Concussion Management in High School Athletics

Statement of Concerns
Concussions at all levels of sports have received a great deal of attention in the past few years. Attention has increased even more over the past year, culminating with the NFL, NCAA and National Federation of State High School Associations testifying before the United States Congress about what each organization is doing to protect athletes from concussion. At least four states have enacted legislation dealing with the issue of head injuries sustained in athletic competitions. Adolescent athletes are particularly vulnerable to the effects of concussion. Once considered little more than a minor “ding” on the head, it is now understood that a concussion has the potential to result in death, or short- and long-term changes in brain function. A concussion is a brain injury that results in a temporary disruption of normal brain function. A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a result of a blow to the head or body. Continued participation in any sport following a concussion can lead to worsening concussion symptoms, as well as increased risk for further injury to the brain, and even death. The well-being of the athlete is of paramount concern during any athletic contest. Officials, coaches and administrators are being asked to make all efforts to ensure that concussed athletes do not continue to participate. Thus, coaches, players, officials, and administrators should also be looking for signs of concussion in all athletes and should immediately remove any suspected concussed athlete from play.

NFHS Rules Change
Previous rules books for most sports included language directing officials to remove an athlete from play if “unconscious or apparently unconscious.” We now know that a person does not have to lose consciousness to suffer a concussion. In fact, according to our most recent data from the High School Reporting Information Online (RIO) and the National High School Sports Related Injury Surveillance Study, only 3.2 percent of all concussed athletes lost consciousness during the 2009 football season. That language has been changed to the following: Any athlete who exhibits signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion or balance problems) shall be immediately removed from the contest and shall not return to play until cleared by an appropriate health-care professional. The common signs, symptoms and behaviors of concussed athletes may be found in Appendix B on page 100 of the 2010 NFHS Football Rules Book.

Role of Officials
Neither officials, nor coaches, are expected to “diagnose” a concussion, as that is the job of an appropriate health-care professional. Officials are being asked to use their best judgment in observing the signs, symptoms and behaviors, but are no longer being asked to make what could be perceived to be a medical opinion. This is the same type of monitoring procedure that has been used with orthopedic injuries and the “blood rule” in the past. The game official is not responsible for the sideline evaluation or management of the athlete after he or she is removed from play. The responsibility of further evaluating and managing the symptomatic athlete falls upon the head coach, appropriate health-care professional, or other individual designated by school administrators. If an appropriate health-care professional on the sideline determines that the athlete HAS NOT suffered a concussion, the athlete may return to play. If there is no appropriate health-care professional available to evaluate the athlete, the athlete SHOULD NOT be allowed by the coach to return to play. The official does not need written permission for an athlete to return to play, nor does the official need to verify the credentials of the appropriate health-care professional. Ensuring compliance with the Suggested Management Guidelines is a health and safety issue and should be the responsibility of the head coach and school administration, NOT the game official.

School Responsibilities

  1. Any athlete suspected of having a concussion should be evaluated by an appropriate health-care professional that day. NOTE: An “appropriate health-care professional” must be determined by each school district with respect to state laws and local preferences. Such individuals should be knowledgeable in the evaluation and management of sports-related concussions and may, depending on controlling law, include MDs, DOs and certified athletic trainers
  2. No athlete should return to play or practice on the same day after a concussion has been diagnosed
  3. Any athlete with a concussion should be medically cleared by an appropriate healthcare professional prior to resuming participation in any practice or competition. The formulation of a gradual return to play protocol should be a part of the medical clearance. NOTE: Athletes with continued concussion symptoms are at significant risk for recurrent, cumulative and even catastrophic consequences of a second concussive injury. Such risks are minimized if the athlete is allowed time to recover from the concussion and return to play decisions are carefully made. No athlete should return-to-sport or other at-risk participation when symptoms of concussion are present and recovery is ongoing.
  4. These guidelines should be applied to both practices and scrimmages.

It is required that coaches participate in a free, online course on concussion management prepared by the NFHS. “Concussion in Sports” is an extremely well-prepared presentation that can be found at

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