Concussion in a 14-Year-Old Soccer Player
A 14-year-old girl is brought to your sports medicine clinic 2 days after a head-to-head collision during a soccer game. She did not lose consciousness but had a headache immediately and felt 'foggy.' She continued to play but developed a worsening headache and nausea. She was seen in the ED that day and diagnosed with a concussion; head CT was normal. Now she reports headache (5/10), difficulty concentrating, and sensitivity to light. She is anxious to return to play for an upcoming tournament in 5 days. She has no history of prior concussions. On exam, she is alert and oriented, with normal cranial nerves, strength, and coordination. She has a normal gait and no focal deficits.
1. What is your assessment and management plan regarding return to play?
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This patient has a concussion with persistent symptoms at 48 hours. Management follows the Zurich/Berlin consensus:
- Physical and cognitive rest initially, but current guidelines recommend relative rest, not strict isolation. She should avoid strenuous activity but can do light activities that do not worsen symptoms.
- Symptomatic treatment: acetaminophen for headache, hydration, good sleep hygiene.
- Graduated return-to-play protocol: only after she is asymptomatic at rest and with cognitive activity. The protocol involves 6 stages: (1) symptom-limited activity, (2) light aerobic exercise, (3) sport-specific exercise, (4) non-contact training drills, (5) full contact practice, (6) return to game. Each stage takes at least 24 hours, so minimum 1 week. She should not return to play in 5 days if still symptomatic.
- Academic accommodations: she may need rest breaks, reduced screen time, and extra time for tests.
- Follow up in 1 week or sooner if symptoms worsen.
Rationale: Returning to play while symptomatic risks second impact syndrome and prolonged recovery. The tournament is not worth the risk.
2. If she becomes symptom-free in 3 days, can she play in the tournament? Outline the steps.
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If she is symptom-free at rest and with cognitive activity, she can begin the graduated return-to-play protocol. However, the tournament is in 5 days, and the protocol requires at least 24 hours per stage. She would need to complete stages 1-6, which takes a minimum of 6 days if each stage is 24 hours. Therefore, she cannot complete the protocol in 5 days. She should not play in the tournament.
Steps:
- Day 1: light aerobic exercise (walking, stationary bike) for 10-15 minutes.
- Day 2: sport-specific exercise (running drills) if no symptoms.
- Day 3: non-contact training drills.
- Day 4: full contact practice after clearance by medical professional.
- Day 5: return to game.
But if she starts on day 3, she would finish day 8, missing the tournament. She should be advised to withdraw from the tournament. If she rushes, risk of re-injury.