Does heading a football lead to brain damage? It's complicated

Photograph by Tetra Images / Alamy
Published 9 Jun 2021, 13:07 BST, Updated 16 Jun 2021, 11:59 BST

When England’s, Scotland’s and Wales’s top footballers compete in the European Football Championship in June and July, their feet will get quite a bashing. So will their heads.

Headers are a key aspect of football, in both attack and defence, often causing impacts so jarring that medical experts are now seriously worried about players’ health. In rugby – where players are regularly subjected to violent tackles, and often concussed – there are health fears too. Former professional players in both sports claim head injuries have caused them permanent damage. 

In football, five members of England’s 1966 World Cup-winning team have developed dementia. Jack Charlton, Nobby Stiles, Ray Wilson and Martin Peters have since died, while Bobby Charlton remains.

A physical legacy

John Stiles is Nobby Stiles’s son, and also a former professional footballer. “I believe the facts will show in time there is a direct correlation between the number of times they headed a ball and dementia,” he says. “It’s just common sense. If you go and head a heavy ball, 30 or 40 times a day, and you do that for ten years...” (Admittedly, modern footballs are lighter than they were in the 1960s.)

Violence has always been a part of football and rugby – but protection has remained optional.  

Photograph by Chronicle / Alamy

Rugby, with its scrums, mauls, rucks and crunching tackles, is far more brutal than football. Steve Thompson played 73 times for the England national team and helped them win the World Cup in Australia in 2003. He has since been diagnosed with early onset dementia, with probable chronic traumatic encephalopathy – a neurogenerative disease linked to repeated blows to the head. “I can’t even remember being in Australia,” he says of that period of his career. “I’m on the pitch but I cannot remember being there at all.”

Alix Popham, who won 33 caps in rugby for Wales, has the same brain condition. “I had a great career and willingly gave my heart, body and soul to rugby,” he says. “I just didn't know I was giving my mind too.”

Tragically, brain injuries very occasionally kill rugby players. In the amateur game, one of the most high-profile cases was 14-year-old Benjamin Robinson who, in 2011, collapsed on the pitch during a match in Northern Ireland. At the inquest the coroner confirmed the youngster had died from a condition called second-impact syndrome, which typically occurs when a player suffers a second concussion before properly recovering from a first.

In the past decade alone there have been at least a dozen deaths worldwide in rugby union as a result of head injuries of people under the age of 31.

The science certainly attests to the danger of head injuries in both sports. A leading study on football from Glasgow University, published in 2019, discovered that former football players are three-and-a-half times more likely to die of neurogenerative disease than age-matched members of the public; and were more likely to be prescribed dementia-related medication.

The lead author of the study, Dr Willie Stewart, who is consultant neuropathologist at the Queen Elizabeth University Hospital in Glasgow, says there is clear evidence of brain injury and chronic traumatic encephalopathy among both football and rugby players.

After the 2018-2019 season, the RFU (the Rugby Football Union which governs rugby union in England) published a report on injuries during that season incurred by players in the England national team and England’s top division, Premiership Rugby. They concluded there were 166 concussions during matches and 38 during training. “For the eighth consecutive season, concussion was the most commonly reported match injury, contributing 20 per cent of all match injuries,” they wrote. “The tackle is the key game event to consider when developing concussion and all injury reduction strategies.”

Controversy in sport

But how seriously are the sporting authorities treating the problem? Allyson Pollock is professor of public health at Newcastle University and author of Tackling Rugby: What Every Parent Should Know About Injuries. She complains of a “tyranny of silence surrounding the subject” and suggests that governing bodies in rugby suppress the true severity of concussion because they fear “a backlash of bad publicity and litigation.”

Dr Judith Gates is co-founder of a charity called Head For Change, which campaigns for brain health in sport. Her own husband, Bill Gates, is a former professional footballer now suffering from dementia, caused by probable chronic traumatic encephalopathy.

Dr Gates claims that much of the research into brain injury in sport has been controlled and obfuscated by sports governing bodies. “Research needs to be independent and transparent,” she told National Geographic UK. “Are the governing bodies wanting to protect the game or the players? We at Head For Change suggest it should be both.”

The header is an intrinsic part of football, to the point where sculptures, such as this in Manchester, have been made depicting it. Many believe removing it from the game due to health concerns could lead to better long-term health for the players – though others counter that it would destroy a key element of it.  

Photograph by lowefoto / Alamy

She warns that if football and rugby do not protect their players, they risk scaring off youngsters from the junior ranks. “Parents will vote with their feet. They won’t involve their kids in the game, which will then be to the detriment of the sport on a long-term basis.”

In the United States, the NFL (the top level of American football) has paid millions of dollars in settling claims from former players with brain injuries. The NHL (the top level of ice hockey) has paid compensation too. In 2017, a neuropathologist from Boston University examined the brains of 111 dead NFL American football players, and discovered that 110 of them had chronic traumatic encephalopathy. 

The question of responsibility

Which begs the question: could we eventually see similarly costly lawsuits in football and rugby this side of the Atlantic?

London-based law firm Rylands is currently pursuing a claim on behalf of around 150 former rugby union players with brain injuries against three governing bodies – the international federation World Rugby, the Welsh Rugby Union and the RFU. Most of its clients are former professionals, including international players Steve Thompson, Alix Popham, Michael Lipman and Dan Scarbrough.

Leading the lawsuit is Richard Boardman, who envisages a future where the rules of rugby are altered to protect the players. “I hope so, otherwise litigation will simply continue,” he told National Geographic UK. “I think all contact sports in the western world need to change out of the 19th century, Victorian view that it’s survival of the fittest. In the 21st century that's just a ridiculous philosophy to have, particularly with regards to the brain. The brain isn’t hardware, like a smartphone or computer. It’s a very delicate organ that has been ignored in contact sports for decades.”

Boardman also believes players should be fully alerted to the risks involved in rugby. “If they choose to continue paying after that point, that's absolutely fine,” he adds.

Sports authorities aren’t burying their heads in the sand. The FA (the Football Association, England’s governing body) told National Geographic UK that they “lead the way in ground-breaking research” into the links between football and dementia. They pointed out how they have modified the way football is played in England, ensuring primary school children never head the ball in training sessions, and that under-18-year-olds limit heading practice.

“The brain isn’t hardware, like a smartphone or computer. It’s a very delicate organ that has been ignored in contact sports for decades.”

Richard Boardman

The RFU also claims to be addressing the problem. “Rugby takes player welfare extremely seriously,” Kathryn Williamson, communications director, told National Geographic UK. “As a result of scientific knowledge improving, rugby has developed its approach to concussion surveillance, education, management and prevention across the whole game. We have implemented coach, referee and player education and best practice protocols. We will continue to use medical evidence and research to evolve our approach.”

Research published in the British Medical Journal in 2019 has analysed thousands of tackles in the professional game. Representatives from the RFU, World Rugby, the Welsh Rugby Union, University of Bath and Cardiff Metropolitan University concluded that concussion is an inevitable part of this contact sport. They discovered it is more serious for the tacklers (than for the ball carriers), especially when their heads strike the ground, or opponents’ heads or knees.

“The most effective, although extreme, method for preventing concussion would be to eliminate exposure by removing the tackle from the game,” they wrote. “However, removing one of the sport’s integral game events would change rugby union beyond recognition and is therefore unlikely to be a practicable option at the professional level.”

A rugby player is examined for signs of concussion after a blow to a head during a match in Dorset, 2016. 

Photograph by Sport Picture Library / Alamy

And that, it seems, is the crux of the problem. To eliminate brain injury from football and rugby, the rules would have to be considerably modified. The eradication of heading in football, for example, would totally transform the game for fans and players, dulling excitement in the goal area. In rugby, the eradication of tackling would kill the sport altogether. It’s unlikely spectators would accept such wholesale change. And since both sports are global, any unilateral alterations would be meaningless.

Of course football and rugby aren't the only sports that risk head injury. Myriad activities from martial arts, equestrian sports and motor sports to cycling and cricket all occasionally administer blows to the head. But several of these protect brains to a certain degree by insisting on helmets.

Arguably, the worst culprit of all is boxing – which has lost many acclaimed fighters as a result of brain injury. It’s worth noting that boxing was phased out of British school sports in the 1960s. And all pugilists are well aware of the brain injury risks in their sport.

Pollock believes rugby won't changes its rules until a really high-profile player dies of head injuries. “They are the things that make the difference,” she told National Geographic UK. “It’s got to be someone in the public spotlight who can change things. Either professional players coming out about dementia or, in the case of youth rugby, the death of a child of someone very prominent, like a politician.”

But that’s no comfort for the relatives of players who are currently suffering, or who have already died. Dr Gates says she lives with the realities of sport-induced brain injury on a daily basis. “I want to be part of the solution,” she says.

“I recognise all of the forces within the arena: the emerging knowledge about the brain; the socio-political-financial issues of corporate interests; the resistance to change. At the end of the day, you have men like my husband who, until his sixties, was a titan of a man, as a sportsman, as an entrepreneur, as a businessman. Then you see what a disease like this does to him, and you realise that it's more than an area of interest. It’s an area of life and death, and a long goodbye.”

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