These aren’t rare events or fluke collisions; they’re frequent, often underreported, and sometimes misunderstood. From football to cheerleading, athletes are experiencing head injuries that don’t just affect playing time, but cognitive function, emotional well-being, and academic performance. Coaches, athletic trainers, and athletic directors aren’t just managing games; they’re navigating a growing public health issue. Understanding concussion trends, risks, and evidence-based care strategies isn’t optional anymore – it’s essential.
Understanding Concussions: What You’re Really Dealing With
A concussion is not just a “bump on the head.” It’s a functional brain injury caused by biomechanical forces, usually a direct or indirect blow to the head, neck, or body that transmits force to the brain. What makes concussions uniquely challenging is that they don’t show up on standard imaging like CT or MRI (the acute injury causes a functional disturbance rather than obvious structural damage).
There’s often no bleeding, no swelling, and no visible structural damage on scans. But the effects are real: altered brain function that can impair memory, balance, coordination, reaction time, mood, and sleep.
The injury itself is metabolic. The brain enters a state of energy crisis – increased demand for glucose but reduced blood flow to deliver it, impairing its ability to function normally. In simpler terms, neurons are burning fuel fast while blood flow (and thus fuel supply) is temporarily reduced, creating an “energy mismatch.” That’s why symptoms often fluctuate, and why physical exertion, screen time, or even academic work can worsen recovery when introduced too early (initial management guidelines emphasize relative rest with limited cognitive/physical activity for the first 24–48 hours).
Concussions are clinically diagnosed based on a constellation of symptoms, observable signs, and cognitive or balance changes, there is no definitive single test. The 2022 Amsterdam Consensus Statement on Concussion in Sport (the most current international guideline) emphasizes recognizing the full scope of possible symptoms, from dizziness and “foggy” feeling to emotional dysregulation and sleep disturbance.
It also reinforces that no single test can diagnose a concussion; instead, a combination of assessments is used for a comprehensive evaluation. Diagnosis requires clinical expertise and often tools like the new SCAT6 (Sport Concussion Assessment Tool, 6th edition), which standardizes symptom assessment, cognitive testing, and balance evaluation on the sideline and in follow-up.
The variability in concussion presentation is precisely why athletic trainers (ATs) are often the first and best line of defense. ATs know an athlete’s baseline and can spot subtle differences; in fact, the presence of an AT has been shown to increase identification and reporting of concussions (one study found athletes with access to ATs were more likely to report concussive symptoms and get post-concussion evaluations than those without). With high athlete volumes and tight timelines, ATs benefit from tools that help capture those “invisible” changes, like slight reaction time slowing, balance issues, or delayed verbal processing, quickly and reliably. Concussions may be invisible to the naked eye, but recognizing the unseen signs is where meaningful care begins.
How Common Are Concussions?
While the numbers vary by level of competition, age group, and reporting standards, concussions remain one of the most common injuries in both high school and collegiate athletics. What’s often underestimated is how many of these injuries go unrecognized. Athletes frequently minimize symptoms, coaches may mistake them for fatigue or stress, and not every program has the resources to track subtle neurological changes.
Among high school athletes, recent nationwide data indicate roughly one in seven students reports having at least one sports- or recreation-related concussion within the last year. And a significant portion of those students – especially in competitive programs – admit to playing through symptoms or returning to action before fully recovering. In one study of high school football and soccer players, 69% of those who sustained a concussion kept playing with symptoms and 40% didn’t tell their coach about the injury. This under-reporting is a major concern.
At the collegiate level, concussion rates are particularly high in full-contact sports. Football often gets the most media attention, and for good reason. It accounts for more than half of all sports-related concussions and has the highest incidence rate in college athletics. But it’s not the only sport where concussions are a regular concern. Wrestling, men’s ice hockey, and men’s lacrosse also show very high concussion rates given the frequency of contact and collision. Notably, certain women’s sports report concussion rates on par with these men’s contact sports.
For example, women’s soccer has one of the highest concussion rates in college sports; in NCAA data it accounts for the most concussions in women’s athletics and the second-highest incidence overall (trailing only football).
Women’s lacrosse and women’s ice hockey programs likewise report concussion rates that are higher than many men’s sports when comparing per-athlete exposure. These injuries aren’t reserved for elite players or highlight-reel hits – they’re happening every day in practice drills, scrimmages, and mid-season games across a range of sports.
The Reporting Gap
The real challenge isn’t just how often concussions happen, it’s how often they’re missed. Studies have consistently shown that athletes underreport symptoms. Sometimes it’s due to fear of being benched; other times it’s because athletes genuinely don’t recognize the signs. A headache, fogginess, irritability, or slowed reaction time, none of these are as obvious as a visible limp or a broken bone. And in the absence of a dramatic collision, many athletes (and even staff) don’t realize an injury has occurred.
For example, despite education and concussion laws, a survey of high school athletes found that over two-thirds of players who knew they had concussion symptoms didn’t report them and kept playing. In many cases the coach wasn’t even aware. This is why early identification depends so heavily on pattern recognition, baseline comparisons, and tools that can catch subtle changes in real time. Athletic trainers are often the first to sense something is off, an athlete who isn’t answering questions as sharply, or who shows slight balance issues, but with large team rosters, they need efficient ways to confirm what their instincts suspect.
Technologies that streamline sideline neurological assessments (reaction time apps, balance testing devices, etc.) are no longer luxuries; they’re becoming practical necessities to bridge the reporting gap.
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Concussions are common, not rare. That shifts the focus for sports programs from reaction to preparation. If concussions are expected, teams must be ready—with clear protocols, reliable tools, and a shared understanding that “playing through it” is no longer acceptable.
Preparation includes pre-season education, baseline testing, and defined remove-from-play and return-to-play procedures. It also means building a culture where athletes report symptoms early and feel supported. The stats don’t tell the whole story, but they speak loudly: teams must take brain health seriously, with systems that support early detection and athlete safety.
Concussion Rates by Sport: What the Numbers Say
Concussions don’t occur evenly across all sports. Some sports carry dramatically higher rates due to their contact level, style of play, and rules of engagement. Contact and collision sports like football, ice hockey, lacrosse, and wrestling – routinely produce the highest rates of diagnosed concussions. These are games where collisions are expected (and often strategic). Football, for instance, still leads in concussion incidence in most high school and college injury reports.
Surprisingly, very high concussion rates are also seen in certain sports that people might not consider “collision” sports – notably women’s soccer and women’s ice hockey. In women’s soccer, head-to-head contact, aerial collisions, falls, and even ball strikes contribute to a concussion rate that, on a per-exposure basis, rivals that of men’s football in some data sets.
In fact, studies have shown higher reported concussion rates in women’s soccer than in men’s soccer, likely due to a combination of physiological factors and a greater likelihood of reporting symptoms among female athletes. Women’s ice hockey, despite rules against body-checking, also has concussion rates comparable to men’s high-contact sports, because unintentional collisions and falls into the boards still occur frequently.
Then there are sports like basketball and cheerleading, where concussions are common but less anticipated. In basketball, unprotected falls and incidental elbows or collisions lead to concussions more often than many realize. In cheerleading – especially in competitive stunt environments – falls from height and hard landings make head injuries a serious concern. Almost all concussions among high school cheerleaders are linked to stunts (tosses or lifts), and the majority occur during practice, often when a spotter is not in place during a high-risk stunt.
In other words, even sports without constant contact can have significant head injury risks due to the nature of certain plays or skills.
The Most at-Risk Positions Within Sports
It’s not just the sport that matters, but the position an athlete plays. Within a single team, some positions are simply exposed to more frequent or more forceful head impacts than others. In football, for example, linemen experience sub-concussive impacts on nearly every play; each snap of the ball involves helmet-to-helmet contact in the trenches. These hits are often lower in magnitude than the highlight-reel tackles, but they happen hundreds of times and accumulate over a season.
Research indicates that linemen can sustain hundreds or even thousands of sub-concussive head impacts in a season. These aren't classified as concussions but still involve force to the brain. Their long-term effects remain under study. Skill positions like receivers and defensive backs experience fewer hits, but the impacts are often high-speed and high-force, increasing the risk of concussion.
Quarterbacks and wide receivers are also at risk for those big blind-side hits with rotational force that can be particularly concussive.
In soccer, concussion risk can vary by position, but the patterns are not universally agreed on in the research. Some studies suggest defenders may sustain concussions more often than other positions, possibly because of frequent physical contact and aerial challenges in defense. In youth female soccer, goalkeepers have been found to represent a higher proportion of concussions relative to their roster size compared with field players.
These findings point to position‑related differences in how concussions occur, but more research is needed to fully understand why certain roles may be more vulnerable in different populations and levels of play.
In sports like lacrosse and hockey, concussion risk varies by position. Midfielders in boys’ lacrosse, constantly in motion and contact, account for the majority of concussions.
These patterns mean concussion monitoring shouldn’t be uniform. High-risk positions (like football linemen, soccer goalkeepers, or hockey forwards) may need more frequent check-ins or tailored assessments, especially after high-contact play.
Where Protocols and Perception Still Diverge
Although many people think there’s a clear “impact threshold” that causes a concussion, research shows that this threshold varies widely between individuals. Studies in concussion biomechanics have found no consistent force level that causes a concussion in every athlete, and substantial variability exists in how different brains respond to the same head acceleration. Some athletes may show symptoms after lower‑magnitude impacts while others tolerate higher forces without immediate signs of injury. This individual variability means impacts that seem modest for one athlete could still result in a concussion for another. Continued research is needed to better understand these differences and improve how risk is assessed and managed in sports.
Most concussions don’t come with dramatic symptoms. Waiting for a player to collapse or black out means most will be missed. In high-risk sports, subtle signs demand objective tools—like reaction time, balance, or cognitive tests, ideally compared to a baseline—to catch what the eye can’t see.
Culture matters too. Athletes shouldn’t assume they’re fine just because they can keep playing. “When in doubt, sit them out” should guide every program. Coaches, officials, and staff must feel empowered to pull a player any time head trauma is suspected—regardless of the game’s stakes.
Concussion safety isn’t just about the sport. It’s about systems: knowing the risks, using the right tools, and acting early to protect athletes for the long haul.
Head Injuries in Sports: More Than Just Concussions
“Head injury” and “concussion” are often used interchangeably, but not all head impacts meet concussion criteria—and not all concussions come from obvious trauma. A hard fall that leaves an athlete briefly dizzy might not qualify as a concussion but still signals brain stress that needs monitoring.
Athletes may also appear “fine” after a hit but show delayed symptoms later. That’s why protocols must go beyond initial sideline checks. Every head impact that raises concern should trigger immediate removal, serial evaluations, and continued monitoring.
Severe head injuries like skull fractures or second impact syndrome are rare but dangerous. Red flags—worsening headache, vomiting, slurred speech, or personality changes—require urgent medical evaluation.
Thankfully, such outcomes are uncommon in organized sports. Still, the safest path is clear: when something seems off, remove the athlete and refer for further care. The risk of missing a serious injury is too high to gamble.
Risk Factors and Vulnerable Populations Concussion risk isn’t the same for every athlete. Factors like age, gender, position, and history of head injury all play a role—and understanding these helps teams make smarter decisions around screening, recovery, and education.
Age: Younger athletes are more likely to get concussions and take longer to recover. A 17-year-old’s brain is still developing, making symptoms more diffuse, like fatigue or irritability, and recovery more complex. High school athletes often need both return-to-learn and return-to-play plans, and decisions should be more conservative compared to older athletes.
Gender: Female athletes report more concussions than males in comparable sports like soccer or basketball. This may reflect a greater willingness to report symptoms, not necessarily a higher injury rate. Either way, it highlights the need for all athletes to be honest, and for staff to stay alert across the board.
Position: Within a sport, some roles carry more risk. In football, linebackers and running backs experience most concussions on defense and offense. These positions deserve closer monitoring and possibly more frequent evaluations.
History of Concussions: The strongest predictor of future concussion is having had one before. Prior concussions increase the risk of repeat injuries and can lengthen recovery time. Athletes with multiple concussions or prolonged symptoms should be managed cautiously, often with input from a specialist.
Concussions aren’t always preventable, but knowing who’s most vulnerable allows for faster responses and safer outcomes. Many programs now track concussion history for each athlete to help guide more cautious management over time.
Which Sports Have the Highest Concussion Risk? While concussions can happen in any sport, contact and collision sports carry the highest risk. Football leads at both high school and college levels due to frequent, high-force impacts. Other high-risk sports include wrestling, men’s lacrosse, and men’s ice hockey, where collisions, falls, and equipment contact are common.
Some “non-contact” sports also see high rates. Girls' basketball ranks in the top 10 for youth concussions, largely due to falls and player collisions. In cheerleading, stunts pose the main risk, especially when athletes fall from height.
The takeaway: concussions aren’t just a football issue. All programs should align their resources, protocols, and assessment tools based on sport-specific risk levels.
Symptoms and Diagnosis
Concussions don’t always show up right away, which makes diagnosis reliant on athlete honesty and consistent sideline evaluation. Symptoms vary but commonly include headache, dizziness, confusion, emotional shifts, and sleep issues. Some athletes just report feeling “off” or “foggy.” Tools like the SCAT6 help standardize evaluations, while technology (like neurocognitive or balance tests) can detect subtle changes, especially when baseline data is available. Regardless of game context, every suspected concussion should trigger a full assessment—no shortcuts.
The Importance of Immediate Management
The first priority after a suspected concussion is immediate removal from play, no exceptions. Continuing to play increases the risk of a more serious injury, especially with a second impact. Early removal leads to better outcomes and is supported by the 2022 Amsterdam Consensus. Initial care includes 24–48 hours of relative rest (avoiding intense physical or cognitive activity), followed by gradual reintroduction of light activity if tolerated. Clear communication with coaches, parents, and school staff is critical, as is setting athlete and parent expectations early. A clear plan not only protects physical recovery but also helps reduce stress and promotes honest symptom reporting.
Tracking and Reporting Concussion Stats
Consistent concussion tracking is essential for athlete safety and program improvement. Every suspected or confirmed case should be documented with key details like date, symptoms, and return-to-play clearance. This data helps athletic trainers spot patterns and monitor at-risk athletes, while athletic directors can use it to justify resources, demonstrate compliance, and guide prevention strategies. Digital tools, such as EMR systems or the NCAA Injury Surveillance Program, streamline this process and can flag concerns automatically. In the end, tracking isn’t about paperwork, it’s about making smarter, safer decisions backed by real data.
Recovery and Return to Play
Concussion recovery is a gradual process, not a set timeline. Athletes must be symptom-free at rest and back to normal daily routines, like school, before starting a return-to-play (RTP) progression. The 2022 Amsterdam Consensus outlines six steps, each lasting at least 24 hours, with no advancement unless the athlete remains symptom-free. If symptoms return, the athlete should rest and return to the last tolerable stage. Return-to-learn (RTL) often comes first, with academic support like reduced workload or breaks during class. Objective tools, like balance or cognitive tests, can aid decision-making, but clinical judgment and patience are key. Rushing recovery risks long-term setbacks, so athletes should only return when fully cleared both functionally and symptomatically.
Stepwise Return-to-Play Progression:
Stage 1: Symptom-limited activity (daily tasks)
Stage 2: Light aerobic exercise (e.g., short bike ride)
Stage 3: Sport-specific drills (no contact)
Stage 4: Non-contact training (intensity + coordination)
Stage 5: Full-contact practice (after medical clearance)
Stage 6: Return to competition
Throughout the recovery, tools that track the athlete’s reaction time, balance, or cognitive function (especially in comparison to baseline tests done pre-season) can help inform decisions. For instance, if an athlete’s balance is still significantly worse than their baseline, that might indicate the brain hasn’t fully recovered even if they feel okay, so you might hold them at a stage longer.
Barriers to Better Concussion Care
Barriers to Better Concussion Care Many programs know what to do, but real-world constraints often get in the way. Only about 66% of U.S. high schools have access to a certified athletic trainer, leaving many athletes without expert care. Time, budget limits, and cultural attitudes—like downplaying symptoms or pressure to play—can all interfere with proper management. Concussions are also invisible, making them easier to dismiss without objective tools or strong protocols in place.
Top Barriers:
Limited staffing and funding
“Play through it” mentality from coaches, athletes, or parents
Lack of objective tools or protocols
Doubts about symptoms due to invisibility of injury
The solution isn’t always high-tech, it’s leadership. Clear rules, consistent tracking, and support from athletic directors and coaches create a culture where safety isn’t optional.
How Athletic Trainers and Directors Can Lead the Way
Athletic trainers are often the first to spot concussion signs, using their clinical skill and close athlete relationships to identify subtle red flags. But their effectiveness depends on strong institutional support. Athletic directors play a key role by setting clear policies, allocating resources, and backing medical decisions, especially when pressure mounts from coaches or parents. When ADs prioritize education, enforce protocol, and publicly support athletic trainers, it sets the tone for a safety-first culture. Together, ATs and ADs form the foundation of effective concussion leadership on the field and at the program level.
Reviewed by Kim Wyand, PT, DPT
Director of Customer Experience, Sway Medical
Dr. Kim Wyand is a licensed physical therapist and concussion education specialist with more than a decade of experience in outpatient orthopedic and neurological rehabilitation. On top of leading the customer experience team, Kim works closely with Sway's research team, ensuring the platform remains grounded in research and consistently aligned with evidence-based best practices. She leads the development of tools and resources that support over 13,000 clinicians and athletic programs in delivering high-quality concussion care.
