Diplopia After a Concussion: What It Is and How to Treat It
Visual disturbances are common following a concussion, but one of the most functionally disruptive symptoms—often underestimated in its impact—is diplopia, or double vision. For athletic trainers, physical therapists, and sports medicine professionals, recognizing and treating this symptom is vital for both short-term recovery and long-term athlete safety.
Understanding Diplopia After Concussion
Diplopia refers to the perception of two images of a single object, and it can present horizontally, vertically, or diagonally. In the post-concussion context, it typically stems from oculomotor dysfunction—disruption in the way the brain coordinates eye movement. While mild traumatic brain injury (mTBI) often resolves spontaneously, visual deficits, including diplopia, can linger and significantly impair performance in academic, athletic, and everyday settings.
The decision for referral to a neuro-optometrist should be based on a comprehensive and individualized concussion evaluation, with targeted interventions such as prism lenses or eye movement therapy considered when clinically indicated (JAMA Ophthalmology, 2024). The decision for referral to a neuro-optometrist should be based on a comprehensive and individualized concussion evaluation.
Mechanisms Behind Post-Traumatic Diplopia
Diplopia after a concussion may arise from several distinct but often overlapping mechanisms:
Central Processing Deficits: The brain's ability to integrate visual input from both eyes may be compromised, even if the eyes themselves move normally. This can affect vergence, accommodation, and tracking.
Disruption of Cranial Nerve Function: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control eye movement. Concussive forces can stretch or compress these nerves, leading to misalignment of the eyes.
Structural issues such as CSF flow disruption are rare but may contribute to persistent diplopia in complex cases. These are typically identified through neuroimaging when red flag symptoms prompt emergency evaluation.(Cureus, 2024)
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Athletes may describe symptoms such as double or overlapping images (“ghosting”), visual fatigue, headaches with reading, or difficulty tracking fast-moving objects. Diplopia can appear in specific gaze directions, or it may occur consistently across all fields of vision. Red flags requiring urgent referral include:
Sudden onset of persistent diplopia
Diplopia accompanied by drooping eyelids (ptosis)
Associated nausea, vomiting, or neurological deficits
In these cases, clinicians should consider neuroimaging and specialist referral to rule out structural or cranial nerve injuries.
Evidence-Based Treatment Strategies
Treatment for post-concussive diplopia is rarely one-size-fits-all. Interventions need to be tailored to the specific cause and severity of the dysfunction, and often require interdisciplinary collaboration.
1. Neuro-Optometric Rehabilitation
A growing body of research supports neuro-optometric therapy as a cornerstone for managing visual dysfunction post-TBI. This can be incorporated into physical therapy interventions, as well as at specific vision therapy centers. Examples of vision therapy may include:
Vergence and saccadic training to enhance binocular coordination.
Oculomotor exercises are designed to improve gaze stability, convergence, and smooth pursuit.
Prism lenses to correct misalignment and provide temporary relief from double vision.
These treatments can be prescribed by concussion-trained healthcare professionals, including neuro-optometrists and neuro-ophthalmologists, and may be integrated into a physical therapist’s vestibular rehabilitation program. The JAMA study referenced earlier notes significant improvement in symptom burden and functional capacity when such therapies are initiated early.
2. Manual Therapy and Cervical-Ocular Connections
Cervical manual therapy can play a supportive role in addressing visual symptoms following a concussion, particularly when neck dysfunction contributes to oculomotor disturbances. The cervical spine and visual system share neural pathways that coordinate head and eye movement. When cervical joints or soft tissues are impaired—often due to whiplash or biomechanical strain—it can disrupt proprioceptive input, leading to visual instability, dizziness, and symptoms like diplopia.
Manual interventions such as soft tissue mobilization, joint manipulation, and targeted stretching can help restore cervical alignment and sensorimotor function, which may in turn support oculomotor rehabilitation efforts.
3. Vestibular Integration and Multisensory Rehabilitation
In many athletes, diplopia does not exist in isolation but as part of a broader constellation of vestibular and cognitive symptoms. Rehabilitation should address:
Visual-vestibular mismatch—where visual input conflicts with inner ear signals, leading to dizziness or imbalance.
Dynamic visual acuity training, which challenges the athlete to maintain visual focus during head movement.
Balance retraining under varied visual conditions, including reduced lighting and head turns.
This multisensory approach is particularly important for return-to-play readiness, as it simulates the complex demands of dynamic environments.
Real-World Implications for Athletic Professionals
For athletic trainers and physical therapists working in school and collegiate settings, diplopia can dramatically alter an athlete’s academic and sports performance. A simulation study published in AJSLP used diplopia-mimicking goggles to train graduate students in TBI awareness. The study underscored how visually-induced confusion, cognitive fatigue, and frustration affect everyday functioning—even in a simulated environment (AJSLP, 2024).
Athletes with visual dysfunction may appear disengaged, slow to respond, or reluctant to participate, often leading to misinterpretation as lack of effort or emotional distress. Understanding the neurological underpinnings of these behaviors is essential for fostering support rather than judgment.
Return-to-Play Considerations
According to the 2022 Consensus Statement on Concussion in Sport (Amsterdam), vision symptoms must be fully resolved before progressing to sport-specific drills. Persistent diplopia warrants a more conservative timeline, with close monitoring of balance, visual focus, and symptom provocation during exertion.
A collaborative approach between neuro-optometry, vestibular rehabilitation specialists, and the athlete's care team is essential for safe and effective return-to-play. Rushing recovery can result in re-injury or chronic symptoms that derail academic and athletic goals.
Looking Forward: A Multidisciplinary Imperative
Diplopia after concussion is not just a visual inconvenience—it’s a clinical sign of disrupted neural function that deserves careful evaluation and a customized treatment plan. With increasing research pointing to the benefits of early vision therapy, targeted rehabilitation, and emerging treatments like FSN, healthcare professionals are better equipped than ever to guide athletes toward full recovery.
As physical therapists and athletic professionals, staying current with these evidence-based interventions is not just a matter of clinical competency—it’s a commitment to athlete safety, long-term health, and performance readiness.
For professionals seeking further education or integration of vision care into concussion protocols, consider collaborating with neuro-optometry specialists and exploring interdisciplinary case reviews. For athletes with unresolved visual symptoms post-concussion, early intervention remains the most effective tool for recovery.
