No easy answer to how many concussions are too many for Tua Tagovailoa

Jan. 1—For Miami Dolphins quarterback Tua Tagovailoa, who has suffered at least three apparent head injuries this NFL season, how many concussions is too many—and at what point should he sit out the rest of the season or even consider retiring from the game ?

For Miami Dolphins quarterback Tua Tagovailoa, who has suffered at least three apparent head injuries this NFL season, how many concussions is too many—and at what point should he sit out the rest of the season or even consider retiring from the game ?

While there's no easy answer, there's also no shortage of concern and discussion among fans and leaders in athletics and sports medicine, especially here in Tagovailoa's home state, as they've watched the Hawaii-born star player's recent run of alarming injuries.

Among them is Saint Louis School head football coach Ron Lee, who says if he got the chance he would advise Tagovailoa to put a halt on at least the rest of the season. "I would rather him take a break this year. Three (head injuries ) is a bit too much in such a short time, " Lee said.

Lee, who was offensive coordinator at Saint Louis when Tago ­vailoa played for the Kaimuki private school, cautioned that as a coach he's not a medical expert, and Tagovailoa is best off consulting with his top-level doctors and coaches. But if Lee could speak with his former charge, he said, he would say : "As a friend I care about, take a break. Take a break. Let it heal. Don't risk. ... Let them do some testing in the offseason and then make a decision."

Yet Lee knows it would be tough for Tagovailoa to step away, even temporarily, especially as his star is rising. At 24 years old, Tagovailoa is 21-13 in his professional career. And with the regular season ending Jan. 8, the Dolphins, 8-7 as of Saturday, are aiming for at least a wild card berth in the AFC playoffs.

"I know he loves the competition, he loves the game, " Lee said. "My main concern is, his health is No. 1. Football will be over in no time. ... He's got a family, terrific parents, he's married now, he has a baby. All of these things are important."

Nathan Murata, a co-founder of the Hawaii Concussion Awareness Management Program—a program within the University of Hawaii College of Education, where he is the dean—said he also thinks Tagovailoa needs at least the rest of the season off.

"The concern should be the distance between the concussions, " Murata said. "If you got a concussion last year and you didn't get one until another year, you'll probably be fine. But when you get one a week or so after the initial one, that's not a good thing. ...

"I just hope his health and well being, that he really considers taking care of, because it can have potentially lasting impact. That, we don't want. That, nobody wants."

TAGOVAILOA on Friday was officially ruled out for today's game at New England after suffering a concussion in Miami's Christmas Day loss to the Green Bay Packers. The quarterback was believed to have been injured in the second quarter of the game when the back of his head hit the turf.

Although it is his second time this season under concussion protocol, it was apparent head injury No. 3.

On Sept. 25 in a Week 3 game against the Buffalo Bills, Tago ­vailoa went out in the first half on what Miami initially announced on Twitter as a head injury, after a Bills linebacker shoved him to the ground. Tagovailoa shook his head as he rose, then staggered a few steps and sank to his knees momentarily. He returned to start the second half and finished with a win.

Tagovailoa later downplayed the incident, telling reporters he had hurt his back and ankle earlier in the game, and that his back "locked up " on the later hit.

Still, while a review by the NFL and the NFL Players Association determined that the league's concussion protocol was followed, a new amendment to the protocol was made to include ataxia—abnormality of balance /stability or motor coordination, or dysfunctional speech—as a "no-go " symptom.

Just four days after the Bills game, in the Dolphins' next matchup Sept. 29 against the Cincinnati Bengals, Tagovailoa struck his head when he was sacked by a defender, and spectators watched in horror as he lay on his back, holding up his hands with his fingers twisted and rigid, which is widely seen as a concussion symptom. He was carried off the field on a stretcher and hospitalized, put under concussion protocol and missed the next two games.

After the Sept. 29 incident, Chris Nowinski, co-founder and CEO of the Concussion Legacy Foundation, tweeted : "Two concussions in 5 days can kill someone. This can end careers. How are we so stupid in 2022."

WHEN CONCUSSION expert Dr. Jennifer King is asked, in general, how many concussions are the limit before any athlete should consider taking an extended break or even retire, she responds, "I think one is too many."

King, one of three doctors in pediatric sports medicine looking after concussion cases at the Bone and Joint Center at Kapiolani Medical Center for Women & Children, was prohibited by the hospital from commenting on Tagovailoa's case because of potential liability issues. But she could discuss concussions in athletes in general.

King, who is also a medical adviser for the Hawaii Concussion Awareness Management Program, acknowledged that "the rumor in the community is that three concussions and you're finished with sports."

But that's not a rule, as each individual manifests symptoms and heals at a different pace, King said.

Adults typically take seven to 10 days to get past initial acute symptoms, but teenagers can take three to four weeks, she said. How long the subsequent recovery stage takes depends on "where the brain was prior to the injury, " King said. Age, medical history, preexisting conditions such migraine headaches and attention-deficit disorder, and more all are factors, she said.

The U.S. Centers for Disease Control and Prevention defines a concussion as a type of traumatic brain injury caused by a bump, blow or jolt to the head, or a hit to the body, that causes the head and brain to move rapidly back and forth. Such sudden movement can cause the brain to bounce around or twist inside the skull, triggering chemical changes in the brain and sometimes stretching and damaging brain cells.

"What you might not know is that these chemical changes make the brain more sensitive to any increased stress or injury until it fully recovers, " says a CDC video on concussions.

Between 800 and 1, 000 concussions are reported each year just from state Department of Education-sanctioned sports, according to King. The concussion clinic where she works treats about 300 youths per year.

Second-impact syndrome—a potentially fatal condition where a subsequent concussion causes rapid brain swelling and /or bleeding—is a risk but seems to occur mainly in younger players, King said.

But repeated blows to the head of any athlete can lead to conditions such as chronic traumatic encephalopathy, commonly referred to as CTE. The condition isn't well understood yet, according to the CDC, but it can include long-term changes to thinking, feeling, behavior and movement. Some doctors have linked CTE to memory loss, depression and suicidality.

Boston University researchers have reported finding evidence of CTE in 99 % of brains obtained posthumously from NFL players, as well as 91 % of college football players and 21 % of high school players.

King said when someone with concussion doesn't "return to baseline, " meaning their original functioning levels, or if an individual starts to suffer concussions from a decreasing amount of impact, "that's when the conversation starts " about whether it's time to stop participating in a sport.

MURATA AND King said they hope an upside to the publicity around Tagovailoa's injuries is an increased public awareness of the importance of reporting and treating concussion.

Hawaii, King said, is already of most states : High school coaches here are required to be certified every year to recognize concussion, she said. Student athletes receive neurocognitive testing in ninth grade and 11th grade.

Murata added that Hawaii currently is the only state with free baseline cognitive testing.

Last year the football teams at Kalani, Roosevelt and Saint Louis wore special helmets with sensors to detect hits to the head and were taught how to tackle without using their heads.

And Hawaii is the only state to require every school that plays sports to have at least two athletic trainers, and that at least one trainer be present at every sports event. Trainers also act as liaisons, alerting teachers when a student has suffered a concussion and may need extra support and adjustments to their academics.

King said she hopes the heightened awareness also leads to a culture shift so that young people stop feeling pressure to play through a brain injury. She said she hopes for a "self-reporting, positive culture where the kids feel like they can self report."------The Associated Press contributed to this report.