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Is There A "Head Count" for Soccer?

Study suggests threshold below which heading is generally safe and above which it is generally unsafe

No consensus

But the importance of neck strength is where the consensus ends.  Some experts, most notably Robert C. Cantu, M.D., in his 2012 book, "Concussions and Our Kids," [29] recommend that soccer heading be delayed until age 14, not just because of the risk of repetitive brain trauma 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]  Other national soccer programs have not, however, followed suit. 

The AAP recommends 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, [21] a position similar to that recommended by the University of Maryland's Dezman 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. 

In the other camp are those, like Dr. William Meehan, Director of the Sports Concussion Clinic and Micheli Center for Sports Injury Prevention at Boston Children's Hospital, and author of 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. 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, he finds support from the American Academy of Pediatrics ' 2010 clinical report, [21] which, while recognizing proper technique as "foremost in reducing the risk of concussion from heading the ball,"  also says that it "is imperative that soccer balls be water-resistant [one of the supposed culprits in the brain damage found in the retired Norwegian players], sized appropriately for age, and not hyperinflated."

Risk versus reward

"After reviewing this study (and discussing it with colleagues), there is definite interest in the findings, and a desire to have more information (larger sample size, perhaps even studies of child and adolescent athletes)," said Koutures, lead author of the AAP's youth soccer study. "Does it alone 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."

"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). There may be contexts where this study carries more impact (perhaps a child with underlying memory issues) and the family may place more weight on the results in making the best decision for their child." 

Decision tree

Where does all of this lead parents? In answering the question, "Should my child head soccer balls?" 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 is always the case, it is ultimately up to parents to decide what is best for their child.

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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.     

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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. Injuries in Youth Soccer. Pediatrics 2010;125:410-414. 

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. (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.