Concussion in grassroots football: what to do

The short version

• Anyone with a suspected concussion is removed from play immediately, and does not return to play that day, even if they say they feel fine.
• Get them assessed by a healthcare professional on site, or call NHS 111, within 24 hours.
• Red flags mean urgent medical assessment on site or at A&E, with an emergency ambulance if necessary.
• If the player is under 18, tell their parent or carer.
• Relative rest for 24 to 48 hours, with screens kept to a minimum, then a staged return to normal life first and sport second. Easy daily activities and walking are acceptable if they do not make symptoms more than mildly worse.
• No return to competition before day 21, and only after at least 14 days with no symptoms at rest and a completed stage 5 of training without symptoms.
• Symptoms lasting more than 28 days mean a GP appointment.

What concussion looks like

Less than one in ten concussions involves loss of consciousness, so waiting for someone to be knocked out is the wrong test. The guidelines group the effects into four areas: physical, such as headache, dizziness or vision changes; mental processing, such as not thinking clearly or feeling slowed down; mood, such as being short tempered, sad or emotional; and sleep, either too little or too much.

Visible clues include: lying motionless or being slow to get up, unsteadiness or falling over, a dazed, blank or vacant look, being slow to respond, confusion about the score or the passage of play, grabbing at the head, a seizure or convulsion, lying rigid, being more emotional than normal for that person, and vomiting.

Symptoms a player may report include: headache, dizziness, feeling in a fog, difficulty concentrating, visual problems, nausea, fatigue, pressure in the head, sensitivity to light or sound, feeling more emotional, or simply not feeling right. Concerns raised by a parent, official or spectator about how a player seems also count.

The guidelines say the first symptoms typically appear immediately or within minutes, but can be delayed over the first 24 to 48 hours, with more appearing over the following days.

Red flags: when it is an emergency

The guidelines list red flags that mean urgent medical assessment, on site or at A&E, with an emergency ambulance if necessary:

• Any loss of consciousness, or consciousness that is deteriorating
• No memory of events before or after the injury
• Increasing confusion or irritability, or unusual behaviour change
• Any new neurological problem: trouble understanding, speaking, reading or writing, decreased sensation, loss of balance, weakness or double vision
• A seizure or convulsion, limb twitching, or lying rigid and motionless
• Severe or increasing headache, repeated vomiting, or severe neck pain
• Any suspicion of a skull fracture, such as a cut, bruise, swelling or severe pain at the site of the injury
• A previous history of brain surgery or a bleeding disorder, or current blood-thinning medication
• Current drug or alcohol intoxication

If a neck injury is suspected, the player should only be moved by a healthcare professional with appropriate training.

What to do on the day

If you are the coach, manager or a volunteer: remove the player from the pitch safely and do not put them back on that game, even if they say their symptoms have gone. Watch them, or ask a responsible adult to. If they are under 18, contact their parent or carer. Make sure they get home safely and that an adult can supervise them for the next 24 to 48 hours. Complete whatever injury report your club, school or competition requires.

If you are the parent or carer: get the full details of what happened. Do not leave your child alone for the first 24 hours. Have them assessed by a healthcare professional on site within 24 hours, or call NHS 111. Watch for worsening signs for at least 24 to 48 hours. Tell their school, and any other clubs or sports they play for. Then support them through the staged return.

If you are the player: stop straight away and tell someone. Under-reporting symptoms is linked to longer recovery. Tell your school and your other clubs. Being assessed does not mean you can go straight back to training: after that assessment you still work through the staged return below.

Anyone with a suspected concussion should not be left alone for the first 24 hours, and should not drive, ride a bicycle or operate machinery within 24 hours. Alcohol should be avoided for the first 24 hours and while symptoms continue. Commercial drivers should be reviewed by a healthcare professional before driving.

The 24 to 48 hours after

The guidelines describe a short period of relative rest, not a dark room for a fortnight. Rest and sleep as needed, keep phone and computer screens to a minimum, and easy daily activities and walking are fine. The old advice of two weeks of complete rest has gone: light activity early on helps recovery, as long as it does not make symptoms more than mildly worse.

Getting back: the six stages

The graduated return to activity and sport programme has six stages, and returning to education or work comes before returning to sport. The guidelines (opens in a new tab) set them out in full. In summary:

• Stage 1. Relative rest for 24 to 48 hours, screens minimised.
• Stage 2. Daily activities away from school or work, plus light physical activity such as short walks.
• Stage 3. More study or work activity with rest periods, and more exercise: walking or stationary cycling for 10 to 15 minutes at an intensity where you can still talk easily.
• Stage 4. Part-time return to education or work, and training that carries no risk of head impact.
• Stage 5. Full return to education or work, and, once symptom free at rest for 14 days, full training including activities with a risk of head impact. This cannot start before day 15.
• Stage 6. Return to competition, not before day 21, and only after 14 days with no symptoms at rest and no symptoms during the training in stage 5.

Day 0 is the day of the injury, and no stage should last less than a day. The conditions for moving on are not the same all the way through. Through stages 1 to 3 you can progress with mild symptoms present, as long as the activity does not make them more than mildly worse, and a brief worsening that settles within an hour or two is acceptable. Stage 4 is different: it needs the player to be symptom free at rest. Stage 5 cannot start before day 15 and needs at least 14 days with no symptoms at rest. Stage 6, competition, cannot come before day 21 and only after stage 5 has been completed without symptoms.

Two things are worth saying plainly. After the initial assessment, the guidelines say the programme can typically be self-managed in grassroots sport, with no expectation of a healthcare professional reviewing each stage. That does not make the initial assessment optional. And the 21-day mark is a minimum, not a target: children and teenagers can take longer, and around two thirds of people are back to full sport by 28 days.

When to go back to a doctor

• If symptoms get worse, or have not improved 14 days after the injury, call NHS 111.
• If symptoms are still there after 28 days, see a GP, who may refer on.
• If progress stalls, for example symptoms worsen every time activity increases, that is also a reason to seek medical guidance rather than pushing through.

Children, teenagers and repeat concussions

The guidelines are explicit that children and adolescents may be more susceptible to concussion, take longer to recover, and are more vulnerable to rare but dangerous complications caused by a second impact before the first has healed. Returning to education too early can prolong recovery. A previous concussion also raises the risk of another one, and of other injuries while recovering.

For a disabled player, the same rule applies, with adaptations. A longer initial period of relative physical and cognitive rest may be needed, and anyone supporting them has to work out whether symptoms brought on during the return programme are part of the concussion or part of how that person normally functions.

What clubs can do before it happens

• Make sure someone at every session knows the guidelines. The FA's concussion module is one of the free e-learning courses on its medical course list (opens in a new tab), and concussion is covered in the first aid courses our guide to first aid in grassroots football explains.
• Agree in advance who takes charge of the response, so that calls, parents and transport are covered. Recognising a suspected concussion and getting the player off is everyone's job, and nobody should have to wait for permission to do it.
• Keep an injury report form with the kit, and use it.
• For tournaments, build it into the plan for the day rather than the moment. Our guide to running a tournament on the day covers weather, referees and medical cover together.

Elsewhere in the UK

These guidelines are UK-wide and were developed with all four home nations. Scotland also publishes its own grassroots concussion guidance, which the UK guidelines were built on.