Heading Safety in Soccer

Proper heading can minimize the risk of brain injury

soccer header
Pedro Blanco

In soccer, except for throw-ins, players other than the goalie can’t use their hands. Although players typically use their feet to move the ball and advance play, heading is another key element. Headers enable the player to pass, clear or shoot the ball with their heads. However, head injury has become a hot-button issue in sports, most notably American football, and this concern has spread to soccer.

The research on heading in soccer is both limited and mixed, with some studies showing no repercussions. Other studies, however, have linked this practice to concussions, subconcussive symptoms, and neurocognitive impairment.

Banning heading at the high school level and beyond is likely untenable. Proper heading is an asset to the sport and ingrained in the culture of soccer. However, those who do engage in heading should be properly trained and use proper technique to minimize injury.

Soccer Statistics

Soccer is the most popular sport in the world. According to the Fédération Internationale de Football Association (FIFA), 265 million people play the sport.

In the United States, soccer has been adopted as a safer alternative to other youth sports, and the number of athletes playing this sport has ballooned. Between 1969 and 1970, soccer was played at 2217 high schools (49,593 male players; 0 female players).

Between 2013 and 2014, boys’ soccer was played at 11,718 schools (417,419 players), and girls’ soccer was played at 11,354 schools (375,564 players).

Among professional footballers, players on average head a soccer ball between 6 and 12 times a game thus totaling at least 2000 headers during a 20-year career.

Among these players, 40 percent of injuries are caused by head-player contact, and head-ball contact—including accidental heading—accounts for 12.6 percent of injuries.  

Among youth soccer players, heading is estimated to cause between 31 and 37 percent of concussions. At the college level, concussions account for 5.8 percent of injuries sustained by male soccer players, and 8.6 percent of injuries sustained by female players.  

Research on Heading

Although little is known about the short-term effects of heading, in the aggregate, heading has been associated with impaired planning, memory, and visuoperceptual performance. Intuitively, these changes seem to make sense because players head with the upper part of the forehead that protects the prefrontal cortex, which is involved in cognitive, emotional and behavioral functioning.

The most disquieting research findings concerning heading in soccer are based on examinations of professional players, who perform headers countless times in games and practices during the course of a lifetime.

In a 2017 article published in Acta Neuropathologica, 14 retired soccer players (13 professionals and one committed amateur) were followed up until death. These footballers played for an average of 26 years, and all these players were skilled at heading. Six of the players had experienced one concussion each during the course of their careers. 

All of these players developed dementia later in life. Ten of these players also had coexisting motor impairments, including parkinsonism, gait instability or postural instability with frequent falls, and dysarthria (dysarthria refers to trouble speaking). Furthermore, mood and behavioral changes were common among these people.

These players began to develop progressive cognitive impairment at an average age of about 64, and the disease lasted for an average of 10 years. Twelve of the 16 players died of advanced neurodegenerative disease. None of the players were reported to experience substance abuse, alcohol abuse or suicidal thoughts.

Autopsies were performed on six of these players, and all showed disease changes indicative of chronic repetitive head impacts. More specifically, four demonstrated the mandatory diagnostic criteria of chronic traumatic encephalopathy, or CTE, which has also been demonstrated in professional boxers, football players, hockey players and so forth. (CTE is a diagnosis made after autopsy.) Furthermore, the other two cases, although not meeting all criteria needed for diagnosis, showed some features that were characteristic of CTE, such as septal abnormalities, tau pathologies, and dilatation of the third ventricle.

In another 2017 article published in Neurology, 222 amateur soccer players (79 percent male) were given questionnaires asking about frequency of headings and frequency and severity of central nervous system (CNS) symptoms, ranging from mild to very severe. Here are some results of this study:

  • For men, the average number of headers for a two-week interval was 44, and the median number was 18.
  • For women, the average number of headers for a two-week interval was 27, and the median number was 9.5.
  • Heading-related symptoms were experienced by 20 percent of respondents.
  • At least one or more unintentional head impacts were reported in 37 percent of man and 43 percent of women.
  • Moderate to very severe CNS symptoms were linked to heading activity and unintentional head impacts. These findings were significant for players who headed most (highest quartile).

According to the authors:

“Heading is associated with lower cognitive performance in high school, adult amateur, and professional soccer players as well as microstructural brain injury, independent of recognized concussion. Notably, head impacts that result in overt concussive events may not represent the full span of risks.”

Results linking CNS symptoms in players who frequently headed the ball concurred with researchers’ data from previous studies, which had shown that 30 percent of soccer players who headed more than 1000 times a year were at higher risk for microstructural white matter changes comparable with those of traumatic brain injury (TBI).

According to the CDC:

"A TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from ‘mild’ (i.e., a brief change in mental status or consciousness) to ‘severe’ (i.e., an extended period of unconsciousness or memory loss after the injury).  Most TBIs that occur each year are mild, commonly called concussions."

What About Protective Headbands?

In an attempt to capitalize on heading fears, several manufacturers have developed headbands that are meant to protect the player from the negative effects of heading and unintentional head injuries. These headbands are typically made of about one centimeter-thick protective foam, which wraps around the head and surrounds the parietal, temporal, frontal and occipital lobes. Manufacturers of these devices claim that they dissipate the force of head impacts and reduce concussions and neurocognitive effects. But do they?

Similar to studies that examined the potentially harmful effects of heading, any conclusions​ that are drawn from analyses of these headbands are also debatable.

For instance, in one small study published in the journal Research in Sports Medicine in 2015, participants wearing the headband showed decreases in verbal memory following heading exercises, and participants who didn’t wear the headband showed faster reaction times following heading exercises. Because these results are intrinsically counterintuitive, the researchers concluded that protective soccer headgear does little to mitigate the subtle neurocognitive effects of heading.

Proper Heading Technique

In light of growing concerns about heading, in November 2015, the National Soccer Coaches Association of America (NSCAA) forbade it in players of “soccer age” 11 years old (U11), and limited the practice in players belonging to U12 and U13 groups. For players U14 and beyond, proper heading technique is a focus of practice and play.

On a related note, several former U.S. Women’s National Team stars, including Joy Fawcett, Brandi Chastain and Cindy Parlow Cone, have joined the call to ban heading before the high school level. Moreover, soccer veteran Abby Wambach is a big advocate for heading safety, and she plans to donate her brain for concussion research.

According to the NSCAA, the key to preventing injury is neck and core strengthening. Youths aged between U11 and U14 should be taught to unite the head, neck and torso so as to prevent injury.  Here are five tips:

  1. Players should use their foreheads while heading. They should also keep their eyes open and mouths shut.
  2. Players should balance with their arms while heading.
  3. Players should place themselves in the ball’s line of flight while heading.
  4. Players should keep their heads still while getting into the ball’s line of flight.
  5. Players should maintain a wide stance with their feet while heading.

Bottom Line

Data examining the potentially harmful effects of heading are as of yet inconclusive and ambiguous. Nevertheless, enough research has been done supporting neurocognitive effects that U.S. soccer has banned the practice in players of soccer age 11 and younger while restricting the practice in 12- and 13-year-olds to—at most—30 minutes of heading training a week and no more than 15 to 20 headers per player.

Protective headgear designed to mitigate the risks of heading and unintentional head injury is probably of little use. Instead, players should learn to and practice proper heading technique so as to minimize the risks of brain injury.

Sources

Comstock RD et al. An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatrics. 2015; 169(9):830-837.

Elbin RJ et al. A Preliminary Examination of Neurocognitive Performance and Symptoms Following a Bout of Soccer Heading in Athletes Wearing Protective Soccer Headbands. Research in Sports Medicine, 23:203–214, 2015.

Ling H et al. Mixed pathologies including chronic traumatic encephalopathy account for dementia in retired association football (soccer) players. Acta Neuropathologica. February 15, 2017.

NSCAA Takes the Lead in Heading Safety. Soccer Journal. September-October 2016.

Stewart WF et al. Symptoms From Repeated Intentional and Unintentional Head Impact in Soccer Players.  Neurology. 2017.

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