An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer | Adolescent Medicine | JAMA Pediatrics | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Fields  SK.  Female Gladiators: Gender, Law, and Contact Sport. Champaign: University of Illinois Press; 2011.
Brown  S.  Fleet feet: the USSF and the peculiarities of soccer fandom in America.  Soccer Soc. 2007;8(2-3):366-371.Google ScholarCrossref
National Federation of State High School Associations. 2013-14 High School Athletics Participation Survey. Accessed December 29, 2014.
Yard  EE, Schroeder  MJ, Fields  SK, Collins  CL, Comstock  RD.  The epidemiology of United States high school soccer injuries, 2005-2007.  Am J Sports Med. 2008;36(10):1930-1937.PubMedGoogle ScholarCrossref
Adams  AL, Schiff  MA.  Childhood soccer injuries treated in U.S. emergency departments.  Acad Emerg Med. 2006;13(5):571-574.PubMedGoogle ScholarCrossref
Marar  M, McIlvain  NM, Fields  SK, Comstock  RD.  Epidemiology of concussions among United States high school athletes in 20 sports.  Am J Sports Med. 2012;40(4):747-755.PubMedGoogle ScholarCrossref
Rosenthal  JA, Foraker  RE, Collins  CL, Comstock  RD.  National high school athlete concussion rates from 2005-2006 to 2011-2012.  Am J Sports Med. 2014;42(7):1710-1715.PubMedGoogle ScholarCrossref
Lincoln  AE, Caswell  SV, Almquist  JL, Dunn  RE, Norris  JB, Hinton  RY.  Trends in concussion incidence in high school sports: a prospective 11-year study.  Am J Sports Med. 2011;39(5):958-963.PubMedGoogle ScholarCrossref
Halloran  JD. The rise and rise of the United States women’s national team. Bleacher Rep Website. April 23, 2013. Accessed December 31, 2014.
Sports Legacy Institute. Safer soccer initiative. Accessed December 30, 2014.
Baroff  GS.  Is heading a soccer ball injurious to brain function?  J Head Trauma Rehabil. 1998;13(2):45-52.PubMedGoogle ScholarCrossref
Putukian  M.  Heading in soccer: is it safe?  Curr Sports Med Rep. 2004;3(1):9-14.PubMedGoogle ScholarCrossref
Spiotta  AM, Bartsch  AJ, Benzel  EC.  Heading in soccer: dangerous play?  Neurosurgery. 2012;70(1):1-11.PubMedGoogle ScholarCrossref
O’Kane  JW, Spieker  A, Levy  MR, Neradilek  M, Polissar  NL, Schiff  MA.  Concussion among female middle-school soccer players.  JAMA Pediatr. 2014;168(3):258-264.PubMedGoogle ScholarCrossref
Tierney  RT, Higgins  M, Caswell  SV,  et al.  Sex differences in head acceleration during heading while wearing soccer headgear.  J Athl Train. 2008;43(6):578-584.PubMedGoogle ScholarCrossref
Teymouri  M, Sadeghi  H, Nabaei  A, Kasaeian  A.  The relationship between biomechanical-anthropometrical parameters and the force exerted on the head when heading free kicks in soccer.  Arch Trauma Res. 2012;1(1):44-48.PubMedGoogle ScholarCrossref
Hanlon  EM, Bir  CA.  Real-time head acceleration measurement in girls’ youth soccer.  Med Sci Sports Exerc. 2012;44(6):1102-1108.PubMedGoogle ScholarCrossref
Witol  AD, Webbe  FM.  Soccer heading frequency predicts neuropsychological deficits.  Arch Clin Neuropsychol. 2003;18(4):397-417.PubMedGoogle ScholarCrossref
Tysvaer  AT, Løchen  EA.  Soccer injuries to the brain: a neuropsychologic study of former soccer players.  Am J Sports Med. 1991;19(1):56-60.PubMedGoogle ScholarCrossref
Downs  DS, Abwender  D.  Neuropsychological impairment in soccer athletes.  J Sports Med Phys Fitness. 2002;42(1):103-107.PubMedGoogle Scholar
Haran  FJ, Tierney  R, Wright  WG, Keshner  E, Silter  M.  Acute changes in postural control after soccer heading.  Int J Sports Med. 2013;34(4):350-354.PubMedGoogle Scholar
Lipton  ML, Kim  N, Zimmerman  ME,  et al.  Soccer heading is associated with white matter microstructural and cognitive abnormalities.  Radiology. 2013;268(3):850-857.PubMedGoogle ScholarCrossref
Rechel  JA, Yard  EE, Comstock  RD.  An epidemiologic comparison of high school sports injuries sustained in practice and competition.  J Athl Train. 2008;43(2):197-204.PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention (CDC).  Sports-related injuries among high school athletes—United States, 2005-06 school year.  MMWR Morb Mortal Wkly Rep. 2006;55(38):1037-1040.PubMedGoogle Scholar
US Census Bureau. Census regions and divisions of the United States, 2014. Accessed May 20, 2015.
Fuller  CW, Junge  A, Dvorak  J.  A six year prospective study of the incidence and causes of head and neck injuries in international football.  Br J Sports Med. 2005;39(suppl 1):i3-i9.PubMedGoogle ScholarCrossref
Andersen  TE, Arnason  A, Engebretsen  L, Bahr  R.  Mechanisms of head injuries in elite football.  Br J Sports Med. 2004;38(6):690-696.PubMedGoogle ScholarCrossref
Jordan  SE, Green  GA, Galanty  HL, Mandelbaum  BR, Jabour  BA.  Acute and chronic brain injury in United States national team soccer players [published correction appears in Am J Sports Med. 1996;24(4):563].  Am J Sports Med. 1996;24(2):205-210.PubMedGoogle ScholarCrossref
Kontos  AP, Dolese  A, Elbin  RJ, Covassin  T, Warren  BL.  Relationship of soccer heading to computerized neurocognitive performance and symptoms among female and male youth soccer players.  Brain Inj. 2011;25(12):1234-1241.PubMedGoogle ScholarCrossref
Straume-Naesheim  TM, Andersen  TE, Dvorak  J, Bahr  R.  Effects of heading exposure and previous concussions on neuropsychological performance among Norwegian elite footballers.  Br J Sports Med. 2005;39(suppl 1):i70-i77.PubMedGoogle ScholarCrossref
Stephens  R, Rutherford  A, Potter  D, Fernie  G.  Neuropsychological impairment as a consequence of football (soccer) play and football heading: a preliminary analysis and report on school students (13-16 years).  Child Neuropsychol. 2005;11(6):513-526.PubMedGoogle ScholarCrossref
Kaminski  TW, Cousino  ES, Glutting  JJ.  Examining the relationship between purposeful heading in soccer and computerized neuropsychological test performance.  Res Q Exerc Sport. 2008;79(2):235-244.PubMedGoogle ScholarCrossref
Stephens  R, Rutherford  A, Potter  D, Fernie  G.  Neuropsychological consequence of soccer play in adolescent U.K. school team soccer players.  J Neuropsychiatry Clin Neurosci. 2010;22(3):295-303.PubMedGoogle ScholarCrossref
Putukian  M, Echemendia  RJ, Mackin  S.  The acute neuropsychological effects of heading in soccer: a pilot study.  Clin J Sport Med. 2000;10(2):104-109.PubMedGoogle ScholarCrossref
Rieder  C, Jansen  P.  No neuropsychological consequence in male and female soccer players after a short heading training.  Arch Clin Neuropsychol. 2011;26(7):583-591.PubMedGoogle ScholarCrossref
Gutierrez  GM, Conte  C, Lightbourne  K.  The relationship between impact force, neck strength, and neurocognitive performance in soccer heading in adolescent females.  Pediatr Exerc Sci. 2014;26(1):33-40. PubMedGoogle ScholarCrossref
Schmitt  DM, Hertel  J, Evans  TA, Olmsted  LC, Putukian  M.  Effect of an acute bout of soccer heading on postural control and self-reported concussion symptoms.  Int J Sports Med. 2004;25(5):326-331.PubMedGoogle ScholarCrossref
Frommer  LJ, Gurka  KK, Cross  KM, Ingersoll  CD, Comstock  RD, Saliba  SA.  Sex differences in concussion symptoms of high school athletes.  J Athl Train. 2011;46(1):76-84.PubMedGoogle ScholarCrossref
American College of Sports Medicine.  The prevention of sport injuries of children and adolescents.  Med Sci Sports Exerc. 1993;25(8)(suppl):1-7.PubMedGoogle Scholar
Bjørneboe  J, Bahr  R, Einar Andersen  T.  Video analysis of situations with a high-risk for injury in Norwegian male professional football: a comparison between 2000 and 2010.  Br J Sports Med. 2014;48(9):774-778.PubMedGoogle ScholarCrossref
Original Investigation
September 2015

An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer

Author Affiliations
  • 1Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora
  • 2Department of Pediatrics, University of Colorado School of Medicine, Aurora
  • 3Department of Communication, University of Colorado Denver
JAMA Pediatr. 2015;169(9):830-837. doi:10.1001/jamapediatrics.2015.1062

Importance  Soccer, originally introduced as a safer sport for children and adolescents, has seen a rapid increase in popularity in the United States over the past 3 decades. Recently, concerns have been raised regarding the safety of soccer ball heading (when an athlete attempts to play the ball in the air with his or her head) given the rise in concussion rates, with some calling for a ban on heading among soccer players younger than 14 years.

Objectives  To evaluate trends over time in boys’ and girls’ soccer concussions, to identify injury mechanisms commonly leading to concussions, to delineate soccer-specific activities during which most concussions occur, to detail heading-related soccer concussion mechanisms, and to compare concussion symptom patterns by injury mechanism.

Design, Setting, and Participants  Retrospective analysis of longitudinal surveillance data collected from 2005-2006 through 2013-2014 in a large, nationally representative sample of US high schools. Participants were boys and girls who were high school soccer players.

Exposures  Concussions sustained during high school–sanctioned soccer games and practices.

Main Outcomes and Measures  Mechanism and sport-specific activity of concussion.

Results  Overall, 627 concussions were sustained during 1 393 753 athlete exposures (AEs) among girls (4.50 concussions per 10 000 AEs), and 442 concussions were sustained during 1 592 238 AEs among boys (2.78 concussions per 10 000 AEs). For boys (68.8%) and girls (51.3%), contact with another player was the most common concussion mechanism. Heading was the most common soccer-specific activity, responsible for 30.6% of boys’ concussions and 25.3% of girls’ concussions. Contact with another player was the most common mechanism of injury in heading-related concussions among boys (78.1%) and girls (61.9%). There were few differences in concussion symptom patterns by injury mechanism.

Conclusions and Relevance  Although heading is the most common activity associated with concussions, the most frequent mechanism was athlete-athlete contact. Such information is needed to drive evidence-based, targeted prevention efforts to effectively reduce soccer-related concussions. Although banning heading from youth soccer would likely prevent some concussions, reducing athlete-athlete contact across all phases of play would likely be a more effective way to prevent concussions as well as other injuries.