Almost all the harm from a concussion comes from what happens in the fortnight afterwards, not from the knock itself.

The strategy race

Set out how this injury is going to be handled — five decisions, each of which real families and real clubs make differently — and the same injury is then run through the graded return twice: once under your decisions and once under the protocol. Both runs use one model of the same head. What you are looking for is not the total on its own but the gap between the day the player reaches the pitch and the day the player is actually recovered.

What a concussion actually is

• It is a functional injury, not a structural one. The scan is normal because there is nothing on a scan to see: the problem is how the cells are working, not how they are arranged. That is why a normal CT does not mean there was no concussion, and why nobody should be waiting for an image to confirm it.
• Losing consciousness happens in a minority of concussions. Most people never black out at all, so “he didn't get knocked out” carries almost no information. Being dazed, slow to answer, unsteady, or blank about the moments before the hit matters far more.
• It does not need a blow to the head. A hit to the body that snaps the head around does it just as well — a tackle, a fall on the back, a collision in the air.
• Symptoms can arrive hours later. A player who seems fine walking off can have a headache and light sensitivity by the evening, which is why any suspected concussion means no return to play that day even when the sideline check looks normal.
• Four groups of symptoms, not just headache. Physical (headache, nausea, dizziness, light and noise sensitivity), thinking (slow, foggy, cannot concentrate), emotional (irritable, tearful, flat — often the first thing family notice), and sleep (sleeping much more, much less, or badly).
• Most people recover fully. Within about two weeks for adults and up to about four for children and adolescents. The minority who do not are heavily weighted towards those who kept getting hit, kept pushing, or were never given the fortnight.

The signs that mean hospital now, not tomorrow

Everything else on this page assumes those have been excluded. A concussion without red flags is managed at home and on the training pitch, not in a hospital — but the red flags are checked for again that evening and again the next morning, because a few of them declare themselves late.

The dark room makes it worse, and that surprises everybody

• Roughly 24 to 48 hours of relative rest, and then gentle activity that stays below the level which brings symptoms on. Relative rest means light, dull, boring — not sensory deprivation.
• Strict rest beyond about two days lengthens recovery. This has been tested directly: prolonged complete rest produced more symptoms and slower recovery than early gentle activity. A fortnight in a dark room is an intervention with a known cost.
• “Below the symptom threshold” is the operating rule. A short walk that leaves the headache where it was is fine. Anything that clearly worsens symptoms is too much today and will be fine in a few days. A mild, brief bump in symptoms that settles within about an hour is not a setback.
• Sleep is allowed and does not need interrupting. Waking a concussed person hourly through the night is an old idea that mostly produces exhausted families; if the red flags are absent, let them sleep, and check on them normally.
• Screens: moderation, not prohibition. Total screen bans in the first days show little benefit and cost a teenager their entire social world at a moment when isolation makes mood symptoms worse. Reduce, break up, and stop when symptoms rise.
• No alcohol, and no second head impact of any kind until fully recovered. That is what the graded return is protecting.

Return to learn comes before return to play

• The classroom is the first load test. Concentrating for an hour is exercise for the injured system, and if a full school day still causes symptoms then the body is nowhere near contact sport, whatever the legs say.
• School comes back in steps too: schoolwork at home, then part days, then full days without adjustments. Most students are back at school well before they are back at sport, which is the correct order and often the reverse of what happens.
• Ask the school for the boring adjustments. Extra time, a quiet room for tests, permission to leave a noisy hall, no exams in the first week, catch-up rather than pile-up. They are temporary, they are ordinary, and they are far easier to get if somebody asks explicitly.
• Sport before school is how symptoms come back. Training loads the same recovering system, so a player who trains all week and then cannot manage a maths lesson has been given the cognitive rest budget backwards.
• Watch the mood, not just the headache. Irritability, tearfulness and flatness are concussion symptoms, and in adolescents they are frequently the last to go. They are also the ones a coach never hears about.

The ladder, and the only rule it has

The graded return is six steps, and the single rule is that each step needs a day free of symptoms at that level before the next one. It is not six days of waiting: it is six steps, each of which can take longer.

1. Symptom-limited daily activity. Normal life kept below the symptom threshold. School, walking, gentle chores.
2. Light aerobic exercise. Walking or a stationary bike at an easy pace. No resistance training, nothing where a fall is possible.
3. Sport-specific exercise. Running, skating, drills alone. Movement patterns, no head impact and no other bodies.
4. Non-contact training drills. Passing, harder drills, resistance training. Everything except contact.
5. Full contact practice — after medical clearance. This is the step that needs somebody qualified to say yes, because it is the first step where a second impact is possible.
6. Return to competition.

The player who says he is fine

• Under-reporting is the norm, not the exception. Large surveys of school and amateur athletes consistently find that a substantial share of concussions are never reported. The commonest reasons are not machismo but arithmetic: they do not want to be dropped, they do not want to let the team down, and they do not think it is serious.
• Hiding it does not shorten the injury; it lengthens it. Continuing to load a brain that is still symptomatic is the single most reliable way to extend recovery, and the days lost to that are days nobody chose.
• The one situation that must never be risked. A second impact before recovery, most often in adolescents, is rarely but genuinely catastrophic. It is uncommon enough that no player should be frightened with it and serious enough that no coach should trade against it.
• Ask the question in a way that has a right answer. “Are you fine?” has one socially acceptable answer. “Tell me what still isn't right, and it doesn't cost you your place” has a real one, and it needs saying before the season, not after the hit.
• Remove the incentive and the reporting follows. A club rule that a reported concussion never loses a player their position is worth more than any amount of education, because it removes the thing they are actually weighing.

What people believe, and what is actually so

The helmet point deserves its own line, because it changes behaviour: helmets are worth wearing and they are not concussion protection. A player who believes the helmet has it covered takes contact they would otherwise avoid, which is why better helmets have never produced fewer concussions.

Children and adolescents are a different case

• They recover more slowly. Up to about four weeks is within the normal range for a child or adolescent, against about two for an adult, so the same injury needs a longer ladder and a more patient adult.
• Under about five, be assessed. A young child cannot report a headache, brain fog or double vision, so the threshold for having somebody look at them is much lower.
• The signs in a young child are behavioural. Unusual crying that will not settle, refusing to feed, not interested in playing, unsteadiness, sleeping oddly.
• School is the priority, not the season. An adolescent's exams are not reschedulable in the way a fixture is, and the cognitive load is the load that matters most at that age.
• The pressure on a talented teenager is enormous and comes from adults. Selection, scouts, a final — and the athlete is the least able of everybody involved to weigh it. The adult's job is to make the decision so the child does not have to.

On the sideline, in the next ten minutes

The drill: 16 decisions

Sixteen ordinary moments — a knock in the second half, a Tuesday when he says he is fine, a parent who wants the trial on Saturday, a teacher who wants to know what to change. Most have an instinctive answer that is kind and costs weeks. Pick your move; every answer explains why.

The card

Print it for the kit bag, the clubhouse wall, or whoever is with them tonight.

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