What Posthumous CTE Diagnoses Tell Us About Soccer Concussions

To understand how concussions may affect soccer players in the future, we have to learn from players in the past. There have been a handful of confirmed cases of CTE detected among deceased superstars, and what their brains reveal is startling, concerning, and crucial. Those findings could predict the outlook for those affected by many brain injuries. More importantly, it will offer some potential measures on how to counteract and reverse those effects.

Bellini

Position(s): Defender

Notable Team(s): Vasco da Gama, São Paulo, Atlético Paranaense

Age of Death: 83

A Brazilian-born defender of Italian heritage, Bellini (Hilderaldo Luiz Bellini), positioned himself as one of Brazil’s most effective defenders. He played his entire career in South America, and went on to win two World Cups, in 1958 and 1962. In his later years, Bellini was diagnosed with Alzheimer’s Disease, leading to complications and a cardiac arrest which led to his death on March 20, 2014. However, an examination of his brain led to a posthumous diagnosis of CTE, the second known case in the soccer world at the time.

Jeff Astle

Position(s): Striker, center-forward

Notable Team(s): Notts County, West Bromwich Albion

Age of Death: 59

Jeff Astle turned pro at seventeen, quickly scoring himself the title of one of England’s best strikers, “The King'' to be exact. He reached the height of his career at West Brom, where he played 361 games and scored 174 goals. Astle also appeared at the 1970 FIFA World Cup in Mexico. Toward the end of his career, injuries plagued him and his fitness deteriorated.

His post-retirement life was marked by tragic details of cognitive decline, including memory loss, decreased speech, and unintentional yet risky behavior. He passed away on January 19, 2002 due to choking. It wasn’t until 2014 that Astle was diagnosed posthumously with CTE via a neurosurgeon’s examination, making him the first known English soccer case. Astle was known as a prolific header, often heading the ball when it was soaking wet with rain water and thus heavier than usual.

Scott Vermillion

Position(s): Defender

Notable Team(s): Kansas City Wizards, Colorado Rapids, D.C. United

Age of Death: 44

The American-born defender stepped on the pitch as a talent to watch during the U17 World Championship in 1993, and then the U20 team in 1996. He retired in 2001 due to a leg injury. Vermillion’s life after retirement was a harrowing one. Friends and family members described dramatic personality challenges, including aggression and impulse control issues, along with depression.

He was arrested in 2018 for aggravated battery against his girlfriend, and spent years in and out of rehab for alcohol and prescription drug abuse. Vermillion died on December 25, 2020 due to acute alcohol and prescription drug poisoning at just forty-four years of age. An examination of his brain at Boston University in 2022 found significant brain degeneration, leading to a posthumous diagnosis of CTE.

Patrick Grange

Position(s): Midfielder/Forward

Notable Team(s): University Illinois-Chicago, University of New Mexico

Age of Death: 29

A notable player at the collegiate and semi-pro level, Patrick Grange was a standout from his high school days. He frequently headed the ball, and was known to suffer three concussions throughout his life, one of which led to him getting seventeen stitches. Unfortunately, Patrick Grange’s career and life came to an abrupt ending. In 2011, he was diagnosed with amyotrophic lateral sclerosis (ALS) at age twenty-eight, and died one year later at the young age of twenty-nine. A posthumous examination of his brain revealed stage 2 CTE, making the first known American player to receive the diagnosis.

Key findings

The obvious connection between all four players is that a CTE diagnosis came after death. At present, neurosurgeons have to examine brain tissue to find structural changes and deposits of tau protein that indicate CTE. This can only happen after a patient is deceased. But based on the trajectories of all four players, there are patterns that researchers now suggest can be used to suspect the disease before a player passes away. Take a look at some of these patterns below.

Summary of findings

• Misdiagnosed before death: All four players had alternate diagnoses before death, ranging from Alzheimer’s disease and dementia to ALS.
• Premature cognitive/physical decline: With the exception of Bellini, all players experienced issues ranging from memory loss and motor deficits at young ages.
• Personality changes: Jeff Astle and Scott Vermillion especially dealt with rapid shifts in personality and temperament. In Vermillion’s case, these changes may have contributed to criminal charges and substance abuse issues.
• Early death: With the exception of Bellini, all players died far younger than average.
• History of heading the ball/head impacts: Astle was known as a prolific header. Vermillion had some notable head injuries on the pitch, and Grange suffered three significant concussions in addition to being a frequent header of the ball.

Aside from early death, these patterns may show themselves relatively early. For example, Astle and Vermillion began experiencing rapid declines five to ten years before their untimely deaths. Even if doctors can’t make a diagnosis before death, they can assign a risk score or make a presumptive diagnosis based on a player’s history and current health.

Predicting the future

These diagnoses remind us that CTE is the ultimate form of repetitive stress injury a brain can suffer. Many hits sustained early in one’s career can have a ripple effect years later in one’s life. But the intent of presenting these cases and findings isn’t to be a scare tactic. It’s more about awareness.

With the exception of Patrick Grange, these stars played during eras when brain injury research was in its infancy. Today’s generation of players, coaches, and parents have plenty of tools and knowledge to empower themselves with preventative measures. We are the first generation that has an understanding of brain injury dangers but, more importantly, the power to reduce the risk of getting them.

So there’s hope. Of course, we can’t act like the risks don’t exist either. We think more needs to be done to protect players, especially now that the patterns are clear.

What researchers and doctors can do

• Monitor players for signs of early cognitive decline or personality changes
• Accelerate development of PET scans and other imaging that may detect CTE in living patients
• Rate players’ risk based on their injury history and current health

Taking ownership of brain injury protection

Currently, when it comes to reducing soccer concussion risk, players, coaches, and parents wield the power. As we mentioned above, the tools and knowledge to reduce brain injury risk already exist. A combination of training approaches, prevention protocols, and safety gear can make the pitch less risky to player’s brains.

Soccer headgear

We’ll start here because soccer headgear doesn’t get enough love. Soccer concussion headgear has existed for over two decades, and it’s only gotten better. Skeptics will say there’s not enough evidence to suggest their efficacy, but that’s untrue. Studies conducted by institutions, such as the Virginia Tech Helmet Lab, have found several soccer headgear models that can reduce concussion risk significantly.

Among them is our Storelli ExoShield headguard, which was rated as the most effective piece of headgear on the market. It demonstrated an ability to reduce concussion risks by 84 percent when tested in head impact simulations and is the only ASTM-certified headguard available.

Training protocols

Soccer conditioning drills aren’t reserved for boosting endurance, strength, or speed—they can do wonders for soccer concussion prevention as well. We’ve written plenty about research-backed exercises that may counteract the factors that lead to brain injuries. They include a mix of brain-based conditioning and physical work, such as:

• Neck strengthening exercises that build muscle mass and strength to increase shock absorption.
• Visual awareness exercises that help players spot opponents sooner to avoid head-to-head collisions.
• Header techniques that help players head the ball safely.

Preventative measures

Of course, there are habits and practices that raise concussion risks, so avoidance is key too. For example, there are bans for heading the ball in the under twelve crowd—coaches and players should adhere to that strictly. And even in older youth, reducing the amount of heading down in practice is a good idea.

And then there are head hits themselves. We can’t prevent all of them but anytime a player collides with another, they should be assessed immediately and sidelined. For players with recurring head hits and injuries, diagnostic imaging might be wise. Even if these scans can’t detect CTE, they might show alterations that may need monitoring in the future.

Looking back to move forward

CTE diagnoses among deceased players can seem frightening. It’s concerning because there are likely other players who will be posthumously diagnosed, and others who will develop this condition. But these tales and findings can be a warning message for current and future generations to prioritize concussion safety. We have the know-how, and it is only getting better as time passes. It’s up to us to make the necessary changes.