The life of a top professional athlete involves hard training, plenty of stress, career-threatening injuries and no shortage of money. But now, some high-profile figures -- think Indianapolis Colts quarterback Andrew Luck and Wales rugby union captain Sam Warburton -- have decided at a relatively early age that the glory and the lucre no longer outweigh the pain. The issue of long-lasting injuries, particularly concussion and its ramifications, looms ever larger for anyone looking to take up a contact sport, either as an amateur or a pro. It’s a growing concern for high schools and parents, not to mention the sports leagues that are facing legal suits.

1. What’s the biggest medical issue?

Chronic Traumatic Encephalopathy. It’s a degenerative brain disease, notably found in autopsies of people with a history of repetitive head injuries. That includes both concussions and smaller head impacts that don’t immediately appear dangerous. The condition isn’t necessarily brought on by a blow, or blows, to the head -- collisions between players can cause a head to oscillate at rates quick enough to harm the brain. CTE symptoms include memory loss, depression, problems with impulse control and suicidal tendencies. It’s a major issue for military veterans -- spool back a couple of thousand years and there’s even evidence that Alexander the Great was a victim.

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2. What does this mean for sports participation?

Teenagers aren’t expected to put their body on the line quite as much as they once were, whether through their own health concerns or those of their parents or high school. In the U.S., flag versions of football -- in which a defender tries to rip a flag from a ball carrier’s waist -- have gained in popularity. In the six years through 2018, participation in core tackle football has fallen 19% to 2.9 million, according to the Sports & Fitness Industry Association. It’s a similar story in rugby union, even in New Zealand where the sport is something of an obsession. The number of students there aged 13 to 18 with a “meaningful involvement” in the sport fell 12% from 2014 to 2018. In rugby league, the 13-a-side version with a reputation for being even tougher, the decline is sharper.

3. When did people first realize this was a problem?

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While the notion of a causal link between contact sports and CTE was for years dismissed, scientists no longer dispute it. There’s been a rash of suicides among football players, including Junior Seau in 2012 and Dave Duerson, who in 2011 shot himself in the chest at age 50 so his brain could be examined. Studies now show there are hundreds of former football players whose brains have CTE in one stage or another. Former Australian Rules Football stars Greg Williams and Shaun Smith have pledged to donate their brains to research. In Britain, a coroner ruled back in 2002 that ex-England soccer international Jeff Astle had died at age 59 from dementia brought on by repeatedly heading the ball. And a 2017 documentary by Alan Shearer, the English Premier League’s record scorer, drove the point home that thumping the ball with the head was a huge risk for all players, regardless of age and playing standard.

4. So it’s a global problem?

Without doubt. Head injuries can occur in any number of sports. A 2017 study on U.S. high school athletes conducted by the American Academy of Orthopaedic Surgeons found that girl’s soccer had the highest rate of concussions, followed by football, and girl’s basketball. And you can add surfing to the mix. Even in cricket, not normally known as a contact sport, concussion is a major part of the conversation. Bowlers launch the ball -- smaller and heavier than a baseball -- into the turf at speeds of 90 miles an hour with the aim of bouncing it at a batsman’s head. Australia’s Phil Hughes died in 2014 after being struck on the neck, while in August, the world’s top-ranked batsman, Steve Smith, had to sit out part of the series against England because of a concussion arising from a blow also to the neck.

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5. How much do fans want the issue fixed?

One caveat to efforts to make mainstream sports safer: There are millions of fans and viewers who still view brutality as entertainment -- a shuddering tackle in a sports arena can generate massive cheers. Hitting someone so they can’t get up from the floor is big business -- witness the continued attraction of a high-profile title fight in boxing, not to mention the global success of Mixed Martial Arts. And when it comes to debating a participant’s longevity, remember that for every Andrew Luck who called it a day while in his prime, there’s a Tom Brady still mixing it with people half his age. A 2017 survey found half of American football fans thought the National Football League had not done enough to address brain injuries, but there was no evidence that they were stopping watching the sport as a result.

6. What are the authorities doing?

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All 50 U.S. states have passed laws in the past decade addressing head injuries in youth sports. Lawsuits abound, and the national leagues for football, hockey, basketball and baseball have shored up their policies in recent years. In soccer, FIFA’s protocol is contained in an eight-page “Sport Concussion Assessment Tool.” For rugby union, getting it right was especially crucial at the six-week-long World Cup in Japan -- in the opening minutes of the final, England’s Kyle Sinckler was taken off the field after being knocked out cold. Looking ahead, the sport’s rulers are planning a radical rule change -- they’ll trial banning a player for making a tackle above the opponent’s waist (currently, tackles are permitted below the shoulder). The theory: Forcing the tackler’s head lower could reduce neural whiplash -- the process by which the entire head accelerates in a collision and damages the brain. The tackle is responsible for half of all rugby injuries, and 76% of all concussions.

7. Are they doing enough?

Former players like Warburton, who quit at age 29, say rugby’s measures are too piecemeal and that each nation has different standards. It’s much the same story in most sports -- FIFA has come in for especially strong criticism. What’s clear is that youth participation is a genuine concern for all stakeholders, from ruling bodies and sponsors to parents. The NFL is a $15 billion enterprise, by far the richest and most popular league in America; and the biggest college programs pull in more than $40 million per year on the sport. The Rugby World Cup calls itself the planet’s third-biggest sports event after soccer’s World Cup and the Olympics. The TV coverage will still home in on the day’s biggest hits. It’s got to the stage that some schools are turning away from contact sports, while the legal bills from concussion claims are mounting.

To contact the reporters on this story: James Ludden in New York at jludden@bloomberg.net;Eben Novy-Williams in New York at enovywilliam@bloomberg.net

To contact the editors responsible for this story: Matthew G. Miller at mmiller144@bloomberg.net, Grant Clark

©2019 Bloomberg L.P.

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