Concussions: The silent epidemic of sports

Behind every touchdown, every knockout, every aerial duel, lurks a hidden danger as head trauma-related illnesses are reshaping the landscape of sports and the health of athletes is at stake, prompting organisations and researchers to take action and tackle the challenge.

In recent years, global sport has been forced to confront a shadow that, for too long, lingered outside the spotlight: concussions. Symptoms such as nausea, pain, and fatigue raised concerns while sports organisations faced criticism for not adressing them in due time, fuelled further by complaints from numerous retired professionals regarding their deteriorating brain health. "I’m paying the price," confided Bristol Rovers football legend Ian Alexander to The Guardian in a poignant recent interview.

From the brutal collisions in American football to the harrowing falls in cycling, leagues and federations across the world have begun sounding the alarm, desperately seeking ways to cool down this growing trend.

Footballer Christoph Kramer is a prime example, having sustained a concussion and temporary amnesia during the 2014 World Cup final, which he won with Germany. Around the 30-minute mark, the former Borussia Mönchengladbach midfielder suffered a heavy impact and approached referee Nicola Rizzoli to ask if he was indeed in the final, the match of his life that he has no recolection of playing to this day.
 

NFL officials said that the Guardian Caps helped reduce concussions in preseason practices by nearly 50%.

So why don't a majority of players want to use them?

It comes down to weight, function... and according to one player, style.

More responses ⤵️https://t.co/wR1JihHAuA pic.twitter.com/8rMmLt3Oc6

— The Athletic (@TheAthletic) October 3, 2024

While rugby and American football adjust their helmets, boxing has ringside medics, and ice hockey meticulously reviews every hit that sends a player crashing to the ice, are those measures truly enough? Progress has been made, the NFL claims with a recent study underlining that concussions dropped by 23% during the 2024 preseason compared to 2023, but the allure of money remains strong, as seen with its expansion to an 18-game regular season, despite opposition from the Players’ Association and medical community.

While modern sport cautiously inches towards a solution, every new impact highlights the long road ahead, as Romain Bardet, the cyclist who crashed during stage 13 of the 2020 Tour de France can attest: after a high-speed collision at 50 kilometres per hour, the Frenchman, visibly disoriented, stayed in the race, a stark reminder of how far world sport still is from fully grasping the risks of this deeply entrenched dilemma.

Trauma or concussion? A neurological viewpoint

Virtue lies in understanding the problem. The terms "traumatic brain injury" (TBI) and "concussion" are often used interchangeably, even though they represent distinctly different injuries. A traumatic brain injury refers to significant physical damage to the skull or brain, while a concussion is subtler but can have equally devastating long-term effects.

Miguel del Valle, President of the Spanish Society of Sports Medicine, compiled a study in 2022 entitled "Concussion and Traumatic Brain Injury in Sports" delving into the issue and explaining how "traumatic brain injury or traumatic cerebral injury represents a major health concern, affecting millions of individuals each year." Its "high incidence of mortality and morbidity” is equally alarming, as he notes that "75% of cases stem from road traffic accidents.”

"Traumatic brain injuries are usually associated with severe, visible damage,” explains Cristina López Pascua, Director of the prestigious Lescer Centre in Madrid, which specialises in neurorehabilitation. "Nonetheless, there are also microtraumatic brain injuries, which may be less visible but can be just as harmful." 

To clarify the concept, López uses a metaphor: "Imagine a daisy. If you shake its stem constantly, its petals weaken and fall. This is what happens in the brain when microtraumas occur."
 

"Concussion, or mild traumatic brain injury, is the most common type of TBI, accounting for 70–90% of all cases," del Valle continues, identifying the most prone to recording these injuries: "Those with the highest risk include rugby, American football, ice skating, football, and even some water disciplines. In most instances, the mechanism of injury is either player-to-player contact or the materials involved."

While men are slightly more affected (66-75%), he points out that women face greater risk in certain sports, primarily due to "constitutional factors." Progress in neurology is being made slowly but surely; however, in the sporting world—particularly within its administrative structures—there remains much work to be done: a recent study of 2,552 retired NFL players found that over 60% reported having suffered one or more concussions during their careers, and 24% indicated they had experienced three or more.

NFL and NHL: The impact-proof intensity

Moreover, Dr. del Valle highlights that "the US Department of Emergency Medicine reports that fewer than 13% of sports-related TBIs are evaluated in emergency departments." In sports such as American football and ice hockey, the violent nature of the games, combined with constant physical contact, places athletes in significantly greater danger of suffering hits.
 

One day we will appreciate Dr. Bennet Omalu. A Nigerian Physcian who first discovered CTE in the NFL and spent years fighting him; receive deportation & death threats and still won the case.

A movie was made about him.
Concussion (2015) pic.twitter.com/ZE4yH0qNjH

— Alhaji Drunkard (@The_Nifemi) November 26, 2017

Dr. Omalu, who was characterised by Will Smith in the movie 'Concussion', was in charge of former NFL player Mike Webster's autopsy which revealed severe brain damage and made a discovery that shook the very foundations of the sport: the link between head trauma and CTE. 

While his research was pivotal to protecting player health, it also positioned him at the heart of a fierce conflict between science and a multi-billion-dollar industry where the well-being of athletes often clashes with the financial interests of team owners in a football-crazed nation.

NFL icon Brett Favre was the latest to open up about his struggles since being diagnosed with Parkinson's, a disease often associated with traumatic brain injuries resulting from repeated collisions and estimated during a 2022 interview that he had endured "thousands" of concussions on the gridiron.

During his opening statement before Congress, @BrettFavre says he's recently been diagnosed with Parkinson’s disease.

Full video here: https://t.co/bANW0t3SK6 pic.twitter.com/IFQzqC847M

— CSPAN (@cspan) September 24, 2024

Another high-profile case is that of Miami Dolphins' Tua Tagovailoa, who suffered multiple concussions recently, sparking renewed debate over the NFL’s current protocols. The Hawaiian has since found himself at a crossroads and faces the heart-wrenching decision of whether to abandon the game or risk future consequences.

The league has made some advancements by mandating the presence of independent doctors on the sidelines or improving helmet technology with, among others, the introduction of the Guardian Cap; yet only a handfull of players currently wears it and player safety remains a crucial issue on commissioner Roger Goodell’s agenda.

An exploration conducted a decade ago by Dr. Aaron Karlin, an expert in Paediatric Physical Medicine, found that the incidence rate of concussion across 12 high-risk sports in teens was 0.23 per 1,000 exposures, with rugby, ice hockey, and American football under the spotlight. Rugby, often compared to American football, is quite distinct in terms of its rules, despite their similarities in physical intensity.

What, then, of ice hockey, where fights and heavy collisions are a regular occurrence? Stability is hardly a defining characteristic as athletes must contend with ice skates on a slick rink, amplifying the frequency and severity of these impacts. While International Federation regulations state that "fighting is banned and must be avoided", skirmishes are still allowed and quite frequent in the NHL, where some claim that they help reduce in-game violence as players allegedly release their pent-up aggression with fists rather than their sticks.

Either way, the sport has seen its fair share of alarming cases of brain injuries and has brought some stories to the big screen, shedding light on this complex and all-too-real dilemma. The tragic case of Derek Boogaard stands out: Known for his role as an 'enforcer', he tragically passed away in 2011 due to an overdose after years of battling addiction provoked by the pain of concussions sustained throughout his career. 

Football’s head injury crisis: Why are women at greater risk?

When concussions are mentioned, it’s almost inevitable that one’s mind turns to the oval ball. Yet, traditional football is also among the top contributors, especially among women. The statistics speak for themselves: women’s football records more concussions than any other sport, largely due to the frequency of headers and the aerial duels that come with it.

As Dr. del Valle noted, this discrepancy is partially attributable to physiological differences: "Women tend to have weaker cervical muscles, which reduces neck stability and rigidity." One of the most vocal advocates for raising awareness is former American icon Brandi Chastain, whose work in the Concussion Legacy Foundation has been instrumental in educating about the importance of preventing head injuries.

Nonetheless, it would be entirely wrong to assume that men’s football is exempt from brain injury concerns. Ian Alexander, a British legend, gave a candid interview to The Guardian recenty in which he thumbed through a 34-year-old signed jersey and struggled to recall the identities of former teammates. Such profound memory lapse can be attributed, in no small part, to the repeated blows his head sustained during his 13 active seasons. "I just want more people to understand the brain injuries footballers suffer," he remarked. 

‘I’m paying the price’: Bristol Rovers legend Ian Alexander on career of concussions https://t.co/P9ZVIj96Xd

— Guardian sport (@guardian_sport) October 13, 2024

Fully aware of the germinating concern, the World Health Organisation (WHO), alongside FIFA, recognised the need to curb this rising trend. In a show of unity, both launched the "Suspect and Protect" initiative. Officially presented last month, the campaign aims to equip players, coaches, and medical staff with the knowledge to recognise the symptoms of a potential concussion and understand how to protect athletes. 

Dementia pugilistica: Boxing's grim legacy

Few sports present as clear a risk of cranial trauma as boxing. At its core, it doesn’t require expert knowledge to grasp that being punched in the cranium is not quite as wholesome as hot yoga. From the first rounds, boxers endure direct blows to the head, which, over time, can lead to a condition intrinsic to the sport. This is known as dementia pugilistica, or, as previously mentioned, chronic traumatic encephalopathy (CTE).

In his book 'Damage: The Untold Story of Brain Trauma in Boxing', author Tris Dixon tackles this subject with remarkable sensitivity, recounting how former champions have been left grappling with tremors, memory loss, and severe mood swings as he delicately weaves together the history and science behind CTE. One of the victims? Muhammad Ali, who was diagnosed with Parkinson's disease after repeated head knocks over the course of his illustrious career. 

No matter how many measures are introduced, the risks of boxing make it a unique element in the world of high-performance sports. The inherent brutality of a discipline where victory is secured by inflicting strikes leaves little room for further intervention beyond what is already in place: medical professionals standing ringside, poised to rush in at a moment’s notice.

A battle on the horizon

Cerebral trauma has left its mark on athletes across all levels and disciplines. While awareness of this issue has increased in recent years, the road to effective prevention and treatment remains fraught with challenges, further complicated by commercial interests.

In the sporting world at large, the obstacles are indeed numerous; in many instances, concussions go unnoticed or, worse still, remain undiagnosed due to the fear that athletes may be sidelined from competition. A study published in the Neurology journal revealed that up to "50% of concussions in sport never receive the necessary medical attention." Indeed, a significant concern, especially in sports where physical, violent contact is deep-rooted.

Innovations in helmet technology, such as those introduced by the NFL, and growing awareness through global campaigns by FIFA, are just a few examples of how sport is striving for solutions. Yet, the question remains: Are these measures sufficient to combat a silent epidemic that continues to claim victims, or can more still be done?