Wrapping your head around concussions

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By Dr. Joelene Huber

When Canadians hear the term “concussion,” the first words that may come to mind are “hockey” or more recently, “Sidney Crosby.” While sports such as hockey, boxing, football and lacrosse are commonly thought of when discussing head injuries or concussions, a recent article reported that soccer-related head injuries are becoming more common. Neurosurgeon Dr. Michael Levy and his colleagues (at the University of California, San Diego) reported that soccer-related head injuries are on the rise.

According to Dr. Michael Levy, studies suggest that concussion rates may be greater in soccer than higher contact sports such as hockey and football. In fact, concussion rates may account for as many as 22 percent of all soccer injuries.

child-hit-in-head-with-soccer-ball-concussionIn a recent Canadian study of nearly 13,000 sports-related brain injuries in children, soccer accounted for 19 percent of all brain injuries. It was the second most common cause of sports-related brain injuries in children after hockey (44.3 percent). Dr. Michael Cusimano, of St. Michael’s hospital in Toronto, and his colleagues, found that soccer-related brain injuries accounted for more than those in football (12.9 percent), basketball (11.6 percent), and rugby (5.6 percent). These alarming statistics highlight the importance of recognizing brain-injuries and concussions as a significant issue in youth soccer, along with the value of implementing strategies for safety and prevention.

What are common causes of concussions in youth soccer? Who is at risk?

Among soccer players, professional male players may be least at risk. An evaluation of 26 professional European teams between 2001-2010 by the Football Research Group in Sweden found that head and neck injuries were relatively uncommon (2.2% of all recorded injuries) among male professional soccer players and noted that the defensive players were most at risk. In contrast, children seem to be particularly vulnerable. According to Dr. Levy, “children are at higher risk of injury after head trauma” which may be due to “weaker neck muscles, thinner skulls, and proportionately larger heads”.

However, the mechanism of injury varies as children develop. According to Dr. Cusimano, the majority of brain injuries in soccer occur in children ages 10-14 and most injuries found in this age group (along with 15-19 year olds) are a result of “being struck by another player” such as colliding head-to-head. Injuries from high kicks to the head are more common in the older age groups, whereas younger children (five to nine year olds and 10-14 year olds) tend to have injuries from the ball. Children ages 5-9 years old are commonly injured by striking an object, such as the goal post or net. According to Dr. Levy, injuries resulting in a concussion are more likely to occur during a game than at practice.

Gender differences have also been reported in a number of studies. According to Dr. Levy, females are twice as likely to become injured in soccer when compared to males. Dr. Cusimano’s Canadian study showed that females (ages 15-19) had more injuries than males in the same age group. Overall, females also had more injuries from the ball.

What are the signs and symptoms of a concussion?

The Canadian Paediatric Society (CPS) provides information for coaches, parents and trainers on their website: http://www.caringforkids.cps.ca/handouts/sport_related_concussion

The CPS describes a concussion as a “brain injury that affects the way you think and remember things for a short time” and caused by “any blow to the head, face or neck, or somewhere else on the body that causes a sudden jarring of the head”. The CPS highlights that it is important to note that a child does not have to lose consciousness (pass out) to have a concussion. Symptoms may last seven to 10 days. While concussions result in a temporary change in neurological functions (i.e., thinking and memory), Dr. Levy points out that repetitive head injuries in soccer are believed to cause long-term cognitive deficits as lower neurocognitive scores have been shown in players who had sustained a concussion.

There are a number of signs and symptoms of a concussion (see Canadian Paediatric Society Table). The CPS notes that young children may not have some of the classic signs of a concussion, such as a headache. Instead, symptoms may be more vague, such as behavioural changes.

Physical signs Changes in behaviour Cognitive impairment (problems thinking) Trouble with sleep



Changes in sight

Loss of consciousness (passing out)


Loss of balance/poor coordination

Decreased playing ability



Inappropriate emotions

Slowed reaction times


Difficultly concentrating

Difficulty remembering

Feeling dazed or in a fog


Trouble falling asleep

Sleeping more than usual

Sleeping less than usual

Table from Canadian Paediatric Society: http://www.caringforkids.cps.ca/handouts/sport_related_concussion- Based on McCrory, Meeuwisse, Johnston et al., Consensus statement on Concussion in Sport Third International Conference on Concussion in Sport held in Zurich, November, 2008 (Clin J Sport Med, 2009; 19(3):185-200).

What immediate steps should you take if you suspect a concussion?

The Canadian Paediatric Society sets out clear steps for parents, coaches and trainers to follow if a child gets a concussion:

  • Make sure they stop playing right away
  • Do not leave them alone
  • Make sure they see a doctor as soon as possible that day
  • If they are knocked out, call an ambulance to go to a hospital immediately
  • Do not move them or remove sports equipment
  • Wait for paramedics to arrive

What are the Canadian Paediatric Society recommendations regarding concussion?

The Canadian Pediatric Society Position Statement published in Pediatric Child Health 2012;17(1):31 by Dr. Laura Purcell provides the following recommendations for sport-related concussion in children and adolescents:

(Below are the direct quotes from the position statement recommendations)

  • Athletes, parents, coaches/trainers and anyone working with children and adolescents involved in sports should be educated about the signs and symptoms of sport-related concussion.
  • An athlete who has sustained a head injury during sport should be removed from play immediately and not allowed to return to play that game. The athlete should be closely monitored for any signs of deterioration, and should not be left alone.
  • All athletes sustaining a head injury should be evaluated by a physician as soon as possible.
  • Diagnostic imaging is not routinely recommended unless a structural injury is suspected.
  • The athlete should rest post-concussion until all symptoms have resolved. This includes both physical and cognitive rest.
  • Once the athlete has been symptom-free for several days, they can begin a medically supervised stepwise return-to-play protocol.
  • Return to sport decisions should be more conservative, cautious and individualized in paediatric athletes.
  • Athletes who have concussions with modifying factors may require management by a multidisciplinary team, including physicians with specific concussion expertise.
  • Approved helmets should be worn in all contact sports and for all activities with a risk of head injury (i.e., cycling, skateboarding, in-line skating, skiing, snowboarding or equestrian activities). All protective equipment should be properly worn, well-maintained and replaced according to the manufacturers’ recommendations.
  • Athletes should be taught proper sports techniques and good sportsmanship to help reduce injuries.
  • Sport rule changes and enforcement should be adopted by sporting organizations and officials to decrease the risk and incidence of concussive injuries.
  • All provinces and territories should require by statute that regional sporting associations and school boards have a written policy on concussion recognition and management that conforms in principle to the Canadian Paediatric Society’s concussion guidelines, and that their policy is enforced.

What are some strategies to improve safety in youth soccer?

Dr. Levy suggests:

  • Education of coaches about prompt identification and management of a concussion and the steps required prior to safely returning to play
  • Educating players about safe techniques when playing soccer and consideration of skills that may be too aggressive and/or advanced for young soccer players
  • Developing and testing effective soccer equipment to reduce sport-related head injuries
  • Use of appropriate equipment for young soccer players such as age-appropriate ball size and not over inflating the ball
  • Enforcing soccer rules strictly to ensure safety
  • Taking a strict position regarding players who intentionally use their head to impact another player’s head (as this is associated with a high risk of concussion)

Dr. Cusimano suggests:

  • Mandatory education about the common mechanisms of brain injury in soccer for players, coaches, trainers, officials and parents at all levels of soccer
  • Education and skill improvement surrounding heading the ball when close to another player, high kicks and scissor kicks is important
  • Padding of goal posts
  • More research should be undertaken regarding the use of protective head gear


For parents, coaches and game officials, a priority in youth soccer should be safety. With a better understanding of the risks, mechanisms of brain injury, identification of a concussion, immediate and ongoing steps to management, as well as strategies for prevention, youth soccer players can be active, be safe and have fun.

Disclaimer: The information provided in this article is meant to provide general information and is not meant to be used as individual medical advice. All individuals should seek medical attention and consult with their doctor regarding the information in this article.

Joelene Huber, MSc(A), PhD, MD, FRCPC

Dr. Joelene Huber is a Pediatrician at St. Michael’s Hospital and a consultant at the Hospital for Sick Children in Toronto. She is an Assistant Professor in the Department of Pediatrics at the University of Toronto. She completed her medical degree at McMaster University, her Master of Science at McGill University and her PhD in Medical Science and Neuroscience at the University of Toronto. She plays women’s indoor/outdoor soccer year round. Her greatest joy is being a mom to her two children who are active little soccer players.

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