Heading in Soccer: The Debate Continues
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,  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.
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.
Proper heading requires a strong neck
As Webbe notes in a 2010 book,  “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  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  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.  “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. The second, a field study involving over 6,700 high school athletes 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.
Delaying heading: a mistake?
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,  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,  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,”  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.”
Stuck in the middle with you
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.  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(link is external)  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  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.