NFL Concussion Protocol – A Primer for Fans

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Concussions in all sports are a fact of life, however, in the NFL because of the nature of the game several players on multiple teams are often in concussion protocol at any given point in the season.  How concussions are handled by the NFL and individual teams has changed drastically in the last few years.  The current concussion protocol is a valid and useful series of evaluations done both before an injury occurs (baseline) and after diagnosis during the recovery phase.

Anyone who watched NFL games 20 or 30 years ago remember seeing  players appear appear badly shaken-up, taken off the field and then return to play fairly quickly.  In the current NFL, if a player is deemed to have sustained a head injury a spotter signals down to the sideline, play is stopped and the affected player or players are immediately removed from the game for further evaluation.

Concussions are difficult to diagnose immediately after the offending injury as symptoms may not manifest until several minutes to hours after the injury was incurred.  This is one of the reasons why there is a perceived increase in the number of players in concussion protocol.

Every team has an independent neurological consultant who along with the team physician are responsible for evaluating and permitting a player to return to the playing field.  Most consultants are aware of the delay possible in symptom onset, so for the sake of player safety and long term well being if there is a question as to whether a player has sustained a serious head injury, they will likely be placed into concussion protocol to provide additional time for further evaluation.

In Game Protocol – “Observable symptoms”

There are seven observable symptoms used to identify players with concussions:

  • Any loss of consciousness
  • Slow to get up following a hit to the head.  The hit may occur when 2 players tackle one another or when one player forcefully strikes the playing field
  • Motor coordination/balance problems.  If a player is slow to get up, requires assistance standing or walking following a hit or stumbles when walking back to the huddle or sideline
  • Blank or vacant look
  • Disorientation -unsure of where he is on the field or location of his teams bench.  Unsure of game context clues such as quarter of play, or who another player on the field is.
  • Clutching of head after contact
  • Visible facial injury in combination with any of the above.  This can include lacerations in the head or neck region or dental injuries.
Photo of Eagles TE LJ Smith after sustaining a concussion in 2008 from

When spotters up in the booth or other medical personnel on either sideline see any of these signs, play is stopped, the player is taken to the locker room or if necessary taken to local hospital by ambulance for further evaluation and the protocol goes into effect.  Once a player is placed into concussion protocol, the players well being is the number 1 concern.  No further information is provided to the head coach or position coaches other than where in the protocol the player is.

This protocol has been in place since 2009 and each off season as more data is available, any necessary changes are made to try to best manage player safety and well being.  There have been a few instances where a team failed to adequately enforce the concussion protocol, particularly the “In Game – Observable symptom protocols” and as a result, the NFL has implemented hefty fines and also the loss of draft picks when a team is felt to have tried to skirt the concussion protocol.

Return to play process

Once in the concussion protocol, the player must progress thru a series of 5 steps before they can be cleared to return to the playing field.  There is no set time table for this evaluation and recovery.  Some players progress thru the protocol fairly quickly and others take longer to be cleared to resume playing.

The full NFL Return to Play Protocol is lengthy without any set timeline for a full return from a concussion.  The link above will take you to the full detailed protocol.

In a nutshell the 5 steps are as follows:

  1. Rest and recovery:  Until a player returns to the “baseline level of signs and symptoms and neurological examination,” only limited stretching and balance activities are recommended. Electronics, social media and team meetings are all to be avoided.
  2. Light aerobic exercise: The NFL recommends 10-20 minutes on a stationary bike or treadmill without resistance training or weight training. The cardiovascular activity is monitored by an athletic trainer to “determine if there are any recurrent concussion signs or symptoms.” A player in step 2 can attend team meetings, position meetings and watch film, however if any recurrence of symptoms occurs the player must stop the offending activity and report the symptoms to the athletic trainer assigned to monitor his recovery.
  3. Continued aerobic exercise and introduction of strength training: Increased duration and intensity of aerobic exercise with strength training added. An athletic trainer will supervise to watch for recurrent concussions signs or symptoms.
  4. Football specific activities: The cognitive load of playing football will be added and players will participate in non-contact activities for the typical duration of a full practice. Non- contact includes contact with sideline apparatus such as sleds and tackling dummies.
  5. Full football activity/clearance:  A player returns to full participation in practice, including contact without restriction.  If he does not experience any symptom recurrence following the practice, the team doctor can deem the player is cleared. Once that happens, all medical records must be made available to the independent neurological consultant who will review the record and has the final say in whether a player is ready to return or not.

A protocol is in place and teams are expected to follow it.  Unfortunately, every year there are one or two instances where the protocol is either ignored outright or misinterpreted, however compliance has improved since the protocol was put into place. Hopefully 2018 will show even better compliance with this important safety protocol.

Editor’s babble: Unfortunately, concussions are all too frequent in the NFL. Although rules changes have helped minimize the most risky plays, they are ultimately unavoidable in a collision sport like football. Thanks to Dr. Beth Sullivan for sharing her expertise on the topic. You can find Beth on Twitter @GAPeachPolymer. 

About Beth Sullivan

I am a lifelong Buffalo Bills fan who grew up in Hamburg, NY but now lives outside Athens, GA. I have been married to a Patriots, Red Sox and Packers fan for over 30 years and we are the proud parents of 5 kids and 8 grandkids. I am a board certified osteopathic physician with over 20 years experience. I am also a polymer clay artist and create one of a kind polymer pieces for jewelry, and home decor. You can see some of my recent work on Instagram @georgiapeachpolymer. If you have an idea for a topic you would like to see covered, shoot me a message on Twitter @GAPeachPolymer