The FA's Concussion Guidelines
- The Boot Room
- 24 January 2017
This article provides helpful information about how to recognise and manage a concussion – from the time of injury through to a player's safe return to football.
The guidance, which is designed to support those managing head injuries in football at all levels, is available as a free-to-download document at the bottom of this page. You can also access our online educational module, here.
Below are some useful facts about concussion, as well as key considerations to think about if you're ever faced with managing a head injury.
If you would like to find out more about concussion, you can watch The FA's video, 'Concussion for players: lessons from the pitch'. It showcases honest accounts from former Reading and Ireland striker, Kevin Doyle, Chelsea and England defender Millie Bright, and grassroots player Mitch Lacey, who all suffered concussion in a game and played on.
- take longer to recover
- have more significant memory and mental processing issues
- are more susceptible to rare and dangerous neurological complications, including death caused by a single or second impact.
Other risk factors include having had previous concussions (which also increases recovery time) and being female.
If any of the following signs or symptoms are present after an injury, you should suspect that a player has a concussion and remove them from play or training immediately – with no return on the same day.
Signs of concussion – what you might see
Any one or more of the following visual clues can indicate a concussion:
- Dazed, blank or vacant look
- Lying motionless on ground / slow to get up
- Unsteady on feet / balance problems or falling over / poor coordination
- Loss of consciousness or responsiveness
- Confused / not aware of play or events
- Grabbing / clutching of head
- Seizure (fits)
- More emotional / irritable than normal for that person
Symptoms of concussion – what the injured player might talk about
Presence of any one or more of the following symptoms may suggest a concussion:
- Headache
- Dizziness
- Mental clouding, confusion, or feeling slowed down
- Visual problems
- Nausea or vomiting
- Fatigue
- Drowsiness / feeling like 'in a fog' / difficulty concentrating
- 'Pressure in head'
- Sensitivity to light or noise
Speaking to your player
To help establish whether a player is injured, you can ask them a number of questions: incorrect answer(s) may suggest that they have a concussion. Some examples questions can be seen below – tailor them to your particular activity and even:
- What venue are we at today / where are we now?
- Which half is it now / approximately what time of day is it?
- Who scored last in this game /how did you get here today?
- What team did you play last game / where were you on this day last week?
- Did your team win the last game / what were you doing this time last week?
Video footage
Video footage, if available, can help to establish how an injury happened – and how severe it might be. This can be used to contribute to the overall assessment of a player.
This may be reviewed by the person assessing the injury or can be commented on by a third party, such as the tunnel doctor in an elite professional setting.
In a non-elite setting, a coach or parent could have captured the incident on video, which could be helpful. However, video evidence must never be used to contradict a medical decision to remove a player.
The Pocket Recognition tool
This can also be used to aid pitch-side assessment (see useful links section).
Anyone with a suspected concussion must be immediately removed from play.
Once safely removed from play they must not be returned to activity that day.
Teammates, coaches, match officials, team managers, administrators or parents who suspect someone may have concussion must do their best to ensure that they are removed in a safe manner
If a neck injury is suspected, suitable guidelines regarding the management of this type of injury at pitchside should also be followed (see useful links for pitch side injury management training)
If any of the following are reported then the player should be transported for urgent medical assessment at the nearest hospital emergency department:
- Severe neck pain
- Deteriorating consciousness (more drowsy)
- Increasing confusion or irritability
- Severe or increasing headache
- Repeated vomiting
- Unusual behaviour change
- Seizure (fit)
- Double vision
- Weakness or tingling / burning in arms or legs
In all cases of suspected concussion it's recommended that the player is referred to a medical or healthcare professional for diagnosis and advice, even if the symptoms resolve.
Rest the body, rest the brain
Rest is the cornerstone of concussion treatment. This involves resting the body, ‘physical rest’, and resting the brain, known as ‘cognitive rest’. This allows symptoms to recover and, in the non-professional setting, allows a return to work or study prior to resuming training and playing.
Rest means avoiding:
- physical activities such as running, cycling, swimming, physical work activities, etc.
- cognitive activities (thinking activities), such as school work, homework, reading, television, video games. Students with a diagnosis of concussion may need to have allowance made for impaired cognition during recovery, such as additional time for classwork, homework and exams.
Anyone with a concussion or suspected concussion should not:
- be left alone in the first 24 hours
- consume alcohol in the first 24 hours, and thereafter should avoid alcohol until free of all concussion symptoms
- drive a motor vehicle and should not return to driving until provided with medical or healthcare professional clearance or, if no medical or healthcare professional advice is available, should not drive until free of all concussion symptoms.
Returning to play after a concussion
The graduated return to play (GRTP) protocol should be followed in all cases.
This staged programme starts at midnight on the day of injury and stage 1 (initial rest period) is 14 days in all players – unless they're in an enhanced care setting. In all cases, progression to stage 2 of the GRTP can only occur if the player has no symptoms
Return to work and study after a concussion
At the non-professional level, adults must have returned to normal education or work, and students must have returned to school or full studies, before starting physical activity (stage 2) in a GRTP program.
Graduated return to play protocol
A graduated return to play (GRTP) protocol is a progressive exercise program that introduces an individual back to sport in a step-wise fashion.
Stage 2 of the GRTP protocol should only be started when a player:
- is symptom free at rest and has completed the initial rest period (14 days in a standard care setting and modified in an enhanced care setting)
- has returned to normal education or work if not a professional footballer
- is not receiving treatments and medications that may mask concussion symptoms, e.g. drugs for headaches or sleeping tablets.
The GRTP Protocol contains six distinct stages
Under the GRTP Protocol, the individual can advance to the next stage only if there are no symptoms of concussion at rest and at the level of physical activity achieved in the current GRTP stage.
If any symptoms occur whilst going through the GRTP program, the individual must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms (this is 48 hours in players under 19 years of age).
It's recommended that a medical practitioner confirms recovery before an individual enters Stage 5 (full contact practice).
The 6 stage GRTP protocol should be followed in all cases. Stages 2-5 take a minimum of 24 hours in adults, 48 hours in those aged 19 and under.
Standard return to play pathway
The minimum time in which a player can return to play in the standard care setting is summarised in the table below. Each day comprises a 24 hour period. The pathway begins at midnight on the day of injury.
It is recognised that players will often want to return to play as soon as possible following a concussion. Players, coaches, management, parents and teachers must exercise caution to ensure that:
- all symptoms have resolved before commencing GRTP
- the GRTP protocol is followed
- the advice of medical practitioners and other healthcare professionals is strictly adhered to.
After returning to play, all those involved with the player, especially coaches and parents must remain vigilant for the return of symptoms even if the GRTP has been successfully completed.
If symptoms recur the player must consult a healthcare practitioner as soon as possible as they may need a referral to a specialist in concussion management.
How are recurrent or multiple concussions managed?
Any player with a second concussion within 12 months, a history of multiple concussions, players with unusual presentations or prolonged recovery should be assessed and managed by a healthcare provider with experience in sports-related concussions working within a multidisciplinary team.
Outcomes in concussion are better if the injured player is well informed and understands what has happened. Measures to improve understanding, and deal with emotional problems and anxiety, should also be considered in the management of concussed players.
In some circumstances – such as professional clubs, international teams and academies – there may be a enhanced level of medical care available. This allows closer supervision of a player’s care and graduated return to play (GRTP).
In these instances, a shorter time frame for return to play (RTP) may be possible, but only under strict supervision by the appropriate medical personnel as part of a structured concussion management programme. If these conditions are met, you may be able to follow the 'Return to play pathway in an enhanced care setting' (this is never suitable for players under 16).
The minimum criteria for this pathway are as follows:1. There's a doctor with training and experience in the management of concussion or traumatic brain injury in sport available to closely supervise the player’s care and GRTP, and clear the player prior to RTP.
2. There is a structured concussion management programme in place for the player as outlined below:
- Baseline SCAT5 and/or computerised neuro-psychometric/cognitive testing of the player has been conducted prior to the injury.
- Clinical serial multimodal assessment of the player occurs post-concussion to guide the recovery protocol.
- Acknowledging that more than one area of brain function can be affected by concussion, this will involve formal documented assessment of areas such as cognitive function, emotional wellbeing, neurological function and any physical trauma sustained.
- A formalised GRTP programme with regular SCAT5 or equivalent assessments is followed and recorded in the player’s medical records
- The player has access to a multi-disciplinary team including neuropsychology / neurology / neurosurgery specialists and other clinicians as required to supervise the return to play and instigate any treatment or investigation required should the RTP progression not be straightforward.
- A formal and documented concussion education programme exists for coaches and players in the club or team involved.
If any element of the above criteria is absent, the player should follow the 'Standard return to play pathway'.
Rest the body, rest the brain
Rest is the cornerstone of concussion treatment. This involves resting the body, ‘physical rest’, and resting the brain, known as ‘cognitive rest’. The period of rest allows symptoms to recover and in the non-professional setting allows a return to work or study prior to resuming training and playing.
Rest means avoiding:
- physical activities such as running, cycling, swimming, physical work activities, etc
- cognitive activities (thinking activities), such as school work, homework, reading, television, video games. Students with a diagnosis of concussion may need to have allowance made for impaired cognition during recovery, such as additional time for classwork, homework and exams.
Anyone with a concussion or suspected concussion should not:
- be left alone in the first 24 hours
- consume alcohol in the first 24 hours, and thereafter should avoid alcohol until free of all concussion symptoms
- drive a motor vehicle and should not return to driving until provided with medical or healthcare professional clearance or, if no medical or healthcare professional advice is available, should not drive until free of all concussion symptoms.
Returning to play after a concussion
The graduated return to play (GRTP) protocol should be followed in all cases.
This staged programme commences at midnight on the day of injury and stage 1 (initial rest period) is 14 days in all players unless they are in an enhanced care setting. In all cases, progression to stage 2 of the GRTP can only occur if the player has no symptoms
Return to work and study after a concussion
At the non-professional level, adults must have returned to normal education or work and students must have returned to school or full studies before starting physical activity (stage 2) in a GRTP program.
Graduated return to play protocol
A graduated return to play (GRTP) protocol is a progressive exercise program that introduces an individual back to sport in a step wise fashion.
Stage 2 of the GRTP protocol should only be started when a player:
- is symptom free at rest and has completed the initial rest period (14 days in a standard care setting and modified in an enhanced care setting)
- has returned to normal education or work if not a professional footballer
- is not receiving treatments and medications that may mask concussion symptoms, e.g. drugs for headaches or sleeping tablets.
The GRTP Protocol contains six distinct stages:
Under the GRTP Protocol, the individual can advance to the next stage only if there are no symptoms of concussion at rest and at the level of physical activity achieved in the current GRTP stage.
If any symptoms occur whilst going through the GRTP program, the individual must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms (this is 48 hours in players under 19 years of age).
It is recommended that a medical practitioner confirms recovery before an individual enters Stage 5 (full contact practice).
The six-stage GRTP protocol should be followed in all cases. Stages 2-5 take a minimum of 24 hours in adults, 48 hours in those aged 19 and under.
Return to play pathway in an enhanced care setting
The minimum time in which a player can return to play in the Enhanced Care Setting is summarised by the table below. Each day comprises one 24 hour period. The pathway begins at midnight on the day of injury.
It is recognised that players will often want to return to play as soon as possible following a concussion. Players, coaches, management, parents and teachers must exercise caution to ensure that:
- all symptoms have resolved before commencing GRTP
- the GRTP protocol is followed
- the advice of medical practitioners and other healthcare professionals is strictly adhered to.
After returning to play, all those involved with the player, especially coaches, support staff and parents must remain vigilant for the return of symptoms even if the GRTP has been successfully completed.
If symptoms recur the player must consult a healthcare practitioner as soon as possible as they may need a referral to a specialist in concussion management.
How are recurrent or multiple concussions managed?
Any player with a second concussion within 12 months, a history of multiple concussions, players with unusual presentations or prolonged recovery should be assessed and managed by a healthcare provider with experience in sports-related concussions working within a multidisciplinary team.
Outcomes in concussion are better if the injured player is well informed and understands what has happened. Measures to improve understanding and deal with emotional problems and anxiety should also be considered in the management of concussed players.
Below you will find a selection of extra resources, guidance and advice for managing head injuries.
Learn how to recognise and manage a concussion from the time of injury through to a player's safe return to football, by completing The FA's short online module.
Berlin concussion group consensus statement
This paper is a revision and update of the recommendations developed following previous International Consensus Conferences on Concussion in Sport. It is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach.
SCAT5
A standardised tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older.
A standardised tool for evaluating injured children for concussion and can be used in children aged from five to 12 years.
A downloadable checklist to help identify concussion in children, youths and adults
Useful additions to concussion assessment and management:
Cogsport
Quick and cost-effective online cognitive tests for concussion for all athletes and to help medical providers measure the cognitive function of athletes after suspected concussions or traumatic brain injuries.
ImPACT
Developed by clinical experts who pioneered the field, ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the most-widely used and most scientifically validated computerised concussion evaluation system.
ISEH
The ISEH provides excellence in elite sports performance and sports injury prevention and management while bridging the gap between elite sport, amateur sports and exercise prescription, for the improvement of the healthcare of the population.
Headway
Headway is the UK-wide charity that works to improve life after brain injury. On this section of their website, they provide information for GPs to assist with diagnosing, managing and appropriately signposting patients and carers affected by the often hidden aspects of brain injury.
This UK-wide charity exists to provide information about neurological conditions and to be there during diagnosis, treatments and, in the longer term, to answer questions and provide support throughout a patient's journey.
Birmingham Sport Concussion Clinic
The team cares for recreational athletes, weekend warriors, enthusiastic exercisers and dancers, as well as elite athletes who choose to use the NHS. The team can treat patients aged 14 and over.
This world-class rehabilitation, sports and exercise medicine, and human performance centre is based in the Millbrook area of the city and offers expert diagnosis and treatment to support athletes to get back to their best.
