The Link Between Concussion and Lower Limb Injury in Athletes


Concussion and Injury in Athletics

There is no question that participation in any type of physical activity comes with inherent risk of injury. When it comes to competitive sports, particularly contact sports, the risk increases exponentially. In recent years, there has been much discussion about the risks of concussion in elite athletes, particularly in sports like football and soccer, where play is fast and intense, and bodies collide with momentous force.

In light of research linking cognitive dysfunction and decline in retired athletes to concussion incurred on the playing field, athletic teams and leagues have been forced to establish guidelines for diagnosis and management of concussed players. After years of litigation, in response to a class action lawsuit, the National Football League Concussion Settlement Program began accepting claims from concussed players in March, 2017. Now new evidence suggests that concussion can lead to acute musculoskeletal injury, even after an athlete has been cleared to return to play.

More Than Just Cognition

Since the onset of discourse about concussion in athletics, a great deal of research has been conducted on the topic. Recent studies reveal that damage to the brain from concussion goes beyond cognitive function, extending to dynamic movement performance on the playing field. In other words, brain damage in concussed athletes can set them up for performance deficits and injury after return to play.

In a study of Division I college athletes from a variety of sports over a three year period, Lynall et al. (2015) found that concussed athletes were at increased risk for lower extremity injury for as long as a year after return to play. Scrutinizing the medical records of previously concussed athletes and comparing their risk for injury to that of non-concussed athletes, data revealed that as late as one year post-concussion, concussed athletes were almost twice as likely to suffer an acute lower limb injury during play. The study’s authors suggest that neuromuscular and postural control deficits are to blame for the increased rate of injury. They propose that disrupted cortical pathways after concussion may play a role.

The Shortcomings of Assessment

One of the issues in assessing athletes for concussion is the difficulty of subjective testing. Most assessment rely on feedback from the athlete, which can be skewed for several reasons, according to Robert Lynall, the head researcher of the study. In a podcast interview with Dr. Andy Franklyn-Miller, Lynall explained that players often try to hide a concussion and mask its symptoms. Particularly at the elite level, athletes want to remain on the playing field, and a concussion means time out of play, putting their position on the field at risk.

The Need for Dynamic Functional Assessment

Lynall goes on to say that neurocognitive tests for balance and gait used to assess concussion are insufficient to evaluate dynamic movement of the type performed on the playing field. He calls for further research to develop assessments that are at the same time objective and sport-specific, both for cognition and dynamic movement. He also highlights the need for future research to uncover the specific mechanisms that link concussions to increased injury risk.

Cutting Edge Sports Physical Therapy in NYC

Injured athletes of all types require specific treatment by physical therapy sports medicine professionals who understand their needs. For sports physical therapy in New York City, NYDNR has cutting edge equipment and trained experienced professionals who can analyze, assess and treat sports and athletic injuries. NYDNR offers sports physical therapy services for Injury Risk Assessment, Gait Analysis, Functional Movement Analysis and Balance Assessment. Our unique Computer Assisted Rehabilitation Environment (C.A.R.E.N) offers a virtual reality environment, using technology developed for the military, to correct and teach healthy functional movement.

REFERENCE: Lynall, RC et al. (2015). Acute Lower Extremity Injury Rates Increase following Concussion in College Athletes. Medicine and Science in Sports and Exercise, 47(12), 2487-2492.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

Buy now 3D Gait
Payment Success
Request TelehealthRequest Telehealth Request in office visit Book now