One of the most pressing issues facing football is this. Head injuries may be viewed simply
as part and parcel of the game, but perceptions are changing.
Research has long been telling us about the dangers of head injuries in football, particularly
the link with neurological illnesses.
The response from the sport's governing bodies however has so far, however, has been negligible.
What they’re basically saying is 'We accept this risk of dementia. And there’s nothing
we’re going to do about it.
I have concerns whether I'm going to be put in a home at 50.
When you watch somebody that you love fade away, the affect on our lives is immeasurable.
So let's take a look at the research and examine exactly what football needs to change.
The 2020 Euros. France against Germany. Benjamin Pavard lies motionless after contesting a corner.
The doctor conducts a quick assessment. The defender continues playing.
But after the match, Pavard confirms most viewers' initial fears.
UEFA said their Concussion Protocol had been appropriately followed by the France medical team.
Brain charity HEADWAY saw it otherwise.
It's very very hard to understand how that wasn’t deemed to be a suspected concussion, particularly
after the player says he lost consciousness. I think it just exemplifies exactly how far
behind football is in dealing with this issue of concussion.
Austria's Christoph Baumgartner and Danilo of Portugal were also involved in controversial incidents.
Back at the 2014 World Cup, Christoph Kramer infamously asked the referee to confirm
he was playing in the final after being knocked out. Kramer kept playing for 13 minutes
and later said he couldn’t remember the match at all.
And who could forget Blaise Matuidi at the 2018 World Cup trying to drink from his water bottle?
These incidents are just a few of many examples.
Lessons have clearly not been learned.
There needs to be greater scrutiny, there needs to be greater accountability.
And they need to share, as medical teams, their findings for what they found.
Just like UEFA, FIFA also has a Concussion Protocol which states that a proper, full
assessment takes at least 10 minutes. But it's an immediate on-field assessment which
determines whether a player is concussed or not.
Any suspicion of concussion should result in the player's removal from the field.
It's not just concussions under the microscope, however. Research also suggests that heading
the football is just as dangerous.
But first, let's take a look at the science.
So what actually happens during a concussion? We spoke with one of the leading experts in
the field, Dr Willie Stewart from of the University of Glasgow.
The brain is a soft jelly, really floating, suspended inside your skull. And the skull,
that rigid box gives us fantastic protection.
So you can knock yourself in the head, and not impact that soft jelly.
But if you spin the head really quickly
after a punch or blow to the head, the skull or the head moves quickly but the brain moves slightly slower
and that slight difference creates stretch on the brain substance and that causes the damage.
This is where CTE – or chronic traumatic encephalopathy – comes in. The progressive
brain condition was first recognized in boxers, but has now been associated with NFL, rugby,
as well as football.
Dr Willie Stewart leads the landmark FIELD study, which is financed by the English Football Association
and the Professional Footballers Association.
What we found is that overall footballers were about 3.5 times more likely to die of a dementia.
That figure of 3.5 times higher risk of death of dementia, it ranged from
around a five-fold increase in deaths with motor neurone disease, around a four-fold
increase in deaths of Alzheimer’s disease, and around a doubling of deaths with Parkinson's disease.
So we know the dangers. But how do you identify a concussion? Only 10% of concussed athletes
actually get knocked out.
Sometimes players don't even realise at first, such as Union Berlin's keeper Andreas Luthe
when he suffered a nasty double head knock in January 2021.
Thankfully, Luthe decided to take himself off the pitch. But that isn't always the case.
Symptoms can be difficult to identify. And they can occur hours or even days after the fact.
And throughout all sport, it's often seen as tough or admirable to play through that pain barrier.
Luthe admits that male footballers are often under pressure due to the ideals of masculinity.
The long-term consequences take time to materialise. But players are of course also at risk in the short term.
For example, what could happen if a footballer stays on the pitch after a concussion?
A further head blow could cause uncontrolled swelling of the brain, which is known as Second Impact Syndrome.
It's fantastically rare, but unfortunately it's not so rare that we should just ignore it.
Because the uncontrolled swelling of the brain can lead to death.
Freya Holdaway was forced to retire after suffering three concussions within 18 months,
one of which was particularly scary for the former Crystal Palace captain.
I passed all the protocols, ticked every single box to be able to go back out onto the pitch and play.
But the fact that then within five minutes of that I then had two seizures on
the side of the pitch, I think for me is quite worrying. Because had I gone back out, and
then taken another knock to the head, what could have happened?
The dangers of head trauma are clear. And the likelihood of suffering a head injury
during a football match is quite high. Research is also increasingly linking heading the football
with neurodegenerative diseases.
An innocuous header was actually the final straw which convinced Holdaway to retire.
She is now assisting the SCORES Project, which is collecting data on both amateurs and professionals.
Project lead Dr Michael Grey wants to see FIFA commit more funds
towards researching the dangers of heading.
These repetitive incidences, where the brain is shaking inside the skull, those cause damage.
So anything we can do, to reduce those occurrences, is a good thing.
In 2020, the British FAs introduced guidelines suggesting children under 18 should not head
the ball during training. But it isn't a ban. And there is no guideline about heading within matches.
Dr Grey wants an outright ban of heading for children. And at least a reduction for adults.
It baffles me that they are so slow to pick this up.
Again, it's the powers that be in the game have this notion that heading is such an integral elemental to the game.
I think it's really telling that football has spent millions and millions of pounds on investigating VAR.
Loads more funding for that than there has been for player welfare for looking at brain injuries.
Holdaway now wants to use her experience to educate younger footballers
about the dangers of head impacts.
I used to wake up crying, wondering if my ears were going to stop ringing in the mornings.
My first thought every day for months and months was
How am I going to feel today? Is my head ok?
It was the right decision to step away from the game. I have concerns whether I’m going
to be put in a home at 50.
So is a header really just as bad as a head clash? Well, just imagine a ball, weighing
about half a kilogram, travelling at 100 km/h, and crashing straight into your head.
It's a head trauma, no matter which way we look at it.
Most headers of course don't connect with balls travelling that fast.
And more research is definitely necessary.
But a player can make about 20 headers per game. That could mean as many as 10,000
headers during a career.
Say you and I were standing together in the lab and I put on a pair of gloves and said
'Do you mind if I hit you over the head a few times'. You'd say 'no, it’s not happening'.
But if I had a football and I said 'let’s play some head tennis'
you'd be like 'no problem at all'.
So could football ever actually consider ditching heading completely? Or is it simply too central to the game?
In Autumn 2021, brain charity HEAD FOR CHANGE organised a match at Spennymoor Town, in the
northeast of England, to find out.
In the first half, heading was restricted to just the penalty box. And in the second,
it wasn’t allowed at all
Head trauma is a topic close to the heart of HEAD FOR CHANGE chairwoman Dr Judith Gates.
Her husband Bill Gates is an ex-pro and suffers from dementia.
When you watch somebody that you love fade away by degrees. When you watch the light
go out in their eyes, where you see bewilderment where previously there was confidence.
The effect on our lives is immeasurable.
Dr Gates is not calling for an outright ban. But she does want to educate players and put
more pressure on governing bodies to take up the fight.
You only have one brain. And if that is damaged and 30 years later you see the signs of that,
there's no going back.
Many former England internationals have also passed away after suffering from dementia
including Ray Wilson, Jack Charlton, and most recently Nobby Stiles.
And that has certainly weighed heavily on the next generation.
Former Newcastle United defender Steve Howey believes it's time to tackle this issue more seriously.
I am a little bit forgetful. I have to be honest, I try not to overthink it too much,
because then you worry yourself a little bit,
but it can't do you any good heading the ball consecutively pretty much every day for 15 or 16 years.
Some of the ex-footballers who participated, however, think heading is just too crucial to the game.
It's a skill, it's an art. You just have to see how many goals every week are scored by headers.
So I think to take that out of game, it wouldn't work.
Roughly 15 to 20 percent of goals in Europe's top five leagues are in fact scored by headers.
Any restrictions would be a major rule change.
So when should health trump tradition? Well, that's on FIFA, the world's governing body, to decide.
What football needs to ask is not the question: 'Is heading necessary for the game of football.
I think the other way they need to ask that question is: 'Is dementia a necessary risk in football?'
What they're basically saying is that we accept this risk of dementia. And there's nothing we're going to do about it.
Let's be honest, a ban on heading isn't going to happen anytime soon. But footballers' health
does have to start coming first. Taking a back seat on this issue is no longer an option.
Research is also starting to show that women are at greater risk.
A 2017 study at the American Academy of Neurology found that women are 50% more likely to suffer concussion.
And they're more likely to suffer harsher and longer lasting side-effects.
There's not much data looking at concussion in female sport, which is really shameful.
The management and return to play in concussion is all based off research in men.
So arguably there are no adequate concussion protocols for women, because we've never actually
done the research to inform them.
That's a wider problem in the medical world. More research is desperately needed to understand
why women are more affected. But it is believed to be down to hormonal and biological differences.
Deep down in the brain there are fine fibres that run between our brain cells and connect out to the body.
And these are known as axons, and they're basically like telephone wires that carry the signal
from one place to the other.
It turns out that in women, if you look at them down a microscope, and you stretch them
in the lab to injure them, these fine fibres, these axons are much more slender than they
are in men and a bit more fragile. So the same stretch in female axons produces more
damage than in male axons.
It is yet another reason why awareness is so important for former athletes likes Freya Holdaway.
I want to help those youngsters who were in my position, who don't have the confidence
or the knowledge to step away from the game.
So considering what we've heard so far, from the links between football and dementia,
the dangers of heading the ball, and the higher risk for women…
What exactly are the authorities going to do about it?
As mentioned, FIFA and UEFA both have Concussion Protocols, but as we've also seen
they aren't really being administered correctly.
English football is leading the way in terms of research and funding.
They introduced Concussion Substitutions as part of a trial set up by the International Football Association Board,
while other top leagues rejected the chance.
The Premier League says medics have as much time as required to make an on-field assessment.
But not everyone is convinced by Permanent Substitutions.
Ultimately, while the concept is that, if you do Permanent Subs there is no risk for
that player coming back on after that assessment.
The reality is that the medics on the pitch still have two minutes, or three minutes,
to assess that player for whether they are potentially concussed or not. So ultimately
you're putting more pressure, not less on the medical teams. And ultimately absolutely
nothing is going to change.
Instead, there is a call for Temporary Substitutions, which already exist in other sports.
Here, the player is immediately substituted and taken off the pitch. Then they have to undertake
a longer assessment before being cleared. If they pass the tests, they can return to play.
Politicians, the administrators, the doctors in many national associations would wish to
go down the line of having Temporary Substitutions and longer assessment.
But it's not within their give. So it needs the global game to respond to
the pressures that are coming from elsewhere.
While football is dragging its feet, other sports in the world are miles ahead when it
comes to dealing with concussion.
The NFL and World Rugby are just two organisations which have been forced to tweak rules and
introduce stringent protocols in the wake of high-profile court cases.
Football could, and should, be next.
I dread to think what's going to cause that, whether it's going to be tragedy or whether
it's going to be legal action.
If nothing changes, nothing happens now, they pretty much can secure themselves the lawyers
for 30-40 years from now.
Ultimately, the buck stops with FIFA. So how exactly are they going to react?
Football has this problem. Dementia is a problem in football. And it's not really taking a
lead on experimenting or trialling or finding a way of resolving it.
It's kind of leaving it up to everybody else to find a way.
It's clear football has to face reality sooner or later. One can only hope, it's not too late.