Repetitive heading in soccer: Does it cause brain damage after all?

A few months ago, I wrote a column for The Post and Courier about whether Abby Wambach’s headers were skills that should be emulated by young soccer players. I presented the idea of many experts that the act of heading in soccer, even if done hundreds or thousands of times per year and over many years, is not likely to be dangerous to young players.

A few weeks ago, a study performed at Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center looked to confirm that hypothesis, namely that repetitive headers are, in fact, dangerous. The authors used magnetic resonance imaging (MRI) and neuropsychological tests on 38 amateur soccer players who had been playing since they were kids. The participants answered questions to estimate the number of times they headed the ball during the last year. The researchers then correlated these heading numbers to the MRIs and neuropsychological tests to see if there was a relationship.

Heading in soccer might lead to brain injury.
Does heading the ball lead to brain damage?

According to a press release from the institution and the abstract from the presentation (I cannot find the actually study, if it has been published), they did find that players who headed the ball frequently had brain injuries similar to a concussion. On the neuropsychological tests it was shown that players with the highest heading frequencies were more likely to have poorer verbal memory and psychomotor speed.

Soccer heading and brain changes

The MRI scans of the players reportedly showed damage to all areas of the brains, but most of the affects were seen in the frontal lobes and temporal-occipital regions. The researchers pointed out that these regions of the brains are vital for memory, attention, executive functioning, and higher-order visual functions. In fact, the study’s lead author, Michael Lipton, M.D., Ph. D. noted that there seemed to be a threshold of 1000 to 1500 headers a year that resulted in detectable brain injury.

Now I have a few initial thoughts, and again I want to point out that I don’t have the actual study to review. My observations and opinions might turn out to be unfounded if the authors did address some of these study design issues.

First of all, the average age of the 38 participants was over 30 years old, and the players had participated in soccer since childhood. Like I pointed out in my Abby Wambach column, what seems to be more important than repetitive contact with the ball in heading is a history of more traumatic injuries. By that I mean true concussions. Athletes who have been playing for 20 or more years likely have suffered concussions, and often many of them. The press release and abstract do not mention whether the authors take a history of concussion into account. And I am guessing that they did not do so in the study.

Soccer concussion
Are traumatic head injuries or repetitive heading more dangerous for long-term brain injury?

Concussions and heading in soccer

We don’t know if the players who headed the ball more than 1000 or 1500 times a year played at a higher level or more often, increasing their risk for a traumatic brain injury (concussion). They naturally would be expected to be more likely to have findings on the MRIs and lower scores on the neuropsychological tests. Knowing which of the 38 players missed practices or games for concussions from collisions with other players or the ground or goalposts would be very helpful to rule out trauma as a variable.

Age and heading in soccer

Second, there is no mention of how age plays a role. While they point out that young players often use balls that are the same size as adults (and therefore would have a potentially higher risk of injury to their developing brains), they don’t show that heading at a certain age had more affect than at a later age. It might be true that this is a problem for younger players more than older ones, but we don’t know.

Now, while I am not sure if I agree that repetitive heading in soccer is necessarily a problem solely based on this information, I still think it is a step in the right direction. We need more information to decrease the risk of brain injuries in all sports. And the idea that there is a threshold above which the risk of brain damage goes up significantly is intriguing. It reminds me of the study published earlier this year which showed that youth baseball players who pitched more than 100 innings per year were 3.5 times more likely to suffer a shoulder or elbow injury.

Is heading in soccer safe?

Hopefully this study will spur further research into concussions. I believe that we need far more data to help us as sports medicine professionals make decisions about whether to allow athletes to play after a concussion. But we also need to focus on prevention. We need to find methods to decrease the risk of these injuries without fundamentally changing each sport, if possible.