Post-Concussion Nutrition Documentation in the Sports RD SOAP: The Symptom-Onset-to-Fuel Timeline Chart, the DHA-Creatine-Riboflavin Stack the Literature Supports, and the Return-to-Sport Handoff to the Athletic Trainer and Team Physician

A 19-year-old NCAA wrestler is referred to the sports RD 72 hours after a mat concussion diagnosed on the sideline by the team's certified athletic trainer, confirmed by the team physician, and staged into the standard graded return-to-play protocol. The AT has the athlete at stage 2 (light aerobic activity). The strength coach wants to know when the lifting can resume at pre-injury loads. The team physician has cleared the neurologic exam and set the next re-evaluation for day 7. The referral to nutrition reads, in full: "post-concussion, please assess for return-to-sport nutrition support."

That referral is the entire prompt the sports RD is given. Nothing about the pre-injury intake baseline, nothing about symptom pattern, nothing about GI tolerance, nothing about the athlete's supplement stack, nothing about the sleep architecture the concussion may have disrupted. The intake either builds the six-dimension workup that this case actually requires — and produces a chart the AT, the strength coach, and the team physician can read against — or it produces a generic "eat a Mediterranean-style diet, hydrate, avoid alcohol" handout that adds nothing to the multidisciplinary plan and does not defend the sports RD's role in the return-to-sport algorithm.

This post is the structured post-concussion nutrition workup for the sports RD. It is not the return-to-play staging (that is the AT and team physician's algorithm) and it is not the neurocognitive testing (that is neuropsychology's). It is the fueling, hydration, micronutrient, and evidence-supplemented plan that runs in parallel with the graded return-to-play protocol and that must be documented in a way the rest of the sports-medicine team can act on.

The concussion pathophysiology the fueling plan responds to

The standard concussion is a diffuse axonal shear injury that triggers a neurometabolic cascade — glutamate release, potassium efflux, calcium influx, mitochondrial dysfunction — that leaves the injured brain in a state of elevated energy demand and reduced energy supply for roughly 7 to 14 days in an uncomplicated case, longer in a symptomatic-persistent case. The brain's resting glucose demand rises. The mitochondrial capacity to meet that demand is compromised. Cerebral blood flow autoregulation is disrupted for 3 to 10 days. Sleep architecture is disturbed. Autonomic tone shifts, most commonly toward sympathetic dominance, which affects heart-rate recovery, GI motility, and thermoregulation. Vestibular and oculomotor pathways are frequently involved and drive nausea that compromises the intake independent of any GI pathology.

The fueling plan does not accelerate the neurologic recovery. What it does is remove the modifiable barriers to that recovery: caloric adequacy against the elevated demand, DHA availability for membrane repair and inflammatory resolution, cellular-energy substrate (creatine, glucose availability) to support mitochondrial function, micronutrient repletion where deficiency would exaggerate the symptom burden, and a GI-tolerant delivery pattern the concussed athlete can actually eat. The sports RD's job is to identify each of those and chart them defensibly.

The six-dimension SOAP frame

The post-concussion SOAP note that the AT and team physician can act on carries six clinical dimensions on the assessment side, not the generic three. Each dimension gets a subjective read (what the athlete reports), an objective read (what the chart shows or what the RD measures), and a plan entry.

Dimension 1 — Symptom-onset-to-fuel timeline. Chart the exact time of injury, the time of last full meal before injury, the time and content of the first food/fluid intake after injury, and every intake episode since. Concussed athletes commonly under-eat for 24 to 72 hours after the event, sometimes because they were held for observation, sometimes because nausea suppressed intake, sometimes because photophobia and screen avoidance disrupted normal meal cues. That deficit is the first thing the plan corrects and the first thing the AT and strength coach need to know about — an athlete at stage 2 of return-to-play who has been in a 2000-kcal deficit for 3 days is not the same physiologic case as one who has eaten normally.

Dimension 2 — Symptom severity and pattern. Use the same symptom checklist the AT is using (SCAT5 symptom evaluation, or the team's equivalent) and document the current score, the trend since injury, and the specific symptoms that affect intake. Nausea, headache, photophobia, dizziness, sleep disturbance, and fatigue each have different fueling implications. A headache-dominant presentation raises the riboflavin question. A dizziness/autonomic-dominant presentation raises the sodium/hydration question. A sleep-disturbance presentation raises the caffeine-timing and evening-fueling question.

Dimension 3 — Autonomic-dysregulation screen. Ask about orthostatic symptoms, exercise heart-rate response since injury, and thermoregulation. If the athlete reports lightheadedness on standing, exaggerated heart-rate response to stage-2 aerobic work, or feeling cold or hot in inappropriate settings, autonomic recovery is incomplete and the fueling plan should include a deliberate sodium and fluid protocol against the plasma-volume side of that dysregulation. Autonomic dysregulation is one of the more common drivers of prolonged post-concussion symptoms and one of the more underrecognized ones in the nutrition consult.

Dimension 4 — GI-motility and tolerance read. Ask about post-injury bowel pattern, food aversions, appetite pattern across the day, and any nausea trigger identified. Concussion-related autonomic shift commonly slows gastric emptying. The athlete who cannot tolerate a full meal at pre-injury volume needs a small-frequent-meal plan with liquid calorie support, not a "eat more protein" instruction that they will not comply with. Chart the tolerated meal size and the tolerated food textures explicitly.

Dimension 5 — Macronutrient and total-energy adequacy against the elevated demand. Estimate pre-injury total energy needs from the athlete's baseline (training load, RMR estimate, body mass). Add 10 to 20 percent for the elevated resting metabolic demand of the acute-phase brain injury — the literature on RMR in the acute concussion window is limited but consistently shows a modest elevation, and the cost of undershooting during the recovery window is real. Target protein at 1.6 to 2.0 g/kg to support tissue repair and to support the exercise the athlete will resume through the graded return-to-play. Target carbohydrate at 4 to 6 g/kg through the acute window to support cerebral glucose demand — this is not the phase to run a lower-carb pattern. Target fat at 25 to 35 percent of total energy with an explicit omega-3 emphasis.

Dimension 6 — Micronutrient and hydration status. Chart hydration status (urine color if not clinically contraindicated, thirst pattern, orthostatic symptoms), and screen for the specific micronutrients that either have direct concussion literature or that the athlete is at risk for based on the intake pattern: vitamin D (baseline status if known; the concussion literature is thin here but the general athletic-population deficiency rate makes it a defensible screen), magnesium (implicated in NMDA-receptor regulation post-injury; low intake worth flagging), and iron (particularly in menstruating female athletes and in endurance-dominant sports where ferritin is already the differential).

The evidence-supplemented stack the RD should own

Four supplement questions come up in every post-concussion nutrition consult. The RD's job is to answer each one with a defensible read of the literature, not to hand the athlete a five-supplement stack because the internet said so.

DHA at the pharmacologic dose. The concussion-and-DHA literature (largely translational work with growing human data) supports a pharmacologic-range DHA dose — commonly 2 to 3 g/day of combined EPA+DHA with a DHA emphasis — through the acute and subacute phase of recovery, based on DHA's role in membrane phospholipid repair, neuroinflammatory resolution (specialized pro-resolving mediators), and BDNF signaling. This is a range where a diet-first approach (fatty fish 2 to 3 times per week) will not reach the target in most athletes and where a fish-oil supplement with a clearly labeled EPA+DHA content is defensible. Chart the specific dose recommended, the specific product characteristics (EPA+DHA per serving, form as triglyceride or ethyl ester, third-party certification for NCAA/WADA compliance if the athlete competes under those rules), and the duration (typically 4 to 8 weeks with reassessment).

Creatine as the cellular-energy substrate. Creatine monohydrate at 5 g/day has a growing body of literature in traumatic brain injury and concussion, based on its role as a phosphocreatine substrate for cerebral energy metabolism and its ability to cross the blood-brain barrier at supplemental doses. The athlete who was already on creatine for training purposes continues it. The athlete who was not can start it — 5 g/day, no loading protocol required in this context, third-party-certified product. Chart the rationale explicitly so the strength coach and AT see that the creatine is not being started for training performance in the return-to-play window but for the cerebral-energy indication.

Riboflavin against the migraine-spectrum symptom overlay. Post-concussion headache that carries migraine features (unilateral, throbbing, photophobia, phonophobia, nausea) responds in some patients to riboflavin at 400 mg/day, based on the migraine-prophylaxis literature that extends into post-traumatic headache. This is a specific indication, not a routine addition — chart the symptom pattern that justifies it and defer to the team physician on any pharmacologic overlay. Riboflavin at this dose is safe, cheap, and evidence-supported for the migraine-pattern athlete; it is not for the athlete without headache or with a non-migraine headache pattern.

The melatonin question the RD should not answer alone. Melatonin comes up in every post-concussion consult because sleep disturbance is nearly universal. The pediatric-and-adolescent-concussion literature supports melatonin in the 3 to 10 mg range for sleep initiation in the acute-to-subacute window, but the dose-response, the duration-of-use question, and the interaction with any concurrent pharmacologic sleep support belong to the team physician's read. The RD's job is to raise the question in the SOAP, document the current sleep pattern, and coordinate with the team physician on whether melatonin becomes part of the plan.

What the SOAP looks like on the page

The assessment section reads through the six dimensions in order — timeline, symptoms, autonomic, GI, macronutrient/energy, micronutrient/hydration — with the objective data on each. The plan section is written as three parallel tracks: fueling plan (energy target, protein target, carbohydrate target, fat target, meal frequency and volume tolerance, hydration and sodium prescription), supplement plan (each product with dose, rationale, duration, and reassessment trigger), and coordination items (specific messages to the AT, the strength coach, and the team physician).

The coordination items are what most post-concussion nutrition SOAPs are missing and what make the note actionable for the rest of the team. Example entries:

• To the AT: "Athlete is currently tolerating small-frequent-meal pattern (5 to 6 meals/day) with intact appetite at breakfast and lunch, reduced appetite and mild nausea in the evening. Recommend timing stage-3 aerobic work in the morning window if possible."

• To the strength coach: "Estimated 1800 kcal cumulative deficit over the 72 hours post-injury has been corrected as of today; expect return of normal training-load carbohydrate needs by day 7. Not yet ready for pre-injury loading volumes; will re-assess energy status at day 10."

• To the team physician: "Sleep-onset difficulty and unrefreshing sleep reported. Not initiating melatonin from the nutrition side pending team physician's read on any pharmacologic sleep support already prescribed. Requesting decision by day 5 if sleep pattern does not improve."

Without those coordination items the note lives in the RD's chart and never reaches the rest of the team. With them, the sports RD is a documented participant in the return-to-sport algorithm, not an adjunct consultation.

The reassessment schedule and the return-to-sport clearance note

Schedule the first nutrition follow-up at day 5 to 7 post-injury (aligned with the team physician's re-evaluation cadence), and a second at day 10 to 14. At each follow-up, re-run dimensions 1 through 4 (timeline, symptoms, autonomic, GI), re-check macronutrient adequacy against the current stage of return-to-play, and re-evaluate the supplement stack against symptom trend.

The return-to-sport clearance note from nutrition is a specific document (see the return-to-sport nutrition clearance documentation guide for the full template). It states, in one page: current energy adequacy against pre-injury training load, current supplement stack and duration expected, resolved GI and autonomic barriers to full fueling, and the transition plan back to pre-injury nutrition pattern including any supplements to continue past the return-to-sport threshold. The AT, the strength coach, and the team physician each get a copy alongside their own clearance documentation. That is the handoff the sports RD's role in the concussion algorithm is documented against.

Where Calsanova fits

Calsanova's SOAP-note workflow supports the multi-dimensional post-concussion assessment as a structured template: the timeline chart, the symptom-severity tracker, the coordination-items block for AT/strength coach/team physician, the supplement plan with dose and duration and reassessment trigger, and the return-to-sport nutrition clearance note as a discrete document that ships to the rest of the sports-medicine team on release. Multidisciplinary sports-medicine handoffs live or die on documentation quality; the platform is built for the sports RD who is documenting into that context, not around it.

[Start your Calsanova trial](/signup?role=dietitian) — the SOAP workflow, the supplement-plan template, and the return-to-sport clearance document are configured for the sports-medicine-team-embedded RD from day one.