Abby Wambach, the leading international scorer in women’s soccer history, is said to have started heading the ball by age 10. Wambach, now 33, has perfected the art of becoming a human missile to intercept passes and corner kicks, blasting the ball into the net. Statistically, nearly every other goal she scores in international play is with her head.
In 2012, Wambach was a guest contestant on the NPR news quiz show, “Wait, Wait . . . Don’t Tell Me!” A panelist reminded the soccer star, “You score a lot of goals with your head.” Wambach responded, “I do. I’m pretty much brain dead at this point.”
The audience, in accordance with the show’s tone, laughed. But should we?
Scientific research increasingly suggests it’s time to discuss a ban on heading in soccer, particularly on the youth level. Consider these findings over the past two years:
■ An Albert Einstein College of Medicine study found amateur players who frequently headed the ball had poorer memories, consistent with findings for patients with traumatic brain injury;
■ A Harvard and University of Munich study found changes in the white matter of soccer players consistent with mild traumatic brain injury;
■ A January review article by Canadian researchers in the journal Brain Injury, citing other studies, indicated that players who frequently headed the ball had lower scores on memory, motor skills, and conceptual thinking than players who headed less often or athletes from non-contact sports.
Then, in February, the Boston University medical team known for diagnosing degenerative brain disease in deceased football and hockey players discovered their first case of chronic traumatic encephalopathy, or CTE, in an American soccer player. Patrick Grange, a star at the University of New Mexico, died in April 2012 at age 29 of amyotrophic lateral sclerosis, or ALS. Researchers now believe his disease was triggered by his brain trauma. His parents said Grange began practicing heading when he was just 3 years old.
No single typical header in soccer is as terrifying to watch as the helmet-to-helmet blows between NFL offensive and defensive players colliding at full speed. Head contact is impossible to avoid in tackle football, while many soccer players on the field, such as goalies, rarely or never head the ball. And indeed, scientists are not at the point of declaring heading in soccer as undeniably dangerous to the brain as cumulative hits in football. Yet comparisons between the two sports offer only deceptive comfort.
For one, the sheer numbers of American young people potentially at risk make this question a public health concern. Some 8 million children in the United States ages 17 and under play soccer, according to the latest census figures. Plus — while not as relentlessly violent as football — girls’ soccer is still, by total numbers, the nation’s second-leading source of sports-related concussions on the high school level. And concussions in the sport occur at a rate only surpassed by men’s football, hockey, and lacrosse, according to a 2012 study from Ohio State University and Nationwide Children’s Hospital in Columbus, Ohio. Boys’ soccer ranks fifth.
In an interview, BU neuropathologist Dr. Ann McKee suggested Grange’s level of CTE was “as advanced as the report on Junior Seau.” Seau was the former star linebacker who, at age 43, committed suicide. His autopsied brain was later found to be ravaged by CTE. “To find that level of disease in someone in their 20s is pretty shocking,” McKee said of Grange’s trauma, likely related to soccer. “You just keep opening the door and you can’t believe what you find.”
No researcher I interviewed wanted to curb enthusiasm for soccer. It is truly a “beautiful game,” as Pele once called it, with its amazing foot skills and team passing work. It is also one of the most aerobic sports a young person can play in a society beset by a growing obesity epidemic.
Where the largest risk lies is when a player, going to head the ball, either collides with another player’s head or elbow or is slammed to the ground, according to Dawn Comstock, a leading researcher on sports-related concussions at the Colorado School of Public Health. “If we could find ways to reduce athlete-to-athlete contact, we’d reduce head injuries,” Comstock said. One way to reduce contact, she suggested, are rules similar to those in basketball where players can receive fouls for too much contact when rebounding.
But we now also know more about airborne impacts with the ball itself. In his research at Albert Einstein, Dr. Michael Lipton, a neuroradiologist, studied 37 male and female amateur players with an average age of 31. Participants, on average, had played soccer 10 months per year for an average of 22 years. The vast majority of players headed the ball up to 1,095 times a year. But one-quarter headed the ball between 1,096 and 5,400 annually.
Lipton said his findings suggest that, with lower levels of heading, the brain may be able to repair itself in most players. But there appears to be a tipping point where trauma cascades into long-term problems. Among his study’s participants, that threshold for worsening memory function was 1,800 headers per year, a level surpassed by four players. Eleven players had abnormalities in the part of the brain relevant to visual attention and processing after just 885 headers annually.
“These are not players in the professional leagues, but the effect size is quite large,” Lipton said. “That should encourage people to take this seriously.”
In the Harvard/Munich study, a team of researchers compared advanced neuroimaging scans of a small group of male players from a German elite soccer club — with no history of concussion — with brain scans of competitive swimmers. The degree to which white matter — the tissue containing the nerve fibers and myelin that carry signals around the brain and out to the rest of the body — was altered in the soccer players was “alarming,” according to Dr. Inga Koerte, who led the study with neuroimaging specialist Martha Shenton.
“It is more subtle than in American football players or ice hockey players,” Koerte said. “But there are changes there in the microarchitecture deep inside the brain.”
But if a young soccer player idolizes Abby Wambach and wants to emulate her, does the coach start teaching or say no?
Although some recommend waiting until age 10 to practice heading, no major youth soccer organization in the United States has called for an outright ban on heading. Many in the sport remain torn as to whether it is safer to teach kids proper heading technique or disallow it altogether.
“There is still a lack of information to make a recommendation one way or the other,” said Mike Singleton, executive director of Massachusetts Youth Soccer and head men’s soccer coach at MIT. “The problem with banning heading is you’d have kids running out of the way of balls, and they might be banging into each other that way.”
Nonetheless, the BU researchers that made CTE a household acronym in football say enough about soccer is becoming known to take another look sooner rather than later, especially since the brain is still under major construction and reconstruction into young adulthood.
Robert Stern, who oversees several of BU’s clinical research studies on CTE, points to new preliminary data that demonstrated former football players who started playing at age 11 or younger display “significantly” greater cognitive and behavioral problems compared to those who started playing at 12 or older, suggesting a vulnerable window for youth brain trauma.
“What would you do if you saw an older guy hitting a 6-year-old with a fist or a softball bat? You’d call the police,” Stern said. “Yet, in football, soccer, and other contact sports, we turn our kids over to coaches and sanction our children be hit in the head.”
“There are certain cases where you have to step back and ask, ‘What are we encouraging our kids to do?’” echoes his colleague McKee. “When it is possible to have this disease at such a young age, what determines who is susceptible? We need to find out.”
Indeed, until we have those answers, youth soccer and parents should step back on the issue of heading and take the time to ask what they are encouraging their kids to do.