Soccer and the Concussion Dilemma: Are They Preventable?

Over the past decade, there has been a 60% increase in the number of sports and recreation-related emergency room visits due to concussions and traumatic brain injury.1  As a result, concussions are at the forefront of media coverage, prompting investigations into management of concussions at multiple levels of play.  This has also prompted a surge of research into Concussionconcussion management and prevention, including the well-known Heads Up campaign.  Concussions are highest in football and girls soccer with females between the ages of 10-19 being most at risk for soccer-related concussions.  There is minimal research to support that concussions are preventable however, there are ways to modify the factors involved in the mechanism of concussions.  Thus far, the majority of the focus has been on modifying helmets and other headgear versus within the players themselves.  The goal of this article is to educate coaches, parents, and athletes about the signs and symptoms of a concussion as well as to explain potential injury prevention strategies.

A concussion is defined as “…a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”2  What does this actually mean? A concussion can occur as a result of a direct blow to the head, face, neck, or any other part of the body where the force is transmitted to the head. This usually occurs during sports or as a result of a fall or car accident.  This trauma usually results in short-lived neurological symptoms (headache, dizziness, tingling, numbness, vision changes) that typically resolve quickly on their own.  These symptoms reflect a change in function of the brain but usually do not cause an injury evident on imaging.  Basically, a decrease in blood flow to the brain causes an energy crisis.  With exercise, blood is pulled away from the brain to support the lungs and muscles that work to sustain activity.  Therefore, if an athlete attempts to return to sport before their brain heals, too much stress is placed on the brain.  This can cause continued symptoms and place the brain at risk for further damage including Second Impact Syndrome.

Symptoms of a concussion may include: loss of consciousness, confusion, headache, dizziness, nausea, vomiting, loss of memory from before or after the injury, mumbling, drowsiness, blank stares, personality change, irritability, mood swings, exaggerated emotions, seizures, poor performance on the field, unsteady gait, poor balance, slow speech, poor coordination, difficulty concentrating, ringing in the ears, double or blurred vision, sensitivity to light or sound, feeling mentally foggy, and numbness or tingling.  If any of these signs or symptoms are present in an athlete after a blow to the body or head, the athlete should be removed from play until cleared by a medical professional specializing in concussion management.  Never return an athlete to play on the same day.

Recovery from a concussion varies.  The metabolic dysfunction (change in blood flow) that occurs in the brain after a concussion is commonly present for up to two weeks.3  About 80% of high school athletes recover within 3 weeks which means the remaining 20% of these athletes have continued symptoms lasting longer than 3 weeks (protracted recovery).Recovery may be longer in athletes with: memory loss, confusion, loss of consciousness, dizziness, and vomiting after the concussion as well as those athletes with a pre-existing learning disability, prior concussions, migraines, younger age, and athletes who tend to over-exert themselves.3

Many important factors may increase the likelihood of suffering a concussion in soccer and therefore, prevention programs should aim to modify these factors.  Females are more likely to sustain a concussion due to differences in head-neck strength as compared to males.  However, this being said, females are also more likely to report their symptoms.2,3  There is an increased risk of concussion in the 10-19 year old female soccer athlete since they start to compete at a higher level but have not yet developed the strength and awareness to control their body.1  Core strength is vital to head control and far too often, developing the correct kind of core strength is overlooked in modern day training regimens.  The core must have good strength as well as endurance to help stabilize the hips, shoulders, and head during contact, especially in soccer.  Many athletes attempt to complete exercises that are too difficult, resulting in loss of form and control. Often these athletes must go back to the basics of core strengthening prior to completing more advanced exercises.   It is vital to maintain a neutral spine at all times during exercise.  The chin should be tucked, pelvis should be in neutral, core should be drawn up and in, and shoulder blades should be lightly pinched.   The deep cervical spine neck flexors are the most important component in neck stabilization during head contact, and unfortunately, one of the most poorly recruited muscle groups.  Strategies to correct this are listed in the exercise table.  By improving core muscle timing, strength, endurance, and recruitment patterns, decreased strain is placed on the head and neck, and therefore the brain during repeated contact in sports such as soccer.

Another important factor in concussion prevention is visual tracking and postural awareness.  Soccer athletes must be able to dribble and kick a ball while accelerating, decelerating, changing direction, cutting, and heading a ball.  They must be able to follow the ball effectively with their Postureeyes and head while paying attention to their surroundings.  Often times when young athletes attempt to head a ball, they are somewhat hesitant, forgetting to protect their head by putting their elbows up.  Occasionally, they will even close their eyes prior to the time of contact.  This loss of visual control and awareness may increase the likelihood of head contact with another player.  Improved education about correct heading mechanics as well as practice to improve visual tracking will only make for a better soccer player.  Some strategies to improve visual tracking are listed in the exercise table as well.  Improved visual tracking may decrease the likelihood of concussions in youth soccer by improving an athlete’s body awareness, heads-up play, and ability to brace their body with contact.

Although many other strategies exist for potential concussion prevention, the main focus should be on improving core strength and control as well as visual tracking.  As young athletes grow, their ability to stabilize their body rapidly decreases, placing them at risk for a multitude of injuries.  A few simple changes to strength and conditioning regimens may be enough to decrease the risk for concussions.  A number of additional strategies for decreasing the likelihood of concussions are listed below.

Concussion injury prevention strategies:

  • Know the signs and symptoms of a concussion: The sooner an athlete is removed from play, the more likely they are to recover. Remember, just because they didn’t get “knocked out”, doesn’t mean they don’t have a concussion.
  • Play heads up soccer: Always watch the play happening around you, even when you aren’t involved. Concussions occur when an athlete is unable to effectively brace their head and neck.
  • Posture: Keep your head in a neutral position especially when heading the ball.
  • No blindsiding: Don’t hit people who can’t see you as this is dangerous to both athletes. Promote fair play and clean body contact from your teammates and opponents.
  • Avoid excessive contact at practice: This decreases the unnecessary force through the brain because as few as 50-60 blows to the head per week may lead to a change in brain function.
  • Heading the ball: Maintain good posture (chin tucked) while heading the ball.
  • Complete an injury prevention program: Improving your posture, awareness, core strength, and visual tracking may decrease your likelihood of concussion.
  • Improve your visual tracking: Just like any other muscle in the body, the eye muscles require use and exercise to get stronger. There are many exercises to improve your visual tracking.  An easy way is to start tracking the ball with your eyes every time you receive a pass, kick the ball, during throw-ins, or if you go up for a header.  Writing a different number on each of your practice balls and having the player call out the number as the ball is being passed to them is one unique way to train this.
  • Develop core strength: A strong core (including hips, shoulders, neck, and abs) helps to stabilize your head during contact, thus decreasing the strain through your neck and brain with contact.
  • Improve your conditioning: The better your conditioning, the less likely you are to place your body into poor situations. You must be able to stabilize your body during all athletic activities.  As fatigue increases, body control decreases, increasing your likelihood for injuries such as ACL tears and concussions.  Cardiovascular fitness, flexibility, strength, agility, power, balance, and control are all important to injury prevention.
  • Correct your asymmetries: Have a medical professional assess side-to-side differences with strength, flexibility, and posture to prevent injury.
  • Cross-train: Find an activity or sport outside of soccer that you enjoy and do it! Playing soccer all year without a break or change in training leaves certain muscle groups weaker.
  • Growth and development: If the athlete is smaller (especially pre-pubescent females with longer necks) but plays against larger athletes, consider activity modifications until adequate strength develops.
  • Nutrition and hydration: The better your nutrition and hydration, the more likely your brain can prevent and recover from a trauma (including smaller, repeated traumas).
  • Skip the head gear: Understand that headgear may or may not prevent concussions (the research is mixed). Often athletes feel invincible with more protective equipment, which may leave them more vulnerable.
  • Advocate for rule changes: Children are not “little adults” and therefore should not play with the same rules as adults.
  • ImPACT testing: Remember ImPACT tests are of little value without baseline testing. Consultation of a skilled professional is also needed to interpret the results.

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Figure 1 credit to:

Figure 2 credit to:

  1. Concussion in Sports and Play: Get the Facts. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.  2011.  Accessed 2/20/2014.
  2. McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in Sport- the Third International Conference on Concussion in Sport Held in Zurich, November 2008. Br J Sports Med.  2009; 43 (suppl 1): i76-i90.
  3. Sabini RC, Reddy CC. Concussion Management and Treatment Considerations in the Adolescent Population.  Phys Sportsmed.  2010; 38 (1): 139-146.

Written by Michelle Feairheller

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