Sports/American Football & Concussions – A Love/Hate Bond

Bernadette Keefe M.D.



“If just 10% of the mothers in this country think that football is a dangerous sport, then that is the end of football” – The NFL 

The sports of American football, European football (U.S. soccer), ice hockey (a Canadian favorite), wrestling, lacrosse, and field hockey, among others, are associated with a significant risk of concussions. In the early 2000s, investigations of early, untimely deaths of several retired National Football League (NFL) players, showed similar microscopic findings in their brains. With this discovery, the disease of chronic traumatic encephalopathy (CTE), associated with multiple concussions on the football field, was introduced to the world.

Concussion, The Movie

League of Denial, The Documentary 

“You’re going to war with a corporation that owns a day of the week! “

Two books, one feature film and one television documentary have been released recounting the story of Dr. Bennett Omalu, the man who linked characteristic brain abnormalities, which he later named chronic traumatic encephalopathy, to the progressive dementia and erratic behavior in the pro-football players he studied. Countless scientific articles have been written, and the issue of traumatic brain injury in contact sports has now become front-page news. 

Concussion Movie Trailer 

The film is a dramatic portrayal of the damage that repeated concussions have upon the brain. It is presented through the eyes of a passionate and gifted forensic pathologist, an expert in neuropathology, Dr. Bennet Omalu. He connected the neuropathological findings he was seeing in a dead NFL player’s brain, the brain of Mike Webster, with an entity reported in boxers (dementia pugilista, or punch-drunk syndrome) due to repeated blows to the head. Dr. Omalu described the constellation of neuropathological findings as chronic traumatic encephalopathy (CTE), changing forever, the world of contact sports.

League of Denial

The Frontline Documentary of Brain Injury and the NFL

 This documentary produced by the Frontline Program of PBS (Public Broadcasting Service) gives an even more unvarnished and complete look into the history of brain injury and the NFL, regarding this issue. The answer is buried in a document granting disability payments to Mike Webster, former center for the NFL team, the Pittsburgh Steelers, who was suffering from severe dementia: exhibiting symptoms of confusion, depression, and insomnia. In the disability agreement, the NFL admitted that Mike Webster’s injuries had been caused by his years of traumatic hits in the NFL. The year was 1999. Notably, the document referred to even earlier admissions by the NFL.

League of Denial – Trailer

Watch Full Documentary Online – (2 hours)

From the end of League of Denial:

You’ve got the most popular sport in America on notice. You’ve got the very real question being asked whether the nature of playing the sport exposes you to brain damage…. 

These additional two videos, produced by ESPN (the sports media network), offer a revealing look.

Mixed Messages on Brain Injuries (click to watch)

In interview with former football player, regarding Mike Webster,

“by the end he was at sea in an open boat unless someone was there to lead him. I don’t think he would have passed grade school.” 

What Is CTE?

Peering Into The Battered Brain 

(video by: Alex Hogan and Hyacinth Empinado for Stat News article, “After concussions, young football player’s plea: Donate my brain to science“)

CTE, or chronic traumatic encephalopathy, is a pathologic diagnosis, made after a person has died. It is the term used when a constellation of specific abnormal changes are seen under the microscope, in the brain of a person with a history of traumatic head injuries. In CTE there is deposition of abnormal protein (called ‘tau’ ) in characteristic regions of the brain (particularly, sulcal, periventricular, subpial, and more sparsely, in the frontal and temporal cortex). In advanced CTE, there is significant loss of brain tissue (brain atrophy).

Deposition of tau proteins is also seen in other neurodegenerative diseases, including Alzheimer’s disease. However, the classic location of deposition of tau, the relatively early age of death, the history of traumatic head injuries, and the clinical presentation of progressive dementia and volatile, even suicidal, mood swings, differentiates CTE from the others.

Screen Shot 2016-01-23 at 5.49.09 AM.png

The above collection of images shows three PET (positron emission tomography) scans, the left hand image is normal brain (the control), and the middle and right images show abnormal brains in two different neurodegenerative diseases, CTE and Alzheimer’s disease (AD), respectively. As the caption notes, the areas of highest levels of abnormal tau protein appear red/yellow; medium, green; and lowest, blue. Note the significant differences in the locations of tau deposition between CTE and AD.


The diagnosis of CTE is made at brain autopsy where the brain is weighed, cut into sections and examined under the microscope after appropriate staining techniques.

The six images above demonstrate the key differences between normal brain and CTE. The upper 3 images are cut sections of whole brain, and the lower 3 images are the corresponding microscopic slides.

Normal brain is depicted by the pair on the left, while the middle and right pair of images show CTE (two different brains).

Note the following features in the lower two abnormal images: scattered, large, irregular brown splotches (special ‘dyes’ for tau identify deposition of the protein, ‘tau tangles’), and severe disruption of the uniform lacy appearance of brain. The upper two abnormal brain cut sections show loss of brain tissue ‘brain atrophy’, and, the brown discoloration of the tau proteins.

Many individuals found to have CTE after death, have had years long history of abnormal behaviors and mental/neurological health issues such as, memory loss, paranoia, parkinsonism, anxiety, aggression, confusion, impaired judgment, impulse control issues, violence (self-harm, harm to others) depression and progressive dementia.

In the Frontline documentary, an interview with Mike Webster showed his early troubles with cognition. Watch Now

There is a designated brain lab in Boston (headed by Dr Ann McKee and others, comprised of researchers from the Veterans Administration and Boston University) for the examination of the brains of deceased football players. Ongoing data is being released from that lab. Thus far, they have found that 87/91 former NFL players had CTE, and 131/165 individuals with brain exams showing CTE, had history of playing some football (pro,semi-pro,college, high school).

Notably, an actuarial report, submitted by the NFL in their settlement negotiations with the player’s union in 2013, indicated that at least 1/3 of their football players will suffer from CTE, and early dementia. Current research suggests that CTE is associated with both concussions and multiple subconcussive hits. However, we still don’t know the minimal, threshold numbers of head hits and concussions, which cause CTE, or whether there is a genetic component to CTE, among other questions.

What Is A Concussion?

A concussion is a clinical diagnosis, made by a professional trained to evaluate this injury, usually caused by a blow to the head.

Normally, the brain (a very soft organ, similar to soft tofu) has adequate dual protection; from the fluid which surrounds it (cerebrospinal fluid),and the boney skull which encases it. However, if our bodies or heads are subjected to significant outside force, the brain shakes within and crashes into the skull. When this occurs, axons, the long slender projections of brain cells that carry messages, stretch and tear, producing characteristic symptoms, and leading to short lived functional impairment.

Common signs and symptoms of a concussion include the following:

  • Headache or a feeling of pressure in the head.
  • Temporary loss of consciousness.
  • Confusion or feeling as if in a fog.
  • Amnesia surrounding the traumatic event.
  • Dizziness or “seeing stars”
  • Ringing in the ears.
  • Nausea
  • Vomiting


Above is an NIH summary info-graphic on concussions. It describes the concussion crisis as becoming an all to frequent occurrence in the game of football, what happens during a concussion, and why they occur, and lists the most common accompanying symptoms.

Not uncommonly, concussions are described as ‘mild traumatic brain injury”. That is because concussions are graded: mild, moderate and severe, depending on symptoms (particularly loss of consciousness). As 90% of concussions are of the ‘mild’ variety (meaning no loss of consciousness), the term mild traumatic brain injury (mTBI) is used interchangeably with concussion. It is worth emphasizing that the word ‘mild’ in no way lessens the importance of the event.

Sports injuries are only one of the causes of concussions, located within the category:’ head/body collisions with people or things’. The percentage breakdown of the common causes of concussions are (from CDC data): falls (40.5 %), car accidents (14.3%) head/body collisions with people or things (15.5%), assaults (10.7%) , military (19%). There are estimated to be at least 4 million sports-related concussions in the U.S. each year.

Concussions have been shown to occur with a wide range of helmet G-force sensor readings, anywhere from 50 G to 150 G.. (G-force is a unit of measurement involving mass and acceleration.) Football players today are larger in size (mass) but are just as fit (speed), thus they can inflict a greater amount of force on each other, than in past years.


What Are Subconcussive Hits?

There is increasing interest in what is termed subconcussive hits; those head hits (counted through helmet sensors, or video) that do not produce a concussion, but seem to cause additive brain injury over time. Subconcussive hits have for the most part G-Force helmet readings in the 40-80 G range. Football players with multiple head hits but no documented concussions, are becoming symptomatic, and the case of Owen Thomas* is alarming. There is growing suspicion, and early research, that suggests subconcussive hits alone, over time, may cause permanent brain injury.

*Owen Thomas, was a football lineman at University of Pennsylvania owen-thomaswho committed suicide in 2010 at the age of 21. His brain showed the classic findings of CTE, and, up to now, he is the youngest football player with that diagnosis. Shockingly, however, Owen Thomas had never had a documented concussion. His brain injury occurred from countless subconcussive hits throughout his high school and college football care

Go-To Concussion Information 

The 4 infographics/ posters below have ‘at-the-ready’ information on the following: the major symptoms of concussion, the immediate action plan (the four Rs), and the ‘return to play’ protocol (often called the concussion protocol). If you are a parent, or a high school /collegiate athlete, it might be very useful to have a copy of these on your refrigerator, and in your athletic bag, or on your person.

Concussion Symptoms


This is a poster provided by the CDC, engaging the youth athlete to know the symptoms, to report, and to take time to recover.

The Four Rs: Actions after Concussion


I like this because of it’s simplicity. However, there are some recent adjustments to ‘Rest’. An early exercise regimen (monitored, very light) is being recommended by some (in setting mild TBI).

The ‘Return To Play’ Protocol /The Concussion Protocol


Given that every athlete is desperate to return to the field, this part of concussion treatment, the ‘Return-to –Play” gets the most attention. The essence of return to play is that it is a monitored, gradual, exercise program with medical check-in (for symptoms, worsening) at each stage.

The Canadian Ice Hockey –Return to Play Protocol


High School /College Sports Related Concussions

The brain is still developing in teens and even into the early 20s, therefore head trauma in high school and college sports play is especially concerning.

“The specific changes that follow young adulthood are not yet well studied, but it is known that they involve increased myelination and continued adding and pruning of neurons. As a number of researchers have put it, “the rental car companies have it right.” The brain isn’t fully mature at 16, when we are allowed to drive, or at 18, when we are allowed to vote, or at 21, when we are allowed to drink, but closer to 25, when we are allowed to rent a car. “ -MIT: Young Adult Development Project


Worryingly, an increasing percentage of sports injuries are concussions. Some of the increase may be the increasing size and weight of players. Youth concussion regulations are hoping to combat this using minimum ‘age to play’ requirements, banning head hits, and training of coaches and players.


The following high school sports are associated with the most concussions. (The numbers given are number of sports concussions per 100,000 athletic exposures (defined as the total of every practice and game.)

  • Football: 64 -76.8,
  • Boys’ ice hockey: 54,
  • Girl’s soccer: 33
  • Boys’ lacrosse: 40 – 46.6
  • Girls’ lacrosse: 31 – 35
  • Boys’ soccer: 19 – 19.2
  • Boys’ wrestling: 22 – 23.9
  • Girls’ basketball: 18.6 – 21
  • Girls’ softball: 16 – 16.3
  • Boys’ basketball: 16 – 21.2
  • Girls’ field hockey: 22 – 24.9
  • Cheerleading: 11.5 to 14

Gradually, regulatory agencies are making changes to increase safety in youth sports All but three states in the U.S. have concussion laws, most of which focus on education of coaches, parents and athletes, mandate immediate removal from play, and require a return to play medical consult.

Screen Shot 2016-01-24 at 7.46.21 AM

Some sports specific regulations are also being released. The U.S. Soccer Federation just issued new guidelines, which include banning heading the ball in children age 10 or younger, and, allowing players 11-13 to head the ball only in practice (presumably a more controlled environment).

Protective Equipment Myths:

1) Helmets 

“The right helmet will solve the problem”

Screen Shot 2016-01-14 at 1.22.40 PM

The tweet above, quoting the NFL’s senior vice president of health and safety, shows the misleading information the NFL continues to disseminate about concussions. Helmets do not protect the brain from the concussion. Helmets can only protect the boney skull from fracture, or, if lucky, crush type injury (as seen in auto, motorcycle accidents.)

2) Thick headbands


The Ad is accompanied by wording: ‘Protect Your Brain”. No, this is, simply, some skull protection. Perhaps its greatest value is as a reminder that the head is worthy of protection!

What Can You Do?

Current athletes, and families:

  1. Be aware of the facts about concussions (prevention, diagnosis, and treatment), understand the particular sport risk, and keep track of your (or your child’s) head hits and concussions.
  2. Be mindful of the ‘silent concussion’: classic concussion symptoms but the head injury is not reported, and unattended (particularly in children or older persons).
  3. Have healthy habits: good nutrition, adequate sleep, minimal, or no alcohol, and no drugs.
  4. Follow the new sports play protocols regarding head protection during games and practices (ie “Head Up” programs etc ) Change your behavior, if you tended to use your head in sports.
  5. Be attuned to neurologic symptoms, changes in thinking or behavior. Don’t hide them from your coaches or family, and seek professional help right away.
  6. Try to put in perspective the relatively short life of an athlete with overall lifespan, and wellness throughout life. Sport is wonderful, but think ahead to life after athletics too.

Former athletes (contact sports)

  1. Be aware of the facts related to head hits, compose a log of your head hits history and other health history (especially your emotional status and mental functioning). Understand that you might be at risk for CTE.
  2. Make sure your physician knows your athletic history, even if you played 30 years ago.
  3. Don’t panic; if you have NO symptoms, take care of yourself, and consider entering a study a research study.
  4. If you have ANY symptoms, see a physician, get evaluated and treated.
  5. Make sure your close friends and family understand your concern, so they can be aware of any changes and offer timely support.

Sports Organizations  

1.) Transparency regarding the association of concussions to permanent brain injury, including the possible association of subconcussive hits to permanent brain injury.

  1. Technologic monitoring of players (ie helmet sensors) to continue to collect data, useful for the reduction in head hits and brain injury.
  2. Adjustment in Rules of the games, such as the pro football changes: banning helmet to helmet hits, and adjusting the kick off return line etc.
  3. Provide education and training of the players and coaching staff as to the risks associated head hits and how to avoid.
  4. Put in place appropriate youth age restrictions and safety regulations.
  5. Strict adherence to established medical guidelines on the handling of concussions, without exception.

Player Pushback/ Player Support 

Oddly enough, there has been some significant pushback from some prominent, and vocal, NFL players on the new rules banning helmet to helmet hits, and targeting the head. These players chief objection center around the fact that, with those rule, players are targeting each other’s knees instead. While a concussion injury has long term, devastating consequences, a knee injury requires longer term absence from the game, with the possibility of the injury being ‘career-ending’.

Gronkowski: So, if we’re sitting here and I had to choose, would I take a concussion right now or would I want my knee blown out, I’m gonna say a concussion.

Rome: Still?

Gronkowski: Yeah. Why would I want to sit there for eight months and not do anything when, with a concussion, I’ll just wake up and I’ll be ready to go again.

Ron Gronkowski , New England Patriots

Interview by Jim Rome on Jim Rome Show with – Huff Post LINK

 Other players would rather the hard hitting game now, and simply not worry about the future consequences, as Chris Conte states below: 

I’d rather have the experience of playing in the NFL and die 10 to 15 years earlier than not play in the NFL and have a long life,” said Conte, who signed a one-year contract with the Tampa Bay Buccaneers in March. “I don’t really look toward my life after football. I’ll figure things out when I get there.”- Chris Conte, Tampa Bay Buccaneers (read more)

Other players, who I might say, are more enlightened, support the new regulations and behavior change around the treatment of concussions in the NFL: see Thomas Davis’ comment below:

“I think the league has taken a better stance, and we’re doing a much better job of holding guys out and allowing guys to get back healthy. And I think that’s very important for guys moving forward, not just throughout the weeks they are playing in the NFL, but for their life, long-term.” – Thomas Davis, Carolina Panthers

from Sports Illustrated Online: The NFL’s Concussion Problem

 Current Areas of Research

Concussion research today is focusing on pre-mortem diagnosis, genetic predisposition, and the threshold number of hits.

“The hope would be if you could identify them while they are in the early states that they could be treated,” said Bailes, who describes the search for a way to identify the disease in living people as the “Holy Grail” of CTE research. – Julian Bailes M.D. , Neurosurgeon

Multiple research centers and organizations including the NCAA*, the Pentagon and the NIH* have concussion investigations ongoing. They hope to be able to, one day, be able to diagnose traumatic brain injuries sooner, pre mortem, so treatment can be started, and, to discover the factors which predispose athletes to CTE, thus enabling effective prevention.

A description of this research follows:

“Through blood analysis, advanced brain imaging, genetic tests, cognitive screenings, and more, researchers will attempt to see what exactly happens to a concussed brain, how long it takes to recover, and if there is any way to speed healing. Some athletes will even wear helmets and other equipment rigged with sensors so researchers can track hits and directly correlate them with injuries” –Stat News

There is some early research implicating APOE gene expression in individuals with suspected CTE. (The APOE 4 gene variant is also associated with Alzheimer’s disease.)

The study participants with CTE were more likely than people without the disease to express the APOE gene, which is associated with slower recovery and worse cognition after traumatic brain injury; it’s also associated with later development of Alzheimer’s disease. – Julian Bailes M. D. –Neurosurgeon (CNN article)

Current treatments for suspected CTE

The pathology seen in CTE, the plaque deposition, tau tangles, and brain destruction, are permanent. Supportive, symptomatic treatments are the only options. Such treatment could include cognitive therapy and medication for depression, other mood changes, protection if suicidal, and dementia care. Lifestyle modifications, such as monitored exercise (non contact), adequate sleep, nutritious diet, no drugs, alcohol, or tobacco, are also recommended. Family and friends can provide an important social support and are useful for monitoring behavior changes over time.


The Tragedy and the Beauty of America’s Game

Remembering our modern day gladiators. . .


. . .the grace in the game



Post Scripts 

1) NFL Settlement with the Players Union

In case you wondered about further legal action against the NFL for withholding scientific information on brain injury associated with the game, they settled the case in such a way so that won’t happen. The core of the agreement is a fund of 750 million dollars to pay for medical care, general care for former players with dementia, symptoms of CTE, and research. There was no admission of guilt, The league would not have to answer questions in court.  

“The settlement likely means the NFL won’t have to disclose internal files about what it knew, and when, about concussion-linked brain problems.” – ESPN 

“Everyone now has a better sense of what damage you can get when you play football. The NFL has given everybody 750,000 reasons why you don’t want to play football”. – League of Denial

2) Definitions *

NCAA: the U.S. National Collegiate Athletic Association

NIH: the National Institutes of Health

Pathologist – physician trained to examine specimens of body tissue taken either before or after death

Neuropathologist – a pathologist with particular expertise in the normal and pathological appearance of brain diseases

Cerebro-spinal fluid (CSF) – normal fluid surrounding the human brain

Concussion – a traumatic brain injury, structurally composed of diffuse axonal injury, causing transient functional impairment.

Mild traumatic brain injury – (mTBI), or Grade I concussion

Moderate-Severe Traumatic Brain Injury – Grade 2, Grade 3 concussion, respectively

Silent concussion- an unreported traumatic incident which causes symptoms typical of concussion, a worrisome, not uncommon occurrence, in youth.

3) The Magic in the Woodpecker’s Head-The Protective Woodpecker anatomy

The woodpecker is instructive with regards to brain protection and head injuries. The particular anatomy of the woodpecker is what allows it to strike wood at 1000 times gravity or 1000 Gs. There are two main reasons the woodpecker can withstand that force, without injuring its tiny brain. One, the woodpecker’s brain fills the skull, and is positioned such as to distribute the force and two, the

tongue (3 times the length of the beak) extends back, and wraps around the brain inside the cranial cavity.



Introduction: History, Business

The History of American Football

The most valuable teams in the NFL

Media: Concussion – The Movie ( and Book ), League of Denial (Frontline), Interview

The chilling first script of concussion is everything the NFL doesn’t want you to see

League of Denial – Trailer

League of Denial – The Frontline Documentary

The NFL’s ‘Concussion’ Problem

Interview with Kevin Guskiewicz PHD – Football and Making Games safer

Definitions, Stats, Research,

Actuarial Reports in NFL Concussion Deal Are Released

New: 87 Deceased NFL Players Test Positive for Brain Disease

List of NFL players with CTE – chronic traumatic encephalopathy

Former Giants Safety Found to Have CTE (age 27)

Too Many Punches, Too Little Concern

Consequences of repeated disruption to the blood – brain barrier in football players (College Football Study)

Anatomy of a hit:

Are NFL Hits getting harder and more dangerous?

Chronic Traumatic Encephalopathy and Subconcussive Head Trauma

Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy following repetitive head injury

The Evidence for Chronic Traumatic Encephalopathy in Boxing – Sports Medicine

High School and College Sports and Concussions

The Young Adult Development Project at MIT

Subconcussive hits are causing serious brain damage

Suicide reveals signs of disease seen in the NFL

Repetitive Head Impacts: A Major Concern At All Levels of Sports

The Reality of Football Head Injuries

Girls suffer sports concussions at a higher rate than boys. Why is that overlooked?

Knocked out: Concussion study questions involvement of young teens in collision sports

The Concussion Protocol, Resources, Centers

 The Layperson’s Guide to Traumatic Brain Injury (TBI) and Chronic Traumatic Encephalopathy (CTE)

NFL’s Head, Neck and Spine Committee’s Protocols Regarding Diagnosis and Management of Concussion

From U.S. Center for Disease Control (CDC) –“Heads Up” Educational Outreach


Traumatic Brain Injury Center at UNC- The Michael Gfeller Sport Related Traumatic Brain Injury Center

The Sports Concussion Institute

The NIH/ NFL team up to fund concussion related research

Protect The Brain

Northeastern University: Traumatic Brain Injury

 Hockey Programs: Safety: Concussions: Facts and Prevention

 Sports Industry’s and Athletes’ Responses

The NFL and Players Settle Concussion Suit

After Heads Bang, Interests Collide for FIFA

Will the law strike a knockout blow on concussion in rugby

On concussions: separate hype from science

NFL suspends use of helmet sensors

Patriot’s Ron Gronkowski says he would rather suffer a concussion than a knee injury

Are NFL Players Using Their Brains

Bears Safety Chris Conte: It’s Worth Dying ‘10-15 Years Early’ to Play in the NFL

The Research On Concussion Continues…

Brain Imaging: Tackling Chronic Traumatic Encephalopathy

Study gives hope for brain disease treatment

Huge studies peer inside brain, blood to unlock mysteries of concussion

Biomechanics of Sport Concussion: Quest for the Elusive Injury Threshold

Exercise Found Effective in Treating Post-Concusssive Syndrome

Scientists hunt for ways to untangle damage of chronic traumatic encephalopathy – Pittsburgh Post-Gazette

Study offers clues about how athletes’ brain disease begins

Topics for #HCLDR February 9, 2016 were:

  1. At what age would you allow your child to play football, ice hockey, rugby, soccer, wrestle etc? Age 12? 14? 16? Never?
  1. Is there enough education (and media attention) on sports related head injuries, both the risks of concussions and cumulative subconcussive hits?
  1. Given pro-football players push back/attitudes, do you believe that behavior change in violent sports, such as football, is realistic?
  1. Are there redeeming aspects of football, other violent contact sports? If so, what are they? 


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