What is the NFL's concussion protocol? The steps that will be taken before resuming play

Since implementing game-day concussion protocol in 2011, the NFL has taken several steps to reduce the number of concussions suffered by players. The league changed rules to make blows to the head illegal, introduced position-specific helmets and recently allowed players to wear Guardian Caps – a soft cover over the helmet – during games.

Still, the number of concussions increased slightly last season, and if a player is suspected of having a concussion, the league has a protocol to follow before the player can return to the field.

Here's what you need to know about the NFL's concussion protocol:

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What happens if a player appears to have suffered a head injury?

If a team's medical staff believes a player is at risk of a concussion, the player must be taken to the sideline and into the medical tent for a focused neurological evaluation. The evaluation will include an examination of the cervical spine (including range of motion and pain), an assessment of speech, an observation of gait, and an examination of eye movements and pupils. If the player shows signs of loss of consciousness, gross motor inability, confusion, or amnesia, the team's medical staff must not allow the player to return to the game.

What symptoms does medical staff look for?

Players will be removed from the game and evaluated if they exhibit symptoms of a concussion, which include dizziness, nausea, and sensitivity to light and sound.

If a player is observed to exhibit or reports any of the following “no-go” symptoms, he will be removed from the game and will not be allowed to return:

• unconsciousness
• Ataxia (impaired balance/stability, motor coordination or speech disorders)
• confusion
• amnesia

The “no-go” symptoms were updated after Miami Dolphins quarterback Tua Tagovailoa was stretchered off the field following a concussion he suffered in a 2022 game against the Cincinnati Bengals.

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How does the medical staff conduct the examination?

If a player has not been ruled out due to any of the “no-go” symptoms, he will be examined by an independent neurotrauma specialist.

First, medical staff will ask the player how the possible injury may have occurred. They will also continue to look for other symptoms of concussion. Staff will also ask “Maddocks questions” where the player will be asked about things like the venue and the team they are playing against. The independent neurotrauma consultant will also conduct a video review of the possible injury.

As mentioned above, the assessment of a concussion also includes a targeted neurological examination.

Who has the final say on the player’s status?

If a player does not exhibit any of the “no-go” symptoms, each step of the league’s concussion protocol will be determined by a team physician in consultation with an independent neurotrauma consultant on the sidelines.

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How can a player play again after entering the log?

When a player is removed from the game under NFL protocol, he must complete a five-phase return to play program.

Phase 1, symptom-limited activity: The player will be prescribed rest and must limit and/or avoid activities that increase or worsen symptoms. Limited stretching and balance exercises may be performed under the supervision of the athletic trainer, then progressing to light aerobic exercise. If tolerated, the player may attend meetings and film studies.

Phase 2, aerobic exercises: Under the supervision of team personnel, players should begin with gradual cardiovascular exercise, such as on an exercise bike or treadmill. The player may also do stretching and balance exercises.

Phase 3, football-specific exercises: The player continues to perform supervised cardiovascular exercise and may mimic sport-specific activities and supervised strength training.

Phase 4, non-contact training exercises: The player may continue cardiovascular, strength and balance training as well as sport-specific exercises in the team sport and participate in non-contact soccer activities.

Phase 5, full football activity/release: The player will eventually be cleared for full contact football activity by the club doctor. The player must be assessed by his club's independent neurological consultant. If the consultant agrees with the club doctor that the player's concussion has resolved, he will be allowed to participate in his team's next training session or match.

How long are players in the protocol?

Each player and each concussion is unique and there is no set time frame for return to the field. Team medical personnel will consider the current concussion, past history and future risk when treating the player.

The player may not return to contact training or participate in a match until he receives clearance from the independent advisor.

Further reading

(Photo: Carmen Mandato/Getty Images)