Condition

Sport-Related Concussion

Editors: Pierre Rouzier MD; Zbigniew Fedorowicz PhD, MSc, DPH, BDS, LDSRCS; Alexander Rae-Grant MD, FRCPC, FAAN

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Background Information

Description

  • Sport-related concussion is a type of traumatic brain injury (TBI) encountered in sports that occurs when impulsive force to the head or body is transmitted to the brain, leading to a neurobiological alteration of brain function and rapid onset of neurological impairment that usually resolves within several weeks.
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Epidemiology

Who Is Most Affected

  • Athletes who participate in full-contact sports, such as:
    • Boxing
    • Martial arts
    • American football
    • Ice hockey
    • Rugby
    • Australian rules football
    • Reference - J Funct Morphol Kinesiol 2019 Jun 19;4(2)
  • Athletes who participate in equestrian sports, such as horse racing, are also commonly affected. (J Funct Morphol Kinesiol 2019 Jun 19;4(2))
  • Children and adolescents are commonly affected, due to the large number of participants in youth and high school sports.
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Incidence/Prevalence

  • The reported annual incidence of sport-related mild traumatic brain injury (TBI) in the United States is:
    • 1.6-3.8 million across all ages.
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    • 1.1-1.9 million in children and adolescents < 18 years old.
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  • The reported incidence of sport-related concussion is increasing.
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    • This increase is likely a result of improved reporting and diagnosis due to increased medical, coaching, and lay public education, and increased media exposure.
    • The increase is also possibly also due to increased opportunities for sport participation in children, and increasing size, strength, and speed of young athletes.
  • However, it may still be underestimated due to under reporting. Possible causes of under reporting include:
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    • Athletes attempting to hide their injury to avoid removal from play.
    • Athletes reporting fear of approaching their coach about injury.
    • Lack of recognition by coaches, athletes, and parents.
  • STUDY SUMMARY
    highest incidence of sport-related concussion among collegiate athletes between 2014 and 2019 in the United States occurred in men's ice hockey and women's soccer
    COHORT STUDY: Am J Sports Med 2022 Feb;50(2):526

  • STUDY SUMMARY
    rugby, hockey, and American football have highest incidence of sport-related concussion among children and adolescents
    SYSTEMATIC REVIEW: Br J Sports Med 2016 Mar;50(5):292

  • STUDY SUMMARY
    about 15% of emergency department visits for traumatic brain injury in children and adolescents associated with sports
    COHORT STUDY: Pediatrics 2013 Oct;132(4):e859

  • STUDY SUMMARY
    70% of concussions were sports related (proportion varied by age) in patients aged 0-17 years
    COHORT STUDY: J Pediatr 2018 Jun;197:241

Risk Factors

  • While high-contact sports such as American tackle football and ice hockey have the highest reported risks of sport-related concussion, concussion is a risk with any sport. Among women's sports, soccer may have the highest risk.
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    ,
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  • In American collegiate football, concussion risk may be greater among linebackers, offensive linemen, and defensive backs as compared to receivers.
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  • In comparable sports commonly played by all genders, such as basketball and soccer, girls may have a higher concussion risk compared to boys (but female athletes may also report symptoms more frequently than male athletes).
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  • Athlete specific factors may increase the risk of concussion, such as:
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    • Body mass index > 27 kg/m2
    • Training time < 3 hours weekly
    • Prior history of concussion, especially within 10 days
  • The risk may be several times higher during competitions compared to practices. (Also see a recent evidence summary reporting an incidence rate ratio of 4.12 for incidence during competition compared to practice.)
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  • STUDY SUMMARY
    male sex, Black race, and history of prior sport-related concussion, learning disorders, and headache disorders associated with increased likelihood of sport-related concussion in university student athletes in the United States
    COHORT STUDY: Sports Med 2023 Jul;53(7):1457

Associated Conditions

  • Sport-related concussion may be associated with other sport-related injuries, including:
    2
    • Musculoskeletal injuries
    • Cervical spine injury
    • Skull fracture
    • Intracranial hemorrhage

Etiology and Pathogenesis

  • A sport-related concussion is a traumatic brain injury due to a direct blow to the head, neck, or body during sports and exercise-related activities.
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  • Concussions may be induced by acceleration, deceleration, and/or rotation of the head, or may be induced by a blow elsewhere on body with secondary force transmitted to the head.
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  • Concussions are not associated with abnormalities on structural neuroimaging studies, suggesting that the pathogenesis of symptoms is a functional or microscopic disturbance rather than a macroscopic structural injury.
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  • The force from the concussive impact transferring to the cerebral tissue triggers a complex neurotransmitter and metabolic cascade that alters cerebral cell functions and homeostasis, and may also cause axonal injury, blood flow change, and inflammation.
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  • The molecular changes from concussion usually persist long after clinical symptoms disappear and neuropsychological tests return to baseline (J Funct Morphol Kinesiol 2019 Jun 19;4(2)).
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1Level 1 (likely reliable) Evidence
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There are two types of conclusions which can earn a Level 1 label: levels of evidence for conclusions derived from individual studies and levels of evidence for conclusions regarding a body of evidence.
2Level 2 (mid-level) Evidence
Representing research results addressing clinical outcomes, and using some method of scientific investigation, but not meeting the quality criteria to achieve Level 1 evidence labeling.
3Level 3 (lacking direct) Evidence
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