Tua Tagovailoa’s return from concussion leaves uncertainty

Tua Tagovailoa is almost back his extended sideline due to concussion. Now let’s hold our collective breath.

The Miami Dolphinsstar quarterback, last seen curled up in a fencing position during an NFL game and then helped off the field after suffering at least his third concussion in two years, returned to practice this week and was fully cleared for Sunday’s game on Friday against the Arizona Cardinals.

Sure, after the latter, Tagovailoa became aware of the widespread debate and concerns about his life, future and career – with so many voices, including credible ones in the NFL universe, belonging to former players, urging him to leave. And he doesn’t want to hear about it. As he admits, he doesn’t pay attention to what others say about him.

“I appreciate your concern, I really do,” Tagovailoa said during a news conference this week when asked to respond to those sentiments. “I love this game and I love it to death. That’s all.”

What a chilling choice of words.

Tagovailoa, 26, undoubtedly hates being a walking poster about the risk of concussion. But for all the spark he can bring to Miami’s offense – a deep passing game that can strike at a moment’s notice with speedy receivers Tyreek Hill and Jaylen Waddle has been non-existent as the team has fallen to 2-4 in Tagovailoa’s absence – even more intrigue will come with the next big hit.

Or maybe not even much of a hit, considering how Tagovailoa last went down on September 12, when he ran into Buffalo Bills safety Damar Hamlin in a collision that was so intense by typical football standards.

He knows. It is an accepted truth in the medical community: the more concussions a person suffers, the more susceptible he or she is to further concussions. Tagovailoa has discussed the issue with experts he has consulted in recent weeks, but has not reached any conclusions regarding future risks.

However, you would think that for any player who has suffered multiple concussions, it must be sobering to consider whether they are at risk of developing chronic traumatic encephalopathy (CTE) or other long-term degenerative brain diseases.

“I think that’s the way the brain is – there’s just a gray area in this case,” Tagovailoa said. “If you know you’re going to get a long-term illness from it or you’re not going to get it, I just think there’s a lot of gray area with it. For me, this is what I love to do. This is what makes me happy and I’m going to do it, that’s all.

But still: How many concussions are too many? How does this affect risk?

“I don’t know if there’s a magic number, but from what I know the number that’s always mentioned is three or more over a finite period of time,” Dr. Julian Bailes, a renowned neurosurgeon at Endeavor Health in suburban Chicago, told USA TODAY Sports.

“So three or more in quick succession has always been a reason for pause for me. And take some time off to hopefully heal. But there is a second factor: susceptibility, a lowered threshold for concussion.

As Tagovailoa mentioned, the gray area in understanding his case includes his rebound from his setbacks in 2022; played the entire 2023 season (starting all 17 regular-season games and one postseason contest) without concussion. On the other hand, the image of him losing again at the beginning of the season immediately brought back memories of two seasons ago. After an extended window for rest and treatment – Tagovailoa maintains he was asymptomatic the day after his latest concussion and played as a substitute for five weeks – doctors have now cleared him to play.

The final step in Tagovailoa’s phased return-to-NFL protocol was to obtain approval from the Dolphins medical staff and an independent neurologist.

But given his history, for Tagovailoa it’s not just about whether he can play right now. Allen Sills, the NFL’s chief medical adviser, admits that even taking into account a player’s concussion history, there is no scientific formula to calculate concussion risk. Of course, variables that are specific to each case are taken into account – such as the number of concussions, the duration of symptoms, and the conditions in which the injury occurred.

“That’s the best guess then,” Sills told reporters during a conference call earlier this month. “An estimate of an individual’s future concussion risk.”

If a player obtains medical clearance, the NFL Players Association or the NFL will not recommend that the player retire. The final decision rests with the player – who, of course, may be influenced by family or advisors. Tagovailoa said he never considered quitting the sport after his latest loss. Although he talked to his family about his future after suffering a concussion in 2022, this time he did not turn to family members other than his wife Annah for any guidance.

As Sills put it, “patient autonomy” is an important element in the process of gathering information from physicians when assessing an athlete’s future risk. He said the league’s primary goal is to ensure return-to-play protocols for recovery from an acute injury are followed, without playing a role in a player’s decisions about his future.

But what if the “patient voice” is misled? Ill-informed? Naive? Egocentric? Disappointed? If someone has suffered a brain injury – and scientifically there is a gray area in determining the extent of the injury – perhaps that voice represents an inherent error in the equation.

Interestingly, Tagovailoa said the Dolphins’ decision to place him on injured reserve for at least four weeks was a matter of the team “protecting itself from me” because the Dolphins realized he would want to get back into the lineup quickly as a player. Dolphins coach Mike McDaniel, however, said the decision was based on a medical opinion that ordered the quarterback to extend his window for rest and recovery.

In any case, there is no doubt that Tagovailoa’s “patient voice” remains very determined. Or even defiantly.

Someone asked a hypothetical question about how he might respond to doctors’ advice to take an extended break from work if he suffered another concussion.

“Man, I think it depends on how the person feels,” Tagovailoa said. “If you feel like you can go, you can go.”

What was striking was that he was so brazen in considering the issue in such terms.

“I just think it only became possible because of what happened two years ago in my sport,” Tagovailoa added. “I hate that this happened, but we don’t look at boxers the same way. We don’t look at hockey players the same way, but I think it’s becoming a bigger problem in the league because of what’s happened on such a scale.

When the NFL revised its protocols after Tagovailoa’s cases in 2022, it was in response to the fact that the quarterback was not diagnosed with a concussion after being ejected from the game against Buffalo (it was declared a neck injury) and only suffered a concussion four days later, when his head bounced off the turf in Cincinnati. The NFLPA fired the independent neurotrauma consultant who examined Tagovailoa after the initial injury, which ultimately set off a chain of events that led to revised protocols.

Still, Tagovailoa is fooling himself if he thinks that the analysis of his case is not part of the bigger picture. The focus on concussions has increased years before the quarterback entered the league in 2020.

Bailes was at the forefront of research two decades ago, working with Dr. Bennet Omalu, who discovered CTE, and reporting on his NFL team’s results. He worries about Tagovailoa, partly because of the unknown threats. As Bailes noted, the big breakthrough in concussion research will come when doctors can diagnose CTE and other degenerative brain diseases in living patients.

“I give him my best wishes; I hope that happens,” said Bailes, who also serves on the advisory board of the Chuck Noll Foundation for Brain Injury Research. I hope he can play as safely as possible, maybe slide more often instead of running and sticking his head into the pitch trying to get more distance.

Tagovailoa admits he needs to make better decisions, maintaining he can play smarter, even if his tendency to run recklessly has been part of his advantage since high school. He will not wear the Ranger Cap, a layer of foam padding attached to a standard helmet to reduce the shock absorbed during hits. Instead, he’s wearing the top-rated “Guardian Cap compatible” quarterback helmet, the VICIS ZERO2 MATRIX ID QB, which the league says is as safe or safer than wearing a Guardian Cap helmet.

Tagovailoa also expressed his desire to remain more available to his team, which he coincidentally signed with in August a massive four-year, $212.4 million contract extension. According to Spotrac.com, his contract included a guarantee of $167.171 million, so his decision to play does not appear to be based on money.

Still, when considering the long-term risks, Tagovailoa sounds like a man with a bit of a blind spot.

“How much risk are we taking when we get up in the morning to go to work?” he said. “Get in a car accident, I don’t know. I think everything comes with risk… Every time we put on a suit, we all run the risk of getting injured, whether it’s a concussion, a broken bone, whatever. If you get out of bed the wrong way, you could risk spraining your ankle. Everything has a risk and I’m willing to take that risk.”

However, some courses cost much more.

This story has been updated with new information.