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9.13.24 UPDATE FROM DR. VINCENT SCHALLER: “This is serious. Tua Tagovailoa displayed an ominous fencing posture in September 2022, and now again in the Dolphins-Bills game Thursday night [9.12.24]. This was actually his 4th diagnosed concussion of his NFL career. The fencing posture is a total brain shutdown and is a symptom of a severe concussion. The video replay shows the crushing forces involved up close. Tua went head first for extra yards, and unfortunately his head slammed into Damar Hamlin’s chest and shoulder. Then he twists and falls, slamming his head into the turf. The soft tissue of the brain slams twice into his hard skull and bounces. These are forces of acceleration and deceleration that his helmet cannot protect him from. I hope Tua gets excellent medical care and advice on his future.“
1.15.24 UPDATE FROM DR. VINCENT SCHALLER: “Last night, LA Rams quarterback Matthew Stafford’s fencing posture after slamming his head on the ground in an a particularly harsh tackle indicated a clear concussion. He appeared daze as he stared up at the dome as well. From what I witnessed in the live broadcast and replays of the tackle, I do not believe he should have returned to the field last night, but after going into the medical tent immediately after late-third-quarter injury, he was back on the field at the start of the fourth quarter.”
10.01.22 UPDATE FROM DR. VINCENT SCHALLER: “What concerning head injuries Miami Dolphins Quarterback Tua Tagovailoa sustained last week. The first against the Buffalo Bills in Sunday’s game resulted in repeated stumbling that demonstrated gross motor instability to me, clearly a severe concussion involving the cerebellum. He’s lucky he did not have second impact syndrome (SIS) four days later in the game against the Cincinnati Bengals, where he exhibited the ‘fencing posture,’ a telltale sign of a second severe concussion involving a shutdown of gray matter resorting to temporary brainstem reflexes. His recovery will likely be prolonged if done properly. After much public backlash, the Miami Dolphins and NFL seem to be stepping up to address this issue.
When the announcers rationalized, ‘well, at least he can move all four extremities,’ concussion specialist everywhere should realize there is much more work to be done to properly educate the public about concussions.”
[Original post]
When Pittsburgh Steelers quarterback Mason Rudolph absorbed a huge hit on October 6, 2019, during a helmet-to-helmet collision against the Baltimore Ravens, horrified viewers witnessed him drop to the ground, unconscious. Anyone watching the game, or the serious playback commentary that followed, may have noticed that Rudolph lay on the ground in an unusual position, with his right arm extended, hand seemingly pointing, and his left arm flexed upwards. This particular posturing position is known as the asymmetrical tonic neck reflex (ATNR) or the “fencing reflex” since it resembles the “en garde” stance taken during fencing.
What Is Asymmetrical Tonic Neck Reflex (ATNR)
When concussion specialists see this position, we believe there has been a traumatic injury. We assume that there’s a shock to the higher cerebral cortex, a crucial part of the brain that supervises over the primitive brain function that automatically controls critical functions, like breathing, heart rate, body temperature, etc.
Studies show that the fencing position has been known to happen right before convulsion in sports injuries. So why was Rudolph allowed to walk (with support) off the field? The question has been hotly debated on television and online. ESPN analytst Rex Ryan noted: “[Was] he in any kind of condition to make that decision? I don’t think so. I thought it was handled poorly.”
Why Does the Fencing Reflex Occur After a Traumatic Brain Injury?
The fencing position is common after someone has experienced an acceleration/deceleration injury of the brain as this soft brain tissues slams into the hard skull and this bruising of the higher functioning cerebrum (aka gray matter) temporarily shuts down its function and lets the primitive brain stem temporarily take over. In the case of Mason Rudolph while he was scrambling out of the pocket he was accelerating. Then he was suddenly stopped or decelerated by the collision with the Baltimore defenders. His higher functioning gray matter was temporarily shut down as he lay unconscious and his primitive brain stem took over resulting in the primitive reflex or posture we call the fencing reflex.
The position is like how newborns sometimes sleep, with one arm flexed and the other extended out with their head facing the extended arm, again, sort of like a fencing athlete. Like many aspects of brain research, there are theories why such primitive reflexes still exist and may have benefits. The primitive rooting reflex that causes a baby to automatically turn its head toward where his/her face is touched helps a baby to be more successful with breastfeeding. With the primitive fencing reflex there are theories that it may have some benefit for the baby coming out of the birth canal. Other theories point to possible benefit of the development of hand-eye coordination.
Was Rudolph’s Head Injury Handled Correctly After He Displayed the Fencing Position?
Many individuals were shocked to see Rudolph walk off the field, even while supported. Protocol, for a head trauma that is enough to knock out an athlete, would be to use a neck collar and a hard backboard and immediate transport the player to an ER for further evaluation.
Rudolph was put in the concussion protocol and cleared from concussion protocol on October 16, 2019. It is hoped that after being cleared of any deficits in his vestibular ocular motor exam (convergence, SACCADES and VOR), he remains symptom free and fully returned to normal on his cognitive testing. If these objective parameters are not returned to normal and a second concussion occurs before the first concussion is not completely cleared, long-term issues may occur including:
- Migraine headaches
- New onset ADD
- Memory deficits
- Anxiety/depression
- And, in rare instances, Second Impact Syndrome (SIS).
SIS occurs in about 300 cases per year and results in severe mental and physical impairment or even death from sudden swelling of the brain inside the skull.
For more on protocols for athletes, please read our blog post on concussion protocols. It also includes our free MAC Alliance protocol download.
[Originally posted on 11.09.2019]
[Post updated on 7.11.2020]
[Post updated on 10.01.2022]
[Post updated on 1.31.2024]
[Post updated on 9.13.2024]
