Return to Sport After Concussion: A Clinician's Dizziness Checklist

Why Dizziness Deserves Attention in Return-to-Sport Planning

Dizziness is a familiar symptom after sport-related concussion, and for many clinicians it is one of the most clinically meaningful signals to track during recovery. From a practical standpoint, the challenge is not simply asking whether dizziness is present, but determining whether the vestibular, ocular-motor, cervical, and cardiovascular systems can tolerate sport-specific demands without symptom recurrence. This checklist consolidates the current consensus-based framework with recent literature so that vestibular rehabilitation clinicians can structure a defensible, criterion-based clearance workflow.

Contemporary management has moved decisively away from prolonged rest toward active recovery. A recent narrative review of pediatric concussion describes an initial period of brief rest (roughly 24–48 hours) followed by sub-symptom-threshold aerobic exercise, structured return-to-learn accommodations, and stepped return-to-sport protocols (Brain Sciences, 2026). For clinicians, this means the dizziness checklist is not a one-time gate at the end of recovery; it is a repeated measurement woven through every stage of progression.

The Graduated Return-to-Sport Framework

The Sixth International Consensus Conference on Concussion in Sport underpins most current return-to-play guidance. A review of sideline assessment and management synthesizes these recommendations, emphasizing recognition tools covering balance, cognition, and behavior domains, and a graduated return-to-play and return-to-learn sequence (Cureus, 2025). A clinical commentary on elite figure skaters confirms that the CISG 6th consensus statement provides an updated Return to Sport Strategy intended to be adapted across sports and disciplines (International Journal of Sports Physical Therapy, 2025), and a circus-arts extension of that statement describes a criterion-based return progression, including guidance by discipline (BMJ Open Sport & Exercise Medicine, 2025).

A note on sourcing: the supplied reviews confirm that a graduated, stepwise return-to-sport sequence exists and is criterion-based, but they do not enumerate the specific step content (for example, exercise types permitted at each stage) or step timing rules. Those specifics come from the CISG 6th consensus statement itself and from your supervising physician’s protocol. The workflow below therefore describes how to layer dizziness assessment onto a graduated progression, without prescribing step details or timing.

The Dizziness Checklist: What to Assess as the Athlete Progresses

1. Resting symptom baseline

Document symptom status at rest using a standardized instrument (for example, the symptom scale within the SCAT6/SCOAT6 family, or the Child SCAT6/Child SCOAT6 in pediatric populations—tools the pediatric review lists among current diagnostic advances). Dizziness, headache, visual strain, and cognitive fog should be rated, not merely reported as present or absent, so that progression decisions rest on measurable change (Brain Sciences, 2026).

2. Vestibular-ocular screening

Vestibular and ocular-motor screening is part of recommended contemporary assessment batteries (Brain Sciences, 2026). Practical components include:

• Gaze stability (VOR x1): head rotations in horizontal and vertical planes while fixing a stationary target; note symptom provocation and visual clarity.
• VOR x2 variations: combined head and target movement, where clinically indicated.
• Smooth pursuit and saccades: observe quality, accuracy, and symptom response.
• Near point of convergence: screening convergence is a standard component of post-concussion ocular-motor assessment; screen and refer for vision therapy collaboration when indicated (see our guide to convergence insufficiency after concussion).

Symptom provocation during these screens—dizziness, blurred vision, or nausea—is a practical signal that the vestibular-ocular system warrants further assessment before dynamic sport demands are reintroduced.

3. Balance and postural control

Static balance on firm and foam surfaces with eyes open and closed, tandem gait, walking with head turns, and dual-task conditions remain practical clinical markers. Because sideline and follow-up tools explicitly assess the balance domain (Cureus, 2025), including objective balance testing in your workflow is a reasonable way to complement self-report—whether or not the athlete subjectively feels recovered. For home-program structure between visits, see our article on walking balance exercises after concussion.

4. Visual motion sensitivity

Assess tolerance of visually complex environments—busy gyms, moving crowds, optokinetic stimuli—because many sport contexts are visually saturated. Provocation in complex visual scenes suggests residual visual-vestibular mismatch. Our articles on visual motion sensitivity exercises and on vestibular rehab for sports-related concussion offer related program ideas.

5. Symptom response to escalating physical load

The decisive clinical question is whether the athlete tolerates increasing physical load without symptom recurrence. Consistent with the sub-symptom-threshold aerobic exercise described in current management protocols (Brain Sciences, 2026), common practice is to reintroduce aerobic work progressively and observe symptom response as sport-specific movement is layered in—following the staging defined by the consensus statement and the treating physician. Coordination with the supervising physician is essential, since formal exertional testing and final clearance are medical decisions. For patient-facing context on symptom recurrence with exercise, see our article on concussion symptoms returning with exercise.

Sport-Specific Adaptation Matters

Generic protocols are a starting point, not an endpoint. The figure skating commentary highlights how rotational, vertical, and inverted elements demand staged reintroduction beyond the standard framework; the authors explicitly label this Level 5 evidence—expert commentary rather than trial data (International Journal of Sports Physical Therapy, 2025). Similarly, the circus-arts extension of the consensus statement provides criterion-based progressions, adapted Maddocks questions, and discipline-specific risk considerations, while calling for ongoing sport-specific research (BMJ Open Sport & Exercise Medicine, 2025). A systematic review in sailing found no standardized sailing-specific concussion guidance and argued for sport-specific protocols to address unique risks; the authors also noted that some referenced tools were outdated relative to newer versions (Sports, 2025). The clinical takeaway: layer your dizziness checklist with the movement demands, visual environments, and impact risks of the athlete’s actual sport.

Consider the Whole Clinical Picture

Two additional considerations strengthen the clearance decision:

• Phenotypic variability. A review of mild traumatic brain injury subgroups describes a vestibular-ocular phenotype alongside cognitive, headache, somatosensory, and affective subtypes, while cautioning that current symptom-based subtypes overlap considerably and lack consistent objective anchors (Neurotrauma Reports, 2026). Dizziness should therefore be interpreted within the athlete’s full symptom profile, not in isolation.
• Kinesiophobia. A prospective two-visit study of 66 adolescents found that higher early post-concussion symptom severity was associated with higher kinesiophobia scores, that kinesiophobia persisted across visits, and that prior musculoskeletal injury was associated with later kinesiophobia (Brain Injury, 2026). This is a modest single-cohort sample and the findings are abstract-level, but they suggest fear of movement can complicate symptom reporting during progression, so screening for avoidance behavior is a reasonable adjunct to vestibular testing.

The same graduated logic has been extended beyond athletes—a framework for law enforcement officers pairs concussion education with a graduated return-to-duty protocol (Journal of Athletic Training, 2024)—reinforcing that criterion-based progression is a general clinical principle adaptable across high-demand occupations.

Red Flags: When to Stop and Escalate

As with any head injury, certain neurological signs warrant stopping activity immediately and seeking urgent medical evaluation—for example, severe or rapidly worsening headache, repeated vomiting, slurred speech or worsening confusion, limb weakness or numbness, significant neck pain, loss of consciousness, or deteriorating behavior or responsiveness. This is generic emergency-medicine guidance rather than a list drawn from the supplied studies; verify the specific escalation criteria against current consensus guidance and your local emergency protocols.

Documentation and Clinical Workflow Tips

• Record symptom scores, vestibular-ocular screen findings, balance results, and symptom responses to escalating load at every stage, so progression decisions are auditable.
• Distinguish subjective symptom resolution from objective test performance; both strengthen the clearance narrative.
• Communicate directly with the supervising physician before contact-risk stages; final clearance is a medical decision.
• Layer sport-specific demands (rotation, inversion, visual complexity, contact risk) onto the generic protocol.

Key Takeaways

• Dizziness reported at rest, during vestibular-ocular screening, or as activity escalates is a practical signal to pause progression and reassess.
• A graduated, criterion-based return-to-sport sequence is the consensus backbone; step content and timing rules come from the CISG 6th consensus statement and the treating physician’s protocol, not from the reviews cited here.
• Sport-specific adaptations—illustrated in figure skating, circus arts, and sailing literature (largely consensus and commentary-level evidence)—matter for athletes whose disciplines involve rotation, inversion, or unusual visual environments.
• Symptom phenotypes overlap, and kinesiophobia can complicate symptom reporting; assess the whole athlete.

Learn More

If you manage athletes recovering from post-concussion dizziness, you can explore Eye Rehab’s clinician platform at Eye Rehab for Physical Therapists.

Medical Disclaimer

This content is for educational purposes only and does not constitute medical advice. Return-to-sport clearance is a medical decision made by the treating physician. Always follow local protocols and current consensus guidelines.