return to play after a moderate traumatic brain injury TBI

The Conundrum of Return to Play after Moderate TBI

Sports and recreation-related concussions (SRRC), a form of mild traumatic brain injury (mTBI), are a very common and heavily publicized injury in sports medicine. This is especially noteworthy given the potentially severe ramifications of continuing to play after sustaining a concussion or multiple concussions. Due to a national spotlight on concussions, especially in the National Football League (NFL) as well as college and youth leagues in all sports, there have been rapidly changing rules governing concussion management. Additionally, there has been a growing effort in the research surrounding concussions. 

Subsequently, there is an expanding body of knowledge within the medical community to help develop guidelines in the evaluation, treatment, education, and return to play criteria of patients with concussions. This provides sports medicine physicians with a road map to follow to efficiently and, most importantly, safely return athletes back to sport. In general, the accepted protocol for returning to full contact play involves graduated return to school full time, or in the case of non-student athletes, other activities of daily living, followed by a five-step graduated return to play algorithm using symptoms as a basis of when the athlete can progress to the next step (BJSM 2008).
There are also a variety of tools that can be used for evaluation of SRRC which include the following: Sport Concussion Assessment Tool 5 (SCAT5), Sway, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), King-Devick, and multiple clinical tests such as vestibulo-ocular motor scoring (VOMS) or Balance Error Scoring System (BESS) testing. Similar to the significant number of tools available for the evaluation of concussion, there are just as many, if not more, different methods of managing concussions. These include rest, fish oil, buffalo protocol, balance therapy, vision therapy, osteopathic manipulative therapy, anti-inflammatory medications, modalities such as electrical stimulation, among others. The buffalo protocol, or some modified version of graduated exercise testing to sub-symptom exacerbation threshold, is frequently utilized in managing athletes with prolonged post-concussive symptoms (PCS).

Image 1. Example of concussion return to play protocol (courtesy of

This robust amount of data and clear return to play guidelines make managing uncomplicated concussions relatively straightforward for physicians. Unfortunately, in rare cases, athletes may present with concussion-like symptoms but have the more dreaded moderate traumatic brain injury. The definition of moderate traumatic brain injury is inconsistent in the literature. A moderate TBI can be defined as prolonged loss of consciousness (typically greater than 20 minutes but no more than 24 hours), post-traumatic amnesia lasting for up to 24 hours, glasgow coma scale (GCS) of 9 – 13 and/or abnormal neuroimaging (Andriessen 2013). Abnormal imaging can include injuries such as intracranial hemorrhage and/or skull fracture . In most cases, life threatening injuries can be safely ruled out by a thorough history and physical exam. In cases where the physician determines there are red flags, or signs or symptoms inconsistent with an uncomplicated concussion, neuroimaging may be indicated.

Once an athlete is diagnosed with a moderate TBI they will require more advanced imaging, typically an MRI (likely having already received a CT) and evaluation by specialists. In the example of intracranial hemorrhage, the athlete should be seen and evaluated by a neurosurgeon. Following acute management, including any required interventions and subsequent release from the hospital, the return to play decisions and management becomes tricky for the sports medicine physician. Primarily, this is due to a lack of high quality data in the literature and lack of consensus among sports medicine physicians. Thus, the most appropriate way to determine the safety of allowing an athlete to return to play with a moderate traumatic brain injury remains unclear. The following paragraphs will attempt to outline the current data on this highly controversial topic in our athletic population.

The American College of Sports Medicine (ACSM) has made recommendations regarding management of moderate TBI and, most notably, recommended that a minimum of 3-6 months is needed for a skull fracture and, if a brain bleed such as a subdural is incurred, that a repeat scan would need to show resolution of the bleed and re-expansion of the brain tissue. However, this can be a complicated requirement due to the fact that residual hemosiderin can be detected in CT and MRI scans for years after a brain insult (Tamraz 2003). After craniotomy or burr hole procedure, a patient must wait one complete year prior to returning to contact sport. There is no clear guideline on how to proceed if this happens in an athlete looking to return to contact or collision sports. In most cases, athletes do return to playing sports at some level, but no data exists on the athletes ability to return to pre-injury level of play and any further injuries which may occur after a moderate TBI. Additionally, most experts in the field suggest a minimum of one year out of contact sports prior to considering return to play after a moderate TBI.

There have also been recommendations on clinical situations or injury patterns that would warrant retiring from contact sports altogether (Cantu 1996). This information was provided to the medical community by the British Journal of Sports Medicine. The following conditions are recognized as contraindications to playing contact sports:

1.Persistent concussion symptoms
2. Permanent central nervous system dysfunction
3. Hydrocephalus
4. Spontaneous subarachnoid hemorrhage
5. Symptomatic painful or neurological abnormalities of the foramen magnum

A recent practical guideline was released from a group of neurologists that suggest a stepwise approach to assist the physician in return to play decisions (Hayes et al 2018). When applying this method, it would suggest that the provider should discuss and perhaps encourage medical retirement. Future management options in patients with moderate TBI from athletics includes diffusion weighted imaging on MRI as a way to evaluate the level of brain recovery and possibly predict individual outcomes (Hou et al 2007). The difficulty of this approach in our resource-strained healthcare system is the high cost burden and the challenges of deploying advanced neuroimaging on a wide scale for assisting in return to play decisions of athletes with brain bleeds. There are also ongoing studies about brain injury biomarkers that may assist in future management and return to play decisions for athletes.

In conclusion, the medical community, athletic trainers, coaches and athletes have a lot to learn in the guidance of return to play decision after sustaining a moderate traumatic brain injury. Currently, we must use the limited evidence available in the literature and tailor our decisions based on athlete’s goals, clinical scenario, and, most importantly, gauging the outcomes and managing risk of future injury in our athletes. It is also suggested that governing bodies help develop consensus definitions of moderate TBI to allow for further research on this rare but critical sports-related injury. As a medical community, we need to continue to strive for more high quality research in this area to better keep our athletes, both young and old, safer and healthier.


1. Nonfatal sport-related craniofacial fractures: characteristics, mechanisms, and demographic data in the pediatric population.MacIsaac ZM, Berhane H, Cray J Jr, Zuckerbraun NS, Losee JE, Grunwaldt LJ. Plast Reconstr Surg. 2013 Jun;131(6):1339-47
2. Does isolated traumatic subarachnoid hemorrhage affect outcome in patients with mild traumatic brain injury? Deepika A, Munivenkatappa A, Devi BI, Shukla D. J Head Trauma Rehabil. 2013 Nov-Dec;28(6):442-5
3. Intracranial hemorrhage. Naidech AM. Am J Respir Crit Care Med. 2011 Nov 1;184(9):998-1006
4. Head injuries in Sport. Robert Cantu. BJSM, 1996 (30); 289-296.
5. Diffusion-weight magnetic resonance imaging improves prediction in adult traumatic brain injury. Hou DJ et al. J Neurotrauma 2007; 24(10); 1558-69.
6. Medical retirement from Sport after Concussions: A practical guide for a difficult decision. Cecilia Davis-Hayes et al. Neurology: Clinical Practice. Feb 2018; 8(1)40-47.
7. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich (2008), Br J of Sports Med 2009; 43: i76-i84 doi:10.1136/bjsm.2009.058248t
8. MRI Principles of the Head, Skull Base, and Spine: A Clinical Approach. Tamraz JC, Outin C, Secca M, and Soussi B. 2003
9. Andriessen, Teuntje MJC, et al. “Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study.” Journal of neurotrauma 28.10 (2011): 2019-2031.
15. Pavlou M, Davies RA, Bronstein AM. The assessment of increased sensitivity to visual stimuli in patients with chronic dizziness. J Vestib Res 2006;16(4–5):223–31.