Rugby Concussion Protocols England: HIA and Recovery

A player takes a shoulder to the head at a ruck in the second half at Kingsholm. Within seconds a doctor is on the pitch, and within a minute the player is walking to the tunnel with a temporary replacement warming up behind him. What happens in the next twelve minutes is governed by a written protocol, watched on multi-angle video by a doctor who does not work for either club, and recorded. What happens when the same collision occurs on a Sunday morning at a community club in England, with no doctor within twenty miles, is governed by something much simpler and arguably more important: an instruction to take the player off and not put them back on.

Both of those things are English rugby union's concussion framework. The RFU sets the community rules, World Rugby sets the elite protocol, and the two are deliberately different, because they are solving different problems with entirely different resources. This page covers both, along with the return-to-play process, the education requirements, the smart mouthguard data now being collected, and the long-running argument about what all of this adds up to.

One boundary first. Everything below is rugby union. Rugby league in England is a separate sport with its own governing body in the Rugby Football League, its own laws and its own concussion protocols, and the two should never be treated as interchangeable — the differences between the codes are set out in our comparison of rugby league and union rules.

What a Head Injury Assessment actually is

The Head Injury Assessment is a screening tool, not a diagnosis. That distinction is the source of most public confusion about it, so it is worth stating at the front: an HIA does not tell a doctor whether a player is concussed. It tells the doctor whether the player can be allowed back on for the remaining half hour, and it errs heavily towards no.

It runs in three stages, spread over roughly two days.

Stage	When	What it involves
HIA1	During the match, off the field	Symptom review, memory and orientation questions, balance testing, clinical judgement, plus video review of the incident
HIA2	Shortly after the final whistle	A fuller assessment repeating and extending the pitch-side tests, comparing against the player's own baseline
HIA3	Around 36 to 48 hours later	A further review, because a proportion of concussions only declare themselves after a night's sleep

Every element of that sequence exists because of a known failure mode. HIA1 catches the obvious cases. HIA2 catches the player who was running on adrenaline and said he felt fine. HIA3 catches the delayed presentation, which is common enough that a protocol without it would miss a meaningful number of injuries.

The off-field window for HIA1 is short and fixed — the assessment has to be completed inside it, and the window was extended from its original length after doctors reported that the first version left too little time to do the tests properly with a player who had just come off a pitch. A temporary replacement covers the absence. If the player passes, they return. If they fail, or if the doctor is not satisfied, the replacement becomes permanent and the player's afternoon is over.

Baseline testing matters more than people assume. Elite squads complete cognitive and balance testing in pre-season while healthy, so the matchday result has something to be measured against. Without a baseline you are comparing a player to a population average, which is close to useless for an individual whose balance was never good in the first place.

The content of HIA1 is a short battery rather than one test. A symptom checklist the player runs through. Orientation and immediate-memory questions of the kind used across sport since the 1990s, which ask about the venue, the half, the score and the last team to score, and which work because a concussed brain finds recall of the immediately preceding minutes disproportionately hard. A balance test performed standing in a tandem stance with eyes closed. And the doctor's own clinical judgement, which sits above all of it and can end the assessment at any point.

Worth noting what the protocol does not do. A player who fails HIA1 has not been diagnosed with concussion, and a player who passes has not been cleared of it — passing means only that no screening threshold was crossed in a twelve-minute window, which is why HIA2 and HIA3 follow regardless of the pitchside outcome. Sanctions apply to competitions and clubs that do not complete the later stages, because those are the stages a busy medical room is most tempted to skip.

1. 1IncidentA head impact or a possible sign of concussion is seen by medical staff, the referee, the match officials or the independent video reviewer.
2. 2Criteria 1 checkIf a permanent removal sign is present, the player is off for good and no assessment takes place.
3. 3HIA1Off-field screening within a fixed window, with a temporary replacement on the pitch. Failure ends the player's match.
4. 4HIA2A fuller assessment after the match, compared against the player's own pre-season baseline.
5. 5HIA3A further review around two days later, to catch the delayed cases the first two stages miss.
6. 6OutcomeA confirmed concussion sends the player into the graduated return to play programme before any contact.

The structure of the World Rugby protocol as published. Timings are set by the protocol and have been revised since it was first introduced.

Who conducts it, and what forces a player straight off

The assessment is carried out by the match-day doctor. In the top-tier competitions in England that role is supported by an independent match-day doctor watching video, with access to multi-angle replays delivered to a screen at pitchside, and by the referee and match officials, any of whom can flag an incident.

The decision is medical and it is final. A coach cannot overturn it, a captain cannot argue it, and the player cannot decline it. This was not always so, and the change is one of the more significant governance shifts in the professional game — removing the return decision from anyone with an interest in the result.

Certain signs mean the player leaves immediately and permanently, with no assessment at all. The protocol lists them, and the list is the practical heart of the whole system:

Sign	Why it removes the player outright
Confirmed or suspected loss of consciousness	The single clearest indicator of a significant brain injury
Convulsion or tonic posturing	A visible neurological event, unmistakable on video
Ataxia or a balance disturbance	Motor control is one of the first functions concussion disrupts
Clearly dazed, or not oriented in time, place or person	The player cannot reliably report their own state
Definite confusion or a definite change in behaviour	Observable to a doctor and to teammates
Oculomotor signs	Eye movement abnormalities that a player cannot mask

A second category of signs permits the off-field assessment rather than forcing removal — a suspected but unconfirmed change in behaviour, reported symptoms such as headache or dizziness, a possible loss of balance. That is the group HIA1 exists to sort. A third category covers signs and symptoms that emerge later, which is what HIA2 and HIA3 are for.

Video is central to the whole thing, and its use here is quite separate from the officiating technology covered in our guide to the TMO in rugby. The medical reviewer is not deciding whether a try was scored. They are watching a collision at half speed, from four angles, looking for the half-second of unsteadiness a doctor on the touchline could not possibly have seen.

If in doubt, sit them out

Almost nobody who plays rugby in England will ever be assessed under the HIA protocol, because it requires a qualified match-day doctor and the community game does not have one. Around ninety-nine per cent of English rugby is played on pitches where the medical provision is a trained first aider with a bag, and often not that.

So the community rule is not an assessment. It is a removal instruction, and the RFU has spent a decade making sure everyone in the game can recite it: if in doubt, sit them out.

The logic is worth spelling out because coaches still resist it. A first aider cannot diagnose concussion. Nor can a doctor at pitchside, reliably, which is why the elite protocol has three stages spread over two days. Given that nobody at a community fixture can tell, the only safe decision rule is to remove any player with a suspected head injury and not return them, accepting that this will take some uninjured players off the pitch. The cost of that error is one player missing forty minutes. The cost of the opposite error can be catastrophic, particularly for a player who takes a second impact before recovering from the first.

The rule has no exceptions in the community game. Not for a cup semi-final, not for a squad with no replacements, not for a player who insists he is fine. A player who insists he is fine is exhibiting one of the symptoms.

Referees have authority here too. A referee who sees a player they believe has a head injury can stop play and require the player to leave, and in age-grade rugby they are expected to. This puts a volunteer official in an uncomfortable position on a Sunday morning, which is precisely why the instruction is worded as bluntly as it is: it gives the person making the call something to point at.

The graduated return to play, stage by stage

Removal is the first half. The return is the half that gets skipped.

Graduated return to play is a staged ladder. Each stage is a defined level of activity, each must be completed without symptoms returning, and a minimum period must pass before moving up. Symptoms at any stage send the player back down. It is deliberately slow and it is deliberately boring.

1. 1Stage 1Relative rest. A short period of reduced activity immediately after the injury, no longer the prolonged dark-room rest once advised.
2. 2Stage 2Light aerobic exercise. Walking or stationary cycling at low intensity, with no resistance training.
3. 3Stage 3Sport-specific exercise. Running and change of direction, still with no head impact activities of any kind.
4. 4Stage 4Non-contact training drills. Passing, more demanding conditioning, and resistance training reintroduced.
5. 5Stage 5Full contact practice. Only after medical clearance, and only if every earlier stage was symptom-free.
6. 6Stage 6Return to play. Normal game participation.

The six-stage structure used in rugby union. Minimum time at each stage, and the total minimum period before competition, are set by the current RFU and UK grassroots guidance and have been revised more than once.

Two things about that ladder have changed in the last decade and both are worth knowing, because the outdated versions are still repeated in clubhouses.

The first is rest. Extended complete rest — the darkened room, no screens, no reading, for a week — is no longer the recommendation. Current consensus guidance supports a short period of relative rest followed by early reintroduction of light activity, because prolonged inactivity appears to slow recovery rather than speed it.

The second is who signs it off. Progression through the later stages, and the clearance to resume contact, is a medical decision. In the community game that means a doctor, not a coach with a stopwatch and a calendar.

Stand-down periods, and why children get longer

Here is where you need to be careful with any number, including one you read on a poster in a clubhouse.

The UK Concussion Guidelines for Non-Elite Sport, published in 2023 and adopted across British grassroots sport including rugby union, set a minimum period between the injury and a return to competition, along with a requirement to be symptom-free for a defined period before contact training resumes. The headline figure for adults is a minimum of 21 days from the injury to the next competitive match. Before those guidelines the RFU ran its own framework with different periods for adults and for under-19s, and with a shorter minimum available where the player was managed by a healthcare professional with concussion expertise.

Those periods have been revised more than once, in both directions, as the evidence has developed. If the exact number matters to you — and if you are a coach or a parent, it does — take it from the RFU's current published guidance for this season rather than from anything written previously, this page included.

What has not changed is the principle underneath. Age-grade players stand down for longer than adults. The reasoning is that recovery in a developing brain appears to take longer, that symptom reporting in children is less reliable, and that the consequences of a second impact before recovery are worse. The RFU's age-grade framework is covered separately in our guide to RFU age grade rugby rules.

There is a further principle for children that adults do not have: return to learn before return to play. A child who cannot yet manage a full school day without headaches or concentration problems is not ready for contact training, regardless of how many days have elapsed. Schoolwork comes back first. Rugby comes back last.

How clubs and schools are expected to record it

An incident that nobody wrote down is an incident that cannot be managed, and this is the weakest link in the community system.

The expectation on an English club is straightforward. A suspected concussion is recorded at the time, with the date, the player, the circumstances and who made the removal decision. The record follows the player, because the person who needs it is the coach three weeks later deciding whether to select them, and that coach may not have been at the game. Clubs with a functioning system use a written form and a designated person — usually the first aider or the club's medical lead — who holds the file.

The RFU also runs injury surveillance in the community game, working with university researchers to collect data on what actually injures players at club level rather than in the professional game. That work is the evidence base for law changes, and it only exists because clubs report.

Schools carry the same obligation and a harder version of it, because a school may have one member of staff supervising a fixture, no medical cover, and a duty of care to a child whose parents are not present. A school should have a written concussion policy, should inform parents the same day, and should be joining up the return-to-learn side with the return-to-play side. In practice the joining up varies enormously between an independent school with a full-time sports department and a state secondary running rugby on goodwill.

The awkward truth is that a player who is removed at a club on Sunday, attends school on Monday and plays for the school on Wednesday has fallen through a gap that no regulation currently closes on its own. It is closed by a parent telling the school.

Spotting it on the sideline with no medical staff

You do not need to diagnose. You need to recognise and remove, and the recognition list is short enough to memorise.

Visible signs first, because they are more reliable than what the player tells you. Lying motionless. Getting up slowly or unsteadily. A blank or vacant look. Grabbing or clutching the head. Falling to the ground unsupported. A seizure, however brief.

Then what the player reports: headache, dizziness, feeling in a fog, nausea, blurred vision, sensitivity to light or noise, not feeling right. And what you can check with two questions, which do not require any medical training at all — ask which ground they are at and who scored last. A player who cannot answer, or who answers slowly, goes off.

A set of red flags require an ambulance rather than a lift home. Neck pain or tenderness. Deteriorating consciousness. Repeated vomiting. Increasing confusion or agitation. Weakness, tingling or burning in the arms or legs. Double vision. A seizure. Any of those, and the call is to 999, not to the player's mother.

Afterwards, the player is not left alone that evening, does not drive, and does not drink. Somebody responsible needs to know what happened, which means the parent of a junior player is told before they get in the car and not by text message the next day.

1. 1StopStop play and get to the player. A player who stays down after a head impact is not to be moved until you have checked for neck pain.
2. 2RemoveTake the player off. This is not a judgement call and there is no version of it where they go back on later in the same match.
3. 3Check red flagsNeck pain, deteriorating consciousness, repeated vomiting, seizure, double vision, limb weakness or increasing agitation all mean an ambulance.
4. 4ObserveKeep the player with a responsible adult, out of the changing room chaos, and watch for symptoms developing over the next few hours.
5. 5RecordWrite down the date, the incident and who made the call, and hand a copy to the player or parent before they leave the ground.
6. 6ReferAdvise a medical assessment, and make clear that no training, no school PE and no other sport happens until a doctor has seen them.

The sequence set out in the RFU's community guidance and the pitchside recognition tool. It is a removal and referral process, not a diagnostic one.

The single most common failure in the community game is none of the above. It is a player who is taken off correctly on Sunday, tells nobody at work on Monday, feels better by Wednesday and turns up to training on Thursday because the coach is short of numbers. The removal was done properly. The return was not done at all, because nobody owned it. Which is why the recording step, dull as it is, matters more than any of the clinical judgement.

What the RFU expects everyone in the game to have done

The RFU runs a concussion education programme under the HEADCASE name, free and online, with separate modules for coaches, referees, players, parents and teachers. It takes well under an hour, it covers recognition, removal and return, and it is the single most useful thing an English rugby volunteer can do in an evening.

Completion is a requirement rather than a suggestion for people in defined roles. A coach working with age-grade players is expected to hold current concussion awareness training alongside their coaching qualification and safeguarding checks, and clubs are expected to keep the records. A club that cannot tell you when its Under-14 coach last completed it has a problem it has not noticed. The broader qualification picture sits in our guide to rugby coaching qualifications in England.

Alongside the education there is a recognition tool designed to be carried in a kit bag or opened on a phone at pitchside — a single card listing visible clues, symptoms, red flags and the memory questions, produced so that a first aider with no concussion training has something to work from under pressure.

The reason all of this is pushed so hard at volunteers is a matter of arithmetic. There is no realistic prospect of qualified medical cover at every one of the tens of thousands of fixtures played in England each weekend. The system has to work when the most qualified person present is a parent who did a first aid course two years ago. Educating that parent is the only available intervention.

Instrumented mouthguards and the data now being collected

Smart mouthguards are the most significant change to concussion practice in the elite game since the HIA itself. An instrumented mouthguard contains accelerometers and gyroscopes and measures head acceleration events — the forces the head experiences in a collision — transmitting them live to medical staff.

World Rugby approved their use and they have been rolled out across elite competitions, including the Premiership and Premiership Women's Rugby. Where an impact exceeds a set threshold, the system alerts the medical team and the player is removed for an HIA1 even if nobody saw anything wrong. The thresholds are lower in the women's game, because the head acceleration profile differs and applying the men's figures would miss events that matter.

That alert function is a genuine advance. The great weakness of the old system was that it depended on somebody noticing, and a collision at the bottom of a ruck involving a player who then gets up and carries on is exactly the kind of event that goes unseen.

The limitation needs stating just as clearly. A mouthguard measures acceleration. It does not measure concussion, and there is no reliable one-to-one relationship between the force of an impact and whether a brain injury results. Two players can take an identical hit and one is concussed. The device is a trigger for assessment, not a diagnostic instrument, and anyone presenting it as the latter is overselling it.

The second use of the data is longitudinal. Aggregate head acceleration exposure across a season, by position and by activity type, tells governing bodies where the load actually comes from — and the early findings pointed at training as much as at matches, which is why the elite game in England now caps full-contact training minutes per week. That cap would have been impossible to justify without measurement.

The brain health debate and what is still unresolved

A group of former professional players has brought legal action against World Rugby, the RFU and the Welsh Rugby Union, alleging a failure to protect them from brain injury during their careers. The case has been running for years and is unresolved. Whatever its outcome, it has already changed the game's behaviour, because the prospect of litigation concentrates a governing body's attention in a way that research papers do not.

The underlying scientific question is harder than either side of the public argument usually admits. Chronic traumatic encephalopathy can currently only be confirmed after death, by examining brain tissue. That means the evidence base linking a rugby career to later neurodegenerative disease comes from post-mortem case series and from population studies comparing former athletes with the general public, and neither design settles causation for an individual. Studies of former contact-sport athletes in Britain and elsewhere have reported elevated rates of neurodegenerative disease. What nobody can yet do is tell a serving player what their personal risk is.

Charitable and university-based research programmes in Britain have funded much of the imaging and biomarker work, and a campaign group of former players and clinicians has pushed the unions towards specific reforms — contact training limits, longer stand-downs, mandatory baseline testing. Some of those have been adopted.

The most consequential law change in England came from this pressure. The community game lowered the legal tackle height, after an initial proposal to bring it to the waist was revised to below the sternum following a fierce reaction from clubs. That process — a proposal, a backlash, a revision — is covered in detail in our guide to the tackle height law in England, and it is a fair illustration of how contested this territory is even among people who agree on the objective.

An honest summary is that the direction of travel is settled and the destination is not. Rugby in England will keep reducing head impact exposure. How far it has to go, and whether the reductions made so far are enough, are open questions, and any page that tells you otherwise is guessing.

What a parent should ask a club before signing the form

Five questions, and the quality of the answers tells you almost everything about how the club is run.

Who provides medical cover at age-grade fixtures and training, and what qualification do they hold? The answer should be a named person and a named certificate, not "one of the dads is a nurse".

Have all the coaches for my child's age group completed current concussion awareness training, and when? A club that keeps this record will produce it in thirty seconds.

Who makes the decision to remove a player, and can a coach overrule it? The only acceptable answer is that removal is automatic on suspicion and nobody overrules it.

How is an incident recorded, who holds the record, and how will I be told? You should expect to be told on the day, in person, before you drive home.

What is the return-to-play process, who signs it off, and does the club talk to my child's school? The last part of that is the one most clubs handle worst, and asking it is often the thing that makes them start.

Clubs that answer these well tend to be well run in every other respect too, which makes the conversation a useful proxy for a great deal more than concussion. The wider question of choosing a junior section is covered in our mini and junior rugby guide, and the equivalent questions for adults joining a senior side are in the women's rugby pathway guide.

More on the laws, the competitions and the English game across both codes sits under rugby.