Whether a player should return to sport after sustaining multiple concussions has been the focus of much media interest in recent months. When a player does end up being cleared to play it can be met with some surprise and concern. People often ask us ‘how many concussions is too many?’ The problem is, the answer is not straightforward.

When a diagnosis of concussion has been made, regardless of the number of concussions the patient has sustained, we need to try to determine when the player’s brain has returned to ‘normal’. One gross measure of this is whether the athlete is asymptomatic. In most cases of concussion, this is used as the primary measure used to help assess a player’s recovery. In these cases when a patient is deemed to be asymptomatic, they are generally progressed through a graded exercise programme that culminates with their return to play. While becoming symptom-free is the most commonly used measure of recovery we do have a number of different clinical and neuropsychological tools that we can use to measure and monitor the player’s progress (with possible use of functional MRI imaging in the future). These more sophisticated tests are often used to help with the assessment of players who have multiple concussions. In these patient’s it is quite likely that the symptoms resolve before the brain has returned to ‘normal’. As a result, the return to play process is generally more conservative.

So ‘how many concussions is too many?’ Unfortunately, when it comes to this the literature is of minimal help. Certainly, there are some signs that are concerning and should prompt a discussion about whether ongoing contact sports participation is wise or whether a break from sport is needed. For me the most critical indicators that help with assessing this risk are:

  1. Concussions are happening more frequently
  2. Reducing force producing the same clinical effect (concussions are happening with less impact)
  3. Increasing time to recovery with each concussion
  4. Increasing severity of symptoms
  5. Importance and stage of higher risk sports in the patients longer term plans

If I were seeing these trends I would be more conservative with the return to play advice I offer. I would also involve a number of other specialists to provide advice about brain functioning and consider whether imaging might be needed, obtaining a formal neuropsychology assessment and involving the player’s family in the decision making progress. Ultimately it is our job to make the best possible clinical assessment, educate the player (and their family) about the risks of their ongoing participation and allow them to make an informed decision about how to proceed.  

Ultimately, however, patients, parents, friends and supporters should be confident that we are not making these decisions lightly. We see the negative impact that concussion can have daily always err on the side of caution.


Axis Concussion Clinic

Have you, or do you know someone who has, suffered a concussion recently? It’s better to play it safe and have your injury assessed by an experienced professional before you return to play, than risk further injury. We run Auckland’s most comprehensive sports concussion service.

  • Fully funded by ACC, so consultations are free to you.
  • Staffed by medical experts with vast experience in rugby and sports concussion.
  • Aim to see each patient within a week of their injury.
  • No referral needed when seen within 10 days of injury.

Learn more here or call 09 521 9811 to make an appointment

By Dr Stephen Kara on