Cleared to Play, Brain Still Broken: The MRI Truth About Concussion Recovery

BLUF (Bottom Line Up Front)

Athletes cleared to return-to-play still show significant brain changes up to one year post-concussion. Magnetic Resonance Imaging (MRI) reveals reduced blood flow and white matter damage persisting long after symptoms resolve and medical clearance is granted. Brain changes exceed normal variability, raising serious questions about when it's truly safe to return to contact sports.

Field Notes:

Study challenges the "symptom-free = recovered" assumption that drives most return-to-play protocols. If you've had a concussion, understand that feeling normal doesn't mean your brain has fully healed. These findings suggest we're clearing athletes too early, potentially setting them up for cumulative damage.

Concussion Protocol:

This research proves what many Traumatic Brain Injury (TBI) survivors instinctively know—recovery takes longer than the medical system acknowledges. Current Return-To-Play (RTP) protocols rely on crude clinical assessments that miss underlying pathology. An asymptomatic athlete can still have significant brain damage and increased vulnerability to subsequent impacts.

Mission Intel: Study Breakdown

The Op

• 187 varsity athletes from various collegiate sports

• Pre-season baseline MRI imaging (before any injury)

• 25 athletes sustained concussions during season

• Re-imaged at: injury, return-to-play (1-3 weeks), 1-3 months, and 1 year post-concussion

• Control group of non-concussed athletes tracked for normal brain variability

Brain Changes Observed

Cerebral Blood Flow (CBF)

• Significant drop in blood flow to frontoinsular region after concussion

• Athletes with longer recovery showed reduced blood flow in medial temporal region

• CBF changes exceeded normal year-to-year brain variability

• Only post-concussion measure that surpassed normal fluctuations

White Matter Damage (Diffusion Tensor Imaging - DTI Analysis)

• Increased mean diffusivity (water movement in brain tissue)

• Decreased fractional anisotropy (organization of white matter tracts)

• Spatial extent and magnitude increased at RTP

• Gradually declined but persisted through one-year follow-up

Physiological Response

All 25 concussed athletes eventually:

• Self-reported as asymptomatic

• Passed medical clearance

• Returned to regular athletic activities

• Yet still showed measurable brain abnormalities

Field Application

For Athletes:

• Symptom-free ≠ brain healed

• Request extended recovery time beyond standard protocols

• Consider additional rest before return to contact

• Understand cumulative damage risk with repeat concussions

For Protocols:

• Current RTP guidelines are insufficient

• Need objective neuroimaging markers, not just symptom checklists

• Consider eliminating practice head impacts (could reduce exposure >50%)

• More research needed on safe exposure thresholds

Long-term Goal: Use neuroimaging to objectively assess when risk becomes too high for continued participation. Currently, we're operating blind during the most vulnerable recovery phase.

Field Assessment: Personal Analysis

My initial reaction to this study: 100% agreement—not just in theory, but from direct experience. After my first concussion, I followed the prescribed 1-week recovery before returning to contact. The medical clearance said I was good to go. My brain disagreed. I still felt slow, dizzy, unable to function at my previous baseline. Those deficits? I still notice them today.

This raises the critical question this study doesn't answer: Is there ever true 100% recovery? Or does damage beyond a certain threshold permanently alter your baseline? Long-term research on this is sparse—maybe this log will be one of the first to document the reality.

Engineering the Recovery Protocol:

As an engineer, I apply safety factors to everything. Standard practice: if a beam needs to hold 1000 lbs, you design it for 2000 lbs. Same logic applies to brain recovery. If a doctor prescribes one week, I'm recommending a minimum safety factor of 2x—that's two weeks minimum. And even then? I'm not convinced that's enough.

Mission Critical Advice for Athletes and Parents:

Don't make my mistakes. Don't do the bare minimum recovery. If this were my child, I'd double every prescribed timeline without hesitation. Even that might not be sufficient.

Here's the reality: Every brain responds to trauma differently. There's no one-size-fits-all protocol. Express your concerns openly and honestly with your medical team. Your long-term brain health depends on it. Better to sit out an extra few weeks now than deal with permanent cognitive deficits for decades.

The game will still be there. Your brain won't regenerate.

Intel Source:

Churchill, N. et al. (2025). Post-Concussion Brain Changes Relative to Pre-Injury White Matter and Cerebral Blood Flow: A Prospective Observational Study. Neurology.

Study conducted by St. Michael's Hospital and University of Toronto research team. Lead researcher: Nathan Churchill, PhD, Toronto Metropolitan University.

Additional commentary: Michael L. Lipton, MD, PhD, Columbia University Translational Neuroimaging Laboratory.