What's the next step for a 15-year-old patient with a history of concussion (traumatic brain injury), who progressed through a 6-step return to play protocol, but now presents with a new headache after two bumps to the head during a water polo game?

Management of Recurrent Concussion Symptoms in a Young Athlete

The 15-year-old athlete should be immediately removed from play, not allowed to return to water polo, and must be re-evaluated by a healthcare professional before resuming any physical activity. 1, 2

Immediate Management

• The recurrence of headache after two bumps to the head during water polo indicates a potential recurrent concussion
• This situation requires immediate removal from play and no same-day return to sports 1, 2
• The athlete must be evaluated by a healthcare professional with experience in concussion management 2
• Monitor for worsening symptoms that might indicate more serious injury (loss of consciousness, worsening headache, vomiting, altered mental status, seizures, visual changes) 1

Return to Play Protocol Reset

The athlete must restart the return-to-play protocol from the beginning:

1. Step 1: No activity - Complete physical and cognitive rest until asymptomatic
2. Step 2: Light aerobic exercise - Only when completely symptom-free for 24 hours
3. Step 3: Sport-specific exercise - Running drills, no head impact activities
4. Step 4: Non-contact training drills - More complex training, progressive resistance
5. Step 5: Full-contact practice - Only after medical clearance
6. Step 6: Return to competition - Only after completing all previous steps without symptoms 1, 2

Key Clinical Considerations

• The athlete had previously completed a return-to-play protocol but now has recurrent symptoms
• Research shows athletes who continue to play after concussion symptoms (rather than immediate removal) have significantly longer recovery times (44.4 vs 22.0 days) and are 8.8 times more likely to have protracted recovery 3
• Each step in the return-to-play protocol requires a minimum of 24 hours, with many athletes needing longer 2
• If symptoms recur at any step, the athlete must return to the previous asymptomatic level for at least 24 hours before attempting to progress again 1, 2

Special Considerations for Adolescents

• Younger athletes typically require a more conservative approach and longer recovery time 2
• The adolescent brain may be more vulnerable to repeat concussions during the recovery period 1, 2
• Academic accommodations may be necessary during recovery (reduced workload, extended time for tests) 2

Pitfalls to Avoid

1. Same-day return to play - This is never appropriate for concussion, even if symptoms appear to resolve quickly 2, 4
2. Premature progression through return-to-play protocol - Each step requires complete symptom resolution for at least 24 hours 1, 2
3. Inadequate medical evaluation - A healthcare professional with concussion management experience should evaluate the athlete before any return to physical activity 2
4. Ignoring recurrent symptoms - Continuing activity with symptoms can lead to prolonged recovery and potentially more serious injury 5, 3

Long-term Considerations

• Multiple concussions in a single season warrant consideration for a prolonged period away from sports 2
• If this is the athlete's third concussion in a season, or if symptoms persist beyond 3 months, specialist referral is strongly recommended 2

The evidence clearly demonstrates that immediate removal from play after concussion symptoms and adherence to a structured return-to-play protocol significantly reduces recovery time and the risk of prolonged symptoms 5, 3. Medical clearance is mandatory before this athlete can return to water polo or any contact sport.