Persistent Symptoms Three Weeks After a Soccer Head-to-Head Collision
A 20-year-old female collegiate soccer midfielder is referred three weeks after a head-to-head collision. She has daily headache, dizziness with quick head turns, and symptoms that worsen in the cafeteria and in lectures. Sleep is five hours a night and she has been taking ibuprofen most days. SCAT6: 16 of 22 symptoms, severity 48/132. Cranial nerve and neurologic examinations are normal; MRI is normal. VOMS shows convergence at 14 cm, saccadic smooth pursuit, and abnormal VOR. Cervical examination shows restricted upper cervical rotation and tender suboccipitals. She wants to play in the conference tournament in 12 days.
1. Is she ready for graded exercise, and what is driving her persistent symptoms?
Read the worked answer
She is not near return to contact play. At three weeks she still reports 16 of 22 symptoms with a severity of 48/132, and her examination localizes dysfunction to several domains rather than one. The VOMS abnormalities - convergence at 14 cm, saccadic smooth pursuit, and abnormal VOR - point to vestibular-ocular dysfunction, which explains her symptoms in busy visual environments and in lectures. Restricted upper cervical rotation and suboccipital tenderness indicate a cervicogenic contributor, common after head-to-head collision and often the reason headaches persist. Five hours of sleep and screen-heavy days amplify both. This is persistent post-concussive symptoms with a multifactorial profile rather than a single unresolved concussion, and management is domain-specific rehabilitation, not rest in a dark room. I would also screen for medication overuse headache given near-daily ibuprofen, and for mood and anxiety, and I would explain that her normal MRI does not exclude the diagnosis. She is ready for sub-symptom threshold exercise, but not for sport.
2. Build the rehabilitation and return-to-play plan, including what would make you stop or regress the progression.
Read the worked answer
Start with sub-symptom threshold aerobic exercise - the Buffalo protocol - 20 minutes on a stationary bike at a heart rate that keeps symptoms no more than 2 points above baseline, progressing 5–10 bpm per week. Add vestibular-ocular rehabilitation with convergence exercises, gaze stabilization, and visual tracking, plus cervical manual therapy and deep neck flexor strengthening for the cervicogenic component. Address sleep hygiene, treat the medication overuse headache by limiting analgesics, and build class attendance gradually. Return to sport is stepwise and symptom-limited: light aerobic work, then sport-specific drills without contact, then non-contact practice, then full-contact practice, then game, with at least 24 hours between stages and no same-day return. I would stop or regress if symptoms increase by more than 2 points, new symptoms appear, or VOMS or balance testing worsens. Twelve days to a conference tournament is unrealistic and I would say so plainly; playing while symptomatic risks prolonged recovery and, with a second impact in this window, potentially catastrophic injury. Reassess weekly.