Tackling the Truth: The Concussion and CTE Crisis in Football
(Cover Illustration by Maia Lazor)
Introduction
On September 12, 2024, during a Week 2 NFL football matchup between the Miami Dolphins and the Buffalo Bills, a harrowing moment involving Dolphins quarterback Tua Tagovailoa reignited a controversial conversation around player safety. Late in the third quarter, Tagovailoa took off on a quarterback scramble, attempting to secure a critical first down for his team. Opting to take a hit instead of sliding to avoid contact, Tua suffered a violent collision with a Bills defender. What followed was deeply unsettling: lying motionless on the turf, Tua appeared paralyzed, clutching his head while making unorthodox motions with his arm. The stadium fell silent as medical personnel rushed to his side. Diagnosed with his third concussion in the NFL and fifth in his football career, Tua became the center of intense debate. Following his injury, many questioned whether he should retire for the sake of his long-term health, noting the concerns associated with suffering multiple concussions. On the other hand, others lauded his resilience for continuing his career. Despite his medical history and public refusal to wear the newly introduced guardian cap– a soft-shell helmet add-on designed to reduce head injuries–, Tagovailoa’s decision to continue playing sparked further controversy about the long-term health effects of playing football.
The CTE Controversy
The controversy surrounding Tua’s situation is deeply rooted in the history of Chronic Traumatic Encephalopathy (CTE) among retired football players, especially in former NFL athletes. A Boston University study found that 345 of 376 players, examined post-mortem, or after death, were diagnosed with CTE. Similarly, a study involving 631 male brain donors who had played football revealed that only 28% showed no evidence of the condition, highlighting the widespread impact of repetitive head trauma in the sport. Moreover, findings from the same Boston University study indicated that each additional year of play increased the risk of CTE by 15%, and every 1,000 head impacts raised the likelihood by 21%. Such data underscore the cumulative nature of such injuries, which often go unnoticed during a player’s career.
What makes these revelations even more troubling is the realization that rather than diagnosed concussions, sub-concussive hits are the primary driver of CTE. Sub-concussive hits refer to the myriad of customary impacts that occur during football which do not cause any reason for injury or concussion. Disregarded blows to the head manifest frequently during practices and games, silently causing structural and molecular brain damage over time. The implications are staggering: CTE serves as a stark reminder of the cost of playing football, with its devastating effects prompting critical changes in safety protocols. However, while awareness has grown, the ongoing prevalence of CTE accentuates the urgent need for further action to safeguard players.
The Biology Behind CTE
CTE is a progressive neurodegenerative disease caused by repetitive head trauma. It leads to neurodegeneration, or the deterioration and loss of function of nerve cells in the brain with symptoms often remaining inconspicuous until significant damage has occurred. Unlike concussions, which exhibit acute symptoms, CTE develops insidiously and can only be definitively diagnosed after death through brain autopsies. The condition is marked by the accumulation of hyperphosphorylated tau (p-tau) proteins that destabilize neurons’ microtubules. Microtubules are long, cylindrical structures within the cytoskeleton of neurons responsible for intracellular transport and cell shape. Destabilization causes tau proteins to misfold and clump together around small blood vessels of the brain’s cortex, triggering inflammatory responses in the brain. Over time, these processes result in widespread brain degeneration, manifesting as cognitive impairment, mood disorders, and motor dysfunction.
CTE typically appears in two forms: an early-onset version characterized by impulsivity, aggression, and anxiety in young adults, or a later-onset form that resembles dementia in older individuals. The disease progression is closely linked to repetitive head impacts, which amplify the accumulation of p-tau proteins in critical brain areas like the frontal lobe and hippocampus. The impacted regions in the brain govern decision-making and memory, explaining the profound behavioral and cognitive changes associated with the disease. Being able to differentiate between the two forms of CTE is essential for developing interventions that could slow or prevent its devastating effects.
Efficacy of the Guardian Cap
In response to the ongoing concussion crisis, a potential solution to mitigate head injuries in football is the guardian cap. The soft-shell helmet absorbs and disperses impact forces, aiming to reduce the rotational forces linked to concussions and long-term brain injuries. Studies reveal that the cap is far more effective when both players involved in a head-to-head collision are equipped. Data suggests that head collision impacts are decreased by 10-15% when one player wears the cap and by up to 30% when both players are protected. Research from Virginia Tech’s helmet lab found a reduction in linear acceleration forces by as much as 14%, translating to a potential 15-35% cut in concussion risk. The findings highlight the cap’s promise in enhancing safety during high-impact plays.
However, the cap’s efficacy remains debated. Some studies involving collegiate players reported no significant reduction in linear or rotational accelerations during impacts, raising concerns about its reliability in real-game conditions. Furthermore, the NFL has only mandated its use during practices, limiting its overall effectiveness. While the cap represents progress, its variable results emphasize the complexity of head injury prevention in football. Continued research and refinement of protective equipment like the guardian cap are essential to better address these challenges and reduce the risk of CTE.
Conclusion
Efforts to make football safer by preventing CTE, reflects a growing dedication to protecting athletes at all levels. Limiting full-contact practices by mandating tackling and enforcing non-contact guidelines has reduced exposure to repetitive head trauma, a key driver of CTE. Innovations in helmet technology, such as the guardian cap, have shown promise in mitigating head injuries, though further refinement is needed to maximize their effectiveness. Beyond equipment, researchers are exploring neuroprotective strategies, including treatments targeting inflammation and tau protein pathology. Educational initiatives about concussion management and early intervention are also critical for improving player safety. While the inherent risks of football cannot be entirely eliminated, advancements in science and technology offer hope for a future where athletes can enjoy the game without jeopardizing their long-term health.