Neurodegenerative disease among male elite football (soccer) players in Sweden: a cohort study

Background Football (soccer) players might be at increased risk of neurodegenerative disease, which has led to questions regarding the safety of the sport and recent measures introduced by football associations to reduce heading of the ball. We aimed to assess the risk of neurodegenerative disease among male football players in the Swedish top division Allsvenskan, compared with matched controls. Methods In this cohort study, we identified all male football players (amateurs and professionals) who had played at least one game in Allsvenskan from Aug 1, 1924 to Dec 31, 2019 and excluded players whose personal identity number could not be retrieved or be identified in the Total Population Register, and those who were not born in Sweden and who had immigrated to the country after age 15 years. Football players were matched with up to ten controls from the general population according to sex, age, and region of residence. We used nationwide registers to compare the risk of neurodegenerative disease (diagnoses recorded in death certificates, during hospital admissions and outpatient visits, or use of prescription drugs for dementia) among football players versus controls. We also assessed each type of neurodegenerative disease (Alzheimer's disease and other dementias, motor neuron disease, and Parkinson's disease) separately, and compared the risk of neurodegenerative disease among outfield players versus goalkeepers. Findings Of 7386 football players who had played at least one game in the top Swedish division between Aug 1, 1924, and Dec 31, 2019, 182 players were excluded for an unretrievable personal identity number, and 417 were excluded due to their number not being identified in the Total Population Register. After a further exclusion of 780 players and 11 627 controls who were born outside of Sweden and who had immigrated to the country after age 15 years, 6007 football players (510 goalkeepers) were included in the study population along with 56 168 matched controls. During follow-up to Dec 31, 2020, 537 (8 center dot 9%) of 6007 football players and 3485 (6 center dot 2%) of 56 168 controls were diagnosed with neurodegenerative disease. The risk of neurodegenerative disease was higher among football players than controls (hazard ratio [HR] 1 center dot 46 [95% CI 1 center dot 33-1 center dot 60]). Alzheimer's disease and other dementias were more common among football players than controls (HR 1 center dot 62 [95% CI 1 center dot 47-1 center dot 78]), significant group differences were not observed for motor neuron disease (HR 1 center dot 27 [0 center dot 73-2 center dot 22]), and Parkinson's disease was less common among football players (HR 0 center dot 68 [0 center dot 52-0 center dot 89]). The risk of neurodegenerative disease was higher for outfield players than controls (HR 1 center dot 50 [95% CI 1 center dot 36-1 center dot 65]) but not for goalkeepers versus controls (HR 1 center dot 07 [0 center dot 78-1 center dot 47]), and outfield players had a higher risk of neurodegenerative disease than did goalkeepers (HR 1 center dot 43 [1 center dot 03-1 center dot 99]). All-cause mortality was slightly lower among football players than controls (HR 0 center dot 95 [95% CI 0 center dot 91-0 center dot 99]). Interpretation In this cohort study, male football players who had played in the Swedish top division had a significantly increased risk of neurodegenerative disease compared with population controls. The risk increase was observed for Alzheimer's disease and other dementias but not for other types of neurodegenerative disease, and among outfield players, but not among goalkeepers. Our study expands on the data that can be used to assess and manage risks in the sport.