Sports-related concussion laws in the United States in children and adolescents: an updated cross-sectional review of state statutes.

OBJECTIVE

Despite growing national consensus on the importance of cognitive evaluation and structured, graduated return-to-play protocols in sports-related concussion care in children and adolescents, it remains unclear how consistently these practices are reflected in state-level legislation. The authors aimed to evaluate the extent to which current state concussion laws in the United States incorporate evidence-based practices, particularly regarding cognitive testing and specification of qualified medical professionals for return-to-play clearance in these athletes.

METHODS

A cross-sectional review of concussion laws across all 50 states and the District of Columbia as of September 2025 was conducted. Statutory texts were abstracted for provisions addressing immediate removal from play, same-day return to play, use of baseline and postinjury cognitive assessments, implementation of graduated return-to-play protocols, and medical clearance requirements with specification of provider type.

RESULTS

All 51 jurisdictions have available state-level statutes regarding concussion care in children and adolescents. All require immediate removal of athletes with suspected concussion, with 74.5% basing removal on suspicion and 25.5% requiring signs or symptoms. Fourteen states (27.5%) explicitly prohibit same-day return to play, 2 (3.9%) allow it after concussion is ruled out by sideline evaluation, and the remainder do not address it. Medical clearance is universally required for return to play; however, only 6 states (11.8%) restrict clearance authority to physicians, while most permit broader categories of healthcare providers. Eight states (15.7%) mandate a graduated return-to-play progression, although protocols vary. Only Hawaii requires baseline cognitive testing, and Rhode Island recommends but does not mandate it.

CONCLUSIONS

State concussion laws now universally mandate education, removal, and clearance before return, yet variability in coach training, return-to-play protocols, and cognitive testing exists. Aligning legislation with evidence-based standards is needed to ensure consistent protection for young athletes across the country.