Return to Sports After Concussion Guidelines
Athletes must never return to play on the same day of concussion, must be completely asymptomatic at rest and with exertion before beginning a graded return-to-play protocol, and must complete a minimum 5-day stepwise progression under medical supervision before returning to full competition. 1
Immediate Management: "When in Doubt, Sit Them Out"
- Any athlete with suspected concussion must be immediately removed from play and not allowed to return to the current game or practice 1
- The athlete should not be left alone and requires regular monitoring for deterioration 1
- Medical evaluation by a licensed healthcare provider trained in concussion management is mandatory 1
- Same-day return to play is absolutely contraindicated in all cases 1
Prerequisites Before Starting Return-to-Play Protocol
The athlete must meet ALL of the following criteria before beginning the stepwise progression 1:
- Complete resolution of symptoms at rest (no headache, dizziness, nausea, cognitive difficulties, etc.)
- Normal neurological examination
- Normal cognitive evaluation (if performed)
- Asymptomatic with physical exertion (not just at rest)
Special Considerations for Pediatric and Adolescent Athletes
- Younger athletes demonstrate longer cognitive recovery periods (7-10 days or longer) compared to college-aged or professional athletes 1
- A more conservative approach with slower progression is warranted for pediatric populations 1
- Recovery typically takes longer than one week in this age group despite symptom resolution 1
The Stepwise Return-to-Play Protocol
Each stage must last a minimum of 24 hours, making the fastest possible return to competition 5 days after becoming asymptomatic 1:
Stage 1: Complete Rest
- No physical activity whatsoever
- Complete cognitive rest (limited screen time, reading, schoolwork)
- Remain at this stage until completely asymptomatic at rest 1
Stage 2: Light Aerobic Activity
- Walking, swimming, or stationary cycling at ≤70% maximum heart rate
- No resistance training
- Duration: 10-15 minutes initially 1
Stage 3: Sport-Specific Exercise
- Running drills for soccer, skating for hockey, etc.
- No head impact activities
- No body contact 1
Stage 4: Non-Contact Training Drills
- More complex training drills
- May begin light resistance training
- Progressive increase in intensity 1
Stage 5: Full-Contact Practice
- Normal training activities with full contact
- Requires formal medical clearance before this stage 1
Stage 6: Return to Game Play
- Unrestricted participation in competition 1
Critical Management Rules
If Symptoms Recur During Progression
- Immediately stop all activity 1
- Rest for at least 24 hours until asymptomatic again
- Drop back to the previous asymptomatic level
- Attempt progression again after remaining symptom-free for 24 hours 1
- Contact healthcare provider if symptoms persist or recur repeatedly 1
Common Pitfalls to Avoid
- Prolonged complete rest beyond 24-48 hours can be detrimental and may prolong recovery 2, 3
- Returning to activity too rapidly increases risk of prolonged symptoms 3
- Failing to increase activity levels over time after initial rest can lead to persistent symptoms 3
- Each step taking only 24 hours is the minimum—many athletes require longer at each stage 1
Special Populations Requiring Extended Protocols
Athletes with the following characteristics may require longer, more individualized protocols 1:
- Multiple previous concussions
- Prolonged symptom duration (>10 days)
- History of migraine headaches
- Pre-existing mood disorders, learning disabilities, or ADHD
- Younger age (pediatric/adolescent populations)
These athletes should be managed by a physician experienced in concussion management 1.
Cognitive Rest and Return to Learn
- Students require cognitive rest during recovery, which may include academic accommodations 4
- Reduced workload and extended time for tests should be provided while symptomatic 4
- Gradual return to cognitive activities should parallel physical activity progression 2