To quantify the burden of football-related traumatic brain injury (TBI) in youth compared with other sports and recreational activities, and to evaluate long-term neurological and psychiatric outcomes across developmental stages.

Sports-related TBI is a leading cause of long-term neurological and psychiatric morbidity in children and young adults. Football, in particular, has been implicated as a major source of injury, yet large-scale comparative studies across sports and developmental stages are limited.

This retrospective cohort study used the TriNetX Research Network, encompassing >150 million patients. Children and young adults (≤25 years) with a first sports- or recreation-related TBI were identified using ICD-10 diagnosis and activity codes and compared with patients with lower-leg fractures from the same activity and no recorded TBI. Outcomes included repeat TBI, post-concussion syndrome, chronic headache or migraine, anxiety, mood, and substance use disorders, and suicidal ideation or behavior. Attributable risks were calculated between matched cohorts (1:1 by age category and sex). Multivariate Cox proportional hazards models adjusted for age, sex, and activity compared risks across sports.

Football accounted for 19.4% of 72,025 activity-related TBIs (mean age, 13.9 years; 32% female). Repeat TBI occurred in 37% of football injuries (32% overall). Attributable risks were significantly elevated for neurological outcomes (chronic headache, 23%; visual impairment, 5%; neurodevelopmental disorders, 0.5%) and psychiatric outcomes (anxiety, 5%; depression, 3%; substance use, 1%; suicidality or violence, 0.5%). TBIs sustained at younger ages were associated with developmental and mood disorders, while those at older ages were associated with substance use disorders.

Football is the single leading source of pediatric sports-related TBI, associated with high recurrence and substantial neurological and psychiatric sequelae. Developmental timing of injury shapes long-term risk. Findings highlight football as a critical public health priority and support delaying tackle participation and regulating institutional promotion of youth football.