The thrills and spills, rough and tumble of elite competitive sports are all part of the attraction for those who pursue them professionally, as well as for spectators who cheer on from the sidelines or the couch. But what is becoming increasingly clear is that the very competitive nature of high-level contact sports can exact a severe price on players through the onset of debilitating brain damage.

This health issue, which is now more widely recognised, has hit home particularly in the likes of football, rugby, American football, ice hockey, boxing and wrestling, where repeated blows to the head and concussions may occur. Constant, crunching tackles are also a concern due to the whiplash-like effect of this impact reverberating through the body to the head. Many parents are discouraging their offspring from participating in sports where head injuries are likely.

Injury blows

Respected BBC rugby commentator Chris Jones has suggested that this effect on brain health is an existential crisis for his sport. More than 300 retired rugby union players in England and Wales are pursuing legal proceedings over brain damage they say was sustained during their years in the game. They accuse the rugby authorities of being negligent and failing to protect them from permanent injury.

The number of claimants has risen rapidly since England World Cup winner Steve Thompson and other former players initiated the lawsuit in December 2020. They say part of their motivation in taking legal action is to save the game for future generations by securing new protective measures.

Failures levelled at rugby union’s world and national governing bodies include taking inadequate steps to inform, educate or warn players about the risks of permanent brain damage; conducting insufficient research into the effects of multiple concussive and subconcussive impacts on the brain and the prevention of permanent brain injury; and not reducing the amount of contact allowed in training or the number of matches per season.

Brain damage hits

This ongoing litigation in the UK has been compared with a successful American football class-action lawsuit brought against the National Football League (NFL). In this case, more than 4,500 former players and their families sued the NFL for misleading them over the long-term dangers of concussions and head injuries. It ended in a 2013 settlement worth about US$765 million (HK$5.9 billion).

This lawsuit highlighted the prevalence in American football of chronic traumatic encephalopathy (CTE), a degenerative brain disease caused by repeated blows to the head. Brain-related injury had been detected in boxers as early as 1928 when US doctor Harrison Martland linked signs of being ‘punch drunk’ – mild mental confusion and a staggering gait – with serial head punches. The condition was given the name dementia pugilistica.

More than 75 years later, in 2005, NFL hero Mike Webster became the first in his sport to be diagnosed with CTE; after retiring from the game, he suffered from dementia, cognitive impairment and mood changes, and brain damage was identified following his sudden death.

Post-mortem revelations

Sadly, a number of American footballers have committed suicide in recent years, most likely triggered by the neurological effects of playing their sport. One of them, Dave Duerson, who took his own life in 2011, had asked for his brain to be donated to the Boston University School of Medicine; subsequent tests found CTE. The autopsy of Australian Rules footballer Heather Anderson, who struggled with depression and killed herself in 2022, also detected this incurable disease of the brain.

England’s Thompson, who suffers from early onset dementia, has talked of being put on suicide watch as a result of his illness – as have other former rugby players involved in the ongoing legal action.

Carrying on with concussion

Ex-Wales international Alix Popham, who was diagnosed with probable CTE and early onset dementia in 2020 at the age of 40, shares in a BBC podcast some of his experiences of playing professional rugby and the lack of concern at the time about head injuries.

“Concussion was a bit of a joke; if somebody got knocked out or had ‘Bambi legs’ … players would have a laugh,” he says, explaining that teammates did not want to show any sign of weakness. “You were expected to chuck some water in your face and sniff some salts and just carry on. That was the way we did it.”

Popham believes most of his brain damage was inflicted during training because of the amount and length of contact required. He says these sessions might last as long as two hours and physios or doctors were not in attendance.

“My neurologists described subconcussive hits like a dripping tap on a piece of mud. [If it drips] once or twice, there will be no mark at the end of the day. But if it dripped for 14 years, there will be a big hole, and that is what is happening with every hit that a player is taking, not just to the head but to the body as well.”

Popham adds that some current players he has spoken to remain hesitant to quit the sport despite being advised that brain scans they have had are not “great”. It was perhaps this lack of clarity surrounding the issue that prompted him – along with his wife, Melanie Bramwell-Popham, and Sally Tucker, an NHS surgeon with a special interest in medical ethics and law – to set up Head for Change. Dedicated to pioneering positive change for brain health in sport, the charitable foundation provides a supportive space for sportspeople with neurodegenerative disease.

Heading for disaster

These laudable goals cannot come a moment too soon. Tucker’s father is a former professional footballer who has been diagnosed with dementia, probably caused by repetitive head injury from heading the ball during his career. Research published in 2019 found that footballers were three and a half times more likely than the general population to die from a neurodegenerative disease.

Just last month two former Premier League football players shared their health concerns after years of heading a ball for a living. Former England defender Gary Pallister talked of how sickening migraines would blur his vision, affect his speech and leave him unable to train for two days. Along with many ex-players, he harbours fears for his future wellbeing.

As for Pallister’s ex-England colleague Steve Howey – who at 53 sometimes struggles to express himself and suffers from short-term memory loss – scans have revealed that his brain is in cognitive decline. The British charity Head Safe Football is campaigning for heading to be declared a national health issue, and the harmful skill is now being phased out at grassroots youth level.

Howey is one of a number of ex-professional players in England who are taking legal action against football’s governing bodies. The group includes the family of former 1966 World Cup winner Nobby Stiles, who had advanced dementia in later life; he was diagnosed with CTE after his death in 2020.

More severe for women?

Sportswomen are feared to be at greater risk from concussion than their male counterparts. Research conducted by SidelinesDr in Australia and others suggest that women are not only more likely to sustain concussion in any given sport, but their symptoms tend to be more severe and their recovery time longer. Some medics have speculated that this is down to weaker neck muscles.

Other research in Australia found that 79 percent of jockeys have had at least one concussion during their horseracing career, and a quarter have suffered four or more.

Last year, World Rugby launched a call for applications to fund player welfare research projects into concussion, injury surveillance and prevention at all levels of the game. It also established a steering group to examine player welfare in the women’s sport. 

Technology is playing a part to help limit head injuries. For instance, researchers at the University of Wisconsin-Madison in the US are working on a new protective foam that could revolutionise helmets in contact sports. Many sports governing bodies are also finally supplying guidelines, education and awareness about the long-term hazards of concussion and repeated blows to the head.