When can a child return to football after a head injury?

Return to Play Protocol After Concussion in Child Football Players

A child should return to football only after completing a stepwise 5-day minimum return-to-play protocol once they are completely asymptomatic, and only with medical clearance from a healthcare professional experienced in concussion management. 1

Initial Management After Concussion

• Under no circumstances should a child return to play on the same day of a concussion, even if symptoms resolve quickly 1
• The phrase "When in doubt, sit them out!" is paramount in pediatric concussion management 1
• Complete physical and cognitive rest is required until the child is completely asymptomatic both at rest and with exertion 1

Return to Play Timeline

• Most concussion symptoms typically resolve within 7-10 days, but younger athletes often have longer recovery periods than college or professional athletes 1
• Children and adolescents may require 7-10 days or longer for full cognitive recovery, necessitating a more conservative approach 1
• A minimum of 5 days is required to progress through the complete return-to-play protocol, even if the athlete becomes asymptomatic sooner 1

Stepwise Return-to-Play Protocol

The following protocol must be followed, with each stage lasting a minimum of 24 hours:

1. No activity: Complete physical and cognitive rest until asymptomatic 1
2. Light aerobic activity: Walking, swimming, or stationary cycling at 70% maximum heart rate; no resistance exercises 1
3. Sport-specific exercise: Football-specific drills with no head impact 1
4. Noncontact training drills: More complex drills, may start light resistance training 1
5. Full-contact practice: After medical clearance, participate in normal training 1
6. Return to play: Normal game participation 1

Important Considerations

• If symptoms recur at any stage, the athlete must stop immediately and rest for at least 24 hours until asymptomatic again 1
• Once asymptomatic for 24 hours, the athlete should return to the previous asymptomatic level and attempt to progress again 1
• Medical clearance from a licensed healthcare professional with experience in concussion management is required before returning to full-contact practice 1
• Children with multiple concussions or prolonged symptoms may require a longer rehabilitation program created by a physician experienced in concussion management 1

Special Precautions

• Any athlete who has sustained 3 concussions in one season or has had postconcussive symptoms for more than 3 months should be considered for a prolonged period away from sports 1
• Sport-specific return-to-play guidelines that maintain the integrity of the stepwise model but add sport-specific movements may be beneficial 2, 3
• Newer helmet technology may help reduce impact forces but has not consistently shown reduction in concussion incidence 1

Common Pitfalls to Avoid

• Returning to play while still symptomatic, even mildly, significantly increases risk of another more severe brain injury 1, 3
• Pressure from coaches, parents, or teammates to return prematurely should be resisted 1
• Assuming that normal neuroimaging (CT or MRI) means it's safe to return to play - these are typically normal with concussion 1
• Relying solely on the athlete's self-report of symptoms, as they may minimize symptoms to return to play sooner 1