Concussion Management Guidelines

Immediate Management and Return to Play Protocol

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, as recommended by the American Academy of Pediatrics 1, 2
Any athlete with suspected concussion must be immediately removed from play and not allowed to return to the current game or practice, according to the British Journal of Sports Medicine guidelines 3, 4
Medical evaluation by a licensed healthcare provider trained in concussion management is mandatory, as stated by the American Academy of Pediatrics 1, 5
Same-day return to play is absolutely contraindicated in all cases, as recommended by the American Academy of Pediatrics 1, 6

The athlete must meet ALL of the following criteria before beginning the stepwise progression, including complete resolution of symptoms at rest, normal neurological examination, normal cognitive evaluation, and asymptomatic with physical exertion, as outlined by the British Journal of Sports Medicine 3, 7, 8
Complete resolution of symptoms at rest, such as no headache, dizziness, nausea, or cognitive difficulties, is required before starting the return-to-play protocol, as stated by the British Journal of Sports Medicine 3

Younger athletes demonstrate longer cognitive recovery periods, typically 7-10 days or longer, compared to college-aged or professional athletes, according to the American Academy of Pediatrics 1, 2, 9
A more conservative approach with slower progression is warranted for pediatric populations, as recommended by the American Academy of Pediatrics 1, 2

Each stage of the return-to-play protocol must last a minimum of 24 hours, making the fastest possible return to competition 5 days after becoming asymptomatic, as outlined by the American Academy of Pediatrics 1, 2, 6
The protocol consists of six stages: complete rest, light aerobic activity, sport-specific exercise, non-contact training drills, full-contact practice, and return to game play, as described by the American Academy of Pediatrics and the British Journal of Sports Medicine 1, 2, 3, 6, 9, 10

If symptoms recur during progression, the athlete should immediately stop all activity, rest for at least 24 hours until asymptomatic again, and drop back to the previous asymptomatic level, as recommended by the American Academy of Pediatrics and the British Journal of Sports Medicine 1, 2, 3, 6, 7
Written medical clearance from a licensed healthcare provider trained in concussion management is required before return to full-contact practice and competition, as stated by the American Academy of Pediatrics 1, 5

A normal neurological examination must be confirmed prior to starting any return‑to‑play (RTP) progression. 11
Clinicians should actively monitor for headache, dizziness, nausea, cognitive difficulties, balance problems, or any other concussion‑related symptoms during each stage of the RTP protocol. 11

Each stage of the RTP protocol must be maintained for a minimum of 24 hours; therefore, the fastest possible return to full competition is approximately 5 days after the protocol begins. 12
Stage 1 – Light Aerobic Exercise: Walking or stationary cycling at low‑to‑moderate intensity; no resistance training is permitted. 12
Stage 2 – Sport‑Specific Exercise: Soccer‑specific running drills (jogging, change‑of‑direction, light ball work) performed at moderate intensity; no contact or heading activities. 12
Stage 3 – Non‑Contact Training Drills: More complex soccer drills (passing, shooting, tactical work) with the option to add progressive resistance training; still no contact or heading. 12
Stage 4 – Full‑Contact Practice: Participation in normal training that includes contact and heading after written medical clearance from a licensed healthcare provider trained in concussion management. 12
Stage 5 – Return to Game Play: Unrestricted participation in competition. 12

If any concussion‑related symptom reappears at any stage, the athlete must immediately cease all activity. 12
The athlete must rest for at least 24 hours until completely asymptomatic before any further activity. [12][13]
After symptom resolution, the athlete should drop back to the previous asymptomatic stage and only progress again after another 24 hours of being symptom‑free. [12][13]

Returning to play on the same day as the initial injury is strictly prohibited. 13