As the calendar changes to December the fall sports season comes to an end. This past fall was particularly busy in our practice, seeing a large number of patients with concussive brain injuries. Although there were soccer, volleyball, field hockey and cheerleading athletes with concussive injuries, the vast majority of patients with concussions were football players ranging in age from an 8 year old Pop Warner athlete to a 20 year old college football player. Brain trauma at any age is serious, but what is becoming an increasing concern with football in particular, are the multiple repetitive sub-concussive head impacts that occur throughout a tackle football game.

Some of the best research into sports related brain trauma is being done locally at Boston University. Their research has shown that the most serious brain injury associated with contact sports participation, chronic traumatic encephalopathy (CTE) is related more to repetitive sub-concussive brain trauma than it is to the number of concussions an athlete has been diagnosed with during their sports career.

One study from Boston University that has received a lot of media attention was published in September 2017 and looked at psychiatric and cognitive outcomes in tackle football players who began play before and after age 12. (Age of First Exposure to American Football and Long Term Neuropsychiatric and Cognitive Outcomes – Robert Stern, et al: Translational Psychiatry, 19 Sept 2017). The study reviewed a group of 214 former tackle football players who had played high school (43), college (103) or professional football (68) and did not participate in any other organized contact sports.

The study showed that adults who began playing tackle football before age 12 were twice as likely to have problems with self control, problem solving and judgment and three times as likely to suffer clinical depression compared to those adults who began playing tackle football after age 12. These adverse effects were independent of education level, age at the time of the study and duration of football participation.

Other research has shown that a youth football player can receive 250-500 sub-concussive hits to the head during a single football season. Using helmets equipped with accelerometers to measure the force of impact during football games, forces of up to 80g have been recorded. In comparison, the maximum force generated on a roller coaster is typically 3-6g and a car driving at 60 mph that slams on the breaks and stops in 4 feet would generate 30g of force. It is thought that this type of high force acceleration and deceleration of the brain into the skull during a football game creates traumatic injury to the brain at the level of individual cells. This trauma occurring multiple times during a tackle football game over the course of a season leads to permanent brain cell injury and loss of function leading to the cognitive and neuropsychiatric changes reported.

The brain is going through a period of tremendous growth from age 8-13. Research done at Wake Forest University in 2016 showed that youth football players between the ages of 8 and 13 had changes in their brain anatomy and function over the course of a single tackle football season. (Sub-concussive Head Impact Exposure and White Matter Tract Changes over a Single Season of Youth Football, C Whitlow et al, Radiology 24 Oct 2016). Using advanced MRI techniques, the study showed a significant relationship between head impact exposure and changes in the brains white matter. The players who experienced more head impacts during the season had more changes in white matter function. Of particular note, none of the players in the study were diagnosed with a concussion. The white matter changes were correlated directly with head impact frequency and force.

This period of rapid brain growth and development between ages 8-13 is a unique time for brain and cognitive development. Brain growth that is slowed by repetitive head impacts is brain growth that will not occur at another time. This is lost opportunity for maximizing the growth and development of a young child’s brain. Children playing tackle football between the ages of 8-13 are all going to be “turning pro” some day in the future in a field other than the NFL. Whatever the field is that these student athletes turn pro in will benefit from a maximally well developed and functioning brain.

Based on my own experience taking care of many student athletes with head injuries over now 28 years of clinical practice and review of the medical research mentioned above and other research studies, I have reached the point where I cannot recommend tackle football as a medically safe athletic activity for athletes before they reach high school. I am a very strong believer that sports participation for children offers unique benefits for the development of mind, body and character. Flag football provides all of these benefits just as well as tackle football while minimizing the vast majority of head impact risks. For those skeptics who will argue that not playing tackle football before high school will put an athlete at a disadvantage when they reach high school, I would remind them that Tom Brady, who most would consider the greatest football player of all time, did not start playing football until he was in high school. By the time a student athlete is entering high school their brains have already gone through the period of rapid growth. They are also older and can participate in a discussion with their parents about the pros and cons of tackle football and reach a decision that works for them.

The decision as to whether a child should play tackle football and at what age to start is a very difficult one for athletes and their families. Parents will often ask me the question: “What would I do if this was my child?” I have three sons, two of which played football in high school. (One is now a high school football coach!) I did not let them play football before high school and would not let them play before high school now if I had to make the decision today. I would still let them play football in high school.