Managing concussions in football: A review of football associations' return-to-play guidance

OBJECTIVES: This study examines the protocols guiding return-to-play following a concussion across the Fédération Internationale de Football Association's Member Associations. DESIGN: Qualitative document and content analysis. METHODS: A document analysis was performed to explore return-to-play following a concussion, as evidenced in formal guidelines, policy documents, and educational resources. Relevant documents were identified through direct outreach to Member Associations and a review of official websites, gathering data from 95 associations. RESULTS: 73 Member Associations reported the existence of a return-to-play protocol, structuring it in six broadly coherent stages: (1) initial relative rest, (2) light aerobic exercise, (3) sport-specific activities, (4) non-contact training, (5) full-contact practice, and (6) return-to-play. Substantial variability was identified across protocol components. Differences included: (a) the nature and timing of initial rest (relative vs. absolute) and subsequent stages; (b) criteria for stage progression and symptom management-ranging from requiring complete symptom resolution to permitting advancement with mild or stable symptoms; (c) medical clearance procedures, particularly whether clearance was mandatory or recommended and when it was required throughout the return-to-play process; and (d) return-to-play timing, which spanned from 30 h to 23 days. This study also identified 42 Member Associations that reported following international standards. Limited availability and accessibility of concussion-related materials was also noted. CONCLUSIONS: The identified differences may hinder optimal concussion management, raising important questions about standardization, player safety, and the evidence underpinning current practices. The findings from this study can support Member Associations in re-evaluating their current approaches and can assist in aligning and improving practices globally.