Key words: Concussion; Brain Injuries; Youth Sport

Greek physician Hippocrates is widely attributed to saying, “The greatest medicine of all is to teach people how not to need it”. The 16th-century Swiss physician, Paracelsus, proclaimed that “Prevention is the daughter of wisdom”. In 1735, Benjamin Franklin wrote that “An ounce of prevention is worth a pound of cure”.  And an ancient Chinese proverb goes something like this: “The superior doctor prevents sickness; the mediocre doctor attends to impending sickness; the inferior doctor treats actual sickness”. 

Stretching far and wide across our history there has been a ‘golden thread’ running through medicine which points to prevention being better than cure. More specifically, primary prevention, being the aim of preventing disease or injury before either ever occurs. Given this context, it is curious that the current public health approach to managing brain injuries in children’s sport appears to defy this widely respected principle in medicine (1). 

Millions of children globally are exposed to entirely preventable brain injuries through participation in impact sports (i.e. contact, collision and combat).  In rugby and American football they tackle each other, in boxing they aim punches at opponents’ heads, and in football (soccer) they head the ball. Across these activities, the shaking of the brain that occurs is not an accidental outcome but built into the rules of the games. There is now more than a century of medical research linking this phenomenon to two distinct but connected problems (2).

Problem one is concussion – or more accurately, traumatic brain injury. These are among the most common injuries in youth impact sports, a direct consequence of rules that sanction heavy body contact. While often dismissed as temporary and transient, brain injuries can lead to lasting cognitive, emotional, and behavioural problems in some children, including persistent post-concussion symptoms that can last for months or even years (3). A history of traumatic brain injury is also strongly associated with increased suicide risk (4) .

Problem two is the accumulation of repeated head impacts, often starting from a young age. Even in the absence of diagnosed concussion, routine actions such as heading a football, tackling in rugby or sparring in boxing can cause measurable, but not always immediately observable, brain damage. For example, a major new study in Nature shows neuronal loss and inflammation in young athletes that had sustained repeated head trauma (5). Over a sporting career these impacts accumulate, and are now strongly linked to neurodegenerative diseases, notably chronic traumatic encephalopathy (CTE) (6,7). Recent neuropathological research has diagnosed CTE in deceased amateur rugby players (8), Australian male and female football players, and in former athletes under 30 years of age (9, 10, 11). 

Despite this ever growing evidence of harm, current policies in youth sport focus largely on recognising and managing injuries after they occur. This amounts to secondary and tertiary prevention, which solves neither of the two problems effectively. It’s putting the cart before the horse. Primary prevention – removing the elements of sport that cause brain injury – remains the missing piece at the youth level (adult sport is a different matter on account of the different legal, ethical and social norms applied to those over 18 years of age). 

Towards primary prevention 

Taking the reasonable step of enforcing primary prevention policies does not mean stopping children from playing sports. Safer alternatives already exist that preserve the potential health and social benefits of sport while eliminating unnecessary brain injuries. For example, authorities in football are already phasing out heading at youth level; rugby and American football have touch, tag, and flag versions; boxing can prohibit head shots; ice hockey can remove body checking (12). 

This preventative approach is supported by research showing that prohibiting body checking in youth ice hockey reduced traumatic brain injuries by 58% (13). Similar effectiveness would likely be seen in other impact sports, but, unfortunately, most governing bodies and leaders in the sporting industry have not yet taken such actions. 

Many children have died from entirely avoidable and preventable brain injuries in sport (14). Many more have been exposed to repeated head impacts that may have negative effects on their brain health in later life. Current policy and practice, and the sporting industry, is failing to protect children appropriately – and we, especially the medical community, should all be angry about that. Our children deserve better. Those not working in the direction laid out above would do well to take heed of a very old and very respected wisdom in medicine: prevention is always better than cure.

Author: Dr Jack Hardwicke, sociologist of sport and health. Nottingham Trent University, UK.  

References

1. Hardwicke J, Matthews CR, Parry K, Lang M, Walker D, Shaw M, Piggin J, Bullingham R, Hurst HT, Anderson E. Preventing sport-acquired brain damage in children: ‘If in doubt, sit them out’ on its own is not good enough. Performance Enhancement & Health. 2025 Aug 1;13(3):100340.
2. Casper, S. (2018). Concussion: A history of science and medicine, 1870-2005. Headache: The Journal of Head and Face Pain, 58(6), 795-810.
3. Pearce AJ, Tommerdahl M, King DA. Neurophysiological abnormalities in individuals with persistent post-concussion symptoms. Neuroscience. 2019 Jun 1;408:272-81.
4. Yang J, Brock GN, Steelesmith DL, Thompson AJ, Llamocca EN, Bridge JA, Fontanella CA. Association between concussion and risk of suicide among youth and young adults. American Journal of Preventive Medicine. 2025 Sep 23:108127.
5. Butler ML, Pervaiz N, Breen K, Calderazzo S, Ypsilantis P, Wang Y, Breda JC, Mazzilli S, Nicks R, Spurlock E, Hefti MM. Repeated head trauma causes neuron loss and inflammation in young athletes. Nature. 2025 Sep 17:1-0.
6. NHS. Chronic Traumatic Encephalopathy. https://www.nhs.uk/conditions/chronic-traumatic-encephalopathy/ 
7. Nowinski CJ, Bureau SC, Buckland ME, Curtis MA, Daneshvar DH, Faull RL, Grinberg LT, Hill-Yardin EL, Murray HC, Pearce AJ, Suter CM. Applying the Bradford Hill criteria for causation to repetitive head impacts and chronic traumatic encephalopathy. Frontiers in Neurology. 2022 Jul 22;13:938163.
8. Stewart W, Buckland ME, Abdolmohammadi B, Affleck AJ, Alvarez VE, Gilchrist S, Huber BR, Lee EB, Lyall DM, Nowinski CJ, Russell ER. Risk of chronic traumatic encephalopathy in rugby union is associated with length of playing career. Acta neuropathologica. 2023 Dec;146(6):829-32.
9. Suter CM, Affleck AJ, Lee M, Pearce AJ, Iles LE, Buckland ME. Chronic traumatic encephalopathy in Australia: the first three years of the Australian Sports Brain Bank. The Medical Journal of Australia. 2022 Feb 10;216(10):530.https://doi.org/10.5694/mja2.51420
10. Suter CM, Affleck AJ, Pearce AJ, Junckerstorff R, Lee M, Buckland ME. Chronic traumatic encephalopathy in a female ex-professional Australian rules footballer. Acta neuropathologica. 2023 Sep;146(3):547-9.https://doi.org/10.1007/s00401-023-02610-z
11. McKee AC, Mez J, Abdolmohammadi B, Butler M, Huber BR, Uretsky M, Babcock K, Cherry JD, Alvarez VE, Martin B, Tripodis Y. Neuropathologic and clinical findings in young contact sport athletes exposed to repetitive head impacts. JAMA neurology. 2023 Oct 1;80(10):1037-50.
12. Stewart W, Carson A. Heading in the right direction. Nat Rev Neurol. 2022 Oct;18(10):573-574. doi: 10.1038/s41582-022-00712-y. PMID: 35999472; PMCID: PMC9553957.
13. Davis GA, Schneider KJ, Anderson V, Babl FE, Barlow KM, Blauwet CA, Bressan S, Broglio SP, Emery CA, Echemendia RJ, Gagnon I. Pediatric sport-related concussion: recommendations from the Amsterdam Consensus Statement 2023. Pediatrics. 2024 Jan 1;153(1):e2023063489.

For a recent example, see https://www.judiciary.uk/prevention-of-future-death-reports/alexander-eastwood-prevention-of-future-deaths-report/#:~:text=CIRCUMSTANCES%20OF%20THE%20DEATH,unresponsive%20apparently%20suffering%20a%20seizure.