Our understanding of the consequences of brain trauma in sports, both concussive and repetitive "subconcussive" trauma, has grown immensely over the last two decades. With that has come growing concern from parents about the safety of their children playing sports.
Sports have so many benefits for children in a variety of areas, including physical and mental health, academics, and social life. Youth sports are a great venue for learning life skills, such as grit, determination, discipline, persistence, and teamwork. Every child should have the opportunity to reap the benefits of playing sports.
But which sports are the safest for a child's developing brain? And how can we make high-risk sports safer?
Concussion Risk
First and foremost, it is important to say that no sport or activity is without risk. Accidents happen, and concussions can happen in any sport or other activities in life. Yet, some sports come with a higher concussion risk than others due to the nature of the sport itself.
In the United States, football is consistently the sport with the highest overall number and rate of concussions. This is true across all levels of play. Each season, around one in twenty youth players under age 14 sustain a concussion each season. Nearly 100,000 youth and 80,000 high school football players sustain a concussion each year.
Other sports carry relatively high concussion risks. Though hockey is often second to football among common sports in the United States, rates have declined over the last decade as a result of a ban on checking in the boy’s game before age thirteen. Soccer falls just behind hockey in most studies, but it is the sport with the highest rate of concussions for females at all levels. Concussion rates in lacrosse, wrestling, and competitive cheerleading are also concerning. Rugby is popular internationally and a growing sport in the in the United States, and it carries a concussion risk similar to football.
A few studies have found higher concussion rates in girls’ soccer or hockey than football, but those are in the minority. The vast majority of concussion epidemiology studies show football has the highest concussion rate. But ultimately, those details don't matter. One sport carrying dangers for the brain doesn’t somehow make another sport safe. All of these sports carry a higher concussion risk, and we should be taking steps to improve brain safety in all of them.
Repetitive "Subconcussive" Impacts
A growing body of research shows that repetitive brain trauma causes changes in the brain over the course of a season and career, regardless of whether or not those impacts result in concussion symptoms. These impacts are sometimes called “subconcussive.” Chronic traumatic encephalopathy (CTE) has been diagnosed in individuals with no known history of concussions but who were exposed to repetitive subconcussive impacts through sports or other exposures. (Though it is important to note that many concussions go undiagnosed, and it is possible, if not likely, that some of those individuals sustained concussions that were never reported.)
Which sports carry the greatest risk for repetitive impacts? I have a chapter of my book dedicated to head impact exposure in sports. Here’s a brief summary to address this question:
Research using accelerometers placed in helmets, mouth guards, patches, or headgear have given us valuable insight into the number and force of impacts athletes sustain in their sport. Football carries the highest average risk for repetitive brain trauma in athletes in the United States. The average high school and college football player experiences hundreds of impacts over the course of a season. In fact, it is common for some athletes studied to have sustained over 1000 impacts, with a few incurring over 2000 impacts in just one season. At the high school level, it is more common for athletes to play both offense and defense, greatly increasing impact exposure. Linemen tend to have higher overall impact numbers, while wide receivers and defensive backs tend to experience higher-magnitude impacts.
You might think that smaller, slower youth athletes can’t hit that much or that hard, but that isn’t true. Youth football players ages 9 to 14 average 200-300 impacts per season, with several experiencing hundreds more. Even the youngest players average over 100 impacts per season. This is despite the fact that the average youth season involves far fewer practices and games than the college or high school season. These impacts are of similar magnitudes to those experienced by the older players, despite their smaller size. This may be because a child’s head grows quickly, making it disproportionately larger than the rest of their body. Like a bobblehead doll, their smaller, weaker necks have a difficult time stabilizing their head, and the weight of a helmet makes this effect even worse.
Though less than football players on average, hockey players can also experience hundreds of impacts each season, including many high-force impacts. Studies of soccer impacts suggest that hits are less frequent overall compared to hockey and football, but they can still exceed 100 in a season. These studies may also be deceiving, given how common it is for soccer players to play year-round and in multiple leagues at the same time. There is limited research on other sports like rugby and lacrosse, especially at the youth level, but early evidence suggests that they tend to expose athletes to impacts at similar levels as football and hockey.
Which sports are safe for the brain?
There are many non-contact or limited contact sports that don’t involve repetitive impacts and carry lower concussion risks. Concussions can still happen in any sport, including basketball, softball, baseball, or volleyball, but the repetitive subconcussive impacts aren’t part of those sports.
For contact sports, the numbers I just presented are concerning, but that doesn’t mean we should be eliminating or avoiding sports like football, hockey, soccer, and rugby altogether. Instead, there are ways to enjoy these sports without the repetitive impacts and high concussion risk. Alternative versions of these sports, or versions with specific rules for the youth level, can be great ways to get kids involved in sports without the greater risk to their brain.
Hockey has banned checking prior to age 13, and concussion rates, as well as overall injuries, have dropped since. Soccer delayed the introduction of heading until age 11, and limited it until age 13. While age 11 may still be early to introduce heading, the delay is a step in the right direction. As I described in an earlier blog post, flag football players experience substantially fewer impacts than tackle football players, while still learning about the game and developing football skills. Other non-tackle forms of football, such as TackleBar and Flex Football, can also be great, safer options.
If athletes do start to play the full contact form of these sports, head impact exposure can still be greatly reduced by substantially limiting or completely eliminating checking, heading, or tackling in practice. For example, many elite high school and college teams have chosen to eliminate tackling from most or all practices. The athletes can still successfully tackle in games without practicing on each other, and the athletes tends to stay healthier overall throughout the season. Coaches make the choices about drills and tackling in practice, and they also create the culture of safety, or lack thereof, on the team. Some coaches value brain safety, concussion reporting, and minimizing contact over a season. Other coaches create a culture that discourages athletes from reporting concussions and valuing their health. When rules or laws limit contact practice time, some coaches simply pack as much contact into the limited time as possible, exposing their players to just as many if not more impacts as they experienced prior to the law. Parents and athletes should feel comfortable with the culture around safety created by the coaching staff before joining a team.
Given the rapid brain development happening in a child’s brain and evidence for potential disruption of these processes, avoiding the full-contact form of high-contact sports before high school is ideal. Though some coaches and leagues may promote “new” and “safer” techniques, the data isn’t there to show these techniques make a meaningful difference in brain safety for youth players. Not only does delaying the introduction of the source of repetitive impacts allow more time for brain development, but it also reduces the overall number of impacts experienced by athletes over their lifetime, which has been linked to long-term cognitive, mood, and behavioral difficulties and the development of CTE. While the risk is not zero, current evidence suggest that only playing a few years of high school football, especially when contact is minimized at the high school level, leaves athletes at low risk of developing CTE.
Brain safety in sports isn't an all-or-nothing issue. With strong measures to eliminate impacts at youth levels, even traditionally high-risk sports can be played in a low-risk way, giving more opportunities for kids to thrive in sports with minimal likelihood of short- and long-term consequences for their brain.
