Kelly Turner scored more with her head than her feet.
“I had a coach from England who was really big on heading, so I was really good at it,” said Turner, who has 23 years of experience coaching, including at Harvard and Northeastern. “I was confident at a young age heading, and I found out that I could score a lot of goals if I wasn’t afraid to get up and redirect in the box.”
The skill helped Turner star for Duxbury and elite local clubs en route to the University of Vermont, where she played center midfield and forward and captained the team in the mid 1990s.
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But the price was high.
When she was 13 or 14, one of her coaches in US Soccer’s Olympic Development Program had players compete to head 20 to 30 crosses near the end of practice. Turner got her head on most of them.
“At the end of the practice, I got in the car and threw up,” she recalled. “I threw up the whole way home, because I was concussed.”
Turner says she sustained several concussions during her career and likely re-injured her brain by returning to play too quickly.
“I was getting headaches all the time,” Turner said. “If this happened now, I would have been out for six months to a year, but I just kept going back to playing.”
Turner struggled with double vision and persistent headaches in college, forcing her to see neurologists and other specialists. They never specified heading the ball as the cause, but she remembers it triggering her symptoms.
Turner was not alone. A traumatic brain injury ended the career of longtime US Women’s National Team goalkeeper Briana Scurry, one of the heroes of the 1999 World Cup, and left her on the brink of suicide. US teammate Cindy Parlow Cone was also forced to stop playing after several severe concussions.
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Brandi Chastain, whose famous penalty-kick celebration in the ‘99 final stands as one of the game’s iconic moments, is one of many current and former national team players who have pledged to donate their brains to research.
Heading is one of the game’s most important skills; researchers, however, are exploring how it puts athletes at risk of not just concussions, but also conditions like chronic traumatic encephalopathy, known as CTE.
On the field, the sport is being forced to change — at all levels.
While England and Spain battled for balls in the air during the Women’s World Cup Final last month, both teams prioritized possession on the ground rather than launching the ball downfield.
In 2015, the United States Soccer Federation prohibited all heading for players 10 and under and limited heading at practice for children ages 11-13. Guidance from England’s Football Association says heading should not be introduced until age 12 and remains a low priority until players graduate from the U16 level.
Turner, who has coached girls’ soccer at Notre Dame Academy in Hingham since 2016, said some athletes arrive at the high school level as weaker headers compared to years past, but on the whole, they also come in more technically skilled. Most importantly, she said, they’re safer.
“It has changed the game,” she said, “but we all have to adapt in order to keep everyone safe.”
Concussions are relatively common in soccer, especially because of collisions when players compete for balls in the air, and are particularly a concern in the women’s game. In 2019, a study in the journal Pediatrics found that the concussion rate in girls’ soccer from 2013-18 was second-highest among the high school sports evaluated, trailing football but ahead of boys’ ice hockey.
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The danger of chronic brain disease, particularly for players at the elite level, also is concerning. Last June, doctors from Boston University’s CTE Center announced former MLS defender Scott Vermillion — who died in December 2020 — was the first player from the league to be diagnosed with CTE, the degenerative brain disease commonly associated with collision sports such as football and boxing.
Data showed sports with the highest concussion rates were:
— CNN (@CNN) October 15, 2019
1. Boys' football, with 10.4 concussions per 10,000 athlete exposures.
2. Girls' soccer, with 8.19 per 10,000 athlete exposures.
3. Boys' ice hockey, with 7.69 per 10,000 athlete exposures.https://t.co/RrCmRdm2n2
Heading is a concern for Dr. Robert Cantu, a clinical professor of neurology in BU’s CTE Center and a leading voice on concussions and other brain injuries in contact sports.
The co-founder and medical director of the Concussion Legacy Foundation, Cantu was a major advocate for the restrictions on heading instituted by US Soccer.
He and Dr. Michael Alosco, a licensed neuropsychologist and a lead investigator in BU’s CTE Center, explained that CTE is caused by repetitive head impacts, which include concussions and blows that cause injury to the brain without symptoms.
Previously, CTE risk was measured with years played — a proxy, Cantu says, for the average number of repetitive head impacts a player sustained. Cantu says the risk of CTE in football players starts to climb after 4½ years of exposure.
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Therefore, Cantu says athletes who only play tackle football in high school are at low risk for CTE. That underlines why he thinks soccer players should not head until high school.
“They don’t learn heading until they’re 12 or 13,” Turner says of today’s players. “[At] a lot of the elite clubs, I don’t even know how much they teach heading, because they want the ball on the ground.”
Cantu and Alosco note recent research indicates it’s not simply the number of hits to the head but the intensity of impacts that better predicts who develops CTE. A study led by Dr. Daniel Daneshvar of BU’s CTE Center, published in June, used accelerometer data from football helmets to derive an index to measure a player’s “cumulative” lifetime exposure to head impacts.
Alosco says cumulative exposure is more difficult to determine in other sports, because individual experiences varies greatly by position and other factors. A center back in soccer typically heads the ball more often than a winger.
Alosco is leading an ongoing study that focuses on contact sports besides football by looking at damage to the brain’s white matter.
Previous studies used MRI techniques, blood draws, and other methods to observe the degradation of the fatty myelin sheaths that protect the brain’s axons — “long telephone cables through the brain,” Alosco described — and give the white matter its color.
Symptoms of CTE include problems with thinking and memory also associated with Alzheimer’s disease, as well as neurobehavioral dysregulation — trouble controlling one’s emotions, rapid mood swings, and being quick to anger. Going into year 3 of his 5-year study, Alosco believes this latter category of symptoms could be more directly linked to white-matter damage than the patterns of tau (a protein in the brain) accumulation that characterize CTE.
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Alosco expects results to be “quite heterogeneous” among soccer players but said the risk of chronic brain disease is much lower than in football, especially for athletes who play the game at just the youth and high school levels.
Calls to restrict heading haven’t stopped at the youth level. The English FA has guidance for all professional and amateur players, including in the Premier League and for England’s national teams, recommending that players carry out no more than 10 “higher force headers” during a week of practice.
Turner, who doesn’t drill heading in practice, admitted her team struggles to make those types of plays in games.
“There’s a lot of fear,” she said. “There’s a lot of not wanting to do it, which is understandable because it’s not fun, but it’s part of the game and you lose games if you don’t win the ball in the box.”
Cantu understands players must learn to be proficient at heading to play the game at a high level, but that should be done thoughtfully.
Cantu learned one of his patient’s teams would line up and head balls fired out of machines typically used to throw footballs at tight ends and wide receivers.
“That’s a ridiculous drill,” Cantu said. “Even at higher levels, where you’re involved with heading, you can have reasonable drills so that the exposure to heading can be reduced.”
Cantu emphasized he does not want to stop any sports from being played.
“We just want them to be played in a safer manner,” he said. “That includes at all levels.”
If it means her players — and four children — don’t go through what she did, Turner is on board.
“We have to look out for our kids,” she said. “At the end of the day, it’s more important that their brain is developing correctly than they’re heading the ball.”
Greg McKenna can be reached at greg.mckenna@globe.com. Follow him @McKennaGregjed.