Heading in Soccer: Dangerous Play? Soccer is the world’s most popular sport and unique in that players use their unprotected heads to intentionally deflect, stop, or redirect the ball for both offensive and defensive strategies. Headed balls travel at high velocity pre- and postimpact. Players, coaches, parents, and physicians are justifiably concerned with soccer heading injury risk. Fur- thermore, risk of long-term neurocognitive and motor deficits caused by repetitively heading a soccer ball remains unknown. We review the theoretical concerns, the results of biomechanical laboratory experiments, and the available clinical data regarding the effects of chronic, subconcussive head injury during heading in soccer. KEY WORDS: Heading, Head injury, Injury biomechanics, Soccer Neurosurgery 70:1–11, 2012 DOI: 10.1227/NEU.0b013e31823021b2 www.neurosurgery-online.com S occer, or football as it is referred to out- side the United States, is the most popular sport in the world. Soccer is unique in that it is the only sport in which players use their unprotected heads to intentionally deflect, stop, or redirect the ball for both offensive and defensive strategies. Headed balls travel at high velocity pre- and postimpact. Hence, players, coaches, parents, and physicians are justifiably concerned with the short- and long- term risks of heading in soccer. The deleterious effects of repetitive minor trauma in other sports such as boxing 1-4 and American football 5-13 are well acknowledged. Unfortunately, risk of long- term neurocognitive and motor deficits caused by repetitively heading a soccer ball remains unknown. The potential for detrimental effects caused by repetitive heading in soccer was thrust into the media limelight in 2002 after the death of Jeffrey Astle, a legendary figure in England whose career spanned 20 years and who had been a formidable header of the ball. During his career, the leather balls used were much heavier, especially in wet conditions, than those used today. Astle died at age 59 after a 5-year history of diminishing mental ability. At autopsy, extensive degenerative brain disease and taupathy consistent with chronic traumatic encephalopathy (CTE) were found, leading the coroner to conclude that minor repetitive trauma was the cause of his death and a verdict of ‘‘death by industrial injury’’ was documented. 14 However, head injury in soccer, in addition to that attributed to heading a ball, may also occur from player-player, player-ground, and player-goal post contact. In 2000, Algerian top scorer Hocine Gacemia died after a scoring header in which he also struck a defender’s head, sustaining a cranial fracture and a large right-sided temporal hematoma. 15 The term CTE, formerly referred to as dementia pugilistica, describes a syndrome of progressive neurodegeneration resulting from repetitive subconcussive brain injury that shares some of the features of Alzheimer disease. 16-22 CTE is associated with behavioral and person- ality alterations, memory disturbance, parkin- sonism, and speech and gait abnormalities. The pathologic hallmarks include gross cerebral and medial temporal lobe atrophy and extensive tau- immunoreactive neurofibrillary tangle deposition throughout the neocortex, medial temporal lobe, diencephalon, brainstem, and spinal cord. 23-25 In view of the current media attention and the mounting evidence supporting CTE resulting from repetitive head injuries via subconcussive impact, we review the theoretical concerns, the results of biomechanical laboratory experiments, and finally the available clinical data regarding the effects of chronic subconcussive head impact during heading in soccer. Alejandro M. Spiotta, MD*‡ Adam J. Bartsch, PhD§{ Edward C. Benzel, MD§{ *Department of Neurological Surgery, ‡Cerebrovascular Center, §Cleveland Clinic for Spine Health, {Cleveland Traumatic Neuromechanics Corsortium, Cleveland, Ohio Correspondence: Edward C. Benzel, MD, Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S40, Cleveland, OH 44195. E-mail: benzele@ccf.org Received, January 19, 2011. Accepted, May 17, 2011. Published Online, August 1, 2011. Copyright ª 2011 by the Congress of Neurological Surgeons ABBREVIATIONS: CG, center of gravity; CTE, chronic traumatic encephalopathy; FIFA, Fe ´de ´ra- tion Internationale de Football Association; F-MARC, Fe ´de ´ration Internationale de Football Association Medical Assessment and Research Center NEUROSURGERY VOLUME 70 | NUMBER 1 | JANUARY 2012 | 1 REVIEW TOPIC REVIEW Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.