sports neurology at MUSC

sports neurology

Return to Play Guidelines

Return to Play Guidelines (RTP ) for coaches, trainers and physicians:

Any athlete who sustains a concussion needs to be removed from play and evaluated by an athletic trainer or other health trained professional with basic first aid principles always coming first (ABC’s and caution with potential cervical injuries).

A graduated return-to-play strategy consists of progressing through five steps of increased activity each 24-hrs as long as the athlete remains asymptomatic after each step increase in activity level. If the athlete does become symptomatic at any point with increasing exercise, the guidelines recommend to go back to the first rehabilitation stage of complete physical and cognitive rest and to not advance to the second stage of light aerobic exercise until the athlete is asymptomatic for at least 24-hrs.

RTP Stages:

First stage in RTP is no activity with cognitive and physical rest.

  • This means having no symptoms for 24hrs.
  • If an athlete was placed on medications for symptoms such as headache he/she should be tapered once symptoms resolve and proceed with 24 hours symptom free off medications.

Second stage consists of light aerobic exercise.

  • Stationary bikes, walking, swimming, cycling with goal to increase heart rate but keep intensity less than 70% maximum predicted heart rate.
  • Keep in mind the goal is to slowly introduce exercise.
  • No resistance training.

Third stage is sport-specific exercise.

  • During this phase introduce movement in simple drills with no head contact.
  • Examples include skating in ice hockey, running in soccer or football.
  • Ideally no drills requiring intense stop and go with quick changes in direction.

Fourth stage is non-contact training drills.

  • Now an athlete can progress to complex training with intense drills, changes in direction, and coordination.
  • Resistance drills can be introduced here.
  • Again there is no contact in this stage!

Fifth stage is full contact practice

  • This stage requires medical clearance.
  • Once cleared coaches/trainers should restore confidence in the athletes and assist with this process as much as possible.
  • Participate in full contact practice with close observation.

Sixth stage is Return to play.

  • Normal game play with no limitations.

Please remember that this guideline requires 24-hours in each step with the athlete remaining symptom free.  An athlete that develops symptoms in any stage needs to return to step one and start over.  That means that some athletes may require going through this process several times before getting to return to play.


© Medical University of South Carolina | 171 Ashley Avenue, Charleston, SC 29425