Athletes and TBI

Sports-Related Traumatic Brain Injury (TBI)

Closeup of a barefooted gymnast negotiating a balance beamQuick Facts

  • Second only to motor vehicle accidents, sports-related injuries are the leading cause of TBI.
  • Sports-related mild concussion has been estimated to account for approximately 300,000 of the 1.54 million mild to moderate TBI’s that occur each year.
  • Approximately 5.5% of all high school athletic injuries, and 6.2% of all collegiate athletic injuries, are concussions.
  • Prevalence rates of concussions in professional athletics have been estimated to be 0.41 concussions per game of the National Football League (NFL).
  • Research has consistently shown that across all sport and ages, females are at a higher risk for sustaining sports-related concussions.
  • Coaches who do not require appropriate precautions (e.g., helmets, allowance of a full recovery before return to the sport) may be found negligent in the event of a TBI occurring during practice or play.
  • There are ongoing efforts to enact legislation regulating return to play guidelines for sports-related TBIs.

Sports-related TBI can occur at any level or type of sport, ranging from Little League to professional athletics, from gymnastics to boxing. While many injuries may occur due to direct impact to the head from a ball or another player, a direct blow is not required for brain injury to occur. A TBI may be caused by acceleration-deceleration forces such as when an athlete is abruptly stopped when running at full intensity (e.g., when a football player is tackled, soccer players collide, etc.).


More information about Sports-Related TBI

Symptoms of Sports-Related TBI

A wide range of symptoms may be experienced as a result of a sports-related TBI. Potential symptoms are similar to those resulting from traumatic brain injuries caused by other events (e.g., falls, motor vehicle accidents). These symptoms may be present shortly after the injury occurs (e.g., loss of consciousness) and they may be experienced during the period of recovery (e.g., persisting headaches, irritability).

Some of the more common symptoms include:

  • Headache
  • Dizziness/Vertigo
  • Confusion, disorientation
  • Loss of consciousness
  • Nausea and/or vomiting
  • Slowed processing speed (e.g., slow to respond to questions)
  • Slurred or nonsensical speech
  • Dyscoordination
  • Memory loss
  • Distractibility
  • Irritability, feeling more emotional
  • Changes in vision and/or hearing (e.g., sensitivity to bright lights or loud noises, blurred vision)
  • Anxiety or depression
  • Fatigue
  • Feeling mentally “foggy”
  • Numbness or tingling
  • Changes in sleep patterns/difficulty sleeping

Classification of Sports-Related TBI’s

There has been much discussion, and sometimes disagreement, about the classification of sports-related TBI. In particular, there have been varying opinions on the classification of mild TBI or concussion sustained in sports-related activities.

The American Academy of Neurology (AAN) released a summary statement in 1997 identifying the main components of each grade of concussion.

Grade 1
(sometimes referred to as having been “dinged” or having one’s “bell rung”)

  1. Transient confusion
  2. No loss of consciousness
  3. Concussion symptoms or mental status abnormalities resolve in less than 15 minutes

Grade 2

  1. Transient confusion
  2. No loss of consciousness
  3. Concussion symptoms or mental status abnormalities on examination last more than 15 minutes

Grade 3

  1. Any loss of consciousness, either brief (seconds) or prolonged (minutes)

Issues Affecting Decisions about Return-to-Play Following Head Trauma

Multiple (sometimes competing) factors contribute to the complexity of making decisions regarding when a return-to-play is appropriate following sports-related head trauma. Several factors may promote decision making regarding a return-to-play that minimizes attention to potential risks. These include:

  • Athletes (and coaches) may be eager for a rapid return to play.
  • Athletes may perceive pressure from multiple sources (e.g., coaches, parents, other players, fans) to return to play sooner than they are ready.
  • Because of these motivations, athletes may minimize complaints when asked if they are experiencing symptoms.

On the other hand, numerous factors support the need for caution and judicious decision-making when forming return-to-play recommendations, including the following:

  • Following a concussion, an athlete is at increased risk for sustaining another TBI, which may be particularly likely when being physically active (e.g., returning to the game).
  • Experiencing multiple concussions may lead to cumulative effects and persisting problems.
  • Student athletes’ academic performance can be affected by experiencing a TBI, which can lead to scholarship issues in collegiate situations.
  • Return to training and/or play before the athlete is ready may exacerbate symptoms (e.g., headache, trouble concentrating) and/or lead to permanent consequences.
  • Athletes are at risk for Second-Impact Syndrome (SIS) after a head trauma.

Guidelines for Return-to-Play Decisions

The following summarizes the American Academy of Neurology (AAN) decision trees.

Guidelines for Return-to-Play Decisions
GradeOn-site evaluationNeurologic EvaluationSame Day Return-to-Play
1 Yes Not required, but may be pursued depending on clinical evaluation Yes, if normal sideline assessment while at rest and with exertion, including detailed mental status evaluation
2 Yes Yes Yes
3 Yes Yes Yes
Grade of ConcussionTime Unitil Return to Play*
Multiple Grade 1 concussions 1 week
Grade 2 concussion 1 week
Multiple Grade 2 concussions 2 weeks
Grade 3: brief loss of consciousness (seconds) 1 week
Grade 3: prolonged loss of consciousness (minutes) 2 weeks
Multiple Grade 3 concussions 1 month or longer, based on clinical decision of evaluating physician

*Only after being asymptomatic with normal neurologic assessment at rest and with exercise

Evaluating Sports-Related TBI

  • A majority of sports-related injuries are likely to be closed head injuries (i.e., no penetration of the skull).
  • Moderate and severe TBI’s may results in readily apparent symptoms -- prolonged loss of consciousness, speech disturbance, significant confusion.
  • Mild TBI’s (e.g., concussion) are less obvious: there may be fewer physical symptoms, and cognitive changes may not be easily noticed by the athlete.

Any athlete experiencing physical or cognitive symptoms following a head injury should receive medical attention and clearance before resuming regular activities

    • Trained professionals (e.g., physician, neuropsychologist) can assess sports-related TBI on the sidelines.
  • Areas assessed include: orientation (to time, place, person, and situation), concentration, memory, neurological status, and symptoms with physical exertion.
  • Measures used include: Post-Concussion Symptom Scale, Standardized Assessment of Concussion, and/or the Balance Error Scoring System.

An athlete should never return to training, practice, or play if he/she is still experiencing symptoms (e.g., headache, confusion) from the TBI.

Neuropsychology and Sports-Related TBI

Neuropsychological evaluation can help assess subtle cognitive symptoms and inform return to play decisions.

  • Neuropsychological evaluations assess cognitive functioning (e.g., intelligence, memory, attention, processing speed, language, visual-spatial functions) in consideration of the medical and psychological (e.g., depression, anxiety) variables that may affect such abilities.
  • In addition to standard paper-and-pencil measures, computer-administered test batteries are used to assess sports-related TBI.

Baseline Assessments

  • Many athletic organizations (e.g., National Football League, National Hockey League, Major League Baseball, high school teams) have their athletes complete cognitive test batteries prior to the start of the season to obtain a non-injured performance profile.
  • If the athlete experiences a TBI during the season, this pre-season testing is used as an index of baseline (pre-injury) functioning to be compared with post-TBI testing.
  • This practice of obtaining information about pre-injury and post-injury functioning can clarify subtle declines in cognitive abilities (e.g., memory, attention and concentration) following brain injury and assist health care providers in providing opinions about return to play, work, and/or school.

One of the main dangers of returning to play before an athlete has recovered from his/her TBI is the potential for second-impact syndrome (SIS). SIS is a relatively rare phenomenon that can occur after an athlete has sustained an initial brain injury (e.g., concussion) and experiences a second brain injury within a relatively short period (e.g., minutes to days) of time following the first insult. The second TBI can be minor or severe, but in SIS, either case leads to a rapid deterioration of function, followed by death if intervention by medical personnel is not swift.