ACADEMIA Letters The shifting media discourse surrounding head injuries in association football

Until recently, there has been a lack of significance placed on concussion in association football, particularly in mainstream media coverage. Contemporary incidents and research show that traumatic brain injuries, which may result in neurodegenerative disease, are common in football, but remain poorly understood. However, following the deaths of several heroised FIFA World Cup winning footballers, as well as a serious head injury to two players in 2020, a noticeable shift in media attitudes towards concussion and head injuries in sport has been detected.


Introduction
In recent years, there has been increasing academic attention focussed on sporting injuries, particularly within the field of the sociology of sport. Much of this focus has been on the impact of concussion on the health and welfare of athletes, with this attention largely driven by cultural conversations inspired by high-profile films such as the Will Smith movie Concussion, or documentaries such as Killer Inside, about NFL player Aaron Hernandez . Initially, concussion was a term that was used loosely in mainstream media coverage, with its significance downplayed. However, there has since been a move to refer to concussion as a traumatic brain injury, alongside recognition that it may be a potential risk factor of Chronic Traumatic Encephalopathy (CTE). As such, concussion has come to be been seen as one of sport's greatest challenges (Anderson & White, 2018). This paper discusses the media discourses associated with head injuries and concussion in association football (soccer), presenting preliminary observations of a shift in attitudes towards the seriousness of the topic, which reflects a move that occurred a few years earlier in American football (Anderson & Kian 2012). Taking an analysis of 2018 media framing of concussion in football as a starting point, initial comparisons from media coverage of head injuries and repeated head impacts are presented.

Head injuries in sport
The link between traumatic brain injury and neurological deficits has been studied for some time. For example, punch drunk syndrome -later described as pugilistic dementia and most recently identified as CTE -was first identified in the early 20th century amongst boxers (Russell et al. 2020). However, until recently, the primary focus of concern for concussion has been on American football. Nevertheless, consideration is now occurring in sports such as downhill mountain biking , rugby (Hill, Magrath & White, 2020), as well as association football (Roderick, 2006). Here, concussion often results from unintentional head impacts (e.g., head-to-head collisions), but a growing number of studies show that detrimental sub-concussive impacts may result from heading the ball (Di Virgilio et al., 2016;Levitch et al., 2018;Maher et al., 2014). Specifically, Di Virgilio et al. (2016) found that 20 consecutive head impacts from heading a standard football (weighing 400 grammes) resulted in immediate and measurable alterations in brain function. Furthermore, a large-scale study of former professional football players in Scotland found that, mortality from neurodegenerative disease was higher and dementia-related medications were prescribed more frequently in the former professional football players (Mackay et al., 2019). This latter study, funded by the Football Association and Professional Footballers' Association, received much media attention and was viewed as vindication by the families of a number of deceased former footballers who had argued that heading footballs during their playing career had led to the onset of dementia (BBC, 2019). Shortly afterwards, in 2020, a major shift occurred when the football associations of Scotland, England and Northern Ireland banned heading of the ball during training sessions for children until the age of 12 (MacInnes, 2020), following a move seen in America five years earlier.
Historically though, there has been a lack of significance placed on concussion in football in media coverage. White et al. (2020), in a study of media reports of a head injury sustained by Loris Karius, found that it was common for media reports to deflect attention away from head injuries and to display a general lack of understanding of concussion causes and symptoms. In addition, former players and those involved in the sport were often used as 'official sources' that downplayed concussion. For example, one ex-player was quoted as saying, "so many players have bumped heads. Could you go back retrospectively and go he was bit dazed?" (Mills cited in Amako, 2018).
Explanations for this disregard include that such injuries are contrary to the popular, hegemonic masculinity narratives surrounding sport (Cassilo & Sanderson, 2018) and that the media, as a stakeholder, wishes to protect the reputation of sport . However, recent incidents show that common traumatic brain injuries, which may result in neurodegenerative disease, and are now known to be common in modern football, are receiving greater media attention. Indeed, following the death of several heroised FIFA World Cup winning footballers in 2020, a noticeable shift in media attitudes towards concussion and head injuries in sport can be identified.

A turning point in football
In late 2020, three notable incidents served as the impetus for a shift in attitudes towards media coverage of head injuries within football. First, Norbert 'Nobby' Stiles, a member of England's 1966 FIFA World Cup winning team, passed away. Reports of his death made reference to the fact that he had been diagnosed with dementia and linked the cause of this disease to repeated heading of the ball in his career (BBC, 2020a;Jackson, 2020a).
Second, it was announced on 1st November that Sir Bobby Charlton, another World Cup winning hero, had been diagnosed with dementia. His brother, who played in the same winning team, had died earlier in the year after a battle with dementia. Charlton's diagnosis meant that five of the eleven starting players in the 1966 final had been diagnosed with neurological diseases. Media reports have linked all of these cases to the repeated heading of footballs during their playing careers (BBC, 2020b;Jackson, 2020b;Wilson, 2020) and a number have referenced Mackay et al.'s (2019) study into Scottish footballers (BBC, 2020b; Jackson, 2020b).
Thus, it appears that the loss of football (and cultural) heroes, as a result of their sporting efforts, has influenced the reporting on head injuries in football and also sparked further debate into the effect of repeated heading of the ball on brain health (Parry, Anderson & Hurst, 2020).
Initial observations suggest that, in all instances, traumatic brain injuries were a significant element of media reporting and the information presented on concussion and head injuries was more accurate than found by White et al. (2020). Significantly, the Daily Mail, a British tabloid newspaper launched a campaign, Enough is Enough, to draw attention to the link between football and dementia (Keegan, 2020). Here, former footballers, family members of players who died from dementia, as well as The Alzheimer's Society, called for a radical intervention into heading the ball in the sport. This campaign produced a 7-point charter calling for research into the link between football and dementia, limiting heading in training, alongside the recognition of dementia as an industrial disease in football. It drew supportive comments from a variety of current and former players and the current manager (Gareth Southgate) of the England men's national team (Keegan, 2020).
Third, a clash of heads that resulted in serious head injuries to two players in an English Premier League match between Arsenal Football Club and Wolverhampton Wanderers Football Club was widely discussed in the media (BBC, 2020c;Rathborn, 2020;Spiers, 2020). While one of the players (Raul Jimenez) was stretchered from the field of play with a fractured skull, the other, David Luiz, initially remained on the pitch despite sustaining a serious cut to the head (bleeding through the bandages applied to cover the injury) before being removed some time later -a move that drew widespread criticism and resulted in calls for the introduction of concussion substitutions (Ingle, 2020;PA Staff, 2020).
The response to Luiz's injury was of particular significance as players have previously been praised for remaining on the pitch following head injuries, including (in)famous cases where they have been bleeding extensively (Gadd, 2015). Athletes that sacrifice their bodies, often in ways that may be seen as deviant in broader society but are considered normative in sport (Anderson & White, 2018;Hughes & Coakley, 1991), have been heroised previously, and it has been found that both players and pitch-side doctors are complicit in the lack of concussion management within elite sport (Ruston et al., 2019).
The symptoms of concussion are "vague and heterogeneous" (McNamee et al., 2015, p. 193) and so diagnoses and prognoses are complicated and contested, allowing players to stay in the game following head injuries. Often, footballers may be pressured through a culture of risk to continue, regardless of the severity of their injuries and physical condition (Sanderson et al., 2017). Roderick (2006, pp. 18-19) notes: "athletes learn to disregard the risk of physical harm to normalize pain and injury as part of their sporting experience". However, in this most recent incident, the widespread media criticism of Luiz remaining on the pitch indicates both reporting and cultural shifts. Indeed, one former footballer, who had similarly played on while blood stained and bandaged, Terry Butcher, was critical of Luiz. Reflecting on his own decision to remain on the pitch, Butcher claimed that he now considered himself to be a "bloody fool" and far from heroic (cited in . The picture of Butcher, with his national shirt stained with blood, has been an iconic image of English masculinity and bravery (Gadd, 2015), so it is significant for him to claim that playing on following a head

Conclusion
In the two years between the 2018 Karius injury and the series of culturally significant events and incidents in 2020, there appears to have been a shift in media reporting on concussion and head injuries in football. Rather than downplaying the significance of head injuries and concussion, media reports now highlight the significance of these injuries and aim to educate readers on this issue. The criticism of David Luiz remaining on the pitch, following what was a significant clash of heads, is further evidence for a move away from heroising athletes for sacrificing their bodies in the pursuit of victory. Although further in-depth investigations of media coverage in football are needed to confirm these observations, it seems that the significance of head injuries and the potential dangers from heading footballs is now a feature of reporting.