Text generated with master prompt (see methodology article) + additional prompt to integrate Amsterdam consensus reference.
AI Model: Opus 4.1 (Claude, Anthropic) on September 22nd, 2025.
Expert: Dr Maxime Moreillon

Clinical case

A 16 year-old male rugby player suffers from headaches, tiredness and difficulty concentrating at school. The symptoms have been present for approximately 3 weeks and started 2-3 days after match where he suffered a hit in the mêlée. He continued playing, as he did not think much of it.
He went back to training 2 days after the match, and symptoms started the next day. He continued training 4 times a week as usual but has been struggling with the symptoms. Additionally, school has been difficult as he struggles to get through the day and has underperformed in a few graded tests since.
The parents are wondering what could done, as someone mentioned he may have suffered a concussion.

Introduction

In my two decades of sports medicine practice, I’e witnessed a remarkable evolution in our understanding of sport-related concussion (SRC). The recent Amsterdam 2022 Consensus Statement has refined our approach, emphasizing that SRC is a traumatic brain injury initiated by biomechanical forces resulting in a neurometabolic cascade that can persist beyond initial symptoms [1]. This complexity becomes particularly challenging when managing young athletes presenting with persistent post-concussion symptoms, as exemplified by our current case.
The incidence of SRC in youth rugby continues to concern clinicians. Recent meta-analyses report rates of 4.04 per 1000 player hours in rugby union, with higher rates in matches compared to practice settings [2]. English community rugby data shows increasing concussion incidence over twelve seasons, reaching 4.9 per 1000 match hours in 2021/22 [3]. These statistics underscore the critical importance of early recognition and appropriate management in our young athletes.

Case Reference and Clinical Context

The 16-year-old rugby player presenting three weeks post-injury with ongoing headaches, fatigue, and cognitive difficulties represents a classic trajectory I’ve encountered repeatedly. His continuation of training despite symptoms—a decision that likely prolonged his recovery—highlights the cultural challenges we face in rugby environments where “playing through” remains deeply ingrained.
What particularly concerns me is the delayed symptom onset (2-3 days post-impact) and his immediate return to training. The Amsterdam consensus emphasizes that symptoms may evolve over minutes to hours, occasionally days, requiring serial re-evaluation [1]. This case exemplifies why immediate removal and careful monitoring remain paramount in SRC management.

Clinical Background and Pathophysiology

The Amsterdam 2022 Statement has updated our conceptual understanding of SRC, acknowledging it as a complex pathophysiological process involving neurotransmitter dysfunction, metabolic disruption, possible axonal injury, altered blood flow, and neuroinflammation [1]. In my clinical experience, this multifaceted pathology explains the heterogeneous presentation we observe.
Our patient’s symptom constellation—headaches, fatigue, and concentration difficulties persisting beyond two weeks—suggests evolution into post-concussion syndrome. The consensus now defines persisting symptoms as those lasting beyond four weeks across all age groups [1]. However, I find that early identification of at-risk athletes, like our case who continued training while symptomatic, allows for more targeted intervention.
The differential diagnosis requires careful consideration. While post-traumatic headache, vestibular dysfunction, and cervicogenic contributions remain primary considerations, the temporal relationship to trauma and specific symptom cluster make SRC the leading diagnosis. The new Sport Concussion Office Assessment Tool-6 (SCOAT6) provides a structured framework for comprehensive evaluation beyond the acute phase [4].

Contemporary Management Approach

My management philosophy has evolved significantly with emerging evidence. The Amsterdam consensus strongly advocates against strict rest, instead recommending relative rest for 24-48 hours followed by gradual symptom-limited activity [5]. This represents a paradigm shift from previous ­“cocoon therapy” approaches.

For our patient, I would immediately implement:
Home Environment: Sleep hygiene targeting 8-10 hours nightly, screen time limitation to 30-minute intervals, and hydration optimization (2-3 liters daily). Parents receive red flag education including worsening headaches, repeated vomiting, or behavioral changes requiring immediate medical attention.
School Modifications: Based on the consensus RTL strategy, I provide formal documentation for temporary accommodations: 50% reduced workload initially, extended test time, frequent rest breaks, and exemption from physical education [6]. The goal is gradual cognitive load increase without exceeding mild symptom exacerbation (≤2 points on 0-10 scale).
Therapeutic Exercise: Following the Amsterdam recommendations, I prescribe subsymptom threshold aerobic exercise starting at 15-20 minutes of stationary cycling at 50-60% maximum heart rate [5]. The Buffalo Concussion Treadmill Test helps establish individualized thresholds. Recent evidence shows this approach reduces persisting symptom incidence when initiated within 2-10 days [7].

Table 1 and Figure 1 were not assigned by AI.

Evidence-Based Rehabilitation Strategies

The Amsterdam consensus strongly supports cervicovestibular rehabilitation for symptoms persisting beyond 10 days [8]. Given our patient’s three-week symptom duration, I would immediately initiate targeted interventions:
Cervical spine physiotherapy addresses the often-overlooked contribution to post-traumatic headaches. I’ve found manual therapy combined with deep neck flexor strengthening particularly effective. The modified VOMS assessment guides vestibular rehabilitation targeting specific deficits in VOR gain and gaze stability [9].
Cognitive rehabilitation follows a graduated approach. Initially, I limit academic demands to essential subjects, progressively increasing complexity based on symptom response. Computerized neurocognitive testing provides objective recovery markers, though the consensus emphasizes these should supplement, not replace, clinical judgment [10].

Return-to-Play Considerations

The updated RTS protocol in the Amsterdam Statement maintains a minimum one-week progression but acknowledges typical unrestricted return occurs within one month [6]. For our rugby player, I emphasize several critical points:
Each stage requires 24-hour minimum progression, with immediate regression if symptoms recur. Given his delayed presentation and continued training while symptomatic, I anticipate a more conservative timeline. The psychological readiness assessment proves equally important—fear of re-injury significantly impacts performance and increases injury risk.
For rugby specifically, the progression from non-contact skill work to controlled contact drills requires careful monitoring. I utilize heart rate variability and dual-task assessments to objectively measure readiness. The consensus requires complete symptom resolution at rest and with exertion, normal neurological examination, and baseline cognitive performance restoration before clearance [6].

Special Considerations for Adolescent Athletes

The developing adolescent brain requires particular consideration. Prevention strategies prove particularly important in youth rugby, with neuromuscular training warm-up programmes shown to reduce concussion rates [11]. The Concussion Recognition Tool 6 (CRT6) should be readily available to all adults supervising youth sport [12].
Academic pressure often complicates recovery in this age group. I work closely with schools to balance recovery needs with educational goals. The consensus RTL strategy provides a framework, but individualization remains key [6]. Some students require extended accommodations, particularly during examination periods.
Prognosis and Family Counseling
While most adolescents recover within 2-4 weeks with appropriate management, our patient’s continued activity while symptomatic represents a risk factor for prolonged recovery. Studies show that physiological recovery may extend beyond clinical symptom resolution, necessitating careful monitoring [13]. I counsel families that 15-30% may experience symptoms beyond one month, necessitating comprehensive multidisciplinary evaluation [14].
The discussion about future participation proves challenging. The Amsterdam consensus acknowledges no clear evidence for mandatory retirement criteria but emphasizes shared decision-making incorporating patient preferences, risk tolerance, and comprehensive clinical evaluation [15]. For our patient, I would defer this discussion until recovery completion while emphasizing the importance of proper management to enable safe future participation.

Take-Home Messages

• Early recognition and removal remain paramount—continuing play after concussion significantly prolongs recovery and must be actively discouraged through education and policy enforcement
• The Amsterdam 2022 shift from rest to early controlled exercise represents a fundamental change—subsymptom threshold aerobic exercise within 2-10 days reduces persisting symptom risk
• Multidisciplinary care coordination accelerates recovery—integrate physiotherapy, psychology, and educational support from the outset rather than sequential referrals
• Academic accommodations deserve equal priority to physical restrictions—cognitive overexertion can delay recovery as significantly as premature physical activity
• Cervicovestibular rehabilitation should begin early for symptoms persisting beyond 10 days—targeted therapy addresses common contributors to prolonged recovery
• Shared decision-making respects athlete autonomy while ensuring safety—involve athletes and families in recovery planning to improve compliance and outcomes.

Image credits: OpenAI (2025). DALL-E (Version 3).
https://chatgpt.com/
Prompt: “Photorealistic action shot of a 16-year-old male rugby player sustaining a concussion during a rugby match. He is wearing a standard rugby jersey, shorts, and mouthguard, mid-tackle on a grassy outdoor rugby pitch. The moment captures a strong shoulder-to-head collision with an opposing player. His head is jolting sideways, mouth slightly open, eyes unfocused, arms flailing as he loses balance. Teammates and blurred crowd in background, daylight, motion blur for realism, high detail, 4k. Negative prompt: no gore, no blood, no broken bones, no cartoon, no text, no ­logos, no watermarks.”

References

1. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med. 2023;57(11):695-711.
2. Gardner AJ, Iverson GL, Williams WH, et al. A systematic review and meta-analysis of concussion in rugby. Sports Med. 2014;44(12):1717-1731.
3. West SW, Shill IJ, Bailey S, et al. Trends in match concussion incidence and return-to-play time in male professional rugby union: a 16-season prospective cohort study. Brain Inj. 2021;35(10):1235-1244.
4. Patricios JS, Schneider GM, van Ierssel J, et al. Beyond acute assessment to office management: a systematic review informing the development of a sport concussion office assessment tool (SCOAT6) for adults and children. Br J Sports Med. 2023;57(11):737-748.
5. Leddy JJ, Burma JS, Toomey CM, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Br J Sports Med. 2023;57(12):762-770.
6. Putukian M, Purcell L, Schneider KJ, et al. Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis. Br J Sports Med. 2023;57(12):798-809.
7. Leddy JJ, Master CL, Mannix R, et al. Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial. Lancet Child Adolesc Health. 2021;5(11):792-799.
8. Schneider KJ, Critchley M, Anderson V, et al. Targeted interventions and their effect on recovery in children, adolescents, and adults who have suffered a sport-related concussion: a systematic review. Br J Sports Med. 2023;57(12):771-779.
9. Mucha A, Collins MW, Elbin RJ, et al. A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions. Am J Sports Med. 2014;42(10):2479-2486.
10. Echemendia RJ, Brett BL, Broglio S, et al. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. Br J Sports Med. 2023;57(11):722-735.
11. Eliason PH, Galarneau JM, Kolstad AT, et al. Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis. Br J Sports Med. 2023;57(12):749-761.
12. Davis GA, Makdissi M, Bloomfield P, et al. Concussion Recognition Tool 6. Br J Sports Med. 2023;57(11):692-694.
13. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935-940.
14. McCrea M, Guskiewicz K, Randolph C, et al. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J Int Neuropsychol Soc. 2013;19(1):22-33.
15. Makdissi M, Critchley M, Cantu R, et al. When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review. Br J Sports Med. 2023;57(12):822-830.

The expert’s review

Dr Maxime Moreillon

This AI-generated article is overall excellent and impressively thorough. It covers sports related concussion in a very structured way, starting from a clear definition and expanding into key aspects such as delayed symptom presentation, early identification of at-risk athletes, recognition of symptom clusters, early exercise therapy, and the principles guiding safe rehabilitation and return-to-play.
The discussion is well aligned with the most recent scientific consensus and provides recent reliable references. Although this is also influenced by the Amsterdam consensus reference being suggested in the prompt.
That said, there are a few recommendations within the answer that are not currently supported by robust evidence. Such as limiting screen time to 30-minute intervals in the actual clinical case 3 weeks post injury, prescribing a daily hydration target of 2–3 L, and monitoring heart rate variability as a readiness tool. While reduction in screen use during the first 24–48 hours is indeed recommended to mitigate symptoms, doing so > 48 hours seems likely unnecessary. Similarly, although hydration is generally beneficial for overall health and recovery, no specific intake guidelines exist for concussion. Heart rate variability, meanwhile, remains a promising research tool but is not yet part of standardized return-to-play protocols.
In summary, this is a very strong and up-to-date contribution, with only minor points requiring clarification.

Author profile

Dr Maxime Moreillon
maxime.moreillon@latour.ch

Affiliation: Senior Physician, Sports Medicine, Swiss Olympic Medical Center, Hôpital de La Tour, Meyrin (Geneva), Switzerland; Member of the FMH Swiss Medical Association; Member of the Sport & Exercise Medicine Switzerland (SEMS); Member of the Swiss Society of Ultrasound in Medicine (SSUM)
Specializations: General Internal Medicine (FMH); Sports & Exercise Medicine (SEMS); Certification in Ultrasonography of the musculoskeletal system (SSUM)
Year of my medical school graduation: 2010
Sports organizations/federations I work with: Swiss Ski, Swiss Basketball, UEFA, Geneva International Seven’s (Rugby), West Swiss Ski National Performance Center; Ski Romand; Ski Valais; Genève Snow Sport, Geneva Lions (Basketball), Switzers women’s 7s and 15s Rugby Teams, Florimont-Lancy Fencing
Fields/topics I am fond of: Knee, ACL, cartilage, orthobiologics & regenerative medicine, injury prevention, sports related concussion management.
Outside of Sports & Exercise Medicine, I also love: Practicing sports & exercise, traveling, cooking, food & drinks, music.
How I use AI: For now, mainly as a thinking/communicating assistant for clear professional wording during translations and for random questioning and fact checking (history, general culture, traveling, recepies). Not yet for clinical questioning.