Suggested Guidelines for Management of Concussion in Sports

By on February 16, 2017

National Federation of State High School Associations (NFHS)
Sports Medicine Advisory Committee (SMAC)

A concussion is a type of traumatic brain injury that interferes with normal function of the brain. It occurs when the brain is rocked back and forth or twisted inside the skull as a result of a blow to the head or body. What may appear to be only a mild jolt or blow to the head or body can result in a concussion.

The understanding of sports-related concussion by medical professionals continues to evolve. We now know that young athletes are particularly vulnerable to the effects of a concussion. Once considered little more than a “ding” on the head, it is now understood that a concussion has the potential to result in a variety of short- or long-term changes in brain function or, in rare cases, even death.
What is a concussion?

You’ve probably heard the terms “ding” and “bell-ringer.” These terms were previously used to refer to minor head injuries and thought to be a normal part of collision sports. Research has now shown us that there is no such thing as a minor brain injury. Any suspected concussion must be taken seriously. The athlete does not have to be hit directly in the head to injure the brain. Any force that is transmitted to the head in any matter may cause the brain to literally bounce around or twist within the skull, potentially resulting in a concussion.

It used to be believed that a player had to lose consciousness or be “knocked-out” to have a concussion. This is not true, as the vast majority of concussions do not involve a loss of consciousness. In fact, less than 5% of players actually lose consciousness with a concussion.

What exactly happens to the brain during a concussion is not entirely understood. It appears to be a very complex process affecting both the structure and function of the brain. The sudden movement of the brain causes stretching and tearing of brain cells, damaging the cells and creating chemical changes in the brain. Once this injury occurs, the brain is vulnerable to further injury and very sensitive to any increased stress until it fully recovers.

Common sports injuries such as torn ligaments and broken bones are structural injuries that can be detected during an examination, or seen on x-rays or MRI. A concussion, however, is primarily an injury that interferes with how the brain works. While there is damage to brain cells, the damage is at a microscopic level and cannot be seen on MRI or CT scans. Therefore, the brain looks normal on these tests, even though it has been seriously injured.

Recognition and Management
If an athlete exhibits any signs, symptoms, or behaviors that make you suspicious that he or she may have had a concussion, that athlete must be removed from all physical activity, including sports and recreation. Continuing to participate in physical activity after a concussion can lead to worsening concussion symptoms, increased risk for further injury, and even death.

Parents and coaches are not expected to be able to “diagnose” a concussion. That is the role of an appropriate health-care professional. However, everyone involved in athletics must be aware of the signs, symptoms and behaviors associated with a concussion. If you suspect that an athlete may have a concussion, then he or she must be immediately removed from all physical activity.


Signs Observed by Coaching Staff
Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score or opponen
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior or personality changes
Can’t recall events prior to hit or fall
Can’t recall events after hit or fal


Symptoms Reported by Athlete
Headaches or “pressure” in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy or groggy
Concentration or memory problems
Does not “feel right” or is “feeling down”


When in doubt, sit them out!

When you suspect that a player has a concussion, follow the “Heads Up” 4-step Action Plan.

  1. Remove the athlete from play.
  2. Ensure that the athlete is evaluated by an appropriate health-care professional.
  3. Inform the athlete’s parents or guardians about the possible concussion and give them information on concussion.
  4. Keep the athlete out of play the day of the injury and until an appropriate health-care professional says he or she is symptom-free and gives the okay to return to activity.

The signs, symptoms, and behaviors associated with a concussion are not always apparent immediately after a bump, blow, or jolt to the head or body and may develop over a few hours or longer. An athlete should be closely watched following a suspected concussion and should never be left alone.

Athletes must know that they should never try to “tough out” a suspected concussion. Teammates, parents and coaches should never encourage an athlete to “play through” the symptoms of a concussion. In addition, there should never be an attribution of bravery to athletes who do play despite having concussion signs and/or symptoms. The risks of such behavior must be emphasized to all members of the team, as well as coaches and parents.

If an athlete returns to activity before being fully healed from an initial concussion, the athlete is at greater risk for a repeat concussion. A repeat concussion that occurs before the brain has a chance to recover from the first can slow recovery or increase the chance for long-term problems. In rare cases, a repeat concussion can result in severe swelling and bleeding in the brain that can be fatal.

What to do in an Emergency

Although rare, there are some situations where you will need to call 911 and activate the Emergency Medical System (EMS). The following circumstances are medical emergencies:

1. Any time an athlete has a loss of consciousness of any duration. While loss of consciousness is not required for a concussion to occur, it may indicate more serious brain injury.

2. If an athlete exhibits any of the following:

     decreasing level of consciousness,
     looks very drowsy or cannot be awakened,
     if there is difficulty getting his or her attention,
     irregularity in breathing,
     severe or worsening headaches,
     persistent vomiting, or any seizures.


Cognitive Rest

A concussion can interfere with school, work, sleep and social interactions. Many athletes who have a concussion will have difficulty in school with short- and long-term memory, concentration and organization. These problems typically last no longer than 2 -3 weeks, but for some these difficulties may last for months. It is best to lessen the student’s class load early on after the injury. Most students with concussion recover fully. However, returning to sports and other regular activities too quickly can prolong the recovery.

The first step in recovering from a concussion is rest. Rest is essential to help the brain heal. Students with a concussion need rest from physical and mental activities that require concentration and attention as these activities may worsen symptoms and delay recovery. Exposure to loud noises, bright lights, computers, video games, television and phones (including texting) all may worsen the symptoms of concussion. As the symptoms lessen, increased use of computers, phone, video games, etc., may be allowed, as well as a gradual progression back to full academic work.

Return to Learn

Following a concussion, many athletes will have difficulty in school. These problems may last from days to months and often involve difficulties with short- and long-term memory, concentration, and organization. In many cases, it is best to lessen the student’s class load early on after the injury. This may include staying home from school for a few days, followed by a lightened schedule for a few days, or longer, if necessary. Decreasing the stress on the brain early on after a concussion may lessen symptoms and shorten the recovery time.

Return to Play

After suffering a concussion, no athlete should return to play or practice on that same day. In the past, athletes were allowed to return to play if their symptoms resolved within 15 minutes of the injury. Studies have shown us that the young brain does not recover quickly enough for an athlete to return to activity in such a short time.

An athlete should never be allowed to resume physical activity following a concussion until he or she is symptom free and given the approval to resume physical activity by an appropriate health-care professional.

Once an athlete no longer has signs, symptoms, or behaviors of a concussion and is cleared to return to activity by an appropriate health-care professional, he or she should proceed in a step-wise fashion to allow the brain to re-adjust to exercise. In most cases, the athlete will progress one step each day. The return to activity program schedule may proceed as below, following medical clearance:

Progressive Physical Activity Program (ideally under supervision)

Step 1: Light aerobic exercise- 5 to 10 minutes on an exercise bike or light jog; no weight lifting, resistance training, or any other exercises.

Step 2: Moderate aerobic exercise- 15 to 20 minutes of running at moderate intensity in the gym or on the field without a helmet or other equipment.

Step 3: Non-contact training drills in full uniform. May begin weight lifting, resistance training and other exercises.

Step 4: Full contact practice or training.

Step 5: Full game play.

If symptoms of a concussion reoccur, or if concussion signs and/or behaviors are observed at any time during the return-to-activity program, the athlete must discontinue all activity and be re-evaluated by his or her health-care provider.

Suggested Concussion Management

1. No athlete should return to play (RTP) or practice on the same day of a concussion.
2. Any athlete suspected of having a concussion should be evaluated by an appropriate health-care professional that day.
3. Any athlete with a concussion should be medically cleared by an appropriate health-care professional prior to resuming participation in any practice or competition.
4. After medical clearance, RTP should follow a step-wise protocol with provisions for delayed RTP based upon return of any signs or symptoms.


American Medical Society for Sports Medicine position statement: concussion in sport. Harmon KG, Drezner J, Gammons M, Guskiewicz K, Halstead M, Herring S, Kutcher J, Pana A, Putukian M, Roberts W; American Medical Society for Sports Medicine. Clin J Sport Med. 2013 Jan;23(1):1-18.

McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 J Athl Train. 2013 Jul-Aug;48(4):554-75.

Returning to Learning Following a Concussion. Halstead M, McAvoy K, Devore C, Carl R, Lee M, Logan K and Council on Sports Medicine and Fitness, and Council on School Health. Pediatrics, October 2013. American Academy of Pediatrics.

Additional Resources:
Brain 101 – The Concussion Playbook

Concussion in Sports-What you need to know.

Heads Up: Concussion in High School Sports

REAP Concussion Management Program

Sport Concussion Library

Revised and Approved October 2013
January 2011
April 2009
October 2008
October 2005

DISCLAIMER – NFHS Position Statements and Guidelines

The NFHS regularly distributes position statements and guidelines to promote public awareness of certain health and safety-related issues. Such information is neither exhaustive nor necessarily applicable to all circumstances or individuals, and is no substitute for consultation with appropriate health-care professionals. Statutes, codes or environmental conditions may be relevant. NFHS position statements or guidelines should be considered in conjunction with other pertinent materials when taking action or planning care. The NFHS reserves the right to rescind or modify any such document at any time.