Higher Rates of Concussion Following COVID-19 Infection in High School Athletes

Keywords: COVID-19, head injury, athletes

In this blog we will detail how we found that high school athletes that contracted COVID-19 were over three times more likely to have a concussion following return to sport, compared to their fellow high school athletes. Our study (recently published in BJSM) was a grassroots initiative, spurred by sports physicians covering high school sport, throughout the ATI Physical Therapy network (1). Sports physicians anecdotally were noticing that athletes returning to sport from COVID-19 were more likely to suffer a concussion. Due to these ongoing community conversations, a research initiative was enacted to evaluate this particular important sports medicine question. A consortium between ATI Physical Therapy sports medicine team, consisting of physicians, athletic trainers, physical therapists, and leadership, in partnership with clinical epidemiologists from the Department of Orthopaedic Surgery & Rehabilitation at Wake Forest University School of Medicine, Sport Injury Prevention Research Centre at the University of Calgary, and the Pharmaco- and Device Epidemiology Unit at the University of Oxford was created to perform this study. 

Why is this study Important?

Concussions in high school athletes are a serious problem. Almost 20% of all adolescents in the United States report experiencing a concussion during high school . High school athletes may be at higher risk for sustaining a concussion compared to adult athletes.

Coronavirus (COVID-19) infections have impacted adolescent health, long after acute COVID-19 has resolved. Adolescent athletes report a high rate of symptoms resultant from COVID-19, including multisystem inflammatory syndrome. Further, COVID-19 may affect the neurological system, potentially impairing cognitive processes (2). 

Concussions have important repercussions in adolescent and high school athletes, due to their growing brains. While COVID-19 infection rates have been quantified, we do not know the potential consequences of long-term COVID-19 symptoms in adolescents, as they return to high school sport.  Understanding the interplay between COVID-19 and concussion rates as high school athletes return to sport could potentially improve clinical examination, decision making, and athlete and parent education. 

How did the study go about this?

A prospective study over one academic year was performed to evaluate concussions rates in high school athletes that contracted COVID-19 and those that did not. All illnesses and concussions were recorded by athletic trainers over the six state ATI network. 

What did this study find?

A total of 72,522 athletes participated in high school sports during the 2020-2021 academic school year. A total of 1,273 concussions (No-COVID-19: 1,241; COVID-19: 32) were documented during the school year. High school athletes who sustained a COVID-19 infection demonstrated over a three times [3.1 (95% CI: 2.0, 4.7), p < 0.001] greater rate of concussion compared to high school athletes that did not contract COVID-19. See Table 1 for more details.

What are the key take home points?

  • Athletes with COVID-19 infection had greater than 3-fold rates of concussion within sixty days following recovery from infection compared to athletes without COVID-19 infection.
  • Further research is warranted to explore why athletes with a recent COVID-19 infection are at higher risk of concussion.
  • Clinical judgement or concern may guide further evaluation or a more cautious return to sport in athletes recovering from COVID-19.


(1) Bullock GSEmery CANelson VR, et al Higher rates of concussion following COVID-19 infection in high school athletes

(2) De Sousa RAL, Improta-Caria AC, Aras-Júnior R, de Oliveira EM, Soci ÚPR, Cassilhas RC. Physical exercise effects on the brain during COVID-19 pandemic: links between mental and cardiovascular health. Neurological Sciences. 2021;42(4):1325-1334.

Authors and Affiliations: 

Garrett S Bullock, PT, DPT, DPhil1,2,3 Carolyn A. Emery, BSPT, PhD,4,5 Vicki Nelson MD,6 Albert Prats-Uribe, MD, MPH, FFPH,7 R. Gil Gilliand, ATC,8 Charles A Thigpen ATC, PT, PhD,8,9 Ellen Shanley PT, PhD, OCS8,9

1 Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine

  1. Department of Biostatistics & Data Science, Wake Forest University School of Medicine
  2. Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford
  3. Chair Sport Injury Prevention Research Centre, Faculty of Kinesiology and Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, 2500 University Dr. NW, Calgary, Alberta, T2N1N4, Canada
  4. Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, 2500 University Dr. NW, Calgary, Alberta, T2N1N4, Canada
  5. PRISMA Health, Greenville, South Carolina. 
  6. Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford
  7. ATI Physical Therapy
  8. University of South Carolina Center for Effectiveness Research in Orthopedics

Email contact: gbullock@wakehealth.edu

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