Why football should heed warnings about heading and brain damage

“Evidence suggests risk of TBI (traumatic brain injury) and participation in heading are in part dependent on field position,” said the paper written by William Stewart, Jill P Pell, John A McLean, Katy Stewart, Daniel F Mackay and Emma R Russell and published in the peer reviewed monthly Journal of American Medical Association (JAMA) Neurology. And that is why compared to the general population, the risk is lowest for goalkeepers – 1.83 – and the highest for defenders (4.98) followed by midfielders (4.59) and forwards (2.79). The findings were based on records of 7676 Scottish footballers born between January 1, 1900 and January 1, 1977 along with 23028 general population members. The study used imaging of what happens when a football is headed and looked at “evidence of immediate short-lived cognitive impairment and brain structural changes.” 

Neurosurgeon Laxmi Narayan Tripathy compared heading’s impact on the brain to kicking a football in a room. “The ball will rebound off the walls before resting. So when the skull moves to head the ball, the brain, floating inside, also moves. In that movement, and till the force completely becomes zero, lies the chance of damage because the inside of a skull is very uneven. 

“The brain’s compartments have fixed tough tissues called dura mater and they too can cause injury. So, yes, there is the risk of concussion and it is directly proportional to the speed of the ball,” said Dr Tripathy, director, Medica Institute of Neurological Sciences in Kolkata.

According to the study published in JAMA Neurology, the diseases can happen late in life. “These are cumulative injuries. It depends on the number and severity of impacts which worsens the normal degenerative process,” said Dr Tripathy. 

Judith Gates knows all about it. Her husband Bill Gates is battling dementia. Gates was a central defender at Middlesbrough from 1961-73 and a teammate of 1966 World Cup winner Nobby Stiles. Gates retired before he was 30 and Judith has said very severe migraine attacks were an important reason for that. His training schedule at Boro involved about 100 headers every day, Judith told Sky Sports in December 2020. “He came home so often with headaches, with migraines, unable to communicate with the family,” she said. 

The attacks ebbed after a while and “we’ve had 20 years of quiescence in terms of possible neurodegenerative diseases,” said Judith in another interview. Things worsened when Bill was in his 60s, she said. Tests showed Bill had elevated levels of a protein called tau, said Judith. “One of the tau pathways lead to chronic traumatic encephalopathy (CTE) which is only a result of head injuries,” she said. 

In January 2021, Judith helped set up Head For Change, a charitable foundation in England which is trying to raise awareness on neurodegenerative diseases due to playing professional football or rugby and support those affected by it. The Stiles family is among its ambassadors because Nobby Stiles, who died in October 2020, had dementia. As did Martin Peters, Jack Charlton and Ray Wilkins, all members of that 1966 squad. Bobby Charlton, another star in that campaign and Jack’s brother, has also been diagnosed with dementia. 

To show that football could be played with minimum to no heading, the foundation helped organised a match on September 26 in England. In an e-mail interview to Hindustan Times, Judith called it “an experiment to see what the game would look like with reduced heading.” In the first half, heading was allowed only in the penalty area which meant “long balls from the goalkeeper up field were more restricted, thus, of course, restricting the high force headers that the FA recognise are dangerous.” 

In the second half, it was banned altogether and free-kicks awarded for every header. “The very first foul that was allowed for heading outside of the box in the first half was a direct result of an instinctive move by the player. The good-natured crowd actually laughed, while the player commented on the need to adjust his game from instinct to intention.” said Judith.” The game was played more on the ground.” 

Many of the players were former professionals with a commitment to raising awareness of the dangers of heading, said Judith. “We received some comments via social media that reducing heading in the game would destroy the game. The challenge, of course, is to balance how to protect the players with how to protect the game.” 

Judith said it is not for the foundation to advocate change in the way football is played. “Head for Change thinks that it is for the sporting governing bodies to determine the rules of the game, so as to ensure that it is safe for players. We are pleased to have been part of helping this discussion to begin and to have provided evidence as to what happens in a game with restricted heading. Our key focus is protection for current and future players and we look to the sporting governing bodies to make informed decisions to protect the players.” 

The English FA’s guidelines for amateurs recommends not more than 10 headers per week in practice and in the USA, heading is banned for under-11 boys and girls. “Our organs usually develop till we are 18-19 so heading could impact adolescents more than adults,” said Dr PSM Chandran, a sports medicine consultant, and former director of the Sports Authority of India.

But unlike international cricket which approved concussion substitutes in 2019, football is trialing with the idea.  This despite JAMA pointing out there were more than one head injury per game in the 2014 World Cup – 67 in 64 games. “I can’t imagine football without heading but I don’t understand why the number of substitutes can’t be increased to deal with something like head injuries,” said Dr Chandran. 

For now, at World Cups, there is a three-minute stoppage rule to assess head injuries. “It is impossible to ascertain the extent of damage in that time. I don’t understand why can’t the player come off and be replaced, if necessary, only for the time it takes to assess the injury properly,” said Dr Chandran. 

Many of these head injuries happen when players clash while going for a header. Wolverhampton Wanderers’ Mexican striker Raul Jimenez had a skull fracture and suffered a major traumatic brain injury in November 2020 following a clash of heads with Arsenal’s David Luiz in a Premier League match. Luiz continued playing but was substituted because Arsenal manager Mikel Arteta said he was uncomfortable heading the ball. 

Jimenez’s recovery took a lot longer. “They told me it was a miracle to be here,” he told reporters nine months later when he played 90 minutes in Wolves’ 2021-22 season opener against Leicester City. Jimenez now wears a specially designed head gear in games.