Why Dolphins player Tua Tagovailoa is subject to the same NFL concussion protocol despite numerous head injuries in recent years

Tua Tagovailoa is one of only a handful of NFL players to have been placed under concussion protocol three times in the past five seasons, but the protocol that will clear the Dolphins quarterback for future games remains the same, the league confirmed Saturday.

“The purpose of the concussion protocol is to make sure the person doesn't return until they've fully recovered from the injury,” Dr. Allen Sills, the NFL's chief medical officer, tells CBS Sports.

“Of course, we don't time stamp the record because each injury is unique. … I would also say that it's intuitively obvious that when someone is repeatedly injured, healthcare providers are going to be increasingly conservative with these time elements. But again, the time interval between injuries and the duration of symptoms have to be considered.”

In the loss against the Bills on Thursday night Tagovailoa suffered his third known concussion in the NFL. According to a CBS Sports investigation, he is one of at least 10 players since 2019 to have gone through the protocol at least three times, and he is the only quarterback to have been in the protocol three times in the last five years.

The league's concussion protocol, developed in consultation with the NFL Players Association, is a five-stage program. Phase One requires low-symptom activity followed by aerobic exercise that continues in the absence of symptoms. Phase Three involves a return to football-specific exercises for no more than 30 minutes before essentially resuming training. Phase Five involves a full evaluation and clearance by a team physician and an independent neurological consultant.

Dolphins head coach Mike McDaniel has not provided a timetable for Tagovailoa's potential return to play. There has been debate throughout the football world about whether Tagovailoa should continue playing.

What Tagovailoa ultimately decides is up to him.

“I have a lot of confidence in the Dolphins medical staff and their plan to work with the player, his representatives and his family to overcome this injury and then address all of the issues that come with it,” said Sills, who added that he did not treat Tagovailoa and had no inside information about his symptoms. “I think ultimately everyone in the medical field would be pretty much in agreement on how to ensure someone recovers from a concussion. What we lack are specific guidelines on how to predict future risk and the number of concussions over a lifetime. And those are questions that smart, talented and experienced physicians disagree on, which shows that none of us know the right answer yet.”

Tagovailoa wore a helmet that the NFL and players union say is the best on the market when it comes to reducing the severity of head impacts. The helmet, a VICIS ZERO2 MATRIX ID QB helmet, has been tested by biomechanical experts and is considered the highest-performing helmet available to NFL quarterbacks this season.

The helmet was subjected to “laboratory impact conditions representative of the severe impacts quarterbacks are likely to experience on the field,” according to the NFL. “The laboratory test conditions were designed to represent potentially concussive head impacts in the NFL for quarterbacks,” and Tagovailoa's helmet had additional padding in the back of the head area.

Of course, a helmet can't completely prevent a concussion. Tagovailoa suffered the concussion on a red zone play in the third quarter of Miami's 31-10 loss to Buffalo. He lowered his head as he prepared for a tackle by Damar Hamlin. The right side of Tagovailoa's head struck Hamlin's chest and arm, and as the quarterback went down, the back of his head hit the turf.

The league, in consultation with the players' union, attempts to reconstruct head injuries using biomechanical data, but this takes more time than the few days since the injury.

“Sometimes it's difficult to pinpoint exactly where a concussion might have occurred because there can be more than one head impact in a game,” Sills says. “…It's really difficult to pinpoint exactly which one caused the injury.”

A growing concern around the league is Tagovailoa's vulnerability to another concussion. A 2003 study of nearly 3,000 college football players found that players “who reported three or more concussions in the past were three times more likely” to suffer another concussion. It also said that “slower recovery was associated with a history of multiple concussions.”

Tagovailoa's first known concussion occurred in college in 2019. He suffered a broken hip in the same game that ended his college career, and there is no public documentation of his recovery from that concussion.

His second known concussion – and first in the NFL – occurred in Week 4 of the 2022 season against the Bengals. The scary scene of him getting into a fencing stance occurred just four days after a hit that left him wobbly against the Bills. He was not diagnosed with a concussion in that game against Buffalo and was cleared to play the following week. The concussion against the Bengals forced him to miss the next two games.

On Christmas of that year, Tagovailoa suffered a concussion sometime during a game against the Packers in which he threw three interceptions in the fourth quarter. He reported symptoms the next day and was placed in concussion protocol. Tagovailoa missed the next three games, including a playoff loss, and it is unclear when his symptoms completely resolved.

Tagovailoa hasn't had a concussion in nearly a year and a half, and hasn't had a concussion in which he assumed the fencing stance in nearly two years. But as scary as that stance is, Sills says it's not always an indication of the severity of the concussion.

“Again, we need to do more research and understand this,” says Sills. “Of course, you might think that the fencing stance indicates a more serious injury. But we often see that players with the fencing stance recover even faster and become symptom-free than players without the fencing stance. It's a very strange symptom.”

In August, Tagovailoa signed a four-year, $212.4 million contract that made him the fourth-highest-paid player in NFL history at the time based on average annual salary.

The deal included $167 million guaranteed in the event of an injury, of which he has already received nearly $43 million. Should Tagovailoa have to end his career for medical reasons, he would be entitled to the remaining $124 million.

If Tagovailoa is cleared to return to football but decides to end his career, he would forfeit any remaining guarantees unless he and the Dolphins reach an agreement regarding the injury.

Raiders coach Antonio Pierce, who has played linebacker in the NFL for nine years, said this week he would advise Tagovailoa to retire.

“It's not worth it. It's not worth it,” Pierce said. “I've played the game and I've never seen anything like what happened to him three times. Scary. You can see the faces of the players on the field immediately. You can see the urgency to help Tua.”

“I just think that at some point he's going to live longer than he can play football. Take care of your family.”

While speculation surrounding Tagovailoa continues, McDaniel said this week it was premature for any talk about his future playing career.

“I just wish people would listen to me for a second when I say that it's not in his best interest to address his future,” McDaniel said. “So I ask anybody who really cares to think about that last, because what do you think, if I answered that question, I would say, 'All right, those are my thoughts on his career,' and he would read them. Whether he agrees with it or not, either way, I just made him worse. So I'm not taking that opportunity.”

“I don't think that's appropriate, just because of my care and respect, and I don't think that's appropriate when it comes to someone's career. It's probably only fair that the person makes their own career decisions.”