Concussion in sport: a case-based approach

The case: a knock on the pitch

Imagine a 17-year-old rugby player who takes a heavy tackle and briefly seems dazed. He gets up slowly, looks confused about the score, and rubs his head. He says he is "fine" and wants to carry on. A few minutes later a teammate notices he keeps asking the same question and seems slower than usual. In the teaching setting, this picture is typical of concussion, even though he did not fully lose consciousness. Losing consciousness is not needed for a concussion to have happened. The key teaching point is simple: any player with a suspected concussion must be removed from play straight away and not allowed back the same day. The guiding rule across UK sport is "if in doubt, sit them out".

Spotting concussion: signs and symptoms

Concussion can show up in several ways, and not everything appears at once. Visible signs on the pitch include lying still, being slow to get up, looking dazed or blank, unsteadiness, or grabbing the head. The person may report a headache, dizziness, feeling sick, blurred vision, sensitivity to light or noise, or feeling "in a fog". Others notice they seem confused, emotional, or unusually quiet. Memory can be affected — they may not recall the incident or the score. Importantly, symptoms can be delayed by hours, so someone who seems fine at first can worsen later. Because of this, anyone with a suspected concussion should be watched closely and reviewed, even if they insist they feel well at the time.

Red flags: when to call 999

Most concussions settle, but some head injuries are serious and need emergency care. Call 999 or go straight to A&E if the person loses consciousness (even briefly), has repeated vomiting, becomes increasingly confused or drowsy, or has a seizure or fit. Other red flags include weakness or numbness in the arms or legs, difficulty speaking or understanding, double vision, a severe or worsening headache, clear fluid or blood from the nose or ears, or being hard to wake. A neck injury should be assumed if the person cannot move or feels tingling, so do not move them and keep them still. When any red flag appears, treat it as an emergency rather than waiting to see if it improves.

The first days: rest and recovery

In the first day or two after concussion, relative rest helps the brain settle — this means easing off both physical effort and demanding mental tasks like screens, schoolwork or gaming. Complete darkness and total inactivity are not needed; gentle daily activities that do not make symptoms much worse are fine. Alcohol should be avoided, and it is safest not to be left alone on the first night so someone can watch for red flags. Painkillers such as paracetamol may help a headache if needed, but medicines that increase bleeding risk should be avoided unless advised by a clinician. After the first couple of days, most people gradually reintroduce light activity as symptoms allow, stopping if symptoms flare. Anyone getting worse rather than better needs medical review.

Graduated return to play

Returning to sport follows a careful, stepwise plan so the brain has time to heal. UK concussion guidance uses a graduated return-to-play (GRTP) programme with stages: complete rest, then light exercise, then sport-specific exercise, then non-contact training, then full-contact practice, and finally match play. A person moves up only if they stay symptom-free at each stage, with a minimum time at each step — so the earliest safe return to competition is typically at least three weeks, and longer for children and teenagers, who need extra caution. Returning to learning or work comes before returning to contact sport. If symptoms come back, the person drops down a level. A second concussion before the first has healed can be dangerous, which is why patience matters.