England’s Raheem Sterling lobs the ball to the far post having picked out Delle Alli, who rises to meet the ball and powerfully heads it past the Swedish goalkeeper for a 2–0 lead.

English fans go berserk, a sea of white turning into waves of white as they jump up and down in alternating unison and jubilation. “WHAT A HEADER” they all scream….“ “but is it worth it?” some neurological experts whisper (in the safety of their own homes).

Headers are an inherent part of soccer, that’s undeniable. They’re used in all facets of the game and can encompass the full majesty of it— a ball beautifully pinpointed into the box with a player rising up to powerfully head and direct it home.

However, when you break down headers into their most basic form, it goes something like this — you’re using the part of your body that isn’t supposed to take any contact (it houses our most vital organ after all) and repeatedly smack it against an object traveling at high speeds.

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That mismatch of function and use clearly doesn’t sound right. That begs the question: Does heading the ball in soccer lead to changes in the brain and brain injury?

This question, with a heavy wind in its sails from the growing outcry against brain injury via concussion, has led to growing concern and heavy debate over the safety of headers. The idea that “sub-concussive” impact may create changes in the brain and eventually lead to concussion-like problems.

So what does the evidence say?

In short — maybe, maybe not…the evidence is still emerging.

In long, there are two main sides to the debate — with one arguing risk/reward and the other arguing practicality.

Let’s take a look at this murky situation — with key experts from both sides of the debate chiming in.

The Risk/Reward Side

The risk/reward side of the debate is summed up as “there’s emerging evidence showing short-term changes in the brain after headers, so why risk potential long-term deficits?”

For example, a study in the journal Neurology found that players who headed an average of 125 balls over two weeks were more vulnerable to concussion than players who headed less than four in that same two-week period. Additionally, the former group reported having some concussion/MTBI-like symptoms including headaches and confusion.

A key figure in this debate has been neuroscientist Michael Lipton, who presides at the Albert Einstein College of Medicine in New York. Here’s how he described the basis of his research:

“In soccer, where you have people repeatedly hitting their head over time, the question is how much does it take to lead to a pathology that rises to a level where there are functional effects.”

He conducted a study in 2013, published in the journal Neuroradiology, in which repeated heading of the ball was associated with cognitive deficits and physical changes to brain structure. However, the sample size (amount of participants) was really small so you can’t draw too many conclusions.

At the time, here was his takeaway:

“There is clearly something going on, but what it means for the long term requires more work.”

And work he, and his team did.

In April of 2018 (that would be this year, just in case you did a bunch of headers today), they released a new study that followed 308 soccer players comparing the effects of heading the ball to “unintentional” head impacts such as elbow-head, head-head, goal post-head contact.

The study found that players who reported a higher number of headers had the poorest performance on key areas of functioning that are affected by brain injury — namely, psychomotor speed (ex: reaction time) and attention — whereas the unintentional head impacts didn’t cause any change in cognitive performance. Additionally, the players reporting a high number of headers had deficits in working memory (short-term applied memory) but not enough to be considered significant.

Overall, none of these cognitive deficits from headers was found to cause overt clinical impairment. Additionally, other researchers have questioned the validity of the study. For example, Anthony Kontos (research director for the UPMC Sports Medicine Concussion Program at the University of Pittsburgh) has questioned the accuracy of self-reporting:

“As a researcher who has published in this area and as a long-time soccer player who played in college and continues to play as an adult, I know first-hand that most players do not accurately recall heading exposure. Most likely, players over estimated their exposure to heading and lifetime head injuries.”

This is where the risk/reward argument really kicks in.

If we’re seeing transient changes in the brain with players who head the ball frequently, but no overt-changes or evidence of long-term changes, is that enough to curtail headers?

These were Lipton’s main takeaway messages:

“Impacts to the head matter even when, at the individual impact level, they may not seem to be causing an immediate problem. Heading is a potential cause of brain injury…and since it’s under control of the player, its consequences can be prevented.”

Lipton advises that soccer players consider reducing the amount of heading that takes place in practice and soccer — clearly, he’s on the risk side of the fence when it comes to the risk/reward calculation of headers in soccer.

This sentiment is shared by Angus Hunter of the Universtiy of Stirling in Scotland (say that 5 times fast) whose team used a specific type of imaging to measure brain function after performing headers. In response to the headers, participants had significantly elevated molecular markers of brain damage.

However, like the study by Lipton above, these changes were very short-lived. That brings us to the counter argument….

The We Need to Focus On Established High-Risk Contact

This side of the debate can be summed up as: “If we don’t know how headers impact the brain, outside of short-term changes, but we DO know that most concussions/MTBIs in soccer occur on contact plays, shouldn’t we be more focused on that?”

A leading proponent on this side is Dawn Comstock, an injury epidemiologist at the University of Colorado’s School of Public Health.

She published a study in JAMA paediatrics investigating the root cause of concussions/MTBI’s in high school sports, using 9 years of data on high school soccer players.

The study found that athlete-athlete contact accounted for 69% of concussion/MTBI incidences in males and 51% of concussion/MTBI incidences in females.

Based on the results, Comstock conceded that yes banning heading in soccer would prevent some concussions but the focus should first be on enforcing rules and reducing rough play, at all levels of the game:

“If you ban heading in soccer, you would prevent some concussions…but nobody is willing to address the elephant in the room, which is rough play. Coach fair play, coach technique and ensure officials enforce the rules of the game. Our children emulate what they see their sports stars do. If they see the women in the World Cup playing so aggressively, they will translate that to the field.”

John O’Kane, a sports physician and professor at the University of Washington Medical Center, agrees that reducing player-player contact and emphasizing technique should be the major emphasis:

“Heading is part of the sport and while there is risk involved, no sport is completely safe. The question is how to make heading and soccer in general safer, especially for kids.”

Both sides have viable points. Personally, it’s really hard to make a decision without finding out just how much headers impact the brain and if that increases the risk of long-term changes — that’s not clear right now and that’s a common dilemma when you’re researching new domains. It takes time for studies to take place and form a majority.

Do we make significant changes to a fundamental part of soccer based on still inconclusive evidence or is any potential risk of brain injury enough of an impetus to make changes?

Multiple organizations like CCMI and Concussion Legacy Foundation decided on the latter and that brings us to…

Limited heading protocols

The US Soccer Federation has implemented new rules in youth soccer to eliminate all heading in kids 10 and under, and limit heading to 30 minutes per week for kids 11 to 13.

Here’s an educational concussion video they created for coaches, parents, and players:

In England, the Professional Footballers Association (PFA) is also pushing to implement similar rules, at least until the long-term effects of heading the ball are better understood.

The PFA’s chief executive, Gordon Taylor, acknowledges that a causal link hasn’t been established but points to the US as an example of proactive thinking (there’s a first time for everything right):

“In America they decided — without establishing a causal link — that youngsters up to the age of 11 shouldn’t be heading the ball, particularly whilst this research is going on.”

UEFA, soccer’s governing body in Europe, has yet to make a decision as they wait for further conclusive evidence that headers lead to long-term damage.

UEFA President, Aleksander Ceferin, was asked if he would consider a similar ban and change in rules if studies showed conclusive risk:

“We need to take this seriously, of course. If it shows clearly that there is damage, especially for children, we have to be strict.”

As you can see, the momentum for limiting headers, at the youth levels at least, is growing and it may engulf all of Europe soon.

All in All

As the evidence currently stands, we still aren’t sure of how headers affect long-term brain health. However, as a parent or coach, the question becomes “ok, we may not know if headers lead to long-term changes but we do know they lead to short-term changes…is heading the ball worth possibly damaging my kid’s brain?”

This dilemma reminds me of American Football in the early 90’s where there wasn’t sure-fire evidence (or it was suppressed) and awareness of how routine football actions involving your head could lead to brain injury. We obviously know the ending to that story.

Let’s use that as a lesson, err on the side of caution, and make sure we really understand the implications of heading in soccer before it’s too late.

A brain is a terrible thing to waste after all.