Are Return-to-Play Protocols Enough? What Athletes and Families Should Know About Returning After a Concussion
Returning to sports after a concussion isn't as simple as checking a box that says an athlete is "symptom free."
Most organized sports now have a return-to-sport (RTS) progression designed to gradually increase an athlete's physical demands before they return to unrestricted competition. That's a major improvement over the old approach of simply waiting a certain number of days and sending an athlete back to play.
But as our understanding of concussion continues to evolve, an important question remains:
Is completing a return-to-play protocol enough to know that an athlete is truly ready to compete?
The answer is more nuanced than a simple yes or no.
A safe return to sport requires more than asking an athlete, "Do you feel okay?" It requires considering how the athlete is functioning physically and cognitively—and whether those abilities hold up as the demands of sport increase.
If you're looking for a broader overview of concussion recovery and why early, specialized care matters, start with our Concussion Care Matters: What to Do After a Concussion.
What Is a Return-to-Sport Protocol?
After a concussion, athletes should not immediately return to practices or competition.
Current guidance recommends a graduated return-to-sport progression, with each stage increasing the physical and sport-specific demands placed on the athlete. The CDC's current six-step progression includes:
Return to regular activities such as school
Light aerobic activity, such as walking or light jogging
Moderate activity, including more intense aerobic exercise and moderate weightlifting
Heavy, non-contact activity, including sprinting, regular weightlifting, and non-contact sport-specific drills
Practice and full-contact activity, when appropriate for the sport
Return to competition
Each step typically takes at least 24 hours, and an athlete should only progress when they are tolerating the current level of activity without new or worsening concussion symptoms. If symptoms return, the athlete should stop, recover, and work with their healthcare provider before progressing again. This graduated approach is important.
Understanding how much physical activity is appropriate during concussion recovery is an important part of this progression.
Why Isn't "Feeling Better" the Whole Story?
Concussion symptoms are an important part of assessing recovery—but they aren't the only thing that matters.
An athlete may report feeling completely normal while still experiencing subtle changes in areas such as:
Balance
Coordination
Reaction time
Visual processing
Attention
Memory
Processing speed
Exercise tolerance
Ability to perform multiple tasks simultaneously
Specialized physical therapy may be an important part of addressing some of these physical and functional impairments during concussion recovery. This is one reason current concussion guidelines have moved toward multi-modal assessment rather than relying on a single symptom checklist or test.
The Amsterdam consensus recommends that clinical recovery consider symptom reports alongside other relevant clinical findings, including physical exertion, balance, vestibular and oculomotor function, cognition, and dual-tasking when appropriate.
Feeling better is important. Functioning normally is important, too.
The Challenge of Self-Reported Symptoms
One limitation of any symptom-based return-to-play protocol is that many concussion symptoms are subjective.
An athlete is often the person who has to say:
"My head hurts."
"I feel dizzy."
"I'm having trouble concentrating."
"I don't feel quite right."
That's important information—but athletes may also have powerful reasons to minimize or hide symptoms.
They may want to play in an important game. They may worry about losing their starting position. They may not want to disappoint their teammates or coaches.
And sometimes, an athlete may genuinely feel fine but still have subtle impairments that aren't obvious during everyday activity.
That doesn't mean athletes are dishonest. It means that concussion recovery shouldn't rely exclusively on whether someone says they feel normal.
What About Cognitive and Physical Dual-Tasking?
This is one of the most interesting areas of concussion research—and one that deserves more attention in return-to-sport discussions.
Dual-tasking means performing a cognitive task and a physical task at the same time.
Think about what actually happens during a sport.
A soccer player isn't simply running.
They're running while:
Tracking the ball
Watching opponents
Communicating with teammates
Making decisions
Changing direction
Anticipating what happens next
Maintaining balance
Reacting to rapidly changing information
A football player isn't simply sprinting or catching.
They're simultaneously processing plays, reading the field, reacting to other players, making decisions, and coordinating complex movements.
Sports are inherently cognitive and physical.
What Does the Research Tell Us?
A 2024 study by Lavoie and colleagues looked specifically at dual-task performance in athletes who had previously sustained a concussion and had already completed a return-to-play protocol.
The study compared athletes with previous concussion to athletes without a concussion history. Participants completed a cognitive and walking task both before and after moderate aerobic exercise.
The researchers found that, after exercise, athletes with a previous concussion demonstrated a significant reduction in gait speed while performing the cognitive task, while the control group did not show the same change.
Importantly, the athletes in the concussion group were considered asymptomatic and had already completed a return-to-play protocol.
That doesn't mean that every athlete who has recovered from a concussion has an underlying impairment—or that dual-task testing should automatically be required for every athlete.
But it does highlight an important question:
Can an athlete perform normally when the physical and cognitive demands of sport are combined?
The Amsterdam consensus specifically identifies dual-tasking as one of the functional domains that may be considered when evaluating recovery.
That means an athlete who performs normally while sitting in a quiet room—or even while completing a simple exercise—may still struggle when cognitive and physical demands are combined.
Returning to Sport Isn't the Same as Returning to Everyday Life
Another reason this matters is that an athlete may be able to tolerate normal daily activities without being ready for the demands of competition.
Going to class, walking around school, or completing a workout in a controlled environment is different from:
Sprinting
Cutting and changing direction
Reacting to an opponent
Making rapid decisions
Maintaining balance while fatigued
Performing under pressure
Experiencing unpredictable contact
This is why the later stages of a return-to-sport progression become increasingly sport-specific.
Current guidance differentiates early symptom-limited activity and aerobic exercise from the later stages where the risk of head impact increases. Those later stages should be completed with appropriate healthcare provider oversight and after the athlete has recovered from the current concussion.
What About the Risk of Another Injury?
This is another reason not to rush the return-to-sport process.
Research has found an association between previous concussion and an increased risk of subsequent musculoskeletal injury after athletes return to play.
A 2019 systematic review and meta-analysis found that athletes with a history of sport-related concussion had approximately twice the odds of sustaining a musculoskeletal injury compared with athletes without concussion.
Other research has similarly found increased risk of lower-extremity injury during the period following return to play.
There are several possible explanations for this association, and the exact mechanisms aren't completely understood. Researchers have proposed factors including altered neuromuscular control, balance, coordination, reaction time, deconditioning, and other changes that may persist after symptoms have resolved.
The important takeaway isn't that every athlete who has had a concussion is destined to sustain another injury.
It's that returning to sport should involve more than simply waiting until symptoms disappear.
What About CTE and Long-Term Brain Health?
It's impossible to talk about concussion and repeated head impacts without acknowledging one of the biggest questions facing athletes, families, and the medical community: What might repeated head impacts mean for brain health later in life?
Chronic traumatic encephalopathy, or CTE, has received significant attention in recent years, particularly in connection with athletes who have experienced repeated head impacts over the course of their careers.
The science here is evolving, and it is important to distinguish what we know from what we are still trying to understand.
CTE neuropathologic change (CTE-NC) refers to a specific pattern of changes found in the brain after death. It is not currently a clinical diagnosis that can be made in a living person. Researchers have found CTE-NC more frequently in brain-bank samples of former professional athletes with high exposure to repetitive head impacts, but these studies cannot determine how common CTE-NC is among athletes generally or establish that repetitive head impacts inevitably cause it.
The relationship between concussion, repetitive head impacts, and long-term neurological health is therefore an active area of research. The 2023 Amsterdam International Consensus Statement identifies potential long-term effects—including neurodegenerative disease—as an important research priority, while noting that many existing studies have significant methodological limitations.
So what does that mean for athletes today?
It means we should take brain injuries and repeated head impacts seriously without overstating what the science currently tells us.
That includes:
Removing an athlete from play when a concussion is suspected
Following an appropriate return-to-sport progression
Allowing adequate time for recovery
Addressing persistent symptoms rather than ignoring them
Reducing unnecessary exposure to repetitive head impacts
Making individualized decisions about participation in contact and collision sports
We don't need to know every answer about long-term brain health to know that protecting athletes from additional injury while they are recovering is important.
And that's one of the reasons return-to-sport decisions deserve more consideration than simply asking whether an athlete feels better.
So, Are Return-to-Play Protocols Sufficient?
The protocol itself is an important part of a safe return—but it shouldn't necessarily be the entire assessment.
The current six-step return-to-sport progression provides an important framework for gradually increasing physical and sport-specific demands. It helps prevent athletes from going directly from recovery to full competition.
But concussion recovery is individualized.
A thorough evaluation may also consider:
Concussion symptoms
Response to physical exertion
Cognitive function
Balance and coordination
Vestibular function
Oculomotor/visual function
Neck function
Exercise tolerance
Sport-specific demands
Dual-task performance
The athlete's concussion history
The Amsterdam consensus specifically recommends considering multiple clinical and functional outcomes when determining recovery, rather than relying on a single measure.
The goal isn't to make return to sport unnecessarily complicated.
The goal is to make sure an athlete is prepared for the actual demands of their sport.
What Should Athletes and Parents Ask?
If you're navigating a return to sports after a concussion, don't be afraid to ask questions.
You might ask:
"Has my athlete been evaluated beyond their symptoms?"
"How are they tolerating exercise?"
"Have their balance and coordination returned to normal?"
"Are there any remaining cognitive or visual symptoms?"
"How will we know they're ready for the demands of their specific sport?"
"What happens if symptoms return?"
A good concussion care plan should be individualized to the athlete, not simply based on a calendar. Athletic trainers can also play an important role in evaluating athletes, monitoring their progression, and helping coordinate a safe return to sport.
The Bottom Line
Return-to-play protocols have come a long way, and a graduated return-to-sport progression is an important part of concussion recovery.
But concussion is a complex brain injury, and an athlete's readiness to compete cannot always be determined by symptoms alone.
An athlete may feel normal in everyday life and still have difficulty when physical exertion, cognitive processing, balance, coordination, and sport-specific demands are combined.
That's why comprehensive concussion care matters.
At Colorado Concussion Clinic, our goal is to help athletes safely progress through recovery and return to the activities they love. Depending on an athlete's individual symptoms and needs, evaluation and rehabilitation may involve multiple systems and multiple members of a multidisciplinary care team.
Medical Disclaimer
The information provided in this article is for educational and informational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Concussion symptoms and recovery can vary significantly from person to person. Always consult a qualified healthcare professional regarding your individual symptoms, diagnosis, and treatment plan.
Content Update: This article was originally published in October 2024 and has been substantially updated for clarity, organization, and current patient education. Clinical recommendations and medical information should be reviewed by a qualified Colorado Concussion Clinic clinician before publication.
Sources
https://www.cdc.gov/heads-up/guidelines/returning-to-sports.htm
Lavoie, G.; Bolduc, M.; Sicard, V.; Lepore, F.; Ellemberg, D. Maintaining Cognitive Performance at the Expense of Gait Speed for Asymptomatic Concussed Athletes: A Novel Dual-Task and Post-Exercise Assessment. Brain Sci. 2024, 14, 715. https://doi.org/10.3390/brainsci14070715
McPherson, A.L.; Nagai, T.; Webster, K.E.; Hewett, T.E. Musculoskeletal injury risk after sport-related concussion: A systematic review and meta-analysis. Am. J. Sports Med. 2019, 47, 1754–1762.
Brooks MA, Peterson K, Biese K, Sanfilippo J, Heiderscheit BC, Bell DR. Concussion Increases Odds of Sustaining a Lower Extremity Musculoskeletal Injury After Return to Play Among Collegiate Athletes. Am J Sports Med. 2016 Mar;44(3):742-7. doi: 10.1177/0363546515622387. Epub 2016 Jan 19. PMID: 26786903.