Jan 29, 2015
Heads & Headers

After football, the sport with the highest rate of concussions is women’s soccer. A veteran athletic trainer takes a look at the causes and offers new ideas on prevention.

By Maria Hutsick

Maria Hutsick, MS, LAT, ATC, CSCS, is Head Athletic Trainer at Medfield (Mass.) High School and former Director of Sports Medicine at Boston University. She is a past president of the College Athletic Trainers’ Society and was honored with an NATA Athletic Trainer Service Award in 2010. She can be reached at: [email protected].

Women’s soccer superstar Abby Wambach is known for her dynamic and dramatic headers. She is admired by fans and competitors alike for her ability to leap in the air, perfectly position her head, and forcefully slam the ball into the back of the net. There is no better example of this than during the 2011 FIFA Women’s World Cup quarterfinals when Wambach scored on a game-tying header during overtime that forced the match into a shootout, earning the 2011 ESPY Award for Best Play of the Year.

This past spring, Wambach was in the news for a very different type of head-on-ball occurrence. While playing a National Women’s Soccer League contest in April, an opposing player kicked a ball that struck Wambach in the head with great force and sent her tumbling to the ground. Wambach returned to her feet and continued to play. Although medical personnel were not called on the field at the time, it was determined after the match that she had suffered a concussion.

In many ways, Wambach’s experiences sum up a growing and difficult problem in women’s soccer: Heading the ball has become a bigger part of the game and so have concussions. There is some confusion, however, over the correlation between heading the ball and concussions and why female soccer players seem to be increasingly at risk for this injury compared to their male counterparts.

When we think of concussions, football is often the first sport that comes to mind. But according to recent research, soccer is not far behind. A study that examined the prevalence of concussions during the 2005-06 high school year found that while the majority resulted from football-related contact at 40.5 percent, the next highest sport was girls’ soccer at 21.5 percent. Also significant are the findings on boys’ soccer players as compared to girls. As detailed in the same study, girls also experienced a higher rate of concussions (.36 per 1,000 athlete exposures) compared to boys (.22 per 1,000).

Concussions are taking a toll on female soccer players in a big way. As athletic trainers, we need to better understand the mechanism of injury, how to work with coaches, and how to bridge the gap with parents and youth leagues.

THE CAUSES

One of the more difficult aspects of preventing concussions in soccer is pinpointing the reason behind the injury. According to statistics compiled by the U.S. Consumer Product Safety Commission on concussions in high school soccer, 40 percent are attributed to head-to-player contact, 10 percent are head-to-ground, goal post, wall, or other surface, 13 percent are head-to-ball (including accidents), and 37 percent are unspecified causes.

Clearly, concussions are occurring in many different ways. There is no one culprit. But from my seat on the sidelines, it’s clear that increased physical play has been a big contributor to the uptick in injuries.

The game has gotten rougher for both genders, but I’ve found that male players seem to fend off the physical play more effectively. Females often lack understanding of how to protect themselves during contact. This leads to the type of head-to-player impact that can easily result in a concussion. When two girls are competing for a ball in the air, they usually don’t keep the space around them protected. They reach for the ball with their necks extended like a turtle coming out of its shell, while their arms remain down by their sides or at waist level. Most boys, on the other hand, will raise their arms to their shoulders in an effort to ward off their opponent and keep them at bay to avoid a collision. I’ve also seen way too many girls shove an opponent from behind during a play, which can also cause a concussion. While they more frequently occur when an athlete is hit straight on, a whiplash type of injury where the head is snapped backwards and the brain is shaken can be as bad as receiving a direct blow. Heading the ball can also be a mechanism of injury. A perfectly positioned head supported by a strong body rarely receives a concussion when performing a header. But improper form, as well as a heavy accumulation of head-to-ball contacts, appears to be detrimental. This is an area that needs more research, although it’s hard to ignore the anecdotal evidence.

While I was the Director of Sports Medicine at Boston University, I had the opportunity to work with both the men’s and women’s soccer teams. The men’s squad experienced very few head injuries, and most were from hitting the ground after having their legs undercut by an opponent. I do not recall very many issues due to heading the ball. I can’t say the same about the women’s team, which had several concussions due to repetitive heading of the ball. One particular player who comes to mind was a midfielder known for her heading prowess. She began to have headaches, trouble in school, and a hard time comprehending information that she was learning in class. While she never had a specific concussion diagnosis, she eventually began showing signs and symptoms of post-concussion syndrome. She ended up having to take time off from the sport and was advised to avoid heading the ball when she returned. Athletic trainers at other schools have relayed similar stories to me.

How can we know if and when cumulative hits are causing harm? Unfortunately, there is not a clear answer to this important question yet, but one recent study on men’s soccer players has shed a light on the topic. Published online in June in the journal Radiology, researchers at Albert Einstein College of Medicine at Yeshiva University studied 37 amateur adult soccer players (with a median age of 31) who had all played the sport since childhood. The study compared their self-reported frequency of heading the ball with scans of their brains using diffusion tensor imaging, an advanced MRI-based technique. It found that the players who accumulated between 885 and 1,550 headers a year had white-matter abnormalities similar to what is seen in patients with concussions. “Our study provides compelling preliminary evidence that brain changes resembling mild traumatic brain injury are associated with frequently heading a soccer ball over many years,” said lead author Michael Lipton, MD, PhD, Associate Director of Einstein’s Gruss Magnetic Resonance Research Center, in a university press release. “While further research is clearly needed, our findings suggest that controlling the amount of heading that people do may help prevent brain injury that frequent heading appears to cause.”

PREVENTION

As researchers continue to work on discovering more about the causes of concussions, I believe we need to upgrade our prevention efforts in soccer, especially the girls’ game, immediately. These efforts should focus on two areas: helping soccer athletes better prepare for rough contact and addressing the role of heading the ball in concussions.

One way to help ward off dangerous collisions is to enhance proprioceptive skills. Two of our concussions this year at Medfield (Mass.) High School were the result of the players not knowing who was around them.

There are many exercises for teaching proprioception and awareness skills. Such activities will also enhance athletic ability, so they should be an easy sell to coaches. Also, the stronger the athlete, the better prepared they are to handle rough contact. Instead of playing on club teams year-round, it may be beneficial for soccer players to be in the weightroom during the off-season building body strength, with a focus on developing the upper back and neck muscles. Improved neck strength can help players absorb the impact of a hit and may help protect their brain by keeping their head stabilized. Neck and upper body exercises can easily be incorporated into on-field practice drills.

Ideally, the athletic trainer and the strength coach can devise strength programs that address each athlete’s functional limitations. Functional movement screens that assess the athlete can help in developing a program tailored toward remedying weaknesses.

Reducing concussions that result from heading the ball starts with talking to soccer coaches about preventive measures. The first step is to make sure they are teaching proper heading form with the right progression. Some coaches may believe that their players have already been taught how to head the ball at the youth level, but with the significant consequences of concussions, I would like to see coaches err on the side of caution and reteach proper form, at least at the j.v. and middle school levels.

The Web site CoachingAmericanSoccer.com provides good instruction for how to teach heading. For younger and newer players, it suggests a progression of starting with a balloon, then moving to a sponge ball, play ball, volleyball, partially deflated soccer ball, and finally a properly inflated soccer ball. When performed properly, heading should not hurt. This is because of thicker bone in the skull at the forehead to protect the brain from injury when falling forward. If heading causes pain, it is likely being performed improperly, or a physical condition may exist that needs to be explored. If a player complains of headaches, dizziness, or blurred vision, they must stop participating in heading drills immediately.

Coaches also need to consider the volume and frequency of heading drills their players do in practice. I have been fortunate in that the soccer coaches I have worked with have solid backgrounds in coaching the sport and never conducted repetitive drills for heading. The heading work was spread throughout the practice, so players were not exposed to multiple head blows in a short period of time. When it comes to head safety, many coaches and parents want to know if helmets are a preventive option. Several head guards have been developed to reduce the risk of head injuries in soccer, but the jury is still out on their effectiveness. One independent research study found that no product on the market provides substantial benefits against minor impacts, such as heading a soccer ball. A helmet may possibly reduce some of the impact when a blow is straight on but will not prevent a concussion that results from whiplash or rotational forces on the brain. Ideally, athletic trainers will work closely with their soccer coaches to implement prevention strategies. If your coach is not open to the idea, or if you cover too many sports to do this on a day-to-day basis, at least try to discuss the topic during the preseason.

PROTOCOLS & PROCEDURES

Over the past few years, more and more high school athletic departments have begun implementing thorough concussion protocol and education programs. The one I’ve developed here at Medfield is focused on all sports, including soccer, and has worked well. I collaborated with both the school nurse and guidance department in developing it.

Our program begins by administering a computerized baseline concussion test to all incoming ninth graders and new students the first week of school during their wellness classes. Those results are kept on file and used for comparison when an athlete is suspected of having a concussion. For their part, coaches are asked to take an online course on concussions. Afterward, a certificate of completion is kept on file with our athletic director. The rest of our faculty is provided with an in-service on what a concussion is and how academic workload must be modified to allow the concussed student to recover both physically and cognitively. Some modifications may include complete rest at home, a partial school day, reduced homework, or going to the nurse’s office to rest during the day. It might also include longer time for test taking.

To get full school buy-in, I have found it important to be up to date on concussion research and reach out to other school personnel. I have attended a number of concussion education programs and webinars. And the nursing staff accompanies me to an annual concussion symposium offered nearby at the Harvard University Medical School.

Massachusetts law allows an athletic trainer to evaluate a concussed athlete and decide when that athlete can return to play. To ensure others feel 100 percent confident in my ability to make these important decisions, I have implemented a thorough return-to-play protocol. It includes using both the baseline computerized test and a physical test. When the symptoms of a concussion have resolved, the athlete must run for 15 minutes, perform 10 sit-ups, do 10 squat jumps, and then retake the computerized test. The results are compared to their baseline scores, and I communicate with the guidance department to see how the athlete is doing academically. Next, I contact the parents to discuss the athlete’s progress. If all seems okay, the athlete is allowed to transition back to full participation. I notify the nurse when an athlete has returned to play, and the academic accommodations are removed from the student’s plan. Of course, my work on the sidelines is also important. Along with assessing any athlete who appears to be shaken up, if I see an athlete receive a blow to the head or hit their head on the ground, I question and evaluate them on the spot. I also do everything I can to relay the seriousness of concussions on a daily basis. From talking to parents to relaying recent news stories to putting up posters throughout the building, our school population understands where I stand. Because of the education component we have in place, I have had players report teammates who displayed concussion symptoms during football games.

STARTING YOUNG

While there’s a lot we can do to decrease concussions in female soccer players in high school and college, what about at the youth level? With very few athletic trainers covering these programs, there is a dangerous gap in parents’ and coaches’ understanding of concussions.

Recently, I have started a small side business that offers baseline concussion testing to the youth sports programs in town at a reasonable price. This has enabled me to get involved in the youth soccer community, and I’m hoping to do more in this area. Parents at this level could benefit greatly from knowing more about recent research and recommendations pertaining to concussions. Robert Cantu, MD, FACS, FACSM, Chair of the Department of Surgery at Emerson Hospital in Concord, Mass., and co-director of the Center for the Study of Traumatic Encephalopathy at Boston University’s School of Medicine, made headlines when he published an eye-opening book last year titled, Concussions and Our Kids. In it, he explained how young brains are more susceptible to injury and suggests no contact in sports before the age of 14. With regards to soccer, he recommends eliminating heading until at least age 13, preferably waiting until the player is 15.

Cantu explains that before the age of 14, children’s heads are larger than their bodies, and their neck musculature is not developed. By age 14 the head, body, and neck strength are better proportioned. Another medical fact that Cantu’s book discusses is the lack of myelin (fat) that insulates and covers the fiber tracts in youth brains. Cantu explains it this way: “Think of a copper wire inside the wall of your house and the plastic or rubber coating around the wire. The coating insulates, protects, and strengthens that wire. The fiber tracts of an adult have a coating of myelin that acts the same way, protecting the fibers from injury or insult. Children’s brains have less myelin and structures in their brains are more easily damaged.” How do coaches feel about removing heading from the youth game? “It is hard to picture the game of soccer without heading, but given the possibility of trauma and the lack of neck strength and brain development, I think it sounds reasonable that heading is not introduced until high school age,” says Nancy Feldman, Head Women’s Soccer Coach at Boston University. “It might even help kids improve their foot skills. This is a radical idea and it will be interesting to see if it can get traction.” “The soccer coach in me strongly believes heading does need to be taught,” says Deb Raber, Head Women’s Soccer Coach at Massachusetts College of Liberal Arts and an instructor for the National Soccer Coaches Association of America. “But coaches need to learn how to teach it properly and incorporate safe heading drills into their practices. I have seen youth coaches have ‘heading practices,’ which are not good. Teaching that way for a long period of time will result in headaches, and kids will eventually shy away from heading.” Many parents coaching youth soccer have little to no background in physical training principles nor any technical understanding of how to teach the fundamentals of the game. In these cases, heading drills should certainly be avoided.

It can also be helpful to relay to parents the stories we see or hear about as athletic trainers. While attending the Harvard Medical School annual concussion symposiums over the years, I have had the chance to hear former pro football and ice hockey players reveal what they have gone through after sustaining multiple concussions.

For example, during one session, Ted Johnson, former linebacker for the New England Patriots, told us about being concussed and unable to see the sidelines to get the defensive play signals. One of his teammates had to tell him what the coaches were calling so he could relay the play to the rest of the defense. Today, he suffers from memory problems, depression, and irritability. While most of the heart-wrenching stories about the long-term effects of concussions currently come from the football community, I don’t think it will be long until we hear about similar problems from soccer players. In the meantime, as athletic trainers, we should put prevention measures in place and continue to educate athletes, coaches, and parents. Along with football players, female soccer players need our attention in order to reduce the risk of concussions in their sport.




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