Residency · Residency · Orthopedic Surgery
Concussion Management and Return-to-Play Protocols
Introduction
Sport-related concussion (SRC) is a traumatic brain injury induced by biomechanical forces that results in a complex pathophysiological process affecting the brain. It is one of the most common injuries in contact and collision sports, with an estimated 1.6 to 3.8 million sport-related concussions occurring annually in the United States. Orthopedic surgeons serving as team physicians must be proficient in the recognition, evaluation, management, and return-to-play decision-making for concussed athletes.
Pathophysiology
Concussion triggers an ionic flux cascade involving potassium efflux and sodium and calcium influx across neuronal membranes. This produces increased metabolic demand coupled with decreased cerebral blood flow, creating an energy crisis. Glutamate release leads to excitotoxicity and further metabolic dysfunction, while axonal stretching causes diffuse axonal injury without macroscopic structural damage. Recovery involves restoration of ionic homeostasis and metabolic balance, typically occurring over 7 to 10 days in adults and longer in adolescents.
Sideline Recognition and Assessment
Any athlete suspected of having a concussion should be immediately removed from play. Red flags requiring emergency transfer include deteriorating consciousness, seizure, increasing confusion, neck pain, vomiting, and worsening headache. Standardized sideline assessment tools include the Sport Concussion Assessment Tool (SCAT6), a comprehensive tool incorporating symptom checklist, cognitive screening, and balance testing; Maddocks questions, which assess orientation to the game situation rather than time, place, or person; and the Balance Error Scoring System (BESS), which evaluates postural stability. Concussion is a clinical diagnosis with no single test being diagnostic. The guiding principle is straightforward: when in doubt, sit them out.
Signs and Symptoms
Physical symptoms include headache (the most common), dizziness, nausea, balance problems, visual disturbance, photophobia, and phonophobia. Cognitive symptoms include feeling in a fog, difficulty concentrating, memory impairment, and slowed processing. Emotional symptoms include irritability, sadness, anxiety, and emotional lability. Sleep disturbances include drowsiness, insomnia, and sleeping more or less than usual. Symptoms may be delayed in onset by minutes to hours after the injury.
Diagnostic Evaluation
Neuroimaging with CT or MRI is typically normal in concussion and is indicated only to rule out structural injury such as hemorrhage or fracture when red flags are present. Neuropsychological testing using computerized platforms like ImPACT and C3 Logix provides baseline and post-injury comparisons for cognitive function. Vestibular and oculomotor screening (VOMS) assesses vestibular-ocular function, and balance and gait assessment complements the evaluation. No biomarker or imaging study can currently confirm or exclude concussion in isolation.
Acute Management
Physical and cognitive rest is recommended for the initial 24 to 48 hours after injury. After this acute rest period, sub-symptom threshold activity should begin, including light aerobic exercise, limited screen time, and gradual return to school. Prolonged strict rest is no longer recommended and may actually delay recovery. Symptom management includes acetaminophen for headache (avoiding NSAIDs initially due to bleeding risk and avoiding narcotics), sleep hygiene counseling and melatonin for sleep disturbance, vestibular rehabilitation therapy for vestibular symptoms, and cognitive behavioral therapy or referral to a sports psychologist for mood symptoms.
Return-to-Play Protocol
| Stage | Activity | Objective | Minimum Duration |
|---|---|---|---|
| 1 | Symptom-limited daily activities | Gradual reintroduction of activities | 24 hours |
| 2 | Light aerobic exercise (walking, cycling < 70% max HR) | Increase heart rate | 24 hours |
| 3 | Sport-specific exercise (running drills, no head impact) | Add movement | 24 hours |
| 4 | Non-contact training drills, progressive resistance | Increase exercise, coordination, cognitive load | 24 hours |
| 5 | Full-contact practice (requires medical clearance) | Restore confidence; assess functional skills | 24 hours |
| 6 | Return to competition | Full unrestricted participation | — |
The Consensus Statement on Concussion in Sport (Berlin 2016, Amsterdam 2022) outlines a graduated return-to-play protocol with six stages. Stage 1 involves symptom-limited daily activities without symptom provocation. Stage 2 introduces light aerobic exercise such as walking, swimming, or stationary cycling at less than 70% maximum heart rate. Stage 3 adds sport-specific exercise including running drills with no head impact. Stage 4 progresses to non-contact training drills with complex drills and progressive resistance training. Stage 5 requires medical clearance for full-contact practice. Stage 6 is return to competition with full unrestricted participation.
Each step requires a minimum of 24 hours without symptom exacerbation before progressing. If symptoms recur, the athlete returns to the previous asymptomatic stage. Medical clearance is mandatory before return to full contact. Children and adolescents should follow a more conservative timeline.
Special Populations
Adolescents typically experience longer recovery (2 to 4 weeks versus 7 to 10 days in adults) and should follow a more conservative return-to-play protocol. Athletes with prior concussions face an increased risk of subsequent concussion and may have prolonged recovery. Same-day return to play is never permitted under current guidelines. Second impact syndrome, though rare, is catastrophic, involving diffuse cerebral swelling after premature return, which underscores the importance of complete recovery before clearance.
Persistent Post-Concussive Symptoms
Persistent symptoms are defined as those lasting beyond 4 weeks and occur in approximately 10 to 30% of concussed athletes. Management requires a multidisciplinary team including neurology, neuropsychology, vestibular therapy, and vision therapy. Active rehabilitation with sub-symptom threshold aerobic exercise (using the Buffalo Concussion Treadmill Test) is beneficial. Cervicogenic contributions and mood disorders should be considered as modifying factors.
Retirement Considerations
There are no universally accepted criteria for sport retirement after concussion. Factors to consider include the number of prior concussions, decreasing force threshold needed to cause symptoms, prolonged recovery patterns, and persistent cognitive deficits. Shared decision-making with the athlete, family, and multidisciplinary team is essential. There is emerging concern about long-term neurodegenerative consequences including chronic traumatic encephalopathy (CTE).
Clinical Pearls
When in doubt, sit them out: any athlete with suspected concussion must be removed from play immediately. Concussion is a clinical diagnosis, and normal imaging does not exclude it. Brief initial rest of 24 to 48 hours followed by graduated sub-symptom threshold activity is the current standard of care. The minimum return-to-play timeline is 6 days after symptom resolution using the stepwise protocol. Adolescents require more conservative management and longer recovery timelines than adults.
References
- Patricios JS, Schneider KJ, Dvorak J, et al. "Consensus Statement on Concussion in Sport: The 6th International Conference on Concussion in Sport." British Journal of Sports Medicine. 2023;57(11):695-711.
- McCrory P, Meeuwisse W, Dvorak J, et al. "Consensus Statement on Concussion in Sport: The 5th International Conference on Concussion in Sport." British Journal of Sports Medicine. 2017;51(11):838-847.
- Leddy JJ, Haider MN, Ellis MJ, et al. "Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial." JAMA Pediatrics. 2019;173(4):319-325.
- Harmon KG, Clugston JR, Dec K, et al. "American Medical Society for Sports Medicine Position Statement on Concussion in Sport." British Journal of Sports Medicine. 2019;53(4):213-225.