Should Buffalo Bills QB Josh Allen be playing tonight?

By Dr. Chris Nowinski, Concussion Legacy Foundation co-founder and CEO

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Photo credit: Thomas Shea/USA Today Sports/Reuters

Buffalo Bills QB Josh Allen’s head struck the ground with incredible force during last Sunday’s game, and his actions after made me concerned he may have suffered a concussion. To my surprise, Allen was cleared and returned to the game. I called for an investigation into what happened the next day on CNN. After seeing the replay, it appeared to me Allen stopped taking protective action on his fall after his head struck the ground, indicating he might have been briefly unconscious.

Allen did not immediately move after the hit, and did not roll over to his back on his own - his teammates rushed over to physically turn him. This prevents us from knowing how long he would have stayed motionless, which might have provided insight for a concussion evaluation. Once on his back, he stayed there for a long time. Doctors leaned over him to have a conversation, but they did not appear to examine any part of his body that suggested an injury other than a concussion, and he did not appear to be in pain. Later, there was discussion of a possible chest injury and possible ankle injury, but there has been no visual evidence for either.

The fact that Allen was “slow to get up” after a hit to the head appears to have triggered the concussion protocol, his removal and brief assessment in the blue tent. Allen was quickly cleared, handed smelling salts outside the tent, which is not appropriate in the case of a suspected concussion, and returned to the game.

The NFL and NFLPA put out a statement saying they investigated Allen’s concussion evaluation and concluded the protocol was properly followed. They say their medical teams confirmed “there was no loss of consciousness.” They have a good argument that the protocol was followed, and I am thrilled there was an investigation.

I am also pleased there is a concussion protocol at all. For those who are newer to this issue, the NFL took their first steps toward a concussion protocol in 2009, summarized nicely in this New York Times article that introduces me as “the primary advocate for reform in the treatment of sports concussions.” I share that as a reminder that I’ve been at this a while, and it remains important to challenge the status quo.

Therefore, I feel comfortable saying that the case is not closed and playing Josh Allen tonight might be a mistake. I said the same thing the day after Tua Tagovailoa was cleared after his four distinct concussions signs were attributed to an earlier back injury. A few days later Tua was knocked unconscious and carted off the field. Tua just suffered his fourth concussion in over two seasons, with many calling for him to retire. In my opinion, Josh Allen showed three concussion signs last week – no protective action when falling, lying motionless, and slow to get up. While eight days might have given him enough time to clear the concussion protocol if he did in fact have a concussion, there is a lot of misinformation out there following the NFL-NFLPA statement, so I’d like to make some educational points that might help others protect youth athletes in the future.

1. The reason we have a concussion protocol is because continuing to play on an injured brain can, in rare instances, cause catastrophic brain injury and death from second-impact syndrome or, far more commonly, simply make an injury worse. Two concussions in a short period of time, especially when the first hasn’t recovered, is a common story for people who have long-term concussion symptoms or never fully recover at all (like me).

2. There is no objective test for a concussion that is accurate 100% of the time. After a head impact, a concussion cannot be ruled out for 48-72 hours because symptoms are often delayed. That’s why a player removed and assessed during the game also must be assessed after the game and the next day to look for delayed symptoms. However, identifying delayed symptoms usually means the player has to self-report. Once a player is past the period where they are showing obvious signs (slow to get up, ataxia, amnesia), which are usually short-lived, self-reporting is how most concussions are diagnosed.

3. Because delayed symptoms are so frequent, when a player is checked on the sideline and returns to the same game, the NFL, NFLPA, and doctors are all accepting there is a chance the protocol created a type II error, or a false negative test. This has been discussed at length and it may be an acceptable risk for an adult, but we all need to remember that the in-game protocol often clears players who are later diagnosed with a concussion.

4. The team medical staff, unaffiliated doctor, and booth spotters are on record saying Allen was not unconscious, but the difficult truth is they cannot be certain he was not. That is their medical conclusion, and they have tremendous experience and I am not being critical of their conclusion, but due to the camera angles neither the spotters nor the doctors could see his eyes while he was down, and the doctors didn’t get on the scene until after he started moving voluntarily. The offensive lineman who felt the need to turn him over might know if he was out, but I doubt they’d admit it if they thought he was unconscious. Also, if that lineman was concerned Allen had any injury other than a concussion, why would they manhandle him like they did and possibly make the injury worse? Allen may not even know he was out. Watch this breakdown from Brian Sutterer, MD where he concludes Allen appeared unconscious. It is compelling. The 2018 Eagles head team physician said he concluded the same, as did Pat McAfee. But the conclusion is subjective – the team doctors can’t be sure he wasn’t knocked out, and we can’t be sure he was.

5. Josh Allen has not denied having a concussion, and studies show football players, even after receiving concussion education, do not self-report the vast majority of concussions. When asked about it Wednesday, he said, “I, obviously, went into the tent. I can only control what I can control. What we talked about there, they deemed me clear to play. That's kind of what happened. That's as deep as I'll get into it.” That is a suspicious statement. He could say, “I appreciate the concern, but I did not have a concussion.” He could have said, “I just had the wind knocked out of me.” He could have said, “I hurt my ankle and wanted more time to recover.” Josh Allen’s statement makes sense to me if he knows he had a concussion but is not the kind of person to lie or mislead, and he wants to protect the team, wants to keep his concussion count low for future contracts, and wants to play next week. If he told me/the public he didn’t have a concussion, I’d believe him. But he hasn’t.

6. Taking all that into account, the last question is one of human strategy. Tua got his latest concussion against the Bills. They know that his football future is not secure, and it all started with two concussions five days apart. Josh Allen is widely considered a top 5 quarterback who is 28 and in his prime. It’s the first half of the season and the Bills first place in their division. If you have any concerns at all that he had a concussion last week, why play him the following week?

Each time an NFL player suits up, there is a risk he gets a concussion. It’s unlikely to happen, but what if this is Josh Allen’s week, and he has two concussions in eight days? I’d hate to be having the difficult conversations about Josh that we are having about Tua. That’s why, if I owned the Bills, he wouldn’t be playing tonight.

As part of Concussion Awareness Month in September, we partnered with USA Lacrosse to Team Up Against Concussions (TUAC), our program asking all athletes and their coaches to speak up if they notice a teammate showing signs of a concussion. And next week, we’ll be doing the same with USA Hockey. If you want to bring the TUAC speech to your own team or your child’s team, find out how here.