Returning Youth Athletes to School and Sports after a Concussion

Executive Summary 

Clearing a student athlete to return to sports after a concussion requires a systematic, thoughtful and group approach. Physicians should thoroughly document the resolution of the symptomatic and neuropsychological consequences of the concussion. Physicians should not clear a student athlete to return to sports until they have fully recovered from a concussion. 

Recommended Actions 

• Determine whether a student athlete is fit to return to their sport based solely on their symptoms and progress rather than a standardized period of time for recovery. 

• Request that people who commonly interact with the student athlete monitor and report their observations of the athlete’s recovery. 
• Allow a student athlete to return to their sport only after the athlete is symptom free and can tolerate a full school day with an age-appropriate workload. 

Jake Snakenberg was a freshman football player at Grandview High School in Aurora, Colorado. Jake sustained a concussion during a game, but didn’t fully understand the injury and did not report any symptoms. One week later, he took a typical hit, collapsed on the field and never regained consciousness. Jake is believed to have died due to a second injury on an already injured brain. 

What You Need to Know About Returning Youth Athletes to Play 

The old days of simply writing a note stating “Bobby has a concussion — take two weeks off and then return to football” are gone. The process of returning an athlete to play requires careful documentation of both symptomatic and neuropsychological recovery; therefore, it is unadvisable to write a note that allows the athlete to resume activity at an arbitrary date in the future because it is impossible to predict how a concussion will evolve and when that concussion will resolve. The decision to return to play must be based solely on the individual. 

Current best practices recommend a multi-disciplinary team approach, meaning everyone who interacts with the student athlete should help manage the concussion and report their observations about the athlete’s recovery. Having multiple eyes on the concussed athlete can help assure that he or she has returned to full functionality. 

The concussion team may include the athlete, parents or guardians, teachers, school nurses, coaches, trainers and medical providers. 

Resources for Managing Concussions 

There are many tools available for concussion teams, including: 

• Dr. Karen McAvoy, the author of REAP (Reduce, Educate, Accommodate, Pace), provides a nice summary of the multidisciplinary team approach. The REAP booklet guides the concussed athlete and their team through the recovery process. 

• The Centers for Disease Control and Prevention (CDC) recommends using the Acute Concussion Evaluation (ACE) tool. 
• The Sports Concussion Assessment Tool (SCAT 2) is another concussion tracking tool. There are many websites that post this tool; you can find it through a Web search of “SCAT 2.” 

Returning the Youth Athlete Back to School 

Although the student athlete should not resume sports or activities that could cause re-injury to the vulnerable brain until fully recovered, the approach to returning to school is quite different. Every attempt should be made to transition the student back to school once the most severe symptoms have improved (usually within one to three days). The student, parents and physician may need to work with the school for specific accommodations so that symptoms can continue to improve while keeping the student engaged in learning. The CDC offers guidelines for return to school.  

Returning the Youth Athlete to Sports Participation 

Returning an athlete to participate in a sport can only begin once they have fully recovered from the concussion. The athlete must be symptom free and have returned to baseline regarding school performance (which means being able to tolerate a full school day with an age-appropriate workload). 

Neurocognitive testing may also be helpful to assess recovery, although neurocognitive recovery may lag behind symptom resolution, theoretically indicating an athlete whose brain is still at risk. 

Once the medical provider has determined that the athlete has fully recovered, it is time to begin the Graduated Return-to-Play Protocol as recommended by the Consensus Statement on Concussion in Sport published in 2017 (also available on multiple websites by searching “Graduated Return-to-Sport Protocol”). Once the athlete successfully completes this graduated return-to-play process — which typically requires a minimum of seven days after they are asymptomatic at rest — they can then receive final clearance to return to full participation. 

Adolescents with concussions may have subtle neurometabolic derangements that may dramatically increase the risk of long-term and potentially severe or life-threatening complications if re-injured before recovery. Because of this, the process of clearing a youth athlete to return to his or her sport after a concussion requires a systematic and thoughtful approach with thorough documentation of resolution of the symptomatic and neuropsychological consequences of the concussion. Even with this approach, we do not yet have clear evidence that the potential for poor outcome has been eliminated. Every parent and youth athlete must individually weigh the risks and benefits of competitive sports after concussion. 

Lessons Learned  

• Utilize concussion management resources to enhance your prescribed treatment plan and assess a student athlete’s recovery. 
• Request written and periodic observations from parents and guardians, teachers and coaches regarding the athlete’s symptoms and complaints. 
• Ensure that student athletes and their parents or guardians understand the severe risks of returning to sports before a full recovery. 

Potential Damages 

Clearing a youth athlete to return to their sport after a concussion can lead to life-threatening complications if re-injured before they fully recover from the concussion. Although the frequency of claims is relatively low, physicians run the risk of negligence claims for clearing a youth athlete too early if further injury is sustained and enhanced by the previous concussion.