Concussion testing in sports is a set of evaluations used to detect brain injuries after a hit to the head and to track recovery before an athlete returns to play. It typically combines symptom checklists, memory and concentration tasks, balance assessments, and eye-tracking exercises. Some tests are given on the sideline within minutes of an impact, while others happen in a clinic over the following days and weeks.
Most organized sports programs also use baseline testing, a pre-injury snapshot taken before the season starts, so that post-injury results have something to be compared against.
Why Baseline Testing Comes First
Before the season begins, athletes complete a battery of cognitive and physical tests while healthy. This establishes their personal “normal” for memory, reaction time, balance, and symptom reporting. If a head injury happens during the season, clinicians compare post-injury scores to the baseline to gauge how much function has changed. Without a baseline, they’re left comparing an athlete’s scores to population averages, which is less precise.
The most widely used computerized baseline tool is ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). It measures four composite scores: verbal memory, visual memory, visual motor speed, and reaction time. These scores come from six test modules that assess attention, recognition memory, visual working memory, and learning. Athletes also report a total symptom score so clinicians can see whether headaches, fogginess, or other complaints existed before any injury occurred.
Baseline scores aren’t one-size-fits-all. Age, gender, history of ADHD or migraines, and even the language the test is administered in can shift results. Athletes who take the test in Spanish, for example, tend to score modestly lower on visual motor speed and reaction time compared to English-tested peers matched on other factors. Clinicians need to account for these differences when interpreting post-injury comparisons.
What Happens on the Sideline
When an athlete takes a blow to the head during competition, the first evaluation happens right on the field. The current standard tool is the Sport Concussion Assessment Tool 6, or SCAT6, developed through the 6th International Conference on Concussion in Sport held in Amsterdam in 2022. It has two phases: an immediate neuro screen and a more detailed off-field assessment.
The immediate screen starts with observable signs. Evaluators look for red flags like lying motionless, visible confusion, a blank or vacant stare, balance difficulties, or a seizure at the moment of impact. They then check basic consciousness using the Glasgow Coma Scale, assess the cervical spine for neck pain or limited movement, and run a quick coordination and eye-movement check (following a finger side to side, looking up and down without double vision, and touching finger to nose). A set of memory questions called the Maddocks Questions rounds out this phase: “What venue are we at today?” and “Which half is it now?” are typical examples.
If the athlete is moved off the field for further evaluation, the SCAT6’s off-field assessment kicks in. It includes a 22-symptom checklist where the athlete rates each symptom from 1 (very mild) to 6 (severe). Symptoms range from the expected, like headache and dizziness, to subtler complaints like feeling “in a fog,” being more emotional than usual, or feeling nervous and anxious. A cognitive screening follows, testing orientation (what month, date, day, year, and approximate time it is), immediate memory (recalling a 10-word list across three attempts), and concentration (repeating number strings backward and listing months in reverse order). After at least five minutes, the athlete is asked to recall that same 10-word list again to test delayed memory.
Balance is also assessed off the field using the modified Balance Error Scoring System (mBESS). The athlete stands in three positions on a firm surface: feet together, heel-to-toe (tandem), and on one leg. Each stance is held for 20 seconds with eyes closed. Errors include opening the eyes, lifting hands off hips, stepping or stumbling, raising the forefoot or heel, moving the hip out more than 30 degrees, or taking longer than 5 seconds to get back into position. A timed tandem gait test, walking heel-to-toe along a 3-meter line, adds another layer of balance data.
Eye and Vestibular Screening
Concussions frequently disrupt the connection between your eyes, inner ear, and brain. The Vestibular/Ocular-Motor Screening, or VOMS, specifically targets this. It tests five functional areas: smooth pursuit (tracking an object moving slowly), saccades (snapping your eyes quickly between two targets, both horizontally and vertically), convergence (focusing on a target as it moves toward your nose), the vestibular ocular reflex (keeping your eyes fixed on a target while turning your head), and visual motion sensitivity (how your brain handles visual movement around you).
For each test, the clinician records symptoms like dizziness, headache, nausea, and fogginess before and after the task. The change in symptoms is what matters most. Convergence also gets an objective measurement: the examiner notes the distance, in centimeters, at which the athlete’s eyes can no longer stay focused on a target. These results help identify athletes who may look fine on memory tests but still have vestibular or visual processing problems that would put them at risk if they returned to play.
Testing for Children
Kids aren’t just smaller adults, and their concussion assessments reflect that. The Child SCAT6 is designed for athletes ages 8 to 12, with limited evidence supporting its use in children as young as 5 to 7. It uses age-appropriate language and adjusted tasks, though it follows the same general structure as the adult version: symptom reporting, cognitive screening, and balance testing. The symptom checklist is reordered slightly, and the questions are simplified so younger children can meaningfully participate.
Children often take longer to recover from concussions than adults, and their symptom reporting can be less reliable. Parents or guardians typically help complete the symptom checklist, since a 9-year-old may not articulate that they feel “in a fog” the same way a college athlete would.
Blood-Based Biomarkers
A newer addition to concussion evaluation is a blood test that measures two proteins released by damaged brain cells. One comes from the structural support cells in the brain, and the other from neurons themselves. After a mild traumatic brain injury, levels of these proteins rise in the bloodstream, signaling that something has happened inside the skull.
The FDA cleared the first combined blood panel for this purpose in 2018, and several testing platforms are now available for clinical use. The test achieves sensitivity above 95%, meaning it catches nearly all cases where there’s a detectable brain lesion. Its primary use so far is in emergency departments, where it can help clinicians decide whether a CT scan is necessary. Studies suggest it could reduce unnecessary head CT scans by about 30%. This technology is still more common in emergency settings than on the sideline, but it represents a shift toward objective, measurable markers rather than relying solely on self-reported symptoms and cognitive tasks.
The Six-Stage Return to Play Protocol
No single test clears an athlete to return to competition. Instead, recovery follows a graduated six-stage protocol, with each stage requiring a minimum of 24 hours before advancing to the next. If symptoms return at any stage, the athlete drops back to the previous step.
- Stage 1: Return to regular daily activities like school, with clearance from a healthcare provider to begin the progression.
- Stage 2: Light aerobic activity only, such as 5 to 10 minutes on a stationary bike or light jogging. No weight lifting.
- Stage 3: Moderate activity that increases heart rate with body or head movement, including moderate jogging, brief running, and reduced weightlifting.
- Stage 4: Heavy non-contact activity like sprinting, high-intensity biking, full weightlifting routines, and sport-specific drills.
- Stage 5: Full practice including contact, in a controlled setting.
- Stage 6: Return to competition.
At minimum, this means an athlete cannot return to full competition in fewer than six days after being cleared to start the protocol. In practice, especially for younger athletes or those with lingering symptoms, the timeline often stretches to two weeks or longer.
Who Administers and Interprets These Tests
The Concussion Recognition Tool is designed for anyone to use, including coaches, parents, and officials, to help spot a potential concussion and pull an athlete from play. The SCAT6 and more detailed cognitive assessments require a healthcare professional, typically an athletic trainer, team physician, or sports medicine specialist.
For athletes who have had multiple concussions or whose symptoms persist beyond a few weeks, more detailed neuropsychological testing by a trained neuropsychologist may be necessary. This deeper evaluation can identify specific cognitive deficits that standard sideline tools miss and help guide decisions about school accommodations or longer-term management. Referral to a neurologist is also common when persistent headaches or other symptoms don’t resolve with standard recovery protocols.