forces, often caused by impact to the head or body. In rugby, this is most commonly seen during tackles, rucks and accidental collisions. The brain is suspended in cerebrospinal fluid inside the skull, and a rapid impact can cause it to move abruptly, sometimes leading to twisting or shearing of the delicate nerve fibres, particularly axons. The corpus callosum, which connects the two hemispheres of the brain, is especially vulnerable to these shearing forces, disrupting communication between the hemispheres.
Following the mechanical injury, a neurochemical cascade is triggered. Excess glutamate is released, causing widespread neuronal depolarisation and an imbalance of ions across neuronal membranes. Calcium enters cells in high amounts, sodium accumulates and potassium leaks out, leading to cellular stress. Energy-demanding processes are activated to restore balance, but blood flow may be temporarily reduced, creating an energy crisis within the brain. This combination of mechanical and biochemical stress results in the classic symptoms of concussion: headache, confusion, dizziness, nausea, and sometimes temporary loss of consciousness.
In rugby, repeated head impacts (even when no single concussion is diagnosed) can contribute to chronic encephalopathy trauma (CET), also referred to in the literature as chronic traumatic encephalopathy (CTE). CET involves long-term neurodegenerative changes in the brain, including the accumulation of abnormal tau proteins, neuronal loss and changes in brain structure. Over time, this damages axons, impairs synaptic function and disrupts normal brain signalling, increasing the risk of cognitive, emotional and behavioural changes over time. CET is also the main concern regarding brain injury in rugby.
What is being done?
The most obvious response from the authorities has been to change the laws of the game. If the head is where the damage happens, then reduce the likelihood of head contact. The principle is deceptively simple: lower the tackle height. In SA’s university game, experiments in 2018 and 2019 lowered the acceptable height to below the armpit. The results were sobering. There was no meaningful reduction in concussion incidence. Sceptics seized on this as proof that law tinkering was cosmetic. But at the professional level, with structured training and elite coaching, the effects have been more promising. In 2023, World Rugby introduced a global shift: the maximum tackle height would be below the sternum. Their research showed that tackles above the sternum carried four times the risk of causing a concussion. They also confirmed that tacklers, not ball carriers, bore twice the risk. In parallel, they introduced regulations for how ball carriers could protect themselves, making both sides of the collision accountable. Early community trials in Scotland indicated a significant reduction in head-on-head contact when tackles were made lower, suggesting that the professional game might, with time, adapt successfully.
Technology has also joined law as rugby’s new defence. Smart mouthguards, developed by companies such as Prevent Biometrics, are now part of elite monitoring. These devices measure head acceleration events in real time. In the 2023 Currie Cup and Super Rugby competitions, the data revealed that the greatest forces occurred in tackles and defensive rucks. The crocodile roll, long controversial, came under scrutiny and was banned in 2024. At the 2025 Women’s Rugby World Cup, the technology will take another leap. Mouthguards will not just transmit data, they will flash visibly when a player sustains a dangerous impact, forcing immediate medical attention. Still, law and technology cannot close all the gaps and longitudinal studies show that former elite players are more than twice as likely to suffer neurodegenerative diseases than the general population.
Biomarker research into proteins such as neurofilament light and tau suggests the possibility of early detection, perhaps even in midlife, before symptoms become debilitating. But the safe threshold (the number of head acceleration events a brain can sustain before long-term risk escalates) remains undefined.
The SA Rugby Union (Saru) has an excellent programme in place through the BokSmart Concussion programme, which aims to safeguard players at all levels of the sport, from grassroots to professional. At the heart of the programme are evidence-based protocols for identifying and managing concussions, ensuring that players are immediately removed from play if a head injury is suspected and are allowed to return only once medically cleared. The programme emphasises a graduated return to play (GRTP), a structured process with multiple stages designed to monitor recovery and prevent premature exposure to contact activities. GRTP is a structured, stepwise approach to ensure that athletes recover fully from a concussion before returning to full-contact sport. It recognises that the brain needs time to heal and that rushing back too soon can increase the risk of further injury or long-term damage.
Typically, GRTP consists of six stages, each lasting at least 24 hours, and athletes can progress to the next stage only if they remain symptom-free. The stages begin with complete rest, allowing the brain to recover from acute symptoms such as headaches, dizziness or cognitive difficulties. Once symptoms have resolved, athletes progress to light aerobic exercise, such as stationary cycling or gentle jogging, which increases heart rate without risking head impacts.
The third stage introduces sport-specific exercise that involves basic movement patterns relevant to the sport but still avoids contact. Next, noncontact training drills are added, incorporating more complex movement, co-ordination and cognitive challenges under supervision. The fifth stage involves full-contact practice, but only once the player has demonstrated full recovery at previous stages and has been cleared by a medical professional.
The final stage is returning to competitive play, in which the athlete resumes full matches with monitoring to ensure no recurrence of symptoms.
GRTP emphasises caution, gradual progression and close medical supervision, making it a cornerstone of modern concussion management and a critical part of programmes such as the BokSmart initiative.
Beyond these protocols and education, BokSmart is also committed to research and continuous improvement. By collecting data and collaborating with medical professionals, the programme monitors concussion trends and outcomes to refine its approach, keeping it aligned with the latest science. This combination of structured protocols, visible enforcement, education and research shows that SA rugby is taking concrete steps to protect players and address the long-term risks associated with head injuries.
The case for academia
If rugby is to solve the concussion issue, it cannot rely on governing bodies alone. Commercial incentives push them to keep the game flowing and audiences entertained, and so they need support. This support needs to come from the academic community. SA, with its rich rugby culture and strong medical research infrastructure, could lead here. The country already runs some of the world’s most intense contact competitions, its scientists are globally respected and it has the scale and rugby resources to build data sets that are meaningful in a global context too (it also has the BokSmart programme as the foundation). Imagine a system in which SA rugby becomes the global hub for head-impact science, in which every law change is tested, every technique analysed and every result shared.
The important aspect of this research need not be focused on concussions only, but on early detection of CTE. There’s no way to diagnose CTE in a living person. The only way healthcare providers can confirm CTE is by examining samples of a person’s brain with a microscope. But they can only do this during an autopsy after someone has died. This makes it difficult to address the problem before it’s too late.
A recent and powerful testimony of just how serious this situation is came from French rugby legend Sebastien Chabal. The 47-year-old made headlines worldwide earlier this year when he said in an interview on YouTube channel Legend: “I don’t remember a single second of a rugby match I played. I realised a long time ago that I had lost my memory of certain things. Part of my family life in Sale is gone. I don’t remember my daughter’s birth. A memory is accompanied by emotions, sensations, images, voices, words; I hardly have that any more. It’s not a blackout but in any case, as far as rugby is concerned, there’s not much left, almost nothing. As I have many other activities, you can’t remember everything. But maybe it’s somewhat correlated. I’m going to get some help.”
A frightening testimony to say the least, and it’s not an isolated one. The most recent incident to rock the rugby world and again brought the concussion discussion into sharp focus was the tragic loss of Shane Christie. Christie, a former Highlanders captain and Māori All Black, was just 39 when his life ended, presumably from suicide. His friends and teammates suggested that the weight of neurological decline had become unbearable. He had long suspected that he was suffering from CTE. What makes Christie’s story even more poignant is the clarity with which he understood the dangers: he spoke openly of the headaches, memory lapses and cognitive struggles that plagued him after retirement, and he resolved to donate his brain to science so researchers could better understand the toll rugby takes on the brain.
His case follows that of Billy Guyton, another New Zealand player and close friend of Christie, who took his own life in 2023 and was later confirmed as the first New Zealander diagnosed with CTE. Together, their stories reveal a pattern that is becoming impossible to ignore. The data is there: multiple concussions, insufficient management during their careers, long-term symptoms post-retirement and, ultimately, lives cut short.
In Christie’s own words, living with CTE felt like “a bruise in your head” that throbbed with every thought, movement or attempt at exercise. It is hard to imagine a clearer account of the invisible damage that players carry long after the stadium lights fade.
Breaking the ‘brave it’ mentality
Rugby has always been about bravery, but bravery without knowledge is recklessness. Concussion has become rugby’s defining test, not only of its laws and technologies but of its culture and governance. Lower tackles and flashing mouthguards are important steps, and passing the research ball to academia is critical, but the real test is whether rugby can face the problem head-on and accept that this is the biggest challenge facing rugby.
The concussion discussion, therefore, is not about softening the game, it is about safeguarding its future. It is about ensuring that gladiators such as Chabal can live not just legendary careers, but long, healthy lives beyond the final whistle. It’s also about ensuring parents don’t stop their children from playing the wonderful game because of concern over future brain injury.
It’s time we change the language: From “tough it out” to “take it seriously”, from “he’ll be fine” to “has he been assessed?” and from “just a knock” to “a possible brain injury”. Let’s protect the game by protecting the minds that play it.
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