What graduated return-to-play protocol should be used for a 14‑day post-concussion, asymptomatic female soccer player?

Return-to-Play Protocol for Asymptomatic Soccer Player 14 Days Post-Concussion

Since this athlete is now asymptomatic at 14 days post-concussion, she should immediately begin a structured 5-day graduated return-to-play protocol under medical supervision, with each stage lasting a minimum of 24 hours, allowing her to return to full competition in approximately 5 days if she remains symptom-free throughout the progression. 1, 2

Prerequisites Confirmed Before Starting Protocol

Your patient has met the critical prerequisite of being completely asymptomatic at rest 1, 2. Before initiating the protocol, ensure she also has:

• Normal neurological examination 1
• Normal cognitive evaluation 1
• No symptoms with light physical exertion (confirm with an exertional test) 1, 3
• Not taking any medications for concussion symptoms 2

The 6-Stage Graduated Return-to-Play Protocol

Each stage must last a minimum of 24 hours, making the fastest possible return to competition 5 days after beginning the protocol 4, 1:

Stage 1: Light Aerobic Exercise

• Walking or stationary cycling at low to moderate intensity 4, 1
• No resistance training 4
• Goal: Increase heart rate without provoking symptoms 1

Stage 2: Sport-Specific Exercise

• Soccer-specific running drills (e.g., jogging, change of direction drills, light ball work) 4, 1, 5
• No contact or heading activities 5
• Moderate intensity cardiovascular exercise 1

Stage 3: Non-Contact Training Drills

• More complex soccer training drills including passing, shooting, and tactical work 4, 1
• May add progressive resistance training 5
• Still no contact or heading 1, 5

Stage 4: Full-Contact Practice

• Participate in normal training activities including contact and heading 4, 1
• Requires written medical clearance from a licensed healthcare provider trained in concussion management before this stage 1, 2

Stage 5: Return to Game Play

• Full unrestricted participation in competition 4, 1

Critical Management Rules During Progression

If ANY symptoms recur at any stage:

• Immediately stop all activity 1, 2
• Rest for at least 24 hours until completely asymptomatic again 4, 1
• Drop back to the previous asymptomatic level 4, 1
• Restart progression from that lower level after 24 hours of being symptom-free 4, 1

Important Caveats and Pitfalls

Age considerations: Since you didn't specify her age, note that younger athletes (pediatric/adolescent) typically require more conservative management with potentially slower progression, as they demonstrate longer cognitive recovery periods (7-10 days or longer) compared to college-aged athletes 1, 2. If she is under 18, consider extending each stage beyond the minimum 24 hours 1.

Symptom monitoring: Watch specifically for headache, dizziness, nausea, cognitive difficulties, balance problems, or any other concussion symptoms during and after each stage 4, 1.

Medical clearance: Formal written clearance from a qualified healthcare provider is mandatory before Stage 4 (full-contact practice) 1, 2.

Same-day return contraindicated: Under no circumstances should she have returned to play on the day of her original injury, which appears to have been appropriately managed 4, 1, 2.

Evidence Supporting Earlier Initiation

Recent research suggests that initiating the return-to-play protocol with minimal residual symptoms (symptom severity scores up to 10) does not prolong recovery and may be appropriate 6. However, guideline consensus emphasizes complete symptom resolution before beginning the protocol 1, 2, which your patient has achieved at 14 days.