Near the end of the high-school football season a few years ago, John Pizzi realized he had a problem. Because of season-ending injuries, the football team at Riverdale Country School, the New York private high school where he is the athletic director, did not have enough kids to finish the season.
He canceled the team’s last game and then called Chris Nowinski, the CEO and co-founder of the Concussion Legacy Foundation, who has been talking for years about the need to better protect athletes of all ages from chronic traumatic encephalopathy (CTE), the degenerative brain disease caused by repeated hits to the head.
“I said to him, ‘You have to help me: football is either not going to continue here or we have to figure something out,’” Pizzi says.
Nowinski dove into research and looked at how Riverdale and its sports league, the Metropolitan Independent Football League, might tweak the game so that players were injured less frequently. He found there were some easy wins—research had found that college kickoffs in the Ivy League specifically made up 6% of plays but 21% of concussions, so getting rid of kickoffs could help easily avoid some injuries—and put together a presentation with about a dozen suggestions.
Some of the changes were minimal, like limiting teams to 6 hours of full-contact practice in the preseason and 20 minutes per week in the regular season. Some were bigger, like eliminating kickoffs. Pizzi and Nowinski presented the ideas to the league and then to parents, and though many people were skeptical, most understood that they needed to do something to get participation up and injuries down. So they decided to try out the new rules.
Their changes were extremely unusual outside of the world of professional football. Although the NFL, pushed by the players’ union, has made some significant changes in recent years to try to reduce head injuries, youth leagues like Pop Warner, the National Federation of State High School Associations (NFHS), and even the NCAA have done very little.
“Everybody in football is aware of what the NFL has done and has made an active choice not to follow,” Nowinski says. “It’s just a dramatic failure of leadership.”
Changes to make football safer have met resistance at all levels—even from the highest office. In a September social-media post, President Donald Trump called the league’s new kickoff policy “‘sissy’ football” and said that “the NFL has to get rid of that ridiculous looking new Kickoff Rule.”
Scientists, meanwhile, are starting to better understand CTE as more athletes say they believe they have it. “Our best understanding of what causes CTE is that it’s the cumulative force that a person gets exposed to,” says Dr. Daniel Daneshvar, chief of the division of brain injury rehabilitation at Harvard Medical School.
CTE is closer to Alzheimer’s disease than it is to a traumatic brain injury, Daneshvar says. Scientists believe that repeated hits to the head damage the brain cells, which causes chronic inflammation and cells to convert into a diseased and dying state. That type of diseased brain cell is similar to the type found in Alzheimer’s and a host of other neurodegenerative diseases.
Because CTE is caused by cumulative head impacts and not just one big blow, people who start playing football as kids—and who often don’t play past high school—can end up with CTE. One 2011 study found that high-school players in some positions experienced as many as 868 impacts to the head over one 14-week season. Another Boston University study found that the risk of developing CTE doubles for every 2.6 years of playing football.
Shane Tamura, the gunman who killed four people in Manhattan in July before taking his own life, believed that he had developed CTE even though he never played professionally or even in college. (CTE can currently be diagnosed only after a person has died.) Tamura, who started football at age 6 and played through high school, reported having frequent, debilitating headaches as an adult. He left a three-page note in his wallet referencing CTE and asking researchers—including, reportedly, Nowinski— to study his brain. In September, New York City’s medical examiner released a statement saying that it had found “unambiguous diagnostic evidence” of CTE in Tamura’s brain.
What the NFL changed to reduce injuries
In recent years, as research about CTE has become more conclusive, some sports leagues have begun to concede that head impacts are a problem. In 2016, NFL commissioner Roger Goodell acknowledged that football-related head trauma was linked to brain disease, a big step for a league that had been reluctant to admit any connection.
Since then, the NFL has made a number of changes to game rules and practice guidelines to try to reduce head impacts. The league has prohibited tackling during offseason practices and in early stages of preseason, and allows only one full-contact practice per week. It reduced the length of overtime in the preseason and regular season to 10 minutes from 15, and prohibited players from lowering their heads to make contact with an opponent using their helmet. Perhaps most importantly, the NFL significantly changed the kickoff in the 2024 season, moving teams closer together to limit how fast players run at one another.
The changes appear to be reducing concussions. Recorded concussions decreased 17% in 2024, the year the new kickoff rules went into place, compared to 2023.
But aside from Pizzi’s Metropolitan Independent Football League, few college, high school, or youth leagues have made major changes to how the game is played—or even acknowledged the connection between the game and CTE.
“If the same rule changes that have been implemented at the NFL level were implemented at the college, high school, and youth level, it would substantially reduce the number of individuals who develop CTE and the severity of CTE for those who develop it,” said Daneshvar.
Fewer changes at the college level
The NCAA, for example, still allows a relatively high number of live contact practices—those in which players wear full pads and practice tackling and blocking—according to its Division I manual. While preseason starts with five days of practice without live contact, students can practice in full pads beginning on the sixth day. After that, schools are allowed to have eight full-contact practices in the preseason, and they are allowed to practice tackling and blocking for as long as 75 minutes in each practice.
The NCAA has also not adopted the NFL’s kickoff changes. (Trump alluded to this in his post: “Fortunately, college football will remain the same, hopefully forever!!” he wrote.)
“The NFL makes changes to the kickoff rule, and that seems like a rule that can be implemented widely. I always wonder why that hasn’t been implemented across other levels,” says Dr. Michael Alosco, a neuropsychologist who is the co-director of clinical research at Boston University’s CTE Center. “When you think about CTE, the best way to mitigate it is to reduce your amount of exposure.”
The NCAA has made some changes, though far fewer than the NFL. Certain drills—like the Oklahoma drill, in which two players essentially collide head-on—have been prohibited in college football since 2021, the NCAA says. Back in 2012, the NCAA also moved kickoffs to the 35-yard line from the 30 in the hope that more balls would be kicked out of play and not returned. Still, many kickoffs are still returned, and NCAA kickoffs are vastly different from those in the NFL today because they still involve players running at each other from great distances, allowing them to build up speed that can lead to hard hits.
The NCAA declined to comment for this story. Its Division 1 manual outlines one way it sets itself apart from leagues like the NFL: “College football is different from professional football and collegiate coaches rely on these practice opportunities to teach their student-athletes the fundamentals of the game,” the manual says.
Nominal changes to high school football
High school football has done even less than college. Although every high school and league can change its own rules, like the Metropolitan League did, most look to the NFHS for guidance on player health and safety.
When asked whether it had changed any aspects to the game, like kickoff, to reduce head impact, a NFHS spokesperson cited a 1975 rule change that defined “spearing”—using the top of a player’s helmet to initiate contact—as a disqualifying personal foul.
In 2014, NFHS issued recommendations for minimizing head impact exposure and concussions in football that included limiting full-contact practice to the regular season and limiting contact in practices. But the recommendations still allowed full-contact practices two to three times a week and limited full-contact time to about 90 minutes per week. The recommendations also acknowledged that preseason practices might require “more full-contact time” than practices in the regular season.
It’s not enough, says Nowinski, of the Concussion Legacy Foundation. “There is still an extraordinary culture of CTE denial at the college, high school, and youth levels,” Nowkinski says.
Karissa Niehoff, CEO of NFHS, wrote in a 2019 blog post that there was no link between CTE and playing high school football. She says she still believes that today, and that there’s no way for researchers to disentangle the possible effects of playing other sports when they study this question. “It's really hard to strictly pinpoint high-school football with CTE, because we often see that the concussion injury is like a snowflake,” she says. “It's different for everybody.” (Scientists say that CTE is caused not only by concussions but also by repeated head impacts.)
“I think we have to remember that at the lower levels, from youth to high school, these are not elite athletes,” says Niehoff. “We've got to really help our athletes learn the sport, and then as they become more skilled and they get bigger and faster and stronger, we just have to watch how the rules help protect them.”
In her blog post, Niehoff cited a study by Munro Cullum and colleagues that studied 35 former NFL players over the age of 50 who had sustained at least one concussion in their careers. It found no association between the number of years they had played or number of head impacts they had sustained and their cognitive function later in life. (The study did not have the brains of the players so it could not report on CTE.)
Cullum, a professor of psychiatry, neurology, and neurological surgery at the University of Texas Southwestern Medical Center, says that although there’s a correlation between repeated head hits and CTE, that doesn’t mean that one causes the other. It could be that some people are at greater risk for CTE because of genetic or other factors. He also believes there’s not enough evidence to link repeated head hits to abnormal behavior or cognitive decline later in life.
“We believe that concussions and head hits can be a risk factor for cognitive decline later in life, but not for most people,” he said. CTE is still very rare, he says, and many NFL players do not have any cognitive difficulties when they get older.
Some recent research, however, suggests that CTE may not be as rare among professional football players as once thought. One 2023 study from the Boston University CTE Center studied the brains of 376 former NFL players and found that 345, or 91.7%, had CTE.
NFHS has taken some steps to reduce contact, such as limiting the amount of playing time kids have in a week, because some kids on both the varsity and junior varsity teams had been playing in two games on a weekend, Niehoff says. Every state has a sports medicine advisory committee that is involved in thinking about protecting kids, she says.
But some states go even further than NFHS requires. In 2019, New Jersey’s Interscholastic Athletic Association reduced the amount of time that teams could engage in full-contact drills to 15 minutes per week, down from the limit of 90 minutes that NFHS suggests. The state also limited preseason contact drills to six hours total and banned spring and summer practices. In 2019, Michigan set a limit of 30 minutes of full-contact practice a week.
Minimal protections for football’s youngest players
Experts argue that youth football is the least regulated of all. “Unlike just about every other sport in America, nobody sets the rules of youth football,” Nowinski says. “You have a bunch of small, capitalist fiefdoms that are rewarded by enrollment, so nobody is willing to be a leader on these changes because they don’t want to scare away clients.”
It’s easy to find TikTok videos of kids in youth football leagues running the Oklahoma drill or the bull in the ring drill, both of which pit two players against each other in close contact. Both lead to high incidents of injury and are not allowed at the professional level. But even without those drills, youth football can result in serious injuries. In 2024, a 13-year-old died from brain trauma after making a tackle during middle-school football practice; in 2023, three young football players died of head injuries.
Unlike at the college or high school level, there often are no medical professionals on the field during youth football games or practices, which can mean that when someone does get hurt, their injuries can turn fatal. In 2023, a 12-year-old New Jersey boy died after collapsing at football practice; no one on the field knew CPR.
Pop Warner, one of the largest youth football leagues in the U.S., made some changes to limit exposure to head impact. In 2012, it banned full-speed head-on blocking or tackling drills where players lined up more than three yards apart. In 2016, it announced that contact is restricted to 25% of practice time and said that if a team has practice on two consecutive days, it can have live contact in only one of them. In 2016 it also eliminated kickoffs for its youngest divisions, according to a spokesperson. But it still allows tackling for even its 6-and-under division.
The best strategy to protect youth, Nowinski and other experts say, is to set minimum ages for the most dangerous activities, like tackling. In 2011, USA Hockey banned body checking in the 12-and-under leagues, and in 2016, U.S. Club Soccer banned heading for players under 12. There seems to be little interest in banning tackling in football for kids under 12, though, Nowinski says.
“American football may be the only sport in the world that has zero discussion of—and will probably never themselves create—an age minimum for tackling,” he says.
The only way for bans on youth tackling to reach all the kids who play would be state or national legislation. In 2023, the Concussion Legacy Foundation worked with legislators in California on a bill banning tackle football for children under 12. The bill had the support of legislators and cleared a key legislative committee, Nowinski says, but in January 2024, Gov. Gavin Newsom vowed that he would not sign it if it reached his desk. (Newsom has said that he believes it’s possible to “strengthen” tackle football and grow flag football in California “without implementing bans that infringe on parents’ rights.”) If California won’t pass such a bill, Nowinski says, it’s unlikely any other state will.
But making changes at the individual league level is doable—just ask John Pizzi. The Riverdale athletic director says that although some other coaches and parents were hesitant at first, the league has fully embraced the safer game rules. That’s probably because they have led to decreased concussions and increased enrollment. As high school football nationally sees its numbers slip, enrollment in the football program at Riverdale is increasing, Pizzi says.
Some families who had prohibited their kids from playing football have relented under the new rules, he says.
The school has figured out ways to make the game safer while still helping players get better, he says; using a tackling wheel—essentially a big foam donut—instead of a person helps teach technique without risking kids’ health, he says. Not having to practice kickoffs frees up more time to practice other aspects of the game. The school now also runs junior-varsity practices as “controlled practices,” essentially having the coaches walk players through what they’re doing rather than just presiding over chaos, Pizzi says.
Now, some players and parents at Riverdale’s games have never experienced a season where the team does a kickoff—they just place the ball on the field and start playing.
Pizzi has heard from parents of kids in other football leagues who are envious of the changes that Riverdale has made, wishing their school would do the same. But, he says, he hasn’t heard from other coaches or leagues who want to implement what Riverdale has done, and make football safer for kids to play.
