A player may say they feel fine, yet struggle to hold a tandem stance without stepping out of position. That gap is why knowing how to conduct balance testing matters in a concussion program. Balance testing can reveal functional changes that athletes, parents, and even experienced staff may not immediately recognize. It also gives the care team an observable measure to compare over time.
Balance is not a stand-alone concussion diagnosis, clearance test, or substitute for a medical evaluation. It is one component of a broader assessment that may include symptom reporting, cognitive screening, physical examination, and clinical judgment. For athletic programs, the value comes from performing it consistently, documenting it clearly, and using the result within an established concussion management workflow.
What balance testing measures after a suspected concussion
Postural stability depends on coordinated input from the visual, vestibular, and musculoskeletal systems. A concussion can disrupt that coordination. An athlete may have difficulty maintaining a position, make more corrective movements, open their eyes when instructed to keep them closed, or step out of a stance.
Balance testing turns those observations into structured data. It can help clinicians identify an area that needs further evaluation and track whether balance deficits improve during recovery. Just as important, it creates a documented record of what was observed, when it was observed, and under what conditions.
Results need context. A poor performance can reflect an acute injury, but it can also be influenced by a lower-extremity injury, fatigue, illness, poor sleep, medications, footwear, testing surface, or an athlete’s usual balance ability. Baseline information is helpful when available, but an athlete’s current symptoms and clinical presentation always matter.
How to conduct balance testing consistently
The specific protocol should follow the tools, training, medical direction, and state or organizational policies used by your program. Common concussion assessment frameworks may use a modified Balance Error Scoring System, often called mBESS, or another standardized balance measure. Do not combine pieces of different protocols or change scoring rules midseason. Consistency is what makes results meaningful.
Prepare the athlete and testing area
Use a quiet, well-lit space with a firm, level, non-slip surface. Clear the area of bags, benches, and other hazards. The athlete should wear the same type of footwear required by the selected protocol, or follow the protocol’s instructions regarding shoes. Avoid testing in a crowded sideline area when possible. Noise, interruptions, uneven grass, and time pressure can affect both safety and performance.
Explain the test before scoring begins. Demonstrate the stance if appropriate, tell the athlete where to place their hands, and explain what will count as an error. Ask whether they have pain, dizziness, or a condition that makes standing unsafe. An athlete who is severely dizzy, unable to stand safely, or showing concerning neurological signs needs prompt medical attention rather than repeated attempts at a balance task.
Record the conditions that could affect the result. Include the date and time, assessor, setting, surface, footwear, recent exertion, known orthopedic limitations, and whether the athlete has symptoms. These details protect the integrity of the record when a clinician reviews results later.
Use the prescribed stances and timing
Many standardized balance protocols use a sequence of double-leg, single-leg, and tandem stances. In a modified BESS approach, the athlete commonly stands with hands on the iliac crests and eyes closed for a defined interval in each stance. The non-dominant foot and stance placement should be determined according to the chosen protocol, not by staff preference.
Positioning should be exact. In a tandem stance, for example, heel-to-toe alignment and the designated foot placement matter. A small variation may make the task easier or harder and can undermine comparisons with a baseline or future assessment. Start the timer only when the athlete is correctly positioned and follow the official instructions for rest periods, retries, and discontinuation.
If your protocol uses a foam surface, use the required foam pad and keep its condition consistent. If it uses only a firm surface, do not add foam because it seems more challenging. The goal is not to make the test difficult. The goal is to administer a validated procedure the same way every time.
Observe and score errors in real time
The assessor should watch the athlete closely for the specific errors defined by the protocol. Depending on the measure, errors may include removing hands from the hips, opening the eyes, stepping, stumbling, lifting the forefoot or heel, moving the hip beyond the allowed range, or remaining out of the test position for too long.
Count only the errors defined by your selected instrument. Do not score based on a general impression such as “looked unsteady.” A narrative note can add valuable context, but the formal score needs to remain faithful to the protocol. If two staff members are assessing the athlete, designate one person as the scorer to avoid duplicate or inconsistent counts.
For a meaningful result, staff need initial and periodic training. Practice scoring sample performances together, review unclear situations, and use the same written instructions. This reduces inter-rater variation, which is a common weakness in paper-based or loosely managed sideline testing.
Stop when safety or clinical concerns require it
Balance testing should never become a test of toughness. Stop the assessment if the athlete is at risk of falling, develops significant symptoms, cannot follow instructions, or has red-flag signs requiring emergency evaluation. Document why the test was stopped and what occurred.
A discontinued assessment is still clinically useful information. It should trigger appropriate escalation, not a rushed attempt to obtain a complete score. Coaches and families should understand that inability to complete testing may be more significant than a number alone.
Interpret balance scores as one part of the clinical picture
A single balance score does not clear or diagnose an athlete. Baseline and post-injury scores can support comparison, but baseline testing is not a pass that overrides current symptoms. Some athletes have naturally variable balance performance, while others may return close to baseline before their symptoms and exertional tolerance have resolved.
Medical professionals should interpret balance findings alongside the injury history, symptom pattern, neurological examination, cognitive measures, vestibular and ocular findings, and graded activity response. For youth athletes, developmental stage and communication ability may also influence performance. A younger athlete may need clearer instruction and closer observation, but staff should not relax the documentation standard.
Repeat testing should occur only as directed by the treating clinician or your program’s approved protocol. Comparing tests conducted under similar conditions is more defensible than comparing a quiet indoor baseline with a post-game sideline assessment. When conditions differ, note the difference rather than treating scores as directly equivalent.
Build balance testing into a documented concussion workflow
The operational challenge is rarely administering one test. It is ensuring that the right people can locate the result, understand its context, and act on it without relying on memory, texts, or scattered paper forms.
A complete record should connect the balance assessment to the injury report, symptoms, other sideline findings, clinical referrals, parent communication, and recovery plan. It should show who administered the test, the protocol used, the score or observation, and any decision or next step that followed. That record supports continuity when an athlete sees a different athletic trainer, physician, or school staff member.
Digital concussion management systems can reduce missed steps by placing assessments and documentation in the same workflow. For example, XLNTBrain enables organizations to capture balance testing alongside SCAT6-based sideline assessment information, symptom monitoring, recovery activities, and return-to-play documentation. Centralizing the process helps sports medicine teams provide timely visibility while maintaining clear accountability across teams and campuses.
Create clear roles before the season starts
Every program should define who may administer balance testing, who reviews abnormal findings, who communicates with parents or guardians, and who has authority over return-to-play progression. Coaches can support a remove-from-play policy and report observable concerns, but they should not be expected to make clinical clearance decisions.
Set expectations during preseason education. Athletes need to know that reporting dizziness, headache, or unsteadiness protects their recovery and their team. Parents need to know how they will receive updates. Staff need a simple process for documenting an incident immediately, even when an injury occurs during a busy road game.
Reliable balance testing is less about asking an athlete to stand still and more about creating a repeatable safety process. When the environment, instructions, scoring, documentation, and follow-up are aligned, each assessment becomes a clearer signal for the clinicians responsible for protecting the athlete.
