Part I: Traumatic brain injuries continue to bring future of football into question
When it comes to sports in the United States, there is no question that football is king. Whether it be the National Football League or the college level, football has long surpassed baseball as America’s national pastime. Below that, high school football is a major part of many small communities across the nation. Youth football is a pipeline that children grow up in as players.
According to Nielsen, Fox’s broadcast of this year’s Super Bowl between the Philadelphia Eagles and the Kansas City Chiefs brought in an average of 113 million viewers, the second-most watched big game ever behind Seahawks-Patriots in 2015 (coincidentally, also played in Arizona).
The Super Bowl brings America’s favorite sport into the spotlight, and it has become more than a game. The week leading up to the game is a celebration of all things football, and by extension, the city hosting it. Even some people that are not football or even sports fans tune in to watch for the halftime show, or the funny commercials or just as an activity to watch with friends.
But less than a week before the biggest day in North American professional sports, came a reminder of football’s dangers. The link between traumatic brain injuries and football has been established, but the Boston University Chronic Traumatic Encephalopathy Center painted a grim picture.
On Feb. 6, the center released a report that 345 of the 376 brains (91.7%) of former NFL players they have studied have been diagnosed with chronic traumatic encephalopathy (CTE). It is a jarring percentage, but meant to reflect only the sample of donated brains the center has studied, not 91% of all current and former NFL players.
Millions will continue to watch a sport that is almost seen as a religion in some parts of the country. That will not change anytime soon. But the work done by the BU CTE Center and other studies drive the existential question that has been on the minds of many associated with the sport over the past few decades — what does the future of football look like?
What is CTE?
CTE is a neurodegenerative brain disease linked to repetitive head impacts from contact sports like tackle football, military service and other activities that could include repeated blows to the head. It is mainly caused by non-concussive impacts that are accumulated over time. An example of a non-concussive impact in football is an offensive lineman slamming into a defensive lineman on a routine running play.
Repeated traumatic brain injuries cause proteins known as tau to build up and clump and impair brain function. The locations of these proteins make the disease distinct from other neurological diseases, like Alzheimer's.
“For some reason, the repetitive brain trauma starts this cascade of events in the brain that changes the way this tau looks and behaves, it goes awry, and starts destroying the integrity of the brain cells,” BU CTE Center Director of Clinical Research Dr. Robert Stern said to FRONTLINE PBS for its documentary, “League of Denial: The NFL’s Concussion Crisis” in 2013.
Much of what we know about CTE today is thanks to neurology and pathology professor and BU CTE Center Director Dr. Ann McKee’s work.
According to a study published in October 2016 by McKee et al. in Neurosurgery Clinics of North America titled “Repetitive Head Impacts and Chronic Traumatic Encephalopathy,” tau builds up in clumps around small blood vessels in the sulci grooves of the brain’s cortex.
There are four stages of CTE, with the final one being the most severe.
A 2013 study in the journal Brain published by McKee et. al titled “The spectrum of disease in Chronic Traumatic Encephalopathy” found that symptoms in Stage 1 included headache and loss of concentration and attention. Stage 2 cases were found to include symptoms of depression, problems with explosive tempers, and short-term memory loss. In Stage 3, cognitive impairment and executive dysfunction. In those later diagnosed with Stage 4, symptoms of dementia were found, as well as aggression and difficulty finding words.
Outside of football, the disease is not a recent discovery. It was first found in boxing, another sport with constant repetitive head impacts. Dr. Harrison Martland is credited with its discovery while treating retired boxers, publishing his findings in 1928. At that point, it was referred to as “punch drunk” syndrome.
CTE can only be diagnosed after death by studying the brain tissue. Due to this fact, it is unknown how many current and former players have the disease. But with hundreds of confirmed cases for football players alone, let alone ice hockey, boxing, soccer and other sports — the numbers are alarming.
Concussions and CTE have often been lumped together, but the two are not mutually exclusive.
A concussion is a traumatic brain injury caused by a blow to the head that causes the head and brain to move back and forth. This movement can damage the brain cells. According to CLF, some symptoms can include issues with balance, loss of consciousness, problems with memory, confusion, sensitivity to light, dizziness, and of course, headaches.
CTE is caused by repetitive head impacts (RHI), repeated hits to the head over time, as confirmed “with the highest confidence” by Chris Nowinski, Ph.D., the CEO and co-founder of the Concussion Legacy Foundation et. al in a study published July 22, 2022 in Frontiers in Neurology.
Brandon Boyd, who teaches media members how to talk about traumatic brain injuries and runs several programs as the education programs manager for CLF, pointed out that they are not one in the same.
“CTE is a degenerative brain disease,” Boyd said. “That can really only happen for anyone who has been exposed to thousands of repetitive hits to the head over their life. “A concussion can happen to everybody, and to anybody, so that’s one big misconception.”
Think of it this way — on every play of every game and every practice, offensive and defensive players collide with each other, particularly linemen in the trenches. Many of these hits, while blunt force, are subconcussive, they do not register or are diagnosed as a concussion.
By the time a professional football player has retired, they have likely accumulated hundreds to thousands of these subconcussive hits over years of playing tackle football at the youth, high school, college and professional levels. That remains the case for players that do not reach that level.
In studies using sensors on football helmets, Jesse Mez Et al. found in Annals of Neurology that players can receive hundreds and up to a few thousand head impacts per season.
How we got here
For decades, the NFL sidestepped, and at times flat-out denied any link between football and traumatic brain injuries. The league did not publicly state that concussions can lead to lasting issues until New York Times reporter Alan Schwarz was told so in 2009. It then took until a 2016 congressional roundtable for a representative of the league to openly say that there was a connection between football and CTE.
In 1994, the league formed the Mild Traumatic Brain Injury (MTBI) committee, which was meant to explore the issue. Then-NFL Commissioner Paul Tagliabue appointed New York Jets team doctor Dr. Elliot Pellman as the chair, despite him having no expertise in neuroscience. Pellman was a rheumatologist, which specializes in arthritis, joint, bone and muscular diseases, not a neurologist. During his time as chair, Pellman regularly dismissed concussion concerns. In one instance in 2003, Pellman sent wide receiver Wayne Chrebet, who was briefly knocked out cold after a hit, back into the game.
That same year the committee was formed, Tagliabue downplayed the seriousness of the problem, instead blaming reporters during a panel. FRONTLINE recounted this for its documentary.
“On concussions, I think is one of these pack journalism issues, frankly,” Tagliabue said at the time. “There is no increase in concussions, the number is relatively small. The problem is a journalist issue.”
In 2003, the committee began publishing league-sponsored research in the journal Neurosurgery.
The “big hit” had always been something that was glorified by the league and its fans. NFL Films, the league’s film production arm, released full highlight tapes showcasing these punishing hits, like this one from 1992, titled “The Best of Thunder and Destruction,” hosted by co-founder Steve Sabol.
Monday Night Football, for decades the league’s premiere primetime game, featured two football helmets banging into each other and exploding in its intro every week.
What the world knew about traumatic brain injuries changed in the early 2000s. Mike Webster, who played center in the league for 17 years and was the anchor of the Pittsburgh Steelers’ four championship teams in the 1970s, died of a heart attack at 50, in 2002.
In the years before his death, Webster, a Pittsburgh icon, was at times living out of his truck. He struggled with his memory and chronic pain from over two decades of playing football and was not able to sleep. His family saw a complete change in his behavior. Webster had to fight to receive disability benefits from the league, claiming that football was the cause of his condition.
After his death, Webster was examined by Dr. Bennet Omalu, a Nigerian-born neuropathologist at the Allegheny County Coroner’s Office in Pittsburgh. Omalu had never heard of Webster, nor did he know anything about football.
Webster’s autopsy would forever change how the safety of football is viewed.
Upon examining Webster’s brain, Omalu found what became the first evidence of CTE in a football player. At the time, the disease was known for being found in boxers.
Omalu compiled his findings in an article titled “Chronic traumatic encephalopathy in a National Football League player,” in Neurosurgery in 2005. Omalu said he thought that the NFL would want to know about what he had found. Instead, the MTBI committee attacked Omalu’s research and demanded it be retracted.
Eventually, Omalu moved out of Pittsburgh.
I wish I never met Mike Webster,” Omalu told FRONTLINE. “CTE has dragged me into politics of science, the politics of the NFL. You can’t go against the NFL, they will squash you. I really sincerely wished it didn’t cross my path of life, seriously.”
Since Webster’s passing, numerous other football players have died and been diagnosed with CTE posthumously. Junior Seau, a former San Diego Chargers linebacker and Oceanside, California native, shot himself in the chest at 43 in 2012, allowing his brain to be studied. Seau, who played 20 years in the NFL, was beloved as much for his on-field play as he was for his charitable work.
Aaron Hernandez, a former New England Patriots tight end who was convicted of murder, was found dead after he hanged himself in prison in 2017. The 27-year-old Hernandez was found by McKee and the BU CTE Center to have the most severe case they had ever examined for someone his age, according to NPR.
All-Pro wide receiver Vincent Jackson was found dead in a hotel room in 2021 and later was diagnosed with Stage 2 CTE. That same year, Super Bowl champion Denver Broncos wide receiver Demaryius Thomas was found dead in his home in December.
The list goes on:
Ken Stabler.
Dave Duerson.
Andre Waters.
Tom McHale.
These are all just some of the more prominent NFL cases.
In 2013, after over 4,500 former players and their families brought a lawsuit to the league, saying that it concealed what it knew about head trauma, the NFL settled and agreed to pay $765 million.
In recent years, the league has overhauled its concussion protocol numerous times. Despite this, instances such as Miami Dolphins quarterback Tua Tagovailoa being inserted back into a game last September after clearly having trouble with his balance and looking dazed, still occur.
According to league injury data going back to 2015, diagnosed concussions in the preseason and regular season have increased each of the last two seasons. These numbers are combined game and practice numbers in the preseason and regular season.
It is important to mention that the NFL cut the preseason down from four games to three and added a 17th game to the regular season starting in 2021.
The effects
For Tom Fitzke, football has always been a fundamental part of his life. The sport is a family affair, as he was born into passionate Arizona Cardinals fandom. His family has been season ticket holders for 30 years, nearly the entire time the team has been in Arizona.
For as long as he can remember, he has gone to nearly every Cardinals home game with his parents, sister, cousin and grandparents at Arizona State University’s Sun Devil Stadium, and later, State Farm Stadium.
Fitzke played flag football early on in elementary school, then switched to tackle around fifth and sixth grade. He played tackle all the way through high school, spending time at every offensive line position but center at Mountain Ridge High School in Glendale, Arizona, graduating in 2017.
Despite all of this, Fitzke said he has openly questioned whether he will let his future child play football.
“When I have a kid, do I want them to play football, or it makes me think about what position I’d let them play in football too, because obviously some other positions out there that don’t take as much head damage or hits,” Fitzke said.
Fitzke now coaches the junior varsity offensive line at his alma mater to stay close to the game. It is his goal to coach at a higher level.
It took Fitzke a minute to recall all of the injuries he suffered in his years playing, like sprained ankles and an elbow, a wrist injury and undiagnosed concussions. It especially took him an extended pause to try and remember how many concussions he had.
“Probably at least five,” Fitzke said.
He paused again.
“At minimum.”
And those were diagnosed concussions, not the smaller, subconcussive impacts a lineman consistently takes.
The Annals of Neurology study titled “Duration of American Football Play and Chronic Traumatic Encephalopathy,” notes that the odds of developing a severe case of CTE double every 5.3 years one plays. The odds of disease double every 2.6 years.
“Definitely in youth football, concussions were like ‘OK, take an ibuprofen or something and go back out there,’ if you had any symptoms,” Fitzke said. “But when you get to high school, if you have a decent athletic trainer or decent coaches, they’re going to know when you have a concussion and you have to sit out.”
Fitzke began his high school career on Mountain Ridge’s freshman team. During that year, he had the worst concussion he can remember.
"When I had a really bad one freshman year, it was like memory loss, confusion a lot of times,” Fitzke said. “I couldn't focus, headache obviously. And sensitivity to light was a big one too, I'd sit in a room and the lights would have to be off because I was so sensitive to them.”
Fitzke hopes to coach football for years to come, but he said he can’t help but think about what the future of the game looks like in 50 years.
Concussions at the high school level
Donte Delia has been at Flagstaff High School since she was a Northern Arizona University student doing clinical hours with former athletic trainer Tom Lyle. She then returned to the school while doing her student teaching and later, took over the permanent position.
As time has gone on, how Delia has treated concussions has changed.
“It used to be, you do absolutely nothing until absolutely all symptoms are gone and then you do everything again,” Delia said. “I found that a lot of times the risk of getting another head injury after not doing anything and then doing everything with little to no progress, really comes at more of a detriment than anything.”
Now, Delia’s method is to slowly rehabilitate a concussion with light cognitive stimulation, like Sudoku and eye exercises. Just like waiting until the swelling goes down for a sprained ankle, Delia waits until some of the concussion symptoms recede, but works with her athlete a little at a time.
If it is a severe concussion where it is taking two or more weeks for the symptoms to decline, Delia refers the athlete to a speech and vision therapist to work on that cognitive stimulation. As their symptoms improve and motor skills increase, Delia said she starts to work in some cardio and other physical exercises.
As time goes on throughout concussion recovery, Delia consistently tests the athlete to see where they are at.
“That’s probably one of the biggest differences between other injuries and concussion injuries is we’re testing you every single day to see how your brain is progressing,” Delia said. “Because of how subjective concussions can be, I can hit my head at the same force that you hit your head, I can get a concussion and you can be completely fine,” Delia said.
In a prevalent sport like football, it can be a challenge for Delia to see every instance when an athlete is showing signs of having suffered a concussion. She has staff that can point out things that she misses, but they are high school students training to get their athletic training license and certification.
Flagstaff is a decent-sized city, with the population measured at 76,989 in July 2021 according to the United States Census Bureau, but it is still in a relatively isolated region. Because of this, Delia has had to work both sidelines at some games because the opposing school does not have an athletic trainer. As of our conversation in late February, Delia said that Mingus Union High School in Cottonwood, a school that plays in the same region as Flagstaff, did not have an athletic trainer. Mingus was one game where Delia had to pull double duty.
“I’m only one person,” Delia said. “NFL, they have at least two people just watching concussions. That’s all, that’s all their job is. I’m watching for concussions, watching for other injuries, dealing with someone who has a cramp, I have all this other job that I'm doing.”
Kim Rodgers is the athletic trainer at Mountain Ridge High School, where she has been since 2006.
Rodgers said she has indicators that she looks for if she suspects one of her athletes have suffered a concussion.
“Things that you look at are changes in their play,” Rodgers said. “Do they seem confused in their sport? Do they have balance problems? Are they shaking their head a lot or they’re rubbing their eyes a lot? The classic one with football, somebody walks to the wrong huddle.”
Glendale is located west of Phoenix, the nation’s fifth-largest city. Since she is at a school located in a humongous metropolitan area, Rodgers said she faces different challenges in her job than athletic trainers at schools in smaller communities. Unlike more isolated areas, Rodgers’ athletes have abundant access to concussion specialists, physical therapists, orthopedists, and other types of specialists.
But like Delia and ATs at many other schools, Rodgers has students assisting her, but does not have a full-time assistant to help her cover MRHS’ 24 athletic programs, many of which have freshmen, junior varsity and varsity teams within them.
“There are so many athletes that I may never see a kid, especially if the coaches aren’t helping notify me when injuries happen,” Rodgers said. “A kid might just go see their own doctors, see their own physical therapist, do things that way and not let us know.”
Delia sees on average one to two concussions in an average week and one a game on what she called “a bad week,” depending on the sports she is covering at that time.
Preventing concussions in football, Delia said, comes down to proper tackling technique.
“The biggest thing to help prevent concussions is how to tackle the consistency of technique of tackle, the angle in which they’re tackling, how they’re driving through, and keeping strong shoulders and strong necks,” Delia said. “Because once their shoulders start becoming compromised, they’re going to drop their head and they’re going to go back to poor mechanics, which is dropping the head, compressing that C spine.”
The final whistle
Fitzke’s question of whether he will let his future children play tackle football is not a unique process. It is a question that parents across the country have been contemplating over the past several years.
Former President Barack Obama said in 2014 that if he had a son, he would have to think about allowing him to play pro football. That same year, LeBron James, the face of the National Basketball Association and regarded as one of the greatest players in sport’s history, said he would not let his two sons play at that time, but that they could talk about it with him once they got to high school.
In 2018, a group of former NFL players came together to support “Flag Football Under 14,” an educational program created by the CLF that advocates for parents to not allow their children to play tackle football until high school.
Brett Favre, a Hall of Fame quarterback that started a record 297 consecutive games from 1992-2010 and is known as the league’s iron man, has been one of the biggest advocates, starring in a PSA for CLF in 2021.
The NFL has a vested interest in youth football. It endowed USA Football, the non-profit governing body for youth football, in 2002. The organization provides certification for new coaches, teaches proper tackling techniques, and is a recognized sports organization by the International Olympic Committee.
The amount of children playing tackle football has significantly decreased in recent years. According to a report by the Aspen Institute in 2022, 677,872 children aged six to 12 played tackle football across the country in 2021 (2.3%). That figure was a 17.9% decrease.
Football remains America’s game. But with the science surrounding CTE advancing every year and the risks more known than ever, the future of the game is unclear.