Concussion Management in the NFL: Gameday Evaluation of Head Injury

In the first of a multi-part series on concussion management in the NFL, find out how sideline providers evaluate and diagnose concussions and why it isn't as straight-forward as you'd think.

This is the first of a multi-part series. With the assistance of multiple sources with knowledge of the league's gameday and sideline concussion protocols, I'm going to take you inside the day-to-day management of head injuries in the NFL.

Today, I'll show you how the NFL evaluates and manages head injuries on gameday and why players might still fall through the cracks. In the next installment, I'll look at the league's Return to Play protocol and highlight where the NFL does things differently than other levels of football. I'll also address the most common misconceptions on head injuries and how the league's approach to concussions may evolve in future seasons.

how does the league manage concussions on gameday?

It happens every weekend at every level of football.

A high school athlete comes off the field dazed after an unwitnessed injury. Athletic trainers and team physicians rush on the field to assess a player who isn't moving after a helmet-to-helmet hit. Television reports of an NFL player being taken to the locker room to be evaluated for a head injury.

The rise in ACL, Achilles and Lisfranc injuries have drawn attention in recent seasons, but concussions are unquestionably the most controversial injury in football. The players and the league may have settled their legal dispute over concussions -- for now -- but the problem isn't going away.

What happens on the sideline in those first minutes after a suspected concussion? How do sideline providers decide whether a player has a concussion or whether he will be allowed to return to play? What tests must a player pass to be cleared for contact after being diagnosed with a concussion? Does the NFL handle concussion protocols differently than other levels of football? Who are the league's Independent Trauma Consultants and what do they do?

The answers might surprise you.

gameday preparations

The gameday management of a suspected head injury has evolved in recent years. We are not far removed from the days when we termed some concussions as "low grade" or  "mild" and allowed an athlete to return to the field if their symptoms resolved after 15 minutes. No more. At all levels of play, if an athlete has any neurologic symptoms concerning for concussion, they are not allowed to return to play that day.

But not every player with a headache or dizziness has a concussion. Some of those players may not have even sustained a hit to the head. And not every player who sustains a concerning helmet-to-helmet hit may have symptoms of a concussion right away. Both situations call for additional testing.

Here's how the NFL approaches those situations to protect players.

Baseline Testing

The preparation to properly diagnose concussions in unclear situations starts well before kickoff. Every player takes a full battery of neurocognitive and balance tests and provides an inventory of symptoms and history of previous head injuries before the season begins. These tests establish a baseline for comparison. The NFL uses a modified set of tests that resemble the Standard Concussion Assessment Tool, the ImPACT test and the Balance Error Scoring System (BESS). All three tests are commonly used in all levels of football.

Here's a YouTube video demonstrating the BESS test.

As teams do with playbooks, practice videos, film cutups and more, much of the testing is either performed or recorded on an iPad and the score is saved for future comparison.

Observational Infrastructure

The sideline gets hectic quickly during the game. Players need injury assessments or re-taping. Some need to be taken back to the locker room for x-rays, IV fluids or carted to an ambulance. Injured players don't make appointments, obviously, so sideline providers work on a triage system.

During the busiest times, athletic trainers and team physicians may not see what happens on the field. A helmet-to-helmet hit or a player with subtle, developing symptoms of a concussion may not be recognized immediately. The NFL now has two mechanisms in place to prevent those players from being returned to the field without an evaluation.

The first mechanism is the "eye in the sky," a team-affiliated certified athletic trainer equipped with an HD screen. These providers closely monitor the game action for hits that commonly result in concussions or players that may be dazed without an obvious injury. The athletic trainer then alerts the sideline to evaluate those players for signs of concussion.

The second mechanism is new in 2013. Every sideline will now have its own Unaffiliated Neurotrauma Consultant (UNTC), a medical doctor with experience in evaluating concussions to observe for injury and assist team physicians when needed.

The NFL has strict protocols in place for these observers, according to a source who will be on the sideline as an UNTC for an NFC team this season. Each team's UNTC will observe from the 25-yard line -- outside the box in which all team personnel must remain -- and may approach the team's bench (or locker room) only when specifically called by the team physician. Though independent observers, they may collaborate, assist or examine players only when asked. The UNTCs are meant to be an independent on-field backup, but technically report to the team physician on gameday.

in-game evaluation

The NFL has mandated that its team physicians take a conservative approach to their evaluations. That's why a Chicago team physician who reportedly saw a clear sign of concussion -- loss of consciousness in the case of Detroit's Rashean Mathis' -- can influence the decision-making of a player's own team physician

Though sideline providers are expected to err on the side of caution, team physicians are afforded some leeway when making decisions on a player they evaluate for head injury, before or after the diagnosis is made. One source told me that, with rare exception, "There are no explicit rules in the protocols. Decisions are at the discretion of the team physician." Directives provided to both team physicians and athletic trainers stress the importance of "knowing the player" to make an accurate diagnosis.

GO - NO GO questions

The first step in the sideline assessment application asks six questions. (Images of the NFL sideline assessment taken from Bob Labriola's excellent feature from March 2013 at

If the answer to any of these GO - NO GO questions is yes, the player is diagnosed with a concussion, removed from the game and taken to the locker room for continued observation under the Madden Rule, which states:

2) THE MADDEN RULE: Named for John Madden, who suggested it, this rules states that, if a player is diagnosed with a concussion and removed from a game, he must leave the field and be immediately escorted to the locker/training room, and a member of the medical staff (e.g., an ATC, paramedic, MD, fellow, or resident capable of medical intervention) must remain with the player to observe him if his injury does not require immediate hospitalization. There are no exceptions to this rule and the player is NOT to return to the field under any circumstances. The Madden Rule is intended to protect the players. It provides a quiet environment to permit the player time to recover without distraction. This rule has been endorsed by the NFL Competition Committee and approved by the Commissioner.

If the answers to all six GO - NO GO questions are no, the next steps are at the discretion of the team physician.

Full Sideline Assessment

Most teams seem to be choosing to take any player needing an evaluation to the locker room for a full assessment. At minimum, should the evaluation continue on the sideline, the team physician is likely to ask an additional set of questions (known as Maddock's Questions) as a orientation and memory check before clearing a player to return to the field.

1. Where are we?

2. What quarter is it right now?

3. Who scored last in the game?

4. Who did we play last game?

5. Did we win the last game?

If the player cannot correctly answer those questions without difficulty or the team physician prefers a full sideline assessment, the player is taken into the locker room. There, the player is put through a similar set of tests as he took during the preseason.

Here's the full two page assessment: (Images again taken from Labriola's feature.)

The scales are then compared to the player's baseline. Any concerning change in performance, within one section or on the entire test, would likely result in a player being removed from the game.

why gameday evaluations are not always straightforward

The increased focus and awareness of head injuries seems to be working. 

According to Frontline's Concussion Watch data, there were 92 players listed on the NFL's weekly injury reports with a concussion in 2009, 129 in 2010, 142 in 2011 and 171 in 2012. The NFL's own data, which includes practice and preseason concussions, shows a similar trend, with 190 concussions reported in 2011 and 217 in 2012.

Still, despite the improvement in diagnosis, there are pitfalls in the NFL protocols for assessing gameday concussions. There have been regular improvements to the SCAT tool and studies show that combining multiple memory and balance tests reduces errors in diagnosis. But it's still possible for a player to equal his baseline performance on the sideline assessment when being evaluated after a possible head injury. When that happens, providers rely on the player to self-report symptoms (e.g. headache or dizziness) that may not be evident on exam. 

Of course, that expectation often isn't met.

A 2012 Sporting News poll of NFL players found that 56% would try to hide concussion symptoms to keep playing. In 2011, Peyton Manning admitted that he tanks his baseline tests to make it easier to equal his performance should he need to pass an in-game evaluation.

Q: How do you feel about all the new research about concussions that's coming out?

Peyton: They have these new [brain] tests we have to take. Before the season, you have to look at 20 pictures and turn the paper over and then try to draw those 20 pictures. And they do it with words, too. Twenty words, you flip it over, and try to write those 20 words. Then, after a concussion, you take the same test and if you do worse than you did on the first test, you can't play. So I just try to do badly on the first test.

The NFL believes the multi-faceted computerized testing makes it more difficult to purposefully underperform on the preseason baseline exams. But it's still a concern for the league's medical providers, who I'm told are strongly encouraged to get to know their players during the preseason and observe those baseline exams closely to make sure players are giving them due attention.

Another concern for sideline providers is that the initial 15 minute period of testing and observation sometimes is not long enough to pick up late developing symptoms. Relatively few players lose consciousness or show the extreme balance issues seen in the Jermichael Finley GIF above after a head injury. And not every player exhibits confusion, memory loss, or headache immediately after an injury. Athletic trainers and team physicians must be vigilant, even after clearing a player, to make sure a player isn't developing symptoms of a concussion after the initial evaluation.

It's easy to play armchair neurologist with the benefit of multiple replays and hindsight, but diagnosing a concussion isn't as straight-forward as diagnosing a broken finger. That's not to say the NFL shouldn't be striving to make evaluation and diagnosis as clear as possible. In the end, the hope is that the NFL directives "at the discretion of the team physician" and "err on the side of conservative care" work hand-in-hand rather than against each other.

gameday followup

The evaluation of those players removed from the game with a concussion doesn't end after the diagnosis is made. Every player with a concussion is watched closely in the locker room and examined often for any changes in their condition. Every stadium has an Emergency Action Plan in place should a player deteriorate while under observation. No player is sent home alone or with any concerning symptoms and all players get a take home packet with instructions on what to watch for during the first few hours after their injury.

A player with a concussion is then re-evaluated the next morning in the training room and the next phase of the NFL's concussion management plan kicks in -- the Return to Play protocol. In the next article in this series, I'll cover the Return to Play protocol in detail, show you where the NFL differs from younger levels of football when deciding when a player is ready for contact, and tell you which players are more likely to stay in the protocol longer than others.

Follow on Twitter @JeneBramel for more discussion on concussions, the league's management of head injuries, and for commentary and analysis of injuries around the NFL.