Is the NFL's Big Bet on Making Football Safer Working?

After former San Francisco 49ers linebacker Chris Borland announced in March that he was giving up football due to medical concerns—specifically, the possibilities of brain damage and long-term neurodegenerative disease—the National Football League needed someone to reassure the public that Borland's retirement was not a problem.

Enter Pittsburgh Steelers-affiliated neurologist Joseph Maroon, who appeared on NFL Network and attempted to calm fears.

"Having been associated with concussions over many years, I really believe that it's never been safer before in terms of the sport," he said.

If that line sounds familiar, it's because you've heard it before: from the NFL, league commissioner Rodger Goodell, and youth football officials. The exact phrase "never been safer" is the party line across the sport, and in a rough way, it makes sense.

From high school to the pros, players, coaches, and fans alike are much more aware that concussions are serious injuries requiring serious, specialized care. Treating brain injuries with smelling salts and sideline exams given by Guadalajra-educated non-neurologists that require players to memorize the phrase "Red Brick Broadway" is becoming passe; meanwhile, rules changes and increased penalties for helmet-to-helmet contact have been implemented in an effort to reduce the total number of violent blows to the head most associated with concussions.

Prominent among those efforts is "Heads Up" football, a "safer" tackling initiative created and promoted by USA Football, the sport's governing body and the NFL's youth arm. Preliminary results from an ongoing study commissioned by USA Football suggest that Heads Up training may decrease concussions among youth players—and that, in turn, seems to support the contention of Goodell and others that if the game is played a particular way, a reformed way, risk can be significantly decreased.

But what if that's not the case?

If concussions were the only concern in football, then the USA Football study—which, it should be noted, is incomplete and has yet to undergo the scrutiny of peer review—would indeed be encouraging news.

Problem is, current scientific evidence indicates that repetitive non-concussive blows to the head—the kind that are inherent to the sport—also can produce significant brain damage. Some experts suspect those blows may lead to the development of chronic traumatic encephalopathy (CTE), the mysterious neurodegenerative disease that has been found in many former NFL players, including some who took their own lives.

"It has been so frustrating for me, seeing so much of the focus being on concussions," said Dr. Robert Stern, a Boston University neuropsychologist and leading CTE researcher.

The big hits that seem most directly connected to concussions—the same hits shown on highlight reels every weekend in the fall—are the ones that catch everyone's attention. But just because a player avoids dramatic collisions and diagnosed concussions doesn't mean they're avoiding brain injury.

To wit: Purdue University researchers studying high school football players have found that while between 5 and 10 percent will be diagnosed with a concussion per season, 50 to 80 percent will suffer brain damage that appears to be equally severe when their brains are examined via magnetic resonance imaging (MRI) tests.

"We found that it's very hard to tell, when you look at the MRI of a person's brain who's had a bunch of hits [and compare it] to the person who has a concussion, the pictures look almost identical," said Dr. Eric Nauman of the Purdue University Neurotrauma Group.

Consider linemen. Players in football's trenches rarely are involved in high-speed, open-field collisions, the kinds of plays pro and college football decision-makers have attempted to limit by passing rules penalizing helmet-to-helmet contact and head-hunting hits on "defenseless" receivers and ball carriers.

On the other hand, linemen frequently absorb low-speed hits to the head. Nauman's group has found that there are three dangerous subconcussive blows on the line on every play. Stern's research indicates that linemen take 1,000 to 1,500 head hits per season "at an adequate amount of force to have some impact to the way the brain is functioning."

"We used to not think much of that repetitive contact," said Dr. Julian Bailes, the medical director of Pop Warner Football and a neurologist at NorthShore University HealthSystem.

No longer. Scientists have yet to establish a definitive causal link between cumulative subconcussive blows and CTE. "We don't know for sure the exact cause of CTE, and so I am never able to say this causes it," Stern said. "But what we have found in all of our research is that every single case of neuropathologically-confirmed CTE has had a history of exposure to repetitive hits to the head, and that is not just concussions."

Indeed, a growing body of research indicates that concussions are not football's only problem. Over the course of both individual seasons and entire careers, subconcussive blows seem to add up. "Changes in brain physiology persist up to five months after the season," Nauman said. "We're starting to look at kids' preseason scans, because a lot of the time they're not fully healed by the time the next season starts."

According to Penn State University researcher Dr. Semyon Slobounov, subconcussive hits have a greater effect on players who have also suffered concussions, and players who move from youth football to college to the NFL experience a "cumulative effect."

A recent Boston University study found that kids who play football before age 12 are more likely to have memory problems as adults.

"Athletes that go into the NFL that have a huge history of concussion injury in high school and in college, they were not recovered fully and they were playing and playing and playing," Slobounov said.

The Heads Up program purports to make football safer by teaching players to hit and tackle without involving their heads, thereby avoiding concussive and subconcussive blows.

In a recent editorial published in USA Today, NFL Health and Safety Director Jeff Miller, the league's former top Washington lobbyist, cited the ongoing USA Football-funded study and wrote that Heads Up has produced "impressive results" and shows "that football can be played well, and more safely."

Similarly, USA Football spokesman Steve Alic told VICE Sports that the Heads Up program "has a positive effect," according to "the medical community and medical organizations that endorse our work," a group that includes the NFL, the Big Ten, the Big 12, and numerous top-level coaches, such as Urban Meyer of Ohio State and John Fox of the Chicago Bears.

Others are less sanguine. Dustin Fink, founder of The Concussion Blog and a high school athletic trainer in Illinois, calls the program and safer tackling "a bunch of bullcrap." "They should've retitled it as not using your helmet as a weapon," he said. "They're not reducing exposure to the brain."

By penalizing players for head-hunting open field hits, football organizations like the NFL can disincentivize purposeful helmet-to-helmet contact; by pushing instructional programs like Heads Up, those same organizations can attempt to teach players to not use their helmets as missile tips and battering rams.

That said, football is a sport built around knocking the other guy to the ground. Doing so requires tackling and hitting, violent collisions in which opposing players attempt to gain leverage and dislodge each other by dipping their shoulders to achieve lower centers of gravity. The head can't be removed from the equation. In Heads Up instructional videos, tacklers wrap their arms around the torsos of offensive players who stand in a crucifixion posture, upright and still; the same defenders protect their heads by essentially tucking them into the offensive players' armpits.

In actual football, ball carriers seldom cooperate.

"It's really the big elephant in the room that nobody wants to talk about because there's no way to take it out right now," said former Northwestern University defensive end Quentin Williams.

Williams played for a program that made concussion awareness a priority. He praises his former coach, Pat Fitzgerald, for his efforts to teach safer tackling. Still, Williams admits that on the field, he used his head in ways that he knows could cause injury in the future—not because he was reckless and unskilled, but because that's how football is realistically played.

"(My head) wasn't necessarily a weapon, but it was a tool," he said. "The offensive lineman would use it the same way. You would use it to try to jolt him."

Williams's brother, Nate, was a linebacker for the Wildcats. He echoed his brother's sentiment that Fitzgerald did a "great job" teaching tackling fundamentals. However, he said he also felt subconcussive blows "all the time" while playing. Which suggests that brain injuries can't be coached or legislated out of football, but rather are inherent to the game itself.

"The problem is that the very nature of the way the game is played currently results in an extensive exposure to subconcussive blows," Stern said.

There are ways to reduce that exposure, and in doing so make football safer: shorter seasons, fewer contact practices, more physical and cognitive rest and recovery time between games, flag football for children, earlier retirements for older players.

Of course, all of these changes require less football, and less pretending that football is about as hazardous to brain health as soccer. None of that is particularly palatable to organizations like the NFL, whose billion-dollar business model is based on more football.

Enter Heads Up. By focusing on counting—and theoretically reducing—concussions, the league and its youth arm can claim that the game can be made acceptably safe without making major sacrifices. That might not be true, but it sounds logical enough if you aren't closely following ongoing research into football-induced brain damage.

After all, football has a long history of responding to safety concerns by touting self-administered reforms, including a late-1960s, early-1970s push for head-up "form tackling" that sounds an awful lot like today's programs.

"A lot of it is PR-driven," Fink said. "They're trying to save their game, okay? They need to win the PR battle."

CTE is a more formidable PR problem than concussions. While concussions may to some extent be reduced through rules tweaks, it's possible—perhaps probable—that the only way to avoid CTE is to reduce or end football.

Is Heads Up legitimate? Or is it, as Fink suggests, simply a public relations hammer, designed to nail home the notion that the game has "never been safer?" It would be cynical to say that the football industry doesn't care about brain trauma, but also hopelessly naive to claim that the same industry facing the fallout from League of Denial isn't furiously trying to spin the issue as favorably as possible.

Goodell recently said that girls' soccer is as dangerous as youth football, even though that is patently false. Miller, the NFL's VP for Health and Safety, wrote an op-ed supporting football by citing a study that claimed NFL players 60 years ago did not see an increased risk of neurodegenerative diseases—never mind that the league's own recently-approved federal class action concussion lawsuit settlement, which does everything it can to minimize brain damage payouts, still estimates that roughly a third of NFL retirees will develop long-term cognitive problems.

During his NFL Network appearance following Borland's retirement, Maroon—supposedly a leader in the sports concussion industry—brushed off concerns about CTE.

"I think the problem of CTE, although real, it's being overexaggerated," said Maroon, who in a recent medical infomercial also said that reports about the disease were casting "the sport of football in a disparaging light." "I think our job is to continue to make it safer, but it's much more dangerous riding a bike or a skateboard than playing youth football."

Actually, this is untrue when the percentage of the population within each category is considered, and it's untrue based on common sense—an activity that involves getting hit in the head on rare occasions is not safer than an activity where getting hit in the head is a necessary side effect to play the game effectively.

"Roger Goodell, and you can say the same about a lot of the NFL team doctors, they're really just being paid to take a lot of punches," Quentin Williams said. "It's ridiculous for me to see somebody brought on the television and talk about the NFL concussion crisis when all of their interests are invested in an NFL team."

At a recent event at Northwestern, Goodell said that it's important to get all the facts on the table related to CTE. Given the league's documented history of downplaying and dismissing those facts, I asked Goodell why the public should believe his league is now focused on learning about the disease—particularly when people paid by the NFL and its teams, like Maroon, are among the few who seem unfazed by the disease.

Goodell dodged the question, saying it was "not fair." As NFL commissioner, that's probably part of his job—disregarding any questions that might cast football in a negative light.

"Nobody's going to protect the NFL more than yours truly," he later said.

The problem, of course, is when protecting the game gets in the way of protecting its players, and when sweet-sounding quick fixes supersede difficult, lasting solutions. Ironically, Heads Up dissidents like Williams love football. Many of the researchers investigating football-induced brain damage love it, too. They simply don't love the sport more than the athletes who play it.

"I think it's just common sense that we do everything else in our society to keep our children safe, to reduce injury, to make sure they have the very best success in life," Stern said. "We do crazy things, we've gone overboard with trying to reduce potential injury, illness to our kids, and then we drop a young kid off at a field, stick on a big helmet on an undersized body, and we say go at it.

"And then they end up purposely sanctioned hitting their heads, moving their brains around in their skull time after time. That just doesn't make sense to me."