Concussion — recognise, remove, return
The signs, the danger signs that mean call an ambulance, and the six-step graduated return to sport from the current international consensus. General information, not medical advice.
This is general information, not medical advice. A suspected concussion needs assessment by a healthcare professional. If someone shows any of the danger signs below, call emergency services immediately.
The one rule that matters most is the simplest: when in doubt, sit them out. A player removed from a game they could probably have finished loses one game. A player left in loses far more than that.
Signs an observer may see
From the CDC's HEADS UP program:
- appears dazed or stunned
- cannot recall events before or after the hit
- forgets an instruction, is confused about the score or the opponent
- moves clumsily
- answers questions slowly
- loses consciousness, even briefly
- shows changes in mood, behaviour or personality
Symptoms the player may report
Headache or "pressure" in the head · nausea or vomiting · balance problems or dizziness · double or blurry vision · sensitivity to light or noise · feeling sluggish, hazy, foggy or groggy · confusion · problems with concentration or memory · and simply not feeling right.
Symptoms are usually worst in the first day or two. They can also appear hours after the game, which is why the player and whoever is with them need to know what to watch for.
Danger signs — emergency care now
Call emergency services or go to an emergency department if a player shows any of these:
- one pupil larger than the other
- drowsiness, or cannot be woken
- a headache that keeps getting worse and will not go away
- weakness, numbness or decreased coordination
- repeated vomiting or nausea
- slurred speech
- convulsions or seizures
- difficulty recognising people or places
- increasing confusion, restlessness or agitation
- unusual behaviour, or loss of consciousness
What to do at the rink
- Remove the player from the ice — the game, the practice, all of it. Do not let them "shake it off" and take another shift.
- Do not leave them alone, and do not let them drive.
- Get a professional medical assessment. Same day.
- Tell the parents or guardians immediately if the player is a child.
- Return only with clearance from an appropriate healthcare professional. Both USA Hockey and Hockey Canada build their protocols around exactly this sequence, and many jurisdictions require it — Ontario's Rowan's Law, in effect since 2018, requires sport organisations to have removal-from-sport and return-to-sport protocols and to review concussion resources annually.
The graduated return to sport
The current international consensus (the Amsterdam 2022 statement, published in the British Journal of Sports Medicine in 2023) moved away from prolonged rest toward early, symptom-limited activity. It sets out six steps:
| Step | What it is |
|---|---|
| 1 | Relative rest, a maximum of 24–48 hours: daily activities, light walking, social contact; minimise screens |
| 2 | Aerobic exercise — 2A light effort (up to about 55% of maximum heart rate), then 2B moderate (up to about 70%). Light resistance work is allowed |
| 3 | Individual sport-specific activity with no risk of head impact — skating alone, change-of-direction work, away from the team |
| 4 | Non-contact training drills at higher intensity — passing drills, practices without contact |
| 5 | Full-contact practice and scrimmages, but no competitive games |
| 6 | Return to sport — unrestricted competitive play |
The rules around the ladder matter as much as the ladder:
- Each step after the first takes a minimum of 24 hours.
- If more than mild, brief symptom worsening happens during steps 1–3, stop and try that step again the next day.
- If symptoms return during steps 4–6, go back to step 3 until you can exert yourself symptom-free.
- Medical clearance and a full return to school or work come before step 4.
- Written medical clearance should come before unrestricted return to sport.
There is no shortcut through this. A second impact before the first has healed is the scenario everyone is trying to avoid.
What equipment does and does not do
Be clear about this, because the marketing is not. No helmet and no mouthguard has been shown to prevent concussion. Helmets substantially reduce the risk of skull fractures and other severe head and facial injuries, and you should always wear a properly fitted, certified one — but their effect on concussion specifically is much less clear, and there is no "concussion-proof" helmet. Mouthguards markedly reduce dental and facial injuries; the evidence for concussion prevention is weaker.
Wear both anyway. Just do not let either one change your judgement about a head knock.
Where to get the real protocols
- CDC HEADS UP — signs, symptoms and action plans for coaches and parents
- Parachute Canada — the Canadian Guideline on Concussion in Sport (2nd edition, 2024)
- USA Hockey — concussion management resources and return-to-play guidance
- Hockey Canada — Concussion Awareness hub and the Hockey Canada Concussion Protocol
Print one and put it in the team bag. Every coach, every parent helper and every beer-league captain should know where it is.
Sources. CDC HEADS UP for signs, symptoms and danger signs; the Amsterdam 2022 consensus statement's graduated return-to-sport strategy, as set out by the Ontario Neurotrauma Foundation's PedsConcussion living guideline; USA Hockey and Hockey Canada concussion resources; Government of Ontario on Rowan's Law; dental-association evidence summary on mouthguards. Checked September 2026.