Safe Return-to-Play Decisions After Concussion: 5 Quick Wins for Clinicians

Return-to-play (RTP) decisions are among the most consequential clinical judgments in sport-related concussion management. Clear an athlete too early and you risk second impact syndrome, prolonged recovery, and medicolegal liability. Keep them out too long and you face deconditioning, psychological harm, and unnecessary disruption to their sporting career.

The Amsterdam 2023 Consensus Statement provides a clear framework for RTP decision-making, but implementing it effectively in a busy clinical setting requires practical strategies. Here are five evidence-based quick wins that will immediately improve the quality and safety of your RTP decisions.

The SCAT6 symptom evaluation comprises 22 items, each rated on a 7-point Likert scale (0-6). This generates a symptom severity score ranging from 0 to 132 and a total symptom count from 0 to 22. Tracking these scores manually across multiple assessments is tedious and error-prone. It also makes it difficult to visualise trends.

Digital symptom logging solves this.When symptom scores are captured electronically, you gain automatic calculation (eliminating arithmetic errors), longitudinal trend visualisation, and the ability to compare current scores against the athlete's pre-injury baseline. This transforms symptom data from a static snapshot into a dynamic recovery trajectory.

The clinical value is significant. A symptom severity score that has plateaued for several days despite stepwise progression suggests the athlete may have hit an exacerbation threshold. A score that is trending downward but has not yet returned to baseline indicates continued recovery. These patterns are difficult to detect from paper forms alone.

Athletes are notoriously unreliable reporters of their own symptoms, particularly when clearance for return to sport is the perceived goal. Research consistently shows that up to 50% of athletes underreport concussion symptoms when they believe it will affect their playing status (Meier et al., 2015). This is why symptom scores alone are insufficient for RTP decisions.

Cognitive screening provides an objective measure that is resistant to sandbagging.The Standardized Assessment of Concussion (SAC), embedded within the SCAT6, tests orientation, immediate memory, concentration (including digits backward), and delayed recall. These tasks are sensitive to the neurocognitive effects of concussion and are difficult to “fake” a normal performance on.

Pay particular attention to:

• Immediate and Delayed Recall: Memory consolidation is one of the most sensitive markers of concussion. Deficits in 5- and 10-word list recall often persist after symptom resolution. Delayed recall (administered after a minimum 5-minute interval) is particularly sensitive.
• Digits Backward: This working memory task requires the athlete to repeat increasingly long number sequences in reverse order. It tests executive function and processing speed -- domains that are frequently impaired following concussion, even when self-reported symptoms have resolved.

An athlete who reports being “symptom free” but scores 2-3 points below their baseline on immediate recall or fails to complete the 6-digit backward sequence should not be cleared for return to full contact activity. The cognitive deficit represents ongoing neurophysiological dysfunction regardless of subjective symptom reporting.

Postural stability is frequently impaired following concussion, and balance deficits can persist well beyond symptom resolution. The SCAT6 includes the modified Balance Error Scoring System (mBESS), which tests three stances (double leg, single leg, tandem) on a firm surface for 20 seconds each.

Additionally, the tandem gait test assesses dynamic balance by requiring the athlete to walk heel-to-toe along a 3-metre line as quickly as possible. This is a highly sensitive test that challenges both static and dynamic postural control systems.

For RTP decisions, balance scores should return to within normal limits of the athlete's baseline. Key considerations include:

• mBESS: Total errors across three stances. A baseline is essential, as individual variation is significant. An increase of 3+ errors from baseline warrants caution.
• Tandem gait: Best time of four trials. Normative data suggests less than 14 seconds for most athletic populations. Times significantly above baseline or normative values indicate persistent postural control deficits.
• Dual-task testing: Where feasible, adding a cognitive task (such as counting backward by 7s) during balance testing increases sensitivity by loading both motor and cognitive systems simultaneously.

An athlete with residual balance deficits -- even in the absence of symptoms -- should not be cleared for full contact sport. Impaired postural control increases the risk of falls, musculoskeletal injury, and vulnerability to a further head impact.

The Amsterdam 2023 Consensus reaffirmed the graduated, stepwise return-to-sport strategy as the standard of care. Each stage must be completed without symptom exacerbation before progressing to the next. A minimum of 24 hours at each stage is required, meaning the fastest possible progression from symptom resolution to full competition clearance is a minimum of 6 days.

The critical principle is that if symptoms recur at any stage, the athlete must return to the previous asymptomatic stage and attempt progression again after a further 24-hour rest period. Document each stage transition, the date, symptom scores, and any recurrence.

The SCAT6 and SCOAT6 are standardised screening tools, not diagnostic instruments. The Amsterdam Consensus is explicit on this point: no single assessment tool should be used in isolation to diagnose concussion or make RTP decisions. The SCAT6 must be integrated within a broader clinical assessment that includes:

• Clinical history: Mechanism of injury, previous concussion history, pre-existing conditions (migraine, ADHD, mood disorders, learning disabilities), and recovery trajectory
• Neurological examination: Cranial nerves, reflexes, coordination, gait, and cervical spine assessment
• Age-specific considerations: Children and adolescents require longer minimum rest periods and may need more conservative progression. The Child SCAT6 should be used for athletes under 13 years.
• Psychosocial factors: Anxiety, depression, fear of re-injury, academic/work pressures, and external pressure to return to sport (from coaches, parents, or the athlete themselves)

The RTP decision is ultimately a clinical judgment that synthesises objective assessment data (SCAT6/SCOAT6 scores, VOMS, balance testing) with clinical history, examination findings, and contextual factors. No algorithm or scoring system can replace this. The tools inform the decision; the clinician makes it.

Each of the five strategies above is significantly enhanced by digital assessment platforms. The clinical rationale for transitioning from paper-based to digital concussion management is not about technology for its own sake -- it is about improving clinical accuracy, efficiency, and medicolegal defensibility.