Head Injuries and HIA: Protecting Players at the 2023 Rugby World Cup and Beyond


The 2023 Rugby World Cup showcased the greatest talent on the biggest stage. 

There was an incredible quarter-final weekend, unless you were Irish, and a riveting final in which having overcome England by a single point in the dying embers of their semi-final, South Africa successfully defended their crown in the face of huge Kiwi pressure. 

Amid exceptional hosting on the part of the French and a series of extraordinary games and individual displays of bravery and skill, the debate over player safety continues to rage. Not least following two divisive refereeing decisions in the final, which saw the All Blacks captain Sam Cane's yellow card for a high tackle upgraded to a red and debate as to whether Bok skipper Siya Kolisi should have suffered the same fate, for his own head high contact with Ardie Savea. 

This article delves into the Head Injury Assessment (HIA) process deployed by World Rugby using examples from the tournament to illustrate how the system remains potentially flawed. It will not examine the laws of the game but instead focus on the medical rules designed to safeguard player welfare. 

Understanding the HIA Process

The temporary substitution for a head injury was introduced permanently into the laws of elite rugby as long ago as August 2015. This allows for medical professionals, who suspect that a player has suffered a head injury, to temporarily remove that player from the field of play and assess them for potential concussions and associated injuries before either a return to the field or permanent substitution and medical care. 

These temporary substitutions can be made by the team doctors, the independent match day doctor or the referee. However, a member of the opposition’s medical staff is not allowed to request an off-field screen on an opposing player, nor are they allowed to make comments on incidents involving opposition players.

A 12-minute period is enshrined in the laws and is designed to engage a variety of potential assessments. These include; a medical symptoms checklist, a balance assessment that involves both single and double-leg stances and a range of cognitive tests including the immediate memory of a 10-word list and assessing a player's ability to recite numbers backwards. These tests, referred to as HIA1, are adapted and repeated at HIA2, a further examination of the player to be conducted within 3 hours of the completion of the game and then again at HIA3, following two nights of rest and typically around 36-48 hours after the match has concluded. 

These rules create important implications for tournament rugby that go far beyond the critical factor of player safety. They leave the system open to potential abuse and might have a negative impact on the affected player's team and broader sporting integrity. 

Delay in finding out if a player is available for the next fixture

Marcus Smith failed his HIA3 between England's quarter and semi-finals at the World Cup. This meant he was unavailable for the next fixture and England only had five days of preparation before their semi-final without a key player who had started their previous game. Whilst  player welfare is paramount, and this article celebrates the increased and detailed number of checks a player completes before they return to play, this issue might well come to a head at the next World Cup. Indeed, World Rugby CEO, Alan Gilpin, has already announced that the 2027 World Cup in Australia will be played in a condensed six-week tournament window, reduced from the current seven. More games, due to the introduction of four new teams, and less time to play them in, might well result in "grumbling" about last-minute changes to availability or open the system to potential abuse, rather than maintaining the intended focus on player welfare. 

"Resting" players

Crucially, a tactically replaced player, who would normally be ineligible to return to the field of play, can legally replace a player who is undergoing a HIA. This has implications on the calculated deployment of substitutes due to the potential to give players a break under the guise of a HIA,  especially when a team's own doctors can request a HIA without any further approval systems. A team might theoretically focus their replacements on key areas of the pitch in the full knowledge that should a player without an obvious replacement or with no substitutes left require a break or a substitution, this can be accomplished under cover of a HIA. 


The modern game of rugby is straining under the constraints of its original rule book and struggling to keep up to date with the reality of professional players and teams desperate to win. It is to be hoped that the horrors of rugby's "Bloodgate" scandal, where a club player was given a fake blood capsule to facilitate a mandatory blood substitution back in 2009 will never be repeated, but the gaming of the HIA system is a distinct possibility. Whilst teams might begrudge losing key individuals to safety rules a few days before an important knockout game, player welfare must of course trump availability concerns. However, a system that introduces verification of HIA requests from team doctors, whilst potentially difficult to organise, must surely be worth looking at more closely as the game continues to develop. 

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