Hey! The NFL has improved its handling of concussions!

The National Football League (NFL) has long been criticized for its approach to brain injuries and concussions. I’ve covered this issue and my thoughts about solving it in great detail. The league was very, very bad on the subject for a long time. It denied that concussions were a major problem. It funded compromised scientific studies to counteract the many legitimate ones which were gradually showing just how damaging brain injury is to current and retired football players. It didn’t provide sufficient health care and other benefits to retired players suffering from the effects of brain injury until forced to by a legal settlement. And on the field, the NFL’s attempts to make the game safer were met with skepticism. How can the NFL punish players for making hits they had been taught were good for their entire lives? Was it even possible to avoid hitting someone in the head in such a chaotic environment. How could the league expect to protect players who so steadfastly refused to bow down to the danger of brain injuries? That last criticism was one that rang true to me. To make it to a professional level in football – one of the world’s most team-oriented sports – you basically have to be someone who will put the success of a team before their own success. Selfish football players do not make it to the NFL. Self-sacrifice is so selected for, that it’s insane to think an NFL player won’t try to play through a brain injury to help their team, even if they know the potential danger of doing so. It felt like an intractable problem until this year, when the NFL made some changes that actually seem to be working! Here’s what they’ve done.

During each game, there are independent certified athletic trainers who are employed to watch and look for any potential head injuries. When they see one, they are empowered to stop the game in order to assess the player. If their suspicion is confirmed and the player does seem symptomatic of having had a brain injury, that player is removed from the game and (although I’m not sure this is a rule — it is the reality) does not return to play that day. Once a player has suffered a concussion, they need to go through a five step process of assessment and escalating activity before they can return to the field. That final decision is no longer in the player or team’s hands, but is controlled by an independent neurologist. Steps like this have been taken before, but they’ve never been as dramatic nor have they ever seemed to work the way this round of changes has. Players this year are staying out longer — something which is essential because of the increased risk one has of suffering a second and more damaging concussion soon after a first.

Football is still easy to criticize when it comes to player safety. Football players, especially young ones, are still dying at unacceptable levels. None of the reforms have addressed what might be the most pernicious aspect of football on its players’ brains – the near-constant sub-concussive blows that linemen experience on every play. Still, the progress I’ve seen this year is more than I expected. Not only do I think players are better protected and cared for than they have been in the past, but it’s also great to see football as a role-model among sports for once. The National Hockey League (NHL) has followed suit and given concussion spotters the ability to stop games during the season which starts tonight. Soccer authorities, (once they are bailed out of prison), should do the same.

What do we know about brain injuries or concussions?

The sight of a football player knocked senseless or woozy during a game is common. For years, the culture of football was to celebrate the roughest elements of the game, including those that caused concussion symptoms like these. Of course, the word concussion wasn’t used, players were “dinged up” or “had their bells rung.” Concussed players rarely left the field, and if they did they were back as soon as they could walk straight. Today the way we observe, comment on, and handle brain injuries in football is very different. Now when a player goes down, we gasp, avert our eyes, and talk in hushed voices. We know now that brain injuries have serious short and long-term consequences. They can cause the toughest football players to seize up, be unable to tolerate sunlight, or vomit uncontrollably. In time, they can cause personality changes, aggression, and dementia.

What has changed? Well, we know more about brain injuries and their effects thanks to some powerful investigative reporting and promising scientific work led by the New York Times and Boston University respectively. The twin forces of knowledge and focus shifted public opinion but have not necessarily conveyed the full story in an easily understandable way. If you’ve ever wanted to understand what’s really going on when a brain is injured and how that pertains to football players, here is a summary.

Brain injuries are generally categorized into two groups: concussions and subconcussive events. Both are caused when a person’s head moves rapidly enough for the brain inside to scrape or hit the inside of the skull. In football, this is often the result of a blow to the head from another person’s body or the ground, but it can also happen if the head moves fast enough, even without impact. Of course, every injury is unique but it helps to classify them.

  • Concussions are injuries that have recognizable short-term symptoms that may not be present immediately after the impact. A concussed player may have a headache, loss of memory, and confusion. They may experience visual symptoms like blurred vision or seeing stars (this actually happens! it’s not just in cartoons). In some cases concussions may cause vomiting or loss of consciousness. Some symptoms of concussions are usually experienced with a short delay of a day to a week. These insidious symptoms include sensitivity to light, trouble sleeping, difficulty with concentration, and depression. Concussion symptoms may dissipate after a few days or may stick with a person for months or even years.
  • Subconcussive events are simply a description of any head trauma that does not cause a concussion. It’s not a very satisfying definition but subconcussive blows are an important concept because of how frequently they occur in football and their potential impact on the long-term effect of football on its players.

It’s hard to know how many concussions there are in the NFL and in other levels of organized football. Estimates range widely mostly because players and teams both have incentives to not report concussions as they happen. The NFL reported 228 concussions in the 2013-14 season, down slightly from 261 and 252 in the previous two seasons. That means every time a player steps on to a football field, (and 96 do, per game) he has a roughly 1 in a 100 chance of getting a concussion. Just from having watched a lot of football, that frequency feels about right. That would mean there is one reported concussion (too obvious to hide) in almost every game.

Football players certainly suffer concussions at a greater rate than normal people. They also suffer broken bones and torn ligaments at a significantly higher rate than normal people. Broken bones and torn ligaments never have and never will be seen as a pernicious element that could conceivably bring down football. The real problem is that a statistically significantly higher percentage of football players experience another set of physical and psychological symptoms that are almost definitely tied to brain damage. We are now morally certain that these symptoms are the result of a neurological disease called Chronic Traumatic Encephalopathy, or C.T.E., and that it has been caused by concussions or other brain injuries suffered while playing football. The New York Times, which did a lot of the earliest and best reporting on C.T.E. thanks to the work of Pulitzer Prize nominated journalist, Alan Schwarz, described C.T.E. as “a degenerative and incurable disease”. Here is the best description of the four stages of the disease from an article by Schwarz’ colleague Ken Belson:

Those categorized as having Stage 1 of the disease had headaches and loss of attention and concentration, while those with Stage 2 also had depression, explosive behavior and short-term memory loss. Those with Stage 3 of C.T.E…. had cognitive impairment and trouble with executive functions like planning and organizing. Those with Stage 4 had dementia, difficulty finding words and aggression.

The popular science author Malcolm Gladwell has also had a big influence on this issue. Gladwell wrote an article about brain injury in football which was published in the New Yorker in 2009. This article was the first one to shift my thinking about the game and it is well worth reading despite its relative age. Here is a quote from the piece which builds on the description of symptoms above:

C.T.E. has many of the same manifestations as Alzheimer’s: it begins with behavioral and personality changes, followed by disinhibition and irritability, before moving on to dementia. And C.T.E. appears later in life as well, because it takes a long time for the initial trauma to give rise to nerve-cell breakdown and death. But C.T.E. isn’t the result of an endogenous disease. It’s the result of injury.

Scientific and medical understanding of C.T.E. has come a long way but it’s still not entirely clear whether concussions or subconcussive events are the main cause of the disease. It’s understandably difficult to figure this out given that almost all football players will experience both types of brain injuries during their careers and that until recently even concussions with fairly dramatic symptoms were largely treated as an unavoidable consequence of playing football which was best ignored.

One of the biggest obstacles to learning more faster about C.T.E. and the brain injuries that cause it is that the disease can only be conclusively diagnosed by examining the brain after death. During a special autopsy, scientists are able to see if the brain shows the degeneration and accumulation of a protein called tau that are characteristic of C.T.E.. As heart-wrenching as it has been to read stories about the handful of football players who have shot themselves in the chest and left instructions for their brains to be studied, they and other players whose families have donated their brains posthumously, have been responsible for virtually everything we know about the disease so far. Luckily, there is some movement on this topic. Researchers at the Semel Institute for Neuroscience and Human Behavior at UCLA have been able to detect evidence of C.T.E. in living brains through the use of a particular dye and a “routine positron emission tomography scan.” In a 2013 Wired article on the topic, Sean Conboy writes that this test “also could help settle the debate over whether CTE is exacerbated by a few major concussions or years of exposure to subconcussive blows. And it could answer the most important question of all: How much tau is too much?

Another facet of testing that is rarely talked about is genetic testing. David Epstein explains in his book, The Sports Gene, that there is a single gene called ApoE that is predictive of Alzheimer’s disease as well as “how well an individual can recover from any type of brain injury.” There are three variants of the gene and everyone has two copies, one from their mother and one from their father. One variant, ApoE4, is particularly bad. People with one copy of ApoE4 are four times more likely than the general population to develop Alzheimer’s, and people with two copies are eight times more likely. Nothing has been proven about any connection between ApoE4 and C.T.E. but, given that people with copies of that gene variant “take longer to recover” from brain injuries and “are at a greater risk of suffering dementia later in life,” it seems likely.

As it stands today, the only sure thing is that C.T.E. is horrible and deadly. Until we know otherwise, I am going to assume that all blows to the head or which cause the brain to hit the skull contribute to the potential development of C.T.E. and that the more violent the impact, the larger its negative consequence. Until the day (and that day may never come) when science can definitively predict which injuries and which players are on the road to C.T.E. and medicine can prevent those players from getting the disease, football has a responsibility to understand how players are injured and to find ways to reduce or eliminate the danger.

This is the first post in a series of posts about brain injuries in football and how to fix the sport. In our next post, we’ll discuss how brain injuries or concussions happen. What kinds of hits cause them? Why do players escape some collisions unscathed and stumble away from others?

Dear Sports Fan provides resources for living in harmony with sports. If you enjoy our content, please share it with your friends and family. If you haven’t signed up for our newsletter or either of our Football 101 or 201 courses, do it today!

Do Not Watch This Football Game: Jacksonville vs Houston

Image from http://bit.ly/18mWCRL

On Thursday, December 5, at 8:25 ET, an NFL football game between Jacksonville and Houston will be televised on the NFL network. Do not watch this football game! This is a blog about sports, written by a sports fan for non-sports fans, but today, I’m writing to all the sports fans out there. If you are a regular non-sports fan reader pass this along to the sports fans in your life! Unless they are from Jacksonville or Houston, there’s no reason for them to watch this football game and there are plenty of good reasons not to. Here are some of the reasons:

1. Do not watch this football game because the teams playing are horrible

The Jacksonville Jaguars have three wins and nine losses so far this year. They are last in the league in total points scored per game and third to last in total points allowed. Their average game sees them giving up 29.3 points and scoring only 14.5 points. (Football scoring can be complicated, but even it cannot produce decimals — these are just averages.) They have been blown out of many of the games they’ve played this year. Beyond being bad, they’re also uninteresting. Early in the season, Jaguars fans held a rally to urge their team to sign popular but probably incompetent quarterback Tim Tebow. Even this was ineffective at driving interest in the team. Almost no one showed up. Tebow, despite fake rumors of the contrary from eyeofthetiber.com, remains unsigned.[1]

If it’s possible, the Houston Texans are an even more depressing team. Their record, two wins and ten losses, is worse than the Jaguars. The Texans are fourth worst in the league in terms of points scored (19.2) and sixth worst in points allowed (26.9). Unlike Jaguars fans, fans of the Texans were not prepared for this type of season.  The previous two years, the Texans were 10-6 and 12-4 and won their division both times. There were no real hints that things were going to go so badly this year, but they did. Their starting quarterback caught a bad case of the yips (according to Wikipedia, “the apparent loss of fine motor skills without apparent explanation, in one of a number of different sports”) and threw interceptions that were returned for defensive touchdowns in four straight games before getting injured and subsequently benched. Their star running back, Arian Foster, is out for the rest of the year after back surgery. Their best defensive player, Brian Cushing, is also out for the year with a torn ligament in his knee and a broken leg. To add injury to injury, their head coach suffered a “warning stroke” at halftime of a game.

2. Do not watch this football game because it will be bad for your social life

Here’s the deal. It’s getting late in the season. Your friends, family, and significant others have lived through thirteen weeks of football so far and you KNOW that you’re going to want to watch a bunch more football because now it’s the fantasy football playoffs (more on that later) and the real playoffs will follow shortly after that. Last week was Thanksgiving, so there were not one, not two, but three football games on Thursday and though we argued for the inclusion of football in Thanksgiving celebrations, it’s an accommodation that your non-sports fan friends and family made for you. Don’t push it. Make dinner, go to a movie, play a card game, studiously avoid decorating the festivus pole.  Do anything, but do not watch this football game.

3. Do not watch this football game because it doesn’t even have any fantasy implications

I know, I know, it’s not a good game, it’s not an important game, but it’s the fantasy football playoffs! In most fantasy leagues, the playoffs begin this week and normally this would drive people to pay close attention to even the most mundane football game. Seriously though, if you have been counting on a player from one of these teams, it’s unlikely your team has qualified for the fantasy playoffs. There’s really not too many players in this game who should be starting on your fantasy team this week anyway. Sure, wide receiver Andre Johnson and running backs Ben Tate and Maurice Jones-Drew are decent plays most weeks, but it’s a reasonably well-studied fact that players perform worse during Thursday games. I say, don’t count on any of these players, do not watch the game, and thank me later.

4. Do not watch this game because watching it is bad for football and terrible for football players

This is the most interesting and most compelling argument for why you should not watch this game. Playing a game on Thursday night, just four days after the previous Sunday’s game, is absolutely brutal. MMQB.com ran a wonderful article about this by Robert Klemko, which initially inspired this post. In it, Klemko quotes Texans offensive lineman, Duane Brown:

“That Friday, everything was hurting; knees, hands, shoulders,” he remembers. “I didn’t get out of bed until that night. I didn’t leave the house at all. You talk about player safety, but you want to extend the season and add Thursday games? It’s talking out of both sides of your mouth.”

“Knees, hands, shoulders” are one thing but heads are another entirely. We’re still learning about concussions but a few things are reasonably clear. Players will hide concussions from their teams and try to play despite them. The most dangerous thing that can happen to a player who is concussed is to get concussed again and this is more likely the less rest they have after their first concussions. Playing games with less than six days of rest is painful and dangerous.

If we give the NFL the benefit of the doubt (which I’m not positive we should) about being sincerely concerned for player safety, how can we rationalize their expansion of the NFL schedule to include more and more Thursday games? Klemko writes that the value of those games to the league is enormous — estimated at over $700 million dollars per year on top of making the NFL network (which televises most of the Thursday night games) a viable network. And it’s our viewing, particularly of bad match-ups like this one, that drives that value. Klemko writes:

Putting aside for a moment the injury concerns, who would actually want to watch these 14 games featuring fatigued players, often pitting bad teams against good ones, or worse, the 2-10 Texans vs. the 3-9 Jaguars (8:25 PM ET, Thursday, NFL Network)?


“You have Houston and Jacksonville, which no one is looking forward to,” Ourand says, “but even that game is going to win the night on cable within the male demographics everybody sells, and it will be one of the top 5 or 10 shows on TV. The power of the NFL and why they want to go to Thursday is more evident in this game than in any other.”

So far at least, that seems to be true. Fans, including myself, have watched the Thursday games faithfully. I can’t say I’m completely happy about it though. I think it seriously dilutes the NFL experience. There’s something special about isolating all of the games on Sunday (and Monday night.) It makes every Sunday an anticipated event; a miniature holiday of the football denomination. I am particularly frustrated about the Thursday game’s impact on my enjoyment of fantasy football. Part of the fun of fantasy football is approaching a Sunday full of football knowing that, like in each game that day, you start 0-0 and anything could happen. The Thursday game almost always means that instead of that “anything could happen” feeling, you have a “oh, I’m ahead, I should win this” feeling or a “oh man, I’m definitely not going to win” feeling. It’s a lot less fun that way.

For this Thursday, at least, let’s do our part for the players, for our relationships, for our sanity, and not watch the football game.

Footnotes    (↵ returns to text)

  1. Thanks Dad for passing me this delightful article

An Introduction to Football for the Curious

Football is America’s favorite sport. The season is anticipated, watched, obsessed over, and celebrated to an incredible extent. From the first week of September to the first week of February, football is almost unavoidable. Football is one of the least accessible sports for new viewers but we believe that with a little care and effort put into explaining it, it can be quite rewarding for a new or beginner viewer. Here is a collection of posts that may spark an interest or explain a long harbored question.

General Questions About Football

Why Do People Like Football
How do I Begin to Enjoy Football
How Should I Feel About the NFL Concussion Settlement
What is a Good Football Book

Rules, Terms, and Other Important Minutiae

How Does Scoring Work in Football
What’s a Down in Football
What is a Fumble in Football

Football Positions

What is a Quarterback in Football
What is a Running Back in Football
What is a Wide Receiver in Football

What is a Tight End in Football
What is an Offensive Lineman in Football
What is a Defensive Lineman in Football
What is a Linebacker in Football
What is a Defensive Back in Football

Fantasy Football

How Does Fantasy Football Work
What are Some Tips for Your First Fantasy Draft
Why Are People Obsessing About Fantasy Football Now

Happy watching! And please submit questions as you think of them. Getting questions is by far my favorite part of this blog and all the best posts come from your questions!

Ezra Fischer

How Should I Feel About the NFL Concussion Settlement?

Dear Sports Fan,

I read over the weekend that the NFL settled a lawsuit out of court with retired players on the subject of concussions. I know concussions are an increasing concern in sports. How should I feel about the NFL concussion settlement?


— — —

Dear Tricia,

Every good settlement is going to leave people on both sides with mixed feelings. The agreement that the NFL made to give $765 million to retired players is no exception to that rule, but I think it is more good than it is bad. Here are a few reasons why:

People Need Help Now

Retired football players who are suffering from the result of head trauma need help now. This is clear from the high-profile suicides of former players like Junior Seau, Ray Easterling, and Dave Duerson as well as the heart-wrenching stories of Steve Gleason and Kevin Turner and many others who are alive but severely affected by early dementia and Alzheimer’s, ALS (Lou Gehrig’s disease, which has been linked in theory, even on nfl.com, to brain trauma), and other issues. You might expect NFL players to have enough money to take care of their own health care but salaries have only skyrocketed to the current  in the past thirty one years since the 1982 strike and there is still an enormous amount of inequality within NFL player salaries. There are a lot of older players and less successful players out there who never made a lot of money. It’s conceivable for recent retirees to be rich beyond our wildest dreams, but if you look at the bigger picture you will find many stories like Terry Tautolo‘s, who ended up homeless.

Retired NFL Players are Not the Public

One of the best arguments you will hear for why this settlement is a bad thing is that it allows the NFL to avoid being forced to reveal in court how much it knew about the effect of concussions and when it knew what it knew. Daniel Engber of Slate.com makes this case forcefully but I don’t totally buy it. It’s easy to see parallels between this situation and Watergate or cigarette companies. The questions “what did they know” and “when did they know it” are instinctive because of those cases. A key difference is that this is a dispute between employees and an employer, not between a government and its citizens or a group of consumer companies and its customers. In terms of being truthful to the general football-watching public, the breach of trust is happening more now that the NFL is trying to market a softer, safer sport than it has in the past. If the NFL knew that it had an unsafe work environment (okay, obviously it’s unsafe, but I mean…really unsafe) and they actively hid information about the hazards from its employees, they should pay and pay punitively. The NFL owes its former employees but it does not owe the public nor would justice be served by its public humiliation or destruction.

It Ain’t Over Till It’s Over

This settlement does not preclude future lawsuits. NFL players like Scott Fujita, who wrote a great article in the New York Times about the settlement, know this. Fujita writes that he did not get involved in the lawsuit because he didn’t want to “risk watering down a potential award for so many people who are legitimately suffering. There are numerous former players experiencing a wide range of brain-related health issues. Right now, I’m not really one of them.” If he starts experiencing symptoms he is free to open his own suit against the league. The NFL knows this too, and that’s why the settlement is not just for players who actively participated in the lawsuit. Any retired player suffering from brain injury is entitled through this settlement to up to $5 million depending on their particular ailment.

A timeline of the lawsuits and settlements against cigarette companies over the past fifty years is a good reminder that the first settlement can be followed by later, larger settlements. The deadspin.com timeline of the NFL concussion issue only has one settlement on it so far but otherwise it looks chillingly similar.

It Would Have Been Tricky in Court

Although it seems obvious that a profession that involves being smashed repeatedly in the head had something to do with the damage done to its employees, it might have been very difficult for the players to win this case in court. Brain injury is more clearly understood all the time, but it remains frustratingly elusive both from a medical standpoint and a legal one. Matthew Futterman and Kevin Clark of the Wall Street Journal made this point convincingly in their article about the settlement:

Legal experts familiar with the case say the plaintiffs’ attorneys didn’t believe they had enough firepower to win in court. NFL lawyers were prepared to probe each plaintiff about his athletic history to try to convince the court the NFL couldn’t be held liable for injuries that could have come from youth, high-school or college football—or substance abuse.

The NFL has virtually unlimited resources to throw against their former employees in court. It might not have been a pretty sight. It still might not be.

Which Lesson Has Been Learned?

It’s easy to point at the overall value of the settlement relative to the wealth of the NFL and argue that the only lesson this will teach the NFL is that they can continue to get away with downplaying the danger of brain injury among their players. This doesn’t seem likely. For one thing, it’s clear from the history of the 2012 NFL referee labor dispute that the NFL often operates on principle instead of or in addition to finance. That the NFL reached a settlement suggests to me that it is ready to understand (or has already understood) that brain injury represents one of the biggest potential threats to its existence as an institution and profit-making machine. If this is true, the league will accelerate its initiatives to create a safer environment for current players.

Thanks for your question,
Ezra Fischer


Can you Explain the Head Injury Issue?

Dear Sports Fan,

Can some one other than Malcolm Gladwell explain the whole head injury issue? How is Toyota going to fix it and why is no sport but football getting flack?



Dear Sarah,

The bottom line is, science is getting better – so while we probably always knew that people smashing into other people (or objects) wasn’t good for them, we can now point to a specific brain injury that results, and it ain’t pretty: chronic traumatic encephalopathy, which basically means that, if you studied some athlete’s brains at 50, you’d think they were 85 year olds suffering from dementia.

Why? There’s a lot of talk about concussions, and that’s the simplest, most straightforward explanation. If you’ve ever had a concussion, you know it’s a miserable experience – you also know that after you get the first one, you’re more likely to get a second one, then a third. If you’re a football player, that’s basically an occupational hazard. What we’re learning, though, is that each subsequent concussion has more serious long term impacts – and can lead to early onset of dementia or other emotional/depression issues. It’s slightly easier to deal with the kinds of massive hits that most frequently cause concussions because, at least in football, these are mostly blindside hits on players who don’t know they’re about to get clobbered and can’t defend themselves. These hits can be phased out of the game by changing the rules. They’re trying to do that now.

What also contributes to this is the so-called “sub-concussive” hits – the thousands of times a player will clash with someone and jostle the brain around in the skull just a little bit. This is one of the things that makes football the center of the brain injury story. In football, offensive and defensive linemen clash every single play with the force of a small automobile accident. Turns out these add up too, especially when you consider these guys have been playing football since they were kids. All of those little hits keep accumulating, and the concern now is that this is an issue that’s even bigger than pro football – that college and maybe even high school players may do some long-term brain damage. That issue is much more difficult to address, because you can’t get rid of that type of contact – it happens every play, all over the field.

Which brings us to Toyota. There is no silver bullet to this problem. The solution will involve a combination of rule changes and improved technology – and acknowledgement that the problem will never be truly solved. People will suffer some amount of brain damage, both because we want to see football and there are people who are willing to take the risk to play it. But the technology involves some really cool research that allows scientists to tell exactly how much force is being delivered with each hit, how the impact is distributed across the body – and, theoretically, how to design equipment to ensure the brain is the recipient of less of that impact. Toyota’s part of that effort because 1. They’ve got an image problem,[1] 2. They’ve got lots of engineers and 3. They’re smart enough to know that nothing makes a foreign company feel less foreign than making America’s favorite game safer and

That last point explains why football is taking the brunt of this. It’s the biggest sport, and sports business, in America today. So while other sports have similar issues – hockey, boxing, Mixed Martial Arts – the research hasn’t been as widespread because those sports aren’t as popular and there aren’t as many kids playing them. It’s only a matter of time though. The science is only going to get better, and I don’t think there’s anyone who thinks that what we learn is going to make us feel better.

The only question is, is there a point at which Americans – the fans and the players – will say the risk is no longer worth taking?

Thanks for the question,
Dean Russell Bell


Footnotes    (↵ returns to text)

  1. Runaway Priuses and Camries + Ford resurgence = need for image makeover.