Intended for healthcare professionals

Rapid response to:

Editor's Choice

What are your burning issues for 2018?

BMJ 2018; 360 doi: (Published 04 January 2018) Cite this as: BMJ 2018;360:k9

Rapid Response:

Re: Soccer and Dementia

Heading the ball in soccer is a classical example of repetitive sub-concussive head injury but it has been largely ignored by the medical community and should now be given priority as one of the burning issues for 2018. During the last 20 years there has been a steady trickle of items in the media reporting a link between heading a football and the eventual development of dementia in soccer players. A startling revelation which had extensive media coverage was the news that the manager and three of the 1986 England World Cup team had Alzheimer's disease and a fourth member had severe memory problems. A recent example was a documentary shown on BBC One in November 2017, “Alan Shearer: Dementia, Football and Me”.

Despite media attention, the medical profession has been reluctant to address the issue. However in February 2017 Ling et al¹ published the first paper in the world to show a definite link between heading the ball in soccer and the development of dementia. It described 14 all excellent headers of the ball who developed dementia. Post postmortems were carried out in 6 together with detailed neuropathological studies; 4 had chronic traumatic encephalopathy (CTE) and 2 had Alzheimer’s disease (AD). Concussion was extremely rare in these players and the brain trauma was caused by repetitive sub-concussive head injuries from heading the ball.

A year has elapsed since this study was published and not a great deal has happened. Little is likely to happen until an epidemiological study is published which clearly demonstrates that the prevalence of neurodegenerative disease is significantly higher in ex- footballers than in the general population. On 23 November 2017 the Football Association (FA) announced that it would be funding jointly with the Professional Footballers Association (PFA) a study of approximately 15,000 ex-footballers and comparing them with a similar group from the general population to find out if the ex-footballers have a higher prevalence of neuro-degenerative disease. The study will be over a period of 2 to 3 years and will be led by Dr Willie Stewart, a Glasgow neuropathologist.

It is disappointing that the footballing authorities and the medical community have not already accepted that this is a significant problem particularly when three factual imperatives are kept in mind. Firstly the human brain is a very delicate fragile structure, with the consistency of jelly or blancmange. Alan Turing, the genius who worked at Bletchley Park likened the brain’s grey matter to tepid porridge. It is highly protected by three membranes and is bathed in cerebro-spinal fluid within the confined space of the strong boney cranium. The brain is not tethered within the skull it is able to move and oscillate within this hard rigid case.

The second factor was introduced in 1960 when the brain was first compared to a computer. During the subsequent 50 years there has been a prodigious development in information technology and miniaturisation to create a highly sophisticated computer in the form of a smart phone. As a result it is now much easier to accept the idea that the brain is the most advanced computer in existence. No one would expect a smart phone to escape severe damage if it was whacked repeatedly over many years.

The third factor is the parallel between heading the ball and the brain injury incurred in boxing. This analogy is compelling. Over the years it had been assumed that the brain damage in boxing was caused by memorable bouts, such as the Floyd Mayweather versus Conor McGregor bout on 26th August 2017, when both fighters took terrific punishment. This is no longer received wisdom. It is now known that the damage is caused by repetitive sub-concussive trauma, which occurs in sparring and is repeated week in week out over many years of training. These mild repetitive head injuries in sparring are virtually identical to heading the ball in soccer. In 2016 this journal published two articles side by side, ‘for’ and ‘against’ boxing², both articles were in agreement that sparring was the cause of the mental deterioration in the sport.

Despite the reluctance of the FA and PFA I have title doubt that two steps should be taken without delay. The first involves the welfare of demented former players. The game of soccer, particularly the Premier League, is awash with money derived mainly from big television companies who are eager to have an almost continuous flow of high quality sport, particularly soccer, on their schedules. It is long overdue for some of this money to be channeled into an earmarked fund to ensure that ex-players with dementia receive high quality care and that their relatives have easy access to an effective support network.

The second step involves children. During the last few years more attention has been given to sports injuries, the problem of concussion in rugby is a good example. As a result parents are now beginning to ask should their children be heading the ball. Although there is no conclusive evidence that heading the ball in children leads to neuro-degenerative disease in later life, nevertheless a child’s brain is still developing and does not have the same level of protection as the adult’s brain. Bearing this in mind and using the Precautionary Principle, the logical next step is for heading the ball to be banned altogether in children under the age of 11, as it is in the United States. At the same time a public education programme should be embarked upon to draw attention to the fragile nature of the human brain.

As soccer is the most popular game in the world and dementia is such a horrific illness serious consideration should be given for soccer and dementia to be adopted by this journal as one of the burning issues for 2018.


1. Ling, H., Morris, H.R., Neal, J.W. et al. Acta Neuropathol (2017) 133: 337.

2. Should we ban boxing? BMJ 2016; 352 doi: 

Competing interests: No competing interests

04 March 2018
Donald R Williams