“I’m Worried They Will Come Back to Haunt Me”: Examining How Retired National Football League Players Make Sense of Concussion Risks

Abstract

This qualitative study examines how former National Football League (NFL) players retrospectively make sense of concussion risks post-retirement. Semi-structured interviews were conducted with retired NFL players (N = 10) who sustained at least one official concussion during their professional career. Guided by sensemaking theory and reflexive thematic analysis, themes were generated to characterize player attitudes toward concussion risks. Themes identified include concussions represent an invisible threat, concussions create more concern than other injuries, and head injuries change player outlooks on career longevity. Player strategies to mitigate concussion risks included avoid thinking about the risks by focusing on the moment or on the financial rewards, rely on teammates to look out for each other’s health, and recognize the fine line between valor and discretion. The findings inform risk communication efforts geared toward reducing head injuries in football, as players must balance competing goals of elite performance and sustaining their football career versus prioritizing their long-term health.

Keywords

sport risk concussions national football league sensemaking theory

On September 29, 2022, Tua Tagovailoa of the Miami Dolphins lay motionless on the field for 12 min after being slammed violently onto the turf (Lev & Yeung, 2022). After the hit, Tagovailoa’s fingers demonstrated a fencing response, an awkward position where a person’s arms or fingers display as unnaturally rigid and still (Miller, 2022). As trainers surrounded the quarterback, concern poured forth from players and fans on social media, noting Tagovailoa had now suffered two significant impacts to the head within a period of 4 days (Rivera, 2022). In response, the National Football League (NFL) and the Players’ Association updated the league’s concussion protocol following Tagovailoa’s injury and the subsequent negative publicity (Al-Khateeb, 2022). Although changes in the concussion protocol may benefit future players from experiencing similar harm, they cannot reinstate Tagovailoa’s health or retroactively prevent any potential damage to Tagovailoa’s brain function.

During the 5-year period from 2018 to 2022, an average of 202 concussions occurred per season in the NFL, including an increase of 18% between 2021 and 2022 (Seifert, 2023). Despite a lack of unanimity surrounding the risks associated with concussions, the negative effects of repeated impacts to the head remain incontrovertible. In February 2023, the Boston University Chronic Traumatic Encephalopathy (CTE) Center reported 345 of the 376 brains of former NFL players they examined showed signs of CTE (91.7%) (Boston University Medical Campus, 2023). CTE is a “progressive degenerative disease of the brain found in people with a history of repetitive head impacts” (Boston University CTE Center, 2023). In comparison, a control group of non-NFL players diagnosed only 1 of 164 (.6%) brains with CTE, with the identified case being that of a person who had played college football. Notably, brain bank samples of NFL players are subject to selection bias, with players who showed symptoms of suffering with brain damage far more likely to donate their brains for analysis. However, the alarmingly high rate of CTE diagnoses in the sample (i.e., 91.7%) is cause for concern for both current and retired players.

The purpose of this study was to examine retired NFL players’ perspectives on concussion risks. Guided by sensemaking theory (Weick, 1995) and the principles of reflexive thematic analysis (Braun & Clarke, 2019), we conducted and analyzed interviews with former NFL athletes to understand their attitudes toward concussion risks after their playing career is over. Each of the players interviewed for the study sustained at least one concussion in the NFL between 2010 and 2021, as indicated by official NFL injury reports. This study strengthens empirical understanding of how professional athletes navigate health risks, how communication shapes athletes’ risk perceptions toward head injuries, and how the uncertainty of head injuries adds complexity to players’ competing goals of athletic success and long-term health.

Review of Literature

Sport and Risk

Injury risk is an inherent element of elite sports (Fagher et al., 2016). The tolerance for risk within a given sport depends on athlete perceptions in that specific context (Fuller & Drawer, 2004), integrating perceptions of both risk and risk factors. Risk is “the probability or likelihood that a hazard will have an impact,” while a risk factor is a “condition, object or situation that may be a potential source of harm to people” (Fuller & Drawer, 2004, p. 349). For example, when athletes push themselves to their physical limit, they put themselves at elevated risk of injury (Bolling et al., 2020). In that case, the probability of harm (i.e., “risk”) increases due to the situational influence (i.e., “risk factor”) of the athlete pushing themselves to their edge. However, the identification that a risk exists does not reduce the potential for injuries. Reducing sport injuries is often an issue of risk mitigation, rather than risk awareness (Fuller & Drawer, 2004).

Concussion Risks

Concussions present a public health threat pertinent to athletes across all ages and levels of experience (Kerr et al., 2017). Although a relevant concern for many sports, concussions receive prominent focus in American football, as football is the sport with the highest incident rate for head injuries (Kerr et al., 2019). Furthermore, sustaining a concussion one time is associated with increased risk for additional concussion likelihood (Abrahams et al., 2014), as well as prolonged recovery periods following concussion onset (Guskiewicz et al., 2005). Experiencing a concussion, and particularly multiple concussions, often corresponds with negative long-term health outcomes for athletes (Kerr et al., 2018), emphasizing the need for research that examines how NFL athletes think about and respond to concussion risks.

Brain injuries have negative effects on cognition, well-being, and mood. For example, sustaining multiple concussions may reduce the brain’s ability to adapt to the changing oxygen needs during exercise (Sirant et al., 2022). Concussions can also affect athletes’ well-being later in life (Guskiewicz et al., 2005), including higher instances of depression and apathy (Montenigro et al., 2017). Head injury severity is also associated with increased cognitive impairment and cerebral blood flow alterations (Vedung et al., 2022). Furthermore, people who experience brain injuries may experience stigma or judgment for their cognitive limitations from other people, including family members (Turcotte et al., 2022).

Recovery from a concussion varies, and in some cases, lingers beyond the initial recovery period through post-concussion symptoms. Full-recovery from a single sport-related concussion typically occurs within 14 days, but athletes who sustain multiple concussions face extended recovery periods (Abrahams et al., 2014); and at least 10%–15% of concussed athletes display post-concussion symptoms for prolonged durations (Voormolen et al., 2018). Post-concussion symptoms may include fatigue, anxiety, dizziness, or headaches (Hiploylee et al., 2017). When dealing with post-concussion symptoms, memory loss and an inability to focus negatively affect athletes’ overall sense of well-being (Haarbauer-Krupa et al., 2021; Marklund et al., 2019).

The Uncertainty of Concussion Risks

Concussions, or traumatic brain injuries (TBIs), present an uncertain risk for professional athletes. The risks of a concussion and the potential negative health effects differ for each individual situation. First, it is uncertain if a concussion will occur, as many athletes play their entire careers without experiencing head trauma. Second, the negative effects of a concussion remain highly variable, as impacts to the brain area can differ in location, severity, and magnitude. Third, differences in the treatment of TBIs, along with the amount of rest and recovery time permitted for the athlete, can have sizable effects on athlete recovery and long-term health.

Despite the uncertainty surrounding these situational risk considerations, multiple studies suggest the rate of cognitive dysfunction is higher for former professional football players (Guskiewicz et al., 2005; Plessow et al., 2020). The findings, however, are not unanimous, and some studies report no significant differences between football players with or without a documented history of head injuries (Schaffert et al., 2022). This lack of consensus increases uncertainty for athletes, as the risks remain ambiguous and specific to individual situations, leaving players to make their own risk assessments toward the potential negative effects of concussions.

Sensemaking Theory

Sensemaking theory, as the title suggests, represents “the making of sense” (Weick, 1995, p. 4) by people as they look back upon decisions, behaviors, and events in their past. Sensemaking theory is a useful lens for situations in which people or groups experience “disruptions,” or the “input of new information” to their processing of prior events (Vigsø & Odén, 2016, p. 72). Athletes who played professional football have unquestionably witnessed disruptions to how media, fans, and team personnel discuss the risks of concussions during their time playing the sport. In the last decade, a multitude of reports have linked football participation with CTE, including the movie Concussion that brought head injury awareness further into mainstream media conversations (Vrentas, 2015). Furthermore, former NFL player suicides (e.g., Junior Seau) and tragic misbehavior (e.g., Aaron Hernandez) have been connected to CTE (Schweizer, 2018). Facing these types of disruptions, sensemaking theory argues that former NFL players will attempt to “structure the unknown” (Waterman, 1990, p. 4) by making sense of their situation through a process of identifying key factors that affect their perspective, and through framing, or “the viewing of stimuli through a particular lens or framework” (Hamel, 2009, p. 237).

Weick (1995) identified seven properties that typify sensemaking, each of which can relate to how retired NFL players make sense of concussions risks after the end of their playing career. First, sensemaking is retrospective, indicating that individuals make sense of events after their completion. Second, sensemaking is ongoing, as the receipt of new information can influence present and future interpretations of events (Dougherty & Smythe, 2004). Third, extracted cues reflect that a person may place an emphasis on particular pieces of information that influence their perceptions of reality, rather than a comprehensive assessment of all the possible information (Dougherty & Smythe, 2004). Notably, this process of selecting particular information can demonstrate personal bias in the form of people extracting cues consistent with their existing worldview (Dougherty & Drumheller, 2006). For instance, when people emphasize information that aligns with their current opinions, or when they seek out evidence that supports an argument that they want to be true.

Weick’s properties of sensemaking highlight the dynamic nature of how people make sense of prior events. The fourth property of sensemaking is that it is social, as perceptions of reality are subject to influence from an implied, imagined, or actual public (Craig-Lees, 2001). Similarly, the fifth property, identity, stands not in isolation, but rather remains embedded in the interactive nature of society. Specifically, identity reflects how the person sees themselves in relation to others, as the property of identity is formed through communication and interaction. Sensemaking processes affect not only the individual, but through social interaction, also contribute to the process of establishing cultural group identities (Dougherty & Smythe, 2004).

The sixth property, enactment, reflects the dynamic and reciprocal nature of communication behaviors in creating constructions of reality. Enactment indicates that people not only receive information from peers and their social environment, but that they simultaneously produce their social environment through active communication (Weick, 1995). Finally, the seventh property, plausibility, argues that sensemaking is based on plausible, rather than verifiable, accounts of events. In this way, the factual accuracy of an account remains immaterial, so long as the person’s account is plausible in the given context. Plausibility speaks to the importance of people’s reflections on events, rather than the establishment of an objective reality, as these personal reflections inform the person’s worldview and beliefs.

Current Study

This qualitative study asks retired NFL players to retrospectively make sense of the concussion risks they experienced while playing professional football. The findings from this study can inform risk communication efforts geared toward preventing player injuries, specifically head injuries, and increase understanding of former players’ perspectives on head injury risks and potential strategies for mitigating risk. To be effective, risk communication must “understand the ways in which people think about and respond to risk” (Slovic, 1987, p. 280).

With research indicating adverse health effects of sustaining a head injury during sport (Kerr et al., 2017; Sirant et al., 2022), it becomes necessary for empirical work to examine player attitudes toward concussion risks and player perspectives of experiencing concussion injuries. Qualitative analyses help to provide context and comprehension to athlete mindsets and to the perceived effectiveness of injury prevention protocols (Jack, 2006). Qualitative analyses of athlete attitudes toward injuries can also expedite the development of effective injury prevention, rehabilitation, and communication-based intervention efforts. Furthermore, engaging athlete perspectives on injuries is vital for understanding athlete risk perceptions and creating effective return-to-play guidelines (King et al., 2019; Shrier, 2015). Thus, we propose the following research question:

How do retired NFL players retrospectively make sense of concussion risks?

Method

Participants

The criteria for participant inclusion included that the person played professional football in the NFL between the years 2010–2021, the player was retired from the NFL at time of data collection, and that the player was listed on the official NFL weekly injury report with a “concussion” at some point during their career. Ten former NFL players were interviewed for this study (N = 10). We contacted more than 300 former NFL players requesting interview participation. Of these players, 10 affirmative responses were received, and we scheduled interviews with those players. The low affirmative response rate reflects the lack of financial incentive available to offer participants, as well as a stated unwillingness by some potential participants to discuss concussion risks and head injuries in the NFL. The vast majority of potential participants did not respond to our initial request. Four potential participants agreed to interviews but did not respond to follow-up messages. One potential participant responded with a simple “No.”

Ages of the participants ranged from 27 to 40 years (M = 33.5, SD = 4.48). Participant experience in the NFL totaled 62 seasons collectively, with a range for individual participants of two seasons to 11 seasons (M = 6.2, SD = 2.62). On-field positions represented in the sample included defensive end, running back, fullback, long snapper, wide receiver, cornerback, and linebacker. The sample included players with draft positions ranging from first-round picks in the NFL draft to undrafted free agents. Participants in the study were retired for an average of 5.7 years (SD = 2.63), with a range of 1–9 years since the player retired from the NFL.

Participants did not receive compensation for participating in the study. To maintain confidentiality, participant names have been replaced with pseudonyms for this analysis.

Procedures

The study procedures were approved by an internal review board (IRB). Participants provided informed consent prior to data collection.

To recruit participants, we employed purposeful sampling (Creswell & Creswell, 2017) in effort to select participants with experience relevant to the study’s research question. Specifically, we reviewed the NFL weekly injury reports for all weeks between the seasons of 2010–2021. Then, we compiled a list of players described as being injured with a “concussion” on the injury report. Following compilation of that list, we searched for publicly available contact information for each player. We contacted potential participants who met the study criteria via social media (e.g., Twitter, Instagram), introduced ourselves as researchers, and asked if they would be interested in speaking with us for the purposes of this research.

The interviews were conducted using a semi-structured, open-ended question format. Interview questions were brainstormed initially by examining related research on athlete risk perceptions, athlete motivations to play through injury, injury influences on athlete well-being, and communication factors that affect athlete experiences. The initial list of 37 questions was then debated and refined by the authors of the study, until the protocol was finalized. The finished protocol included 15 questions across a variety of topics, including athlete motivations to play through injuries, athlete approaches to injury risks, the influence of coach communication, perceptions of the NFL culture toward injuries in general and concussions specifically, the players’ attitudes and concern for concussions and head injuries, and player perceptions of teammate influences on willingness to play through injury and player desires to preserve their health status. As relevant topics emerged during the interviews, the authors asked follow-up questions as necessary (Tracy, 2020).

Interviews were conducted via telephone or Zoom, depending on participants’ preference. Interview length ranged between 19 and 61 min (M = 31.42 min, SD = 12.83). All interviews were audio-recorded and then transcribed by the authors of the study. The interview transcripts generated 78 single-spaced pages, with a total of 37,684 words of data for analysis.

Data Analysis

To analyze the data, we employed reflexive thematic analysis (Braun & Clarke, 2019), an analysis process that accents the importance of reflexively thinking about the data throughout the analysis process in effort to highlight participant experiences accurately and to generate themes that tell the story of the data. Toward this goal, we first sought to familiarize ourselves with the entire dataset to become familiar with the experiences of the athletes. We then engaged in open coding of the data, where individual units of analysis (i.e., each unique participant phrase) (Charmaz, 2014) were given a code, or label, to represent the participant perspective of that utterance. During the open coding process, we placed an emphasis on using “in vivo” codes, or codes that use the participants’ own language, whenever possible. Using in vivo codes helps to “preserve participants’ meaning of their views and actions in the coding itself” (Braun & Clarke, 2006, p. 55). Once the initial codes were created, existing codes were compared to each other, edited for clarity, and combined when overlap existed to encapsulate categories of similar codes.

Having created codes for each unit of analysis in the dataset relevant to the research question, we then reviewed the individual codes and their overarching categories in effort to identify the core ideas that reflect participants’ perspectives (Lindlof & Taylor, 2017; Tracy, 2020). In doing so, we sought to generate themes, or “stories about particular patterns of shared meaning across the dataset” (Braun & Clarke, 2019, p. 592). Themes were created by identifying relationships between codes and categories that spanned across participant responses. As part of the reflexive thematic analysis approach, themes were edited through an iterative process, with similar themes being grouped together and removing themes with minimal support across participant data. We then proceeded to refine the labels of each identified theme to best portray the narrative of the dataset, as effective themes tell a story of participant experiences (Braun & Clarke, 2006). Once themes were generated, we identified exemplars of each theme, or “particularly vivid examples” (Braun & Clarke, 2006). To provide a form of analysis validation, we present multiple participant quotes to depict each theme, a validation process specified as “thick, rich description” (Creswell & Miller, 2000, p. 128).

Results

Following reflexive analysis of the data (Braun & Clarke, 2019), themes relevant to the research question were generated. The themes describe a multitude of challenges associated with head injuries for professional athletes, including the difficulty of managing an “invisible” injury, how sustaining a concussion can change athletes’ perspective on career longevity, and the players’ shift in prioritization of keeping their head safe above everything else. Players in the current study further described concussions as mentally and physically draining, as a generally terrible experience, and that sustaining a concussion increased isolation and separation from their teammates. In addition, results indicate that athletes sought to reduce their concern for concussions risks by focusing on aspects of the game that they do control, by relying on teammates to look out for each other’s best long-term health interests, and by seeking to thread the needle between courage and irresponsibility with regard to playing through injury.

The themes are presented within two broad categories: concussion risk perceptions and concussion risk mitigation strategies. Each of the themes generated during data analysis are supported by verbatim quotes from participant data to illustrate each theme.

Concussion Risk Perceptions

Concussions Represent an Invisible Threat

Participants in the study noted the difficulty of managing an injury that you cannot see. As Keith, who played the position of fullback, mentioned,

You don’t know really how bad a concussion is. How do you grade a concussion? Nobody can, there’s no scale. People when they get cut, they’re like, “oh I got 50 stitches.” They know it’s a bad cut. But with concussions, it’s like, it’s so fuzzy.

In this statement, Keith indicates the challenge of measuring the magnitude of the concussion. Similarly, Alexander, a defensive lineman, said,

Early on in my career it wasn’t that guys didn’t want to report concussions. Guys didn’t know from their own diagnosis that they had potentially been concussed. The narrative was “I got my bell rung.” So now, once I got my bell rung turned into, “Oh, you could potentially be concussed,” then it became a whole different thing.

Alexander’s statement emphasizes how players themselves had to adjust from a normal-for-football hit where they felt like they had “their bell rung” into recognizing the gradations of hits to the head that can signify a more concerning head injury. Describing how he was not sure how to measure a concussion’s magnitude, but simply that it was a terrible feeling, Stephen, a running back, said,

It’s dangerous. It sucks. It’s such a sucky position to be in. It’s terrible, it doesn’t feel good. It’s time consuming. You can’t do anything. It kind of shuts you down all around. It’s draining, it’s very physical, very mentally draining. It sucks.

Speaking further to the uncertainty posed by concussion risks, Nicholas, a defensive end, mentioned,

I think the scary thing with concussions is I don’t really know, like what role that’s really going to play, or what effect that can have on me when I’m older. And I think that’s why it kind of gives a lot of players pause. And I mean, it has with me. So I think that’s something that I’m always going to kind of look at a lot differently.

In this statement, the future uncertainty of concussion effects gives Nicholas pause and led him to think more deeply about the risks. Further noting the uncertainty of concussions and stating how they are an injury that can go unnoticed due in part to the pomp and circumstance that comes with playing in the NFL, Keith said, “Football comes with a big, you know, ticker tape parade and all that. So it’s kind of like, yeah, it’s one of those things that can slide under your nose. It’s not cancer.”

Concussions Create More Concern than Other Injuries

Players interviewed for this study noted their increased level of concern for concussions, relative to other injuries. As Alexander stated,

When a guy says, “Oh, I can’t play because I got a poor hammy.” Like, you laugh. It’s like, what you mean? My hamstring is tight too, you know? But once you get a real concussion, not like your bell rung or a minor one, but to where you have behavioral changes, it really wakes you up. And I felt like for probably about a week, I wasn’t right. It was something that I didn’t really want to go through again.

Elijah, a wide receiver, furthered this notion that concussions created more concern than other injuries, as he said,

It’s your brain. For me, that was always something I was worried about. That’s how you function. That’s how I think. That’s how I am able to do anything that I can do. So for me, if I don’t have my right mind, anything else I can deal with. I can deal with knee, arms, toes, whatever else it may be, elbows. But brain? That’s always been scary to me just because of how serious it is. You can get a knee replacement. You can get your bone fixed. I’ve never heard of no brain replacement.

Nicholas echoed a similar sentiment, indicating that concussions concerned him much more than other injuries, saying,

Definitely, definitely more. The way I look at it is, all injuries, I mean they take a toll on your body. But even with something like when I tore my Achilles, I rehabbed it and went through everything and I feel like I know kind of what to expect down the road. But I had one concussion and after that I was like, okay going forward, this is going to have to be like a discussion if I have any more going forward. Like, how do I want to approach this?

In this statement, Nicholas described how other injuries, even serious ones such as a torn Achilles’ tendon, have an aspect of predictability to them, where the player knows what to expect moving forward. With head injuries, however, their unpredictability leads to greater concern and internal consternation for the athlete. As one player succinctly stated, “For me, I got out of the game, because I started to prioritize my head over everything.”

Head Injuries Change Player Outlooks on Career Longevity

Interview participants described how head injuries caused them to pause and consider the effects of head injuries on career longevity. Specifically, incurring a head injury led to a changed perspective on their priorities and career. As Alexander described,

I had two big concussions that really changed my outlook on everything. And I just felt like football wasn’t my best skill in life. It was like my third, fourth, or fifth best skill. And so to risk not being able to do my top three skills because of a concussion, when I had already got a degree and made a couple of million dollars, it just didn’t make sense to me anymore. I felt like my plans off the field were better than what was going on on the field. And so I left. I was 27.

Retiring at age 27 may sound ideal for people who dislike their profession, but for an athlete who has spent their energy chasing a goal to play in the NFL, it represents a surprisingly young age for a person to elect to move on to other pursuits on their own accord.

Alexander was not alone in his perspective, as Jake, a linebacker, described how his perception of concussion risks changed over the course of his career. When asked if having a concussion changed his attitudes toward playing football, he said, “Early on in my career, no. Later on in my career, yes. There became a point in time where I had to seriously consider if I wanted to continue to play.” He went on to say that early in his career, he considered concussions to be part of the price of admission to playing in the NFL, saying that concussion risks were “part of my position, and my DNA, and who I am as a player. Concussions was, to me, a part of the game. That’s how I viewed it. Towards the end of my career, the concussion protocol changed dramatically.” Later in the interview, Jake returned to this idea, saying,

Concussions, when I was in high school, when I was in college, it really wasn’t a thing. It really didn’t concern me that much. I really wasn’t concerned for my future when it came to concussions. But I will say towards the end of my career, you know, it was something that it made me stop and think, “Okay, this is something I want to make sure I take care of later on in my life, so I can have my sanity.” You know, so that all the legacy and the wealth that I had built for my family is not destroyed simply because, you know, I’m chasing and trying to further my career.

In that statement, Jake describes his desire to continue playing and to chase his goal of a long-term NFL career. Although other injuries he sustained did not cause any concern, the build-up of multiple concussions over the course of his playing career led to increased worry that he would not be able to enjoy the wealth and the family he had built during his playing days. Similarly, Nicholas stated,

It was never really like, oh, I need to I need to watch this to make sure I’m good for when I’m older. I was just playing and having fun and enjoying it, and I never really worried about the long term, or how it could affect my health down the road. I’d never had anything that kind of made me have pause and think about that. But I did have a concussion at one point. Those things kind of stop you and make you think, I need to monitor stuff like this to make sure that I’m going to be good, whenever football is done in the years that come afterwards.

Concussion Risk Mitigation Strategies

Avoid Thinking About the Risks

As concussions can be outside of your control, participants in the current study noted their strategy of avoiding thinking about the risks and to focus instead on the moment. As Elijah said,

I think that when you’re in the moment, you don’t think about it. You don’t think about the after-effects. You don’t think about what can happen after football. But the reality is the average career is 3–4 years, and your life after is going to be a lot longer than your NFL career. Depending on what you’ve dealt with in the past, not just the NFL, in high school, in college. Some guys play little league. That stuff, as you get older, it lingers, and it comes back to haunt you in ways that you don’t even realize.

Nicholas echoed these sentiments, as he described, “I think it would be hard to be able to focus on being out on the field, if I’m thinking, whether it’s directly or subconsciously, about the effect that all of it can have on me.” Nicholas later expanded on a similar idea, noting,

In my experience, it’s something where, like I know the risks of it, and I think it’s not something I tried to dwell on, until it’s something that, like, I’m specifically confronted with. That’s a lot of, probably, a lot of other players’ viewpoints towards it. Like if I was guy who has never had a concussion, I’m not going to sit there and think about like the risk of a concussion.

Other players noted similar thoughts, but instead of focusing on the moment, they focused on the benefits and wealth that playing professional football provided. Stephen, a running back, said,

The reward is that you hope that one day that you have a chance to play in the NFL, that you give yourself the opportunity to make it that far. It comes with getting concussions as a little kid and not knowing you got a concussion and just saying you have a headache. It starts young.

Mark, who played long snapper, described the influence of financial incentives on reducing concern for risks, saying,

We talked about injuries, but we never really weighed the risk. The amount of money we were making playing this game far outweighs the risk of getting hurt.

As some players discussed focusing on the moment or on the money, other players highlighted the importance of teammates looking out for each other in effort to minimize health risks.

Rely on Teammates to Look Out For Each Other’s Health

Nicholas described how players would proactively look out for each other if they were showing symptoms of a head injury. He said,

Players would definitely come to somebody if they were trying to play through something that’s like, definitely not a good idea to do, players would come, and I’ve seen it where a player comes, like “Hey, like, that's not a good idea, like you need to chill and take a rest,” whether it be a serious bodily injury, or like, a muscular, or skeletal injury. Or definitely if it’s a concussion.

Alexander furthered this notion, describing how teammates would recognize when a player was trying to come back too quickly from a head injury, describing,

I know players who have tried to come back a little early and teammates are like, “Hey like you need to, like obviously bro, you need some more time. Like, don’t. I know you’re trying to get back ASAP but don’t rush it. You got to protect like your brain and your mind for all the years to come.

As players indicated the importance of social communication and teammates looking out for each other, participants also noted the importance of knowing your own limits.

Recognize the Fine Line Between Valor and Discretion

Jake described the importance of knowing your own limitations, as well as the consequences that can come from pushing the envelope too far. Speaking about challenging limitations, he described wanting to play through injury at all costs, saying,

No doubt. That’s that competitor’s mindset. But I do, you know, as I’ve gotten older, I do believe that there’s a fine line. There has to be a fine line. You want to push your body to the limit. But at the same time, there has to be a fine line of when too much is too much.

Jake’s recognition of needing to understand the line between pushing yourself adequately and giving far too much is rooted in that he admitted concussion symptoms are something he struggles with regularly. He noted his symptoms and then his concerns, as he stated,

So, concussions, that’s definitely been something that I’ve suffered with for some time. And, it worries me. I’m not gonna lie, it worries me if later on down the road in life that it’ll come back to haunt me. But for the most part I feel fine. I feel fine. I don’t feel any symptoms or anything. I do sometimes have trouble with memory loss, you know, I don’t remember specific details. You know, but for the most part I feel I feel like I have my mind. I feel like I’m stable. I guess I should say, still to be determined.

Jake’s candid description of his struggles with concussion effects, combined with his hope toward an uncertain future, offer a reminder to fans, media, and current players of the sacrifices that are made for the sport of football beloved by many.

Discussion

The purpose of this study was to investigate how retired NFL athletes’ make sense of concussion risks. Through the lens of sensemaking (Weick, 1995) and reflexive thematic analysis (Braun & Clarke, 2019), data analysis generated themes to describe the former players’ attitudes toward the threats posed by head injuries, as well as strategies the players employed to mitigate concussion risks or to simply minimize the players’ concern toward concussion risks. During the interviews, players spoke to the challenge of mitigating an “invisible” threat, the importance of social communication and looking out for teammates to help them prioritize their long-term health instead of returning too quickly from concussion onset, and the candid concerns expressed by players that the concussions they sustained in the past will continue to affect them in the future. These results emphasize the need for risk communication efforts to develop strategies that both reduce physical risk probability and also curb player anxiety toward the negative effects of head injuries.

Open communication about injuries between teammates and coaches can facilitate successful injury prevention (Bolling et al., 2020). Players in the current study described how teammates looked out for each other, indicating the importance of communication between members of the team, and particularly between members of the same position groups (e.g., wide receivers, defensive lineman). Coach communication and team culture affect injury reporting by NFL players (Cassilo & McGlynn, 2023), highlighting the influence of team dynamics and communication factors on athlete well-being and health outcomes. On the contrary, ineffective or nonexistent communication within a team can result in increased injuries (Ekstrand et al., 2019), specifically with regard to load management and injuries resulting from overuse (Dijkstra et al., 2014; Sporer & Windt, 2018).

For concussion-related injuries, it is difficult for athletes to have load management conversations, as concussion recovery may require complete rest for an extended period. Lengthy recovery from injury can increase player feelings of isolation (Cassilo & Sanderson, 2019), as the injury and subsequent solitude precludes the athlete from contributing to team success. To combat the likelihood of players returning too quickly from concussions, coaches and team leaders must emphasize the importance of brain health as the primary goal, even over team performance. Notably, this mindset shift contrasts with established sport goals of performance over everything in elite sport settings (Bolling et al., 2020). Nonetheless, with regard to players’ brain health, prioritizing prevention of further harm above team performance remains an important shift in mindset for players, coaches, and the team collective.

Participants in the current study noted the negative effects of subconcussive hits to the head, even though media outlets tend to focus on big collisions that lead to players being knocked out or unconscious (Jeckell et al., 2023). However, many positions on the field, such as fullback or offensive line, sustain repeated small or relatively minor hits to the head that add up over the course of a game or a playing career. Subconcussive hits to the head may represent an underrated risk for athletes in collision sports (Vos et al., 2018), as length of playing career for NFL athletes is associated with reduced attentional performance, independent of individual concussion history (Toepper et al., 2022).

Concern for players’ health remains elevated for many fans and stakeholders following reports of negative player health after retirement, with some stakeholders going so far as to question the ethicality of supporting professional football (Coaston, 2023). Still, popularity of the NFL remains robust (Draper, 2022). While some fans point to the sizable financial compensation garnered by NFL athletes, it is important to note that the risks of CTE are not exclusive to professional athletes. College, high school, and even youth athletes can experience negative cognitive effects incurred by repeated hits to the head and brain area (Nowinski, 2023).

Prevention of Sport-Related Concussions

Despite recent efforts and renewed focus from teams, injury prevention strategies in elite sport contexts remain suboptimal (Bahr et al., 2015; Lindblom et al., 2018). Injury prevention in professional sports presents a layered problem, with an understanding of context and process required to aid injury prevention (Bolling et al., 2020). Professional athletes understand that pain is part of their profession (Cassilo & McGlynn, 2023), and many remain willing to risk injury to increase performance (Bolling et al., 2020). Increased awareness of the need for education on injury prevention remains a key emphasis in sports health, as athletes who receive guidance from trainers and team staff on the importance of injury-prevention processes experience the best outcomes (Bonell Monsonís et al., 2021). However, athletes often do not want to consider the possibility of injuries for a number of reasons, including not wanting to introduce negative thoughts to the locker room or simply wanting to focus on efforts to reach peak performance in their sport (Cassilo & McGlynn, 2023). The prevention of sports injuries is a learning process for all sport stakeholders, with the most effective prevention-centric practices emphasizing consistent communication between athletes, coaches, and trainers (Bonell Monsonís et al., 2021).

Practical Applications

Given the retrospective perspectives provided by the retired players in this study, age restrictions of tackling in youth football should be considered with increased seriousness. Although many parents support age restrictions for tackling, particularly highly educated female parents (Chrisman et al., 2019), more work is needed to pursue attitude changes among coaches, league organizers, and players themselves. The viewpoints provided by participants in this study can perhaps nudge youth football stakeholders to consider more seriously the possibility of banning tackling practices until high school. Championing this effort to eliminate tackling in youth football is the campaign started by the Concussion Legacy Foundation, aptly titled, “Stop hitting kids in the head” (Concussion Legacy Foundation, 2023). The concern for head injuries expressed by retired NFL players should propel the impetus for reducing or eliminating tackling and excessive contact in youth football leagues.

Proponents for eliminating tackling in youth football should note that parents allow children to play tackle football for a variety of reasons, including family identity and the experience of social benefits. Family football identities are cultivated at young ages, particularly in regions of the United States where football fervor is commonplace (Boneau et al., 2020). Social benefits of football participation, including team camaraderie, further motivate football enrollment (McGlynn et al., 2020), as does parental trust in helmet technology and equipment advances that attempt to reduce concussion risks (McGlynn et al., 2023). However, media narratives of concussions can induce negative emotions and increase parent likelihood of discussing concussion-related risks with their children (Tallapragada & Cranmer, 2022). Taken together, proponents of eliminating tackling in youth football should emphasize that football identities can still be maintained through safer forms of play, that social and community benefits of football participation can be achieved despite reduced contact, and seek to highlight media coverage on concussion risks, particularly in youth sport settings.

Caregivers and spouses of former football players regularly seek mediated information concerning TBIs and CTE (Ott et al., 2022). Specifically, caregivers often turn to social media for brain health information, as they rate social media as a “highly credible” source for such knowledge, despite the noted dissatisfaction from those same caregivers toward league-sponsored websites and online information presented by physicians and healthcare providers (Ott et al., 2022). Notably, former NFL players describe general distrust toward league officials regarding brain health, indicating skepticism that the league truly has their best interest in mind when instituting rule changes designed to make the game safer (Cassilo & McGlynn, 2023). The tendency for caregivers to seek out CTE-related information through social media channels, rather than official league-sponsored websites, illustrates the importance of providing accessible and updated health information to athletes and their caregivers via social media channels.

Limitations and Future Research Directions

This study has limitations that warrant consideration. First, this study analyzes data from a small sample, due to the difficulty of recruiting participants who met the criteria of having played in the NFL between the years 2010–2021, had sustained at least one officially documented concussion on the weekly NFL injury report, and who were willing to be interviewed for the current study with no compensation. As such, these results should not be generalized with the assumption that the current findings represent the attitudes of the entire former NFL player population. Future work should seek to build on these findings by collecting data from a wider, larger, and more representative sample of former NFL players. Second, we emphasized interviews with athletes who had played during the 2010s, as this era marked a time where the NFL displayed notable changes in philosophy toward head injuries (Cassilo, 2021). Although players in our study had been retired for an average of 5.7 years, their perspectives may not mirror those of athletes who played prior to 2010. Collecting data from athletes who retired prior to 2010 may yield further insights on former NFL players’ retrospective attitudes toward head injuries and effective mitigation strategies.

Third, although we made efforts to recruit a diverse sample, including diversity in position group, draft status, and demographic characteristics, the current investigation is unable to contrast or compare factors such as NFL position group, player ethnicity, or other demographic factors, such as player age, within the current analysis. Race and demographic information can influence NFL players’ assessment of personal health risks and perceptions of cognitive decline (Walton et al., 2022). Future studies should seek to account for factors such as player race and ethnicity, career earnings, and incoming draft status (e.g., first-round pick vs. undrafted free agent), as players in the current study described how roster spot security and financial incentives can motivate player risk-taking. Risks and benefits display a mutual influence (Slovic, 1987), and as financial incentives rise, players may, in turn, illustrate higher levels of risk tolerance in relation to the benefits of continuing to play. Future work should seek to evaluate the external rewards that motivate athlete risk-taking, and the communication factors that influence players to tolerate physical injury risks, despite the negative effects on their long-term health.

Conclusion

Concussions present a persistent and pernicious risk for athletes. This study examined how former NFL players make sense of concussion risks after their retirement. Players in the current study described the challenges of managing an “invisible” injury that cannot be measured the way other injuries can, that concussions concern them more than other injuries they sustained, and that incurring a concussion caused them to ponder their career longevity. Athlete efforts to mitigate concussion risks included social communication and relying on teammates to help each other prioritize their long-term health, as well as to avoid thinking about the risks by focusing on the moment or on the financial incentives. Although the paychecks and perks of professional athlete status stop arriving after retirement, health concerns linger beyond the end of their playing career. The current findings emphasize the persistence of concussion concerns that retired football players confront, as they face an uncertain future with potential susceptibility to consequent health risks.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Joseph McGlynn

David Cassilo

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