Football offers long-term benefits and potentially negative outcomes as adults. People assume that playing football leads to long-term brain and health problems. However, life after football is variable, and the majority experience net benefit from playing football.

Despite the numerous long-term benefits of football, some can suffer the aftereffects of injuries sustained while playing. Head injuries can occur in all contact sports, but football involves a higher risk of sports-related concussion. When not properly treated, concussions can cause long-term symptoms. Subconcussive impacts are also a potential long-term risk of football.

Players, parents, and coaches must understand these risks because education influences decisions, which can prevent concussions and worse outcomes. This post discusses the myths involved with playing football, the current evidence regarding these myths, and potential long-term risks of playing football. Below are the topics:

Life After Football Myths

Playing Football Does Not Cause Chronic Traumatic Encephalopathy

Players Are Not at Higher Risk of Neurodegeneration in Life After Football

Life After Football Does Not Lead to Higher Rates of Depression and Suicide

Second Impact Syndrome and Long-Term Disability

Post-Concussion Syndrome Can Result in Long-Term Symptoms

Subconcussive Impacts May Cause Temporary Brain Changes

Benefits During Life After Football

Life After Football Myths

Over the last 15 years, the media has portrayed disabilities that can occur in one’s life after football. They often say that football causes these disabilities; however, this science is far from settled.

Headlines commonly say that playing football causes chronic traumatic encephalopathy (CTE)—a chronic neurodegenerative condition that is associated with repetitive head impacts. Diagnosis can only occur after death on an autopsy, but symptoms of the disease normally do not start till years after playing football. There is also evidence of CTE in people without head trauma.

More headlines say that football players are more likely to have neurodegeneration in life after football. Neurodegenerative diseases usually start in one’s 60’s to 70’s but sometimes will begin in the late stages of life. These include Alzheimer’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis (ALS).

Lastly, the media often portrays increased rates of depression and suicide in former football players. The world’s attention to this myth occurs when popular players express their symptoms or even take their life. While these occurrences are devastating, the news stories do not represent the norm for players in life after football.

Playing Football Does Not Cause Chronic Traumatic Encephalopathy

Chronic traumatic encephalopathy (CTE) is a pathological diagnosis consistent of tau protein buildup in the brain. Tau is a normal structural protein inside cells, but when cells die and turnover, the protein must be drained from the brain. If it builds up in an irregular pattern at the depths of the cracks or fissures in the brain, CTE becomes the diagnosis.¹

The main story that has hit every major news source comes from a study showing that 99% of former NFL players had CTE.² This study is a case series of 202 former football players whose brains were donated to the brain bank at Boston University from 2008 to 2017.

The results showed that CTE was diagnosed in 177 of the 202 brains with “0 of 2 pre–high school, 3 of 14 high school (21%), 48 of 53 college (91%), 9 of 14 semiprofessional (64%), 7 of 8 Canadian Football League (88%), and 110 of 111 National Football League (99%) players.”²

There are grave limitations to this study that the public never saw from the media. First, the case series is a convenience sample, which means that the research did not randomly pick deceased former football players. Rather, families of former player donated the brains because they had mood and cognitive symptoms prior to death. They suspected and wanted a diagnosis for the players’ experiences.

Next, this study did not examine confounding variables like obesity, alcoholism, opioid abuse, and other chronic diseases. These all can lead to chronic neuroinflammation and deposition of tau that is characteristic of CTE pathology.

For instance, this pathology has been recognized in individuals without previous history of concussion or subconcussive repetitive head trauma.³ These include people with substance abuse, schizophrenia, temporal lobe epilepsy, and other neurodegenerative diseases.^4,5

The media emphasizes a study that only shows association between football and CTE with no cause and effect relationship. I will discuss CTE and the faulty science further in a future post.

Players Are Not at Higher Risk of Neurodegeneration in Life After Football

Like CTE, other neurodegenerative diseases involve protein buildup in the brain. There are many potential causes and factors for protein buildup including cell damage, chronic inflammation, blood brain barrier (BBB) disruption, chronic infections, high blood sugar, and poor waste drainage.

Concussions and head trauma sustained during sports like football can cause cell damage, inflammation, and BBB disruption. When treated properly, the brain can return to a normal state. If players begin playing too soon and receive more head impacts, it can lead to a chronic inflammatory state, the hallmark of neurodegeneration. Players, parents, and coaches must understand this risk.

Concussions and head trauma can be a trigger for neurodegeneration, whereas other factors maintain the process. Poor nutrition, obesity, sedentary lifestyle, poor sleep, and chronic infections during life after football may play greater roles. Hence, there is lack of substantial evidence that football players are at higher risk of neurodegeneration.

For instance, 296 former high school varsity football players were compared with nonfootball athletes between 1956 and 1970 in Rochester, Minnesota.⁶ Football players (despite having more documented head trauma) did not have an increased risk of neurodegenerative disease overall or of the individual conditions of dementia, parkinsonism, and ALS.

A 2012 study examined causes of death for retired NFL players who played between 1959 and 1988.⁷ They found that overall mortality for the players was half of the general US population, so playing football was associated with greater longevity.

However, death due to neurodegenerative disease was three times higher than the general population with Alzheimer’s (AD) and ALS being about four times higher.⁷ The problem with this study is that the sample was small with only 334 deaths from the 3,439 players tracked, and only 2 deaths from AD and 6 deaths from ALS.

Life After Football Does Not Lead to Higher Rates of Depression and Suicide

The media also portrays higher rates of depression and suicide among former players. Depression is possible for any athlete who retires and needs to find a new purpose in life. Also, improperly treated concussions can lead to post-concussion syndrome in which depression is a main symptom. Despite these possibilities, life after football is not associated with increased rates of mood disorders.

A 2022 study questioned 435 men between the ages of 35 and 55 years old about mental health, cognitive functioning, and chronic pain.⁸ Those who played high school football did not have any higher rates of depression, anxiety, anger, concentration problems, memory problems, headaches, migraines, neck or back pain, or chronic pain compared with those who played other contact or non-contact sports or no sports.

Additionally, a 2017 study surveyed 3904 men who were 65 years old and graduated high school in Wisconsin in 1957.⁹ They looked at cognitive tests, depression scores, anxiety, anger, and heavy use of alcohol at this age. The conclusion states “cognitive and depression outcomes later in life were found to be similar for high school football players and their nonplaying counterparts from mid-1950s in Wisconsin.”

Lastly, another study looked at mortality from mental disorders and suicide in over 27,000 professional contact sport athletes, 13,217 being former NFL players.¹⁰ The NFL players had a significantly lower risk of death from mental health disorders and suicide compared to the general population.

Second Impact Syndrome and Long-Term Disability

When an athlete returns to play too soon and sustains another head impact, a more serious phenomenon can occur. This is called second impact syndrome. This syndrome is so rare that it is controversial to many in the medical field; however, the possibility should be taken seriously.¹¹

Second impact syndrome occurs after a second head injury only after the first head injury is not fully healed. The underlying brain swelling from the first injury is exacerbated by the second leading to diffuse cerebral (brain) edema, brain shifting or herniation from the skull to the spinal canal, and possibly death.

If diagnosed fast enough, surgery can be performed to make a hole in the skull, drain fluid, and relieve the pressure. This can save a life, but there will likely be long-term complications or even disability.

Second impact syndrome is another reason to stress the importance of concussion education and symptom reporting. A concussion return-to-play protocol is also necessary to prevent these devastating consequences.

Post-Concussion Syndrome Can Result in Long-Term Symptoms

Post-concussion syndrome (PCS) is a collection of non-specific symptoms that can be different in everyone. It is not a single pathophysiological entity and does not necessarily reflect ongoing physiological injury to the brain.¹² There are many non-physiological factors that can influence persistent symptoms in PCS; however, it is treatable when factors are identified.

The person dealing with PCS may be able to live with the symptoms, but the symptoms often affect daily activities, school, work, and/or social life. If proper evaluation and treatment of the brain’s functions is not performed, the person can become limited in life.

It is estimated that 20-30% of children with concussions do not spontaneously resolve and move on to chronic PCS.¹³ At the same time, athletes involved in a sport-related concussion may recover faster than the general population who sustain a non-sport-related concussion, so this percentage may be less in athletes.¹⁴

Postconcussion syndrome can involve symptoms from the seven different concussion subtypes: autonomic, cervical, migraine, emotional, cognitive, vestibular, and ocular. These subtypes represent different networks in the brain. Some subtypes have overlapping symptoms, which show how these networks affect one another. An individual can also have symptoms in multiple categories.

While PCS may cause more time away from school and sport, it is often treatable. Many people do not need to suffer from long-term PCS symptoms. Athletes that have persisting symptoms should be evaluated and treated as soon as possible to prevent time loss from school and activities.

Subconcussive Impacts May Cause Temporary Brain Changes

Subconcussive impacts are any hits to the head that are not enough to produce a concussion in that individual. This force can vary from a love tap on the helmet from a coach to two linemen hitting helmets to contact of head to ground after a tackle. A subconcussive impact could even be during a pillow fight. The definition is loose.

Despite the definition, there are white matter changes that occur in the brain over the course of a football season. Brain white matter represents connections between areas. Studies show that starting college football players have increased neurofilament light—marker of white matter disruption—compared with non-starters and collegiate swimmers after the season.¹⁵

Also, MRI diffuse tensor imaging (DTI) can be used to measure white matter alterations. A 2020 study looked at white matter changes on 213 football players who did not suffer a concussion from seven Midwest high schools.¹⁶ Players had significant white matter alterations from pre- to post-season, whereas players wearing a Q-collar had partially preserved changes in white matter.

Previous Q-collar studies have shown that white matter changes partially resolved during the offseason.¹⁷ It is unknown whether these white matter alterations compound and persist in life after football; however, there are many dietary and lifestyle factors that can play a role.

Benefits During Life After Football

While there are some long-term risks with playing football, the common myths do not have research support. Life after football is not an inevitable decline to CTE, neurodegeneration, and mood disorders.

Rather, many former football players praise the sport because of the lessons they learned that contributed to their success in life after football. These include character and leadership development skills. Former football players, who played at any level, have become doctors, surgeons, lawyers, entrepreneurs, and CEOs.

When athletes continue to prioritize their health, they will have long-term success in life after football.

References

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