The evaluation and care of an athlete with a concussion is one of the most challenging problems facing physicians who care for athletes. The difficulty in evaluating these persons is the assignment of severity of the injury. Wojtys and associates clarified issues concerning concussions in sports based on the work of the American Orthopedic Society for Sports Medicine Concussion Workshop Group.

The initial on-the-field evaluation of an athlete who has had a concussion is the most important aspect of caring for these patients. A well-thought-out plan of care must be established, including stabilization and immediate transfer. The initial evaluation of the athlete suspected of having a head or neck injury includes the basic ABCs, airway, breathing and circulation. After that assessment is completed, an evaluation for cervical spine (C-spine) injury is performed.

The rule in this evaluation is that the C-spine is injured unless it is proved otherwise. The next assessment is to determine the level of consciousness based on the Glasgow Coma Scale. If the C-spine is not injured and the level of consciousness is not significantly altered, the athlete can be allowed to sit up and, if stable, walk off the field with support. A review of symptoms and a complete neurologic and head and neck evaluation are performed on the bench. If the examination is negative, the athlete should be observed for 15 minutes unless there is a history of loss of consciousness. If no loss of consciousness and no return of symptoms occur during the 15 minutes, the next step is a provocative test such as a 40-yard dash. If no symptoms return, the athlete may be returned to the game, but repeated observations must be performed. If any symptoms return, the athlete must be removed from the game.

In the case of the athlete who has documented loss of consciousness, signs and symptoms that did not clear in 15 minutes or that returned with the provocative test, the athlete should not be allowed to return to competition. Any new or unusual headaches within the first 48 to 72 hours after the injury should be treated as a medical emergency. In addition, any deterioration in mental status or deterioration in physical condition is a medical emergency.

The issue of when to return the athlete to play after the first concussion that resulted in loss of consciousness is controversial. Most studies recommend that the athlete not compete for five to seven days. Before any return to competition, the athlete must be evaluated by the same clinician who performed the initial evaluation.

Providing medical care for athletes must include thorough evaluation and management of any head and neck injury. This step includes basic and advanced evaluation of the athlete. This approach will allow the physician an opportunity to permit those who are not at risk for further deterioration to return to play and to quickly identify those who are at risk.