Put Me Back In, Coach: Returning to Play After Football Concussions

The field of sports medicine has changed rapidly since the turn of the 21st century. We now know more about orthopedic and neurological sports injuries than we ever thought possible, and we’re continuing to uncover new connections and correlations.

Few sports medicine matters are more controversial than football-related head trauma — in particular, concussions sustained on the field of play. (Repeated subconcussive impacts, though related, present their own pathologies, indications and, of course, controversies.)

Until relatively recently, it was common and, frankly, expected for student and professional footballers to play on after sustaining probable concussions. Veterans of the game speak knowingly of playing past “stingers,” hits that leave stunned players unable to focus their eyes or think clearly for minutes or hours. The NFL didn’t even have a formal concussion protocol until the 2010s, and players — particularly second-stringers desperate for playing time — have long been reticent to report serious injuries for fear of losing spots in the lineup.

At this point, we know enough about the science of head trauma to know that football players shouldn’t continue to play after sustaining probable concussions. We’re a bit fuzzier on exactly when it’s safe for players to return to the field after concussive impacts. Here’s an overview of the NFL concussion protocol and the generally accepted facts around post-concussion recovery for student and professional football players.

NFL Concussion Protocol

The NFL’s concussion protocol has several game-day components for evaluating, treating and clearing players suspected of sustaining in-game concussions. These include:


  • Removal to the Locker Room: Players who sustain an obvious injury (“big hit”) on the field of play, or who exhibit symptoms of probable concussion (e.g. wooziness, blank staring, loss of coordination) after a play, must be removed from the field of play and taken to a quiet area for evaluation, generally the locker room.
  • Evaluation by Team Staff: Team medical staff subject concussion-suspected players to a full neurological evaluation using the NFL’s Sideline Concussion Assessment Tool.
  • Evaluation by Unaffiliated Neurotrauma Consultant: Unaffiliated neurotrauma consultants (not on the payroll of any team, booster organization, or other group with a potential conflict of interest) must be present at all NFL games and independently assess players for concussion signs and symptoms. The neurotrauma consultant conducts assessments in parallel with team medical staff, auditing their work to maintain process integrity.
  • Spotter Evaluation: Independent spotters review video footage of the impact and aftermath to gather more information about the injury and its potential symptoms, corroborating or contradicting medical analysis and players’ verbal feedback.
  • Recurring Examinations: If necessary, players are to be evaluated at regular intervals for the remainder of the game and beyond. These recurring examination help plot players’ return to baseline function and/or indicate if further treatment is necessary.


Clearing Players to Return

There’s a multi-step process for clearing players to return to play or practice following concussion protocol participation:

  • Players must return to prior baseline, as judged by team medical staff and the unaffiliated neurotrauma consultant (with exams conducted separately)
  • Players must successfully complete a “graduated exercise challenge” to ensure that they’re capable of performing safely on the field
  • Players must be formally cleared, and then subjected to on-field observation until team medical staff have judged that recovery is complete

Best Practices For Non-Professionals

Non-professional players typically aren’t bound by the NFL’s concussion protocol, particularly in amateur settings that don’t have concussion protocol analogues (e.g. high school football leagues). As such, it’s important for players and their parents to understand when it’s appropriate to seek evaluation and treatment for potential concussions, and when it’s okay to return to the field of play.

Parents concerned about their kids’ exposure to concussions can:

  • Obtain a preseason baseline cognitive evaluation
  • Send the child to an unaffiliated specialist to ensure that there’s no conflict of interest in return-to-play procedures and to obtain an all-important second opinion
  • Speak with coaching staff about using extra safety equipment
  • Lobby coaching staff for equal sideline treatment, e.g. not penalizing the child for voluntarily sitting out after being cleared to return to play

Everyone Is Different

Every human is different. It’s worth reiterating that adults and children have very different neurological profiles. What make sense for a highly paid NFL player might not fly for a 10-year-old child. While the medical community is more than capable of issuing recommendations around these issues, it’s ultimately up to parents and role models to set the bounds of acceptable behavior and participation for young athletes. The future of American sports quite literally depends on it.