Orthopedic surgeons should dissociate themselves from football at all levels of the sport rather than enabling an activity that carries a risk of brain injury, according to an editorial by senior editors of a Philadelphia-based orthopedics journal.
No team sponsorships, such as the marketing arrangement that the Rothman Institute and Thomas Jefferson University have with the Eagles. No standing on the sidelines. No performing sports physicals for high school and college players.
The authors of the piece in Clinical Orthopaedics and Related Research said their conclusion was prompted by a July study of the brains of deceased football players. In the brains of 110 of 111 men who had played in the NFL, researchers identified a condition called chronic traumatic encephalopathy — CTE — that is associated with memory loss and dementia. For those whose highest level of football was in college, this type of degeneration was apparent in 48 of 53 brains.
Orthopedic surgeons obviously would continue to treat injured football players off the field, said Seth S. Leopold, a professor at the University of Washington School of Medicine and the lead author of the editorial. But engaging in activities that directly support the game is "not consonant with the best values of our profession," he said.
No one knows how often football players develop CTE, as the telltale buildup of abnormal proteins cannot be detected in those who are still living. Nor can physicians say for sure how often it occurred among those who are already dead, as most families have not donated deceased players' brains for examination. Those that have done so are typically the ones with concerns about the player's behavior before death.
And the authors of the editorial acknowledge that brain injury is not their prime area of expertise. Still, the evidence from the July study, led by the CTE Center at Boston University School of Medicine, was enough, Leopold said.
"When we sat down to write this, it wasn't to convince anybody that we know everything there is to know," he said. "It was simply to make the point that with what little we know now, we have enough already to be really concerned."
The NFL and the league's players' union did not respond to requests for comment. The Eagles, the Rothman Institute, and Jefferson also declined to comment.
In November, the Eagles announced an eight-year extension of the team's long-running contract with Jefferson and Rothman, which is partly owned by Jefferson.
Financial terms were not disclosed, but such arrangements are common in many cities, with orthopedics centers paying pro and college teams for the right to advertise that they are team partners.
The Eagles-Jefferson-Rothman deal was described as a "fully integrated partnership" in the announcement. The health care institutions get "a strong branding presence at Lincoln Financial Field, which includes prominent messaging on the stadium's LED and video boards during Eagles games."
Rothman and Jefferson also get mentioned on TV and the team's website, and Eagles practice jerseys feature a Rothman Institute at Jefferson patch.
The announcement of the deal included this statement of support from Stephen K. Klasko, president and chief executive officer of Thomas Jefferson University and Jefferson Health:
"This has been a championship combination. Jefferson is fortunate to be a leader, along with the Eagles and Rothman Institute, in impacting the health and well-being of the community and caring for everyone from elite athletes to weekend warriors."
Leopold, editor-in-chief of the journal, said he anticipated it might draw objections on two fronts: first, that players might be worse off if orthopedic surgeons are not standing on the sidelines; and second, that the surgeons have an opportunity to promote safe play if they remain involved in an official capacity.
Regarding the first point, injured players are commonly stabilized and taken to the hospital by trainers and other personnel, not by surgeons, he said. "Nobody's doing surgery on the football field," he said.
As for the second, he agreed that it was important to promote research on safe play, but he said there was no evidence that certain kinds of helmets or rules changes would decrease the risk of CTE.
In the meantime, Leopold said, "we're continuing to run this experiment on human beings."
Though the odds of a football player's developing CTE are unknown, Leopold and his five co-authors cited an estimate of the minimum rate in pro football that was calculated by the New York Times. The newspaper divided the 110 cases by the number of all NFL players who died during the same period, roughly 1,300, for a rate of about 8.5 percent.
That method leaves out the unknown percentage of CTE cases among the living, which could be lower or higher.
Still, looking only at players who died is a reasonable way to "ballpark" a low end for the rate of CTE, said Chris Nowinski, a co-author of the study of players' brains. A formal study would require a detailed analysis of the changes in life expectancy and other causes of death over time, among other factors, he said.
Leopold and his co-authors began their editorial by urging members of their profession to ask themselves whether they should be involved in football, saying that "well-meaning individuals will disagree." That includes one of the journal's seven senior editors, who opted not to join in the editorial.
But the six who wrote it said that for them, the answer was clear: