I’d been meaning to do a podcast on concussion with Thomas Fallon, a clinical specialist musculoskeletal physiotherapist, sports medicine researcher at Queen’s University Belfast, and PhD candidate in cycling injury epidemiology, for over a year. But as if to highlight the importance of this episode, that podcast only happened after I suffered a suspected concussion of my own recently.
Concussions are one of the most overlooked and insidious injuries in professional cycling. Unlike broken bones or deep abrasions, concussions are invisible, yet they can have long-term consequences that impact brain function, mental health, and even life expectancy. Research by Fallon has shed new light on just how frequently concussions occur in cycling and how poorly they are diagnosed and managed.
A forthcoming systematic review, currently in peer review with the academic journal BMJ Open Sport and Exercise Medicine, highlights that road cycling has the highest proportion of head, neck, and facial injuries of all cycling disciplines and yet also has one of the lowest reported rates of concussions. This suggests that many concussions go undiagnosed, leaving riders at risk of serious long-term complications. In fact, research has not only highlighted the underreporting of concussions in cycling but has also drawn attention to the lack of structured protocols for diagnosis and recovery. In this week’s Performance Process podcast and this article, we break down what actually happens during a concussion, why cycling is failing to address the issue, and what needs to change to make the sport safer.
Fallon is one of the leading voices in concussion research within cycling. His work has focused on understanding injury and illness in professional cycling, including the long-term effects of concussions. Fallon has been involved in large-scale studies tracking over a million kilometres of racing and training data, providing some of the most comprehensive insights into the prevalence and management of head injuries in the sport. He himself suffered several concussions – including a particularly nasty one – in a racing career which saw him compete internationally on the road and track.
Through his academic work, presentations at international conferences, and collaborations with professional teams, Fallon has become a crucial advocate for improving concussion management and making cycling safer for all athletes.
What is a concussion?
A concussion is a mild traumatic brain injury (TBI) that occurs when an external force causes the brain to move rapidly within the skull. This movement can stretch and damage brain cells, leading to chemical imbalances that affect cognitive function, coordination, and overall brain health. Unlike fractures or muscle injuries, concussions do not show up on standard medical imaging, making them harder to diagnose. (As a note, "mild" is both a formal classification and a relative one, mild only in comparison to more serious injuries; even in a mild TBI, victims can lose consciousness and have an altered mental state on reawakening.)
There are three main mechanisms that cause a concussion:
- Direct impact: A blow to the head, such as hitting the ground during a crash.
- Rapid deceleration: A sudden stop, where the brain continues to move inside the skull even if there is no direct head impact (for example, whiplash).
- Rotational forces: Twisting motions that cause the brain to shear within the skull, damaging neural connections.
When a concussion occurs, the brain experiences a cascade of physiological changes. The impact disrupts normal cellular function, leading to an excessive release of neurotransmitters, which overstimulates nerve cells and depletes their energy stores. At the same time, blood flow to the brain may decrease, making it harder for the brain to recover from the injury. This energy crisis can impair normal neural communication, leading to symptoms such as confusion, dizziness, and difficulty processing information.
One of the challenges with concussions is that they do not always present with immediate symptoms. A rider may experience an impact but feel relatively normal in the minutes or even hours afterward. However, as the brain struggles to restore its chemical balance, symptoms such as headaches, nausea, fatigue, and cognitive impairment can develop. This delayed onset is exactly what I experienced following a recent crash which ultimately saw me check myself into hospital with excruciating headaches a full 36 hours post-crash. It also makes it difficult for both athletes and medical staff to diagnose concussions in real time, increasing the risk that a rider will continue competing (or training) while unknowingly suffering from brain trauma.
Additionally, repeated concussions can have compounding effects, as prior brain injuries make the brain more vulnerable to subsequent impacts. Furthermore, a concussion increases the likelihood of subsequent crashes on the same day due to the impaired reaction time and decision-making it can cause.
Worse still, the more concussions an individual sustains, the longer it typically takes to recover, and the greater the risk of lasting cognitive and neurological issues. This is why concussion management and proper recovery protocols are so critical for athletes in high-risk sports like cycling.
Common concussion symptoms and red flags
Concussions can present with a wide variety of symptoms, and, as previously mentioned, not all of them appear immediately. Symptoms can be grouped into four main categories: physical, cognitive, emotional, and sleep-related.
- Physical symptoms:
- Headache or pressure in the head
- Dizziness or balance problems
- Nausea or vomiting
- Sensitivity to light and noise
- Fatigue or drowsiness
- Blurred or double vision
- Ringing in the ears (tinnitus)
- Neck pain or stiffness
- Cognitive symptoms:
- Confusion or feeling “foggy”
- Difficulty concentrating or remembering things
- Slowed reaction times
- Difficulty processing new information
- Feeling disoriented or having trouble finding words
- Feeling mentally slower than usual
- Emotional and behavioral symptoms:
- Mood swings, irritability, or emotional instability
- Increased anxiety or panic attacks
- Depression or feelings of sadness
- Lack of motivation or apathy
- Increased frustration or aggression
- Sleep-related symptoms:
- Difficulty falling asleep or staying asleep
- Sleeping too much or feeling unusually drowsy
- Feeling unrested even after sleep
- Disturbances in normal sleep cycles
Red flags: When to seek immediate medical attention
While most concussions resolve with proper management, some can result in more serious complications. The following red-flag symptoms indicate a potentially severe brain injury and require immediate medical evaluation:
- Loss of consciousness, even for a brief moment
- Repeated vomiting
- Severe or worsening headache
- Slurred speech or difficulty speaking
- Seizures or convulsions
- Weakness or numbness in limbs
- Unequal pupil size or difficulty focusing vision
- Extreme drowsiness or difficulty staying awake
- Persistent confusion or inability to recognise people or places
- Agitation or significant behavioral changes
If any of these symptoms are present, the affected individual should be taken to a hospital immediately. A concussion should never be dismissed, and riders should always err on the side of caution when dealing with head injuries.
What should a cyclist do immediately after a crash if they suspect a concussion? If a cyclist crashes and suspects a concussion, immediate action is critical to ensure safety and proper recovery. Here’s what they should do:
- Stop riding immediately – Continuing to ride can worsen symptoms and increase the risk of further injury. If a concussion is suspected, the safest course of action is to stop and assess.
- Assess symptoms – Riders should perform a quick self-check or have a teammate help:
- Do they feel dizzy, nauseous, or disoriented?
- Are they experiencing a headache or pressure in the head?
- Do they have blurred vision or difficulty focusing?
- Are they struggling to recall details of the crash?
- Are they slurring words or feeling foggy?
- Seek medical evaluation – If any concussion symptoms are present, a rider should be evaluated by a medical professional before deciding whether to continue. If medical staff are unavailable, they should not return to riding.
- Avoid exertion – Even if symptoms seem mild, any physical exertion –including light pedaling –can worsen brain trauma. The first 24-48 hours should involve complete rest from both physical and cognitive activities.
- Monitor symptoms – Concussion symptoms can be delayed, meaning a rider may feel fine immediately after a crash but develop issues later. The rider and those around them should keep an eye out for worsening headaches, vomiting, confusion, or extreme fatigue.
- Do not take painkillers immediately – Painkillers like ibuprofen or aspirin can increase the risk of bleeding in the brain. If medication is needed, paracetamol (acetaminophen) is the safer choice, but a doctor should be consulted first.
- Follow a gradual return-to-ride protocol – Detailed below.
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