Heading in Soccer: The Debate Continues
Heading in youth soccer
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.  The issue, however, as Webbe notes, is “not trivial,” citing a 2009 study of which he was a co-author  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. 
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 of female middle school soccer players  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.”
Does heading cause brain damage?
The 2010 AAP Clinical Report on youth soccer injuries  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  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 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  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.
Adding fuel to fire
The decision by the United States Soccer Federation (“USSF”) in November 2015 to ban heading in programs under its control for soccer players 10 and under and to limit heading in practice for those ages 12 and 13, and 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, adds 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, 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 reiterated 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.”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.”
Also 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 toldNBC News 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.”