Officials Part of Team in Game Management of Concussions

During her junior year of high school basketball in 2008, Minnesotan Elizabeth Sullivan was in her element in a rivalry game between two schools in the northern suburbs of the Twin Cities.

While a soft, left-handed mid-range jumper or slick, athletic baseline drive were her fortes on offense, what really brought her joy was playing staunch defense and doing all those things that didn’t show up in a box score. That toughness was infectious to her teammates, applauded by fans, but also was a recipe for injury.

It happened in this rivalry game. During a play in the low post, Sullivan was firmly entrenched while absorbing a heavy charge. The force sent her backward and she hit the back of her head on the playing floor.

For a moment, all eyes were on her as she lay still. As she slowly sat up, she asked, “Did I get the call?” Smiles of relief ensued from her teammates as a school athletic trainer hustled out to attend to her.

But medical attention wasn’t for a reason we are aware of now. Instead of looking at concussion-like symptoms, Sullivan had a mouthful of blood. That was the reason she left the floor, because of the blood rule.

“I lost consciousness briefly,” said Sullivan, now a Twin Cities- based nurse practitioner who specializes in orthopedics. “I likely had a concussion, but at the time, guidelines didn’t dictate any protocols. There was no follow-up for return to play. I was back to practice on Monday.”

It is situations like this that paved the way to concussion awareness and the creation of return-to-play protocols that are implemented today. Concussion training and certification are now preseason requisites for coaches, officials and other administrators crucial to the running of a safe event.

“It takes all of us,” Sullivan said. “The partnership of all is crucial to ensure the safety of the participant. Athletes just want to get back and play. I know it stinks to have to come out of a game and to be held out of practice, but it is so much smarter for the student and their long-term health to abide by protocols at the time of the occurrence. When you have many sets of eyes on the athletes, it is in their best interest for their health and long-term care.”

While much of the conversation focuses on coaches, athletic trainers and parents, sports officials (referees, umpires and judges) also play an essential role in the recognition and management of concussions at the high school level. Officials are often on the front lines of competition, and their ability to recognize the signs of a potential head injury and respond or refer appropriately can significantly impact the health and safety of student-athletes.

It is crucial for activities administrators, onsite supervision and medical staff in attendance to understand the officials’ role in the recognition and referral criteria in concussion assessment.

A concussion is a type of traumatic brain injury (TBI) caused by a bump, blow or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce or twist inside the skull, leading to chemical changes and, in some cases, damage to brain cells.

Unlike many other sports injuries, concussions do not always involve visible signs. Symptoms of concussion may include loss of consciousness, which is easily observable, but more often than not there are less observable signs and symptoms such as dizziness, headache, light sensitivity or balance issues just to name a few. All lead to the awareness and education that are vital for anyone involved in youth sports.

High school sports officials are not expected to diagnose concussions as that responsibility belongs to medical professionals such as an athletic trainer or medical doctor. However, officials are key participants in helping to promote a safe playing environment. During the contest, officials interact directly with the participating athletes and are often the closest to the action when an impact occurs.

Key reasons officials need to be aware include:
• Immediate Observation: Officials are often the first people to see a potentially dangerous hit or fall. Their perspective allows them to recognize when an athlete may be in distress.

• Neutral Authority: Unlike coaches, who may be focused on strategy or winning, officials are independent figures whose priority is enforcing rules and promoting fair play. This neutrality allows them to prioritize athlete safety without the bias of competition.

• Enforcement of Rules: Many rules in high school sports (especially collision or contact sports like football, lacrosse, or soccer) exist specifically to prevent head injuries. Rules such as targeting in football, checking from behind in hockey, or dangerous fouls in soccer and basketball were enacted to lessen the chance of a brain injury. Officials must be consistent in enforcing these rules to minimize concussion risks.

• Legal and Ethical Responsibilities: State laws, school policies and national governing bodies emphasize concussion awareness. Failing to recognize or appropriately respond to a suspected concussion could place an official in a difficult legal or ethical situation.

While officials are not medical professionals, they should be familiar with the observable signs that may indicate a concussion. These include:
• Appearing dazed, stunned or confused

• Forgetting plays or being unsure of the score or opponent

• Moving clumsily or with poor coordination • Slow to rise after a fall or collision

• Loss of consciousness, even briefly

• Behavior or personality changes

While athletes typically report the following to coaches or trainers, officials may overhear or be informed of:
• Headache or “pressure” in the head

• Nausea or vomiting

• Dizziness or balance problems

• Sensitivity to light or noise

• Feeling sluggish, hazy or foggy

• Difficulty concentrating

If an official observes any of these warning signs, they should take them seriously and follow the appropriate protocols for removal from the contest and referral to a medical professional who ideally is at the contest.

Officials have clear roles in recognition and response. The most important principles are:
• “When in Doubt, Sit Them Out” This phrase has become a cornerstone of concussion safety. If an official observes the participant exhibiting signs and symptoms of a head injury, then the athlete should be removed from play immediately and evaluated by a qualified health professional.

• Stopping Play Safely If an injury appears serious, officials may need to stop play immediately. In contact sports, this can prevent further injury and ensure the athlete receives prompt attention.

• Communication with Coaches and Medical Personnel Officials should alert the coach or athletic trainer on the sideline when they observe potential concussion symptoms. Clear, calm communication is critical.

• Enforcing Return-to-Play Policies Officials should be aware of their state’s concussion laws and the governing body’s return-to-play rules. In nearly every jurisdiction, an athlete suspected of a concussion cannot return to play the same day without medical clearance. Officials may be asked to ensure compliance with this rule.

As of today, all 50 states and the District of Columbia have passed laws addressing concussion management in youth sports. While specifics vary, most laws include three central components:
• Education: Coaches, athletes and often officials must receive training on concussion recognition and management.

• Immediate Removal: Athletes suspected of having a concussion must be removed from play.

• Medical Clearance: A licensed health-care provider must clear the athlete before returning to play. Depending on the state, the health-care provider that is allowed to clear the athlete for return varies.

To fulfill their responsibilities effectively, officials should adopt the following best practices:
• Complete Required Training: Take concussion awareness courses offered by NFHS, state associations or other reputable organizations. Refresh this knowledge annually.

• Know the Rules of the Sport: Many sports have rules designed to minimize dangerous contact. Strict enforcement not only ensures fairness but also protects athletes.

• Work as a Team: In multi-official crews, communicate with one another about potential injuries. If one official sees an impact from a better angle, they should share their observations.

• Stay Neutral and Firm: Officials may face pressure from coaches, players or fans to keep a key athlete in the game. Officials must remain impartial and prioritize safety above competition.

• Document Serious Incidents: While the school or athletic trainer usually handles documentation, officials should make brief notes about incidents they observed, in case questions arise later.

• Promote a Culture of Safety: By enforcing rules consistently and showing attentiveness to injuries, officials help create an environment where safety is valued as much as performance.

Concussions can have long-lasting consequences for young athletes, including problems with memory, concentration and mood. In rare cases, repeated concussions can lead to life-threatening conditions such as second impact syndrome or long-term neurological issues.

By being vigilant and proactive, high school sports officials contribute to the larger effort of protecting student-athletes. Their role as observers, enforcers and communicators makes them essential partners in the fight against concussion-related injuries.

Tim Leighton is communications coordinator for the Minnesota State High School League, and he is a member of the High School Today Publications Committee.

Mike Carroll, M Ed, LAT, ATC, is assistant athletic director and head athletic trainer at Graham (Texas) High School, and he is a member of the High School Today Publications Committee.