Discussions about the dangers of football have resurfaced after Buffalo Bills’ Damar Hamlin suffered cardiac arrest during Monday night’s game against the Cincinnati Bengals.
But is football really the riskiest sport? “Yes and no,” says Daniel Daneshvar, an assistant professor at Harvard Medical School and a brain injury medicine physician at Mass General Brigham.
“When it comes to the most dangerous sports, it really depends on the type of injury. Most sports have some level of risk, but football,” he says, “is among those with injuries that often cause permanent damage — especially when it comes to the brain.”
And head injuries are common in the game. In addition to the 187 National Football League (NFL) officially recognized concussions during the preseason and 2021 regular season, there were likely thousands of subconcussive headbutts. Subconcussive head impacts can also cause problems and have been linked to the degenerative brain disease known as chronic traumatic encephalopathy, or CTE. Just a few months ago, Miami Dolphins quarterback Tua Tagovailoa was stretchered off the field after suffering head and neck injuries. (He has suffered three concussions this season.)
Grid spoke to Daneshvar about the risks associated with football, other sports that involve a lot of head injuries that don’t get much attention, and how sports organizations can help prevent injuries (and if they seem to want to). The interview has been edited for length and clarity.
Grid: Let’s start with soccer because that gets the most attention. Is it really the most dangerous sport with the most injuries or is it just the sport with the most serious injuries because it so often attacks the brain?
Daniel Daneshvar: It’s important to determine exactly what you’re talking about when we ask if football is the most dangerous sport in terms of injuries. There are injuries to the brain, there are injuries to the body, and different sports have different risks associated with each of these types of injuries.
If we are talking about neurological injuries or brain injuries, soccer is certainly one of the riskier activities. And partly for two reasons. There is a lot of repetitive headbutts and the risk of traumatic brain injuries in soccer, and far more people play soccer at far more levels than really any other sport in the United States.
G: What are the short and long term risks of brain injury? What about other types of football-related injuries?
DD: Brain injuries, including concussions, can have both short-term and long-term effects on an athlete’s life and life path. However, there are also well-known and well-understood risks of orthopedic injuries. A recent study brought out by colleagues of mine at Harvard found that people who play football throughout their lives, including in their 20s, are about three times more likely to develop arthritis. The same study found that professional soccer players were twice as likely to develop high blood pressure in their 20s compared to the general population.
G: Some youth soccer leagues and professional leagues are trying to protect themselves from brain injuries with better helmets. Are they effective at all or just a band-aid for the problem?
DD: In lab studies, the best helmets were able to absorb about 10 percent of the force associated with a head impact. And if you’re talking about a head impact that’s 60 or 70 g of force, that might reduce the head impact by five or eight g. But that difference in force isn’t enough to significantly reduce the risk or severity of concussions an athlete might suffer. I think people want helmets and gear to be the answer because that would mean there doesn’t have to be any major changes to how the game is practiced or played, but the technology to date doesn’t really show any meaning Advantage.
It’s the total amount of exposure to those repeated brain injuries that puts you at risk for problems later. So what we could do is reduce that overall lifetime exposure to head impact.
One way is to limit the total duration of head impact loading experienced by an athlete. For example, in a study we published two years ago, we found that each additional year of playing soccer was associated with a 30 percent increased risk of CTE (chronic traumatic encephalopathy), a neurodegenerative disease that can lead to dementia.
The other thing you can do to reduce the total number of headbutts athletes suffer is to change the way they train and play. Almost two-thirds of these headbutts occur in training, so it’s difficult to justify all types of exercise that lead to these headbutts that athletes are subjected to.
G: What happens if a concussion or brain injury is left untreated?
DD: It puts people at risk for later and more serious brain injuries. A concussion is an injury to the brain that results in a metabolic imbalance between what the brain needs to function and what the brain can absorb. During the time immediately after the concussion, there is what is called a window of vulnerability when brain tissue is still recovering, and a subsequent blow to the head during this time can prolong or worsen the injury itself. If an athlete is not properly evaluated and treated for a concussion, they may be at higher risk for persistent post-concussion syndrome, in which it takes months or even years for concussion symptoms to resolve.
One of the other things that’s often overlooked about untreated concussions is that not only are you at a higher risk of injuring your brain, you’re also at a higher risk of injuring the rest of your body. For example, an athlete with an untreated concussion has about three times the risk of an orthopedic injury. This is because the brain isn’t working as it should, so their reaction time is slower and their balance and proprioception are disrupted.
G: What should we know about Chronic Traumatic Encephalopathy (CTE)?
DD: When athletes – or anyone else – are hit repeatedly in the head, a toxic protein can build up in their brains that can lead to nerve cell death. When this process begins, it can lead to a neurodegenerative disease that progresses as an athlete continues. So the problems associated with this toxic protein don’t really appear until decades later. When we talk about athletes who have memory problems, attention problems, concentration problems later in life and die of dementia, we find that the underlying process in their brain is CTE, a neurodegenerative disease process. For example, if we find that NFL players are 10 times more likely to die from dementia than other athletes, the disease process thought to be responsible is CTE.
G: Is there anything misleading that the NFL or other sports organizations are saying to protect themselves?
DD: At least the NFL is letting athletes know there are risks associated with those headbutts. Posters hang in the changing rooms. We could debate the extent to which the NFL adequately conveys these risks, but they at least acknowledge that there is a risk. This contrasts with other sports organizations, including the NCAA, which to date has failed to recognize a link between headbutts suffered by their athletes and problems later in life.
Thankfully, many of the misconceptions about concussions have been dispelled — including the idea that a knockout punch is something required to have a concussion, or that losing consciousness means the concussion is worse. We are increasingly realizing that these ideas are not the case. Whether or not a concussion is serious depends on how long it takes a person to recover from a concussion.
G: What about head injuries in other sports? Are there any that we would be surprised to hear put players at particularly high risk?
DD: One of the sports most associated with headbutts that people might not think of is cheerleading. Many of these athletes are involved in maneuvers that involve altitude and speed. Any contact or collision sport puts individuals at risk of concussion. Sports like hockey, boxing, and soccer involve many repetitive headbutts. In fact, soccer athletes have higher rates of dementia later in life than would be expected from a sport that is not considered a high-contact sport.
Since the focus of head injuries in sports has been primarily on football – and to a lesser extent hockey – these other sports receive less attention. I can’t say if the organizations themselves have been proactive to ensure the health and safety of their athletes, but I know that from a societal perspective, female athlete [dominated] Sport has attracted far less attention and focus than male-dominated sports.
Thanks to Brett Zach for editing this article.
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