What is the diagnosis and recommended management for a patient who experienced a skiing incident with a fall, initial neck soreness, transient visual disturbances, and ongoing sensitivity to sounds, despite wearing a helmet and not hitting their head?

Diagnosis: Sport-Related Concussion

This patient has sustained a sport-related concussion despite not directly hitting their head, and requires immediate removal from activity, symptom monitoring, and gradual return-to-activity protocols once asymptomatic.

Clinical Presentation Consistent with Concussion

The constellation of symptoms strongly indicates concussion:

• Visual disturbances (rainbow lights/visual phenomena) are a recognized postconcussion symptom, classified under the physical symptom category 1
• Noise sensitivity (phonophobia) is one of the most common postconcussion symptoms and appears on standardized symptom scales 1
• Initial neck soreness is common in skiing-related head injuries and does not exclude concussion 1
• "Feeling weird" represents the cognitive fogginess that may predict slower recovery from concussion 1

The mechanism—falling forward after ski caught—creates rotational and linear acceleration forces sufficient to cause traumatic brain injury even without direct head impact 2, 3. Falls represent 54% of skiing-related traumatic brain injuries 3.

Immediate Management Algorithm

Acute Phase (First 24-48 Hours)

Cervical spine clearance is the first priority:

• Any athlete with altered mental status after head/neck trauma must be assumed to have cervical spine injury until proven otherwise 1
• The patient requires evaluation for neck pain, cervical spine tenderness on palpation, and intact neurologic function in all four extremities 1
• Given initial neck soreness, if not already done, cervical spine imaging may be warranted before proceeding with other management 1

Red flag assessment requiring emergency evaluation:

• Loss of consciousness (even brief) 1
• Worsening headache or confusion 1
• Repeated vomiting 1
• Seizures 1
• Focal neurological deficits 1
• Severe or increasing neck pain 1

Subacute Management (Days to Weeks)

Symptom monitoring using standardized scales:

• The Postconcussion Symptom Scale should be completed by the patient at each encounter to track 22 specific symptoms including headache, nausea, balance problems, light sensitivity, noise sensitivity, visual problems, and cognitive difficulties 1
• Symptoms are rated 0-6 in severity 1

Activity restrictions:

• Complete cognitive and physical rest is no longer recommended; instead, gradual return to activity as tolerated below symptom threshold is preferred 1
• Avoid activities that significantly worsen symptoms 1

Treatment Recommendations

Early Intervention (Within 4 Weeks)

Systematic early information and advice:

• Provide education about expected symptoms, recovery timeline, and self-management strategies within the first 4 weeks after injury 1
• This can be delivered individually or in groups, in person or via telephone by healthcare professionals 1

Persistent Symptoms (Beyond 2-4 Weeks)

If symptoms persist beyond initial recovery period, consider:

Graded physical exercise:

• Offer supervised, gradually progressive aerobic exercise in addition to other treatments 1
• This has weak recommendation based on low-quality evidence but shows benefit for persistent postconcussion symptoms 1

Vestibular rehabilitation:

• Specifically indicated if vestibular dysfunction persists (dizziness, balance problems) 1

Manual treatment of neck and back:

• Consider for persistent neck pain, given the initial neck soreness in this case 1

Psychological treatment:

• May be beneficial for emotional symptoms or if recovery is prolonged 1

Common Pitfalls to Avoid

• Do not assume helmet use prevents concussion: While helmets reduce head injury risk by 22-60%, they are less effective at preventing concussion than focal injuries 4, 2
• Do not dismiss symptoms because there was no direct head impact: Rotational forces from falls cause diffuse axonal injury even without direct contact 2, 3
• Do not require complete symptom resolution to zero if baseline symptoms existed: Athletes with pre-existing conditions (ADHD, depression) don't need to reach zero on symptom scales 1
• Do not overlook cervical spine injury: The initial neck soreness warrants careful evaluation, as cervical myofascial strain can coexist with concussion 5

Follow-Up and Return to Activity

• Symptoms typically resolve within days to weeks with conservative management 5
• Seek further evaluation if symptoms persist beyond 4-6 weeks, worsen, or new neurological symptoms develop 5
• Return to skiing should only occur after complete symptom resolution at rest and with exertion 1
• Consider interdisciplinary coordinated rehabilitative treatment if multiple symptom domains persist 1