When can I compete again? Return to sport after a mild traumatic brain injury (concussion).
In this post, we're going to talk about:
You will know what you can expect on your road back to competing and if your doctors are keeping you on the right track by the end of this. The RTP process is essential because concussed athletes have a 2X higher risk of an injury (e.g., ankle sprain) in the following season. I'd argue this is at least partly due to athletes returning too quickly without proper recovery.
What are the expected recovery timelines?
"When can I compete again?" is usually the first thought of any athlete after any injury. But with a concussion, things can feel a bit more unknown because you can't see a concussion the way you see a swollen ankle. And unfortunately, there are still far too many doctors out there prescribing prolonged (>72hrs) rest after a concussion. Because of that, you may genuinely be wondering, "When the f*** can I get back out there."
Here are some common "checkpoints" after a concussion:
Symptoms usually peak (are worst) 3-5 days after the injury.
Symptoms usually resolve (go away) 5-10 days after the injury.
Brain metabolism (energy production) returns to normal by 3-4 weeks after the injury.
How might this look? Let's say that you sustained a concussion on Friday. You might feel symptoms (e.g., headaches, head pressure, brain fog, nausea, etc...) immediately after or within hours of the injury. Then, as your brain energy levels continue to drop, you begin to feel more tired and symptomatic. You may progressively feel more and more "like a dumpster fire" through the weekend until Mon-Weds the following week. Around this time, your symptoms may begin to let up. And, you may feel "normal" again by the following Friday.
Not so fast, though. Symptomatic recovery does not equal metabolic/performance recovery. Your brain energy levels are still low and will take roughly 3-4 weeks to return to normal. Your posture, walking, running, jumping, reaction time, and concussion may also impair your multitasking ability for the next 3-4 weeks. These are things you may not notice because you "feel normal."
What do we need to see over those 3 to 4 weeks to know we can return an athlete to play?
We need to see three big things: no symptoms at rest or with exertion, typical physical performance, and healthy psychological function. Essentially, we need to know that you feel and perform like you before being injured.
Symptoms: We want your symptoms to be normal at rest and with physical or cognitive exertion. We measure symptoms with questionnaires like the PCSS or CP Screen.
Physical Performance: We want you to be able to tolerate aerobic and anaerobic exercise (to near maximal effort, 85-90% HRmax) without symptoms, normal balance, normal reaction time, and normal visual processing.
Psychological Health: We need to be sure we're screening for PTSD or trauma around the injury and return to play. We also need to see that your neurocognitive function (e.g., memory, attention, executive function) returns to normal.
What is the recommended protocol to ensure the fastest and safest return to sport?
The recommended RTP protocol takes you from the days after injury to regular practices and gameplay. The idea behind this is kind of like walking up a staircase with six steps, taking each step one at a time. If your symptoms flare at any stage, you take one step back and repeat the previous stage for at least 24hrs.
Symptom-limited activity
Light aerobic activity
Sport-specific activity
Non-contact practice/training
Contact-practice/training
Return to sport/competition
What does this look like in action? Again, let's say you sustained a concussion on Friday. Ideally, you will visit a concussion specialist by Monday. This visit will confirm the diagnosis and rule out any need for special imaging or referrals. Stage one is from the time of injury until around days 5-7. During this time, you are not hibernating. You are doing small doses of normal school (or work) activities as long as they don't flare your symptoms too significantly.
Stage two begins after your concussion specialist runs you through a Buffalo Concussion Treadmill Test (BCTT) or similar exercise testing. Once you know your exercise tolerance, you can begin the prescribed aerobic activity, which can lower your risk of PCS by almost 50%. Throughout stage two, you will perform 20-30min of aerobic exercise each day. How long this stage lasts will depend on how fast you regain your exercise tolerance. Many young athletes will only spend 7-10 days at this stage and begin stage three around two weeks after their concussion.
Once you pass your Buffalo Concussion Treadmill Test (BCTT), you're ready to begin doing more sport-specific work - like agility and light resistance training. You may spend 3-5 days here completing 2-3 training sessions without symptoms. Once symptom-free with sport-specific agility, reaction, resistance, etc... training, you are ready to move onto non-contact practice.
Stage four is when you can return to the ice, court, field, etc... with the exception that you cannot be a participant in contact drills. So a hockey player can perform flow/passing/systems drills but can't participate in corner battles or training areas that may result in head contact. We like athletes to spend 2-3 practices here without symptoms.
Now, you don't just get a free pass into contact training in a legitimate specialist's office. Remember, balance, reaction time, and visual processing can show deficits for up to a month after a concussion. Many of those deficits will show up when we make you work at similar intensities to gameplay - and that may be why we see a 2X increased injury risk. So, to move on to stage 5 (full-contact practice), you need to pass an exertion protocol (e.g., Gapski-Goodman or EXiT) symptom-free. After the exertion protocol, you need to prove your performance by passing your neurocognitive and baseline tests (if available) or passing a vestibular-oculomotor screening (VOMS) assessment.
While it can take up to three weeks before reaching the exertion protocol and stage five, it's important to note that you probably only spent a couple of weeks away from your team. Most folks will begin sport-specific training by two weeks after their concussion. They will have been skating, running plays, and training with their team in a non-contact fashion after that.
The good news about passing your exertion protocol and entering stage 5? You begin contact practice, and as long as you're symptom-free for 2-3 practices - you, my friend, are ready to play.
The whole RTP process can be as quick as three weeks and as long as eight or more, depending on your injury, previous health history, etc...
A concussion is a relatively "fast" injury in the sports world.
I want to provide some context for the RTP timeline. When folks hear that they're going to miss at least three weeks for their concussion, a sort of dreadful resistance takes over. "I don't want to miss my sport when I feel fine! I'm not even bruised!"
Well, let's take a look at a concussion recovery timeline compared to other musculoskeletal injuries.
Ankle Sprain: 2-6 weeks recovery time
Concussion: 3-8 weeks recovery time
Arm Fracture: 11-14 weeks recovery time
ACL Reconstruction: 36 weeks recovery time.
Rotator Cuff Tear: 16-48 weeks recovery time
*Reference: DynaMed
In the grand scheme (of randomly selected injuries), a concussion recovers about as fast as an ankle sprain when you go through the proper RTP protocol. And I venture to guess that you will likely take the other injury rehab processes more seriously so that you can get out of the boots, braces, and slings. But, remember, just because you can't see the concussion on the outside doesn't mean your brain didn't take a metabolic hit on the inside.
Find a specialist, take your time, and return to sport as good as (or better than) new. For your own concussion/PCS recovery back into competition, go ahead and schedule a consultation at the link below.
Dr. Mark Heisig is a licensed naturopathic doctor with continuing mTBI education from The American Academy of Neurology (AAN), Complete Concussion. Management (CCMI) and The Carrick Institute. His office is located in Scottsdale, AZ.