The Head Case
Fixing the NFL Concussion Crisis
O N A WARM FLORIDA EVENING IN
February, 2011, Dave Duerson, a
fifty-year-old retired NFL safety,
climbed into bed. Sitting on a table across the room were
the helmets of the three teams he had played for during
his eleven-year careerthe Chicago Bears, the New
York Giants, and the Arizona Cardinals.
By JACOB LEIBOWITZ
Duerson had always enjoyed surrounding
himself with reminders of his success. That night,
however, he wasnt thinking about his two Super Bowl
rings, which he had won in 1985 and 1990, or his Walter
Payton Man of the Year Award presented to him for his
charity work. Duerson had something else on his mind:
the loaded, .38 caliber handgun that he held to his chest.
Seconds later, Dave Duerson pulled the trigger.
Among the hand-written letters that he had left for his
family, one included a slightly different message:
Please, see that my brain is given to the NFLs
brain bank.[1]
Duersons death shocked the football
world. Even long after his retirement from
the game, Duerson had a stable income and
a wide support system. Many of his friends
and family were left pondering the same
question: what could have caused such a
loved, successful man to find himself in
such a dark place?
A few months later, an autopsy
provided some answers. As per Duersons
request, researchers at the Boston
University School of Medicine were given
his brain to examine. They found
evidence of chronic
 traumatic encephalopathy (CTE), the same degenerative
brain disease that doctors found in the brains of other
former NFL players that also took their own lives.2]
The Impact of Concussions
Discovered by Dr. Bennett Omalu in 2002, CTE
develops most commonly in the brains of athletes after
they experience repeated blows to the head. This brain
trauma eventually begins to damage nerve fibers,
consequently triggering the release of a protein called tau
that pools in the brain and destroys cells.
These changes dont necessarily happen
immediately after the last significant impact to the head,
howeverthey can begin months, years, or even
decades later.[3] Symptoms of CTE include memory loss,
confusion, impaired judgment, impulse control
problems, aggression, depression, and, eventually,
progressive dementia.[4]
While also found in the brains of boxers and
other contact sport athletes, CTE has become infamous
for its link to professional football players. A 2015 study
performed by the Department of Veterans Affairs and
Boston University found that 96% of deceased NFL
players examined by researchers (87 out of 91) tested
positive for CTE.[5] Permanent damage caused by brain
trauma in football doesnt just appear in isolated cases
its widespread, and its dangerous.
Whether competing in practices or games,
professional football players receive a concerning
number of blows to the head. From the full-speed
collisions that make highlight reels to the celebratory
smacks on the head from teammates, football players get
hit in the head far too often.
In fact, researchers funded by the National
Institutes of Health set their sights on quantifying
exactly how often. They outfitted football teams from
Dartmouth College, Brown University, and Virginia
Tech with sensor-equipped helmets, measuring the
magnitude, location, and angle of each hit over the
course of an entire season.
Their findings were shocking: some of the
athletes studied received close to 1,500 hits to the head
per season, which rounds out to about 6 per practice and
14 per game, on average. Lineman and linebackers
would typically receive more hits per game, and running
backs were hit less often but with greater magnitudes for
each impact.[6]
These results expose a much-overlooked
problem. The NFL primarily focuses on serious blows
to the head, but these skull-cracking hits are just the tip
of the iceberg. Football players receive just as much if
not more damage from small, successive hits that
accumulate over time to cause trauma. These repeated
small impacts are almost entirely ignored by medical
staff.
So when the NFL reported in 2015 that the
league saw 271 concussions[7] throughout the course of
the season, that number dramatically fails to quantify the
real harm done.
Far too frequently, players get hit hard during a
game, stumble off the field, and then, almost
miraculously, return on the very next play. As long as the
requirements for a medical evaluation remain
inadequately defined, coaches can continue to keep their
starters in the game after a blow to the head. No
diagnosis, no problem.
Clearly, concussions are a serious dilemma,
threatening the very livelihood of each and every player
long after they hang up their cleats. Thankfully the
league has begun to recognize this problem and has
taken steps to make the game safer for its players.
However, it took decades for NFL executives to even
admit that concussions pose a major threat to the game
of football and the players.
Visible Damage
A normal, healthy brain (left)
compared to a brain with advanced
levels of CTE (right). Since its
discovery in 2002 by Dr. Bennett
Omalu, CTE has been found in the
brain of football players as young as
17 years old.
(Photo courtesy of Frontline)

The Backstory
The NFL began to examine the issue of
concussions in 1994 when it established the Mild
Traumatic Brain Injury (MTBI) committee. During the
first few weeks of the committees existence, its
chairman, Dr. Elliot Pellman, publicly announced that
concussions posed only a minor threat: We think the
issue of knees, of drugs, and of steroids and drinking is
a far greater problem [than concussions]. At the time,
nobody comprehended the impact that repeated blows
to a players head could have on his brain. Most NFL
executives just considered concussions, as Pellman put
it, part of the profession, an occupational risk.[8]
300
250
Number of Concussions
200
150
100
50
0
2010 2011 2012 2013 2014
Year of Season Start
It took the NFL fifteen years to finally admit that
concussions pose a long-term threat to players health.
Until then, the MTBI committee continued to deny all
research suggesting that playing professional football
can lead to brain damage and disease. They instead
published their own research that attempted to discredit
the studies performed by renowned neuroscientists.
However, a 2016 confidential study performed
by the New York Times revealed that the research
released by the NFL was far more flawed than previously
known, suggesting that the league cared more about
protecting their revenue than their players health. The
Times claimed that more than 100 concussion
diagnoses were omitted from the studies, including
serious ones to stars like quarterbacks Steve Young and
Troy Aikman.[9]
Even more concerningYoungs concussion
ended his career, and Aikman stated after his own
concussion, I didnt know what planet I was onI still
to this day have no recollection of ever having played in
that game.[10]
Brain trauma cases as serious as these should
have been identified and treated immediately. Instead,
NFL executives ignored them and, therefore, ignored
the health of the very people that keep the league alive.
In fact, Dr. Ann McKee, a neuropathologist at
Boston University School of Medicine, went as far as
likening the NFLs handling of the concussion issue to
the way the tobacco industry suppressed the link
between smoking and lung cancer.[11]
In 2011, former Atlanta Falcons safety Ray
Easterling decided to fight back against the NFLs
mistreatment of its players. He filed a lawsuit against the
No End in Sight
Over the last seven NFL
seasons, the league has not
seen any significant signs of
progress towards better
protecting its players.
(Data courtesy of CNN)
2015 2016
NFL, on which he later gained the support of 4,500
other players, claiming that the league engaged in a
concerted effort of deception and denial in its
handling of concussion and brain trauma research. Two
years later, the NFL agreed to pay $765 million as part
of the settlement but did not admit any wrongdoing.
Although Commissioner Roger Goodell
reiterated that there was no admission that anything
was caused by football, the NFL did acknowledge in
federal court documents that nearly one-third of former
NFL players developed long-term cognitive problems at
a younger age that the general population.[12]
Since the settlement, the NFL has shown much
improvement in its attempts to alleviate the concussion
crisis. Players have begun receiving fines ranging from
just over $9,000 to just under $50,000 for each
dangerous football play. In 2013, the NFL began placing
independent neurologists on the sidelines for every
game[13] to objectively evaluate each player suspected of
a possible concussion. The NFL has even moved
kickoffs up 5 yards (encouraging touchbacks instead of toward certain programs that will remodel the
returns that involve full-speed collisions), agreed to the foundations of American football with time. In order to
new labor contracts reduction of contact allowed in mitigate the dangers of concussions from professional
practice, and sponsored numerous research projects football, the NFL, with the support of the NFLPA,
themselves. should do three things: better identify concussions, fund
No matter the efforts made by the NFL and the high school programs, and research safer helmets.
calls for better protection from the NFL Players
Association (NFLPA), the concussion crisis lives on. Identifying Concussions
Between the 2014 and 2015 seasons, the league saw a
32% increase in diagnosed concussions[14], and that When discussing concussions, researchers
number could even be understated. mention many technical terms: head trauma, linear
In a series of interviews with the Associated acceleration, brain deformation, impact velocity, CTE.
Press, 23 of 44 NFL players said they would rather However, those commonly used terms are not broadly
conceal a possible concussion than pull themselves out understood. While progress has been made, doctors still
of the game, indicating that they feel obligated to return dont know the exact causes, distinguishing features, and
to the field even if they suspect a head injury. The exact outcomes of a concussionin fact, nobody does.
bottom line is: you have to be able to put food on the Currently, there exists no standardized criteria
table, said former for diagnosing a
Jacksonville Jaguars
running back Maurice
Jones-Drew. Injuries
This is the only concussion or any type of
head injury for that
matter.[16] Researchers
place where you
are part of the game. If are trying to establish
you dont want to get hit, some type of clear-cut
then you shouldnt be system, but little progress
playing.
Other players can Actually has been made.
Dr. Jamshid
expressed even more

legally assault
Ghajar, a neurosurgeon
morbid sentiments. and director of the
Stanford Routt, a former Stanford Concussion and
cornerback for the
people.
Brain Performance
Oakland Raiders, stated Center, even claimed that
in an interview, Youre most doctors accept a
never going to be totally -Stanford Routt headache after a potential
safe from concussions in head injury as a
this game. This is the only place where you can actually concussion. [17]
Since a headache may not appear until
legally assault people.[15] hours or even days after the initial trauma, this criterion
for diagnosis seems altogether inadequate.
Steps Toward Safety If the NFL and its players ever want to see a
game of football with fewer concussions, then they must
work towards better defining and identifying
Obviously, the players need better protection. concussions. The steps towards this goal arent entirely
They should not have to risk their mental health in order well-defined, but the Simbex Head Impact Telemetry
to make a living. The NFL neglected its athletes for years (HIT) System provides a promising starting point.
when they deserved betterDave Duerson and many Designed by Simbex, a biomechanical
others deserved better. That leaves one simple question: engineering firm, the HIT System uses small sensors
what more can be done to prevent concussions in installed in a players helmet to analytically monitor the
football? severity of impacts taken by a player. The sensors record
Unfortunately, that simple question doesnt impact data and have the capability of forwarding the
come with a simple answer. The NFL cant rid football results to an external computer in real time.[18]
of concussions by merely tweaking the rules or issuing
five-digit fines. Instead, the league should shift its efforts

 A FORGETTABLE GAME
During the 1994 NFC Championship game, Dallas Cowboys starting quarterback Troy Aikman suffered a concussion
after receiving a knee to the head. Medical staff removed Aikman from the game, which Dallas won regardless. In the following
week, doctors tested Aikman and ultimately cleared him to return for the next gamethe Super Bowl, where he led the
Cowboys to their fourth championship.
However, the severity of Aikmans concussion went almost unknown until Frontlines program League of Denial
conducted an interview with Leigh Steinberg, Aikmans agent at the time.
Steinberg recounted his first interaction with Aikman after the concussion. He walked into a pitch-black hospital room,
where the Cowboys quarterback lay motionless. When Aikman saw Steinberg, he immediately asked him, Leigh, what am I
doing here? Steinberg informed Aikman that he was in the hospital after suffering a concussion. Aikman then asked, Did we
win? Yes, you won. What does that mean? It means youre headed to the Super Bowl.
Five minutes later, Aikman looked back at Steinberg and asked again, What am I doing here? That pattern of
forgetting cycled on for the next two hours.
When asked to describe how he felt after seeing Aikman in the hospital that day, Steinberg responded, It terrified me
to see how tender the bond was between sentient consciousness and potential dementia.[19]

The HIT system is a powerful tool that could
potentially evolve into a standardized method of
diagnosing concussions on the sidelines of football
games. However, some doctors have found that the HIT
System is not entirely accurate. Specifically, a 2009 study
performed by Steven Broglio, a kinesiology professor at
the University of Michigan, found that the HIT System
correctly diagnosed only 1.4% (5 of 349) of measured
impacts exceeding the concussion threshold of 70 G of
linear acceleration.[20] Broglio concluded that the HIT
System should only function in research and not in the
real world.
Not all hope is lost, however. The Simbex HIT
System has received vast upgrades since Broglios study
in 2009, and with an investment from the NFL it can
become even more reliable. Eventually, doctors on the
sidelines could use the HIT System as a method of
accurately diagnosing concussions by tracking the data
in each players helmets during every play and promptly
determining when a player should exit the game.
If the NFL wants to solve the concussion crisis
once and for all, it has to first accurately identify the
occurrence of concussions. Developing and imple-
menting a method similar to the HIT System that clearly
defines and measures the criteria for a proper diagnosis
is crucial to taking players out of the game before they
can receive another damaging blow to the head.
Standardizing concussions is the first steppreventing
them entirely is a completely different challenge.
High School Programs
Most NFL players can probably track the roots
of their passion for the game back to high school. They
participated in daily practices, played in front of their
fellow classmates on Friday nights, and got recruited by
collegiate teams. High school football sets the stage for
those that will continue to play later in life, but it also
incorporates an added level of danger when it comes to
head injuries.
According to Northeastern University, these
teenagers are under-developed and play with improper
mechanics, which increases their risk of injury.[21] A 2009
study conducted at a central Illinois high school actually
found that high school athletes generally experienced
greater post-impact acceleration to their heads than the
accelerations collegiate players endured. The researchers
speculated that high schoolers weaker muscle structure
was not as effective in controlling their heads after
impact.[22] But how does any of this relate to the problem
of concussions with adult, professional football players?
A football players mechanics habituated during
his high school years will most likely stick with him the
rest of his career. If a high school football player doesnt
learn how to properly tackle, or protect himself, or even
strap his helmet on correctly, he will be less likely to
repeat those same correct behaviors when facing more
demanding competition.

96%
of deceased football players tested
167
is the average number of
52%
of players wouldnt leave the game
 With additional funding, high school football
programs can invest in more advanced education for
their students on safer mechanics and proper
fundamentals. Such education could also include helpful
lessons on the importance of wearing custom-made
mouth guards, which have been found to cut the
frequency of traumatic brain injuries suffered in half,[26]
and the benefits of helmetless training, which sounds
contradictory but can actually reduce the number of
head impacts by forcing players to feel more
vulnerable.[27]
Just two years ago, five high school football
players died from head injuries.[28] In a time when the
sport of football continues to receive less and less
support (25% of parents wouldnt allow their children to
play some contact sports due to concussion risks[29])
because of its arguably life-threatening consequences,
there exists a tremendous need to make the game of
football safer in high school to ensure its existence at the
professional level in the future.
If the NFL and the NFLPA want to exist in fifty
years, let alone exist with fewer concussions, their
executives should certainly consider investing in high
school programs.
Improving Helmets
When asked to address the concussion crisis in
the NFL, most people would probably point to the
helmets right off the bat. Clearly, the one piece of
equipment that protects the brain most directly must
play a major role in preventing concussions. Perfect the
helmet, eliminate traumatic brain injuries. Its as simple
as that, right?
Alas, therein lies one of the most over-simplified
notions in all of professional sports. Helmets, even
though visibly simple from the outside, are complex
pieces of technology that scientists continue to research
and develop every single day. The flashy helmets that
footballers use today have come a long way from the
optional leather helmets first developed in 1896. Even
more can be done to make helmets saferits just a
matter of funding the appropriate research.
Modern helmets consist of a rigid, polycarbonate
shell, a steel facemask, a chinstrap, and padding on the
1 in 3
former NFL players developed signs
$125k
is the total value in fines that James
inside. Some use more advanced material designs than
others, resulting in a spectrum of capabilities when it
comes to concussion prevention.
Riddell, the largest helmet manufacturer and
official helmet sponsor of the NFL, develops one of the
most commonly used and highest rated helmets on the
market: the Revolution Speed. This system utilizes a
custom inflated high-density vinyl nitrile foam for better
energy absorption, a specialized facemask that contorts
to take some of the impact, and a larger shell to encase
additional padding.[30]
Currently, there are numerous studies in the
works that are searching for better answers to the
engineering design of helmets. For example, researchers
at UCLA have developed an energy-absorbing micro
lattice material, which they call architected lattice, that
reduces the peak impact force of a head-to-head blow by
about 26% compared to conventional foam.[31] These
researchers hope that one day their architected lattice
could replace the padding inside football helmets.
All of these advancements in helmet research
have occurred in the last five years. With the proper
funding, what could the players expect to change when
it comes to helmets in the next five years?
First of all, the helmet approval process needs to
see changes that account for more realistic conditions.
Currently, the National Operating Committee on
Standards for Athletic Equipment (NOCSAE) has the
responsibility of administering a test to approve helmets
for use in the NFL based on certain safety standards. For
each helmet in question, NOCSAE performs a drop test
from a height of 1.5 meters and measures its impact
velocity in 6 different locations on the crown of the
helmet.[32] Somehow, NOCSAE has managed to squeak
by NFL standards with this primitive testing system for
the last 40 years.
NOCSAEs drop test method only checks for
protection against linear acceleration, which comes from
powerful, centered impacts.[33] If linear acceleration was
truly the only source of head trauma, helmet
manufacturers could simply stuff their products with
more padding and solve the concussion problem then
and there. Where the drop test method falls short is
measuring the effectiveness of each helmets ability to
prevent off-axis impacts and rotational acceleration
the type of motion that researchers from the University
19
times more likely that an NFL player
of Ottawa and the University of Dublin deemed as
more associated with brain deformation impacts.[37]
In order to construct an accurate list of
approved, adequately-protective helmets, NOCSAE
must alter its testing system to also consider the factor
of rotational acceleration. Without that adjustment,
helmet manufacturers will continue to set their ceilings
at NOCSAEs lower standards, and, as a consequence,
the players will continue to suffer.
When it comes to the helmets themselves, some
current developments suggest massive upgrades in the
Its time for the
players to
stand up for
their right to a
healthy future
and demand
changes.
future of helmet safety. In addition to the designs
created by startup companies, other fresh designs
include a bristly foam with spring-like fibers, an internal
suspension system that would create two independently
moving layers inside the helmet, and an outer material
covering the polycarbonate shell that has the consistency
of dried tar.[38]
Neck stabilization devices are another promising
addition to future helmets that could eventually be seen
as a requirement on game days. According to Dr.
Jamshid Ghajar, reducing how quickly the flexible neck
accelerates could help prevent concussions.[39] Currently,
only a handful of NFL players (mostly linebackers or
defensive lineman) wear some type of neck stabilization
in the form of dense padding that rises above their
shoulder pads to reduce the effects of whiplash.
Building upon the idea of NASCARs Head and
Neck Support device, the United States Army Research
Lab has begun working on an elastic tether system that
could reduce sudden head motion. The straps, filled with
fluid that becomes increasingly solid when stressed,
would attach from a lightweight harness around a
players waist to the bottom of his helmet, acting like a
shock absorber.[40]
With so many advancements in the past few
years and so much more to discover, football helmet
research must receive funding to continue finding better
ways to keep players safe. As the last line of defense
between a charging 250-pound linebacker and the fragile
human brain, helmets must receive more attention if the
NFL and its players want to improve safety in the sport
they love.
Looking Ahead
The NFL has found itself on a precarious and
dangerous path, one that has taken human lives with it.
Without some course of action, the concussion and
brain disease trend will continue. Active players will
continue to do their jobs and receive permanent damage
to their brains and, ultimately, their lives. Retired players
will continue to show signs of CTE and suffer the tragic
yet inevitable consequences. And the NFL will continue
to profit.
Looking past the multi-million dollar contracts,
wide-scale commercialization, and celebrity status of the
athletes, theyre no different from any other member of
the American workforce. Why, then, are they not
protected under the same federal laws established by the
United States Department of Labor that entitles every
employee to a safe and hazard-free workplace?[41] Why
can professional football players legally work in a life-
threatening environment?
Its time for the players to stand up for their right
to a healthy future and demand changes. By investing in
programs similar to the ones suggested above, the NFL
may one day be able to tell their players that they no
longer have to suffer the consequences of concussions.
Thats the style of football that the NFL and its players
must strive to achieveand the one that the players and
their loved ones deserve.
 Notes

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