As recently as 2009, members of the National Football League’s Mild Traumatic Brain Injury Committee denied that repeated concussions as experienced by some professional football players could result in permanent harm [6]. Earlier this year, that viewpoint changed. The NFL’s senior vice president for health and safety policy recently acknowledged to the US Congress that there “certainly” is a link between football and degenerative brain disorders, including chronic traumatic encephalopathy [2, 3]. It seems clear enough that this is true [5].

Recurrent concussions in children likewise appear to result in later cognitive impairment [26, 28], and evidence suggests that high school football players experience more-prolonged neuropsychological effects of concussion than do NFL players [19]. It is worth noting that the latter came from the same NFL traumatic brain injury group that spent years denying any connection between concussions and more-permanent neurocognitive harm. Based on what we now know, we believe that physicians—including orthopaedic surgeons—should recommend that young people not play tackle football.

Physical fitness and the social aspects of team sports are important, but given the severe impairment that recurrent concussions may cause, the gaps in our knowledge about how to mitigate or prevent these injuries, and the lack of a compelling case for other health benefits of football, the burden of proof now lies with those who say the sport is safe. Until that proof has been delivered, orthopaedic surgeons—as advocates for the children and young adults whom they treat—should encourage families and their children to pursue other sports, and avoid tackle football.

Although concussions occur in many other sports, and some sports (including wrestling, women’s soccer, and women’s basketball at the collegiate level [32]) may have higher rates of concussion per athlete-exposure, football has properly come to attention because as a public-health problem, it causes vastly more concussions than do other sports. In fact, in that same large NCAA study, football caused about as many concussions over the study period as the next four sports put together [32]. Another large epidemiologic study found that football had both the highest concussion rate of any sport studied, and because of the large number of athletes who play, it caused by far the most concussions—nearly as many the next 10 sports on the list combined [18]. While other studies question whether football is at the top or merely near the top in terms of concussion rate [20], it is clear that in aggregate it causes far more concussions than any other US sport. Football stands out both because of the frequency and severity of the blows that can cause concussion, and the large number of children who are exposed to this injury because they play.

Exposing millions of children to an activity that may permanently alter the structure of their developing brains [23, 27] in the interest of “fitness” as some have suggested [15], is shortsighted and wrong. The fitness argument is further undermined by preliminary evidence that obesity is more common in youth football players than in normative samples of age-, race- and sex-matched children [17]. While that study had some shortcomings, we believe its main message likely is correct given that the finding persists in more diverse populations of football players as they mature in that sport, through high school [25], college [30] and even at the professional level [4]. Other serious health risks appear in football players at unusually young ages; one study found metabolic syndrome in nearly 20% of collegiate football players [30], and studies on professionals and retired pros found even-more severe health problems [14, 24, 29], despite those athletes presumably having the best access to trainers, dietary advice, and the ability to focus full-time on physical fitness. Metabolic syndrome, obesity, and carotid plaques simply do not come up in conversations about hockey, soccer, and basketball, and these findings cast additional doubt on the idea that football is an activity that improves the health of young men.

Other sports cause as many injuries, but injuries in football—including concussions but also other potentially life-changing orthopaedic injuries—are more likely to be serious or catastrophic [10, 22]. It is true that severe injuries and even deaths happen in many sports, and many are not caused by head injuries. But football is the only youth sport in the United States where the responsibility of the defensive player is to tackle the opponent to the ground. There are many other, better athletic opportunities for children, and surgeons should direct children and families towards them. Many other team sports provide comparable camaraderie, better cardiovascular and musculoskeletal fitness, and far less risk.

Concussion guidelines are good, but we are concerned that conflicting interests will limit their effectiveness; it may be too much to ask for coaches to bench their own stars, and at higher levels, it is not always clear for whom the team physician really works [12]. Education is helpful, but hard to maintain at a consistently high level even among medical professionals; it seems unreasonable to expect amateur volunteers to handle this vital issue safely. Besides—and this is critical—current guidelines and consensus statements from major organizations acknowledge major, critical gaps in the science [8, 13]. In the face of those gaps, we do not see how patients or their doctors can perform a fair risk-reward calculation when the downside risk is so devastating. We should not need proof to protect children from exposure to a life-threatening activity; we should require evidence to prove that the exposure is safe.

Decreasing contact in practice—an approach garnering some attention of late [3, 21]—does not seem adequate; indeed, one well-designed study suggested it may actually increase the risk of concussions in games [16] since tackling technique matters, and it must be taught and learned. In any case, concussion risk appears higher in games than practices [9]. While fewer hits to a developing brain seems better than more, small changes around the edges—like decreasing contact in practices—strikes us as insufficient given the potential harms involved.

Perhaps better helmets and equipment will help. But until they are available and demonstrated to be effective, and until they are affordable enough to be used by all [11], this approach is too hypothetical when the risk of getting it wrong may be permanent neurological impairment.

For a couple of years, participation in youth football was declining, but that trend appears to have reversed in the last year or two [1, 7]. Reports of the death of American youth football plainly are premature. Nonetheless, we need to protect our children better. It will be difficult to get good epidemiology on this problem; it is hard to imagine large autopsy studies of children’s brains assaying for deposits of β-amyloid or phosphorylated τ. But until good information is available, we should err on the side of safety. Unfortunately, the existing guidelines are written as though the goal is to return children to play [8, 13] where they are likely to be reexposed to recurrent head trauma [31], rather than what common sense seems to dictate: In the face of a potentially life-threatening harm, physicians should protect children from such exposures.

We are not anti-sport. We both have played sports at high levels, and we have children who continue to do so. But we do prioritize health and safety over a leisure-time activity. Children need our protection and our guidance; we believe that as physicians we are obliged and well positioned to advocate for them. Orthopaedic surgeons should look for ways to guide families and their children away from tackle football.

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Acknowledgment The authors acknowledge with gratitude the thoughtful suggestions of Lee Beadling, which improved this essay considerably.

Additional information The authors certify that they, or any members of their immediate families, have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or The Association of Bone and Joint Surgeons®.