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Heading in Youth Soccer: The Debate Continues

Is ban on heading before age 14 most effective concussion prevention strategy?


A youth soccer safety campaign urging middle schools and under-14 soccer leagues to eliminate heading in the sport as a way of reducing concussions continues to grab headlines, but is viewed in a new study (47) not only as culturally unacceptable in a sport that has been allowed to become more physical over time, but as a less effective way to prevent concussions than by reducing athlete-athlete contact across all phases of the game through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching.  

Dubbed the Safer Soccer Campaign, and bearing the tagline "U14 - No Header, No Brainer", the year-old campaign by the Boston-based Concussion Legacy Institute (formerly the Sports Legacy Institute) and the Santa Clara Institute of Sports Law and Ethics is spearheaded by three former US Women's National Team players (ISLE board member, Brandi Chastain, and teammates Cindy Parlow Cone and Joy Fawcett), along with SLI medical director and prominent concussion expert, Dr. Robert Cantu, and co-founder and Executive Director, Chris Nowinski.

Girl soccer players knocking heads going up for a header

In a June 25, 2014 press release [38] Chastain recommends a ban on heading before age 14 and encourages coaches and parents to consider the risks of heading before high school or age 14 in age-based leagues "while we wait for more research to clarify [that] risk." 

In an accompanying "White Paper" [39] on the group's website, however, Dr. Cantu, Mr. Nowinski, and SLI's Educational and Research Program Manager, Cliff Robbins, aren't content to wait, asserting flatly that the "scientific evidence paints a clear picture that heading a soccer ball will result in more concussions and repeated subconcussive trauma, which can have long term neurological consequences in both adolescents and adults."

Indeed, in a July 24, 2014 blog post, [40] Jack Bowen of ISLE, relying on what he refers to as "the heavy hitters" from SLI who have provided the science, goes so far as to suggest that the ban on soccer heading before age 14 proposed by SLI and ISLE "is not just in the best interests of children but one of moral necessity." In other words, says Bowen argues, that to fail to do so "would be to act immorally."

From a review of the peer-reviewed literature and interviews with a number of experts, however, a much more nuanced and equivocal picture than portrayed by SLI and ISLE emerges; one in which a consensus has yet to develop, on a host of issues, among them:

  • whether the cumulative effects of heading always have adverse neuropsychological consequences, 
  • when is it safe for children to begin heading
  • whether a ban on heading in youth soccer is the most effective prevention strategy, or 
  • whether such a ban is even "culturally tolerable" to the soccer community. 

As one expert said, while the Safer Soccer Campaign has garnered a great deal of national media coverage, much of the discussion - including Bowen's blog post - has been "over-dramatized."

The 2015 study [47] by a team of researchers headed by the country's leading expert on high school sports injuries, Dr. Dawn Comstock,* and published online in the Journal of the American Medical Association - Pediatrics, flatly concludes, based on a review of ten years of data, that a simple ban on heading is likely not the most effective way to prevent concussions in youth soccer.

Moreover, says Comstock, the Safer Soccer Campaign fails to account for the level of cultural acceptance of its proposed heading ban which is essential to effectively drive prevention efforts in sports. "Banning heading from youth soccer, while preventing some concussions, may not be culturally acceptable" in a sport that "has been allowed to become a more physical sport over time [in which] more athlete-athlete contact is occurring, without a concurrent increase in the frequency of fouls or sanctions awarded by referees."

Instead, she says, "it may be more culturally tolerable to the soccer community to attempt to reduce athlete-athlete contact [which is the leading concussion injury mechanism at all levels of soccer] across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading ... than simply banning heading." 

To delay or not to delay: that is the question

On one side of the debate about when it is appropriate to introduce heading in youth soccer are those experts, including Dr. Frank Webbe,* a professor of psychology at Florida Institute of Technology, and perhaps the most prominent researcher on the subject of heading in soccer, who support the no-heading-before-age-14 recommendation.

Indeed, if Webbe finds fault with anything, it is not with the Safer Soccer Campaign recommendation, but more with the assertion that the science unequivocally supports the position CLI and ISLE have staked out on the controversial issue of heading in soccer.

"As might be expected," Webbe says, "since I am on record as suggesting that heading in children should be eliminated, I agree with the [CLI/ISLE] recommendation that children under 14 should not be heading the ball. Period. My rationale then and now is that there is sufficient evidence that concussions and heading are highly correlated, and anything we can do within the confines of the sport to decrease concussions should be done."

"My concern [about the CLI White Paper] is that specific conclusions about heading, concussion risk, and the risk of lifetime neurological pathology were developed by citing the literature selectively, and by generalizing outcomes from one or two studies with small sample size and non-equivalent controls."

"Although my own research and conclusions have pointed toward a limitation on heading because of higher concussion risk and the frequency of subconcussive impacts, I have also pointed out [in two recent books which sift through all the literature in order to avoid bias [2,3] that there are studies as good or better than mine that do not support such conclusions." *

"The biggest elephant in the room" in the SLI press release," Webbe says, is the hypothesized link between soccer heading and later onset of neuropathology, including chronic traumatic encephalopathy. "Small N studies - including the newer imaging reports - are not sufficient to make that inferential leap."

Not new

The Safer Soccer Campaign proposal is not new; it simply restates a proposal made by Dr. Cantu that soccer heading be delayed until age 14 first made in his 2012 book, Concussions and Our Kids[29] where he argued for the delay, not just because of the risk repetitive brain trauma he said heading posed, but because "so much happens when a young player springs into the air expecting to meet the ball with her forehead, and so much of its results in head trauma [e.g. concussions]. Head meeting ball is the scenario of least concern. Problems arise when head meets shoulder, elbow, or another head."

Such concerns have led some soccer programs, including AYSO, with 650,000 participants, to recommend against heading in soccer before age 10. [30] 

Most recently, in November 2015, the United States Soccer Federation also came out against heading at age 10 and under, banning the practice in its own programs and imposing limits on heading in practice for players 11 through 13, and recommending adoption of its ban and practice limitations to other youth soccer organizations not under its direct control.