Objectives:

To examine level of play (LOP) as a risk factor for concussion severity and recovery-related outcomes among high school athletes, stratified by sex, and among boys, by sport (football, non-football male sports).

Design/Setting:

Secondary analysis of data collected through the High School Reporting Information Online surveillance system for academic years 2007–2008 through 2018–2019.

Participants:

A total of 9916 concussions were reported between the academic years 2007–2008 and 2018–2019 from 9 sports (5189 from football; 2096 from non-football male sports; 2631 from female sports).

Main Outcome Measure:

Examined the association between LOP (Freshman, Junior Varsity [JV], and Varsity teams) and concussion outcomes (number of concussion symptoms, symptom resolution time [SRT], and time to return to play [RTP]).

Results:

Compared with Varsity football athletes, concussed JV football athletes had on average 0.19 fewer concussion symptoms, longer SRT (>1 week vs <1 week: odds ratio [OR] = 1.3; 95% confidence interval [CI], 1.1–1.5), and longer RTP (1–3 weeks vs <1 week: OR = 1.5; 95% CI, 1.2–1.9; >3 weeks vs <1 week: OR = 1.6; 95% CI, 1.1–2.3). Compared with Varsity football athletes, Freshman football athletes had on average 0.48 fewer concussion symptoms, longer SRT (OR = 1.3; 95% CI, 1.1–1.5), and longer RTP (1–3 weeks vs <1 week: OR = 1.5; 95% CI, 1.1–2.0; >3 weeks vs <1 week: OR = 2.0; 95% CI, 1.3–3.0). Similarly, compared with female athletes on Varsity teams, concussed JV female athletes had longer RTP (1–3 weeks vs <1 week: OR = 1.8; 95% CI, 1.2–2.7). Trend analyses revealed an increase in the number of concussion symptoms between 2015–2016 and 2018–2019, a decrease between 2009–2010 and 2018–2019 for SRT of less than 1 week, and an increase between 2014–2015 and 2018–2019 for RTP of less than 1 week among Varsity football athletes. Among Varsity female athletes, there was a linear decrease during the study period for RTP of less than 1 week.

Conclusions:

Despite a higher number of symptoms overall and in recent years, Varsity football players had shorter RTP than Freshman and JV athletes.