UPMC Sports Surgery Clinic’s head of Physiotherapy, Colm Fuller, contributed to this article by Sharon Ni Chonchuir which was published in the Irish Examiner in December 2022.

A growing number of women are togging out to participate in team sports. The Football Association of Ireland’s 2019 review found that there were more than 19,000 female youth and 4,800 adult soccer players in Ireland. The Ladies Gaelic Football Association has more than 1,000 clubs nationwide. And as of 2018, there were 2,500 girls and 1,341 women playing rugby union.

While this level of women’s involvement in sport is to be celebrated, it is concerning that their injury rates are increasing in tandem with their participation rates. A 2019 study [exa.mn/women-rugby-injuries] reported that St Vincent’s Hospital in Dublin had experienced a 243% surge in injured female rugby players presenting at the hospital in the previous ten-year period and its authors warned of an increasing number being treated for concussion.

It’s happening in ladies’ Gaelic football too. A recent DCU survey of 657 players found that 10% had been diagnosed with concussion in 2020 and a further 8% thought they had been concussed but hadn’t reported it.

Experts point out that delaying seeking medical attention for concussion can lead to persistent symptoms.

International research warns that women may be more vulnerable to concussion than men. A 2021 study [exa.mn/soccer-concussion] led by Abigail Bretzin, a research investigator at the University of Michigan’s Injury Prevention Centre, looked at data from 43,000 male soccer players and 39,000 female soccer players over three years. It concluded that girls’ chances of concussion were 1.88 times higher than boys’ and that they were more likely to require longer recovery times.

“It proves something we’ve suspected for a while,” says Bretzin. “When comparing sports that men and women participate in, women have a higher rate of concussion.”

Bretzin is one of many academics working to uncover the reasons for this gender bias.

“Some studies suggest there are differences in axonal structures in male and female brains,” she says. “Axons are tiny fibres that form a network within the brain, transporting information from neuron to neuron. A 2017 study [exa.mn/axonal-structure] found that female axons were predisposed to greater mechanical damage and physiological dysfunction compared to male axons receiving the same injury. However, this is limited to animal studies and more research is needed.”

Other research points towards the difference in neck strength, girth and circumference as a factor that may reduce females’ ability to resist a head impact compared to males. “Using neck strengthening and muscle activation is now being studied as a way to protect athletes, and military personnel, from concussions,” says Bretzin.

Dazed and contused

Colm Fuller is the head of physiotherapy at the UPMC Sports Surgery Clinic in Santry and has worked with the London Irish, Munster and Ireland Rugby teams. He explains that concussion is a “mild traumatic brain injury that results from a transfer of mechanical energy to the brain from external forces”.

This can happen in all sorts of ways. Players can sustain a direct knock to the head by bashing against another player or hitting a ball or a goalpost. Concussion can also be indirect, resulting from the brain absorbing some of the impact from a fall on another part of the body.

“Sports – particularly contact and collision sports – account for approximately 20% of concussion injuries, but concussion can happen in many other circumstances,” says Fuller.

Losing consciousness only happens in about 10% of cases. “The brain has three main parts: the left and right hemispheres and the brain stem,” says Fuller.

“A loss of consciousness may only occur when the brainstem itself is or both hemispheres are disrupted at once. If only one side is disrupted, the other side can usually compensate and help it out.”

Because concussion is a mild form of brain injury, it affects how the brain works but doesn’t cause structural damage that is visible on current standard imaging such as MRI. This means it’s typically diagnosed by analysing the symptoms that follow a head injury.
“It could be a cognitive test such as asking the patient their name, where they are and what time of day it is,” says Fuller. “Or maybe a balance test or seeing how their eyes move and react to vision tasks.”

While symptoms can be serious, Fuller reassures us that they are usually temporary. “Most of the time, they resolve and people recover,” he says. “Adults are typically symptom-free within two to four weeks of their injury.”

“Early intervention promotes better recovery,” says Fuller. “Up to 30% of concussions may have persistent symptoms lasting longer than normal recovery times and, unfortunately, these are the cases that tend to present for medical attention. Therefore, it is recommended to at least check in with a health professional in the event of a concussion to help guide your recovery.”

Governing bodies have introduced guidelines to protect their male and female players from concussions. These guidelines are similar across GAA, soccer and rugby.

As soon as someone sustains a suspected or confirmed concussion, they must immediately be removed from play and subjected to a medical examination before following a graduated return to play.

This phased return consists of five steps. The first is two days of complete physical and cognitive rest. The second involves building up to normal activities and light exercises. Then aerobic exercises are introduced, followed by sports-specific and non-contact exercises before players finally return to full contact practice. Players can only progress from one step to the next if they remain symptom-free during the various exercises and for 24 hours afterwards.

Different guidelines

The Irish Rugby Football Union and the Football Association of Ireland apply the same guidelines to male and female players but the GAA distinguishes between the sexes. In recognition of the evidence that females may require more time to recover, they are advised to take at least two weeks before returning to full contact training and matches, while men are advised to take at least one week.

Increasing medical personnel at women’s sports could help redress the concussion gender imbalance.

“We have seen that the quality of medical personnel available at the time of injury may not always be equal for women and men,” says Bretzin. “Equal access to trained medical providers could help in early concussion management.”

Fuller agrees. “Women’s sports tend to have less financial support than men’s, which means that they’re less likely to have medical personnel at games,” he says. “This has to be addressed and, in the meantime, players, referees and coaches should be educated about the risk of concussion.”

His advice to all players is never to ignore a head injury. “If in doubt, sit them out,” he says. “Take them off the pitch and seek medical attention.”

Regardless of the risk, Fuller doesn’t want to deter women from playing sports. “Sports participation is to be encouraged and promoted for all the benefits it brings from a physical, mental, emotional and social point of view,” he says.

“There is a varying risk of concussion in a lot of sports, and this needs to be addressed with education of participants, parents, coaches and administrators/referees. The better informed we are about it, the better decisions we can make to keep the game safe while ensuring high levels of participation.”

Concussion checklist

Concussion is defined as a mild traumatic injury to the brain and most people are symptom-free within four weeks. However, this depends on you and those around you recognising the signs and symptoms of concussion and getting the treatment you need in time.

The range of symptoms varies from person to person and case to case, and they may develop over minutes, hours or even days. If you think you might be concussed, the Ladies Gaelic Football Association has compiled a checklist of critical symptoms.

• Are you displaying cognitive symptoms such as difficulty concentrating, difficulty remembering, fatigue or a feeling of brain fog? Are there any physical symptoms like headache and pressure in the head to neck pain, nausea, dizziness, vision problem or sensitivity to noise and light?
• Concussion can have an emotional impact. Are you feeling more irritable, nervous or more intense emotions than usual?
• Concussion can have a wide-ranging impact on sleep. Some people feel drowsy, while others have difficulty falling asleep. Some sleep more than usual, and others sleep far less.
• If you suspect someone else of sustaining a concussion, they may be unable to tell you their symptoms. You will have to rely on the signs you can see. These include poor balance and loss of coordination, slurred speech, vomiting, constant clutching of the head, a vacant facial expression or a loss of consciousness.
• If you’re in doubt, err on the side of caution and seek medical attention. Then rest for 48 hours, avoiding screens, alcohol, recreational and prescription drugs, and driving.