Understanding of head injury assessment and return to play processes and associated factors in United States Major League Rugby players.

Objectives: Evaluate professional rugby players' self-reported perceived understanding of the head injury assessment (HIA) and return to play (RTP) processes and determine factors related to understanding and trust pertaining to these processes.

Methods: An electronic survey measured concepts of interest. A thematic analysis of player understanding was performed, and player statements were coded.

Results: 207 U.S. Major League Rugby (MLR) players participated (26.7 ± 3.4 years). HIA and RTP protocol understanding was not correlated with concussion history (p = 0.41). International rugby experience and trust regarding MLR support of the following protocols and opposing team medical staff practices varied in their relationship to HIA understanding. Trust that all MLR teams follow the same protocols was positively correlated with all HIA questions (ps < 0.03). No HIA questions were correlated with trust in their own team's medical staff. All trust questions were significantly correlated with RTP process understanding. Qualitative analysis identified four HIA- and RTP-related themes: education needs, staffing needs, HIA criticisms, and importance of player safety.

Conclusion: International playing experience and greater trust in the MLR and league stakeholders were associated with greater player understanding of the HIA and RTP protocols. These results provide insight into the importance of educating players on league-specific concussion protocols.