Introduction
In the world of sports, concussions have become a major topic of discussion. With more people participating in athletic activities than ever before, the number of reported concussions has risen substantially. While part of this increase can be attributed to greater awareness and improved recognition, there’s more to the story than media attention and research alone.
It’s often puzzling how one athlete can return to play within a week of a concussion, while another may take several weeks or longer to recover. Why is that? Is it due to differences in medical clearance, symptom presentation, or perhaps the nature of the concussion itself? The truth is that no two concussions are exactly alike, much like snowflakes, each one affects the individual differently. Let’s dive right in.
Pathophysiology of Concussion
What ultimately causes a concussion? It is the increase in acceleration and deceleration of the head and neck that essentially causes the brain to shake. Why is this so important? Well, our nice squishy brain resides in a skull that contains bony prominences and rigids. And our brain doesn’t like it when it forcefully slams into the skull. The rapid movement then triggers a complex sequence of events including neurometabolic and neurochemical changes. These changes can result in decreased blood flow to the brain thus decreasing function or permanent damage to the brain depending on the severity.
The Vestibular Component
A concussion doesn’t just cause mechanical and metabolic implications, affecting strength and conditioning, it can also involve the vestibular system. This system plays a huge role in balance, spatial awareness, eye movement, and how we sense motion. When it’s disrupted, athletes often notice symptoms like dizziness, vertigo, blurred vision, poor balance, motion sensitivity, or trouble focusing and concentrating. The vestibular system works closely with the eyes and inner ear, so even a mild concussion can interfere with how the brain processes movement and space. That is why athletes may feel unsteady, struggle to track moving objects, or feel nauseous when they move their head. If vestibular issues are not addressed, recovery can take longer than expected and performance can suffer. Rehabilitation often includes vestibular therapy to help retrain balance, improve gaze stability, and restore coordination. Addressing these deficits early helps calm lingering symptoms and supports a safer, more complete return to sport.
How do we assess concussions?
The NCAA uses Sport Concussion Assessment Tool (SCAT) 6 to indicate whether an athlete has sustained a concussion. This tool is not a diagnostic tool but can indicate red or yellow flags that strongly suggest the presence of a concussion. The SCAT assesses the following areas:
On field/court assessment:
– Observable Signs
– Glasgow Coma Scale
– Cervical Spine Assessment
– Coordination/Oculomotor Screening
– Memory Assessment
Off field/court assessment:
– Athlete background
– Symptom evaluation
– Cognitive screening
– Coordination/balance exam
– Delayed Recall
Understanding the Cervical Spine
The upper part of the spine, called the cervical spine, allows the neck to move forward and backward, side to side, and to rotate left and right. Because of the natural curve of the neck, muscles in the front generally help bring the head forward, while muscles in the back help lift the head up and back, especially in the lower cervical spine.
As you move higher toward the top of the neck, muscle function becomes more position dependent and specific to each joint level. Changes in joint orientation and how the head moves over the spine mean that many muscles play a greater role in fine control and stability rather than pure movement. This is why motion near the upper cervical spine often feels different and why the image below helps illustrate how these mechanics change.
The neck also moves through three main planes of motion. Turning your head left and right occurs in the transverse plane. Side bending happens in the frontal plane. Nodding your head up and down occurs in the sagittal plane. While the neck is capable of moving well in all directions, many athletes tend to rely more heavily on one plane than others without realizing it.
Strength and control imbalances can also play a role in concussion risk. The muscles at the back of the neck that help extend the head are often stronger than the muscles in the front that control flexion. In addition, the smaller muscles that help rotate and stabilize the head are commonly undertrained. When these imbalances exist, the neck is less able to absorb and manage the forces created during contact or rapid head movements, which can increase the risk of concussion and slow recovery.
Return to Sport Progressions
So what does a return to sport actually look like once symptoms have settled? A variety of symptoms are assessed throughout recovery, many of which are outlined in the image below. Before an athlete can begin the return to sport process, they must be completely symptom free for at least 24 hours.
Once all their symptoms have dissipated they start the following process:
– Light intensity activity
o Ex. 10 minutes on a stationary bike
– Moderate intensity activity
o Ex. 10 minutes on a stationary bike, 10 minutes of jogging
– High intensity activity
o Ex. 10 minutes, 10 minutes of jogging, light plyos and sprints
– Return to practice non-contact
o Ex. Sport specific practice/ drills
– Return to practice with contact (normal practice)
o ex. A football player would be cleared for tackling
– Full competition ex. Back to games
If symptoms return at any point during this process, the athlete must stop, allow symptoms to fully resolve for at least 24 hours, and then restart the return to sport progression.
Understanding Concussion Differences Among Athletes
You may wonder why one football player can take a hard hit and return to play within a week or two, while another takes much longer to recover. It might seem like the difference comes down to how hard they were hit, but the amount of force alone doesn’t tell the whole story. Even two players who experience similar impacts can have very different outcomes. What then really determines who sustains a concussion and who doesn’t? How can one athlete walk away from a tough tackle without symptoms while another develops a concussion?
That difference comes from a combination of impact factors, individual physiology, and context around the injury. Below is a clear breakdown that explains why recovery can be quick for one athlete and prolonged for another.
1. Force and Mechanics of the Impact
Not all hits affect the brain the same way.
- Direction of force matters. Rotational or twisting forces tend to disrupt the brain more than straight line impacts.
- Speed and acceleration of the head often matter more than the size of the hit.
- Unexpected impacts are usually worse because the neck cannot brace or absorb force effectively.
- Location of impact can influence how forces travel through the brain.
Two athletes can take hits of similar intensity, but different mechanics can produce very different neurological effects.
2. Neck Strength and Motor Control
Neck strength and motor control play a major role in how much force reaches the brain.
- Stronger and better coordinated neck muscles help slow head acceleration.
- Poor neck strength or delayed muscle activation allows greater head movement.
- Imbalances between flexors, extensors, and stabilizers can increase vulnerability.
This is one reason smaller or less prepared athletes can experience more severe symptoms from the same contact. But by improving neck strength and stability, athletes can take one more proactive step toward protecting themselves and reducing their risk when contact happens.
3. Individual Brain and Nervous System Differences
Every brain responds differently to trauma.
- Baseline nervous system sensitivity varies.
- Differences in cerebral blood flow regulation and metabolism affect recovery.
- Some athletes have nervous systems that are more reactive to stress or injury.
This explains why one athlete feels foggy for days while another feels normal within hours.
4. History of Previous Concussions
Prior injuries matter a lot.
- Previous concussions can lower the threshold for future symptoms.
- Recovery often takes longer with each additional concussion.
- Incomplete recovery from a prior injury increases risk of prolonged symptoms.
Even a mild hit can feel severe if the brain has not fully recovered from past trauma.
5. Age, Sex, and Hormonal Factors
Biology influences concussion response.
- Younger athletes often recover more slowly.
- Hormonal fluctuations can influence symptom severity and duration.
- Structural differences in neck strength and head mass may play a role.
These factors help explain why concussion timelines are not one size fits all.
6. Vestibular and Visual System Involvement
When balance and vision systems are affected, symptoms often feel worse.
- Vestibular involvement increases dizziness, nausea, and motion sensitivity.
- Visual deficits affect focus, reading, and screen tolerance.
- Combined involvement tends to slow recovery if not treated early.
Athletes with these deficits often struggle even after other symptoms improve.
7. Cognitive, Emotional, and Psychological Load
The brain does not heal in isolation.
- High academic or work demands increase symptom burden.
- Stress, anxiety, and poor sleep worsen recovery.
- Fear of reinjury can heighten symptom awareness.
Two athletes with identical injuries may recover differently based on lifestyle and stress exposure.
8. Timing and Quality of Early Management
What happens in the first days matters.
- Continuing to play worsens severity.
- Delayed diagnosis increases recovery time.
- Lack of guided rehabilitation can allow symptoms to linger.
Early, individualized care often leads to faster and more complete recovery.
So, how can the The Charlotte Athlete help?
At The Charlotte Athlete, our sports physical therapists perform comprehensive assessments to identify concussion-specific risk factors, joint dysfunctions, muscular imbalances, vestibular dysfunctions, and root cause risk factors. By combining neck strengthening, manual therapy, vestibular therapy, individualized education, and individualized return-to-sport programs, we help athletes recover fully and return to play safely. While concussions can never be completely prevented, the right proactive care can make all the difference in recovery and long-term brain health. Have you suffered a sports concussion and not sure what to do? Take the next step and schedule a call. We can help!
Thanks for reading,
The Charlotte Athlete