Why Head Injuries Go Unreported in the Military and in Sports

We ground aircraft over warning lights.

If an F-35 shows one system behaving slightly abnormally, that aircraft does not fly. It stays on the ground until every reading is where it should be. Nobody argues about it, nobody suggests the plane push through, and nobody treats grounding it as a mark against the aircraft.

Now consider the pilot.

A pilot sustains a head injury and reports that he can't see straight. He comes off the flight roster — and in many cases, off the team entirely. The organization moves to the next person.

We invested enormously in both. One gets protected until it's right. The other gets replaced.

How Many Head Injuries Are We Actually Talking About?

The Defense Health Agency's Traumatic Brain Injury Center of Excellence tracks this. From 2000 through the third quarter of 2025, **533,519 service members** were diagnosed with a traumatic brain injury. Of those, **436,895 were classified as mild** — roughly 82% of the total (TBICoE, 2026).

One detail in how that count is kept matters. If a service member has had more than one traumatic brain injury, only one is counted. So the figure describes people, not injuries, and the number of actual events behind it is higher.

And it only counts the ones that were reported.

What Does the Reporting Penalty Do to the Numbers?

Military populations are exceptionally good at *not* reporting head injuries when they happen, and that has been measured directly.

In an anonymous survey of 5,174 Army soldiers, 10% reported having sustained one or more mild traumatic brain injuries during their military careers. Of those, only **52% sought medical care**. Among the ones who didn't, 64% said they didn't think the injury required care — and **18% said they feared a negative impact on their career**. The same paper cites earlier work finding that among previously deployed service members who experienced a mild traumatic brain injury, **57% did not seek medical care** (Escolas et al., 2020).

The reason isn't complicated, and it isn't about toughness.

If saying "I need help" reliably costs you your position, your team, your incentives, your promotion track, and your identity, then the rational response is to not say it. That calculation gets made instantly and it gets made correctly. Given those consequences, staying quiet is the sensible choice for the person making it.

You cannot fix that with encouragement. As long as reporting carries a penalty, people will decline to report, and no amount of messaging about the importance of speaking up will change the arithmetic.

Does the Same Thing Happen in Sports?

The same structure operates in sports, with different specifics and identical logic.

In a study of 1,532 high school football players, 15.3% sustained a concussion during that season — and only 47.3% of those injuries were reported. Just over half went undisclosed. The reasons the players gave are worth looking at directly (McCrea et al., 2004).

Two of those three reasons are about knowledge — not recognizing the injury as significant, or not recognizing it as a concussion at all. That is an education problem, and it is fixable.

The third one is different. Forty-one percent stayed quiet specifically because they did not want to be held out of competition. That is not ignorance. That is a person accurately reading the consequences and acting on them.

A separate study of high school athletes found disclosure rates lower still: 40% of concussion events and only 13% of what players called "bell-ringer" events were reported (Register-Mihalik et al., 2013). It was a small preliminary study, so I'd hold the exact numbers loosely — but the direction is consistent everywhere anyone has looked.

Report the hit and you lose playing time, position, scholarship consideration, and standing. The arithmetic is the same as the pilot's.

"Maybe You Just Can't Handle It"

There's a second problem, and it's the one I find hardest to accept.

When someone is exposed to a blast, or sustains repeated head impacts, and then isn't doing well — the explanations offered often circle back to the person. Talk to someone. Get support for the stress. And underneath it, sometimes stated and sometimes not: perhaps this is more than you can handle.

Try saying that to a tier-one operator.

Consider what that person has already demonstrated they can handle. The selection process alone eliminates almost everyone. Their entire professional existence is built around functioning under conditions that would incapacitate most people. Suggesting that the intensity of the work exceeded their capacity misreads the situation completely.

**What they cannot handle is not the intensity. It's the pathophysiological damage.**

Their thoughts are spinning out of control. Their [sympathetic nervous system is running continuously](post-why-fight-or-flight-shuts-down-digestion-immunity-and-thinking.html) and won't stand down. Their sleep is destroyed. Their cognition has degraded in ways they can measure against who they used to be. They are asking for someone to explain why they cannot function when their determination hasn't changed at all.

That's not a character problem being described. It's a physiological one, and the person describing it usually knows the difference even when nobody else does.

What Would Actually Change This?

The way out involves three layers, and they have to be aligned in a specific order.

**Physiology first.** What actually happened in the injury determines what treatment makes sense. If we don't understand the mechanism, everything built on top of it is guesswork.

**Policy has to match the physiology.** A policy written around an incorrect understanding of the injury is a failing model no matter how carefully it's enforced. If a protocol says to watch, wait, and manage symptoms because it assumes an injury we can't find, it will keep producing the same outcomes. You cannot enforce your way out of a wrong premise.

**Culture has to match the policy.** This is the hardest of the three, and it's where most efforts fail. You can write an excellent, physiologically sound policy, and if the surrounding culture punishes the person who uses it, that policy will sit unused. People respond to consequences, not to documents.

Get all three aligned and the whole picture changes. Miss any one and the other two can't compensate.

What Is This Actually About?

The argument for changing this isn't primarily compassionate, though I think compassion is warranted. It's practical.

These are the people organizations invested the most in. The trained ones. The seasoned ones. The ones who took years and enormous expense to develop, whose judgment cannot be replaced by someone new. Veterans, in the literal sense of that word.

Losing them to an injury we could identify and address is an avoidable loss, and it's happening constantly.

The alternative isn't lowering standards. It's building a system where reporting an injury leads to an actual evaluation, an accurate diagnosis, and a return — the same way we treat that F-35. Ground it, find the problem, fix the problem, put it back in service.

That requires a policy built on [what actually happens in these injuries](post-why-whiplash-and-concussion-produce-the-same-symptoms.html), and a culture where using that policy doesn't end a career.

Did You Stay Quiet About an Injury?

If you didn't report a head injury at the time — or reported it and were cleared without much of an evaluation — and you've been dealing with the consequences since, that history is worth revisiting.

Investigating what actually happened, and what it left behind, is the work we do at Cerebral. If you or someone you serve with is still struggling, we're here.

References

• Traumatic Brain Injury Center of Excellence, Defense Health Agency. DOD TBI Worldwide Numbers. U.S. Department of Defense, Military Health System. https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/DOD-TBI-Worldwide-Numbers
• Escolas SM, Luton M, Ferdosi H, et al. Traumatic brain injuries: unreported and untreated in an Army population. *Military Medicine*. 2020;185(Suppl 1):154–160. https://doi.org/10.1093/milmed/usz259
• McCrea M, Hammeke T, Olsen G, et al. Unreported concussion in high school football players: implications for prevention. *Clinical Journal of Sport Medicine*. 2004;14(1):13–17. https://pubmed.ncbi.nlm.nih.gov/14712161/
• Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, et al. Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. *Journal of Athletic Training*. 2013;48(5):645–653. https://pubmed.ncbi.nlm.nih.gov/23848520/