Soccer Head Injuries
Justin Morneau. Corey Koskie. Ben Hamilton. Taylor Twellman. Brett Favre. Pierre Marc Bouchard. Cindy Parlow. All of them are high level athletes who have had their careers and/or seasons cut short because of concussions. We can also start calling them what they really are…BRAIN INJURIES.
A concussion is a type of traumatic brain injury that causes dysfunction of the brain and can be caused by a direct blow to the head, a jolt to the body, or a rapid deceleration/acceleration of the brain within the skull. The brain is fairly soft and squishy in consistency but does not do well when it is hit against unforgiving bones that make up the head. Essentially, the brain is being bruised. Bruise = bleeding. Just like there are different types of bruises from mild to severe there are different levels of brain injuries from mild to significant bleeding of the brain. Only this time it isn’t muscles that need to heal; it’s the circuitry of your brain (see concussion leaves 14-year-old basketball player amnesic and left handed). In severe cases with internal bleeding of the brain, the skull causes brain pressure to increase since blood has nowhere to go – this can be fatal.
Concussion Animation
HOW OFTEN DO THEY OCCUR?
The National Institute of Health cites that 4-8% report suffering concussions in soccer, but they also believe that 90% go unreported or unrecognized so the actual incidence could be closer to 40%.
According to the Center for Disease Control, 3.5 million sports-related concussions occur in the U.S. each year. In addition, it is reported that 60% of college soccer players will experience concussion symptoms in a single year. (Clinical Journal of Sports Medicine, 2002) Younger athletes are at a higher risk than adults of experiencing a concussion. Females are more likely to experience concussion than males in similar sports. Athletes who have had a previous concussion are at a higher risk for future concussions and will require less force to reinjure their brains.
HOW DO HEAD INJURIES TYPICALLY OCCUR IN SOCCER?
1. Elbow to head and head-to-head contact when two or more players are contesting for ball in the air. MOST COMMON
2. Goalkeepers getting kicked or getting a knee to the head or hitting head on goalpost.
3. Body-to-body contact without direct contact to the head in which the head accelerates or decelerates violently.
4. Getting hit in head unexpectedly with the ball and hitting head on ground after a fall.
5. Deliberately heading the ball LEAST COMMON
NOTE: Typical boxing punch produces head acceleration of 100g v 20g for typical header. American soccer players head a ball 5-6 times per game and roughly 9 times at practice. In addition, FIFA’s Medical and Research Center concluded that “forces generally associated with heading the ball are not sufficient to cause concussions.”
SYMPTOMS
Everyone is different and symptoms can be very subtle. Being knocked UNCONSCIOUS is not a requirement and a “ding” can very well result in a concussion, especially for young athletes and athletes who have had previous head injuries.
Confusion, foggy/groggy feeling, sluggish
Dizzy, poor balance
Sensitivity to noise or light, blurry vision
Headache, feeling of pressure
Poor memory: can’t remember what they ate earlier that day, the score of the game, what happened, etc.
Poor coordination and concentration
Nausea/vomiting
Males typically experience more cognitive symptoms such as fogginess and lack of concentration. Females typically experience more somatic symptoms such as drowsiness, sensitivity to light, headaches, and nausea. (Journal of Athletic Training, 2011)
If an athlete is experiencing ANY of these symptoms or just doesn’t seem right, DO NOT LET THEM PLAY.
Athletes who have a suspected concussion should not be given pain relievers to mask symptoms (headaches). In addition, athletes should be supervised hourly for 24-48 hours following a suspected concussion to monitor for worsening symptoms. Do not leave them alone.
SIGNS OF A MEDICAL EMERGENCY
HEADACHES THAT WORSEN
REPEATED VOMITING
SEVERE NECK PAIN
LOSS OF CONSCIOUSNESS OR UNABLE TO BE AWAKENED EASILY
SEIZURES
INCREASING IRRITABILITY
WEAKNESS/NUMBNESS IN ARMS OR LEGS
UNABLE TO RECOGNIZE FAMILIAR FACES/THINGS
LIFE-LONG EFFECTS
Everyone has different rates of healing, and short-term effects can last from a few hours to several months. Long-term effects are not currently completely understood, but there are a number of studies that are presently being conducted to investigate Chronic Traumatic Encephalopathy (CTE). This is in response to an increasing number of former NFL players with a history of head injury committing suicide and experiencing depression. Boston University is home to the Sports Legacy Institute in which a number of prominent athletes, including Taylor Twellman and Cindy Parlow, have agreed to donate their brain for the sake of research on head injuries.
A very candid interview of the effects of Twellman’s concussion
Feb 17, 2011: Former Chicago Bear Commits Suicide & Renews Debate on Effects of Concussion
NY TIMES: Long-Term Effects of Concussion Later in Life for Young Athletes
TIPS FOR COACHING HEADING WITH YOUNG SOCCER PLAYERS
1. Learn proper heading technique – contact with the ball at the hairline/forehead NOT the top of the head.
2. Learn to properly prepare for contact with the ball and a mentality of initiating contact with the ball instead “letting the ball hit you.” This will prepare the neck and postural muscles to help absorb impact and force to the body and head …and make you a more effective player.
3. Use under-inflated soccer balls or even balloons with younger kids (U12 and younger or inexperienced older players) until they get comfortable with heading and learning proper technique.
4. Strengthen neck muscles
5. Limit the amount of repetitive heading at practice to 10 minutes or less
GOALKEEPING
In 2006, Chelsea Goalkeeper Petr Cech injures his head requiring skull decompression surgery.
USWNT Goalkeeper Hope Solo, Leading with Hands
Watch his hands move down toward his stomach while finishing the save leaving his head exposed. Proper and safe breakaway technique for goalkeepers should include keeping the ball and arms out in front of the head and head hiding behind the hands. It allows the goalkeeper to keep their eye on the ball through the entire save and also protects the head.
POOR TECHNIQUE ON BREAKAWAY
Sliding out feet first…and with eyes closed.
Dropping down to knees
HEAD GEAR & NEW DIAGNOSTIC TESTS
Does head gear work? The jury is out. One study that tested the head gear on mechanical models concluded that although it does not prevent concussions from ball to head contact it does significantly reduce concussions for head to head contact. I could not find any conclusive studies on the effectiveness of head gear during actual soccer activities with players. The United States Soccer Federation medical staff has voiced concern that head gear may actually promote head injuries via the superman effect or feeling like players are invincible to injury as a result of using the gear.
TECHNOLOGY TO DIAGNOSE:
IMPACT TESTING
2-Minute Vision Test
Blood Protein Marker
DETECT
RETURN TO PLAY GUIDELINES:
Physical symptoms almost always resolve before cognitive/neuropsychological symptoms.
There is no set schedule for recovery; everyone is different.
Time is needed to heal; players must rest cognitively (limit reading, computer, texting, TV).
Once players are 100% asymptomatic at rest they can they follow a graded return to play protocol under the supervision and direction of their doctor. (see Justin Morneau, Minnesota Twins)
Second Impact Syndrome – A potentially fatal medical emergency which results from rapid swelling from returning to play before brain is healed and can occur in days, weeks, or minutes after the initial concussion.
ESPN Video: Second Impact Syndrome
TAKE HOME MESSAGE ABOUT HEAD INJURIES: WHEN IN DOUBT, SIT IT OUT.
Want a soccer injury topic addressed? Feel free to send in requests!
About the Author: Julie Eibensteiner PT, DPT, CSCS is a physical therapist and owner of Laurus Athletic Rehab and Performance LLC, an independently owned practice specializing in ACL rehab and prevention in competitive athletes. In addition to being a regular contributor to IMS on topics of sport injury and prevention, Eibensteiner holds an USSF A License, coaches a U18G MRL team for Eden Prairie Soccer Club, and assists with the Men’s and Women’s soccer programs at Macalester College.
Comments are closed.
@IMS,
Great article and I so appreciate the effort that went into this. In a highly competitive world wrapped around a full contact sport, it is hard to tie together injuries to all of the young people (male and female) that play this great sport and get hurt with injuries that chnage not only their lives and can cause permenant disabilities. It is easy to overlook head and spine injuries in soccer when ther is so much contact in football. But these injuries are real and happen all the time and often go unreported and undiagnoised. Headers, conatct in the box and one on one challenges can result in high grade concussions.
Thanks again and keep the great articles coming.
Well written – nice to see such a thorough article.
Top notch Julie, very comprehensive and un-editorialized article.
Base on the symptoms, I think I was born and have lived with a life long concussion,,,,,,,,,hence the phrase, “did the Dr. drop you on your head when you were born” ?
Dear Ms. Ebensteiner:
I was pleased to read your recent review of the role assessment protocols can play in assessing payers post-concussion relative to return to play decisions and outlining the dangers of concussions. I was equally disappointed however by the overall focus on Neurocognitive testing as if it was the “answer’ to the problem. Hence this email to draw your attention to the NCAA position statement on concussion management which can be reviewed at:
http://www.ncaa.org/wps/wcm/connect/327bf600424d263692cdd6132e10b8df/Memo+Concussion+Managment+04292010.pdf?MOD=AJPERES&CACHEID=327bf600424d263692cdd6132e10b8df
The critical emphasis being that a 3 pronged approach based on symptoms, cognition and balance control is required to understand the impact of a concussion and the resolution of the same. In short, no one test stands alone in the process.
Thank you for your time.
JON F. PETERS, Ph.D. | Vice President and General Manager
NeuroCom®, a Division of Natus Medical Incorporated
9570 SE Lawnfield Road, Clackamas, OR 97015
+ 1 503 353 4011| JPeters@natus.com
+1 503 702 3896 | +1 503 653 1991
That just made my head hurt!
Hi Jon-
Thanks for your interest in the article.
The article wasn’t intended to be a comprehensive review of concussion assessment tools or clinical diagnostics (That is certainly for the patient’s MD or ATC, not the lay person); it was rather intended to be a general information piece for the every day athlete/parent/coach/fan on:
1. The prevalence of concussions in soccer (and that they happen more than people think)
2. The symptoms to recognize one and ones that are life threatening
3. How they typically happen (the soccer mom myth is that they are caused from headers)
4. The need to ensure that all SYMPTOMS (physical, cognitive, neurological) are resolved before returning to play (dispelling the myth that if a headache is gone, you can play.)
5. The long term effects are real.
The diagnostics listed are simply some of the more common ones showing up in high schools (IMPACT) and some newer and interesting ones people may have never heard of before.
I 100% agree with you (and the NCAA statement) that we need to look at all facets of brain function before return to play and at the end of the day getting awareness out there is going to help prevent more stories like Taylor Twellman and most recently, Mr Miller at Marquette http://www.topdrawersoccer.com/college-soccer/college-soccer-archives/nid-19648/Concussions-cut-Millers-career-short-Part-1
Thanks again for the feedback!
@ Mr. Peters,
I think we all agree that the more comprehensive testing the better and I doubt that anyone would disagree with your assessment. One quick question……are you associated in any way with the following website which sells products necessary to fulfill the comprehensive testing that is recommended?
http://www.onbalance.com/
Overall a good article. I believe this is a topic that players, parents, and coaches should be very aware of. I have been working in sports medicine for 10 years and cringe every time I hear a player come back from a doctor with a release stating “No play for a week”.
With that said I would like to say that I disagree with the return to play protocol listed after following the link provided. The last sentence( “If any concussion symptoms return during any of the above activities, the athlete should return to the previous level, after resting for 24 hours.”) is wrong and could lead to further injury. If concussion symptoms return you must return to the first level only after the athlete is completely symptom free again. Only backing up one level after resting 24 hours defeats the purpose of a gradual progression to return to play. Can anyone be sure that all athletes will be symptom free after 24 hours.
As for the NCAA position statement. No big news there. Many if not all college sports medicine programs have had strong protocols in place for years. I know when I graduated several years ago we had a very good concussion protocol in place. The NCAA is joining in with all major sporting authorities in verbalizing that they are making concussions a priority.
Great information. I have read the research in the BJSM that you linked above. You mentioned that there is no studies of headgear on the field in actual soccer situations, however in the BJSM there is another study called, “The effect of protective headgear on head injuries and concussions in adolescents football (soccer) players”. This is a field study that concluded that the headgear reduced the concussion rate by roughly 50%. When not wearing a headgear, the player was 2.65 times more likely to get a concussion.
Another interesting piece of information I just learned was that the ImPact test misses roughly 50% of concussions. Dr. Jon Becker said this during his presentation in Louisville for US Youth Soccer.
Hi LB-
Thanks for the comments and interest!
The BJSM methods used non-human models in a lab: “High severity heading contact and head to head impacts were studied with a biofidelic surrogate headform instrumented to measure linear and angular head responses.”
The owner of Full 90 equated it to using crash dummies in cars. No IRB is going to give approval for smacking two people’s heads together for the sake of research. The good part is: In a mechanical model we know it reduces forces hypthesized to produce concussions by 50%.. The bad news is: soccer isn’t played in a lab and with mechanical models. So it very well could still reduces forces needed…there just isn’t a study to show it (that I could find) in a real life setting. Part of this is due to the difficulty in setting up the methods of such a study. Also…not everyone requires the same amount of force for a concussion and its dependent on age, gender, neck strength, prior head trauma to name a few.
Regarding IMPACT – That is interesting, thanks that bit of info. All the more important to make sure it is just understood as a tool and should not be the only tool used. The point is the time of “wait a week and return when your headache is gone” is hopefully out the window by now! The tough part is not everyone has access to all of this testing, perhaps in another article I can discuss ways the parent-coach or professional youth coach can manage players with a concussion appropriately in terms of return to play when they don’t have access to all of the more indepth assessments that a HS, college, or pro organization would have available.
Wow!
I’ve had a bad soccer-related concussion, and it’s too bad I didn’t read this before. Unknowingly thinking I was better after a few days, I went back to playing and had the symptoms come back. This time, it put me out for a lot longer, 4-5 months. Good information, kind of scary what can happen during the game!