Fitness
Would I Play Football Again Knowing What We Know About CTE?
I’m a doctor and former wide receiver. My brother’s in the NFL. Chronic traumatic encephalopathy (CTE) is on my mind.
I’m settled into a desk chair with my coffee, fueling up for another day of Zoom medical school, broadcast live to my New York City apartment. The bloc we’re on now—neurology—is a doozy. Well, truthfully, they’re all doozies.
Today’s lecture topic: traumatic brain injury.
The fourth lecture slide includes a picture of Mike Webster, the former Pittsburgh Steeler whose story was made famous by the 2015 film Concussion—starring Will Smith as the physician who discovers the explosive link between football and a neurodegenerative disease found in athletes and others with a history of brain trauma called chronic traumatic encephalopathy—or CTE.
I know what’s coming. It’s not often you get a football reference during a med school lecture. The next few slides outline the consequences of repetitive head trauma. Here it comes. CTE.
My classmates are aware I’m an ex-football player. I get a direct message from one of them: “Knowing what you know now, would you play again?”
It’s not the first time I’ve been asked. I’d asked myself that same question a long time ago.
Football is deeply ingrained in my family. My father and both grandfathers played in college. Justin, my younger brother, is the starting quarterback for the Los Angeles Chargers. My youngest brother, Patrick, is a freshman tight end at the University of Oregon.
I played 11 years of football, four of them as a starting wide receiver at Montana State University. During all that time, I never had a diagnosed concussion. That isn’t to say I haven’t had my fair share of violent collisions.
After my career at MSU, I had an opportunity to attend an NFL team’s rookie mini-camp—basically a tryout for undrafted players. I declined for a few reasons. I knew I wasn’t cut out to be an NFL wide receiver. I also wanted to start the long journey to become a doctor.
My brain health wasn’t a factor in that decision.
Tracing the timeline of CTE discovery
The first link between football and CTE was unearthed in 2005 by Bennet Omalu, M.D., a neuropathologist who’d examined the brain of former Steeler and NFL Hall of Famer Mike Webster while working in a coroner’s office in Pittsburgh.
“Iron Mike,” as he was known, played in 220 NFL football games. The most of any player in Steelers’ history. He’d suffered repeated head trauma during his career.
Webster’s symptoms are now characteristic of repetitive head trauma: memory loss, behavioral and mood changes, cognitive impairment, and dementia.
The underlying process in the brain tissue is an accumulation of an abnormal protein called tau, which forms neurofibrillary tangles. Tau is also believed to be one of the culprits behind Alzheimer’s disease. Because similar regions of the brain tend to be affected, most individuals display these characteristic symptoms.
As public awareness of the links between repetitive brain injury, football, and CTE grew in the early 2000s, things began to change in the NFL. In 2009, the league introduced concussion protocol.
It was also around this time that Texas Tech University head coach Mike Leach was featured on the front page of The New York Times for having abused a player with a concussion by confining him to a small, dark space while the rest of the team practiced. Leach was fired.
The world was finally beginning to take notice—and action.
Fast forward to 2017, when a groundbreaking Boston University study was published in the Journal of the American Medical Association. Out of 111 former NFL football players who displayed symptoms of CTE at death, 110 were found to have diagnostic criteria of CTE from brain autopsies revealing tangles of tau protein.
The ages of the NFL players, whose brains had been donated to science by family members, ranged from as young as 23 to as old as 89. The study encompassed all player positions. Most notably, 44 lineman, 17 defensive backs, 10 linebackers, and seven quarterbacks.
I remember reading about this study while gearing up for my fourth and final season on the gridiron at Montana State. The finding was monumental—an irrefutable argument that football caused CTE.
Or did it?
When it comes to CTE and football, the relationship isn’t black and white
The issue with the 2017 study and, really, much of the CTE research up to this point, comes down to who was included—and who wasn’t.
These brains had been donated by families for evaluation specifically because they displayed the characteristic symptoms of CTE from players with known head trauma.
“It’s biased sampling,” says Steve Kernie, M.D., professor and chief of Critical Care and Hospital Medicine at New York-Presbyterian Morgan Stanley’s Children Hospital, whose research focuses on brain self-repair following injury. “It’s hard to make really strong conclusions other than players in contact sports who have repetitive head trauma are certainly at risk,” Kernie adds. “This is also something we’ve known for 100 years.”
A control group would be required to un-bias the data—such as adding into the pool of participants the brains of former NFL players who didn’t exhibit signs of CTE, plus the brains of non-athletes.
Kernie references a condition originally called “punch-drunk syndrome,” first described by American pathologist Harrison Martland in a 1928 Journal of the American Medical Association essay about the strange behavior of boxers—another brutal, beloved sport long associated with head trauma.
“For some time, fight fans and promoters have recognized a particular condition occurring among prize fighters which, in ring parlance, they speak of as ‘punch drunk,’ ” Martland wrote. “Fighters in whom the early symptoms are well recognized are said by the fans to be ‘cuckoo,’ ‘goofy,’ ‘cutting paper dolls,’ or ‘slug nutty.’ ”
A decade later, the term punch-drunk would be replaced by the more appropriate dementia pugilistica.
It’s important to point out that the link between repetitive brain injury and CTE isn’t exclusively associated with football or boxing. Other contact sports like soccer and wrestling have been implicated too.
There are also documented cases of CTE resulting from military blast injuries.
“During the Iraq War, service personnel were coming back with symptoms that weren’t quite PTSD,” says Kernie, explaining a growing military merger with CTE in these cases, which hasn’t been nearly as mined by the media. “The NFL gets more attention than the military unfortunately,” says Kernie.
Back to my original question. Would I play football again?
Absolutely.
The friendships and life lessons I gained from over a decade of tackle football have shaped the person I am today.
Moreover, while I believe the association between repetitive head trauma, football, and CTE is real, I think the general public has a skewed perception. The presence of a concussion or two doesn’t guarantee a diagnosis of CTE. Many other factors are likely at play—including adequate recovery after an initial concussion and genetic predispositions to the disease.
My own hindsight question about playing football is now being asked at the outset by parents who are nervous about signing their kids up for the sport.
The dwindling numbers are telling. Peewee football participation is at an all-time low. Meanwhile, the waning interest in football appears to be providing gains for soccer, which ironically is not without its neurological risks.
I asked Dr. Kernie what his advice would be to parents considering whether or not to let their children engage in contact sports—particularly football.
“As a parent of kids who played sports, I think you can’t live in a bubble,” he says. “Everything we do carries some risk. It’s really about mitigating those risks as best you can.”
One significant way to mitigate these risks, especially in youth football, is by delaying the tackle element.
My brothers and I began tackle football in fifth grade. If you asked us now, we would have all put off tackling until late middle school or even high school. Not just to minimize repetitive head trauma, but to first master other football skill essentials like body positioning, blocking technique, and hand-eye coordination. All of these skills can be developed through flag football.
As I see it, the focus for budding football players at a young age should be on developing those skills rather than celebrating the traditional physicality which inevitably comes later.
Despite the public’s skewed perception on the pervasiveness of CTE among football players, we can hopefully all agree on two things: First, minimizing repetitive head trauma. Second, tackling this problem progresses by delaying youth tackle leagues and promoting the fundamentals of a phenomenal sport.
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The key to 360-degree muscle: 90-degree eccentric isometrics. It might seem like we’re throwing a lot of geometry at you, but the concept behind time under tension (TUT) is simple, says Joel Seedman, PhD, owner of Advanced Human Performance: “Perform the lowering phase of a movement in a slow, controlled fashion, usually 3 to 5 seconds; pause in the stretched position, typically around 90 degrees; then perform the lifting phase in a powerful yet controlled fashion.” Believe us, a time-under-tension workout can humble even seasoned lifters…Eccentric isometrics are like the pressure cooker of training.
“Rather than mindlessly performing slow-tempo reps, you’re using the increased time under tension as a means to fine-tune your body mechanics and alignment, which requires more mental engagement and focus,” Seedman adds.
If you want to forge functional muscle mass and strength while simultaneously bulletproofing the joints and connective tissue, give this 10-move, full-body eccentric isometrics workout a go.
Directions
Perform the following moves as 90-degree eccentric isometrics following the above protocol. Use heavy weight, but not at the detriment of proper form. Rest 60 to 90 seconds between sets and 2 minutes between circuits. Perform once every 2 to 4 days for optimal results.
Best Time-Under-Tension Workout for Total-Body Strength
Circuit 1
A. Barbell Back Squat
Set a squat rack up with heavy weight, then grasp bar and step under it. Squeeze shoulder blades together, then stand to unrack bar and step back with feet shoulder-width apart. Inhale, hinge at hips and slowly bend knees to 90 degrees. Pause, keeping natural arch in low back, then extend through hips to powerfully stand. 3 x 4-6 reps
B. Renegade Row
Start in the top position of a pushup with hands shoulder-width apart on moderate-to-heavy dumbbells (shown). Explosively drive right elbow back to row dumbbell toward ribs while balancing on opposite hand and feet. Pause, then slowly lower weight, stopping a few inches above floor. Switch sides after all reps are done. 3 x 5 reps each side
Circuit 2
A. Dumbbell Bentover Row
Stand with feet hip-width apart, holding two moderate-to-heavy dumbbells in front of thighs, palms facing you. Push hips back and hinge torso forward so it’s nearly parallel to floor, soft bend in knees. Dumbbells should be near shins. Drive elbows back to row weights toward ribs. Pause, then slowly lower down for 3 to 5 seconds. 3 x 4-5 reps
B. Incline Dumbbell Chest Press with Legs Raised
Set an adjustable bench to a 30- to 45-degree angle and lie back with dumbbells in either hand. Engage core and lift legs off floor, flexing feet. Press weights overhead, palms in. Slowly lower to 90 degrees, staying tight and compact. Pause, then drive weights up directly over chest. 3 x 4-5 reps
Circuit 3
A. Dumbbell Bulgarian Squat
Stand lunge-length in front of a flat bench, holding heavy dumbbells in each hand by your sides, palms facing in. Rest the ball on top (shoe’s laces) of your right foot behind you on the bench. Slowly lower your body until your front thigh is parallel to the floor. Pause, then drive through your heel to stand. Switch sides after all reps are complete. 2 x 3-4 reps each side
B. Single-leg Romanian Deadlift
Stand with feet hip-width apart holding dumbbells or kettlebells. Drive right leg up, foot flexed, knee aligned with hip, making a 90-degree angle. Hinge at hips as you slowly lever your torso toward floor, lowering weights and driving right leg back for counterbalance. Hold, then squeeze glutes to reverse. 2 x 3-4 reps each side
Circuit 4
A. Pullup
Hang from a pullup bar using an overhand grip with legs extended and feet flexed. Engage lats and draw shoulders down your back, then pull yourself up until chin is higher than hands. Pause at the top, then slowly lower. Pause at bottom, then reset before your next rep. 2-3 x 4-5 reps
B. Kneeling Overhead Barbell Press
Hold a bar with moderate-to-heavy load at shoulder level with forearms perpendicular to floor. Kneel at end of bench with feet flexed to grip edge for support. Inhale, engage your core and glutes, then press the bar overhead, pushing your head forward so it passes your face, exhaling at the top.
Slowly lower until elbows are at 90 degrees, then hold to maintain tension. Begin your next rep from here. 2-3 x 4-5 reps
Circuit 5
A. Dumbbell Pushup
Place hands on dumbbells (this provides greater range of motion) at shoulder width and feet wider than shoulder width with just toes touching the ground. Keep head neutral and hips high to increase tension on core, chest and tris and reduce stress on spine. Slowly lower to the floor. Stop
once elbows hit 90 degrees, pause, then push up to start. 1-2 x 6-8 reps
B. Biceps Curl
Stand with feet hip-width apart with moderate-to-heavy dumbbells in each hand hanging by sides. Engage biceps to curl the weights up, keeping upper arms still. Pause at the top, then lower slowly. Don’t let arms drop all the way down to keep greater time under tension on biceps. 1-2 x 6-8 reps
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