Head Impact Assessments (HIAs) have become a familiar part of elite rugby matches. When a player takes a significant knock to the head, they are removed from the pitch for evaluation. But what exactly does this process involve — and how does it compare with medical and scientific guidance on concussion?

Understanding the difference between grassroots and elite protocols is essential when discussing player safety.

World Rugby’s Concussion Guidelines

World Rugby introduced the HIA pitch-side process in 2015. The organisation states that its Player Welfare strategy is to put the player first and rely on an evidence-based approach for all decisions.

For non-elite players — including children — World Rugby’s published guidelines state:

• All concussions are serious.
• Head injuries can be fatal.
• Children are more susceptible to concussion.
• Young players may take longer to recover.
• Two or more concussions within 12 months increase the risk of further brain injury.
• Adults and children should not return to play for 21 days after a concussion.

They also advise that players with multiple concussions or prolonged recovery should be managed by healthcare professionals experienced in sports-related concussion and should not return to rugby until medically cleared.

These recommendations broadly align with NHS and UK Government grassroots guidance. However, the situation differs in elite rugby.

What Is a Head Impact Assessment (HIA)?

The HIA process is used in elite matches to assess suspected concussion.

HIA 1 – Pitch-Side Assessment

• A player is removed from the field for up to 10 minutes. During this time:
• Memory is tested
• Balance is assessed
• Observable concussion signs are reviewed
• If the player fails, they are permanently removed from the match.
• If they pass, they return to play.

The Concern: Timing of Symptoms

Scientific research consistently shows that concussion symptoms may not appear immediately. Symptoms can evolve over:

• 24 hours
• 48 hours
• Several days

This creates a potential concern: a 10-minute assessment may not always capture delayed or subtle symptoms.

World Rugby’s own guidelines state that any player showing clear signs of concussion should be removed permanently. However, high-profile incidents — such as the 2022 Six Nations match between England and Wales involving Tomas Francis — have raised public questions about whether observable symptoms are always acted upon consistently.

Following HIA 1:

• A player must undergo further medical evaluation within 3 hours
• They are reassessed again within 36–48 hours

This layered system aims to monitor symptom progression. However, if a player passes the initial HIA and continues playing, they remain exposed to further head impacts during that match — at a time when the brain may already be vulnerable.

Research indicates that sustaining another concussion before full recovery increases the risk of:

• More severe symptoms
• Prolonged recovery
• Rare but catastrophic complications
• Return-to-Play Timelines in Elite Rugby

Another key difference concerns recovery time.

While grassroots players are advised to follow a minimum 21-day return-to-play protocol, elite players have historically been permitted:

• A return after 7 days (standard risk)
• Around 12 days for higher-risk cases(under advanced medical supervision)

World Rugby states that earlier return is only allowed when managed by an advanced concussion care team, including:

• Doctors experienced in concussion management
• Access to neuroimaging
• Multidisciplinary neurological expertise

While elite environments have greater medical oversight, critics argue that shorter return timelines contradict broader medical caution around brain recovery.

The human brain does not distinguish between grassroots and elite sport. A concussion remains a brain injury — regardless of the level of competition.

Elite Rugby: Higher Risk Environment?

An argument can be made that elite rugby may involve greater force exposure due to:

• Faster gameplay
• Larger, stronger athletes
• Higher collision intensity
• Increased match frequency
• Full-contact training throughout the week

These factors may increase cumulative sub-concussive exposure compared to grassroots levels.

If risk exposure is potentially higher, some question whether recovery standards should be stricter — rather than shorter — in elite sport.

Where Do RFU & World Rugby Stand?

World Rugby and the RFU have made significant progress in:

• Increasing awareness of concussion
• Introducing pitch-side assessments
• Standardising protocols
• Emphasising that all concussions are serious

However, differences between grassroots and elite return-to-play timelines continue to generate debate within the medical and brain injury communities.

The Bigger Question

Do current elite protocols fully reflect the growing body of scientific evidence on:

• Delayed symptom onset
• Cumulative head trauma
• Long-term neurodegenerative risk
• Vulnerability after initial injury

As research evolves, so too must concussion policy.

Our Position

At Marshalling Brain Injuries Alliance, we recognise the positive steps that have been taken to improve concussion safety in rugby.

However, we believe:

• Brain health must always come before performance.
• Return-to-play decisions should err on the side of caution.
• Protocols should prioritise long-term wellbeing over short-term competition.
• Standards protecting players should be consistent across all levels of sport.

A concussion is a brain injury — whether sustained in a school match or an international test.

Protecting players today protects lives tomorrow.