Head games: Debate surrounds U.S. Soccer’s decision to ban, limit headers

LOS ANGELES – Jazmarie Mader, an Arizona State women’s soccer player, was on a flight back home to Phoenix in 2016 when she felt nauseated. She headed toward the restroom and tried to push the door open.

The next thing she said she remembered was waking up on the restroom floor, surrounded by flight attendants.

Mader believes she fainted as the result of a concussion she suffered in a match seven days earlier, striking her head again.

“It was like a movie almost … where there’s a black screen. You can watch the screen and hear things that people are doing, but you can’t see anything,” Mader said. “I could feel that and I was touching it with my hand, but I still couldn’t see anything.”

The result was Mader’s second concussion in a week. The second was more severe and ended her junior year season at ASU.

Mader’s first concussion occurred in a 2016 match against Pac-12 rival Colorado. The ball had struck Mader in the head as the opposing player attempted to play a ball over her head.

“I just didn’t brace for it,” Mader said. “I think if I would have braced for it, I would have been fine.”

Her experience isn’t unusual. From 1.6 million to 3.8 million sports-related and recreation-related head injuries occur in the United States each year, according to Children’s Hospital Los Angeles.

After her two concussions, Mader, 22, was bedridden for three weeks and underwent vision therapy for two months. When she was finally allowed to return to the soccer pitch, she experienced episodes of anxiety.

“My heart rate would jump through the roof. I would jog around the field maybe once, and my heart rate would jump to 180, 190″ beats per minute, Mader said.

She didn’t return to action until her senior year, when she was cleared to play before the start of the season. Her story is familiar among soccer players and athletes involved in other contact sports in which concussions are common.

The effects of concussions on adult soccer players are dangerous enough. But concussions among youth soccer players can potentially be more life changing.

In 2015, the U.S. Soccer Federation, facing growing concern about concussions and the potential for liability, made a dramatic cultural change, implementing safety initiatives that include a ban on heading the ball in games or practices involving players 10 or younger. Players 11 to 13 are allowed to head the ball in games but are limited to no more than 30 minutes of practice time heading the ball and no more than 15 to 20 headers during that time each week.

Three years ago, the U.S. Soccer Federation limited or banned headers among young players. But some argue that player collisions can be more damaging than heading the ball. (Photo by Jorge Ramos/Cronkite News)

The moves came in the wake of a class action lawsuit in which a group of families sued the U.S. Soccer Federation and FIFA – the governing body of international soccer – along with other American soccer organizations, accusing them of negligence for failing to implement policies that would protect young players from concussions.

A federal court judge in California dismissed the case against FIFA without prejudice – meaning it cannot be refiled – in July 2015. However, the judge ruled that other organizations, such as youth leagues, could be sued if the plaintiffs show they have standing to file suit, such as evidence of injuries.

U.S. Soccer made the dramatic rule changes, but debates remains about whether they’ve made a difference.

Recording data

The federation, which did not respond to requests for comment, has no all-encompassing system to record data on head-related injuries and can’t definitively state that its rule changes have reduced injuries.

Researchers have some possible solutions to help alleviate the number of concussions that occur in soccer and to deal with the lack of data collection.

But if concussions are such a large problem in soccer, why doesn’t U.S. Soccer have a system to track head-related injuries?

The answer is two-fold, said Dr. Dawn Comstock, associate professor of epidemiology at the University of Colorado-Denver’s School of Public Health and a board member of the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.

Comstock said it is expensive to track the data, and there aren’t enough certified people to report such data accurately.

“It always comes down to money,” she said. “A surveillance system is a pretty labor-intensive effort, and there is just no research funding. Who are you going to get accurate information from?

“Even if I have a system set up to collect information about injuries in a youth soccer population, who is going to give me that information if there’s no trained sports medicine clinician available to give it to me? We don’t expect the 7-year-old soccer player to tell us accurate information.”

Comstock is in charge of the Program for Injury Prevention Education and Research, a high school sports injury surveillance study that records data from hundreds of high school athletes and tracks injuries, including concussions, through athletic trainers. Even with her system, she said, scant funding is difficult to overcome.

“In my 13 years running my system, I have had 10 different funding sources,” she said. “That’s how hard it is to get consistent funding for this kind of program. Nobody wants to pay for the work to collect the data.”

Researchers are left with a few ways to collect data.

According to one study, 1.6 million to 3.8 million sports- and recreation-related head injuries occur in the United States each year. (Photo by Jorge Ramos/Cronkite News)

One way is tracking emergency room visits for sports-related head injuries. Although ER visits provide some insight into the frequency of soccer-related head injuries, they don’t paint the whole picture.

Comstock pointed out that parents don’t always take their child to an emergency room, fearing the expense.

“They can take them to their own pediatrician, they can take them to an urgent care clinic, they can take them to a pediatric-sports medicine facility, and they can take them to a concussion clinic,” she said.

Tracking insurance records is another option for researchers, but that method also has shortcomings. For instance, pediatricians who specialize in younger children might not diagnoses concussion symptoms that can differ depending on the age of the child. Also, parents might not seek medical treatment for their child for every head-related injury, meaning no insurance claim is recorded.

Some of the obstacles to tracking data for youth soccer don’t exist for high school and college athletes because at that level, health care professionals, such as a team doctor or a certified athletic trainer, are present at matches.

Athletic trainers at the high school and collegiate level track all injuries, and the NCAA has a system that also compiles data on head injuries, making the information readily available.

With the exception of a few studies tracking youth sports head injuries at the hyper-local level, reliable data is limited.

Getting their head around it

Concussions can often be an abstract concept for parents of young children to grasp.

Dr. Tracy Zaslow, medical director of the Children’s Orthopaedic Center Sports Concussion Program at at Children’s Hospital Los Angeles, said when a concussion occurs, the brain moves around in the head and changes at the cellular level.

“There is more a biochemical change,” Zaslow said. “You can compare it to a computer that crashes. When a computer crashes, it has got to reboot. Recovery is kind of the reboot period after the head trauma.”

It can become especially difficult to treat younger athletes because they might present symptoms different from older counterparts.

“It’s the opposite of most other injuries. You break a bone as a 5-year-old, you’re going to get better faster than your 30-year-old,” Zaslow said. “When it comes to concussion and brain injuries, it is slower.”

Dr. Tracy Zaslow said that when a concussion occurs, the brain moves around in the head, causing biochemical changes at the cellular level. (Photo courtesy Children’s Hospital Los Angeles)

She said seven to 10 days is a normal recovery time for adults who suffer a concussion, but three to four weeks is considered normal for some children.

Many parents whose children play contact sports fear their child could someday suffer from chronic traumatic encephalopathy, or CTE, a degenerative brain disease often found among athletes and military veterans.

The disease was highlighted in the 2015 blockbuster film “Concussion,” starring Will Smith as Dr. Bennet Ifeakandu Omalu, the American forensic pathologist and neuropathologist who identified the disease. Omalu worked for the Allegheny County Coroner in Pittsburgh, studying brain samples from several deceased former NFL players, beginning with former Steelers center Mike Webster.

According to the Mayo Clinic, CTE may include symptoms such as cognitive impairment, impulsive behavior, short-term memory loss, depression or apathy, loss of executive function, emotional instability, substance abuse and suicidal thoughts. It is most commonly found among athletes who play or previously played football, hockey, rugby, soccer and other contact sports.

CTE can’t be detected until after a person has died and physicians can inspect their brain. Research into the links between contact sports and CTE is in its early stages.

Comstock’s research into the effects of heading surprised her after she conducted a study on the rate of concussion among boys and girls playing high school soccer from 2005 through 2014.

“It makes sense that if you ban heading we should have a positive affect,” Comstock said. “In both boys and girls, the heading is the phase of play in which most concussions occur. But if you look more closely, it’s not the ball striking the head, it is two athletes colliding while they are trying to head the ball. It’s athlete-(to)-athlete contact that’s causing the concussions.”

The results of Comstock’s study found that in girls, 627 concussions (4.50 concussions per 1,000 athletic exposures) occurred in 1,393,753 athlete exposures and in boys 442 (2.78 concussions per 1000 athletic exposures) were sustained during 1,592,238 athletic exposures.

However, 68.7 percent of concussions among boys and 51.3 percent among girls occurred as a result of athlete-to-athlete contact rather than heading the ball itself.

More numbers

In another study published in 2015 in the Journal of Biomechanics, researchers examined the short-term and long-term impact of acceleration that the head experiences in both women’s high school and collegiate soccer, rather than strictly the rate of concussions.

Purdue University researchers studied 29 high school soccer girls ages 14 to 18 years and 24 college women in the sport ages 17 to 22, and among their findings, they saw the gravitational force experienced by the women in college soccer when heading back a goal kick was the equivalent of the forces experienced by college football players during a tackle.

Gravitational force or “G force” is a measure of acceleration, with 1 G equal to the force of gravity at the Earth’s surface. So, 2 Gs is twice the force of gravity, and so on.

“To be perfectly honest, women’s college soccer looks just like (college) football,” said Dr. Eric Nauman, director of Purdue’s Human Injury Research and Regenerative Technologies Laboratory, who led the study. “That surprised us because I didn’t think that we would get to the 120-, 140-Gs range.”

The study took place over a season where both female high school and college level players had MRI scans of their brain in preseason, mid-season and postseason. Each player wore an X2 patch behind the ear for training sessions and games, which allowed Nauman and his fellow researchers to record the G force of every impact as well as the rotational acceleration of the brain after any blow greater than 20 Gs.

A patch behind the ear can help measure G-force impacts. (Photo courtesy X2 Biosystems)

“Based on the data that we’ve seen, the hit distributions are the same in women’s soccer” and tackle football, Nauman said. “A lot of the brain changes in the physiology are very similar.”

Other sports

Soccer is one of several contact sports facing concussion-related issues. Leagues in sports such as hockey and football also have taken steps to prevent head-related injuries.

The Los Angeles Kings High School Hockey League launched a partnership with CHLA to make player safety the league’s highest priority beginning in 2015. Currently, the league has an athletic trainer at every hockey event.

Golden Empire Youth Tackle Football, an independent organization in Bakersfield, Calif., that involves about 3,000 youth players from 6 to 14 years of age, adopted heads-up, rugby-style tackling, limited contact in practices and instituted a two-part concussion protocol.

Players are pulled from games or practices if there is any suspicion of concussive symptoms, parents are contacted and a report is filed through the league.

The player must see a specialist and if a concussion is diagnosed, the player must sit out a minimum of seven days.

The second principal of the protocol is to inform the child’s school about the incident within what is allowable under health information privacy laws. The idea is to keep an eye out for potential concussion-related complications.

“That’s an aspect that’s often overlooked,” said Ron White, executive director of the league. “If a player is concussed, how is that impacting him in the home and in an educational setting?”

White is among the leaders of a California save youth football coalition that is taking the lead in trying to make the sport safer – despite the fact that he is skeptical about the correlation between contact sports and CTE.

Meanwhile, U.S. Soccer is taking steps beyond the heading rules, hoping to raise awareness and educate parents, coaches and players about player safety.

While research continues into the effects of heading soccer balls on the brain, those studying the effects agree there are simple steps that can be taken that might help until more is known.

Comstock believes simply enforcing existing rules will help.

“Our conclusion from our paper was that if you really want to try to eliminate concussions in soccer, you should just better enforce the rules and reduce the athlete-athlete contact that is occurring,” Comstock said. “It was intriguing to me that U.S. Soccer was willing to make such a big culture shift as their first effort rather than simply trying to reinforce the rules.”

Zaslow said another solution is to implement more athletic trainers in all levels of soccer as it is shown to reduce injury, including head-related injuries.

“Every study has shown that having an athletic trainer on the sideline is your best injury prevention and treatment,” Zaslow said.

In 2017, the US Soccer Federation made $152 million in revenue and with the help of state and local affiliates, it can realistically implement more athletic trainers and physicians at more of its sanctioned events. (recreational and competitive).

Zaslow added that individual leagues and clubs could also help with the costs in exchange for the latest soccer apparel. According to the California Athletic Trainers Association, the minimum recommended pay for an athletic trainer is $35 per hour and is a small price to pay for the safety of youth players.

Many believe that making sure balls are properly pressurized and dry will reduce concussions.

“They all absorb water,” Nauman said of soccer balls. “They all get heavier in the rain. To be perfectly honest, I wouldn’t allow any soccer in the rain because those balls turn into bricks.”

Mader said she remembered noticing a difference in ball pressure between practice and games.

“We had to pump up the balls everyday for practice. For practice they would be at 8 (pounds per square inch of pressure) and then on game days we would pump them up to 10 (PSI),” Mader said. “Ten was so hard, and we would all complain about it. It would be so hard and so painful to the point that I did not not want to head it.”

Mader said she doesn’t regret playing soccer, despite lingering effects from the her concussions. She said her memory is not as good, and she constantly writes things down to reminder herself.

“You can tell me something and I will be full blown paying attention and three minutes later, I cannot remember for the life of me what you said,” Mader said. “I take notes for everything now. I record people because I can never remember.”

Madder added that now she suffers from panic attacks, which she never suffered from before to the concussions and will also occasionally faint.

“I get the same feeling that I am going to pass out … I never had passed out or anything before, and now I have passed out while I was working,” Mader said. “I pass out in the weirdest places. My heart rate jumps through the roof, and I have maybe 10 seconds. Then my whole body gives out, and I black out.”

Mader said she is not certain sure that these symptoms are related to her concussions but she knows one thing.

“I have never had anything like that happen to me (before).”

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