Concussion Evaluation in Teenagers: Essential History Questions and Physical Examination
For a teenager presenting with suspected concussion, you must systematically assess four symptom domains (physical, cognitive, emotional, and sleep), evaluate for loss of consciousness and amnesia, perform vestibular-ocular-motor screening, assess balance, and conduct a focused neurological examination—all while ruling out cervical spine injury and more severe intracranial pathology. 1
Critical Initial Assessment
Immediate Safety Questions
- Was there loss of consciousness? If >30 seconds, this signals potential serious intracranial injury requiring imaging 1
- Any neck pain or tenderness? Assume cervical spine injury in any unconscious athlete until proven otherwise 1
- Mechanism of injury: Direct blow to head, face, neck, or indirect force transmitted to head 2
Amnesia Assessment (High Priority)
Ask specific questions to identify both types:
- Retrograde amnesia: "What happened right before you got hit? What play were you running? What was the score?"
- Anterograde amnesia: "Do you remember being evaluated on the field? Do you remember coming to the clinic?" 1
Pitfall: Athletes may falsely report remembering events after hearing others discuss them—probe for specific details they couldn't have learned secondhand 1
Four-Domain Symptom Assessment
Use a structured symptom scale (0-6 severity rating) covering 1:
Physical Symptoms
- Headache (most common symptom) 1
- Nausea/vomiting
- Dizziness
- Balance problems
- Light sensitivity
- Noise sensitivity
- Numbness/tingling
- Visual problems
Cognitive Symptoms
- Feeling "foggy" or "slow" (strong predictor of prolonged recovery) 1
- Difficulty concentrating
- Difficulty remembering
- Mental confusion
Emotional Symptoms
- Irritability
- Sadness
- Nervousness
- Feeling more emotional than usual
Sleep Disturbance
- Trouble falling asleep
- Sleeping more or less than usual
- Drowsiness
- Fatigue
Essential History Questions
Concussion History
- Number and timing of previous concussions (increased risk with prior concussions) 2
- Specific symptoms from past concussions, not just perceived number of injuries 2
- Pattern of vulnerability: "Have smaller hits been causing worse symptoms over time?" 2
Premorbid Risk Factors (Predict Delayed Recovery) 3
- Previous mTBI history
- Pre-existing neurological or psychiatric disorders
- Learning difficulties or lower cognitive ability
- ADHD, depression, anxiety
- Family and social stressors
- Baseline symptoms similar to concussion symptoms
Current Injury Details
- Time of injury
- Immediate symptoms vs. delayed onset
- Symptom progression or improvement
- Any worsening with physical or cognitive activity
Physical Examination Components
Neurological Examination
Mental Status 1:
- Orientation (person, place, time, situation)
- Immediate recall: Read 5 words, have patient repeat immediately (3 trials)
- Delayed recall: Ask for those 5 words after 5 minutes
- Concentration: Digits backward (e.g., "7-1-9" → patient says "9-1-7"), months in reverse order
- Mood, affect, insight, judgment
Cranial Nerve Screening 4:
- Visual fields
- Pupillary reactivity (if LOC or severe symptoms)
- Extraocular movements
- Facial symmetry
- Hearing
- Tongue/palate movement
Vestibular-Ocular-Motor Screening (VOMS) - Critical Component 5, 6, 7
This is highly sensitive for concussion and predicts prolonged recovery:
- Smooth pursuits: Follow finger horizontally and vertically—assess for symptom provocation
- Saccades: Rapid eye movements between two targets—note accuracy and symptoms
- Near point convergence: Measure distance where eyes can no longer maintain convergence (abnormal >6 cm)
- Vestibular-ocular reflex (VOR): Head movement while maintaining visual fixation—assess for symptom increase
- Visual motion sensitivity: Move visual target while patient remains still—check for dizziness/nausea
Document: Baseline symptoms before testing, then symptom changes (0-10 scale) after each component
Balance Assessment 1
Modified Balance Error Scoring System (mBESS):
- Three stances (double leg, single leg, tandem) on firm surface
- Eyes closed, hands on hips, 20 seconds each
- Count errors: opening eyes, lifting hands, stepping/stumbling, remaining out of position >5 seconds
- Enhanced version: Add dual-task (counting backward by 7s) to increase sensitivity 5
Tandem Gait:
- Walk heel-to-toe in straight line
- Note deviations, balance loss, time to complete
Cervical Spine Examination 4
- Inspection for trauma, swelling, deformity
- Palpation of cervical spine for tenderness
- Active range of motion (if no midline tenderness)
- Spurling maneuver (if appropriate)
- Upper extremity strength and sensation
Additional Examination Elements
If symptoms suggest:
- Headache predominant: Assess temporomandibular joint, palpate cervical musculature 4
- Dizziness/imbalance: Orthostatic vital signs, Dix-Hallpike maneuver
- Visual complaints: Visual acuity, fundoscopic exam (if trained)
Risk Stratification for Prolonged Recovery 3
Higher risk if:
- Older adolescent (vs. younger teen)
- Female (especially for persistent headaches) 3
- Hispanic ethnicity or lower socioeconomic status 3
- More severe acute symptoms (>4 symptoms at presentation)
- Presence of premorbid risk factors listed above
- Intracranial lesion on imaging (if obtained)
Critical Management Points
Immediate actions:
- Remove from play immediately—never same-day return 1
- Physical AND cognitive rest initially 1
- Screen time reduction 5
- School workload modification 1
Follow-up timing:
- Most resolve in 7-10 days, but adolescents take longer than adults 1
- If symptoms persist >2-4 weeks, refer to concussion specialist 3, 8
Common Pitfalls to Avoid
- Relying on LOC for diagnosis: Occurs in <10% of concussions 1
- Missing cervical spine injury: Always assess in unconscious athletes 1
- Accepting athlete's memory of events: Verify with specific details, not just "yes/no" 1
- Ignoring premorbid symptoms: Baseline ADHD or depression symptoms don't need to resolve to zero 1
- Skipping vestibular-ocular testing: This is one of the most sensitive examination components 5, 6
- Not documenting symptom severity: Use numerical scales for tracking recovery 1