Lizzy Banks’ career was on an upward trajectory. The British cyclist came to the sport late but had been making up for lost time, winning two stages at the Giro d’Italia Women, and was on track to represent Team GB on the road at the delayed Tokyo Olympics.
But 30km into 2021’s Strade Bianche Donne, the then-30-year-old went down in a crash that would change everything, flipping over the handlebar and landing on her neck.
“When you have a crash involving the neck area, you lie there for a second, and think, ‘have I broken my neck? Can I move?’," she says. "After 30 seconds to a minute, you sit up, but I remember seeing stars. Before you know it, there's a mechanic with a new bike.”
Her racing instinct meant Banks was immediately back in the saddle and didn’t hang around to get checked by a medical professional – “I think there was one crash in my career where I didn’t get back on,” she says – and she completed the remaining 100km, finishing 48th.
Inspecting her wounds at the end of the race, Banks asked her team to check her helmet and spent the next 48 hours travelling home from Siena to Sheffield. Little did she know, she was in the early stages of concussion.
“There were all these signs I didn't realise at the time. I missed my flight – I've never missed a flight before – and I was completely distraught.
"I finally was on the train home, and standing on the platform, the lights on the notice board seemed a lot brighter than usual.
"I got a call from my sports director Carmen Small who wasn't at the race, and she said, ‘Are you all right? I've seen your helmet and it's destroyed’. I said, ‘I think I'm okay. I'll be careful. I know what to look out for’.
"That evening, I rode from Sheffield over to Hathersage, and I felt like I was swimming. It was the weirdest feeling ever. At that point, I knew something was wrong.”
Although it wasn’t Banks’ first concussion, the symptoms wouldn’t go away as they had done before. “I couldn't walk down the street," she recalls.
"If my husband was speaking to me, we couldn't have any other noise or music or anything in the background.
"I had to close my eyes when other people came round because looking at their face was so much energy for my brain.”
She enlisted the help of the Great Britain Cycling Team’s medical unit and was soon referred to a specialist neurophysiologist. “It was clear that it wasn't that simple, and it wasn't getting better,” says Banks.
A couple of months after the accident, she was taken off the list for Tokyo – “it was the biggest relief because I knew I couldn't do it, and I knew how unwell I was” – and spent the next 12 months recovering before returning to racing in March 2022.
What is a concussion?
Banks’ case was towards the extreme end of the scale, but Professor Mike Loosemore, who runs the concussion clinic at the Institute of Sport, Exercise and Health, says the length of symptoms doesn’t seem to relate to the severity of the initial injury. “It often can be something really quite trivial that causes it,” he says.
Professor Loosemore explains that a concussion is a minor traumatic brain injury and occurs when you get energy transmitted into your brain.
“It can either be through a direct blow to the head or rapid movement of the head, and rapid movements can be caused indirectly – for example, a whiplash type injury, or transmitted from falling from a height.
"You don't even have to land on your head; the energy [of the impact needs to be] transmitted to your brain.”
A concussion is the brain’s reaction to this energy. “It's neurological tissue and it works on a balance of chemical transmitters and electrical impulses. It’s susceptible to being moved around too much – it doesn't like it.”
There is a long list of symptoms, ranging from extreme (you’re knocked out) to minor, such as a slight headache, and they can appear immediately or be delayed for two-to-three days.
These symptoms can last up to two weeks, but if they go on longer than this, Loosemore suggests getting it checked out.
“Around 97% of cases are completely resolved within two weeks. If you've had symptoms of concussion for a lot longer, there are usually other issues that are causing the symptoms – vestibular ocular problems, cervical ocular problems, cervical proprioceptive problems, inner ear issues, migraines, autonomic nervous system dysfunction.
“There's lots of things that happen when your head moves quickly, particularly in the upper cervical spine, that can cause you longer-term problems.
"The trouble is that people just say ‘rest more’ or ‘we'll give you some tablets for dizziness’. But what you need to do is define what the issue is, and then once you have a diagnosis, you can do a treatment.”
Problems in the peloton
Banks’ concussion wasn’t an isolated incident in the peloton. High-profile cases include Jonas Vingegaard, who didn’t compete for two months after crashing on stage five of this year’s Paris-Nice, and Luke Rowe – the Welshman was forced to retire early because of a crash at the E3 Saxo Classic in March 2024.
In fact, a meta-analysis by Queen’s University Belfast’s Thomas Fallon found concussion accounted for 4.19% of road cycling injuries, while Sport Doktor's Dr Jelle Posthuma, who is Amstel Gold’s race doctor and works with the Dutch national team, believes it could be much higher.
“We have a big database in the Netherlands where we analyse all crashes that happen during Dutch races. We found a concussion rate of 11-12% – that's way more than we ever thought.”
Although half that of professional rugby, where recent data has shown concussion accounted for 24% of all injuries during the 2022-23 season, it highlights the risks of suffering a concussion in what is a non-contact sport.
Awareness in road cycling has grown because of cases such as Banks, Vingegaard and Rowe, while the UCI introduced its own concussion protocol for the 2021 season onwards.
A three-stage process that starts with an assessment immediately after the incident, before re-assessing after the race and then the day after, has the power to withdraw a rider from a race if they’re showing signs and symptoms of concussion.
Its application though, as Banks and Vingegaard found, isn’t perfect. “From their perspective, I totally get it – I went down, nobody checked me, so what are these race doctors doing?” says Posthuma.
But he explains that when there is a group of 20 riders who have hit the deck, concussion cases are at the bottom of his priorities.
“How we screen on the road is based on this strict structure, which we call the ABCD [airway, breathing, circulation, disability].
"If a rider is on the ground and isn't properly breathing, we should do something about that because it's life threatening.
“D is where all the tests for brain injuries or concussions comes in. By the time you get to checking people for concussions, they're either already gone or some team coach is already there.
“That's why [in the Netherlands] we also involve the mechanics, the coaches and the riders themselves to let people know that it's not only the responsibility of the race doctor – the race doctor is there to keep someone alive until the ambulance arrives.”
He suggests that in big crashes, he’d like to see races neutralised so all riders can be checked, while Banks argues technology is available that would be a lot more effective than the current testing protocol.
“There's a company called NeuroFlex, and they have a VR device and it measures vestibular ocular dysfunction. It’s an objective device, which measures real things like eye tracking that you cannot fake, and it can tell you the deficiency straight away.”
A gradual return
With results and performance-related financial incentives on the line, there can often be a conflict of interest when it comes to the peloton taking the effects of concussion seriously.
Research has even found that, despite professional cyclists having a concussion knowledge comparable to other sportspeople, “they portrayed a willingness to stay within a race when experiencing signs and symptoms of sports-related concussion”, with younger riders willing to take greater risks.
But what should amateurs do if they have a bang to the head when riding or racing? “If you're concerned that you have concussion at all, then you should stop cycling and take it easy for 48 hours, and then see how you feel,” says Loosemore.
“If you're feeling OK, then I'd start exercising again, and then see how you feel.
“There is the standard return to sport protocol, which is a graduated return, and if you're not being medically supervised, that usually takes around 24 days.
"It's a case of increasing your physical activity without any symptoms, allowing your brain to settle down. It’s graduated with increasing levels of physical activity and increasing complexity of activity. At the end of that, if you've got no symptoms, then you can return to sport.”
British Cycling’s Graduated Return to Play Protocol
Stage 1: a short period of relative rest (first 24-48 hours). Earliest return to sport-specific training is 14 days and only progress to the next stage if undertaken activity does not more than ‘mildly’ exacerbate existing symptoms.
Stage 2: focus on return to your normal daily activities outside of school or work, with light physical activity.
Stage 3: focus on increasing tolerance for thinking activities, including light aerobic activity in week 1-2.
Stage 4: focus on your return to study and work, with non-contact training allowed in week 2.
Stage 5: focus on your return to full academic or work-related activity. Unrestricted training activities is not allowed before week 3.
Stage 6: return to competition. This should not be reached before day 21 after your concussion (day 0 is the day of the concussion).
