Sport‐Related Traumatic Brain Injury


Sport‐related traumatic brain injury (SRTBI) is a disease process with a high incidence, complex pathophysiology and heterogeneous outcomes. SRTBI is generally dichotomised into sport‐related concussion (SRC) and sport‐related structural brain injury (SRSBI). A variety of sporting events can lead to these injuries. The diagnosis of SRC relies on sound clinical judgment, although multiple adjuncts have been investigated. Prompt diagnosis is essential for the management of all SRTBI, and it is critical to differentiate SRC from a potential SRSBI. Depending on the specific SRTBI, a variety of treatment options are available ranging from conservative rehabilitation to, rarely, prompt neurosurgical intervention. Finally, clinical outcomes are inherently linked to the nature of the injury and vary from full recovery to patient death. Given the high incidence, importance of prompt diagnosis and heterogeneous outcomes, SRTBI is an essential topic not only for clinicians and researchers but also for athletes, parents, coaching staff and officials.

Key Concepts

  • Sport‐related concussion (SRC) has a high incidence and is largely differentiated from other SRTBI by negative neuroimaging.
  • Sport‐related structural brain injury has positive neuroimaging and is typically diagnosed with a noncontrast computed tomography (CT) scan of the head.
  • Second‐impact syndrome is exceedingly rare, but the associated high risk of morbidity remains a relevant driving force for SRC management.
  • Diagnosis of SRC remains clinical with sideline tools as adjuncts including but not limited to SCAT5, King‐Devick, and Sway. Clinical judgment and evaluation supersede all concussion assessment tools.
  • Recovery from SRC usually occurs within 14–28 days, and no focal neurologic deficit is expected.
  • Post‐concussive syndrome is commonly defined as the presence of concussive symptomatology for greater than 4 weeks.
  • The outcome of SRSBI is highly variable and dependent on the nature of the intracranial injury.

Keywords: sport‐related traumatic brain injury (SRTBI); sport‐related concussion (SRC); sport‐related structural brain injury (SRSBI); second‐impact syndrome (SIS)


Boden BP, Tacchetti RL, Cantu RC, Knowles SB and Mueller FO (2007) Catastrophic head injuries in high school and college football players. The American Journal of Sports Medicine 35: 1075–1081.

Boden BP, Breit I, Beachler JA, Williams A and Mueller FO (2013) Fatalities in high school and college football players. The American Journal of Sports Medicine 41: 1108–1116.

Breedlove EL, Robinson M, Talavage TM, et al. (2012) Biomechanical correlates of symptomatic and asymptomatic neurophysiological impairment in high school football. Journal of Biomechanics 45: 1265–1272.

Brett BL, Zuckerman SL, Terry DP, Solomon GS and Iverson GL (2018) Normative data for the sway balance system. Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine. [published online ahead of print, 2018 Aug 15]. DOI: 10.1097/JSM.0000000000000632.

Bretzin AC, Covassin T, Fox ME, et al. (2018) Sex differences in the clinical incidence of concussions, missed school days, and time loss in high school student‐athletes: part 1. The American Journal of Sports Medicine 46: 2263–2269.

Brown DA and Wijdicks EFM (2017) Decompressive craniectomy in acute brain injury. In: Wijdicks EFM and Kramer AH (eds) Handbook of Clinical Neurology, vol. 140, pp 299–318. Elsevier.

Cantu RC and Mueller FO (2003) Brain injury‐related fatalities in american football, 1945–1999. Neurosurgery 52: 846–853.

Cantu RC and Gean AD (2010) Second‐impact syndrome and a small subdural hematoma: an uncommon catastrophic result of repetitive head injury with a characteristic imaging appearance. Journal of Neurotrauma 27: 1557–1564.

Cantu RC. (2018) Catastrophic Sports Injury Research. Available at:‐Catastrophic‐Report‐AS‐36th‐AY2017‐2018‐FINAL.pdf [Accessed July 25, 2019].

Cardenache R. (2009) The Relationship Between the Glasgow Coma Scale and the Functional Independence Measure in a Sample of Traumatic Brain Injury Patients in a Neurorehabilitation Setting. Doctor of Psychology thesis, University of Miami.

Choe MC (2016) The pathophysiology of concussion. Current Pain and Headache Reports 20: 42.

Daneshvar DH, Nowinski CJ, McKee AC and Cantu RC (2011) The epidemiology of sport‐related concussion. Clinics in Sports Medicine 30: 1–vii.

Davis GA, Makdissi M, Bloomfield P, et al. (2019) International consensus definitions of video signs of concussion in professional sports. British Journal of Sports Medicine 53: 1264–1267.

Ellis MJ, Ritchie LJ, Koltek M, et al. (2015) Psychiatric outcomes after pediatric sports‐related concussion. Journal of Neurosurgery Pediatrics 16: 709–718.

Forbes JA, Zuckerman S, Abla AA, et al. (2014) Biomechanics of subdural hemorrhage in American football: review of the literature in response to rise in incidence. Child's Nervous System 30: 197–203.

Giza CC and Hovda DA (2014) The new neurometabolic cascade of concussion. Neurosurgery 75: S24–S33.

Halstead ME, Walter KD and Moffatt K (2018) Sport‐related concussion in children and adolescents. Pediatrics 142.

Hattrup N, Gray H, Krumholtz M and Valovich McLeod TC (2019) Early controlled exercise and timing of treatment following concussion: a critically appraised topic. Journal of Sport Rehabilitation: 1–7.

Henry LC, Elbin RJ, Collins MW, Marchetti G and Kontos AP (2016) Examining recovery trajectories after sport‐related concussion with a multimodal clinical assessment approach. Neurosurgery 78: 232–241.

Iverson GL, Gardner AJ, Terry DP, et al. (2017) Predictors of clinical recovery from concussion: a systematic review. British Journal of Sports Medicine 51: 941–948.

Iverson GL (2019) Network analysis and precision rehabilitation for the post‐concussion syndrome. Frontiers in Neurology 10: 489.

Kamins J, Bigler E, Covassin T, et al. (2017) What is the physiological time to recovery after concussion? A systematic review. British Journal of Sports Medicine 51: 935–940.

Kim AK, Moonis G and Loevner LA (2011) Brain: anatomy, trauma, and tumors. In: Pretorius ES and Solomon JA (eds) Radiology Secrets Plus, 3rd edn. Mosby/Elsevier: Philadelphia, PA.

King D, Brughelli M, Hume P and Gissane C (2014) Assessment, management and knowledge of sport‐related concussion: systematic review. Sports Medicine 44: 449–471.

Kovacs G and Sowers N (2018) Airway management in trauma. Emergency Medicine Clinics of North America 36 (1): 61–84.

Laker SR (2015) Sports‐related concussion. Current Pain and Headache Reports 19: 41.

Leddy JJ, Haider MN, Ellis MJ, et al. (2019) Early subthreshold aerobic exercise for sport‐related concussion: a randomized clinical trialearly subthreshold aerobic exercise for sport‐related concussion–a randomized clinical trialearly subthreshold aerobic exercise for sport‐related concussion–a randomized clinical trial. JAMA Pediatrics 173: 319–325.

Legarreta AD, Brett BL, Solomon GS and Zuckerman SL (2018) The role of family and personal psychiatric history in postconcussion syndrome following sport‐related concussion: a story of compounding risk. Journal of Neurosurgery Pediatrics 22: 238–243.

May T, Foris LA and Donnally IC (2019) Second impact syndrome. In: StatPearls. Treasure Island (FL). StatPearls Publishing, StatPearls Publishing LLC.

McCrea M, Broglio S, McAllister T, et al. (2019) Return to play and risk of repeat concussion in collegiate football players: comparative analysis from the NCAA concussion study (1999–2001) and CARE consortium (2014–2017). British Journal of Sports Medicine pii: bjsports‐2019‐100579. DOI: 10.1136/bjsports-2019-100579. [Epub ahead of print] PubMed PMID: 31036562.

McCrory P, Meeuwisse W, Dvorak J, et al. (2017) Consensus statement on concussion in sport‐the 5(th) international conference on concussion in sport held in Berlin. British Journal of Sports Medicine 51: 838–847.

McLendon LA, Kralik SF, Grayson PA and Golomb MR (2016) The controversial second impact syndrome: a review of the literature. Pediatric Neurology 62: 9–17.

Monk SH, Legarreta AD, Kirby P, et al. (2019) Imaging findings after acute sport‐related concussion in American football players: a systematic review. Journal of Clinical Neuroscience : Official Journal of the Neurosurgical Society of Australasia 61: 28–35.

Morgan CD, Zuckerman SL, King LE, et al. (2015a) Post‐concussion syndrome (PCS) in a youth population: defining the diagnostic value and cost‐utility of brain imaging. Child's Nervous System: ChNS: Official Journal of the International Society for Pediatric Neurosurgery 31: 2305–2309.

Morgan CD, Zuckerman SL, Lee YM, et al. (2015b) Predictors of postconcussion syndrome after sports‐related concussion in young athletes: a matched case‐control study. Journal of Neurosurgery Pediatrics 15: 589–598.

Mullally WJ (2017) Concussion. The American Journal of Medicine 130: 885–892.

Mummareddy N, Legarreta AD, Yengo‐Kahn AM, et al. (2019) Sport‐related structural brain injury in high school soccer: epidural hemorrhage after a “header”. World Neurosurgery 127: 20–23.

O'Connor KL, Baker MM, Dalton SL, et al. (2017) Epidemiology of sport‐related concussions in high school athletes: national athletic treatment, injury and outcomes network (NATION), 2011‐2012 through 2013‐2014. Journal of Athletic Training 52: 175–185.

Potts MA, Stewart EW, Griesser MJ, et al. (2012) Exceptional neurologic recovery in a teenage football player after second impact syndrome with a thin subdural hematoma. PM & R : The Journal of Injury, Function, and Rehabilitation 4: 530–532.

Register‐Mihalik JK and Kay MC (2017) The current state of sports concussion. Neurologic Clinics 35: 387–402.

Rose SC, Fischer AN and Heyer GL (2015) How long is too long? The lack of consensus regarding the post‐concussion syndrome diagnosis. Brain Injury 29: 798–803.

Sarmiento K, Thomas KE, Daugherty J, et al. (2019) Emergency department visits for sports‐ and recreation‐related traumatic brain injuries among children–United States, 2010‐2016. MMWR. Morbidity and Mortality Weekly Report 68: 237–242.

Saunders RL and Harbaugh RE (1984) The second impact in catastrophic contact‐sports head trauma. JAMA 252: 538–539.

Sprecher AM (2019) Injury Data. NFL Play Smart, Play Safe, Online. Available at:‐data/. [Accessed July 29, 2019].

Tator C, Starkes J, Dolansky G, et al. (2019) Fatal second impact syndrome in rowan stringer, a 17‐year‐old rugby player. The Canadian Journal of Neurological Sciences 46: 351–354.

Tsai NT, Goodwin JS, Semler ME, et al. (2017) Development of a non‐invasive blink reflexometer. IEEE Journal of Translational Engineering in Health and Medicine 5: 3800204.

Wasserman EB, Kerr ZY, Zuckerman SL and Covassin T (2016) Epidemiology of sports‐related concussions in national collegiate athletic association athletes from 2009‐2010 to 2013‐2014: symptom prevalence, symptom resolution time, and return‐to‐play time. The American Journal of Sports Medicine 44: 226–233.

Winkler EA, Yue JK, Burke JF, et al. (2016) Adult sports‐related traumatic brain injury in United States trauma centers. Neurosurgical Focus 40: E4.

Yang SH and Liu R (2017) Cerebral autoregulation. In: Primer on Cerebrovascular Diseases, 2nd edn, pp 57–60. Academic Press.

Yengo‐Kahn AM, Gardner RM, Kuhn AW, et al. (2017) Sport‐related structural brain injury: 3 cases of subdural hemorrhage in American high school football. World Neurosurgery 106: 1055.e5–1055.e11.

Zemek R, Barrowman N, Freedman SB, et al. (2016) Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the edchildren with acute concussion presenting to the emergency departmentchildren with acute concussion presenting to the emergency department. JAMA 315: 1014–1025.

Zuckerman SL, Kuhn A, Dewan MC, et al. (2012) Structural brain injury in sports‐related concussion. Neurosurgical Focus 33: 1–12.

Zuckerman SL, Kerr ZY, Yengo‐Kahn A, et al. (2015) Epidemiology of sports‐related concussion in NCAA athletes from 2009‐2010 to 2013‐2014: incidence, recurrence, and mechanisms. The American Journal of Sports Medicine 43: 2654–2662.

Zuckerman SL, Yengo‐Kahn AM, Buckley TA, et al. (2016) Predictors of postconcussion syndrome in collegiate student‐athletes. Neurosurgical Focus 40: E13.

Further Reading

Brett BL, Kuhn AW, Yengo‐Kahn AM, Solomon GS and Zuckerman SL (2018) Risk factors associated with sustaining a sport‐related concussion: an initial synthesis study of 12,320 student‐athletes. Archives of Clinical Neuropsychology: The Official Journal of the National Academy of Neuropsychologists 33: 984–992.

Broglio SP, Surma T and Ashton‐Miller JA (2012) High school and collegiate football athlete concussions: a biomechanical review. Annals of Biomedical Engineering 40: 37–46.

Haider MN, Johnson SL, Mannix R, et al. (2019) The Buffalo concussion bike test for concussion assessment in adolescents. Sports Health 11: 492–497.

Legarreta AD, Monk SH, Kirby PW, et al. (2018) Long‐term neuroimaging findings in american football players: systematic review. World Neurosurgery 120: e365–e379.

Narayana S, Charles C, Collins K, et al. (2019) Neuroimaging and neuropsychological studies in sport‐related concussions in adolescents: current state and future directions. Frontiers in Neurology 10: 538.

Post A, Oeur A, Walsh E, Hoshizaki B and Gilchrist MD (2013) A centric/non‐centric impact protocol and finite element model methodology for the evaluation of American football helmets to evaluate risk of concussion. Computer Methods in Biomechanics and Biomedical Engineering.

Rowson S, Duma SM, Beckwith JG, et al. (2012) Rotational head kinematics in football impacts: an injury risk function for concussion. Annals of Biomedical Engineering 40: 1–13.

Yengo‐Kahn AM, Hale AT, Zalneraitis BH, et al. (2016) The sport concussion assessment tool: a systematic review. Neurosurgical Focus 40: E6.

Zuckerman SL, Brett BL, Jeckell AS, Yengo‐Kahn AM and Solomon GS (2018a) Prognostic factors in pediatric sport‐related concussion. Current Neurology and Neuroscience Reports 18: 104.

Zuckerman SL, Brett BL, Jeckell A, Yengo‐Kahn AM and Solomon GS (2018b) Chronic traumatic encephalopathy and neurodegeneration in contact sports and American football. Journal of Alzheimer's disease: JAD 66: 37–55.

Contact Editor close
Submit a note to the editor about this article by filling in the form below.

* Required Field

How to Cite close
Ahluwalia, Ranbir, Mummareddy, Nishit, Bonfield, Christopher M, and Yengo‐Kahn, Aaron M(Feb 2020) Sport‐Related Traumatic Brain Injury. In: eLS. John Wiley & Sons Ltd, Chichester. [doi: 10.1002/9780470015902.a0025799]