HIA in rugby: head injury assessments, concussion and return to play in Wales

A player goes down after a tackle, walks off with the medical team, and the commentator says "HIA". At a club on a Saturday afternoon in the valleys, the same knock is handled very differently. This guide explains what an HIA is, what the community game does instead, how the graduated return to play works in Wales, and when a head injury needs A&E rather than a seat on the bench.

If someone has just hit their head and is getting drowsier, more confused, vomiting repeatedly or has had a fit, call 999 now. The full warning list is further down.

What is an HIA in rugby?

HIA stands for Head Injury Assessment. World Rugby describes the HIA Protocol as a four-stage process for elite adult teams, designed to help identify, diagnose and manage head impacts that could cause concussion. It works alongside the law allowing a temporary replacement for a head injury, which became permanent in elite adult rugby in April 2015.

The four stages are:

1. HIA1, during the match. When concussion is possible but not obvious, the player leaves the field for an off-field assessment. The temporary replacement lasts a set 12 minutes of real time, not playing time. A player with clear signs of concussion, which World Rugby calls criteria 1 signs, is removed immediately and permanently without that off-field check.
2. HIA2, the same day. Every player entered into the protocol has a medical evaluation within three hours of the end of the match.
3. HIA3, after two nights' rest. Further testing, including a computer-based thinking test, takes place 36 to 48 hours after the head impact.
4. HIA4, clearance. The player returns to full play only after individualised rehabilitation and clearance.

The later stages exist because concussion is not always obvious in the first few minutes. NHS inform notes that concussion symptoms can take up to 48 hours to appear, so passing the first check is not the end of the process.

What happens after a failed HIA?

A player who fails the off-field assessment, or shows criteria 1 signs, takes no further part in that match. They still complete the HIA2 and HIA3 reviews and an individualised rehabilitation programme before being cleared. How many days that takes depends on the player and the competition's regulations, so check the current rules rather than relying on a figure quoted from a past season.

Does community rugby use the HIA?

No. The WRU's 2024 concussion guidance is explicit that the HIA Protocol and the temporary substitution law apply only in elite adult matches and tournaments approved by World Rugby, and not in the community game.

Community rugby works on a simpler rule: recognise and remove. World Rugby's guidance says a player with a concussion, or even a suspected concussion, must be removed from play immediately and referred to a qualified healthcare professional trained in evaluating and treating concussion. The WRU makes clear that teammates, coaches, match officials, team managers, administrators and parents all share the job of getting that player off the pitch safely.

The WRU guidance then adds that the player:

• must not return to activity that day
• should be monitored by a responsible adult for the first 24 hours
• should not drink alcohol or drive until free of symptoms
• should be seen by a medical practitioner or NHS 111, even if the symptoms settle

If a neck injury is suspected, the player should only be moved by emergency healthcare professionals trained in spinal care.

The UK-wide grassroots guidelines sum all of this up as "If in doubt, sit them out". GOV.UK says they recommend calling NHS 111 within 24 hours of a possible concussion, resting and sleeping as much as needed for the first 24 to 48 hours, and avoiding screen time. They are aimed at people of all ages in all four home nations.

Signs to watch for on the touchline

The grassroots guidelines list visible clues and symptoms such as:

• loss of consciousness or not responding
• lying still on the ground or being slow to get up
• being unsteady on their feet or having balance problems
• confusion or a blank, vacant look
• headache, dizziness or changes in vision

When should a rugby player go to A&E after a head injury?

The WRU says a player should be taken for urgent assessment at the nearest hospital if any of these are reported or seen:

• severe neck pain
• weakness, or tingling or burning in the arms or legs
• becoming more drowsy
• increasing confusion or irritability
• a severe or worsening headache
• repeated vomiting
• an unusual change in behaviour
• a seizure (fit)
• double vision

The NHS advises calling 999 if someone has been knocked out and has not woken up, cannot stay awake or keep their eyes open, has clear fluid coming from their ears or nose, or has problems with their vision or hearing. If you are unsure, call NHS 111. Do not let the player drive.

How does the graduated return to play work in Wales?

The WRU says 80 to 90% of concussions resolve within a short period of 7 to 10 days. The return to rugby still takes longer than that, because the brain is more vulnerable to further injury while it recovers.

WRU guidance for community players, adults and children alike, sets out this sequence:

• Rest first. Complete physical and mental rest for the first 24 hours, or until symptoms have gone.
• Relative rest for at least a week. No strenuous exercise, with a gradual return to normal daily activities. Students should be back at school or full studies before exercising again.
• Approval to start. Once free of symptoms at rest, approval from a medical practitioner, NHS 111 or a physiotherapist is recommended before starting the graduated return to play.
• From day 8: sport-specific exercise.
• From day 10: non-contact training drills. Medical clearance is recommended before moving on.
• From day 15: unrestricted full training.
• From day 21 at the earliest: return to play.

These are minimum times. If symptoms come back at any stage, the player drops back to the previous stage, has at least 24 hours of rest without symptoms, and tries again. Anyone who does not recover within these timeframes needs longer.

The grassroots guidelines make the same point: no return to competition before day 21, and only after 14 days free of symptoms at rest. The NHS advises not playing contact sports for at least 3 weeks after a head injury. Guidance is reviewed from time to time, so check the current WRU version with your club or school.

Hyperbaric oxygen therapy is not part of any rugby return-to-play protocol, and it is not a way to get back on the pitch sooner.

Why does a second knock matter?

The WRU explains that a player who returns before fully recovering may prolong their symptoms, risk long-term health consequences, and expose themselves to further concussions that in rare cases could be fatal, because of severe brain swelling known as second impact syndrome. NHS inform describes the same condition as very rare, possible when concussions happen close together, and potentially fatal.

Less dramatic but far more common, the grassroots guidelines note that playing on with concussion symptoms can make them worse and significantly delay recovery. That is the reasoning behind "If in doubt, sit them out". One missed match is a small cost against those risks.

What about youth players?

World Rugby recommends a more conservative return to play for children and adolescents. The grassroots guidelines say young players may be more susceptible to concussion, take longer to recover, and are more susceptible to rare and dangerous complications, including death from a second impact before recovering from a previous concussion. Going back to school or college too early can also make symptoms worse.

For parents in Wales, the WRU's day 21 earliest return applies to child and adult community players alike, mental rest should be supported at home, and a return to school comes before a return to sport. If your child's symptoms are slow to settle, their return will take longer than the minimum, and their GP or NHS 111 can advise.

What if symptoms are still there months after a rugby concussion?

Both the WRU and the grassroots guidelines say that anyone with symptoms after 28 days should see their GP. Headaches, poor concentration, tiredness and sensitivity to light or noise that carry on for months are a different question from return to play, and they deserve a proper medical review.

Some people then ask about hyperbaric oxygen. The most relevant recent study is a 2025 double-blind, sham-controlled trial in adults whose brain injury had happened between 6 months and 10 years earlier. Participants had 40 sessions at 1.5 ATA or 40 sham sessions over 12 weeks. Across the 47 people analysed, symptom scores improved by 10.6 points with hyperbaric oxygen and 3.6 points with sham. The trial recruited about a third of its intended sample and was stopped when funding ran out and recruitment slowed.

An earlier US military trial of 72 service members, also using 40 sessions at 1.5 ATA, found no benefit over sham, and its authors suggested placebo effects could explain the improvement seen in both chamber groups.

So the evidence is mixed, it concerns symptoms that have lasted many months, and it is not a promise for any individual. Our head injury evidence page sets out the trials in more detail, who HBOT is not suitable for explains the safety screening, and what happens in an HBOT session describes the hour itself.

If you are months past a concussion, your GP has looked for other causes and you would like to talk the research through, you can see available times. No referral needed. Medical consultation included.