InjuriesNeurologyPreventive MedicineSports Medicine Info


Every week during the football season, players from every team, college or professional, sustain head injuries that prevent them from returning to play. Head injuries from football are common, and research over the last 10-15 years has revealed that when unrecognized or untreated, they can have serious long-term adverse effects. Repeated head injuries cause concussions and repeated concussions eventually lead to chronic traumatic encephalopathy (CTE). CTE is a devastating, often fatal consequence of concussions that can be prevented if players don’t return to play too soon. To mitigate this problem, concussion protocols were developed to decide if a player was safe to return to competition.

The concussion protocol is a complex medical procedure that indirectly tests the function of the injured brain. In addition to headaches, dizziness, and balance issues, most concussions affect an athletes memory and reasoning, so the protocol is focused on determining if these deficits have returned to normal. Additional focus is placed on resolution of symptoms, as well. A player cannot return to practice or game play until he has completed all the tasks required by the protocol. So what is included in the protocol? What role do trainers and team doctors play in it? How many phases are in the protocol? What determines when the athlete can return to play?

In years past, concussions were considered a normal consequence of playing football and  recognized but not dealt with seriously. Then, several years after retiring from pro football, players began developing memory problems, behavioral changes, and suicidal tendencies. There were several high profile former players who took their own lives. This upset the football “fraternity” and ultimately led researchers to discover that concussions were directly responsible for the devastating long term effects.

Thus, the National Football League (NFL) developed guidelines for the evaluation and management of concussions and the prevention of CTE. I was able to find an article titled “The National Football League Concussion Protocol: A Review” which was in HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery. It was a thorough explanation of the details of the protocol. What follows is an abbreviated summary of the salient points involved with the concussion protocol. There are several elements of the protocol of which I was  unaware, and was surprised how comprehensive it really is. Obviously, a considerable amount of thought, planning, and organization has gone into developing this protocol because it addresses just about any possible scenario.

Once a player has been determined to have a concussion, he must complete all five phases of the “Return-to-Participation (RTP) Protocol.” I will explain these phases later, but completion of the protocol has “no set timeline.” The time between phases and the time it takes to complete the protocol are based solely on the rate at which the athlete progresses through each phase. One phase is not started until the observing/supervising individuals are certain the athlete has successfully completed the previous phase. “A recent study of concussions in the NFL indicated that the RTP process requires a median of 9 days, and a mean of 15 days…”

The NFL protocol actually starts during the off season when the team’s medical staff educates players about the signs and symptoms of concussion and the specifics of the concussion protocol. An effort is made to stress the importance of the player reporting his symptoms to the medical staff. In the preseason, “every team’s medical staff performs an annual preseason physical exam on all players, including….pertinent neurologic issues and details and outcomes of all prior concussions. A club-designated neuropsychologist consultant (NPC) assists in conducting preseason baseline neurocognitive testing on all players once every 3 years…..Every two years players undergo baseline testing with the NFL’s Locker Room Comprehensive Assessment,” to establish each player’s neurocognitive baseline. Any player exhibiting signs or symptoms from past concussions is thoroughly evaluated before being allowed to practice or play.

Game Day concussion surveillance is an area about which I was completely unaware, but  learning about it is reassuring for athletes and fans alike. In the video replay booth, the NFL has placed two independent, thoroughly trained injury spotters. These athletic trainer spotters watch the game, assisted by the Injury Video Replay System (IVRS) and “identify injuries, some that may have gone undetected by sideline medical staff.” The IVRS “provides [spotters with] multiple views of each play from cameras positioned throughout the stadium….the spotter can review plays multiple times at varying speeds and from various camera angles.” 

If the spotter detects a worrisome head or neck injury, “he may activate the concussion protocol by alerting the team medical staff.” Sideline medical staff also have dedicated video monitors used to review injuries. The spotters can call a “medical timeout” if they feel a player still in the game demands attention that has not been given. The qualifications to be a spotter require athletic trainer certification, a 4-year college degree, 10 years of athletic training experience, “significant” college or professional sports experience, and must not have any current or past affiliation with an NFL team. 

To assist the spotter, an “Unaffiliated Neurotrauma Consultant (UNC)” is also in the video booth. UNC’s are physicians who are “experts in traumatic brain and spinal cord injury….and must be board certified or board eligible……in neurosurgery, neurology, emergency medicine, or physical medicine and rehabilitation, and be qualified in Sports Medicine.” These physicians add professional expertise to the identification of concussions and share responsibility for the determination.

Sixty minutes before kickoff, the “60-Minute Meeting” is held that “includes medical staff from both teams, game officials, UNC’s, all medical emergency response personnel, ambulance personnel, and radio communications team. Here the unaffiliated spotters and Neuro Consultants are assigned to each team and take positions in the video booth. They discuss  information about players who are playing with injuries or have prior concussions.

When a player is injured and has signs or symptoms of a concussion, he is immediately removed from the game and undergoes an evaluation before returning to competition. The medical staff follows the “Concussion Game Day Checklist” established by the NFL. This step-wise evaluation is usually done in the blue tent on the sideline. The staff asks the player. Maddock’s Questions (see blog on “Concussion” from 1/24/2021) which are questions specific to the game in which they’re playing. Also, if the injury caused loss of consciousness, the player had involuntary muscular posturing when injured, cannot stand steadily, is confused, has amnesia, and cannot answer Maddock’s questions, he is sent to the locker room for further observation.

It is now when the team physician does a complete neurologic exam and decides if imaging studies are needed. It is also now that the athlete enters the “Return-to-Participation” protocol. When you hear the player hasn’t cleared concussion protocol, it means he is in the RTP protocol and hasn’t completed the current step to get close to returning to competition. 

The Return-to-Participation protocol has five phases. 

PHASE I: Rest phase. Player avoids all activities that aggravate the symptoms. Under athletic supervision, he may do limited stretching and balance training and light aerobic exercise.

PHASE II: Under medical staff supervision, the player may begin gradual cardiovascular exercise, dynamic stretching, and balance training. 

PHASE III: Under supervision, increased CV exercise and strength training are done plus mild football-like activities may be done. Athletes can participate in football activities for 30 minutes or less.

PHASE IV: Continue CV exercises, strength and balance training, and may throw, catch, and run.

PHASE V: Clearance for full football activity. Player is cleared by the UNC and the team physician. 

Obviously, if during any of the activities in each phase, the player has recurrent symptoms, he remains in that phase until asymptomatic. If he has been asymptomatic and develops recurrent symptoms, he must start the RTP protocol all over again. So when you hear the play-by-play announcer say so-and-so has yet to clear the concussion protocol he means he is being held out by his inability to remain asymptomatic during progressively increasing physical stresses.

“Once the athlete demonstrates the ability to engage in all non-contact football activities without exacerbation of symptoms, the club physician may clear the player for full football activity involving contact in practice. If that is tolerated without signs or symptoms, and the club physician concludes the player’s concussion has resolved, he or she may clear the player to return to full participation. The player must then be examined by the UNC; if the UNC confirms the club physician’s conclusion that the player’s concussion has resolved, the player is considered cleared.”

Concussions are serious. They have been proven to have sometimes-fatal long term consequences. For a long time, the NFL denied that Chronic Traumatic Encephalopathy was a result of repeated concussions, but ultimately they had to admit there was a correlation. A 2012 class action lawsuit by 4500 former players was enough motivation for the NFL to do the ultimate “CYA” by developing the concussion protocol. It’s a procedure that should have beneficial effects long term, but time will tell if the protocol has the desired effect.

Reference: Jacobi J, Wasserman EB, Mack CD, Heinzelmann M, Cardenas J, Rehberg R, Solomon G, Sills A, Vargas B. The National Football League Concussion Protocol: A Review. HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery 2023;19(3):269-276.

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