When Protocols Replace Clinical Reasoning: Rethinking Concussion Care in Elite Sport

Last month I had the opportunity to speak at the Royal Society of Medicine about concussion in elite sport. What struck me most during the discussion afterwards was something that has increasingly concerned me in clinical practice: protocols designed to improve care may, paradoxically, be undermining clinical reasoning.

This is not a criticism of the intent behind concussion protocols. Their introduction was both necessary and overdue. But their implementation has had unintended consequences that deserve reflection.

A brief history of good intentions

Across UK sport, concussion protocols emerged largely in the 2010s in response to growing recognition of head injury risks. The Rugby Football Union introduced structured return-to-play pathways and head injury assessments in elite rugby earlier than most sports. The England and Wales Cricket Board adopted formal concussion management guidance in the mid-2010s and later introduced concussion substitutions following international regulation changes. The Football Association followed with formal concussion guidelines shortly afterwards.

Each governing body introduced graduated return-to-play pathways, typically involving staged progression over a minimum number of days before an athlete could return to competition. These frameworks were created to address a genuine problem: historically, athletes returned to play too quickly, often under pressure from competitive environments.

And while these protocols created structure, safety, and accountability, they also created something else.

When timelines become the diagnosis

Today, it is not uncommon to hear clinicians, coaches, and even athletes speak about “being on stage 3 of the concussion protocol”.

The timeline becomes the treatment.

The implication is that concussion behaves like a fracture: a defined injury with a predictable biological healing timeline. But concussion is not a fracture. In fact, “concussion” is itself a problematic term. The clinical term describes the outcome of a rapid head acceleration rather than the specific functional disturbance that results.

The clinical question should not simply be: Has the protocol timeline elapsed?

The question should be: What functions have been disrupted by this rapid head acceleration, and have they recovered?

That requires clinical reasoning, not simply protocol adherence.

The misuse of tools

One example of this shift toward protocol-driven care is the ongoing misuse of assessment tools.

The Sport Concussion Assessment Tool 6 (SCAT6) is a valuable instrument in the initial assessment of suspected concussion. It provides structured evaluation of symptoms, cognition, balance, and neurological signs.

But it was never intended to be used indefinitely. In fact, its diagnostic utility declines significantly after the first 48–72 hours.

Yet in our clinic at the Institute of Sport Exercise and Health, we still routinely see professional athletes who have had SCAT6 assessments repeated throughout their  “concussion protocol”. At that stage, the tool adds little. What is required instead is clinical evaluation of the systems affected by the rapid head acceleration .

The tool designed to fix this problem

The irony is that the most recent international consensus attempted to address precisely this issue.

The introduction of the Sport Concussion Office Assessment Tool 6 (SCOAT6) was intended to support clinicians in structured post-acute evaluation. Unlike the SCAT6, the SCOAT6 is designed for use in the clinical environment and emphasises assessment of domains such as:

• Vestibular-ocular function
• cervical spine involvement
• cognitive function
• autonomic regulation
• mental health disturbance

In other words, it supports clinical reasoning about which systems have been functionally affected.

Yet in practice, its dissemination and implementation have been limited. Many clinicians remain far more familiar with the SCAT6, despite it being the wrong tool for the later stages of recovery.

Confusion across sports

Adding further complexity is the fact that concussion protocols differ between sports. Elite rugby, cricket, and football all have slightly different return-to-play timelines. For athletes, clinicians, and support staff working across sports, these inconsistencies can be confusing.

More importantly, they reinforce the idea that recovery is governed by a predetermined number of days, rather than by individual clinical recovery.

The risk of protocol medicine

Protocols are valuable. They protect athletes from premature return and provide clear guidance in high-pressure environments.

But protocols should support clinical reasoning, not replace it.

If clinicians begin to rely on timelines instead of functional assessment, we risk replacing one problem with another. Instead of athletes returning too early, we risk athletes progressing through pathways without truly understanding what has recovered, and what has not. Concussion care should not be about counting days. It should be about identifying which neurological systems were disrupted by rapid head acceleration and determining when they have recovered. That requires skill, assessment, and judgement. In other words, it requires clinicians.

A call for better clinical thinking

If concussion protocols achieved one thing, it was to ensure that head injuries are taken seriously and that was a vital step forward. The next step must be ensuring that protocols remain tools for clinicians, not substitutes for them. Better dissemination of tools such as the SCOAT6, greater emphasis on domain-specific assessment, and continued education in concussion pathophysiology are essential.

Otherwise, the well-intentioned structures designed to improve care may inadvertently do the opposite.