Football sentences to ponder

Question  What are the neuropathological and clinical features of a case series of deceased players of American football neuropathologically diagnosed as having chronic traumatic encephalopathy (CTE)?

Findings  In a convenience sample of 202 deceased players of American football from a brain donation program, CTE was neuropathologically diagnosed in 177 players across all levels of play (87%), including 110 of 111 former National Football League players (99%).

Here is the research paper, via Peter Metrinko.  Here is NYT coverage of the result.


Football average is over?

The question is: So what? Are they going to end all contact sports? Unlikely so, so what? Is this really about money and full employment for trail lawyers??? I think that is the correct answer to the question "so what". They aren't going to decrease the injuries and this isn't about decreasing the injuries it is about going after the money and there is big money in football. So after the money is gone and athletes are still playing football and still getting these injuries; so what? It won't matter then.

More likely this reduces the pool of potential football players as more parents forbid their children from playing football. Wasn't this the subject of an episode of the Brady Bunch?

Exactly, this is about informed consent. Players can play but they need to know the risks. Same as smoking really. And like smoking it will likely happen less and less. More and more kids from families with options will decline to play, more and more kids from families without options (lower class, foreigners) will fill in those slots.

So that's how it ends: America must have its gladatorial games anyway!

Informed consent is a good argument when we are talking about adults.

When we are talking about high school students and younger players it's not so good.

And by the way, what are universities doing sponsoring and promoting a game that very likely destroys some of their students' brains? Seems to me there is a serious ethical issue there.

A further thought on "knowing the risks:"

What if further research reveals that it's not a risk at all but a certainty?

"And by the way, what are universities doing sponsoring and promoting a game that very likely destroys some of their students’ brains? Seems to me there is a serious ethical issue there."
Famous brilliant scientist Boris Sidis wrote that American universities are controlled by philistines that promote the savage sport American Football.

>so what

It likely results in the athletes getting a bigger share of the available revenue vs. coaches and schools/owners. In the "exempt from antitrust laws" landscape that is college/pro sports, I'd tend to call that result pro-justice.

"It likely results in the athletes getting a bigger share of the available revenue..." The athletes already get most of the revenue. And it is likely that lawyers will get the lions share of the spoils of this somewhat hyped up issue. But that isn't my point. IF it is so bad; as bad as described THEN football and other contact sports should be banned. But that won't happen. Players will keep playing, they will make some meaningless changes around the edges under the guise of making it safer and a couple hundred lawyers will become multi-millionaires. But in the end the football players will still be out there destroying their brains and the owners will raise all the profits they can to pay off the bloodsucking lawyers and it is all meaningless as in "so what"!

Just like cigarettes cause millions of deaths and the government used it to get an incredible amount of money every year from the sale of cigarettes and a couple hundred lawyers became fabulously wealthy but you can still smoke these little coffin nails. I.e. "so what"!

This is all about the money. The NBA is next, if not brain damage than something else. The lawyers are going to suck professional sports dry and in the end the only thing that will change is a couple hundred blood sucking lawyers will be fabulously wealthy. So what!

Actually, that's what we're seeing in the national health care discussion. Neither Obama care nor any Republican alternative has a mechanism that assures a large enough income stream to the legal community so there won't be a replacement until one is designed that makes attorneys more wealthy.

In the NFL, players don't get most of the revenue. There are some various buckets, but the total is capped at 48% and doesn't include a lot of non-football revenue that owners can use by having separate wholly owned subs handle parking etc. In college, players receive 0% of the revenue.

What matters is are there any publicly traded makers of lacrosse equipment we can invest in to try to profit from this news?

Real football is beginning its real rise at America.

The word 'football' was invented to describe games played in England 400+ years ago that were nothing like soccer. Soccer is the modern type of football that is least like real football. It became least like real football about 1880 when it removed scrumaging, and has been least like real football ever since.

Football must be played with feet hence its name. Maybe the game Americans play should be called handball.

And maybe you should stick to Brazil, since I don't think you know a lot about other subjects.

No, football is a game played on your feet (so not polo) with an inflated ball on a grassy field. It all came from English schoolboys. Rugby football substantially predates "asSOCiation football" (the SOC is where the word soccer comes from).

Also, if they successfully come for football, rugby and lacrosse are next.

"No, football is a game played on your feet (so not polo) with an inflated ball on a grassy field."
So it should be called glassinflatedballfoot or something like that. The only thing the name conveys is that the game is played with a ball and feet. The football Brazilians play fulfills those conditions and yours does not.

"And maybe you should stick to Brazil, since I don’t think you know a lot about other subjects."
Do not shoot the messenger.

Hey, when you invent a sport, you get to call it what you want. I think Capoeira should be called "absurd dance fighting" ("Luta de dança absurda" if Google translate serves), but dems da breaks. The fact is, the English named Rugby as the first organized football, and the Irish, Americans, Canadians, and Australians extended it from there. If you say "futebol" everybody is going to know you mean the part dance, part melodrama, nonscoring brand of grassy outdoor non horsey game played with an inflated piece of simulated leather. Look up Australian football if you want to see a fast kicking game that manages to have scoring and a minimum of pretend injuries. It's gonna have the same CTE problems, but personally I don't think Soccer is going to be out of the woods if we take CTE as opposed to actual neurological problems as our endpoint.

"If you say 'futebol' everybody is going to know you mean the part dance, part melodrama, nonscoring brand of grassy outdoor non horsey game played with an inflated piece of simulated leather. " Played with one's feet because it is foot+ball. It is like when they added "with broad flat nails" to Plato's definition of human to avoid chicken to be counted as human.

I've never seen anyone play any type of football without using their feet, or without using a ball.

The term foot-race is old terminology for a running race, it was not a race between feet. It meant a race in which people were on their feet as in all types of football.

The foot in football didn't necessarily refer to feet. Footer is an old word meaning to mess around wasting time. It remains with a similar meaning in Scotland. In the past it had quite a negative conotation. Footle was a related word used until the early 1900s in the US.

If you look at the remnants of old style football that still exist - look up medieval football on youtube - you'll see that the word football refered to games with little kicking of the ball.

If kicking the ball was key, it would be called kickball.

I found the study alarming but got this response from a long time professional sports (not football) doctor. I have no idea how valid his comments are:
"Despite many pleas from many groups, they have refused to do normal control brain exams. If they find it in everyone, it could be that this is normal aging and not evidence of CTE. It would be so easy for them to do it that it leads me to suspect that they don't want to look anywhere that may disprove what they want to believe. Until they do some normal controls, it is very hard to take their results seriously. Also, given the number of football players, hockey players, etc over the past 20 years in the US, if this was as prevalent as they say, where are the numbers? You would expect the hospitals to be filled with only that. My guess is that there is some genetic pre-disposition that puts people at risk."

This does seem to have a significant probability of falling into the correlation is not causation trap. Professional football players live lives that are far from normal, and many other controls should be considered, such as professional athletes from non-contact sports, PED users, people with a history or alcohol and drug abuse, people who retire in their late 20's or early 30's, and probably a bunch more possible confounders. A significant risk of selection bias also exists, since they are looking at deceased players whose relatives allowed their brains to be studied. Also, it's not clear whether the medical examiners had a vested interest in finding problems, with payouts from the NFL on the line.

What a call for science instead of fear mongering, schadenfreude, and moneygrubbing? I'm shocked to see that!

I'm a doctor and that's a weird criticism. There's an entire subspecialty of neuropathology - doctors who do nothing but look at slides of brains (and nerves) all day. So they know what normal brain tissue looks like and how prevalent CTE-like findings are in non-football players. Also, CTE and other forms of dementia can be quite common (and in fact there are loads of Alzheimer's patients) without the "the hospitals to be filled with only that." There's no reason for these patients to be in the hospital as there is no treatment. Patients with dementia are out of public sight. They're in nursing homes, rehab facilities and at home when they have family or can afford home nursing.

Well I'll be darned, a comment from someone who actually knows something. Is that really permitted in this comments section?

"...including 110 of 111 former National Football League players (99%)."

What is the incidence in the general population? If it's 0%, I'm worried. If it's 82%, I'm not.

It's a hell of a lot closer to 0 than 82:

Basically you get it from blows to the head, football of course, but also boxing, soccer, rugby, hockey, etc. Also in the military it crops up.

Nothing to worry about, just don't do those sports.

"It’s a hell of a lot closer to 0 than 82"

I saw nothing in the wiki article about occurrence in the general population.

How often are tests made to determine if someone had it? Most US deaths do not have autopsies performed.

Sure but of the autopsies of the general public that are performed, if you had to guess, what % would have CTE? Closer to 0 or 82? Try to set aside whatever football fandom you have and use common sense.

I like football, but obvious fact is obvious.

Bigger question/concern for me is whether there is a material impact on youth athletes through high school. The impact is so much less severe, and of course there's much lower cumulative frequency. My guess would be that players who stop after high school have a similar incidence of CTE as the general population.

I think that's probably reasonable. I still wouldn't want my kid playing but people can make their own choices.

You are blinded by what you understandably believe is "obvious". It's understandable because an old condition got a new name that the media ran with and it begs causal confusion. Let's say that somebody announced that they had examined X-rays submitted by 100 tennis players who complained of elbow pain and that 99% of them were diagnosed with "tennis elbow". If you were to conclude from this that it was an "obvious fact" that that most tennis players have lateral epicondylitis or that tennis is the commonest cause of lateral epicondylitis or even that most cases of lateral elicondylitis are caused by chronic trauma, you'd be wrong. Tauopathys have been around forever but you didn't notice until they were rebranded with a sexy new name and linked to an old NYTimes agenda. Behold the power of marketing.

@Thanatos: my point is about common sense. Obviously all that crashing into one another isn't a good thing for your brain or body. The fact that it's an old truth given new marketing doesn't make it less true. Common sense says lots of football is not healthy for one's body. I did notice, even before it got a sexy new name. I doubt there's any way you can prove otherwise.

If I had to guess, I would guess that I have no idea.

From the NYT article:

The set of players posthumously tested by Dr. McKee is far from a random sample of N.F.L. retirees. “There’s a tremendous selection bias,” she has cautioned, noting that many families have donated brains specifically because the former player showed symptoms of C.T.E.

But 110 positives remain significant scientific evidence of an N.F.L. player’s risk of developing C.T.E., which can be diagnosed only after death. About 1,300 former players have died since the B.U. group began examining brains. So even if every one of the other 1,200 players had tested negative — which even the heartiest skeptics would agree could not possibly be the case — the minimum C.T.E. prevalence would be close to 9 percent, vastly higher than in the general population.

Good enough?

"Good enough?"
Not really. There are other sample issues - specifically, the sample is heavily skewed toward lineman. You can't really say whether this is a football issue generally or an issue for certain positions. This is important for those involved in football because it will determine the best ways to approach changes to the game.

Let me make it clear that I am not trying to defend the NFL or football in general. I played one season in junior high and quit; I hated playing the sport. And I don't like watching it, either; I find it boring. I agree with George Will's description - American football is an endless series of committee meetings interrupted by brief outbursts of violence.

Also, it is a convenience sample. Likely to be some selection bias in sample opt-ins. But, 99% is high.

The study doesn't have random selection - in fact it selects for a high rate of CTE because its all from donor families a lot of whom are preparing to present claims against the NFL. It also isn't even representative of the football population because so many are lineman. And there's no control.

Please see my comment above. It addresses your objections.

10 of the 22 players on the field during normal play are linemen. So yeah the number of linemen in the study was nearly perfectly representative of the football population.

How can America compete with Red China when their brains are scrambled while chasing a ball?!

It's not a ball.

It is a ball, it is in the name.

A couple q's:

1. Everybody loves to bash the NFL, but this if this is an issue, it is a football issue, not just an NFL issue. 67 of 91 non-nfl players had it.
2. How long did these players play in the NFL? The avg NFL career is less than 3(?) years. You cannot blame the NFL after a lifetime of playing football
3. This was not a random sample, right? The loved ones sent in these brains knowing they likely had some problems/issues
4. to Ricardo's comment above, what is the percentage of CTE in the non-football population


An undergraduate friend of mine at a big-time football school gave up his athletic scholarship at the end of our junior year. Six weeks later I ran into him and after chatting for a while, remarked that he seemed more cheerful than I could ever remember. "Well," he said, "I played big-time high school football, with year-round training, for three years. Then I played big-time college football, with year-round training, for another three years. I realized this morning while I was showering that for the first time in six years, nothing hurts."

Can we simultaneous convey that the NFL has a serious brain health problem AND be honest about selection bias??

They tested a sample of 111 brains of men who had sufficiently bad neurological issues before death that they or their families agreed to have their brains autopsied and tested. As an economist, you of all people should be aware that it is not be particularly newsworthy that in a convenience sample that is consciously selected on the dependent variable, the dependent variable =1 a large percentage of the time.

None of this is to diminish how serious the brain issues in the NFL may be. The fact that so many retired players have these issues is a really big deal. But the headlines, blurbs about this study are super misleading from a straight science perspective.

Lewis77 has the appropriate response to this issue.

Not for anyone who read the article and saw this point addressed at the very beginning.

Directly from the NYT article:

The set of players posthumously tested by Dr. McKee is far from a random sample of N.F.L. retirees. “There’s a tremendous selection bias,” she has cautioned, noting that many families have donated brains specifically because the former player showed symptoms of C.T.E.

But 110 positives remain significant scientific evidence of an N.F.L. player’s risk of developing C.T.E., which can be diagnosed only after death. About 1,300 former players have died since the B.U. group began examining brains. So even if every one of the other 1,200 players had tested negative — which even the heartiest skeptics would agree could not possibly be the case — the minimum C.T.E. prevalence would be close to 9 percent, vastly higher than in the general population.

But where did "vastly higher than in the general population" come from? We're never told!

(I'm not saying it isn't true... just that everyone seems to be assuming it is true, with -- as far as I can tell -- zero evidence.)

Presumably it came from the knowledge that CTE is quite rare in the general population, much less common than 9%.

And the evidence for your claim can be found....

This is all fine and good. Especially the point about 9%. Makes complete sense. Seems like a very well done, legitimate study, with a very troubling conclusion. Not discounting any of that.

My beef is with the way journalists and editors are summarizing it in headlines. Look around the internet today. Lots of "90% of football players have CTE" headlines all over the place, that are straight misleading, including for that very NYT article.

Another job for the robots!

CTE more or less dampened my enthusiasm for college football. At least in the Pros they have some sort of compensation. Think of all the kids out there that their moment of glory was being a 3rd string running back and ended up with mild CTE. FYI, 3rd string running backs = tackling dummies in practice.

Yeah. How many hits you take/give and how hard they are is dependent on your position and role. If you're a starting QB or RB/WR, you take less hits. 2nd string MLB, you probably have bashed your head for 8+ years even before starting college.

I have one son, age less than a year (I'm pushing 50...ugh) and I don't think I'd allow him to play football, but hopefully I'll have more information by the time that issue could come up. Being a star in high school or a third stringer on a college team is quite the accomplishment and will provide a lifetime of happy memories and numerous other benefits. I'm not saying it's worth a brain injury, but it's worth a lot.

I mean, no compensation, but college football players have high status at pretty much every school, and at high-end D1 schools they're rock stars. Plus, if you play high-end D1 football, people admire you for it for the rest of your life.

Does this control for race?

Should this?

There are racial differences in brain size and skull thickness and density.

When basically 100% have CTE, there's nothing to "control for". Every function returns -> CTE.

According to Wikipedia, "The primary physical manifestations of CTE include a reduction in brain weight, associated with atrophy of the frontal and temporal cortices and medial temporal lobe."

The athletes may already have reduced brain weight to begin with.

"Currently, CTE can only be definitively diagnosed by direct tissue examination, including full autopsies and immunohistochemical brain analyses."

Am I the only one who thinks that kid football is morally equivalent to underage porn?


It's more like morally similar to underage active combat.


I would have thought it was closer to skateboarding... the number of 12-year-old football players who will develop CTE is small, but non-zero. Maybe about the same, percentage-wise, as kids who break their necks skateboarding?

To be clear, there aren't a lot of skateboarding moms and skateboarding dads and skateboarding coaches pushing kids to do 360 flips down 7 stairs.

I believe that in Ice Hockey, they are trying to eliminate body checking at the lower levels (age levels) of the sport. I.e., introducing the most physical play in the late teen years.

I don't know if they are studying the brains of soccer players, but they used to say that each young player in his or her 20s had headed the soccer balls tens of thousands of times.

They are and you are correct, heading causes damage too. I believe many youth soccer leagues and even high school teams do not allow heading.

That sounds like a horrible version of the sport.

And indeed, when they look at the brains of soccer players who died with symptoms of brain trouble, they find the same thing. See the paper above.

These studies aren't worth the paper they're written on and the hyperbolic headlines are shameful. Which is not to say there is no head trauma-CTE effect or connection - I'm cautious with my own kids. But this kind of no-controls work tells us nothing.

Look at the brains of pro baseball players with and without premortem neurological symptoms and then tell me about incidence of CTE.

Wow, hyperbole much? Be a good internet sport and compare it the Hitler Youth or something.

They found in a biased sample that there are heightened levels of CTE. It means that there are grounds to do more research, including a random sample of the brains of football players and a control study of people of similar demographics who never played football.

And that's about all the study's authors rightly claim as well.

Elsewhere, Tyler has argued that the concussion problem signals the eventual end of pro-football. Justifiable fear of concussion among teens will kill high school football, which will kill college football and eventually pro. I suspect the NFL will try to save its multi-billion-baby by shifting to a new recruitment model that gets players from Eastern Europe. That or the robots take over.

Anyway, Americans will have their gladiatorial games.

The rules and equipment will be changed. American football is not going anywhere, much as I would like to see rugby football supplant it.

I expect the number of full-contact practices will continue to be reduced, "helmet wraps" utilized for practice, and tackling and blocking techniques refined, along with rule changes. Perhaps another good change would be to eliminate the specialized offense, defense and special teams so their would be greater emphasis on conditioning. The effect would be to drive down size among linemen and linebackers, perhaps. Another effect would be more money for fewer players.

Maybe introduce a rule where the tackler has to release the tackled player immediately post tackle and the ball carrier has to immediately play the ball and the game continues.

The problem is that better protection yields harder hits i.e. greater blunt force trauma.

This. Hits on the QB have already been curtailed. Now it is not a matter of "intent" (let alone intent to injure). All contact to the head is punished.

Similarly, spearing has been eliminated, as has clipping, etc.

AG is correct. The rules will be changed.

I'd prefer Australian Rules or Gaelic.

With robots you could reintroduce clipping, spearing, and head hitting. Perhaps the robots will have exploding heads with red components! Fans will love it!

You're all forgetting that the NFL.... (1) is a solidly reliable Dem/Liberal organization and (2) basically prints money.

No way the Dems put a bullet in its head. If anything, they might bleed it dry over decades, Tony Soprano style --- publicize a report, extort a bit more money from the NFL, repeat. But it'll still be the #1 sport in the USA on the day your children are buried.

and (3) probably the number one producer of african american millionaires

Nope, that's basketball. Most football careers last 3-4 years, the contracts are much smaller, and they are not guaranteed. Very few NFL players end up multimillionaires.

Maybe a few end up with $1 mil after expenses, agent cut, taxes, etc. And they are only 30 years old or so, that has to last them. Most get jobs selling cars and insurance and the like. I bought a term insurance policy from Hall of Fame Raiders tight end Dave Casper. He played when they really made almost nothing.

That's a great story, but I'm sure Dave Casper is doing pretty well financially. Interestingly, as of a few years ago he was still in the insurance industry.

No one compares with Roger Staubach. He spent the offseasons working in real estate mostly as career ending injury insurance and eventually turned it into a 9-figure fortune.

Why is that a "great story"?

I've bought a lot of insurance, but never from a HOF football player. It's at least a good story. It's not like you went to McDonald's and Dave Casper was at the cash register. He had a pretty good job. Of course, a HOF caliber TE would be making tens of millions today...or possibly found hanged in his jail cell.

Got it, +1. Well done on the Aaron Hernandez reference, even though he's unlikely to make the HOF :-)

On the day my parents where born, the top three sports in the U.S. were boxing, baseball, and horse racing. I hesitate to make any assumptions about taste in sport on the day my children are buried.

Someone tell Bob Kraft the NFL is a 'Dem/Liberal' organization LOL

Streaming/unbundling/cord cutting will probably cause a bigger (and much sooner) detriment to the NFL

Why? The majority of their product is on broadcast TV.

Because there is probably a substantial portion of cable cutters who will opt out of ESPN.

On the other hand, if cable cutting really becomes a thing, the vast majority of channels are in a lot of trouble.

Glad to see that selection bias is addressed early in the NYT article. Most of the reporting I've seen online has not been as honest about the obvious problems with this study.

"Almost all players suspected of CTE with families willing to donate their brains for research actually had CTE" doesn't seem particularly noteworthy. I just wonder when the huge amount of concern for high-status and high-paid NFL athletes will filter down to folks who face occupational injury without the aforementioned high status and high pay.

Wouldn't we have noticed before if the vast majority of NFL players and a substantial portion of NCAA players were neurologically compromised? It's gotta be CTE + some other factor. The best numbers I recall is that 1% of Americans have early onset neurological problems and for NFL players it's more like 2%. That means there are a lot of CTE cases walking around that are asymptomatic.

A convenience sample is, of course, not a fully adequate study. But, it is a good first step to learning and most generous of those who have lost loved ones to donate brains towards discovery about CTE. The correlative results of this biased sampling will likely encourage what is needed; a complete research study. The findings of an adequate study that includes players who do not have symptoms of CTE as well as those who have shown signs of CTE would help in clarifying the ultimate dilemma. Will all who play football will get CTE? Are there are other factors to consider as well that may indicate a stronger propensity to CTE? Such research work could aid in finding what the legitimate risks a player will be taking with CTE so that they can actually be weighed. It could also alert the public at large who else might be prone to CTE. Presently the arguments are often emotional between those who love football and those who hate it.

1. This like yhe families of competitive eaters who die of heart attacks donating their bodies to science and finding that 99% of them had major blockages. It doesn't tell you anything about competitive eaters generally.

2. As a kid, my friends and I played a lot of backyard tackle football and other contact games. We got our bells rung a few times. Is this more dangerous than supervised play?

3. The culture around the game has changed dramatically. My friend was telling me that as a jv player the coach put a mat around a tree and they had to "tackle" it. The days of puke buckets, Oklahoma drills, and head butting have been replaced with a focus on teaching safe approaches to tackling, proper hydration, and sensible training. Equipment has come a long way too. Outcomes for players who started in pads in the 20th century will be different from those coming along later.

I think you would find a much lower incidence of CTE in rugby players. I played football in high school and rugby in college. Anecdotally, there are many fewer high impact head collisions in rugby, primarily because without a helmet, there's a lot more incentive to avoid head contact. The helmet is what makes football so dangerous.

Also, I don't think anyone who has actually played football thinks it's safe or good for your long term health. By the time they make the NFL, these guys understand the risks they're taking. I don't see how the NFL could be liable in these concussion lawsuits.

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