A youth soccer safety campaign urging middle schools and under-14 soccer leagues to eliminate heading in the sport as a way of reducing concussions continues to grab headlines, but is viewed in a new study (47) not only as culturally unacceptable in a sport that has been allowed to become more physical over time, but as a less effective way to prevent concussions than by reducing athlete-athlete contact across all phases of the game through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching.
Dubbed the Safer Soccer Campaign, and bearing the tagline "U14 - No Header, No Brainer", the year-old campaign by the Boston-based Concussion Legacy Institute (formerly the Sports Legacy Institute) and the Santa Clara Institute of Sports Law and Ethics is spearheaded by three former US Women's National Team players (ISLE board member, Brandi Chastain, and teammates Cindy Parlow Cone and Joy Fawcett), along with SLI medical director and prominent concussion expert, Dr. Robert Cantu, and co-founder and Executive Director, Chris Nowinski.
In a June 25, 2014 press release [38] Chastain recommends a ban on heading before age 14 and encourages coaches and parents to consider the risks of heading before high school or age 14 in age-based leagues "while we wait for more research to clarify [that] risk."
In an accompanying "White Paper" [39] on the group's website, however, Dr. Cantu, Mr. Nowinski, and SLI's Educational and Research Program Manager, Cliff Robbins, aren't content to wait, asserting flatly that the "scientific evidence paints a clear picture that heading a soccer ball will result in more concussions and repeated subconcussive trauma, which can have long term neurological consequences in both adolescents and adults."
Indeed, in a July 24, 2014 blog post, [40] Jack Bowen of ISLE, relying on what he refers to as "the heavy hitters" from SLI who have provided the science, goes so far as to suggest that the ban on soccer heading before age 14 proposed by SLI and ISLE "is not just in the best interests of children but one of moral necessity." In other words, says Bowen argues, that to fail to do so "would be to act immorally."
From a review of the peer-reviewed literature and interviews with a number of experts, however, a much more nuanced and equivocal picture than portrayed by SLI and ISLE emerges; one in which a consensus has yet to develop, on a host of issues, among them:
As one expert said, while the Safer Soccer Campaign has garnered a great deal of national media coverage, much of the discussion - including Bowen's blog post - has been "over-dramatized."
The 2015 study [47] by a team of researchers headed by the country's leading expert on high school sports injuries, Dr. Dawn Comstock,* and published online in the Journal of the American Medical Association - Pediatrics, flatly concludes, based on a review of ten years of data, that a simple ban on heading is likely not the most effective way to prevent concussions in youth soccer.
Moreover, says Comstock, the Safer Soccer Campaign fails to account for the level of cultural acceptance of its proposed heading ban which is essential to effectively drive prevention efforts in sports. "Banning heading from youth soccer, while preventing some concussions, may not be culturally acceptable" in a sport that "has been allowed to become a more physical sport over time [in which] more athlete-athlete contact is occurring, without a concurrent increase in the frequency of fouls or sanctions awarded by referees."
Instead, she says, "it may be more culturally tolerable to the soccer community to attempt to reduce athlete-athlete contact [which is the leading concussion injury mechanism at all levels of soccer] across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading ... than simply banning heading."
On one side of the debate about when it is appropriate to introduce heading in youth soccer are those experts, including Dr. Frank Webbe,* a professor of psychology at Florida Institute of Technology, and perhaps the most prominent researcher on the subject of heading in soccer, who support the no-heading-before-age-14 recommendation.
Indeed, if Webbe finds fault with anything, it is not with the Safer Soccer Campaign recommendation, but more with the assertion that the science unequivocally supports the position CLI and ISLE have staked out on the controversial issue of heading in soccer.
"As might be expected," Webbe says, "since I am on record as suggesting that heading in children should be eliminated, I agree with the [CLI/ISLE] recommendation that children under 14 should not be heading the ball. Period. My rationale then and now is that there is sufficient evidence that concussions and heading are highly correlated, and anything we can do within the confines of the sport to decrease concussions should be done."
"My concern [about the CLI White Paper] is that specific conclusions about heading, concussion risk, and the risk of lifetime neurological pathology were developed by citing the literature selectively, and by generalizing outcomes from one or two studies with small sample size and non-equivalent controls."
"Although my own research and conclusions have pointed toward a limitation on heading because of higher concussion risk and the frequency of subconcussive impacts, I have also pointed out [in two recent books which sift through all the literature in order to avoid bias [2,3] that there are studies as good or better than mine that do not support such conclusions." *
"The biggest elephant in the room" in the SLI press release," Webbe says, is the hypothesized link between soccer heading and later onset of neuropathology, including chronic traumatic encephalopathy [1]. "Small N studies - including the newer imaging reports - are not sufficient to make that inferential leap [2]."
The Safer Soccer Campaign proposal is not new; it simply restates a proposal made by Dr. Cantu that soccer heading be delayed until age 14 first made in his 2012 book, Concussions and Our Kids, [29] where he argued for the delay, not just because of the risk repetitive brain trauma he said heading posed, but because "so much happens when a young player springs into the air expecting to meet the ball with her forehead, and so much of its results in head trauma [e.g. concussions]. Head meeting ball is the scenario of least concern. Problems arise when head meets shoulder, elbow, or another head."
Such concerns have led some soccer programs, including AYSO, with 650,000 participants, to recommend against heading in soccer before age 10. [30]
Most recently, in November 2015, the United States Soccer Federation also came out against heading at age 10 and under, banning the practice in its own programs and imposing limits on heading in practice for players 11 through 13, and recommending adoption of its ban and practice limitations to other youth soccer organizations not under its direct control.
As Webbe notes in a 2010 book, [2] "Generally speaking, there is general consensus that proper heading technique requires strong neck muscles to form a stable platform bridging the body and head."
A 2013 study [3] [28] found that balanced neck strength may reduce the acceleration of the head during the act of heading a soccer ball, thus reducing the risk of brain injury from such low-grade, subconcussive hits. "Achieving and maintaining a balance in neck strength may be a key preventative technique in limiting acceleration, hence limiting the potential risks of repetitive heading in soccer," wrote lead author Zachary D.W. Dezman, M.D., a resident in the University of Maryland School of Medicine Department of Emergency Medicine.
In a 2010 clinical report on injuries in youth soccer (reaffirmed in May 2014), the American Academy of Pediatrics' Council on Sports Medicine and Fitness [21] recommends, rather than age limits, that heading of the ball only be taught when the child is old enough to learn proper technique and has developed coordinated use of his or her head, neck, and trunk to properly contract the neck muscles and contact the ball with the forehead. The AAP's position is similar to that recommended by Dezman and his colleagues in the 2013 study on neck strength in soccer. [27] "Balancing muscles may be particularly beneficial," writes Dezman, "for younger players learning the game and would perhaps be a more objective, quantitative parameter when deciding when to introduce heading," rather than strict age limits.
Since publication of the AAP report and the Dezman study, two more studies (both appropriately cited by SLI in its White Paper)[34, 35] have joined the growing body of evidence supporting the view that having a strong neck may help reduce risk of concussion. The first, conducted in a laboratory environment, found that adolescent soccer players with weaker necks experienced greater head acceleration during heading than those with stronger necks. [34] The second, a field study involving over 6,700 high school athletes [4] in boys' and girls' soccer, lacrosse, and basketball, reported that neck strength was a significant predictor of concussion, with the odds of concussion falling by 5% for every one pound increase in aggregate neck strength, and that the quarter of the subject group with the weakest necks suffered the greatest number of concussions, while the quartile with the strongest necks suffered the fewest.[35]
Beyond agreeing that neck strength is correlated with concussion risk, there appears to be little consensus on when heading should be introduced.
Arrayed against the position staked out by CLI/ISLE, and Drs. Cantu and Webbe are some other "heavy hitters," including Dr. William Meehan, former Director of the Sports Concussion Clinic and currently Director of the Micheli Center for Sports Injury Prevention at Boston Children's Hospital and author of the 2011 book, Kids, Sports and Concussions, [31] who don't think there should be any age limits on heading and believe delaying the teaching of heading "would be a mistake."
Dr. Meehan argues that, as children become stronger and better coordinated, they are able to kick the ball at a much greater velocity. "It seems unwise," he writes, "to have their first time trying to head a ball occur at an age when the ball can be kicked with significant speed and force."
"Instead," Dr. Meehan suggests, "using smaller, softer balls that weigh less while children are younger allows them to develop the skills necessary for proper heading of the ball. This seems like a safer approach. They can learn proper technique, develop strength, and master the timing and coordination necessary for proper heading of the ball when young, before they begin to play with an adult-size ball that can be kicked with significant force." Learning to head with a dry, soft, foam ball may be another useful way to start, he says.
In this recommendation, Dr. Meehan finds support from an important ally: the American Academy of Pediatrics. Its 2010 clinical report, [21] the AAP recognizes that, while, proper technique as "foremost in reducing the risk of concussion from heading the ball," it also "is imperative that soccer balls be water-resistant [one of the supposed culprits in the brain damage found in early studies of retired Norwegian players,[8-12] [see discussion below], sized appropriately for age, and not hyperinflated."
In a post on the AYSO website entitled "Is Heading Safe," [30] John Ouellette, AYSO's National Coach Instructor, largely takes the side of Dr. Meehan and the AAP. The AYSO believes that "heading is part of the game," he says, which "should be introduced and taught properly to players at the appropriate age and time."
While acknowledging the preliminary scientific research indicating that young players who head too early in their physical development are susceptible to potential risks," Ouellette says the act of heading "should be regarded within a complete context of risk."
Instead of setting a particular hard-and-fast age at which heading is introduced, he recommends a more flexible approach: that a "general rule of thumb to follow is to start teaching heading when a player shows an interest, not when the coach thinks it should be taught."
In the middle are experts like Chris Koutures,* a pediatric and sports medicine specialist in Anaheim Hills, California, and lead author of the AAP's youth soccer study. [21] Although welcoming CLI's discussion of heading in soccer and commending its efforts to enhance study and ultimately the safety of young athletes, Koutures said he was personally disappointed that the CLI White Paper made no reference to the AAP youth soccer study: "I thought that the paper has good insight and the AAP truly wants to be a point of reference in matters of pediatrics and sports medicine in particular."
Koutures noted that youth soccer was not alone in contemplating or legislating delays in introducing higher risk activities, but warned about the downsides of doing so "without solid evidence bases of support to determine actual benefits," and without consideration of potential risks that "delaying certain actions might actually increase injury risk." Echoing Dr. Meehan's concerns, Koutures wondered whether "kids who don't learn a skill until later might not be as adept/competent, and that could increase risk of concussion and other injury."
In ice hockey, Koutures pointed to data from a recent AAP study [5] [46] which definitively showed that delaying body checking until age 15 did not increase injury risk before or after the age. By contrast, he noted that two pilot studies examining the effect of limiting full-contact practices in youth football [36,37] have yielded inconsistent results about the effectiveness of such measures as a primary concussion prevention strategy.
"Where the science is lacking is the ability to definitively state that delaying heading will reduce both short-term and long-term concussion burdens, and won't actually increase the risk of concussion or other injury," said Koutures. He noted that even though the AAP report on youth soccer injuries [21] advanced the consensus opinion of the authors on the importance of neck strength and delaying introduction of heading until appropriate biomechanical control of head, neck, and chest could be obtained, the evidence to support the statement was lacking at the time of the paper's publication. "That evidence still does not fully exist today," Koutures said.
"One could accurately argue - with good scientific support - that restricting heading (at any age) could reduce concussion, because the mere act of going up for a header is itself associated with a risk of concussion, due to head/head, head/shoulder, and head/ground contact. This might be even more definitive at older levels of play where stronger, faster, and more experienced/confident players going into heading contacts with more speed, determination, and even intent to harm. However, if kids aren't as comfortable with the act of heading, there might actually be more risk, not less."
"Many of my discussions about sport safety (and head injuries in particular) revolve around acceptable risk, risk tolerance, what we know and do not know about the injury in question, potential risk reduction techniques (helmets, not heading, switching to a non-heading position), and alternatives (less risky activities)."
"Does [the recent research] make me want to restrict heading or express more caution? Not quite yet, though I have brought it up in clinical conversations when discussing risks/benefits of soccer with young patients and their families. If I were sitting in front of a young soccer player and his/her parents to discuss risks/benefits of delayed introduction to soccer heading, at this time I could not summon up enough evidence to categorically support delayed introduction, but am eager to continually review evolving studies and share thoughts with others," Koutures said.
The more than 30-year-long debate about soccer heading is well-chronicled in Webbe's 2010 Handbook of Sports Neuropsychology. [2] It began in the early 1980's with studies by Alf Tysvaer and his colleagues of retired Norwegian professional soccer players which reported abnormal EEG findings and other neurological, cervical spine, and neuropsychological difficulties. [8-12]
Tysvaer's findings were dismissed at the time as being due to a combination of the fact that the players were using old, heavy balls and their known predilection to drink alcohol. After a study appeared in 1990 [13] that supported Tysvaer's findings, with results that could not be explained away by the type of ball used, a "spate of studies ensued," writes Webbe, "some of which supported findings of neurocognitive impairment in soccer players and some of which did not."
Significantly, however, it was during this period that the "most controversial of Tysvaer's findings" - that neurocognitive deficits were correlated with lifetime frequency of heading soccer balls - received additional support, setting the stage, Webbe says, "for years of confrontational rhetoric over whether heading was causative in neurocognitive impairment" in which the science and politics of soccer intertwined.
The soccer community, he said, resisted reports that suggested difficulty regarding heading, even in the face of growing concern [6] among the scientific community and the media, not just about concussions in soccer, but the risk of brain injury from repetitive heading, with even the scientists becoming embroiled in the controversy; some maintaining that soccer heading had the potential for harm and some saying it didn't.
On one side, Webbe says, is what he loosely refers to as the "soccer establishment," consisting of FIFA, the United States Soccer Federation, England's Football Association (FA), and the various groups advising them. Studies that reported on heading-related concerns and impairment among players were, he says, "dismissed in almost a knee-jerk reaction" by these groups, with heading becoming essentially a "sacred cow within some segments of the soccer establishment." When peer-reviewed, objectively well-done studies showed adverse outcomes of heading, [6,14,15] the soccer establishment discounted them in favor of other studies that showed no effects or relationships. [16-18]
But, as Webbe notes, it wasn't just soccer governing bodies that reacted "defensively and aggressively" to studies showing that heading may be systematically injurious to players; many soccer aficionados, players, coaches, parents, and even scientists also, he says, "discounted the science, arguing against some decent studies that heading was a perfectly safe practice." [19]
In addition to the political controversy, Webbe says, the disparity in scientific outcomes - with many studies by capable researchers reporting no relationship between soccer heading and neurocognitive impairment and a "different set of studies by equally capable authors using similar methodologies and similar tests to the first set f[inding] significant relationships between the cumulative and/or seasonal amount of heading and neurocognitive deficits," are difficult to reconcile.
A comprehensive meta-analysis in 2003 [20] identified several methodological issues that the authors said explained the false positive findings, chief among them the fact that many of studies relied upon self-report of the players - which numerous studies have found to be problematic in terms of reliability and validity - while only a very few [4,8] used direct observation.
Recent findings from a pilot study [7] of retired professional English soccer players [33] found that, once their playing careers end, the chronic low-level head trauma they sustained from repetitive heading did not put them at greater risk of long-term cognitive decline than the general population, but, as with many of the other studies, that study has since been criticized (by Webbe, among others) as being methodologically flawed. Several other recent studies using formal cognitive testing - neither cited in the SLI White Paper - have also failed to detect changes with ball heading in young adults, [41] or in 13- to 16-year-old soccer players.[42]
A number of recent studies, however, point in the other direction. In a 2013 study [8] [1] cited in the SLI White Paper, researchers at the Albert Einstein College of Medicine, using an advanced imaging technique called Diffusion Tensor Imaging or DTI, linked frequent heading of a soccer ball with changes to the white matter of the brain and poorer performance on a neurocognitive test of memory in adult amateur soccer payers who had been playing the sport for many years. Their findings suggested that there may be a heading threshold above which the risk of short- and possibly long-term brain injury dramatically increases.[1]
Similar findings were also obtained in another recent imaging study[43] (also cited by the SLI White Paper) which found differences in white matter integrity in a small sample of young (e.g. 20 year old) professional male soccer players who had played since childhood, as compared with a control group of swimmers roughly the same age.
In another 2013 study, [44] researchers at the University of Texas found that frequent sub-concussive heading caused at least short term cognitive dysfunction in a small sample of female high school soccer players tested right after practice which was consistent with mild traumatic brain injury to the frontal lobe of the brain. The researchers found that the cognitive impairment was marginally related to the number of headed balls, but significantly related to hours of soccer per week and years playing soccer.
The study was cited by the SLI White Paper as adding to the "growing body of evidence showing that heading a soccer ball can result in problems with memory and attention, as well as structural and metabolic differences on advanced brain imaging, even in the absence of a symptomatic concussion." But, as Webbe notes, left out of the White Paper is any mention of the fact that the research was a pilot study involving only 12 subjects, did not explain the nature of the heading that occurred during practice, and did not make a comparison to a control group of soccer players who practiced, but did not head.
The SLI White Paper also implies that the cognitive dysfunction the players experienced was long-term, but the authors of the University of Texas study were careful to point out that the "most conservative interpretation of our findings is that these changes are transient and the result of the immediately preceding soccer session," and to state that, without additional data, they preferred that more conservative interpretation.
In his 2010 book, Webbe suggested two alternative explanations for the inconsistent findings of these studies:
First, that heading-related neurocognitive impairment may simply not be very "robust," a hypothesis supported by (a) data demonstrating that the forces that occur during heading are typically less than would be predicted to cause concussions; (b) anecdotal evidence that the vast majority of adult soccer players appear to remain cognitively intact during and after their playing careers, and (c) the absence of known risk factors (other than players putting themselves in a position to challenge for the ball) that would predict who would be adversely affected by heading and when; [5] or
Second, that the deleterious effects of heading upon neurocognitive functioning may represent the interactions in repetitive sub-concussive trauma of unknown factors unique to the individual, a hypothesis supported by data from studies showing that soccer players most likely to exhibit lower levels of neurocognitive functioning (and/or, in the case of the Albert Einstein study, exhibiting changes in the white matter of the brain and impaired memory) have been those who headed at relatively high frequencies. [4] Again, this is what the Einstein study found.
As Webbe suggests, and, as the Einstein researchers appears to confirm, "it may well be that susceptibility to the minor blows associated with heading in soccer players is not a graded phenomenon that distributes across all individuals, but rather is not only idiopathic [i.e. of unknown origin] but also somewhat dichotomous." In other words, as the Einstein study suggests, "some individuals may have significant heading-related difficulties, while others may have none."
As Webbe notes, that this is so should be "no surprise" because identifying the concussion-prone individual in advance is exceedingly difficult. Using American football as an example, two players can seemingly exhibit the same hit, but one suffers a concussion and the other doesn't, and we don't know why.
The bottom line, Webbe says, is that heading-related cognitive impairment due to repetitive sub-concussive blows may occur in relatively few individuals, but, whatever the reason, the "clinical response is the same": to determine who is prone to injury from repetitive heading and intervene to prevent further damage."
As is so often the case in head injury research, pediatric studies on the effect of cumulative soccer heading on the brains of children are few and far between, with only a handful of studies providing data on heading in youth soccer. [24-26, 41-44]
Similar to the studies on adults, the outcomes are contradictory. [2] The issue, however, as Webbe notes, is "not trivial," citing a 2009 study of which he was a co-author [25] which found that almost 50% of a sample reported concussion-like symptoms (headache, dizziness, balance problems) after heading a soccer ball, similar to post-concussion reports from adolescent and Olympic soccer athletes. [27]
In addition, Webbe suggests that, as in adult soccer, politics regarding heading leads some coaches and parents to be reluctant to participate in studies at the youth level because it might "deter children from heading behavior and competitiveness in the sport."
A 2013 study [9] of female middle school soccer players [43] sustained concussions at a rate higher than their high school and college counterparts, that most continued to play despite experiencing symptoms, and that less than half sought medical attention. (All arguments advanced by the SLI White Paper as supporting its recommendation for delaying heading in soccer).
SLI cites the study as support for its assertion that 30.5% of concussions "are caused by heading the ball or by attempting to head the ball and colliding with a player, object or the ground," but, first, it should be noted that such a percentage is in line with the percentages of concussions resulting from heading among high school athletes in two recent studies (which suggests that middle school soccer players are not uniquely vulnerable to concussions occurring during the act of heading), [45,47] and, second, as at least one prominent researcher, Dawn Comstock, an epidemiologist at the Colorado School of Public Health who has studied sports injuries at the high school level more extensively than any other researcher, notes, that study fails to provide a breakdown of how many of the heading-related concussions were from athlete-athlete contact versus contact with the ball versus contact with the ground.
"This is disappointing, Comstock told MomsTEAM at the time the study was published, "since they had the data and just didn't present it," an omission that she felt was was "really important from a prevention standpoint: if we want to significantly reduce concussions in youth soccer, [we need to know] do we need to ban heading altogether, or would we be successful if rules prohibiting athlete-athlete contact during heading were enacted and strictly enforced?"
Not surprisingly, Comstock's comments in 2014 presaged both the findings and conclusions of a 2015 study47 of concussions in high school soccer, of which she is the lead author, reporting that, while heading is the most common activity associated with concussions for both high school boys and girls, contact with another player is the most common mechanism in heading-related concussions among high school boys (78.1%) and girls (61.9%), with contact between player and ball a far less common as a injury mechanism among girls (32.3%) and boys (15.3%). Such data lead Comstock to conclude that "reducing athlete-athlete contact during heading through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading ... will more effectively prevent concussions, as well as other injuries, than will simply banning heading."
As Dr. Comstock told New York Times health reporter Gretchen Reynolds, [49] "If referees, coaches, and players would enforce existing rules, there should be less physical contact and far fewer concussions among young players. While saying more research was "desperately needed," she said that reminding young athletes and their coaches to play cleanly and by the rules "could go a long way toward making soccer more safe."
The 2010 AAP Clinical Report on youth soccer injuries [21] suggests - in what some might characterize as wishful thinking - that the "contribution of purposeful 'heading' of the soccer ball to both acute and potential long-term concussive effects, such as cognitive dysfunction, seems less controversial today, as previously."
At the time, the AAP concluded that a critical review of the literature "does not support the contention that purposeful heading contacts are likely to lead to either acute or cumulative brain damage, and additional study is necessary to provide confirmatory evidence of neuropsychological consequences of subconcussive soccer-related head contacts." That it reaffirmed the Clinical Report as recently as May 2014 suggests that the AAP does not view any of the studies published since the report was initially published in 2010 as warranting a change in its position.
A 2012 study [10] [22] by researchers at the Cleveland Clinic concurred with the AAP, concluding, after reviewing theoretical concerns, the results of biomechanical laboratory experiments, and then-available clinical data regarding the effects of chronic, subconcussive head injury from soccer heading, that there were, in its words, "no support" in recent studies for the findings of the early Norwegian studies. Moreover, they asserted that the more recent studies failed to show that soccer players experience neurocognitive impairment compared with athletes in other sports, or that more frequent headers scored more poorly on sophisticated neuropsychiatric evaluation than less frequent headers.
This is exactly what a 2013 study by the Albert Einstein researchers [1] did find, although, to be fair, the Cleveland Clinic researchers were quick to include a caveat to their conclusions: that damage building up over the long term could not be ruled out. The authors thus said that players, parents, and coaches needed "to be aware that ... any possible detrimental effect from repetitive subconcussive heading may only become clinically evident decades into the future."
Where does all of this lead parents and middle school and Under-14 youth soccer programs?
In answering the question, "Should my child head soccer balls?" (for parents, at least) Webbe proposes in his 2010 book [2] the use of the following "decision tree":
Should My Child Head Soccer Balls?
If Yes to ALL: OK with Caution |
If Yes to ANY: NO |
13 or older |
Under 13 |
Proportional musculature for head size |
Large head relative to body |
No history of head injury | Positive history of head injury |
Has had technical heading instruction from a qualified coach |
No technical heading instruction from a qualified coach |
No history of learning or attention problems |
Positive history of learning or attention problems |
As Webbe notes, however, while this decision tree is useful for individual children, it "does not address the practical application of such a decision matrix. Clearly, it would be awkward at best and chaotic at worse to allow some children on a team to head and not others."
In his view, a ban on heading for all children would thus be the best practical solution.
As for middle-school and U14 soccer programs, time will tell whether the science will prove him and CLI right. For now, however, one thing is clear, and that is that the science is far from clear: that the evidence simply does not permit an unqualified answer to the question of whether heading a soccer ball results in more concussions and repeated subconcussive brain trauma which can have long-term neurological consequences in both adolescents and adults, much less that delaying heading until age 14 will result in fewer concussions and measurably less long-term neurological consequences for those who delay heading versus those who don't.
The decision by the United States Soccer Federation ("USSF") and a number of other national soccer organizations in November 2015 to ban heading in programs under their control for soccer players 10 and under and to limit heading in practice for those ages 12 and 13, to recommend to other youth soccer organizations that heading in practices or games be banned at the U11 level and younger, and that heading in training at the U12 and U13 be limited to a maximum of 30 minutes per week, with no more than 15 to 20 headers per player per week, has added considerable fuel to the fire of the debate over heading in soccer, with experts quickly lining up on both sides.
Commenting by email, Dawn Comstock, the author of the 2015 study on heading in scocer, [47] stated that, "As always, I support any and all efforts to keep young kids as safe as possible while playing sports, so, in general, I support the new U.S. Soccer initiative."
But Comstock expressed four concerns. First, she wondered "what effort will be made to educate all those affected by the recommendations but not actually included in the requirement?"
Second, she had concerns about enforcement and feasibility: "who will enforce these new regulations and what will be the penalty for violating them, and from a feasibility [standpoint], who will be counting how many headers each athlete takes in each practice and where/how will that be recorded and referred to?
Third, Comstock questioned the rationale for limiting heading in practice for 12- and 13-year-olds but allowing heading in games. "This is completely backward from an injury prevention perspective," she said, "since concussion rates are significantly higher in competition and because we want young athletes to learn proper technique in the controlled practice environment."
Finally, fourth, Comstock reitterated her view that there was "no strong scientific evidence for these age cut points."
Likewise critical of U.S. Soccer's actions was Chris Koutures, the lead author of the AAP youth soccer clinical report. [21] "There is no evidence-based, peer-reviewed literature to support a ban on heading at age 11 versus age 14, versus any age for that matter. When the American Academy of Pediatrics Council on Sports Medicine and Fitness looked at the introduction of heading in youth soccer, we concluded that it "only be taught when the child is willing to learn proper technique and has developed coordinated use of his or her head, neck, and trunk to properly contract the neck muscles and contact the ball with the forehead." This came from consensus opinion of our members, not from any direct study interpretation.
So, "as for the ban on heading U11 and under" is concerned, Koutures was "fairly OK with that, [because] most kids [at] those ages tend to shy away from balls in the air and I can't fathom most kids U11 and under [being] able to muster the ability to protect themselves and initiate coordinated head, neck and trunk action." As a result, said Koutures, that U.S. Soccer came out against heading U11 "is fairly consistent with our AAP recommendations."
Having said, however, Koutures viewed the practice limitations in heading at U12 and U13 as "arbitrary" and without "roots in evidence-based studies." They may prove to be a "good start" or "we may learn down the road that even those restrictions may allow too much exposure." The fact is, he said, that we "just don't have that supporting knowledge at this time."
Koutures also expressed concern that people will look strictly at the numbers of headers taken in practice and not watch the kid. He cited as an example pitch counts in baseball, which while well-intentioned, sometimes cause some parents/coaches to focus just on the number of pitches, without observing the pitcher's performance on the field. "There is no apparent concern about fatigue [as long as] the pitcher is 'under his limit', even if his pitches are way out of the strike zone, he is grimacing on every throw and shaking his arm between pitches." Koutures cautioned that, when heading is introduced, "it will be important to look not just at numbers. but on how the kid is approaching and relating to the ball. Any evidence of shying away or hesitation, forget the number, that session should be done."
That the new U.S. Soccer guidelines on heading in soccer make no mention of the importance of neck strengthening, Koutures said was "disappointing, as again, if the goal is to protect kids, then publicizing the emerging and growing body of literature that supports neck strengthening would be quite sensible." "The realist is me grudgingly must admit that even with great data and programs (on-line, free, evidence-based) for ACL injury reduction, adoption has been quite dismal, and perhaps that's in part why neck strengthening could suffer the same fate and thus not be as attractive to promote."
Although, as a longtime advocate of a ban on heading in soccer below age 14, Webbe generally supported the new heading rules and recommendations, echoed some of the criticisms expressed by Comstock and Koutures. "I found the failure [of the new rules and recommendations] to comment on rules enforcement to be a stunning omission," Webbe said in an email. "As a former referee, I know firsthand that enforcement of existing rules sets the tone for style of play on the field. In my opinion, soccer lags far behind football in legislating rules to make play safer (regarding concussions) and in enforcing rules. This issue is fully under the control of the organizing structures, and they are failing when it comes to protecting players."
Webbe also found it surprising that little mention of neck strength or neck strengthening was made, since, "from a theoretical perspective that gravitates to best practices, weakness in the muscles supporting the head is a primary argument against youth heading."
Critical of the new soccer heading rules, but for different reasons, was Michael Kaplen, an attorney who represents concussion victims and teaches brain injury law at George Washington University Law School, who told NBC News [50] that the new rules were actually a bad idea. The age limits seemed "arbitrary" and "stupid," Kaplen said. He advocates a complete ban for youth players.
And they make it seem like U.S. soccer officials found a fix, he said.
"These leagues are trying to solve a concussion problem by creating rules that give people a false sense of security," Kaplen said. "By creating rules, they imply they have addressed and solved this problem, which they have not."
Commenting on the new rules in the same NBC News article [50], CLI's Nowinski said the new rules fell short because they left middle school-age players vulnerable.
"From that perspective, we still have a ways to go," Nowinski, said.
But Nowinski also told NBC News that it was a good sign that U.S. Soccer that willing to draw a line somewhere. "For soccer to even set an age is a big step," he said.
Concussion Legacy Institute co-founder Cantu predicted that the new rules would cut the number of concussions among the youngest players and shorten the time when those children are at risk for experiencing "sub-concussive hits" that can cause brain injuries later.
Children between the ages of 10 and 12 are most susceptible to concussions because their brains are underdeveloped and their necks are not strong enough, Cantu said.
By delaying the introduction of headers, Cantu asserted, U.S. Soccer "is avoiding the most injurious time period for the brain - and you're also shortening the total amount of trauma somebody takes," he said.
________
* In the interest of transparency, and to avoid any suggestion of bias in reporting this story, it should be noted that Dr. Comstock, Professor Webbe, and Dr. Koutures are uncompensated members of MomsTEAM Institute's Board of Advisors [11], which is developing best practice youth sports health and safety checklists, including youth soccer, for the Institute's SmartTeamTM program [12]. It remains to be seen where the Institute will ultimately come down on the issue of the age at which heading in soccer can safely begin, or whether, as banning heading is the best way to reduce concussions at the youth level, as SLI proposes and Professor Webbe supports, or via better rules enforcement, enhanced education of players, and better coaching, as Dr. Comstock recommends.
1. Lipton M, Kim N, Zimmerman M, Kim M, Stewart W, Branch C, Lipton R. Soccer Heading Is Associated with White Matter Microstructural and Cognitive Abnormalities. Radiology 2013;DOI:10.1148/radiol.13130545.
2. Webbe, FM, & Salinas, C. (2010) The relationship of soccer heading and neuropsychological functioning: When Science and Politics Collide. In F.M. Webbe (Ed.). Handbook of Sport Neuropsychology (pp. 275-294). New York: Springer Publishing Company.
3. Webbe FM. (2006). Definition, physiology, and severity of cerebral concussion. In R. J. Echemendia (Ed.), Sports neuropsychology: Assessment and management of traumatic brain injury (pp. 45-70). New York: The Guilford Press.
4. Webbe, FM. & Ochs, SR. Recency interacts with frequency of soccer heading to predict weaker neuro-cognitive performance. Applied Neuropsychology 2003;10:31-41.
5. Webbe FM. & Ochs SR. Personality traits related to heading frequency in male soccer players. J Clin Sp Psychol 2007;1:379-389.
6. Witol AD. & Webbe FM. Soccer heading frequency predicts neuropsychological deficits. Arch Clin Neuropsychol 2003;18: 397-417.
7. Henry C, Tremblay J, Tremblay S, Lee A, Brun C, Lepore N, Theoret H, Ellemberg D, Lassonde M. Acute and Chronic Changes in Diffusivity Measures after Sports Concussion. J Neurotrauma 2011;28(10): 2049-2059.
8. Tysvaer A, Storli O. Association football injuries to the brain: A preliminary report. Br J Sports Med 1981:15:163-166.
9. Sortland O, Tysvaer A. Damage in former association football players: An evaluation by cerebral computed tomography. Neuroradiology 1989;31:44-48.
10. Tysvaer A, Storli O, Bachen N. Soccer injuries to the brain: A neurologic and electroencephalographic study of former players. Acta Neurologica Scandinavica 1989;80:151-156.
11. Tysvaer A, Lochen E. Soccer injuries to the brain: A neuropsychologic study of former soccer players. Am J Sports Med 1991;19:56- 60.
12. Tysvaer A. Head and neck injuries in soccer: Impact of minor trauma. Sports Medicine 1992:14:200-213.
13. Abreau F, Templer D, Schuyler B, Hutchison H. Neuropsychological assessment of soccer players. Neuropsychology 1990;4:175-181.
14. Matser J, Kessels A, Jordan B, Lezak M, Troost J. Chronic traumatic brain injury in professional soccer players. Neurol 1998;51: 791-796.
15. Matser J, Kessels A, Lezak M, Jordan B, Troost J. Neuropsychological impairment in amateur soccer players. JAMA 1999;282: 971-973 (amateur soccer players found to have diminished ability on tests of memory and planning).
16. Barnes B, Cooper L, Kirkendall D, McDermott T, Jordan B, Garrett W. Concussion history in elite male and female soccer players. The
Am J Sports Med 1998;26:433-438.
17. Guskiewicz K, Marshall S, Broglio S, Cantu R, Kirkendall D. No evidence of impaired neurocognitive performance in collegiate soccer
players. Am J Sports Med 2002;30(2):157-162.
18. Kirkendall D, et al. Heading in soccer: Integral skill or grounds for cognitive dysfunction? J Ath Tr 2001;36:328-333.
19. Spear,J. Are professional footballers at risk of developing dementia? Int'l J Geriatric Psych 1995;10:1011-1014.
20. Rutherford A, Stephens R, Potter D. The neuropsychology of heading and head trauma in association football (soccer): A review. Neuropsychol Rev 2003;13:153-179.
21. Koutures C, Gregory A, and The Council on Sports Medicine and Fitness. Clinical Report: Injuries in Youth Soccer. Pediatrics 2010;125:410-414. Reaffirmed May 2014 (http://pediatrics.aappublications.org/content/132/1/e281.full [13])
22. Spiotta A, Bartsch A, Benzel E. Heading in Soccer: Dangerous Play? Neurosurgery 2012;70(1):1-11.
23. Fakhran S, Yaeger K, Alhilali L. Symptomatic White Matter Changes in Mild Traumatic Brain Injury Resemble Pathologic Features of Early Alzheimer Dementia. Radiology 2013. DOI:10.1148/radiol.13122343.
24. Janda D, Bir C, & Cheney A. An evaluation of the cumulative concussive effect of soccer heading in the youth population. Injury Control and Safety Promotion 2002;9(1), 25-31.
25. Salinas C, Webbe F, & Devore T. The epidemiology of soccer heading in competitive youth players. J Clin Sport Psychol 2009;3:1-20.
26. Stephens R, Rutherford A, Potter D, & Fernie G. Neuropsychological impairment as a consequence of football (soccer) play and report on school students (13-16 years). Child Neuropsychol. 2005;11:513-526.
27. Barnes B, Cooper L, Kirkendall D, McDermott T, Jordan B, & Garrett W. Concussion history in elite male and female soccer players. Am J Sports Med 1998;26:433-438.
28. Dezman Z, Ledet E, Kerr H. Neck Strength Imbalance Correlates With Increased Head Acceleration in Soccer Heading. Sports Health: A Multidisciplinary Approach 2013; 20(10). DOI: 10.1177/1941738113480935 (published online ahead of print March 20, 2013)(accessed March 21, 2013).
29. Cantu R (2012). Concussions and Our Kids. New York: Houghton Mifflin Harcourt
30. Oulette J. Is heading safe? http://www.ayso.org/resources/safety/is_heading_safe.aspx [14]. (accessed March 20, 2013).
31. Meehan WP, III, (2011). Kids, Sports & Concussion. Santa Barbara: Praeger
32. Small G, Kepe V, Siddarth P, Ercoli LM, et al PET Scanning of Brain Tau in Retired National Football League Players: Preliminary Findings. Am J Geriatr Psych 2013;21:138-144.
33. Van Jones SA, Breakley RW, Evans PJ. Heading in football, long-term cognitive decline and dementia: evidence from screening retired professional footballers. Br J Sports Med. 2014;48:159-161, doi:10.1136/bjsports-2013-092758.
34. Gutierrez GM, Conte C, Lightbourne K. The relationship between impact force, neck strength, and neurocognitive performance in soccer heading in adolescent females. Pediatric Exer Sci. 2014;26:33-40.
35. Collins CL, Fletcher EN, Fields SK, Kluchurosky L, Rohrkemper MK, Comstock RD, Cantu RC. Neck Strength: A Protective Factor Reducing Risk for Concussion in High School Sports. J Primary Prevent. 2014; DOI:10.1007/s10935-014-03555-2 (published online ahead of print June 15, 2014)
36. Cobb BR, Urban JE, Davenport EM, Rowson S, Duma SM, Maldjian JA, Whitlow CT, Powers AK, Stizel JD. Head Impact Exposure in Youth Football: Elementary School Ages 9-12 Years and the Effect of Practice Structure. Ann Biomed Eng ( 2013): DOI: 10.1007/s10439-013-0867-6 (online ahead of print)
37. Kontos P, Fazio V, Burkart S, Swindell H, Marron J, Collins M. Incidence of Sport-Related Concussion among Youth Football Players Aged 8-12 Years. J Pediatrics 2013. DOI 10.1016/j.jpeds.2013.04.011
38. Sports Legacy Institute, "US Women's Soccer Legend Brandi Chastain, Sports Legacy Institute and Santa Clara Institute of Sports Law and Ethics Launch Educational Campaign on Concussions and the Risks of Heading In Soccer Before High School." (press release; June 25, 2014)(http://www.sportslegacy.org/wp-content/uploads/2014/06/Soccer-Heading-Pr... [15])(accessed August 2, 2014).
39. Cantu R, Nowinski C, Robbins C. White Paper: The Neurological Consequences Of Heading In Soccer. Sports Legacy Institute (undated)(http://www.sportslegacy.org/wp-content/uploads/2014/07/Soccer-Heading-Wh... [16])(accessed August 2, 2014)
40. Bowen J. "The Ethics of Headers in Youth Soccer: Using Our Heads Correctly." Santa Clara Institute of Sports Law & Ethics (July 24, 2014)(http://law.scu.edu/sports-law/the-ethics-of-headers-in-youth-soccer-usin... [17])(accessed August 2, 2014)
41. Stephens R, Rutherford A, PotterD, Fernie G. Neuropsychological consequences of soccer play in adolescent U.K. school team soccer players. J Neuropsychiatry and Clin Neuroscience 2010;22:295-303.
42. Rieder C, Jansen P. No neuropsychological consequence in male and female soccer players after a short heading training. Arch Clin Neuropsychol. 2011;26:583-591.
43. O'Kane J, Spieker A, Levy MR, Neradilek M, Polissar NL, Schiff MA. Concussions Among Female Middle-School Soccer Players. JAMA Pediatr. 2013;doi:10.1001/jamapediatrics.2013.4518 (published online January 20, 2014).
44. Zhang MR, Red SD, Lin AH, Patel SS, Sereno AB. Evidence of Cognitive Dysfunction after Soccer Playing with Ball Heading Using a Novel Tablet-Based Approach. PLOS One. 2013;DOI: 10.137/journal.pone.0057364 (accessed August 2, 2014)
45. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med. 2012;40(4):747-755
46. American Academy of Pediatrics' Council on Sports Medicine and Fitness. Position Statement: Reducing Injury Risk from Body Checking in Boys' Youth Ice Hockey. Pediatrics. 2014;133:11151;originally published online May 26, 2014;doi:10.1542/peds.2014-0692.
47. Comstock RD, Currie DW, Pierpoint LA, Grubenhoff JA, Fields SK. An Evidence-Based Discussion of Heading The Ball And Concussions in High School Soccer. JAMA Pediatrics 2015; doi:10.1001/jamapediatrics.2015.1062 (publilshed online July 13, 2015)
48. http://www.sportslegacy.org/policy/safer-soccer/ [18] (last visited July 16, 2015)
49. Reynolds, G. Heading Ban for Youth Soccer Won't End Head Injuries. New York Times. July 15, 2015 (http://well.blogs.nytimes.com/2015/07/15/heading-ban-for-youth-soccer-wo... [19] (accessed July 16, 2015).
50. Jon Schuppe. "Will Soccer's New Header Rules Make Kids Safer?" www.NBCNews.com [20]. November 10, 2015 (accessed at http://www.nbcnews.com/news/us-news/will-soccers-new-header-rules-make-kids-safer-n460916)
Posted August 3, 2014. Most recently reviewed and substantially updated July 16, 2015. Updated November 10, 2015 to reflect breaking news about the new rules and recommendations on heading in soccer announced by U.S. Soccer. Most recently updated April 20, 2016 to include Professor Webbe's views on the new youth soccer heading ban and practice limitations.
Links:
[1] https://mail.momsteam.com/repetitive-brain-trauma-and-chronic-traumatic-encephalopathy-CTE-cause-and-effect-relationship-scientifically-premature
[2] https://mail.momsteam.com/alzheimers/cte-media-narrative-ahead-science-say-researchers
[3] https://mail.momsteam.com/heading/stronger-necks-may-reduce-brain-trauma-from-soccer-heading-study-says
[4] https://mail.momsteam.com/health-safety/stronger-necks-may-reduce-concussion-risk-study
[5] http://pediatrics.aappublications.org/content/early/2014/05/20/peds.2014-0692.abstract
[6] https://mail.momsteam.com/sub-concussive/sub-concussive-hits-growing-concern-in-youth-sports
[7] https://mail.momsteam.com/soccer-heading-subconcussive/heading-in-soccer-doesnt-lead-long-term-cognitive-decline-study-finds
[8] https://mail.momsteam.com/subconcussive/frequent-soccer-heading-linked-brain-damage-impaired-memory-study-finds
[9] https://mail.momsteam.com/concussions-common-among-female-middle-school-soccer-players
[10] https://mail.momsteam.com/heading/heading-in-soccer-long-term-effect-remains-unclear
[11] http://www.momsteaminstitute.org/momsteam-institute-boards-advisors
[12] http://www.momsteaminstitute.org/smartteams™-0
[13] http://pediatrics.aappublications.org/content/132/1/e281.full
[14] http://www.ayso.org/resources/safety/is_heading_safe.aspx
[15] http://www.sportslegacy.org/wp-content/uploads/2014/06/Soccer-Heading-Press-Release-062414.pdf
[16] http://www.sportslegacy.org/wp-content/uploads/2014/07/Soccer-Heading-White-Paper-072914.pdf
[17] http://law.scu.edu/sports-law/the-ethics-of-headers-in-youth-soccer-using-our-heads-correctly/
[18] http://www.sportslegacy.org/policy/safer-soccer/
[19] http://well.blogs.nytimes.com/2015/07/15/heading-ban-for-youth-soccer-wont-end-head-injuries/
[20] http://www.NBCNews.com
[21] https://mail.momsteam.com/sports/soccer/studies-suggest-repeated-heading-of-soccer-balls-effects-short-term-mental-performance
[22] https://mail.momsteam.com/sports/soccer/two-studies-suggest-soccer-heading-may-lower-test-scores
[23] https://mail.momsteam.com/sports/soccer/safety/florida-tech-studies-raises-concerns-for-parents-about-soccer-heading
[24] https://mail.momsteam.com/concussive-and-subconcussive-blows-may-speed-up-brain-natural-aging-process-studies-suggest