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Divided on Messi vs Ronaldo, but neurologists agree headers cause long-term damage to footballers

Breakthroughs in neuroscience have established that headers can result in repeated sub-acute head trauma for professional football players, leading to neurodegenerative diseases in the long run.

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New Delhi: A striker who scored over 200 goals in a storied career for the likes of Notts County and West Bromwich Albion and even played for the England squad, Jeff Astle passed away in 2002, aged 59, having reportedly suffered Alzheimer’s late in life.

His daughter Dawn, recalling the death of her father, had told a local UK paper in 2015: “He choked to death in front of his whole family…It was the most horrific thing I have ever seen.”

Media reports dating back to 2002 show that the coroner at inquest linked Astle’s passing to head trauma suffered during his playing career, and set a precedent by declaring a “death by industrial disease” verdict. 

But it wasn’t until 2014 when Glasgow-based neuropathologist Dr Willie Stewart specifically determined the medical cause of Astle’s death to be chronic traumatic encephalopathy (CTE). 

The BBC, at the time, termed CTE a “boxing brain condition”, since this neurodegenerative disease was common among boxers who suffered repeated head trauma. 

In other words, the CTE Astle suffered from was the result of what he did best during his playing career — repeatedly heading footballs. Headers were a crucial part of his playing style and made him a goal threat, from his 1959 debut for Notts County until his retirement from professional football in 1977. 

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FIELD study, The Jeff Astle Foundation

The detailed retrospective diagnosis of Jeff Astle was a shot in the arm for the growing movement to phase headers out of football. 

Besides funding research, the foundation set up by Astle’s family — with help from Dr Stewart’s Football’s Influence on Lifelong health and Dementia risk (FIELD) study — has been lobbying for institutional change. 

Led by Dr Stewart, the FIELD study has been spearheading research on the link between headers and neurodegenerative diseases diagnosed among footballers, having regularly published new research and studies since 2019. 

Although initial results of the FIELD study’s research revealed that footballers were three-and-a-half-times more likely to suffer from neurodegenerative disease, a more direct link was established in FIELD’s player position-specific study released in August 2021.

The findings showed a reduced risk of neurodegenerative disease for goalkeepers compared to outfield players, with defenders flagged as the most affected, which is in line with the notable tactic of centre-backs repeatedly heading the ball away from oncoming attackers.

Another peer-reviewed study published in 2019 found that thousands of former footballers had suffered from neurodegenerative disease later in life, including five members of England’s 1966 World Cup-winning squad. 

Several footballing confederations and nations, such as the United States, Scotland and England, have either banned the act of heading the ball for children under 12 or begun trials to phase out the act among young players.

While the Union of European Football Associations (UEFA) has released broad guidelines on header safety for youth footballers, FIFA (International Federation of Association Football) is yet to come out with universal guidelines in this regard.

The road ahead is long and the impact of removing headers in the future would be far-reaching, fundamentally changing the way football is played on the pitch. However, even suggestions and policies to ban children from partaking in the act have historically been met with “mixed reception”, The Guardian had reported in 2020.  

What experts say 

So how does heading the ball actually affect the brain of a professional footballer in the long run? The answer lies not so much in individual instances of acute head trauma but in repeated sub-acute trauma, according to experts in the field of neuroscience. 

“The brain is floating in a fluid inside the skull. It’s inertia — when you have a sudden stoppage of your skull, your brain is still moving and can hit the skull. More than to and fro, it’s a shearing force and rotational angle which causes more microscopic, neurological damage by killing neurons,” says Dr Anurag Gupta, a Gurugram-based neurosurgeon with Narayana Health. 

But Dr Gupta adds that this damage is less apparent than concussions caused by incidents like a clash of heads or a collision with a goalpost. Rather, these are subtle impacts that lead to loss of neurons and later dementia over a 10-15 fifteen year period, synonymous with the average duration of a professional footballer’s career.

Symptoms such as confusion, memory loss, disorientation, emotional instability and failure to perform routine tasks may be apparent post-retirement and similar to standard cases of dementia, Dr Gupta explains, adding that imaging methods like an MRI or CT scan only show brain atrophy and make it challenging to diagnose such neurological damage accurately in footballers.

“Only through a post-death autopsy or brain biopsy do you see any evidence of CTE [in footballers]….children were found to be especially prone to the issue due to the brain not being fully developed,” he adds. 

For young or college-level players striving for a future professional career, an improper technique in heading the ball can also risk lasting damage, as experienced by Dr Surajit Nundy, a neuroscientist working in healthcare AI who played college level football in the United States and continues to play recreational football in Delhi.

“As a centre-back at an American university in the early ‘90s, I was made to mark the striker and repeatedly head the ball away, 20 times per match. If I didn’t go for a header, I was substituted, but my technique was flawed.

“Instead of using my forehead, I’d sometimes head the ball from the fontanelles — a fairly weak part of the skull — and feel dazed immediately afterwards. People would simply say well done but I’d often worry, because trauma to the brain is a bad idea,” says Dr Nundy. 

The line for acceptable amount of headers for professionals per training session and per game remains a grey area, according to Dr Gupta. But efforts of the Jeff Astle Foundation and the FIELD study have established a base level of evidence linking headers to “lower mental functioning”.

But for Dr. Nundy and many others, the headers issue ultimately boils down to sporting trade-offs, as “no one has really figured out any medical benefits” to heading, but on the field, it adds to the diversity of playing styles. 

This diversity is visible when looking at the goal scoring records of the two most prolific forwards in the 21st century — Lionel Messi has scored 24 headed goals, of which seven led his team to victory, while Cristiano Ronaldo has scored 112 header goals, of which 29 won the match for his team.

“While I think heading the ball hampered parts of my brain functioning, by banning them you’re essentially banning Cristiano Ronaldo and favouring Lionel Messi. If you believe the future of football is more about Messi, that’s all well and good, but it’s not how I see it,” Dr Nundy tells ThePrint.

A Manchester United supporter, Dr Nundy is firmly in the ‘Ronaldo camp’ and even joked about the number of headers Nemanja Vidic made throughout his career, while recognising the long-term head trauma the Serbian centre-back would have risked. 

Dr Gupta sees the “effective and entertaining qualities” in both styles of play, but expressed agreement with Dr Nundy, saying that “it’s too early to outright ban” heading in professional football,

He, however, added a caveat — “players need to be aware of the potential dangers. Kids definitely should be prevented from heading until they are old enough”.

(Edited by Amrtansh Arora)

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