Heading the Ball: Soccer's Concussion Controversy and Why Headers Deserve Their Own Baseline Protocol

Soccer presents a unique challenge in concussion management: it’s the only major sport where athletes deliberately and repeatedly use their head to contact the ball. This creates a form of repetitive head impact exposure that exists outside the framework of traditional concussion diagnosis.

Where the concussions actually come from

According to the NCAA Injury Surveillance System, girls’ soccer is the leading cause of concussions among female high school athletes. While many of these concussions come from player-to-player collisions (head-to-head, head-to-elbow, head-to-ground), the cumulative effect of purposeful heading itself has become a growing scientific concern.

What the heading research shows

Research on heading is evolving rapidly. A landmark study by Lipton et al. (2013), published in Radiology, used diffusion tensor imaging (DTI) to detect white matter changes in adult soccer players who headed the ball frequently — with a threshold effect appearing above approximately 885–1,550 headers per year. A more recent review in Frontiers in Neurology confirmed that heading volume (total number of headers) may be more important than the force of any individual header.

U.S. Soccer’s policy response

U.S. Soccer implemented heading restrictions in 2015: no heading for children under 11, and limited header practice for players 11–13. The policy was developed in consultation with the U.S. Soccer Development Academy and was influenced by a class-action lawsuit settlement. Similar policies have been adopted by some European federations, though implementation and enforcement vary.

Why soccer baselines should include VOMS

This raises an important question for baseline testing: should soccer players receive a different or expanded baseline protocol? Standard baselines assess cognitive function, symptoms, and balance. But soccer players who head the ball regularly may benefit from additional vestibular-ocular screening (VOMS) to catch subtle inner ear and eye movement changes that accumulate with repetitive head contact.

Research by Mucha et al. (2014) in The American Journal of Sports Medicine demonstrated that vestibular-ocular deficits are the strongest predictor of prolonged concussion recovery — making VOMS particularly relevant for a sport where subconcussive vestibular stress is ongoing.

Our recommendation for soccer programs

At Headquarters, we recommend comprehensive baselines for all soccer players that include VOMS and balance assessment in addition to standard cognitive testing. For athletes who head the ball regularly, we also advocate for mid-season and end-of-season follow-up testing to monitor for cumulative changes.

The goal isn’t to eliminate heading from soccer — it’s to make sure we’re monitoring the athletes who do it. For deeper context on why women’s soccer deserves particular attention, read our piece on the concussion gender gap.

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