What are the appropriate next steps for a young adult or adolescent hockey player with tenderness in the left occipital region after using a hockey helmet?

Evaluation and Management of Occipital Tenderness in a Hockey Player

Immediately remove the player from participation and evaluate for concussion, as any head region tenderness following helmet use warrants comprehensive assessment for potential head injury. 1

Immediate Assessment

Perform concussion screening immediately, even though the injury involves the occipital region rather than direct frontal impact. 1, 2

Key Signs and Symptoms to Evaluate:

• Cognitive symptoms: Memory problems, confusion, difficulty concentrating, feeling "foggy" 1, 3
• Physical symptoms: Headache (any location), dizziness, nausea, balance problems, visual disturbances 1, 2
• Behavioral changes: Irritability, emotional lability 1
• Loss of consciousness (occurs in <10% of concussions but indicates more significant injury if >30 seconds) 1, 3

Structured Assessment Tools:

• Use the SCAT6 or Standardized Assessment of Concussion (SAC) to objectively document cognitive function, balance, and symptoms 3
• Perform balance testing using the Modified Balance Error Scoring System (mBESS) at least 15 minutes after exercise cessation 1, 3
• Document all symptoms using a standardized symptom checklist with severity ratings 3

Critical Management Decisions

If ANY concussion symptoms are present, the player must not return to play that day, regardless of symptom resolution. 1, 2 This is non-negotiable for pediatric and adolescent athletes who require more conservative management than adults. 1

When to Consider Neuroimaging:

CT imaging is indicated if the player demonstrates: 1, 2

• Glasgow Coma Scale <15 at 2 hours post-injury 1
• Prolonged altered consciousness or repeated vomiting 2
• Focal neurological deficits or seizure activity 2
• Suspected skull fracture or worsening headache 1
• Persistent severe symptoms 1, 2

Routine neuroimaging is NOT required for typical concussion presentation with normal neurological examination. 1, 2

Post-Injury Management Protocol

Immediate Phase (First 24-48 Hours):

• Complete physical AND cognitive rest until asymptomatic at rest 1, 4, 2
• Avoid acetaminophen and NSAIDs initially due to theoretical risk of potentiating intracranial bleeding, though evidence is limited 1
• Monitor closely for symptom progression over 24-48 hours 1, 2

Cognitive Rest Requirements:

• Temporary modifications to school attendance: shortened school days, reduced workload, extended time for assignments 1
• Avoid activities that worsen symptoms: reading, screen time, standardized testing 1
• Communication with school personnel is essential, as students physically appear well but may have significant cognitive difficulties 1

Return-to-Play Protocol

The player must complete a minimum 5-day stepwise protocol, with each stage lasting at least 24 hours: 1, 4

1. Complete rest until asymptomatic at rest and with exertion 1, 4
2. Light aerobic activity: Walking, swimming, or stationary cycling at 70% maximum heart rate; no resistance exercises 1, 4
3. Sport-specific exercise: Hockey-specific drills without head impact 1, 4
4. Noncontact training drills: More complex drills, may start light resistance training 1, 4
5. Full-contact practice: After medical clearance only 1, 4
6. Return to play: Normal game participation 1, 4

If symptoms return at any stage, immediately stop activity. Once asymptomatic for 24 hours, return to the previous asymptomatic stage. 1, 4

Special Considerations for Young Athletes

Pediatric and adolescent athletes typically require 7-10 days or longer for recovery, significantly longer than college or professional athletes. 4, 3 The developing brain is more vulnerable to concussive injury and second-impact syndrome. 1

History of Multiple Concussions:

Athletes with 3 or more previous concussions require more conservative management and may need temporary or permanent disqualification from contact sports, particularly if experiencing slowed recovery. 1

Equipment Considerations

Ensure the helmet meets National Operating Committee on Standards for Athletic Equipment (NOCE) standards and is properly fitted. 1 While helmets reduce catastrophic head injuries, they have not been conclusively shown to prevent concussions. 1

Common Pitfalls to Avoid

• Never dismiss occipital tenderness as minor without proper concussion screening 2
• Never allow same-day return to play after any head impact with symptoms, even if symptoms resolve quickly 1, 2
• Do not assume absence of loss of consciousness rules out concussion (LOC occurs in <10% of cases) 1, 3
• Do not rely solely on the athlete's self-report, as young athletes may minimize symptoms to continue playing 1