There was a time when most parents and student-athletes believed that getting dinged in the head or having their “bell rung” during a sports activity was just something to shake off. However, such perceptions overlooked the real dangers of untreated head and neck injuries, which can range from minor neck strains to traumatic brain injuries (TBIs), a term describing any bump, blow, or jolt to the head that disrupts the normal function of the brain. The severity of TBIs range from mild (a brief change in mental status or consciousness) to severe (an extended period of unconsciousness or memory loss after the injury). Most TBIs tend to be mild, and are generally known as concussions.1 Effects of these types of injuries can include impaired thinking or memory, movement, sensation (e.g., vision and hearing), or emotional functioning (e.g., personality changes and depression).1

Crash course

Student-athletes may experience a wide variety of injuries to the head and neck, but TBIs are the most common. In fact, during 2001 to 2005, an estimated 207,830 emergency department visits for concussions and other TBIs related to sports and recreational activities were reported annually, with 65 percent of TBIs occurring among children 5 to 18 years of age. Compared with adults, younger persons are at increased risk for TBIs with increased severity and prolonged recovery.2

The Fourth International Conference on Concussion in Sport held in Zurich, Switzerland, noted several common features that define a concussion3:

  • Causes include a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head.
  • Results are a rapid onset of short-lived impairment of neurological function that resolves spontaneously. Symptoms and signs may evolve over several hours.
  • No abnormality appears on standard structural neuroimaging studies.
  • A possible loss of consciousness may result. The clinical and cognitive symptoms typically follow a sequential course, although some symptoms may last longer.

Headed for trouble

The general signs of concussion fall into four categories4 and may include the following symptoms:

  1. Physical: Headaches, nausea, visual problems, and fatigue
  2. Cognitive: Mental fogginess, difficulty remembering and concentrating, and confusion
  3. Emotional: Irritability, sadness, and nervousness
  4. Sleep related: Drowsiness, sleeping more than usual, sleeping less than usual, and difficulty falling asleep

Some of these symptoms may appear right away, while others may go unnoticed for days or months after the injury, or until the person resumes everyday life. People may not even connect their problems to the concussion.5

Parents and patients should be on the alert for the symptoms getting worse. “There are a group of warning signs following head injuries that indicate an injury more serious than a concussion may have occurred,” says Mark Halstead, MD, a spokesperson for the American Medical Society for Sports Medicine, Leawood, Kansas. “These can include a progressively worsening headache or the worst headache of that person’s life, repeated episodes of vomiting, numbness or tingling in extremities, inability to move an arm or leg, slurred speech, and difficulty keeping the patient conscious or awake.”

The presentation of certain symptoms require instant action. “The patient [should] be taken immediately to the emergency department as [symptoms] may signify an intracranial bleed,” says Margot Putukian, MD, FACSM, former president of the American Medical Society for Sports Medicine and director of Athletic Medicine, Princeton University, Princeton, New Jersey.

The following symptoms indicate a deteriorating neurological condition:

  • Neck pain or tenderness
  • Double vision
  • Seizure or convulsions
  • Increasingly restless, agitated, or combative behavior
  • One pupil larger than the other
  • Inability to recognize people or places

Good sports

The key features of a follow-up examination should encompass the following5:

  • A comprehensive history and detailed neurological examination, including assessment of mental status, cognitive functioning, sleep-wake disturbance, ocular function, vestibular function, gait, and balance.
  • Assessment of the clinical status of the patient, including whether there has been improvement or deterioration since the injury. This may involve speaking with parents, coaches, teammates, and eyewitnesses to the injury.
  • Determination of the need for neuroimaging to exclude a more severe brain injury (e.g., structural abnormality).

Even if an athlete’s symptoms cease on the same day as the concussion and he or she feels better on the sidelines, the athlete should not be allowed to return to play that same day.5 The phrase “When in doubt, sit them out!” is key to the management of pediatric and adolescent concussions.4


Recovery time depends on several factors, such as the severity of the concussion, health of the patient, and aftercare. “I discourage health care professionals from telling patients that they can return to full activity when they are headache-free for a week,” cautions Dr. Halstead, who is also an associate professor at Washington University School of Medicine, Chesterfield, Missouri. “That may happen, but [a] headache is only one of many symptoms following a concussion, and they may be headache-free, but still experiencing other issues related to the concussion.”

He notes that most students who experience a concussion while participating in sports are symptom-free within three weeks of the injury. “Symptoms can persist longer, but it is less common for them to be prolonged. In the cases of prolonged concussion, it is desirable to refer that patient to a specialist.”

As far as prevention goes, encouraging the use of mouth guards, helmets, and headgear is crucial. Ultimately, education and awareness are the central components of improving care for student-athletes.