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Concussions in Sports: Recognition and Management

Person wearing a helmet while doctor checks with stethoscope.

By Rachel Evan, ATC
Athletic Trainer
MUSC Health Sports Medicine

Concussions have been a major topic of discussion in the last few years and are unfortunately often common in athletics. This injury has been the subject of some debate as our knowledge and understanding of concussions, as well as recognition and management have evolved. A concussion is defined as a mild traumatic brain injury. This often causes immediate, although usually temporary, impairments to some brain function. A concussion is a type of injury that can be sustained by any blow to the head or an impact injury from almost any mechanism. While concussions in sports have become a major topic, it is unclear whether this is due to an increase in occurrence of concussive injuries or if recognition and diagnostic testing are getting better. This injury most often occurs in contact-heavy sports including football, soccer, and lacrosse, though they may occur in any sport or even other accidents. Because this is a common injury, it is important to be able to recognize and manage the symptoms of a concussion and prevent further injury from occurring.

On the sideline, an Athletic Trainer or other healthcare provider will often assess the athlete to try to determine the presence and severity of a concussive injury. An on-field assessment of a concussion will often be concise and is ideally compared to pre-injury baseline scores for that athlete if pre-injury data is available. Sport Concussion Assessment Tool, 5th edition (SCAT5) is an assessment often used by Athletic Trainers to assess for concussion. This test consists of three primary assessments: signs and symptoms, cognitive assessment, and balance and stability. Practically, this may look like asking the athlete to answer a series of questions to assess orientation and memory, such as, "What day is today?" "Where are we playing?" The athlete might then be asked to remember and repeat a series of numbers or words. The athlete would also be asked to rate their symptoms on a severity scale. Finally, balance may be assessed as mild balance and stability problems could accompany this type of injury. Responses and assessment would then be recorded by the Athletic Trainer and the athlete would then be removed from play if necessary based on the clinical findings of the assessment.

In the absence of an objective test or experienced health care provider to administer an on-field assessment, concussions can often be recognized based on signs and symptoms as well as shifts in mood and personality that are not typical for that individual. The athlete may report common symptoms such as headache, feeling dizzy, nausea, confusion, and sensitivity to light or noise. Pupils of eyes may appear larger or constricted, the athlete may have memory issues, or trouble maintaining balance. Parents and athletes should be aware and be able to advocate for themselves, their child, or their teammates if something about their behavior seems off or symptoms of a concussion are noted or reported following a potential head injury.

Treatment of a concussion that has been diagnosed or suspected depends on the severity of signs and symptoms for that individual with a few key guidelines. Athletes should be immediately removed from play until cleared by an appropriate healthcare provider if a concussion is suspected. If symptoms are severe, the athlete may need to be evaluated with a CT scan or other imaging to rule out more significant injury such as an active brain bleed. Mild symptoms can often be managed at home where the athlete is comfortable, as long as parents or other responsible adult are able to monitor for increased symptoms. Management of a concussion injury often involves managing symptoms, including rest, limiting physical and cognitive activities, and avoiding screen time as much as possible. If symptoms are mild medication may not be needed to help manage symptoms; however, if medication is being used it is often recommended to use acetaminophen to treat symptoms rather than medications in the NSAID class (eg. ibuprofen or Aspirin). This is because this class of medications often contain a mild blood thinning property that can slightly increase severity of concussive injury.

Once the athlete no longer has symptoms and is cleared by a physician, as required by South Carolina state law, it is important that athlete follow a return to play progression rather than directly returning to competition. This helps ensure athletes are not returning to play too early and risking a second impact injury. Return to play progression often includes five to seven phases each separated by approximately 24 hours, and is generally overseen by the Team Physician or the Athletic Trainer. This progression might look like having an athlete walk or run to increase heart rate for the first several days to ensure that symptoms do not return when heart rate is increased. The next several days might consist of sports specific drills and non-contact practices with the team. After an athlete has completed phases of return to play progression with no return of symptoms, they will be allowed to return to team practice and finally competition.

It is very important to recognize that a concussion is a severe injury even if symptoms are seemingly mild. Not being able to visually observe a concussion does not decrease the severity of the injury. It is also important to be able to recognize signs and symptoms as well as red flag warning signs of more serious injuries. Below is a list of some symptoms, though not exhaustive, that are commonly reported with concussions. It is important to note that symptoms that become suddenly worse, weakness or unsteadiness, slurred speech or inability to recognize people or places should be recognized as symptoms of potentially more serious injury and the athlete should be evaluated in a hospital with experienced providers and access to imaging.

Commonly reported symptoms of concussion from SCAT5:

  • Headache
  • Head pressure
  • Neck pain
  • Nausea or vomiting
  • Dizziness
  • Blurred vision
  • Balance problems
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling slowed down
  • Feeling like "in a fog"
  • Difficulty concentrating
  • Difficulty remembering
  • Fatigue or low energy
  • Confusion