Every fall, a lot of parents and coaches find themselves standing over an athlete trying to work out how serious it is.
The athlete says they’re fine. They usually want to go back on. The game is close, there’s no obvious injury to look at, and everyone involved has an incentive to believe it’s nothing.
So it’s worth having the decision made in advance, when nobody’s under pressure.
The Rule That Overrides Everything
If a concussion is suspected, the athlete comes out and does not return to play that day.
Not “sits out a few minutes and gets reassessed.” Not “returns if the symptoms settle by the fourth quarter.” No same-day return, full stop.
Why the rule is absolute rather than a judgment call:
Symptoms frequently develop or worsen over the following hours. An athlete who seems fine on the sideline at minute forty can be considerably worse by evening.
An athlete with an unrecognized concussion has impaired reaction time, balance and judgment — which raises the risk of a second injury of any kind.
And a second head impact before the first has resolved carries risks that nobody wants to be responsible for.
“If in doubt, sit them out” exists as a phrase because the cost of being wrong in one direction is a missed half, and in the other direction it can be catastrophic.
What You’re Actually Looking For
A concussion doesn’t require loss of consciousness. The large majority don’t involve it, which is one of the most common misconceptions.
Signs others might notice:
Appearing dazed or blank. Confusion about the score, the play, or where they are. Moving clumsily or unsteadily. Answering questions slowly. Any loss of consciousness. Changes in mood or behavior. Forgetting events before or after the impact.
Symptoms the athlete might report:
Headache or pressure in the head. Nausea. Dizziness or balance problems. Blurred or double vision. Sensitivity to light or noise. Feeling foggy, sluggish, or “not right.” Difficulty concentrating or remembering.
And a practical point: athletes underreport. They know what reporting means. So the threshold for asking should be lower than the threshold for them volunteering, and the question shouldn’t be “are you okay?” — because the answer is always yes.
The Signs That Mean Emergency Care, Immediately
Some presentations aren’t a sideline decision at all. Call 911 or go to an emergency department for:
A headache that is worsening. Repeated vomiting. A seizure or convulsion. Weakness, numbness, or decreased coordination. Slurred speech. Increasing confusion, agitation or unusual behavior. Inability to recognize people or places. One pupil larger than the other. Drowsiness or an inability to be woken. Any loss of consciousness.
Also treat as urgent: any suspected neck injury. If there’s neck pain, don’t move the athlete — stabilize and get help.
The First 48 Hours
Guidance in this area has changed meaningfully in recent years, and a lot of people are still working from the older version.
The old advice was complete rest in a dark room until symptoms resolved. That approach has been superseded.
The current approach is a brief period of relative rest — generally around 24 to 48 hours — followed by gradual reintroduction of light activity, staying below the level that significantly worsens symptoms.
Why the change: prolonged strict rest is associated with slower recovery in some people, along with deconditioning, isolation and low mood. Sitting alone in the dark for a week turns out not to help.
What “relative rest” means practically: reduced screen time and cognitive load, no sport, no risk of further impact, adequate sleep, and light activity like short walks as tolerated.
Then, guided by a healthcare professional, gradual reintroduction — including sub-symptom-threshold aerobic exercise, which has become a recognized part of management rather than something to avoid.
Return to Learn Comes Before Return to Play
This gets skipped constantly, and for school athletes it matters more than the sport.
A student should be managing school demands before returning to full sport. Concentration, screen work, reading and testing all place cognitive load on a recovering brain, and academic accommodations — reduced workload, extra time, breaks, reduced screen exposure — are frequently needed and rarely requested.
Tell the school. Teachers can’t accommodate what they don’t know about, and an athlete quietly failing to keep up is a recovery problem as well as an academic one.
The Graduated Return to Play
Return happens in stages, each typically separated by at least 24 hours, with symptoms guiding progression.
The standard structure moves roughly through:
Symptom-limited daily activity.
Light aerobic exercise — walking, stationary cycling, no resistance training.
Sport-specific exercise — running or skating drills, no head impact activity.
Non-contact training drills, progressing to resistance training.
Full-contact practice, following medical clearance.
Return to competition.
The key rules:
If symptoms return at any stage, drop back to the previous stage and progress again after a further period without symptoms.
Medical clearance is required before full-contact practice — that’s a physician decision, not a coach’s or a parent’s.
And nobody skips stages because a game is coming up.
Where Physical Therapy Fits
A common assumption is that concussion recovery is purely a matter of waiting. For many people it largely is — most recover within a few weeks.
But for those whose symptoms persist, there are frequently identifiable, treatable contributors — and this is where rehabilitation has a genuine role.
Cervical spine involvement. The same impact that shakes the brain also loads the neck, and neck-related symptoms — headache, dizziness — can look identical to concussion symptoms and persist after the concussion itself has resolved.
Vestibular and oculomotor problems. Dizziness, difficulty with visual tracking, discomfort in busy visual environments, and problems with balance. These respond to targeted rehabilitation.
Exertional intolerance. Symptoms triggered by exercise, which can be assessed and then progressively addressed through graded sub-symptom-threshold aerobic work.
And deconditioning, after weeks of reduced activity.
Which means the honest framing is: if an athlete is still symptomatic several weeks out, “keep resting” is usually the wrong answer, and an assessment to identify which system is driving the persistent symptoms is usually the right one.
What Parents and Coaches Should Set Up in Advance
Decide the policy before the season. Who makes the call, what happens after, and who clears the athlete.
Make it clear to athletes that reporting won’t cost them their place. If they believe it will, they won’t report — and that belief is the single biggest obstacle to recognition.
Know the emergency signs, listed above.
Tell the school promptly.
And take previous concussions seriously. History matters for both risk and management.
Get the Persistent Symptoms Assessed
Most athletes recover well with appropriate early management. For the ones who don’t, waiting longer is rarely the answer.
Sports PT Centers offers a free discovery visit at no cost and no obligation. If an athlete is weeks out and still dealing with headaches, dizziness, neck pain, visual symptoms or exercise intolerance, we can assess the cervical, vestibular and exertional contributors and build a graded plan.
We work alongside the physician managing their care and their clearance, not around them.