Sports-related concussions, especially concussions in soccer, have become a significant public health concern in the United States, with more attention being directed towards youth sports and in particular, potential prevention measures. This attention is warranted, as youth athletes between ages 5 and 18 account for 65% of all sport- and recreation related head injuries in U.S. emergency rooms.1 Unfortunately, this incidence is rising, with concussions comprising approximately 13% of all sport-related injuries at the end of the 20th century, compared to only 5% 20 years earlier.5

Concussions in soccer too many to ignore

Concussions in soccerThe rates of concussions in high school soccer players is not to be underestimated. Among the nine most popular high school sports studied, the rate of concussions per athlete exposure (AE) for female soccer players is second only to male football players (0.73 vs. 0.94 per 1,000 AEs), and male soccer players are fourth in incidence with 0.41 per 1,000 AEs.

Youth soccer has gained significant popularity in the last four decades, with the number of high school participants increasing from 49,593 male and 0 female players at 2,217 schools in the 1969–70 season to 417,419 male and 375,564 female players at 11,718 and 11,354 schools, respectively, in the 2013–14 season.4 As a sport, soccer contributes multiple physical, social, developmental, and psychological benefits to many of our youth during their formative years, yet it also has been shown to pose the risk of injury.

Most commonly, these injuries involve the lower extremity such as the ankle and knee, with the most common injury involving player-to-player contact during competition and noncontact mechanisms more common during practice.11

However, soccer players are also at significant risk of sustaining sport-related concussions. The rates of soccer-related concussions during competition has been reported to be 9.2 per 10,000 AEs for girls, and 5.3 per 10,000 AEs for boys.The increased awareness of the incidence and severity of concussions in sports has led to increased attention on the subject. Several former US Women’s National Team members, including Brandi Chastain, Cindy Parlow Cone, and Joy Fawcett have joined the Sports Legacy Institute in forming the organization Parents and Pros for Safer Soccer, in an effort to address this issue.

Stop heading the ball

They have called for banning soccer ball heading in programs below the high school level as a means to reduce concussions.9 While this effort is notable, it also assumes that heading is a major contributor to the incidence of concussions and the banning of this aspect of the sport will lead to a significant decrease in injury.

The research around concussions in soccer is still not fully developed. Some studies have reported that heading is responsible for between 31% and 37% of youth-related soccer concussions.3,11 Concussions have also been implicated as a cause of neurocognitive, neuropsychological, and postural control impairments.10 

However, the connection and causation between the act of heading the ball, player-to-player contact, and the sustainment of a concussion is still being explored. A large review of the National High School Sports-Related Injury Surveillance Study’s High School Reporting Information Online (High School RIO), an Internet-based sports injury surveillance system, has demonstrated that heading was the most common soccer-specific activity associated with concussions (in 31% of boys’ and 25% of girls’ concussions).2

However, the same review also determined that the most common concussion mechanism of injury was
direct player-to-player contact (69% in boys and 51% in girls), regardless of whether the act of heading was involved or not.2 Additionally, several controlled laboratory studies have shown that the act of heading a soccer ball is not associated with neuropsychological or neurocognitive test performance or postural control measures.6,8

Concussions come from player to player contact

Thus, it has been postulated that the act of heading itself is not an isolated causative factor for concussions, but rather the nature of contested heading during competition leads to more frequent player-to-player contact, which is the driving factor related to concussions in soccer. 

To affect the most change, prevention efforts need to be evidence-based and culturally acceptable. Banning heading from youth soccer is a controversial topic and is just one aspect of the overall picture. Soccer is a physical sport, and evidence has shown that player-to-player contact is by far the most common mechanism of sustaining concussions.

Efforts to reduce player-to-player contact across all aspects of the game, whether through stricter enforcement of current rules of the game, athlete education, and focused coaching techniques, will likely result in the most meaningful reduction in all injuries, including concussions.

Article by, Christopher J. Tucker, MD

References

  1. Centers for Disease Control and Prevention (CDC). Nonfatal traumatic brain injuries from sports and recreation activities—United States, 2001–2005. MMWR Morb Mortal Wkly Rep. 2007.56:733-7.
  2. 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 Pediatr. 2015.169:830-7.
  3. 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;40:747-55.
  4. National Federation of State High School Associations. 2013-14 High School Athletics Participation Survey. http://www.nfhs.org/ParticipationStatics/PDF/2013-14_Participation_Survey_PDF.pdf. Accessed January 31, 2017.
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  6. Rieder C, Jansen P. No neuropsychological consequence in male and female soccer players after a short heading training. Arch Clin Neuropsychol. 2011.26:583-91.
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  8. Schmitt DM, Hertel J, Evans TA, Olmsted LC, Putukian M. Effect of an acute bout of soccer heading on postural control and self-reported concussion symptoms. In J Sports Med. 2004.25:326-31.
  9. Sports Legacy Institute. Safer soccer initiative. http://www.sportslegacy.orgpolicy/safer-soccer/. Accessed January 31, 2017.
  10. Tysvaer AT, Lochen EA. Soccer injuries to the brain: A neuropsychologic study of former soccer players. Am J Sports Med. 1991.19:56-60.
  11. Yard EE, Schroeder MJ, Fields SK, Collins CL, Comstock RD. The epidemiology of United States high school soccer injuries, 2005-2007. Am J Sports Med. 2008.36:1930-7.