Concussion
In football, females have a higher incidence of concussion than males. This is in contrast to many sports where males have higher incidences, or where there is no significant difference between gender. In recent research findings, female incidences were over double that of male players.
Key takeaways
- Females appear to be more vulnerable to concussion within football than males at all ages.
- The CRT6 recognition tool has been developed for non-medically trained individuals.
- The FA have clear heading guidelines for different age groups.
- Coaches and parents should be aware of Return to Learn (RTL) and Return to Sport (RTS) guidelines.
- Preventative measures are available but no one method of prevention is currently agreed.
* The information below is based on research sources and the FA website, it should not be used as a
replacement for medical advice from a trained medical practitioner.
Risk
Factors
Children & adolescents
A developing brain
Weaker neck muscles
Larger head to body ratio
+ Adolescents:
undeveloped pre-frontal cortex
Symptoms
Females
Evidence appears to suggest females suffer enhanced physical and psychological issues as a result of a concussion.
Detection
Recovery
guidelines
Evidence recommends cognitive rest (reduced screen time) and relative physical rest (supervised walking allowed with only mild symptom increase lasting < 1 hr)
Progress >48 hrs up to moderate* aerobic exercise 3 - 5 times per week in a safe controlled supervised environment.
*Moderate exercise = an increase in breathing and sweating but being able to hold a conversation.
Females, children and adolescents have shown to have longer recovery times when compared to adult males.
return to Learn (RTL)
return to Play(RTP)/
RETURN to sport (RTS)
Prevention
Psychology
The psychological background of the player must be considered during the rehabilitation period as do previous known issues such as mood, anxiety and other neurodevelopmental disorder.
Menstrual Cycle
Menstrual cycle may be a consideration in concussion incidences and recovery.
Recent research findings suggest that children and adolescents may be more vulnerable to longer-term problems as a result of a concussion than adults.
The developing brain, weaker neck muscles and a larger head to body ratio appear to be factors in increasing the risk of a concussion. A mis-match of height and weight amongst younger players is also a factor.
Adolescents may be particularly at risk as the pre-frontal cortex is not fully developed while incident rates increase with age.
The reduced strength compared to males therefore increases the risk relating to weaker neck muscles with regard to females.
Symptoms of concussion include fatigue, headache, loss of concentration, sleep issues, vision or hearing issues and decreased physical activity. Emotional development may be impacted by concussion with some evidence suggesting females suffer increased risk of anxiety, depression and mental health issues. Long-term issues related to repeated concussions are a particular concern.
Diagnosis of a concussion relies on the clinical assessment of signs and symptoms and should be completed by a medically trained professional. However, when not available, the odds of immediate removal from the field are increased when an athletic trainer makes the initial evaluation, early removal is linked with a quicker return to sport.
Guidance for non-medically trained individuals for the identification and management of a suspected concussion is provided by the concussion recognition tool CRT6. Note that this is not designed to diagnose but its use is encouraged within grassroots sport. The CRT6 tool also contains questions to ask players if concussion is suspected. Note that incorrect answers do not necessarily indicate a concussion and visa versa but should be used alongside other information including signs and symptoms.
The FA mantra 'If in doubt sit them out.' should be adhered to with further guidance provided in the England football document of the same name. The UK government also provides guidance for UK grassroots sport. (see links opposite).
Currently, cognitive rest and relative physical rest are recommended for optimal recovery although this is dependent on player symptoms and individualised response. Recovery should include supervision in the first 24 hours along with reduced screen time and cognitive (thinking) activities, with relative physical rest that still encourages supervised walking and light daily activities in the first 24 - 48 hours. No additional benefit from complete rest or a prolonged rest period has been shown once the player is medically stable.
For female adolescents over 12 years of age, recent evidence points towards an active therapeutic approach to recovery, involving low volume aerobic exercise within a controlled and supervised environment and non-contact activities.
Progress after the first 48 hours should be based on symptom response with only mild exacerbation in symptoms during activity acceptable and these symptoms should not last more than an hour. Progressing to 20 minute moderate aerobic exercise, 3 - 5 times per week, within a supervised environment has been suggested to alleviate symptoms. Aerobic exercise intensity should progress with recovery.
Children, adolescents and females have been found to have longer recovery times than adult males. At present there is limited evidence available for ages 5 - 12.
Due to the longer recovery times associated with children and females plus the health issues that are associated with a repeat concussion, it is important to proceed cautiously with return to learn and return to play protocols for youth athletes. Repeat concussions maybe linked with an increased risk of neurodegenerative conditions (1), although research in this area is still in its early days.
The intervention of a medical professional at any stage during the process is the ideal scenario but not always possible in grassroots sport. Persistent symptoms lasting over 4 weeks should be referred to a medically trained health care professional.
The 2022 consensus statement on concussion in sport offered guidance on 'Return to Learn' (RTL) and 'Return to Play' (RTP) protocols. It suggests that the majority of players will be back to normal learning patterns in 10 days or fewer. However the longer recovery time for females and youth players shown within research should be factored in to recovery.
With regard to RTL, environmental adjustments including decreased screen time and other cognitive (thinking) activities should be part of a recovery plan and should be reintroduced progressively alongside symptom recovery. It is suggested that school curriculum adjustments are included with a progressive return to normal learning. Note that a history of ADHD and / or anxiety may potentially impact and increase RTL recovery times.
Return to Play (RTP) / Return to Sport (RTS) protocols must be individualised and each progression must be based on symptom response and not a fixed timeline. Only a mild increase in symptoms during the activity (0-2 on a scale of 0 -10), with alleviation within an hour is acceptable to enable the athlete to move to the next step, +24 hours later. More detail is contained in the link opposite. It is crucial that following a concussion, a medically trained health care professional gives the go-ahead for a return to contact activities and the game.
Step 1: Symptom-limited activity - Daily activities and supervised walking only, usually for the first 24-48 hrs, also see RTL information above.
Step 2: Aerobic Exercise - Light (<55% maxHR) and then moderate (<70% maxHR) aerobic exercise. Light resistance training if tolerated (see above)
Step 3: Individual Sport-Specific Exercise - Sport-specific training away from the team environment, such as running, change of direction etc
No activities with a risk of head impact. Medical clearance would be required to progress beyond this step.
Steps 4–6: These later stages involving the risk of head impact should only begin after the full resolution of any symptoms.
Step 4: Non-Contact Training Drills - The goal is to resume usual intensity of exercise, coordination, and increased thinking within a team environment.
Step 5: Full Contact Practice - Normal training activities to restore confidence and assess functional skills, with oversight from coaches.
Step 6: Return to Sport - Normal game play
* Athletes experiencing concussion-related symptoms during Steps 4–6 should return to Step 3 to establish full resolution of symptoms. Written determination of readiness to RTS should be provided by an HCP before unrestricted RTS as directed by sporting regulations.
Understanding of concussion prevention is in its infancy in terms of research evidence, particularly for females. However, emerging evidence suggests that strengthening neck muscles and education of the signs and symptoms of a concussion to players, parents and coaches should all be a part of concussion prevention alongside the progressive learning of heading technique.
Neuromuscular exercises within a warm up, 3 times per week; and game awareness may also play a role in protecting individuals with regards to concussion.
Precaution must be taken when completing neck strengthening. Very little research exists for children but some recent evidence for adolescents shows promise suggesting a neck strengthening programme is effective with neck strength linked with a reduction in concussions. Some simple and safe exercises are shown in the links but qualified supervision of youth athletes and a gradual progression is important for this area.
In addition, research using the 'roll and tuck' exercise has been shown to 'increase isometric neck strength and decrease head impact magnitude during heading'. A link to this research can be
found opposite.
Educating heading technique should be completed following the FA's training guidelines. Heading should remain a low priority until the post U16 age groups with strict guidance and control of heading within training. The link FA link opposite contains the relevant guidance for coaches.
Decision-making in young athletes regarding sports-related concussions (SRC) is complicated due their cognitive development. Younger children may not understand the risks of contact sports, making parental involvement crucial in decisions about discontinuation or treatment. Although older adolescents may participate in shared decision-making, their ability to consent is uncertain. Incorporating factors like mental health and sleep assessments and discussions is important, as is the understanding of the individual's background, especially relating to anxiety. The priority for children and adolescents is completing the Return to Learn phase before Return to Play considerations.
Recent research has linked different phases of the menstrual cycle and symptom response. The luteal phase, has been reported to be associated with higher somatic symptom reporting after concussion in women, possibly due to a drop in progesterone levels following the injury. However, research to confirm links is ongoing and at present is not fully developed.
references
Alashram, A. (2025) Effects of aerobic exercise on concussion-related symptoms: a systematic review of randomized controlled trials. Brain Injury Mar 10 : 1-10.doi: 10.1080/02699052.2025.2476494 Bazarian JJ,,et al. (2014) Persistent long-term cerebral white matter changes after SR repetitive head impacts.PLoSONE9(4):e94734.doi:10.1371/journal.pone.0094734 Bennett H, Garrett J, Peek K. Enhancing Sport-Related Concussion Return-to-Play Protocols for Non-Professional Athletes. Exerc Sport Sci Rev. 2025 May 1. doi: 10.1249/JES.0000000000000363. Epub ahead of print. PMID: 40307996. Bishay AE, (2025) Return-to-learn following sport-related concussion: a systematic review. J Neurosurg Pediatr. 2025 May 9:1-13. doi: 10.3171/2025.1.PEDS24482. Epub ahead of print. PMID: 40344757. Bretzin, A.C., Esopenko, C., D’Alonzo, B.A. and Wiebe, D.J. (2021). Clinical Recovery Timelines following Sport-Related Concussion in Men’s and Women’s Collegiate Sports. Journal of Athletic Training, 57(7). doi:https://doi.org/10.4085/601-20. Bretzin, A.C. et al (2024). Acute Sport-Related Concussion Management and Return to Sport Time in High School Athletes. The American Journal of Sports Medicine, 52(3). doi:https://doi.org/10.1177/03635465231219263. Chizuk, H. et al (2025). Sex Differences in Response to Low- Versus High-Volume Aerobic Exercise for Sport-Related Concussion: A Pilot Randomized Controlled Trial. Journal of Head Trauma Rehab April 16. | DOI: 10.1097/HTR.0000000000001061 Foster, E. et al (2025) Promoting early aerobic exercise initiation post-concussion: A pilot study examining how prescription method can influence recovery in a non-athlete, adult population. American Journal of Phys Med Rehabilitation Mar 7; DOI: 10.1097/PHM.0000000000002732 Haley, C (2025) Sex Differences in Response to Low- Versus High-Volume Aerobic Exercise for Sport-Related Concussion: A Pilot Randomized Controlled Trial. Hardaker, N., King, D., Hume, P.A., Stewart, T., Sims, S., Basu, I., Shilton, B. and Selfe, J. (2024). Female RNA concussion (FeRNAC) study: assessing hormone profiles and salivary RNA in females with concussion in New Zealand: a study protocol. BMC Neurology, 24(1). doi:https://doi.org/10.1186/s12883-024-03653-9. Ingram , V. et al (2025) The incidence of SRC in children and adolescents: A systematic review and meta-analysis. Sports Med Open April ,11 (1): 36 Kline, A.C. (2017). BET 2: Should children with sport-related concussion observe strict physical rest until symptom-free? Emergency Medicine Journal, 34(11), pp.764–765. doi:https://doi.org/10.1136/emermed-2017-207232.2. Langevin P, et al (2020). Aerobic Exercise for Sport-related Concussion: A Systematic Review and Meta-analysis. Med Sci Sports Exerc. 2020 Dec;52(12):2491-2499. doi: 10.1249/MSS.0000000000002402. PMID: 32520867. Leddy, J.J., Haider, M.N., Ellis, M. and Willer, B.S. (2018). Exercise is Medicine for Concussion. Current Sports Medicine Reports, [online] 17(8), pp.262–270. doi:https://doi.org/10.1249/jsr.0000000000000505. Maciej Michałowski, Sudomir, M., Wilkowska, K., Kaczorowski, W., Knysak, K., Maj, A., Szczerba, M., Aleksandra Hejnosz, Michał Jastrzębski, Maja Piątek, Maciej Michałowski, Sudomir, M., Wilkowska, K., Kaczorowski, W., Knysak, K., Maj, A., Szczerba, M., Aleksandra Hejnosz, Michał Jastrzębski and Maja Piątek (2025). Sport-related concussion in children: a comprehensive review of current evidence. Quality in Sport, 47, pp.66806–66806. doi:https://doi.org/10.12775/qs.2025.47.66806. Manzanero, S., et al. (2017). Post-concussion recovery in children and adolescents: A narrative review. Journal of Concussion, (1) doi:https://doi.org/10.1177/2059700217726874. Seehusen, C.N., et al. (2021). More Physical Activity after Concussion Is Associated with Faster Return to Play among Adolescents. Int J of Environmental Research and Public Health, 18(14), p.7373. doi:https://doi.org/10.3390/ijerph18147373. Stone, S., Lee, B., Garrison, J.C., Blueitt, D. and Creed, K. (2016). Sex Differences in Time to Return-to-Play Progression After Sport-Related Concussion. Sports Health: A Multidisciplinary Approach, 9(1), pp.41–44. doi:https://doi.org/10.1177/1941738116672184. Patricios, J.S., et al (2023). Consensus Statement on Concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), pp.695–711. doi:https://doi.org/10.1136/bjsports-2023-106898. Peek K, et al (2023) Injury-Reduction Programs Containing Neuromuscular Neck Exercises and the Incidence of Soccer-Related Head and Neck Injuries. J Athl Train. Jun 1;58(6):519-527. doi: 10.4085/1062-6050-0340.22. Pedroni et al (2025) Mitigating SRC in adolescent athletes: A systematic review and meta-analysis of communication and education interviews. Public Health Review (46) Putukian, M. et al (2023). Clinical recovery from concussion–return to school and sport: a systematic review and meta-analysis. British Journal of Sports Medicine, 57(12), pp.798–809. doi:https://doi.org/10.1136/bjsports-2022-106682. Wilson, Julie C.1,2; Levek, Claire3; Daoud, Ariel K.1; Brewer, Matthew1; Brooks, Katelyn1; Sochanska, Ada1; Randall, Melissa1; Provance, Aaron J.1,2. Web-Based Exercise Program Increases Cervical Strength in Adolescent Athletes. Journal of Strength and Conditioning Research 35(4):p 1149-1155, April 2021. | DOI: 10.1519/JSC.0000000000002907 Wunderle, K., Hoeger, K.M., Wasserman, E. and Bazarian, J.J. (2014). Menstrual Phase as Predictor of Outcome After Mild Traumatic Brain Injury in Women. J of Head Trauma Rehab 29(5), pp.E1–E8. doi:https://doi.org/10.1097/htr.0000000000000006.