12.1 Acute Athletic Injury Assessment and On-Field Management

Acute Athletic Injury Assessment and On-Field Management

An athlete who collapses or stays down after an impact needs an immediate check for threats to life or limb. A routine sideline examination begins once those threats have been addressed. The mechanism and the initial findings determine whether to activate emergency care, remove the athlete for assessment or begin a local musculoskeletal examination.

On-Field Primary Survey

Check scene safety and responsiveness. For an unresponsive athlete, activate the venue emergency action plan, call emergency medical services (EMS) and have someone bring an automated external defibrillator (AED). A trained responder checks breathing and pulse together for no more than 10 seconds. If the athlete is not breathing normally and no pulse is definitely felt, begin cardiopulmonary resuscitation (CPR) and use the AED as soon as it arrives. Gasping is abnormal breathing. If there is a pulse but breathing is absent or abnormal, provide ventilatory support as trained.

In trauma, the ABCDE survey organizes assessment and treatment of immediate problems. Treat each threat when identified and reassess. For example, control obvious catastrophic external bleeding immediately while the team assesses airway and breathing. Follow the cardiac arrest algorithm when its criteria are met.

1. A — Airway with cervical spine protection. Assess airway patency. After significant head or neck trauma, minimize cervical motion and provide manual in-line stabilization when feasible. Do not force the neck into position or delay airway access, ventilation or CPR to manage the spine.
2. B — Breathing. Assess breathing rate and effort, chest movement and adequacy of ventilation. Respiratory distress after a chest impact requires urgent evaluation and support.
3. C — Circulation. Assess perfusion and look for bleeding. Apply direct pressure to external bleeding and use a tourniquet for life-threatening extremity bleeding that pressure does not control, according to training and protocol.
4. D — Disability. Check consciousness and gross neurological function. The AVPU scale describes alertness and response to voice, painful stimulus or neither. Record deterioration and reassess while awaiting transfer.
5. E — Exposure and environment. Expose enough to identify injury while preventing unnecessary heat loss. If exertional heat stroke is suspected, activate EMS and begin rapid cooling. On-site teams with appropriate facilities can cool with cold-water immersion before transport, while monitoring and coordinating with EMS.

For a suspected cervical spine injury, the clinical team must ensure airway access and minimize spinal motion. Trained staff decide whether protective equipment needs removal based on circulation, airway, breathing, consciousness, equipment design and available help. Communicate the mechanism, initial findings, changes and interventions to EMS.

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Secondary On-Field and Sideline Assessment

A secondary examination evaluates the injury after immediate threats have been addressed. Check distal sensation, movement and perfusion when a limb injury could involve a fracture, dislocation or neurovascular injury. Major deformity, an open injury or compromised distal circulation warrants urgent care. Protect the injured area and avoid loading or stress tests while a serious injury is suspected.

TOTAPS and HOPS

TOTAPS is a sequence for a local athletic injury: Talk, Observe, Touch, Active movement, Passive movement and Skills testing. Ask about the mechanism, onset, location and any numbness or weakness. Inspect for swelling, skin injury and alignment before palpation. Use comfortable active motion first when safe. Add gentle passive motion or targeted tests when the findings warrant them. Reserve functional skills testing for athletes whose initial examination supports loading and progression.

HOPS organizes the same clinical reasoning by History, Observation, Palpation and Special tests. Choose tests to answer a specific question. For example, after an inversion injury, assess for fracture indicators before stressing the lateral ligaments or asking the athlete to hop. A normal range of motion alone is insufficient to clear the athlete.

Acute Soft Tissue Management

Protection in the first few days limits further injury while pain and swelling are assessed. Once serious injury has been excluded, load the tissue progressively as tolerated. For an uncomplicated lateral ankle sprain, the 2021 Academy of Orthopaedic Physical Therapy guideline supports external support and progressive weight bearing, followed by structured exercise. Severe sprains may need a brief period of immobilization before functional rehabilitation.

The PEACE & LOVE editorial proposed a useful mnemonic for sequencing protection and rehabilitation. Its advice about inflammation is a proposal. First aid and condition-specific guidelines allow cold for short-term symptom relief, and the ankle sprain guideline allows intermittent ice as an adjunct to exercise. If using cold, protect the skin and monitor the response. Medication decisions belong with the patient and prescribing or advising clinician.

For example, an athlete with a mild lateral ankle sprain who can walk with support can practice controlled weight shifts and comfortable ankle motion after fracture screening. Progress walking and balance work as tolerated. Increasing swelling, recurrent giving way or inability to progress calls for reassessment before higher-load drills.

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Sports-Related Concussion (SRC)

A direct blow to the head or an impact to the neck or body can transmit force to the brain. Both linear and rotational acceleration can occur. Concussion can affect symptoms, cognition, balance and other neurological functions even when standard structural imaging appears normal. Imaging may still be indicated to assess a suspected structural injury.

Neurometabolic changes

Experimental studies support a model in which impact disrupts normal membrane ion gradients and increases excitatory neurotransmitter activity. Energy-dependent pumps use more ATP to restore those gradients. At the same time, changes in mitochondrial function and cerebral blood flow can limit the energy available. This creates a temporary mismatch between demand and supply. The model explains why the brain can be vulnerable after an impact. It does not supply a fixed metabolic recovery period or a sideline clearance test.

Mechanical force transmitted to the brain
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Ion shifts and increased excitatory signalling
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Increased ATP demand to restore ion gradients
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Potential disruption of energy production and cerebral blood flow
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Temporary mismatch between energy demand and supply

On-Field Red Flags and Removal From Play

Activate emergency care for serious findings after a head or neck impact, such as:

• Loss of consciousness, reduced or deteriorating alertness, or seizure.
• Severe or worsening headache, vomiting, or increasing agitation.
• Double vision, weakness, or numbness or tingling in multiple limbs.
• Neck pain or tenderness or visible skull deformity.

These findings raise concern for head or cervical injury and warrant urgent medical evaluation. Use spinal motion restriction when cervical injury is suspected while maintaining airway, breathing and circulation. Do not move the athlete without a clinical need or trained assistance.

Remove an athlete with suspected concussion from play for assessment. If concussion is diagnosed or remains suspected, keep the athlete out that day. Same-day return after a suspicious sign is considered only if an experienced healthcare professional completes a multimodal evaluation, determines the sign had another cause and applicable rules permit it. Monitor for evolving signs after the initial evaluation.

Acute assessment with SCAT6

The Sport Concussion Assessment Tool 6 (SCAT6) supports acute multimodal evaluation by healthcare professionals for athletes aged 13 or older. It is most useful in the first 72 hours and can be used up to seven days after injury. Use Child SCAT6 for ages 8–12. The Concussion Recognition Tool 6 (CRT6) helps non-clinicians recognize a suspected injury and act on it.

• Immediate assessment includes red flags, observable signs, the Glasgow Coma Scale, cervical assessment and Maddocks questions about the game. A missed question such as which team played in the last match supports further assessment. A correct response does not clear the athlete.
• Off-field assessment includes a 22-item symptom inventory scored 0 to 6 per symptom, a 10-word immediate memory list over three trials, concentration, coordination, balance and gait. Test delayed recall at least five minutes after the immediate memory trials. Use the modified Balance Error Scoring System and tandem gait when safe.
• Interpret results alongside the history, examination and serial findings. A normal SCAT6 can occur with concussion. Clearance requires clinical recovery and the appropriate graduated progression.

Graduated Return to Sport After Concussion

During the first 24–48 hours, use relative rest, with daily activities and reduced screen time as tolerated. Light walking can begin in this period if it causes only mild, brief symptoms and there is no risk of another injury. Return to learning and return to sport can progress in parallel. Student-athletes should complete return to learning before unrestricted sport.

The Amsterdam 2022 consensus, published in 2023, describes the following steps. Each successive step typically takes at least 24 hours.

Early symptom rule. During appropriate low-risk Steps 1–3, a symptom increase of at most 2 points on a 0–10 scale relative to the pre-activity rating is acceptable if it lasts less than one hour. If symptoms rise by more than 2 points, stop and try exercise the next day when appropriate. A smaller increase that lasts an hour or more is outside the mild-and-brief limit and calls for reassessment and adjustment of the load.

Later progression. Begin Steps 4–6 after concussion-related symptoms, cognitive abnormalities and other clinical findings have resolved, including during and after exertion. Obtain authorization by the appropriate healthcare professional before any activity carrying a risk of head impact, including Step 3 when applicable. A return of concussion symptoms during Steps 4–6 calls for a return to Step 3 to re-establish symptom-free exertion. Obtain written readiness before unrestricted return as directed by local requirements and sporting rules.

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Musculoskeletal Sprains and Strains

A sprain involves a ligament. A strain involves a muscle or musculotendinous unit. A simple three-grade description distinguishes minor, partial and complete injury. Use the injury-specific classification when it affects treatment. For example, British Athletics uses a separate MRI-based grading system for muscle injuries.

Pain, swelling and guarding can limit examination soon after injury. Repeat the assessment when appropriate and interpret the findings with mechanism, local anatomy and function. The grade alone cannot specify a rehabilitation timeline or whether surgery is indicated.