Heading in Soccer

Preliminary report submitted to Summerfield Waldorf School

By Ofer Zur, Ph.D. ~ https://www.zurinstitute.com

Concern has been raised over whether “heading” in soccer may be the basis for concussion and both short-term cognitive decline and the risk of long-term cognitive degeneration. The issue is highly controversial and scientific studies contradict each other. It is the general consensus that the issue should be explored further, but the level of concern remains high enough for the American Academy of Pediatrics to issue the following policy statement in March/2000:

Currently, there seems to be insufficient published data to support a recommendation that young soccer players completely refrain from heading the ball. However, adults who supervise participants in youth soccer should minimize the use of the technique of heading the ball until the potential for permanent cognitive impairment is further delineated.

Synchronistically, The New York Times published an article on Oct. 19, 2009, titled SOCCER; Concerns About Heading by Youth Soccer Players Set Off Debate.



What We Know:

In the United States, there are well over 3 million children and adolescents playing in high school or youth soccer teams, with participation increasing at a range of about 21% annually. Soccer is among the sports with the highest risk of concussion, with greatest risk occurring with head to head collision while players are “in the act heading”. Players in positions where heading is common are likely to have head to head collisions more often. Most concussive injuries seen in soccer derive from such head to head rather than ball to head contact. Concussions constitute 20% of soccer injuries.


Boys playing soccer

There is very limited research specifically related to “heading” and concussion in soccer and there is no consensus of opinion. Many of the studies are inconclusive or contradict one another. A Norwegian study of adult players, who began playing in youth leagues, showed mild to severe deficits in attention concentration, and memory in 81% of players tested. Players who headed the ball more frequently had higher rates of cognitive loss than those who used the technique less often. A Dutch study shows similar results. Another study published in the British Journal of Sports Medicine shows contradictory results indicating that repeated low-severity impacts due to heading in soccer are not associated with and neurochemical signs of injury to the brain. A study reported in Neurosurgery found reduced neuropsychological performance was found after minor head impacts in soccer, even in allegedly asymptomatic players. However, the log term cognitive consequences are uncertain. In another study, a multidisciplinary team of university researchers, with members from both the School of Medicine and the School of Engineering and Applied Science concluded that the main danger is that soccer “heading” involves linear and angular accelerations with changes in velocity over time. Animal studies have shown that angular accelerations cause the greatest injury. The brain experiences a shear force that causes deformation in the areas of the brain where the blood vessels penetrate and where the hemispheres come in contact with the brain. They believe this can occur with mild impact depending on the velocity and the random amount acceleration.

Age and Gender Considerations:

Most studies have focused on professional and collegiate athletes, however special consideration is increasingly being directed to young athletes, as the effect of concussion on the developing brain is still not fully understood. We do know that studies tracking symptoms and neuropsychological function find high school athletes to be more vulnerable to concussion and slower to recover from symptoms of retrograde amnesia, post traumatic confusion and memory impairment and that young brains are more vulnerable to severe damage (Cantu). Researchers studying the relation of soccer to age have found that higher rates of injury occur among males 16 to 18 years of age and in girls 17 to 19 years of age. Girls have higher rates of concussion, which may be attributed to greater willingness to report symptoms.

Factors that Increase Risk:

Returning to play while experiencing symptoms of concussion places a player at a great risk. Also, players with a history of multiple concussions may be at risk for experiencing concussion-linked symptoms well beyond the acute stage of injury.

Boy heading a soccer ball

The consequences of repeat concussion are often long-lasting and sometimes permanent: persistent headaches, fatigue, difficulty paying attention, memory problems, mood swings and personality changes or a rare but catastrophic deregulation of brain activity that can occur, and result in death, when a young player sustains another hit before the brain has had time to recover from a prior concussion. The risk for second impact syndrome is higher for soccer.

Many experts recommend that following repeated concussions, a player should be sidelined for longer periods of time and possibly not allowed to play for the remainder of the season. Second Impact Syndrome results from acute, sometimes fatal brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion. This causes vascular congestion and increased intracranial pressure, which may be difficult or impossible to control.

Guidelines from the International Concussion Consensus Statement (Zurich 2009), the National Athletic Trainers Association Position Paper, and the American College of Sports Medicine conclude that no athlete 18 or under should be allowed to return to the same contest if they suspected of having a concussion. Additionally, the improper use of heading techniques increases risk.

Cerebral concussions frequently affect athletes in both contact and non-contact sports. Cerebral concussions are considered diffuse brain injuries and can be defined as traumatically induced alterations of mental status. A concussion results from shaking the brain within the skull and, if severe can cause shearing injuries to nerve fibers and neurons.

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Checklist of Common Signs and Symptoms Observed by Coaching Staff (Adapted from CDC)

  • Appears to be dazed or stunned
  • Is confused about assignment or position
  • Forgets sports plays
  • Is unsure of game, score, or opponent
  • Moves clumsily
  • Answers questions slowly
  • Loses consciousness (even briefly)
  • Shows behavior or personality change
  • Forgets events prior to hit (retrograde amnesia)
  • Forgets events after hit (antrograde amnesia)

Athletes who experience any of these signs or symptoms after a bump or blow to the head should be kept from play until given permission to return to play by a health care professional with experience in evaluating for concussion. Signs and symptoms of concussion can last from several minutes to days, weeks, months, or even longer in some cases. Athletes may not experience and/or report symptoms until hours or days after the injury. If you have any suspicion that your athlete has a concussion, you should keep the athlete out of the game or practice.

Checklist of Common Signs and Symptoms Reported by the Athlete (Adapted from CDC)

  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or fuzzy vision
  • Sensitivity to light or noise
  • Feeling sluggish
  • Feeling “foggy”
  • Change in sleep pattern
  • Concentration or memory problems
  • Confusion
  • Does not feel “right”

Checklist of Common Signs and Symptoms Observed by Parents (Adapted from CDC)

  • Appears dazed or stunned
  • Is confused about assignment or position
  • Forgets instruction
  • Is unsure of game, score, or opponent
  • Moves clumsily
  • Answers questions slowly
  • Loses consciousness (even briefly)
  • Shows behavior or personality changes
  • Can’t recall events prior to hit or fall
  • Can’t recall events after hit or fall

What to do if you think your child has had a concussion:

  • Seek medical attention right away.
  • Keep your child out of play. Concussions take time to heal. Don’t let your child return to play until a health professional says it’s OK. Second or later concussions can be very serious. They can cause permanent damage, affecting your child for the remainder of his or her life.
  • Tell your child’s coach about any recent concussions.




According to recommendations from Dr. Cantu, once the athlete is medically stable it is helpful to:

  • Stop physical exercise and activity or do mild aerobic exercise such as walking.
  • Get as much sleep as possible.
  • Get cognitive rest.
  • Refrain from schoolwork, video games and texting until symptoms clear.
  • Wait until symptoms are fully cleared before returning to play.


Recommendations for Soccer Safety:

  1. Teach kids the art of heading the ball, which may include strengthening the back and neck. Different age groups will need to develop different skill sets.
  2. Educate players about the danger of ‘head to head’ collision.
  3. Use smaller or lighter balls for younger players and pad the goal posts.
  4. Coaching staff must learn to identify mild and other concussions. As noted above, one simple option is to use The Graded Symptom Checklist.
  5. Educate kids and parents about the symptoms of concussion and encourage both of them to report them to coaches and staff.Most importantly:
  6. Remove players from play immediately if there is any suspicion of concussion.
  7. Develop and follow a clear policy of not returning players prematurely to practice or games after they suffer a concussion.
  8. Follow up with post-concussion care to prevent permanent brain damage.




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