Overview

The long and short-term effects of head impacts are becoming a bigger talking point in football by the week. While potentially lethal brain injuries – such as those suffered by former Chelsea goalkeeper Peter Cech or Spurs midfielder Ryan Mason – have always been a concern, the longer-term impacts of average game-to-game brain trauma are beginning to be taken more seriously.

This is due to an increasing number of former players being diagnosed with Chronic Traumatic Encephalopathy (CTE) and the premature death of former football players, including five members of England’s 1966 World Cup team.

In football, brain injury has become overly focused around heading the ball, with increasing concern on heading in the game, calls to limit heading and to ban outright. But this is not just about heading, the real issue is rotational forces to the brain from concussion and sub-concussive impacts. Rotational forces occur from angled hits to the head, be it head-to-head, head-to-ball, head-to-ground impacts, all of these cause the brain to rotate inside the skull and brain cells to shear in a twist-like movement. Heading is only 13% of impacts based on the study of mechanics of head impacts in football (Biomechanical investigation of head impacts in football, 2005). 87% of angled impacts to the head come from other sources e.g., head to head, head to knee, head to elbow, foot and hand. Focusing on heading is really missing the point on brain trauma in football!

Also confused in this debate around brain trauma in football is that former players have CTE with dementia like symptoms, and not dementia as is understood in the context of aging. Dementia is an umbrella term, not a specific condition, and refers to a number of cognitive symptoms. Conflating CTE and dementia by the media, governing bodies and others means that CTE as a condition is not being understood, nor the risk factors appreciated.

The most significant mitigation to reduce brain injury in football is reducing the transmission of rotational forces to the brain, which is where Rezon is focused. Halos® is uniquely and intentionally designed to lessen the risk of rotational brain injury due to the reduction in the transmission of rotational forces to the brain.

Football and brain trauma

How dangerous is heading in football - FIFA article 1984Has brain trauma in football suddenly become a problem or is it that we haven’t been noticing it? It’s a combination of both.

FIFA (the International Federation of Association Football) was first aware of the alleged link between football and brain damage in 1984, following the publication of an article in the FIFA magazine. The article titled How Dangerous Is Heading? was presented to the FIFA Medical Committee at a meeting on 26 October 1984.

The governing bodies through practices, guidelines and protocols are now seeking to reduce brain trauma through limiting heading and trialling permanent concussion substitutions.

How do head impacts in football injure the brain?

Concussion occurs when an impact to the head or body sends a strong force to the brain, resulting in significant, acute brain injury with symptoms including headache, mental fogginess, changes in memory, balance, coordination, behaviour, irritability, and slowed reaction time. Greater than 90% of concussions are not associated with a temporary loss of consciousness, and more than 80% of concussions are diagnosed the next day or several days later.

Repetitive, sub-concussive impacts cause injury to the tiny blood vessels in the brain. This in turn results in damage to the ‘blood brain’ barrier, a structure designed to protect the brain. When this structure is damaged by repetitive trauma, an abnormal ‘immune” mediated inflammatory response is triggered, with the production of neurochemicals. The neurochemicals and inflammatory response should be protective. However, the problem arises when the brain is subjected to repetitive blows before the protective neurochemicals and inflammatory changes from the initial head injury have had time to return to normal.

The subsequent, repetitive head injuries can then result in an abnormally exaggerated further production of neurochemicals and an exaggerated inflammatory response which is harmful to the brain, instead of protective. This response damages the brain tissue and eventually leads to the irreversible death of brain cells. Over time, this abnormal inflammatory pathway which is triggered, repeatedly by frequent head injury in contact sports eventually leads to changes in a brain protein called tau.

The tau protein which is found within cognitive brain cells normally stabilises brain cells to ensure they work efficiently and communicate effectively, with all the other cognitive brain cells, so an individual can think and behave normally. When the tau protein becomes damaged, it can no longer stabilise the brain cells and the brain cells lose their ability to function efficiently and effectively. As the tau protein spreads around the brain, it affects and kills more and more precious brain cells, needed for thinking and control of emotions and behaviour.

Brain injury is not specific to elite or professional football, it is very much part of amateur football. It can impact men, women, children, whatever age and fitness level. From the cages to the Camp Nou, the parks to the Parc des Princes.

Limiting heading

The FA has issued guidelines that are specifically focused on heading in training sessions, recommending that a maximum of ten higher force headers (headers following a pass of more than 35 metres, including headers from free kicks, corners and crosses) are carried out in any training week. But there is an argument that no category of header creates any less risk.

For youth football it has been focused on no heading in training in primary school children and a graduated approach to heading training for children between under-12 to under-16. Also, with required ball sizes for training and matches for each age group.

The guidelines apply to every level of the game in England, including professional, amateur and grassroots.

In the US, similar rules around children not heading the ball have been in place since 2015. The heading of the ball for children aged 10 and under was banned, after a lawsuit was filed against the US Soccer Federation by a group of concerned parents and players. The links between football and degenerative brain disease is a global concern.

Child heading football, in-game
Grassroots football game - goalkeeper clearance

Brain trauma is more than heading

The game is faster and more physical than ever, and there’s more at stake. Crosses and passes are struck with more power, and today’s professional trains for several hours at least five times a week.

But there is more to this than a glancing strike, a rising header from a set piece or a diving header from a cross to clear the ball off the line. The real issue is rotational forces to the brain.

Rotational forces occur from angled hits to the head, be it head-to-head, head-to-ball, head-to-ground impacts, all of these cause the brain to rotate inside the skull and brain cells to shear in a twist-like movement. Meaning brain trauma in football is more than heading.

Heading is only 13% of impacts based on the study of mechanics of head impacts in football. 87% of angled impacts to the head come from other sources e.g. head to head, head to knee, head to elbow, foot and hand. How many times outfield players will challenge for the ball with a goalkeeper’s fist rushing out to meet them? How many times will a player go flying into one another after a last-ditch slide tackle?

This also better explains why CTE, a progressive brain condition caused by repeated impacts to the head is recognised in sportsmen and women who have played many different contact sports, aside from football and where heading is not present.

Focusing solely on heading continues the confusion around brain injury, and fuels a debate that does not re-educate and more correctly better inform players, coaches and parents.

Trialling permanent concussion substitutions

The International Football Association Board (IFAB), at its Annual Business Meeting on 16 December 2020, approved a trial with additional permanent “concussion substitutes” for any competition wishing to take part (subject to The IFAB’s approval). The trial period currently runs until the end of August 2023.

Premier League logoThe Premier League was the first league in the world to begin trials for concussion substitutes on Saturday 6 February 2021. The Premier League concussion substitute law allows each team to make two permanent concussion substitutes if players have head injuries, assessed by qualified medics and even if all replacements have already been used.

The trial works on the following basis: If a player shows no clear signs of concussion they will be allowed to continue, but will be continually monitored by medics on the sidelines. The player will then undergo a formal clinical assessment at half time or full time to find out the extent of the injury. The opposing team is also allowed to make an additional substitution if a concussion substitute comes on to avoid one side gaining an advantage through fresher legs.

Permanent substitutions have been criticised on the basis that a player may feel pressure not to ask their manager to be subbed off despite experiencing a serious injury. Also, the club’s decision to let players continue playing following head impacts have been criticised. with Leeds United’s Robin Koch and Manchester City’s Phil Foden as recent examples.

There have been calls to IFAB for the implementation of temporary concussion substitutions, allowing a club’s medical team appropriate time to assess a player suspected of experiencing concussion and make an informed decision as to whether that player should return to the game. IFAB has stated it has no plans to change the trial.

Other mitigations suggested for reducing brain trauma in football include for footballs to be sold with health warnings to warn on neurodegenerative disease, better highlighting the risk of heading to longer-term neurodegenerative disease, and to the outright banning of heading in football.

Concussion guidelines

In football, as many as 22% of all recorded injuries are head-related and concussions (Head and neck injuries in football (soccer). Al-Kashmiri, Ammar & Delaney, J. (2006). 89-195. 10.1177/1460408606071144).

The FA crestWhen someone is suspected of having a concussion, either during training or in a game, FA Guidelines dictate that the player should immediately be removed from the pitch and not be allowed to return until the appropriate treatment has been administered. The FA advisory guidelines have been designed for those who manage head injuries in professional and grassroots football – from clubs and schools, to parents and doctors.

The FA guidelines do not reference sub-concussive impacts, frequent smaller impacts that create accumulated sub-clinical brain injury and trigger longer-term neurodegenerative consequences. The risk and severity of CTE is caused primarily by multiple smaller, sub-concussive impacts, and not by one hit concussions. 20% of people with CTE diagnosed after life were recorded as never having sustained a single concussion.

Brain injury happens at the microscopic level, c. 4,000 times smaller than the eye can see on a regular brain scan. So, with little pain, and no obvious physical injury, brain trauma in football really is a serious injury that is “hidden in plain sight” in football. This is very different from other more visible and painful injuries e.g. knee and ankle injuries. Brain injury isn’t isolated; you can’t apply ice, rest, then forget the impacts.

Returning to play

Returning to play after a concussion, a graduated return to play (GRTP) protocol is a progressive program that introduces an individual back to sport in a step-wise fashion. The GRTP Protocol contains six distinct stages. Under the GRTP protocol, the player can advance to the next stage only if there are no symptoms of concussion at rest and at the level of physical activity achieved in the current GRTP stage.

GRTP is really an informed guess on how long it takes the brain to recover post injury. Damage to the brain cells from an impact can be both immediate (damage to the brain cell structure) and delayed (blood flow changes or neural inflammation). Research and opinion from medical literature reviews suggests that 30 days is the minimum period before returning to play post a concussion event.

Returning to play too soon can increase the risk of sustaining further injury and subsequent symptoms, requiring a prolonged period of recovery. Changes in white matter, brain connections and blood flow can persist a year or more after a concussion. Research provides a significant association between a history of concussion and lower extremity injury, especially lateral ankle sprain, knee injuries and muscle strains. All athletes of all levels in sport have a greater risk of lower body injury issues for more than a year following a sport-related concussion. In some cases, this risk is as high as 67%.

Technological solutions

Eye-tracking technology

Eye-tracking technology is also being introduced to help with the detection and management of concussion. Studies have suggested that oculomotor function – eye movement – alters at the time of a concussion or shortly afterwards. This technology is being piloted in matches alongside the return-to-play protocols. This technology does nothing to reduce brain trauma and protect against, it is a measurement and management tool.

Measuring brain patterns

Measuring brain patterns through an electroencephalogram (EEG) is also being introduced to better spot and manage concussion. An EEG tracks and records brain wave patterns. Localised brain activity is recorded via a number of metal electrodes. The EEG brain test is typically used for tracking and observing brain state changes. This technology does nothing to reduce brain trauma and protect against, it is a measurement and management tool.

Saliva biomarkers

The Premier League are funding a study testing biomarker in players’ saliva to detect if they have been concussed. As with many things in sport, the majority of research on brain injury is focused on males. So too, is much of the reaction. Note the Women’s Super League (WSL) is not funding a similar study.

All of these technologies focus on measuring and managing brain injury after it has happened.

Rezon’s answer to brain trauma in football

The brain is at risk, not just to a single or high-force impact which triggers a concussion, but also to the multiple, relatively minor impacts which are invariably unnoticed and undetected in football. Every single impact to the head has the potential to be career ending and life-changing.

Whilst the effects of brain injury may be instantly visible, repetitive brain injury over many years may not be recognised until later, meaning it is never too early to protect the brain in football.

The most significant mitigation to reduce brain trauma in football is reducing the transmission of rotational forces to the brain, which is where Rezon is focused. Halos® is uniquely and intentionally designed to lessen the risk of rotational brain injury due to the reduction in the transmission of rotational forces to the brain.

Footballer wearing Rezon Halos blue