Since forming its game-day concussion protocol in 2011, the NFL has taken several steps to try and reduce the number of concussions suffered by players. The league modified rules to make hits to the head illegal, added position-specific helmets and, most recently, allowed players to wear Guardian Caps — a soft-shell cover over the helmet — during games.

Even so, the number of concussions increased slightly last season. And when a player is suspected to have a concussion, the league has a protocol that must be followed before that player can return to the field.

Here’s what you need to know about the NFL’s concussion protocol:

What happens when a player appears to suffer a head injury?

If a team’s medical staff feels any player is at risk of a concussion, it is required to pull the player to the sideline and into the medical tent for a focused neurological exam. The exam includes a cervical spine exam (including range of motion and pain), an evaluation of speech, observation of gait, and an eye movement and pupillary exam. If the player displays signs of loss of consciousness, gross motor inability, confusion or amnesia, team medical staff are not permitted to let the player return to action.

What symptoms are a medical staff looking for?

Players will be removed from a game and evaluated if they show any symptoms of a concussion, which include dizziness, nausea, and light and sound sensitivity, among many others.

If a player is observed or reports one of the following “no-go” symptoms, they are removed from the game and will not be allowed to return:

• Loss of consciousness
• Ataxia (abnormality of balance/stability, motor coordination or dysfunctional speech)
• Confusion
• Amnesia

The “no-go” symptoms were updated after Miami Dolphins quarterback Tua Tagovailoa was stretchered off the field following a concussion he suffered against the Cincinnati Bengals in 2022.

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How does the medical staff conduct the evaluation?

If a player hasn’t been ruled out by exhibiting one of the “no-go” symptoms, an unaffiliated neurotrauma consultant will evaluate them.

First, the medical staff will ask a player about how the potential injury might have occurred. They’ll also continue to check for other concussion symptoms. The staff will also ask “Maddocks’ questions,” which include asking the player to name the venue and the team they are playing. The unaffiliated neurotrauma consultant will also conduct a video review of the potential injury.

The concussion evaluation also includes a focused neurological exam as mentioned above.

Who has the final say about the player’s status?

If a player doesn’t exhibit one of the “no-go” symptoms, then each step of the league’s concussion protocol is determined by a team physician in consultation with an unaffiliated neurotrauma consultant on the sideline.

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How can a player return to play after entering the protocol?

Once sidelined under the NFL’s protocol, a player must complete the return-to-participation program, which includes five phases.

Phase 1, symptom-limited activity: The player is prescribed rest and limiting and/or avoiding activities that increase or aggravate symptoms. Under athletic training staff supervision, limited stretching and balance training can be introduced, progressing to light aerobic exercise. If tolerated, the player can attend meetings and film study.

Phase 2, aerobic exercise: Under the supervision of team staff, players should begin graduated cardiovascular exercise, such as on a stationary bike or treadmill. The player may also engage in stretching and balance training.

Phase 3, football-specific exercise: The player continues supervised cardiovascular exercises and may mimic sport-specific activities and supervised strength training.

Phase 4, non-contact training drills: The player can continue cardiovascular, strength and balance training, team-based sports-specific exercise and participate in non-contact football activities.

Phase 5, full football activity/clearance: The player is finally cleared by the club doctor for full football activity involving contact. The player must be examined by the independent neurological consultant assigned to his club. If the consultant agrees with the club physician that the player’s concussion has resolved, he may participate in his team’s next practice or game.

How long are players in the protocol?

Each player and concussion is unique and there is no set time frame for returning to the field. Team medical staff consider the player’s current concussion, history and future risk in managing a player’s care.

Until the player is cleared by the independent consultant, he may not return to contact practices or play in a game.

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(Photo: Carmen Mandato / Getty Images)