Residency · Residency · Family Medicine

Sports Concussion: Evaluation and Return-to-Play Protocols

Overview

Concussion is a mild traumatic brain injury caused by biomechanical forces transmitted to the brain. Family physicians frequently manage concussions in athletes and non-athletes alike. Accurate diagnosis, symptom management, and adherence to graduated return-to-learn and return-to-play protocols are essential to prevent prolonged recovery and second impact syndrome.

Definition and Pathophysiology

Concussion is a functional disturbance of the brain caused by direct or indirect force, and neuroimaging is typically normal. The underlying pathophysiology involves a neurometabolic cascade characterized by ionic shifts, indiscriminate glutamate release, an energy crisis, and impaired cerebral blood flow autoregulation. Most symptoms resolve within 10 to 14 days in adults and 2 to 4 weeks in children and adolescents. Importantly, loss of consciousness is not required for diagnosis and occurs in fewer than 10% of concussions. Structural brain injury is absent on standard CT and MRI.

Sideline Assessment

Immediate Actions

Any athlete suspected of having a concussion should be removed from play immediately. The initial assessment should evaluate for cervical spine injury and red flags including deteriorating consciousness, focal neurological deficits, seizure, and repeated vomiting. The guiding principle is "when in doubt, sit them out."

Assessment Tools

The SCAT6 (Sport Concussion Assessment Tool, 6th Edition) is a standardized sideline assessment for athletes aged 13 and older. Its components include immediate memory, orientation, a symptom checklist, cognitive screening, balance examination (modified BESS), and delayed recall. The Child-SCAT6 is designed for ages 5 to 12. The King-Devick test is a rapid number naming test that is sensitive to saccadic eye movement dysfunction after concussion. Maddocks questions assess orientation to game-specific context such as the opponent, score, and period. The Standardized Assessment of Concussion (SAC) is the cognitive component of the SCAT.

Red Flags Requiring Emergency Transfer

Red flags that warrant emergency transfer include a GCS below 15, suspected skull fracture or penetrating injury, seizure, progressive neurological deterioration, persistent vomiting, double vision, increasing confusion or agitation, and weakness or tingling in the extremities suggesting cervical spine involvement.

Office-Based Evaluation

History

The office evaluation should gather information about the mechanism of injury and acute symptoms, loss of consciousness, amnesia (both retrograde and anterograde), and current symptoms using a validated checklist. Prior concussion history including the number and recovery duration of previous injuries is important. Pre-existing conditions such as migraine, ADHD, anxiety or depression, and learning disabilities should be documented, along with current medications.

Symptom Assessment

The Post-Concussion Symptom Scale (PCSS) is a 22-item self-report tool that tracks symptom severity over time. Physical symptoms include headache, dizziness, nausea, visual disturbance, balance problems, sensitivity to light and noise, and fatigue. Cognitive symptoms include difficulty concentrating, memory problems, mental fogginess, and slowed processing. Emotional symptoms include irritability, sadness, anxiety, and emotional lability. Sleep symptoms include drowsiness, difficulty falling asleep, and sleeping more or less than usual.

Physical Examination

The neurological exam should assess cranial nerves, strength, sensation, coordination, and reflexes. Vestibular and oculomotor screening (VOMS) evaluates smooth pursuits, saccades, convergence, the vestibulo-ocular reflex (VOR), and visual motion sensitivity. A near point of convergence greater than 6 cm is abnormal, and symptom provocation with each maneuver is clinically significant. Balance assessment uses the modified BESS (Balance Error Scoring System) and tandem gait. The cervical spine examination includes range of motion, tenderness, and provocative maneuvers.

Neuroimaging

Routine neuroimaging is not recommended for diagnosed concussion. CT of the head is indicated when red flags are present, focal neurological deficits exist, symptoms are worsening, GCS is below 15, the patient is on anticoagulants, or skull fracture is suspected. The Canadian CT Head Rule or PECARN criteria (in pediatric patients) guide imaging decisions. MRI may be obtained if symptoms persist beyond 30 days to exclude structural pathology but is typically normal in concussion.

Management

Acute Phase (First 24-48 Hours)

Management in the acute phase involves relative rest rather than complete dark-room rest, with brief periods of cognitive and physical activity as tolerated. Activities with a risk of re-injury should be avoided, and screen time should be limited if it exacerbates symptoms. Acetaminophen is appropriate for headache, though the recommendation to avoid NSAIDs in the first 48 hours due to theoretical bleeding risk is debated. Adequate sleep and hydration should be encouraged, and the patient should be monitored for worsening symptoms.

Graduated Return-to-Play Protocol

Active Rehabilitation (After 24-48 Hours)

There has been a paradigm shift in concussion management: early sub-threshold aerobic exercise within 48 hours has been shown to improve recovery compared to strict rest. The Buffalo Concussion Treadmill Test determines the symptom-exacerbation threshold, and exercise is prescribed at 80% of that threshold heart rate. Activity should be gradually increased as tolerated. Physical therapy is indicated for vestibular and cervical dysfunction. Cognitive pacing, which involves returning to cognitive activities with breaks as needed, is also recommended.

Symptom-Specific Treatment

Headache is managed with acetaminophen and NSAIDs after the acute phase; migraine-type headaches may respond to triptans, though opioids and butalbital should be avoided. Vestibular symptoms are addressed with vestibular rehabilitation therapy, and canalith repositioning is indicated if concurrent BPPV is present. Oculomotor dysfunction is managed with vision therapy through an optometrist or neuro-ophthalmologist. Sleep disturbance is treated with sleep hygiene measures and melatonin 3 to 5 mg, while sedative-hypnotics should be avoided. Mood symptoms are addressed with CBT and counseling, with SSRIs considered for persistent depression. Cognitive difficulties benefit from cognitive rehabilitation and academic accommodations.

Return-to-Learn Protocol (Children/Adolescents)

The return-to-learn protocol progresses through four stages. Stage 1 involves daily activities at home with symptom-limited cognitive activity. Stage 2 allows return to school with accommodations including reduced workload, extra time, breaks, limited screen time, and no standardized testing. Stage 3 involves a gradual increase in academic workload with reduction of accommodations as tolerated. Stage 4 is full academic workload without accommodations. Each stage requires a minimum of 24 hours, and the student can progress if symptoms are not significantly worsened. Return-to-learn should be completed before return-to-play in student athletes.

Return-to-Play Protocol (Graduated RTP)

The graduated return-to-play protocol should begin only when the athlete is symptom-free at rest and off symptom-modifying medications, though expert opinion varies on this requirement. A minimum of 24 hours should be spent at each stage, and the athlete should return to the previous stage if symptoms recur.

Stages

Stage 1 involves symptom-limited activity consisting of daily activities that do not provoke symptoms. Stage 2 introduces light aerobic exercise such as walking, swimming, or stationary cycling at less than 70% of maximum heart rate, with no resistance training. Stage 3 involves sport-specific exercise including running and skating drills, but no head-impact activities. Stage 4 consists of non-contact training drills with the introduction of resistance training and increased complexity. Stage 5 is full-contact practice after medical clearance, with coaching staff assessing functional skills. Stage 6 is the return to competition.

Timeline

For adults, the minimum timeline from symptom resolution to return to play is 6 days, at one day per stage. Children and adolescents require a more conservative approach, with a minimum of 7 to 10 days per many protocols. No same-day return to play is permitted at any level, which is a consensus recommendation.

Prolonged Recovery / Post-Concussion Syndrome

Prolonged recovery is defined as symptoms persisting beyond the expected recovery window, which is more than 14 days in adults and more than 4 weeks in children. Risk factors include female sex, prior concussions, migraine history, psychiatric history, ADHD, learning disabilities, and a high initial symptom burden. Evaluation should include consideration of MRI, neuropsychological testing, and vestibular assessment. Management centers on active rehabilitation, targeted symptom treatment, and a multidisciplinary approach. Most patients recover fully, and reassurance combined with graduated activity is essential. Referral to a concussion specialty clinic should be considered.

Chronic Traumatic Encephalopathy (CTE)

CTE is a neurodegenerative disease associated with repetitive head impacts, not just concussions. The pathology involves perivascular deposition of hyperphosphorylated tau protein, and CTE can currently only be definitively diagnosed post-mortem. When symptomatic, clinical features include cognitive impairment, behavioral and mood changes, and motor dysfunction. Risk communication requires caution, as research is ongoing, and definitive prognostic statements to patients and families should be avoided. Shared decision-making about continued contact sport participation is essential.

Special Populations

Children and adolescents generally require longer recovery periods and more conservative return-to-play approaches, with school accommodations being critical. Female athletes may have higher concussion rates and longer recovery, with hormonal factors under investigation. Athletes with prior concussions face cumulative risk, and a lower threshold for retirement discussion is appropriate if recovery is prolonged or concussions are recurrent.

Medical Clearance

Medical clearance is a clinical decision, and no single test determines clearance. The athlete should be asymptomatic at rest and with exertion, have a normal neurological and vestibular examination, and have completed the graduated return-to-play protocol without symptom recurrence. Neurocognitive testing (such as ImPACT) compared to baseline should be considered if available. Clearance should be documented in writing.

<image>The six-stage graduated return-to-play protocol displayed as a stepwise progression from symptom-limited activity through light aerobic exercise, sport-specific exercise, non-contact training, full-contact practice, and return to competition, with minimum time at each stage, activity examples, and criteria for advancing or returning to a previous stage.</image>

<image>The VOMS (Vestibular/Oculomotor Motor Screening) assessment components showing the five domains tested (smooth pursuits, saccades, convergence, VOR, visual motion sensitivity), the technique for each test, normal versus abnormal findings, and the symptom provocation scoring system used to track recovery.</image>

<image>A concussion management timeline showing the acute phase (first 24-48 hours with relative rest), active rehabilitation phase (sub-threshold aerobic exercise beginning within 48 hours), symptom-specific treatment options, the return-to-learn protocol (4 stages), and the return-to-play protocol (6 stages), with decision points for escalation to specialist referral if recovery is prolonged.</image>

Clinical Pearls

Loss of consciousness is not required for concussion diagnosis and occurs in fewer than 10% of cases; amnesia, confusion, and symptom burden are more important diagnostic features. The paradigm has shifted from strict rest to early active rehabilitation, with sub-threshold aerobic exercise within 24 to 48 hours of concussion improving recovery time. No same-day return to play is a universal recommendation regardless of age, level of competition, or apparent symptom resolution. Return-to-learn should be completed before return-to-play in student athletes, as academic recovery takes priority. Prolonged symptoms beyond 2 to 4 weeks should prompt vestibular and oculomotor screening, since vestibular dysfunction is the most treatable cause of prolonged post-concussion symptoms. A near point of convergence greater than 6 cm is one of the most sensitive clinical signs for concussion and is easy to assess in the office. Neuroimaging is normal in concussion by definition, and CT is only indicated for red flags suggesting structural injury. Multiple concussions warrant a serious discussion about cumulative risk and potential retirement from contact sports, using shared decision-making.

References

• Patricios JS et al. Consensus Statement on Concussion in Sport: The 6th International Conference (Amsterdam 2022). Br J Sports Med. 2023
• Leddy JJ et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion (RCT). JAMA Pediatr. 2019
• McCrory P et al. Consensus Statement on Concussion in Sport: The 5th Berlin Conference. Br J Sports Med. 2017
• Harmon KG et al. AMSSM Position Statement: Concussion in Sport. Br J Sports Med. 2013
• Master CL et al. Vision and Concussion: VOMS Assessment. Neurology. 2020

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