Sports Concussion: Symptoms and Return-to-Play Protocol

What is a sports concussion?

A concussion is a traumatic brain injury caused by a biomechanical force transmitted to the brain — either from a direct blow to the head or an indirect impact (such as a body check that causes the head to snap) that creates an acceleration-deceleration force 1Ref 1Harmon KG, Clugston JR, Dec K, Hainline B, Herring SA, Kane SF, Kontos AP, Leddy JJ, McCrea MA, Poddar SK, Putukian M, Wilson JC, Roberts WO (2019).American Medical Society for Sports Medicine position statement on concussion in sport.Concussion definition, symptom domains, graduated return-to-sport protocol, medical clearance requirements, same-day return prohibition2Ref 2McCrory P, Meeuwisse W, Dvorak J, et al. (2017).Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016.Six-step graduated return-to-sport protocol; conservative approach for youth athletes; second-impact syndrome context; early light aerobic activity in recovery.

Concussions do not usually cause structural damage visible on CT or MRI. The injury is functional: a disruption of neuronal activity from the mechanical force triggers a cascade of neurochemical changes that temporarily impair brain function. This is why a normal CT scan does not rule out a concussion.

Concussions occur across all contact and collision sports — football, ice hockey, soccer, rugby, lacrosse, wrestling, basketball — and in recreational activities. They also occur without loss of consciousness; most athletes with concussions do not lose consciousness.

What are the symptoms of a concussion?

Concussion symptoms span several domains 1Ref 1Harmon KG, Clugston JR, Dec K, Hainline B, Herring SA, Kane SF, Kontos AP, Leddy JJ, McCrea MA, Poddar SK, Putukian M, Wilson JC, Roberts WO (2019).American Medical Society for Sports Medicine position statement on concussion in sport.Concussion definition, symptom domains, graduated return-to-sport protocol, medical clearance requirements, same-day return prohibition2Ref 2McCrory P, Meeuwisse W, Dvorak J, et al. (2017).Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016.Six-step graduated return-to-sport protocol; conservative approach for youth athletes; second-impact syndrome context; early light aerobic activity in recovery3Ref 3Centers for Disease Control and Prevention (2025).Signs and Symptoms of Concussion.Concussion symptom recognition for athletes and parents; physical, cognitive, emotional, and sleep symptom domains:

Physical: - Headache (the most common symptom) - Dizziness or balance problems - Nausea or vomiting (brief vomiting right after impact; repeated vomiting is a red flag — see below) - Sensitivity to light (photophobia) or noise (phonophobia) - Visual disturbances — blurred or double vision - Feeling slowed down or "in a fog"

Cognitive: - Difficulty concentrating or remembering - Feeling mentally foggy - Slowed processing speed - Memory gaps around the injury (retrograde or anterograde amnesia)

Emotional/behavioral: - Irritability or mood changes - Anxiety - Emotional lability (crying more easily)

Sleep: - Sleeping more or less than usual - Difficulty falling asleep - Fatigue

Symptoms may not appear immediately — some develop hours after the injury event.

What is the graduated return-to-sport protocol?

Medical consensus is clear: an athlete should not return to sport on the same day as a concussion, and return must follow a structured, stepwise protocol 1Ref 1Harmon KG, Clugston JR, Dec K, Hainline B, Herring SA, Kane SF, Kontos AP, Leddy JJ, McCrea MA, Poddar SK, Putukian M, Wilson JC, Roberts WO (2019).American Medical Society for Sports Medicine position statement on concussion in sport.Concussion definition, symptom domains, graduated return-to-sport protocol, medical clearance requirements, same-day return prohibition2Ref 2McCrory P, Meeuwisse W, Dvorak J, et al. (2017).Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016.Six-step graduated return-to-sport protocol; conservative approach for youth athletes; second-impact syndrome context; early light aerobic activity in recovery. The standard six-step graduated return-to-sport (GRTS) protocol, originating from the Berlin Consensus Statement, is widely adopted by sports medicine organizations 2Ref 2McCrory P, Meeuwisse W, Dvorak J, et al. (2017).Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016.Six-step graduated return-to-sport protocol; conservative approach for youth athletes; second-impact syndrome context; early light aerobic activity in recovery:

Key rules: - Each step takes a minimum of 24 hours - If symptoms return at any step, the athlete drops back one level and waits until symptom-free again before attempting to progress - Medical clearance from a qualified clinician is required before Step 5 (full-contact practice) - The minimum total time from Step 1 to full return is five days if everything goes smoothly — but most athletes take longer

For younger athletes (under 18), protocols are generally more conservative, with longer rest periods and more gradual progression.

Who can clear an athlete to return to sport?

Medical clearance for full-contact return (Step 5) should come from a clinician trained in concussion evaluation — typically a sports medicine physician, a team physician, or a neurologist with sports concussion expertise 1Ref 1Harmon KG, Clugston JR, Dec K, Hainline B, Herring SA, Kane SF, Kontos AP, Leddy JJ, McCrea MA, Poddar SK, Putukian M, Wilson JC, Roberts WO (2019).American Medical Society for Sports Medicine position statement on concussion in sport.Concussion definition, symptom domains, graduated return-to-sport protocol, medical clearance requirements, same-day return prohibition.

Clearance involves confirming: - Complete symptom resolution - Normal neurological examination - Satisfactory performance on balance and cognitive assessment - Normal or back-to-baseline performance on neurocognitive testing (ImPACT or similar tools) if baseline was established

Athletic trainers and physical therapists who are trained in concussion protocols often manage the day-to-day monitoring and step progression, escalating to the physician for final clearance.

How long does concussion recovery take?

For most adult athletes, concussion symptoms resolve within 7–14 days. For adolescents, recovery typically takes longer — often two to four weeks.

Prolonged concussion (symptoms lasting more than four weeks in adults) occurs in a minority of athletes and is more likely when: - There is a prior history of concussions - Sleep disruption is prominent early in recovery - Migraine history is present - The athlete returned to play too soon after a prior concussion

Early light aerobic activity — at a level that does not provoke symptoms — is now recommended as part of recovery rather than strict total rest. Complete physical and cognitive rest beyond the first day or two is no longer the standard approach.

What is second-impact syndrome?

Second-impact syndrome refers to the rare but catastrophic outcome when an athlete sustains a second concussion before fully recovering from the first. The brain's impaired autoregulation during the recovery window makes it significantly more vulnerable to a second force. This is the primary reason that same-day return-to-play is prohibited and the GRTS protocol is strictly graduated.

The risk is most clearly established in adolescents and young athletes, which is one reason youth return-to-sport protocols are more conservative than adult protocols.

Who manages sports concussion care?

• Sports medicine physician or team physician — initial evaluation, ongoing monitoring, final return-to-sport clearance
• Neurologist — prolonged or complicated concussion, seizure history, concern for structural injury
• Athletic trainer — on-field recognition, protocol monitoring
• Physical therapist — vestibular and cervical rehabilitation when dizziness, neck pain, or balance problems are prominent

Gale is not the right provider for sports concussion management, which requires hands-on neurological evaluation. Gale can help with primary care follow-up, academic or work accommodations, and coordination with the sports medicine team.