Editor’s Note: We’ve received messages for years asking for coverage of medical issues facing the NFL and fantasy football owners. We’re excited to unveil this article today and also to introduce a new mailbag of sorts. ”The Dynasty Doctor” will be a series we run on an as needed basis. If you have any questions in regards to concussions, ACL procedures, recovery times from specific injuries or anything else related to medical science, submit your question here and it may be featured in an upcoming article with our own resident M.D., Dr. Scott Peak. He’s a board certified neurologist, neuro-oncologist and is the Director of Neuro-Oncology in the Department of Neuroscience/Neurosurgery for a large health care system.
It’s a new age in the NFL and player safety is more important than ever. The NFL understands how to protect its brand, and has done so with great vigilance and success for decades. Yet, a health risk once disregarded amongst a culture of toughness and invincibility, now threatens to undermine the foundation of the NFL. The scariest thing is, the NFL may be powerless to stop it. In this article, we will discuss concussions, chronic traumatic encephalopathy (CTE) and how it impacts dynasty football owners.
The American Academy of Neurology (AAN) defines a concussion as a traumatic-induced alteration in mental status that may or may not result in a loss of consciousness. The AAN published a consensus statement on Management of Concussion in Sports, and it includes a grading system to evaluate concussions:
No loss of consciousness
Symptoms and mental status abnormalities resolve in less than 15 minutes
Players with grade 1 concussions may return to the game if symptoms clear up within 15 minutes, but a second concussion mandates removal from the game.
No loss of consciousness
Symptoms and/or mental status abnormalities lasting more than 15 minutes
Any loss of consciousness, lasting seconds or minutes.
Grade 2 or 3 concussions mandate removal from the game. Grade 1 or 2 concussions require at least 1-2 weeks off until returning to play, but only on the condition a player must be free of symptoms with a normal neurological examination at rest and with exercise. Players with multiple grade 3 concussions are out at least one month, but a return depends on complete resolution of symptoms, both at rest and with exercise, and approval from the evaluating physician.
It is important to understand how concussions will be handled, as the NFL recently announced a neurologist will be present on the sidelines of every game, and will be tasked with evaluating all players suspected of having a concussion. Neurologists will likely be using a similar set of criteria to evaluate concussions, and understanding these criteria may help dynasty players predict how long a player may be out of action.
A neurologist will look for immediate symptoms, such as headaches, dizziness, vertigo, confusion, or nausea. Longer lasting symptoms include persistent headaches, light-headedness, problems with attention and concentration, memory loss, fatigue, irritability, light and sound sensitivity, mood changes and insomnia.
Concussions can place a player at risk for Chronic Traumatic Encephalopathy (CTE). Repeated blows to the head subject the brain and its neurons to injury. Force applied to the head can result in structural injuries like contusions, bleeding in or around the brain or skull fractures. A more subtle injury involves stretching of neurons in the brain, and this can lead to irreversible damage, neuronal death and ultimately CTE. Modern helmets used in the NFL are very good at reducing risk of lacerations or skull fractures typical of blunt force injury. However, NFL helmets may be no better than old leather helmets at preventing concussions. The Journal of Neurosurgery published an interesting article that simulated concussive force applied to both leather and modern helmets, from many different angles, and found that injury risk was as good or better with leather helmets.
It is somewhat sobering that NFL football has been played for almost 100 years, and helmet designs may be no better at preventing concussions in the modern era. In fact, there is no good evidence to show that helmets prevent concussions at all. In order to understand this better, a brief review of neuroanatomy is needed.
A human brain contains over 100 billion neurons, and these are responsible for all bodily functions including speech, movement, balance, multi-tasking, motivation and emotion. Injury to these neurons will result in a neurological deficit, depending on which set of neurons are damaged. Neurons have a cell body and an axon. The cell body makes all the decisions, and axons carry these orders to many parts of the body. Like any object, neurons are subject to the forces of inertia. The brain weighs about three pounds, and feels firm when held. The brain is protected by the skull and floats in spinal fluid. Imagine taking an old biology class, and a jar filled with formaldehyde contained an animal or organ as it sat on a classroom shelf. If that jar were lifted up and moved, only the jar moved, but not the organ. Objects float in bodies of water due to force of water balancing out weight of the object, otherwise known as buoyancy. The brain floats in the skull, carried by spinal fluid and is supported by the base of the skull. This helps to keep the brain from moving too much whenever we walk, jump or move our heads around. Our brains would not function well if they were constantly banged around inside our skulls.
While skulls are meant to protect our brains from blunt force, it is ironic that this construct is a big reason why concussions are very hard to avoid in high-impact sports like NFL football. Whenever concussive or even sub-concussive forces are applied, the brain can push forward and impact the skull. This can result in contusions, most commonly on the frontal or temporal lobes of the brain. The principle that leads to such injury is inertia. NFL players collide on a big tackle, or two large men might smash into each other on the line of scrimmage. Each time that happens, the brain can be subjected to such force that it gets impacted against the skull. Even worse, inertia can result in stretching of axons, and this can lead to cell death. When neurons are injured, toxic metabolites build up, called tau proteins, or neurofibrillary tangles, neurons swell up and eventually explode or degenerate. This is the fundamental basis for CTE, repeated blows to the head that can result in neuronal injury and permanent loss of function.
CTE is relatively new to the NFL, and the first player diagnosed with it was in 2005. In reality, CTE has existed for a lot longer, probably as long as the NFL has been in existence. CTE has been reported in boxers as far back as the 1920’s. It is also well-known to occur in the military, usually resulting from blows to the head from firing high-caliber weapons or explosions. The postulated mechanism of injury resulting in CTE are both concussive and sub-concussive impacts. This is critical to understand, as CTE is not just a result of players getting knocked unconscious. The ground work for CTE might, in fact, lay in repeated blows absorbed from the start of playing football. It is unlikely that children in a Pop Warner league can hit each other hard enough to result in brain injury, but it is theoretically possible, and much more likely to occur as players grow larger in size, such as high school, college or pro levels. Impacts as routine as an offensive and defensive lineman exploding off the line, play after play, in practice or game conditions, can take its toll. One study followed 45 Division 1A collegiate football players, and assessed their cognitive performance before and after a game. 71% of players in this study, none of which were diagnosed with a concussion, showed limitations in cognitive functioning or balance after a game. This study suggests that brain injury is more common than we think, and does not solely depend on a formal diagnosis of a concussion.
Even though the NFL is extremely powerful and arguably the most popular sport in the United States, it is nearly powerless to eliminate concussions. Unless the NFL finds a way to alter inertia and change the rules of physics, they simply cannot stop neurons from being injured when two large men crash into each other. So how can the NFL improve player safety?
- Encourage proper tackling. It is interesting that, since the advent of modern helmets, there is an increased risk of concussions. Players feel a false sense of security surrounded by body armor. As a result, players feel free to launch themselves at players, often times leading with their helmets thinking that such armor will prevent injury. Helmets cannot stop inertia. Players need to understand this point. One study found 67% of all concussions were associated with impact from another player’s helmet. Plus, a little appreciated point is that offensive players are not the only ones impacted by poor tackling, but so are defensive players. Players must understand that current technology cannot completely prevent concussions, and probably never will. Players must be educated to tackle properly, starting in Pop Warner leagues, and it must be reinforced at every level, including pro football.
- Reduce frequency of impacts. Coaches may not like this rule, but concussive and sub-concussive events do not only happen during games. Practices result in significant blows to the head. The cumulative effects of each play in practice, or in games, can damage neurons and culminate in irreversible neurological injury, including CTE many years later. One way to reduce neurological injury is simply to reduce the frequency of impacts in practice.
- The NFL must admit there is only so much it can do to prevent concussions. I think the NFL is doing all it can to prevent concussions and CTE, but it just cannot stop it completely. The laws of physics cannot be altered by commissioner Goodell. Players and their families must understand this point. Police officers or soldiers must accept they could die or become seriously injured in their line of work. It is already well-known amongst boxers that brain injury can be debilitating, such as with Muhammad Ali. Parents could discourage or refuse to let their children play organized football. The pipeline to the NFL could theoretically dry up overnight, and there is nothing that can be done to prevent it. The NFL should research new ways to prevent injury in its players. As leaders in this sport, the NFL should continue advocating for player safety at all levels, and raise awareness on issues like proper tackling and limited practice repetitions. Lastly, the NFL should provide greater resources for players who suffer from lasting effects of concussions or CTE. I do not believe it is fair to blame the NFL or sue them for these injuries, but I do believe they should provide all the help needed to care for players seriously wounded from playing professional football.
There are several points relevant to dynasty football players, in regards to concussions impacting their teams:
- Concussions are not going away. In fact, the number of players diagnosed with concussions and pulled from games will probably increase over time. Neurologists on the sidelines will probably have a quick trigger to pull players from games. After all, patient safety will take priority over a return to the game, and it should. This will, however, impact dynasty football owners, as they will often scramble to replace players who may be out a long time.
- Consider a history of concussions when evaluating talent. Players who sustain concussions are 4 to 6 times more likely to have a second concussion, and up to 20% of players may have a concussion per football year, according to the American Association of Neurological Surgeons (AANS). Given there is greater awareness, both publicly and privately within the NFL, players demonstrating signs or symptoms of a concussion may miss significant playing time, anywhere from two weeks to several months. Jahvid Best is a classic example, and many more will follow. It is impossible to predict which player will get a concussion, but a history of concussions should be a major red flag for dynasty owners.
- Have a deep roster. This might seem logical, concussions or not. But, the reality is, concussions will likely result in lost time for players on dynasty rosters, and it will only increase over time. Owners who have better talent on the bench are going to win more games. Fantasy football owners often want to maximize their starting lineups, in terms of talent, at the expense of bench depth. This new age of football might reward dynasty owners who have depth to overcome players lost for months on end from concussive events.
- Avoid players with high-risk playing styles. Mobile quarterbacks like Robert Griffin III or Cam Newton might be in vogue, and provide owners with additional scoring opportunities. Mobile quarterbacks are also more likely to sustain concussions, as demonstrated by RG3 and Michael Vick this year. Certain running backs may have a style that reduces risk of concussion. Quick, shifty players like Chris Johnson might be less likely to sustain a concussion compared to big, bruising backs like Isaac Redman or Mike Tolbert. LaDainian Tomlinson often mentioned conforming your running style to avoid injury, and players who understand this concept may be at lower risk to sustain a concussion.
- Not all NFL positions are equal. According to Concussion Watch, in 2012 wide receivers were most frequently concussed, a total of 29 such players. Tight ends and running backs each had 19 concussions, and a total of seven quarterbacks were concussed. Three of the seven quarterbacks could be considered mobile (Jay Cutler, Vick and RG3), and six played behind offensive lines ranked in the bottom ten for pass blocking (Vick, Cutler, RG3, Alex Smith, Matt Cassel, Brady Quinn). Avoiding quarterbacks who run frequently or play behind suspect offensive lines might help reduce risk of losing an important piece to a dynasty team.
References applicable to this article:
- Practice Parameter: The management of concussion in sports (summary statement). Neurology 1997;48:581-585.
- Impact test comparisons of 20th and 21st century American football helmets. Laboratory investigation. Journal of Neurosurgery, Jan 2012 / Vol. 116 / No. 1 / Pages 222-233
- Prevalence of neurocognitive and balance deficits in collegiate aged football players without clinically diagnosed concussion. J Orthop Sports Phys Ther 2012;42(7):625-32.
- Concussion in professional football: epidemiological features of game injuries and review of the literature: part 3. Neurosurgery, 2004 Jan;54(1):81-94.