The most common concern with football is the risk of head injuries. Football is a collision sport that involves player-to-player contact and players hitting the ground. This inevitably leads to head impacts. Not all head impacts cause head injuries in football. But higher quantities of impacts in football result in greater head injury risks.

There are many types of head injuries that a player can sustain while playing football. Some are more serious than others, whereas others are much more common than some. Understanding head injury risks in football can provide empowerment to players, parents, and coaches.

Knowledge of these risks and types of head injuries can help people identify them faster to seek appropriate management. Moreover, when players truly understand these risks, they are more likely to disclose head injuries to the appropriate personnel. This leads to optimal management, prevention of further injury, and a safer game of football.

In this article, we will discuss the different types of head and brain injuries and those common in football. Then, there will be a focus on concussion risks in football verses other contact sports. Below are the following topic sections:

Types of Head Injuries

Risk of Head Injuries in Football

Urgent Head Injuries in Football

Common Brain Injuries in Football

Concussion Risks in Contact Sports

Subconcussive Head Impacts in Football

How to Decrease Head Injuries in Football

Types of Head Injuries

There are two major areas that can be injured in the head. These are the external skull/face and the brain within the skull. Often when the skull is injured, the brain is also involved. However, the brain can be injured without damage to the skull or face.

Common external injuries to the head include facial and skull fractures, skin cuts/lacerations, and dental damage including chipped and lost teeth. In football, helmets almost eliminate these external head injury risks.¹

On the other hand, brain injuries are categorized into three types: severe, moderate, and mild traumatic brain injuries (TBIs). While not everyone agrees on the criteria for these injuries, they are still used frequently.

Severe TBIs involve loss of consciousness for over 24 hours.² Post-traumatic amnesia (memory loss) last over 7 days, and memory may never return. Typical brain imaging studies like CT scan and MRI often show abnormalities. The prognosis is not well.

Moderate TBIs also involve loss of consciousness but normally between 30 minutes and 24 hours.² Post-traumatic amnesia lasts between one and seven days. Brain imaging studies may be abnormal, but the prognosis is better.

On the other hand, a mild traumatic brain injury (mTBI) does not need loss of consciousness or post-traumatic amnesia, but both may occur. There will rarely be abnormalities in brain imaging. Many people lump concussions into mTBIs, but others prefer to keep them separate. More recently, a better distinction for research is to separate sports-related concussions from other concussions/mTBIs. Either way, they all have similar characteristics.

Risk of Head Injuries in Football

Since the incorporation of football helmets in 1943, external head injuries have progressively decreased. With more helmet innovation, skull and facial fractures are essentially zero. Despite external head injuries being rare, brain injuries are relatively common.

Because football helmets have greatly decreased bone fracture, they have also protected against moderate and severe brain injuries. For instance, between 1989 and 2002, there have only been an average of seven severe TBIs per year among all high school and college football players.³

Hence, the highest head injury risks in football are mTBIs and concussions. There is no equipment that can effectively prevent concussions, but some may help to slightly decrease risk. Helmets do not prevent concussions in football because they cannot prevent the mechanism of a concussion.⁴ Concussions are discussed in more detail below.

Urgent Head Injuries in Football

Most head injuries in football are concerning but not an emergency. However, there are some rare but possible head injuries that need urgent attention and care.

Hematoma occurs when a blood vessel breaks in an enclosed space leading to an accumulation of blood and pressure. Between the skull and the brain, there are brain coverings called meninges. The outermost meninge is the dura mater. Blood accumulation on either side can cause hematomas.

The most common hematoma is subdural hematoma.⁵ The vein that breaks below the dura mater causes a slow accumulation of blood between two layers of meninges. It will develop within 24-48 hours following head trauma leading to increased pressure and pain in the head. The main symptom is the worst headache imaginable that is not relieved by laying down or other pain relievers.

In the past, parents would prevent children with head injuries from sleeping with fear of a hematoma development. This is not necessary as in this case, they will be awoken by significant pain. If children are examined by a medical professional for signs of urgent trauma, their sleep should be prioritized as it is essential for recovery.

Second impact syndrome is another potential urgent head injury.⁶ The significant swelling that occurs can greatly increase pressure in the skull. The excess pressure can push on the brain leading to herniation into the spinal canal. While the brain can move, this type of movement and pressure can result in death.

Second impact syndrome occurs after a second blow to the head when the first impact occurred 15 seconds to a few days before.⁶ The second blow may even be milder than the first one. However, because the immune system is primed for inflammation, the second impact causes an extreme response. There is lost control over the blood flow and swelling in the skull.

The best way to prevent second impact syndrome is to remove any player with a potential head injury from the field. This requires proper education and symptom disclosure from the players. If they understand the potential ramifications of continuing to play with a head injury, they are more likely to remove themselves from play.

Concussions are Common Brain Injuries in Football

The most common brain injuries in football are by far mTBIs or concussions. Concussions occur when there is a blow to the head or body resulting in forceful acceleration of the head and neck.⁷ When the head rotates quickly around one or many axes, the brain sloshes around within the skull. This results in shearing stress and blunt trauma classified as the primary injury in a concussion.

Following the primary injury, global inflammation produces secondary injuries in other areas of the brain. Decreased blood flow leads to lack of oxygen and nutrients required for brain recovery. This can lead to further dysfunction and more symptoms.

Due to multiple brain areas involved, many symptoms can occur following a concussion. These include headaches, dizziness/lightheadedness, balance problems, sensitivity to light and noise, fatigue, brain fog, forgetfulness, and sleep problems.⁷

Most athletes will recover fully from concussions within a couple weeks. During this time, inflammation is reduced, and the brain learns to compensate for any damage that occurred. Nevertheless, there are about 10-15% that continue to have symptoms after one month.⁸ This is called post-concussion syndrome.

Concussion Risks in Contact Sports

Concussions are the most common form of TBIs. It is estimated to range from 100 to 300 per 100,000 people in the general population.⁹ Concussions may occur more often in the general population from motor vehicle accidents and falls in the elderly than in sports.

The incidence of sports-related concussion ranges from 0.17 to 0.99 per 1000 athlete exposures.⁹ “Exposures” involve the number of players in practices and competitions, rather than athletes alone. Therefore, the incidence per player is not as great as the general public.

While head injury risks are present in all contact sports, some have more than others. Football has the greatest risk of concussion among contact sports. However, this risk is not much higher than the next sports.

One article examined injury rates among multiple male high school sports between 2008-2013.¹⁰ Football only had 0.27 times higher risk for concussion over ice hockey and 0.67 times over lacrosse. However, football had as high as 2.27- and 2.98-times higher risk of concussion over wrestling and soccer, respectively.

Subconcussive Head Impacts in Football

Within the last few years, there has been more awareness regarding subconcussive head impacts. Although they are not injuries, the repetitive subconcussive head impacts that occur in football are associated with chronic traumatic encephalopathy (CTE).

Symptoms of CTE include depression and cognitive impairment. They usually begin after a 5-10-year period following the repetitive head impacts. Because it can only be identified in autopsy, nobody knows its prevalence in football players. Many assume it is very common, but only 30% of professional football players are suspected to develop CTE or another chronic brain injury.¹¹ According to Boston University researcher, Dr. Ann McKee, the minimum risk of CTE is 1/10 professional football players, 1/250 college football players, and 1/20,000 for high school players.¹¹

Head trauma is not the only factor associated with CTE. Others include alcohol and opioid abuse.¹² Hence, CTE is a multi-factorial disease in which many factors can be modified to decrease risk. While refraining from sports involving head impacts is helpful, abstaining from drugs and alcohol are also important. There may be other strategies that can decrease risks of CTE.

How to Decrease Head Injuries in Football

While risks are higher, there are ways to decrease head injuries in football. Recent rule changes have decreased blindside hits on special teams and reduced helmet-to-helmet contact between players. Limitations to contact practices during the pre-season or each week have also decreased concussion rates. These are making the game of football safer.

Moreover, players, parents, and coaches are important in decreasing head injuries. Proper education for these groups will identify the signs and symptoms of concussion. Players will be more likely to disclose concussion symptoms when they understand them and the potential consequences of continued play. While education doesn’t prevent the initial injury, it can decrease further injury and improve recovery outcomes.

Coaches can help decrease head injuries by teaching proper tackling and blocking techniques. Creating strong relationships with players will increase adherence to these techniques and disclosure of concussion symptoms. Coaches should also implement concussion pre-hab for their players including neck strengthening exercises and neuro-visual training.

Parents can support their children in a variety of ways. They can ensure their children are eating a healthy diet to decrease inflammation. They can provide supplements that increase brain resilience from head impacts and can improve outcomes following head trauma.

Players must understand head injury risks, so they use proper techniques. They can eat a healthy diet by avoiding processed foods like processed carbs, sugar, and seed oils. They should prioritize protein like meat and eggs with lots of fruits and vegetables. They can also take supplements for brain health like creatine, fish oil, magnesium, and vitamin D.

Everyone has a role to play in reducing head injuries in football. It all begins with the education of these groups.

Summary

There are head injury risks in football. They should not be ignored. People need to know the different types of head injuries that are possible and common in football.

Helmets are effective against external head injuries like skull and facial fractures. They even greatly reduce moderate and severe TBIs. These injuries are therefore rare in football. However, there still are possible head injury emergencies like subdural hematoma and second impact syndrome.

Because helmets do not protect against the mechanism of concussion, mild TBIs or concussions are the most common head injuries in football. Concussion risk is present in all contact sports. But risks in football are slightly higher than ice hockey and lacrosse and between 2-3 times higher than wrestling and soccer. Although concussion risk is higher, 85-90% of athletes will fully recover within one month.

Subclinical head impacts that occur in football can predispose players to chronic brain injury in the future. While these head impacts are associated with chronic traumatic encephalopathy, they are not the cause of the disease. There are many factors in chronic brain injury and neurodegeneration. Most are modifiable risk factors.

Understanding head injury risks can empower players, parents, and coaches to make appropriate decisions before and after head impacts. This involves the many prevention strategies that can be implemented. Football leagues, coaches, parents, and players all have a role to play in decreasing head injuries in football.

While head injuries in football are unavoidable, knowledge of the risks provide empowerment for everyone involved in the game.

References

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