Dr. Amaal Starling

Returning the Athlete to Competition After a Concussion

Amaal Starling, MD, shares the five steps every coach and parent should follow

The importance of a safety protocol for a possible concussion seems common knowledge, but Dr. Amaal Starling says as recently as six years ago, when she’d ask coaches about their team’s post-head injury protocol, they’d say, “Oh, we pull [athletes] off the field and we’ll ask them a question or two, and then we watch them for a couple of minutes. It was very unstructured, which leaves room for error and missed diagnoses,” says Dr. Starling, Assistant Professor of Neurology at the Mayo Clinic in Phoenix and member of the International Concussion Society’s Scientific Advisory Board.

Relying on an injured athlete to self-report is dangerous, because, “when you’re concussed, you’re confused, and when you’re concussed, you’re not playing at your best,” which can lead to unsafe play and risk of subsequent head injuries. This is why Dr. Starling advocates for schools, youth athletic organizations and professional teams to set a standard structured protocol for concussed athletes to follow prior to returning to play. “If you think about life in general, really important emergencies always have a specific structured protocol,” she says. “Policemen, firemen and emergency medical services have a protocol to approach emergencies. When patients come in concerned about a possible stroke, as neurologists we have a specific protocol to assess, diagnose and treat as rapidly as possible. This is important in emergencies and time-sensitive conditions including head injuries.”

While protocols should be allowed some flexibility according to age, sport and level of play, Dr. Starling believes a standard concussion and return-to-play protocol should include the following:

1. Pre-concussion education

“Protocol should start even before a head injury occurs,” Dr. Starling says, calling for concussion education for athletes, parents, coaches, administrators, nurses and counselors. In order for any concussion program to exist—at a school or on a sports team—there has to first be an awareness of the injury itself and an understanding of the symptoms and risks. To successfully and safely rehabilitate an athlete, “concussion education is really the first start,” says Dr. Starling.

2. Pre-game brain function testing

Dr. Starling believes that brain function should be measured as a part of any athlete’s annual physical, which examines the heart, lungs, muscles and bone health but tends to leave out the brain. The King-Devick eye movement test is easily applied (versions of the test can be downloaded and administered on a tablet) and provides baseline information so that when another test is administered post injury, abnormalities in eye movement coordination, attention, concentration and language may objectively suggest a brain injury or concussion immediately post injury.

3. When in doubt, check them out

The moment a parent or coach suspects a potential head injury based on the hit or athlete’s behavior, the athlete should be immediately removed from play to reduce the risk of subsequent head injury. If a well-validated sideline tool like the King-Devick test shows abnormal objective results or there are any symptoms and signs concerning for a concussion, it’s time to see a concussion specialist. “[The visit] should occur within a week of injury so that we can administer appropriate tests and provide recommendations for management including returning to learn/school and returning to physical activity,” Dr. Starling advises. At return-to-play clinics like the one at Mayo, doctors administer various objective tests to provide a comprehensive clinical picture of the patient in order to treat physical, cognitive, emotional and sleep symptoms.

4. Wait for the all clear

Whether on the sideline or in a clinic, concussed athletes need to be completely symptom-free at rest and with full exertion in order to return to contact play. “They must have completed an exertion protocol where we have them exercise, raise their heart rate, complete balance and movement work without any return of symptoms,” says Dr. Starling.

5. Post-game discussion

“The last and very crucial step is to have a discussion with the athlete and parents about returning to sports, particularly if there is a history of prior concussions,” says Dr. Starling. A concussed athlete faces an increased likelihood of future concussions occurring, which brings risk of a longer recovery for subsequent head injuries. Coaches, parents and athletes should review safety measures and future protocol in case there is another injury.

Dr. Starling would like to see sports programs at every level equip themselves with a checklist for concussions.  “I hope that we have more standardized protocols so that every potentially concussed athlete is evaluated in a structured fashion and thus has the best chance of immediate identification and diagnosis, appropriate recovery and continued participation in sports,” she says.


Amaal Starling MD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.