I have a number of patients who used to be professional footballers at a high level in the 1950’s and 60’s. This week I had to sit down with one of them and tell him that his memory loss was rather more serious than he thought and that he was in fact suffering from dementia. He took the diagnosis very stoically and then said ‘I guess all those years heading a heavy ball didn’t help, did they?’
In that sentence he tapped into a rapidly evolving area of medicine. Does heading a football actually cause brain damage? At least four players in the 1966 World Cup winning team have suffered from dementia. The ex-England forward Jeff Astle died aged 59 in 2002 with the coroner ruling it was a result of brain trauma, listing it as an ‘industrial disease’ due to football, and a post mortem twelve years later found he had died from chronic traumatic encephalopathy (CTE) – a condition normally associated with boxing, and which was linked to Astle heading a football repeatedly.
Post-mortems on the brains of footballers are understandably rare but recent research has focused on these as they give the best evidence of any link between heading footballs and the development of CTE. One post mortem study looked at six players who suffered dementia and found that every one of them had suffered tearing to their brain membrane consistent with repetitive head impacts, with two thirds of them suffering from degenerative CTE. (The incidence of CTE in the general population is just 12 per cent).
The study authors concluded that the brain damage found was probably related to their past prolonged exposure to repetitive head impacts from head to player collisions and heading the ball thousands of times. (In fact, when I speak with my elderly footballers they all say that it was during training that they headed the ball hundreds of times rather than during a match.)
Looking at old films of football matches from four decades ago, one of the things that catches your eye is the old lace up leather football, and which looks much heavier than a modern football. Surprisingly, the average older ball only weighed around 390g compared to the modern version at 430g. However, when the old ball got wet, its weight could get towards 600g making it a completely different proposition and as a young footballer I remember being knocked flat on my back after heading a wet leather ball. Modern footballs are now coated in polyurethane to keep out water but the principle of repetitive brain injury due to constant heading remains. It is important to realise here that any brain changes that may occur after impact are minor compared to a full concussion for example, but the effects build up over time and in America, which is slightly ahead of the UK in its approach to sport and brain injury, under-11s are banned from heading a football, with limitations in place for players between 11 and 13. Although no absolute causal link has been found, the US has decided that youngsters should not be heading a ball, particularly while more research is ongoing.
So, should we be banning it in the UK? The short answer is ‘no’, the slightly longer answer is ‘no, but more research is vital’. The Professional Footballers Association is working with the Football Association to fund a comprehensive research programme that will be correct, independent and objective, with the game owing a duty of care to all its participants. We are certainly not at a stage where we can state there is a definitive link between CTE and exposure to repetitive low-level head trauma but large studies are needed to see if advice may need to be given to football teams such as limiting the number of headers each footballer does in training. Dementia is such a multi-factor illness that lifestyle, diet and genetics all need to be considered and whether the well-known benefits of exercise outweigh any potential dementia risks.
One thing is likely though – we might never look at football again in the same way as we did back in 1966.