Five Steps to Managing Concussions in Youth Sports

In this guest article, Dr. Steve Horwitz provides 5 steps that should be taken to manage concussions in youth sports.

By Dr. Steve Horwitz

Concussions and CTE. These have been the two buzz words in the sports headlines for the last few years. We read and see how concussions are managed in professional sports (recent World Cup) and the recent examples of this management are disconcerting. The NFL and NHL lawsuits continue and the more we learn, the uglier it gets. What is the influence of professional sports on the decisions made by youth athletes, parents, coaches, and administrators?



#1 – Lack of Preparedness: Kids are not little adults and youth sports are not the NFL.

Over 30 million children ages five to 14 participate in organized youth sports. While the benefits of youth sports are many, there are inherent risks in physical activity. Youth athletes bear a disproportionate burden of sports and recreation-related (SR) injuries (Ref). Sports-Related Concussion (SRC) represents a subset of mTBI which occur during both competition and/or practice (Ref).

Between 1.6 and 3.8 million SRCs occur annually in the United States. (Ref) These figures likely underestimate total concussion burden, as many children who sustain concussions may not seek medical advice. Youth are especially at risk with regard to concussion. (Ref) The rate of reported concussion in high school athletes has doubled since 2005 (Ref), and youth demonstrate more prolonged recovery from symptoms (Ref) (Ref) (Ref)

In addition, there is no comprehensive and systematic data collection in youth sports (Ref) and no effective state concussion registry.

Most of youth sports is played within organizations which do not provide sideline medical staff. In non-scholastic youth sports, the burden of recognizing a concussion falls primarily on coaches and parents (Ref). Only 37% of public high schools (Ref) have one full time athletic trainer and only 28% of private high schools have one full time athletic trainer (Ref). Youth leagues, clubs, tournaments, etc. rarely provide sideline medical support. (Ref)

Studies show that parents are concerned more about concussions than any other sports injury (Ref). They have high confidence in their ability to recognize concussions, yet misconceptions are pervasive and knowledge is marginal at best. Most parents do not know that a concussion is an mTBI and few can classify a group of signs and symptoms as concussion related. Most parents are not familiar with concussion protocols, unaware if their child’s coach received formal concussion training, yet trust coaches’ ability to instruct them once an injury occurs and the coaches’ knowledge in return-to-play rules. (Ref) (Ref)

The same is true for athletes and coaches. (Ref) (Ref) The real world consequences have been devastating:

Rashaun Council: 1) the coaches of Council’s freshman team had failed to complete the state’s mandated concussion training program, and 2) they failed to recognize the clear and obvious symptoms that Council was suffering from a concussion and sent him back into competition rather than putting him in an ambulance bound for a hospital. (Ref)

#2 – What Does “the protocol” mean?

When an athlete enters the “concussion protocol” it typically means the period of time from when the player is removed from play to when he/she is returned to play.

In January Rob Gronkowski was removed from the AFC Championship game with due to a helmet to helmet hit. That Monday the media reported he had sustained a concussion, was in the protocol and was not expected to play in the Super Bowl. It was then reported that he was still in the protocol yet participated in football specific drills. This was followed by a report that he was officially listed as “limited,” still in the protocol but was in pads and practiced two days in a row. Finally he was cleared from the protocol and played in the Super Bowl.

Each professional sport and the NCAA has its own concussion protocol. They also have dozens of medical staff to oversee each step of their processes. Athletes undergo different sideline examinations, locker room examinations, and the final “remove/return” decision responsibility is in the hands of the team physician. Conflict of interest is a widely debated topic. “Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning.” (Ref)

How is a youth sports coach or parent with no medical support staff going to make sense of this? How has decision making authority and responsibility?

#3 – Remove From Play

The overriding rule in youth sports is “If in doubt, taken them out!” This sounds simple enough, but what is the reality of this critical decision? Close to 50% of youth athletes are returned too soon (Ref) putting the youth athlete at risk for further harm from premature return.

The remove from play decision must be documented:

  • Date & Time of Removal
  • Signs & Symptoms
  • Decision Maker


Hard Collision


Loss of Consciousness


Slow to Get Up Balance/Unsteady Walk


Falling to the ground
Holding Head Dazed & Confused Blank or vacant look Facial Cut, Bruise Seizure (Fencing Response)
Change in behavior Vomits Irritable Inability to stop crying Answers questions slowly
Slurred Speech


Headache, head pressure Neck pain Feels like going to vomit Nausea Dizzy
Vision blurry Vision double Radiating pain arms/legs Numbness/tingling arms/legs Sensitivity to light
Sensitivity to noise “I don’t feel right” “I can’t think clearly” “I feel sluggish, groggy” “I feel very tired”
“I feel nervous” “I feel sad” Memory Loss

In addition, this decision must be communicated in real time to all stakeholders: parents, coaches, and administrators. Since there are no providers to guide the process, “what to do now” instructions must be passed on to the parents.

  1. Carefully observe your child for the 1st 24 – 72 hours.
  2. Look for Emergency Signs and Symptoms
  • One pupil larger than the other
  • Drowsiness or inability to wake up
  • A headache that gets worse and does not go away
  • Slurred speech
  • Weakness, numbness, or decreased coordination in arms and legs.
  • Neck pain or tenderness
  • Dizziness
  • Repeated vomiting or nausea
  • Convulsions or seizures (shaking or twitching).
  • Change in behavior
  • Increased confusion, restlessness, agitation, irritability, or combativeness
  • Unable to recognize people or places
  • Less responsiveness than usual
  • Will not stop crying and cannot be consoled
  • Loss of consciousness (passed out/knocked out). Even a brief loss is an emergency.
  1. Seek professional medical attention

#4 – Return To Learn(School)/Play(Sport)

In the current literature, two separate and distinct protocols are suggested: Return to Sport (RTS) and Return to Learn (RTL). The 2016 Consensus Statement deemed youth a “special population” that “requires special paradigms” with regard to RTS and RTL guidelines. The literature describes “graduated return to play protocols” which currently guide clinical decision making.

Most youth sports organizations do not have any written policy, nor do they have an athletic trainer to guide the process. Even if there is a policy, it is frequently outdated. Just today, I reviewed the Sports Medicine Policies & Procedures of a Division 1 university and they were still using the SCAT3 from the 2008 International Consensus Statement.

Stage 1: No School

·    No television, video games, computer use, phone, texting or loud music

Stage 2: School Part Time – Maximum Adjustments

·    Half Day attendance with appropriate academic adjustments

·    No homework or testing

Stage 3: School Part Time – Moderate Adjustments

·    Full Day attendance with appropriate academic adjustments

·    Limited homework (does not cause symptoms to return), no testing

Stage 4: School Part Time – Minor Adjustments

·    Full day attendance with no academic adjustments

Stage 5: Full Time School with no special accommodations



·    An initial period of 24–48 hours of both relative physical rest and cognitive rest is recommended before beginning the RTS progression.

·    There should be at least 24 hours (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back to the previous step. Resistance training should be added only in the later stages (stage 3 or 4 at the earliest). If symptoms are persistent (e.g., more than 10–14 days in adults or more than 1 month in children), the athlete should be referred to a healthcare professional who is an expert in the management of concussion.

Stage 1

Aim: Symptom-limited activity

Activity: Daily activities that do not provoke symptoms

Goal: Gradual reintroduction of work/school activities

Stage 2

Aim: Light aerobic exercise

Activity: Walking or stationary cycling at slow to medium pace. No resistance training

Goal: Increased heart rate

Stage 3

Aim: Sport-specific exercise

Activity Running or skating drills. No head impact activities

Goal: Add movement

Stage 4

Aim: Non-contact training drills

Activity: Harder training drills, e.g. passing drills. May start progressive resistance training.

Goal: Exercise, coordination/thinking

Stage 5

Aim: Full contact practice

Activity: Following medical clearance, participate in normal training activities

Goal: Restore confidence and assess functional skills by coaching staff

Stage 6

Aim: Return to Sport

Activity: Normal game play

#5 – A System

“a timeline dense with failures in communication that could have saved the 16-year-old kid.” (Ref)

The case of high school football player Robert Back makes clear the necessity for more than policies and protocols, especially in youth organizations with no medical providers. In September of 2014, Robert sustained a concussion in a Friday night football game. He played the next week’s game and is now a quadriplegic.

Even with medical staff and a written policy what ensued was a week of poor documentation and communication between all parties layered on top of a lack of education: medical, administrative, coaches, parents, and the athlete himself.

The three biggest breakdowns were poor overall concussion knowledge, lack of clarity with regard to “the protocol,” and lack of real time communication of documentation, most importantly the doctor’s note. With today’s technology, these breakdowns can be solved by a simple tool that can be on all stakeholder’s phones.

Dr. Steve Horwitz is a graduate of Cornell University and the National University of Health Sciences.

He was selected by the USOC to be the sole chiropractor on the US Olympic Team medical staff for the XXVI Olympiad. He has traveled internationally with USATF and been a sports medicine consultant to several Division 1 university sports programs.

Dr. Horwitz has served as chairman of the Maryland Council on Physical Fitness, the Maryland state director for the NSCA, and the co-chair of the Care and Prevention of Sports Injuries program in Montgomery County, MD.

Dr. Horwitz is training for the Unleash the Beast and is a two-time champion of the Tactical Strength Challenge Men’s Master’s Division. He is the founder of TeamSafe™Sports.

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