Concussion: the protocol most teams skip steps in.

The graduated return-to-sport protocol after concussion has been internationally agreed for more than a decade. In amateur sport, adherence is poor — coaches skip steps because they look excessive, players minimise symptoms because they want to play, and clinicians sometimes write off the protocol as bureaucratic. This is the version that holds up.

Recognition is still the bottleneck

Most amateur concussions are missed at the moment they happen. Loss of consciousness occurs in fewer than one in ten cases — the rest present with symptoms that are easy to attribute to fatigue, dehydration or a knock to the body. The current consensus diagnostic tools (SCAT6 for clinicians, Concussion Recognition Tool 6 for sideline non-clinicians) cover symptom checklists, balance and cognitive screening; both take less than ten minutes.

The single highest-leverage rule in amateur sport is also the simplest: any suspected concussion is removed from play and not returned the same day, regardless of how the player looks fifteen minutes later. The window in which a second impact is dangerous is precisely the window in which symptoms typically resolve briefly.

The six-step return — and where it actually breaks

The graduated return-to-sport protocol has six steps. Each step is at least 24 hours, and any return of symptoms drops the athlete back one level.

• 1. Symptom-limited daily activity — light cognitive and physical activity that does not provoke symptoms.
• 2. Light aerobic exercise — walking or stationary cycling at low intensity, no resistance training.
• 3. Sport-specific exercise — running drills, skating, skill work; no head-impact risk.
• 4. Non-contact training drills — passing drills, more complex coordination work; resistance training resumed.
• 5. Full-contact practice — only after medical clearance; restores confidence and assesses tolerance.
• 6. Return to sport — competitive play.

Why steps get skipped

In our experience, three steps are most often skipped or compressed in amateur settings. Step 2 is often replaced with 'rest and see how it goes' — but the absence of any provocation testing is what extends symptom durations, not what shortens them. Step 4 is often jumped past straight into Step 5 when training starts on a Tuesday and the match is on Saturday. And Step 5 is sometimes treated as a single training session rather than a deliberate test of contact tolerance.

The protocol is not a checklist for the team manager. Each step is an active provocation test of a specific function. Skipping one is not 'being efficient' — it is choosing not to know whether that function has recovered.

Long-tail risk and how to talk about it

Repeat concussions, especially within a short window, have well-documented cumulative effects on recovery time and on long-term cognitive outcomes. The risk profile for a single mild concussion in an adult amateur, recovered fully and returned through the protocol, is far smaller than recent media coverage often implies — but not zero, and the asymmetry between 'play this Saturday' and 'play next year' is what the protocol exists to manage.

For coaches, the productive conversation with players is rarely about long-term brain health in the abstract. It is about not playing this Saturday so that the rest of the season is available.

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