Deciding Whether to Clear a College Soccer Player With a Recent Concussion
A 20-year-old Division I midfielder sustained a concussion 9 days ago in a head-to-head collision. She had no loss of consciousness, but had headache, photophobia, and balance problems for 4 days. She is now symptom-free at rest. On examination today: VOMS is normal, King-Devick is within baseline, and she completes the Buffalo Concussion Treadmill Test to 85% of age-predicted max HR without symptoms. She is eager to play in a conference match in 3 days and reports she has 'felt fine for days.' Her coach calls asking whether she can play. She has a history of one prior concussion 3 years ago with full recovery in 2 weeks. She takes no medications and has no migraine history.
1. Using the Amsterdam consensus framework, what is the appropriate next step for this athlete, and what specifically must happen before she returns to match play?
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At day 9 she has completed relative rest and is symptom-free at rest with a normal exam and a symptom-limited exercise test that stopped at 85% predicted max HR without provocation. She is ready to begin the graduated return-to-sport protocol, not to play a match.
The Amsterdam 2023 framework requires a stepwise progression: symptom-limited aerobic exercise, then sport-specific exercise without contact, then non-contact training drills, then full-contact practice, then return to match play - each step at least 24 hours, with return to the previous step if symptoms recur. Because she is 9 days out and symptom-free, she can start the progression now, but she cannot compress it into 3 days safely.
Key points to communicate to the coach and athlete:
- No same-day return to full contact or match. The progression is time-gated, not symptom-gated alone.
- Monitor for symptom recurrence at each step; a return of symptoms means step back 24 hours.
- The 85% HR test result is reassuring but not clearance. It supports initiating the protocol.
- Document the shared decision and the plan in the record. If the conference match is in 3 days, realistic clearance is unlikely; state this explicitly rather than leaving ambiguity.
2. The coach argues that because her exam is normal and she 'only had symptoms for 4 days,' she should be allowed to play. How do you respond, and what evidence-based reasoning supports your position?
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A short symptom duration and normal exam are favorable prognostic signs, but they do not substitute for the graduated progression. The Amsterdam consensus and the 6th International Conference on Concussion in Sport emphasize that early return to contact increases risk of repeat injury and, in the setting of incomplete recovery, of more prolonged recovery.
Reasoning to present:
- Physiology: Cerebral blood flow and autonomic regulation may remain altered beyond symptom resolution; exercise tolerance testing at 85% is reassuring but not equivalent to match-intensity contact exposure.
- Risk of repeat concussion: A second impact during the recovery window carries higher risk of prolonged symptoms and, rarely, more serious injury.
- Legal/ethical: Clearance is a clinical decision, not a coaching one. The clinician's obligation is to the athlete's health.
- Practical compromise: Offer a written stepwise plan with dates so the coach can see exactly when she could be eligible if she remains asymptomatic.
Avoid being drawn into a debate about 'only 4 days' - redirect to the protocol and the athlete's long-term availability.