What happens next after latest link between heading and brain disease?

When a senior coroner declared on Monday that repeatedly heading footballs "likely" contributed to the brain disease which was a factor in the death of former Leeds United and Manchester United defender Gordon McQueen, the relationship between heading and neurodegenerative illnesses was thrown into the spotlight again.

The link between heading and brain injuries relates to an illness called chronic traumatic encephalopathy (CTE), which is caused by repeated head impacts, and which McQueen was found to have suffered from, alongside vascular dementia.

CTE can only be diagnosed after death, following analysis of the brain, which typically shows protein deposits and other types of damage which are caused by head injuries.

Research has shown that athletes such as footballers, rugby players and fighters have a significantly higher risk of developing CTE than the general population.

The verdict in McQueen's case has led to renewed calls for football to take more action on brain injuries.

It depends how you look at it - McQueen is arguably the most high-profile former footballer whose death has been directly linked to CTE by a coroner. Such a clear verdict in a case as prominent as his means more people are aware of the link.

But this is far from the first time the link has been made official - Jeff Astle, who died following years of neurological symptoms, is considered the first footballer whose death was shown to have been impacted by heading footballs.

The confirmation that CTE played a role in Astle's death, rather than Alzheimer's as previously thought, came after analysis from Professor Willie Stewart, a pre-eminent neuropathologist who specialises in CTE cases in sportspeople and has advised sports bodies around concussion protocols.

"Former professional footballers are at much higher risk of degenerative brain diseases, dementias and related disorders," says Prof Stewart, who is a consultant neuropathologist at the University of Glasgow.

"What we see is the risk is about three and a half times higher than it should be. There is a very unique change in the brain which only appears in athletes that we don't see in other individuals."

The reason coroners have thus far only gone as far as to say it is "likely" that heading footballs led to CTE, which then contributes to death, is because it is impossible to say with 100% certainty how and when the damage was done to the brain, as analysis is only possible post-mortem.

But experts generally agree that there is no other logical explanation in cases of professional sportspeople with long careers like McQueen, whose daughter Hayley told the inquest she had never known her father suffer any head injury other than concussions from playing football.

"CTE contributed to Gordon McQueen's death significantly," said Prof Stewart, adding that the only available causal evidence was exposure to repeated impacts - heading footballs.

A handful of former players - including McQueen, ex-Cardiff defender Keith Pontin, former Hull City man Alan Jarvis, and amateur player Goff White - have now had their deaths formally linked to football.

There are rules across England, Scotland and Wales restricting heading in children's games, while different restrictions are in place around training in the English and Scottish professional games.

In 2019 the 'Field' study, funded by the Football Association and Professional Footballers' Association, found that footballers were 3.5 times more likely to suffer from neurodegenerative disorders. It was the largest study to date looking at the links to heading footballs.

Since then, the FA has brought in a phased ban of heading in under-11s football and says it is investing in objective and robust research to get a better understanding of the issue. It has also issued guidelines to clubs on limiting high force headers in training, such as from balls which come at speed from free-kicks and corners.

The Scottish FA has gone further, banning heading the day before and after matches in the professional adult game.

In September 2023 the PFA set up a £1m brain health fund, with help from the Premier League, which former professional players and their families can make applications to for financial support. The union is being assisted by Dawn Astle, the daughter of Jeff, and applications are assessed by an independent panel.

But critics say the amount needs to be much higher, given the soaring costs of care homes.

Culture secretary Lisa Nandy has met with family members affected by dementia, and the government told BBC Sport that it has been keeping a close eye on the situation.

The general consensus among experts is that the UK is taking the link between sport and brain disease more seriously than other countries.

A similar study to 'Field' conducted in Sweden reinforced the links, while Australia has begun looking at changes to training.

The International Football Association Board, which decides the laws of the game, has brought in concussion protocols, with designated concussion substitutions now seen in leagues far and wide, but changes to rules about heading the ball are not currently on the agenda.

"In the UK in particular, and also in some American sports, organisations have gone quite a long way to recognising and managing what the problems are," Prof Stewart explains.

"There are limitations on heading at youth level and guidelines for the professional level. That's a real acknowledgement of heading and head impacts being a potential risk for brain health.

"Going away from the UK to global sport - to Fifa and Uefa - we're seeing less pick up of this as a problem, less of what might be required to meet to keep the sport safe."

BBC Sport has contacted Fifa for comment.

Families of footballers who have died with neurodegenerative conditions and charities have combined for many years to call for a reduction of heading in football.

They welcomed the guidelines when they were introduced in England, Wales and Scotland, but believe they are largely being ignored as things stand.

"The guidelines from the FA are out there but coaches don't know them," said, Dr Judith Gates, founder of Head Safe Football and widow of former Middlesbrough defender Bill Gates, who died after suffering from CTE.

"We have worked with 44 EFL clubs and only 1% knew about them, and that's just the professional game.

"This begins in youth, so it's young people whose brains we need to be caring for."

One of the key points campaigners have made so far is that they are not seeking to remove heading from football, or fundamentally change the way the game is played, but to reduce the amount for heading in training in order to lessen the frequency of head impacts which have the potential to cause damage.

"I work as a broadcaster in sport, and I love it," McQueen's daughter Hayley, a Sky Sports presenter, said outside court. "People say, 'Oh, you've ruined the game if you take heading out of it'. But we can still continue to have heading in football, but do it so much safer."

Prof Stewart added: "Cutting exposure as much as possible at that elite level, reducing it as much as possible in training, is a very good starting point."

Hayley and her sister Anna Forbes also insisted more changes should be made regarding care for former players suffering from neurodegenerative diseases and their families.

They believe that the Professional Footballers' Association (PFA) should play a greater role.

"I emailed the PFA literally begging for help when my dad was at his lowest point, and we were looking for respite care," Hayley McQueen explained.

"That email was left unanswered. After three attempts at chasing, they sent me on a wild goose chase for support where they offered something called an admiral nurse, which was a Zoom call with a nurse to tell me what government support we were able to access - which was none, by the way.

"It depleted my parents' lifetime savings looking for private care for my dad, and we relied on charities for respite care. The PFA gave us nothing - no support whatsoever."

The PFA said: "There is an ongoing need for a collective response, from football and beyond, to ensure former players affected by neurodegenerative disease, and their families, are properly recognised and supported."

Hayley McQueen also called for football clubs to pay for annual brain scans for current players.

"I think there is an epidemic at the moment," she told Times Radio. "I speak to a lot of the wives and daughters and sons of players, who are terrified, and they're already showing signs and don't know what on earth to do about it.

"Had they known the risks when they played, maybe they'd have made a major decision not to head the ball as much.

"If you were to scan a footballer at the start of every season, almost like having a full medical, why not? There's enough money in football."

No new measures have been announced, but after the McQueen verdict on Monday, various football authorities released statements insisting they are committed to ensuring player safety.

The FA said: "While any association between heading a football and later life brain health outcomes remains an area of ongoing scientific and medical research and debate, we continue to take a leading role in reviewing and improving the safety of our game together with all stakeholders and international governing bodies."

The Scottish FA added: "We will continue to monitor guidance based on evolving research as part of the association's commitment to ensuring the national game is a safe and enjoyable environment for all players."