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10 Articles in Volume 16, Issue #4
Achilles Tendon Injuries
Brain Trauma in Sports
Genetic Testing: Adjunct in the Medical Management of Chronic Pain
Letters to the Editor: Sleep Apnea, SPG Blocks for Migraines, Pancreatic Pain, CDC Guidelines
Pain and Weather—A Cloudy Issue
Phulchand Prithvi Raj, MD, Pioneer in Pain Management, Dies at 84
Physical Medicine & Rehabilitation
Preventing Chronic Overuse Sports Injuries
Sports-Related Pain: Topical Treatments
The “Missing Link” in the Physiology of Pain: Glial Cells

Brain Trauma in Sports

Heading the soccer ball and roughing in hockey often lead to head trauma and other serious injuries. Frequent headaches are often experienced after multiple blows to the head, as well as chronic depression, anxiety, and insomnia.

Brain trauma in sports is not a new occurrence, and much has been done to improve the safety of contact sports. But recent studies have shown that heading a soccer ball is not as innocuous as once was thought. Headers sometimes result in a concussion, and thousands of headers over a career could lead to permanent brain damage.

In addition, hockey Luddites have traditionally dismissed brain traumas with “don’t worry, it’s only your coconut.” However, even big, tough hockey players, football players, and soccer stars suffer mightily from the result of repetitive head traumas. A recent rash of suicides by ex-players in the National Football and Hockey Leagues, most of whom probably suffered from chronic traumatic encephalopathy (CTE), has again awakened the sports world to the dangers of concussions.1 We are dealt only one brain for a lifetime.

Headers in soccer are a frequent cause of brain inury.

Soccer Players Not Immune

A growing body of evidence points to the adverse toll of multiple headers over the course of one’s career. One study of 19-year-old amateur soccer players revealed serious damage to the white matter in the brain.2 White matter is vital for most of our brain functions. These troubling findings were not found in any of the “control” swimmers who were examined.

Another study concluded that as the number of headers increased, cognitive function (such as memory) declined.3 This study also discovered that with increasing numbers of headers, the brain damage grew more severe. They measured damage by assessing the white matter of the brain. According to the study, participants had headed between 32 and 5,400 times (median 432 times) over the previous year. Heading was associated with lower fractional anisotropy (FA) at 3 locations in temporo-occipital white matter. Lower levels of FA were also associated with poorer memory scores (P<0.00001), with a threshold of 1,800 headings per year.3

The physics and mechanics of headers are complex. A soccer ball weighs about 1 pound, and the speed of a kicked ball may easily exceed 40 miles per hour. Our fluid-filled brains cannot be compressed to any great extent, which limits how much of the blow may be safely absorbed. When struck by a soccer ball, the brain often sustains a significant “G” force. The angle of impact is important, along with the position and acceleration of neck muscles. If the ball is overinflated and wet, a more severe impact can result. Goal kicks will result in a higher “G” force than is encountered from a simple throw-in. Many headers result in no brain damage, while others might disrupt sensitive brain pathways, at least temporarily.

Based upon available evidence, many young soccer players will travel through life with a compromised brain. Thinking, memory, and attention may be diminished. Many years of soccer could lead to an increased chance of developing a devastating neurologic condition. These include amyotrophic lateral sclerosis (ALS), Parkinson disease, and dementia.4 CTE, a familiar condition among professional football players, has been identified in several professional soccer players.

At least 25% of soccer concussions are the result of heading the ball. However, I am equally concerned about the cumulative effects of many “subconcussive” hits throughout a career. Collegiate and professional players may head the ball from 700 to 1,400 (or more) times per season. Over a number of years, some players may have headed the ball more than 8,000 times. When I played soccer in the ‘70s, the season was only 3 months long. Now, with many kids playing soccer 8 months per year, their total number of headers has dramatically increased.

There are multiple factors that determine how one’s brain copes with head trauma. Many football and soccer players suffer long-term consequences, while others remain perfectly fine. The variables include genetics, psychiatric makeup, the position played, total number of blows to the head, strength of the neck muscles, number and severity of concussions, and other factors.

Making the Game Safer: More Research Needed

Further research is necessary. A helpful study would compare soccer players with age-matched “controls” who did not play contact sports. Memory, IQ, and attention testing for the 2 groups, from ages 30 through 80, could reveal major differences. Another helpful study would be to compare the rates of neurologic degenerative conditions in soccer players versus controls, particularly at older ages.

There are interventions that would result in a safer game. Eliminating headers prior to age 12, 13, or 14 would help. Using a lighter ball that is slightly underinflated would minimize the “G” force. Even if the ball weighed 5% less, it would result in a significantly lower impact. Strengthening neck muscles, which absorb much of the blow, would certainly help to prevent injury. Headgear research may lead to a helmet that actually protects the brain. There is scant evidence that the current soccer helmets offer any real benefit. These helmets are being sold with promises that are not backed by data.

As with football, most soccer-related subconcussive brain traumas occur during practice. The number of headers should be minimized. Headers during practice should be low velocity (throw-ins, as opposed to long corner or goalie kicks). The balls used during practice ideally would be smaller, lighter, and underinflated.

Even considering that headers are integral to the game, it would help if we minimized the high-velocity impacts. Goalie punts to midfield result in higher “G” forces. I remember playing midfield in November. The ball was wet and heavy. The goalie would kick it high in the air, sending it crashing down on my head with an enormous force. Players should not be allowed to head the goalie’s punt. This would only marginally affect the game, as midfield play rarely leads to a goal. Players can field a high punt with their chests or feet.

Corner kicks often result in collisions between 2 players’ heads. The ball may travel at a high velocity. In addition, the forward may whip his/her head into the ball, creating an angular acceleration that increases brain trauma. Corner kicks are a vital part of soccer, and cannot be eliminated. However, there may be means by which we can lessen the danger. One possibility is to move the corner kick closer to the goalie box, minimizing the speed of the ball.

Soccer is a wonderful and universal game, accessible and inexpensive. When I played and coached, little thought was given to the cumulative effects from headers. We now realize that years of small blows to the head have consequences. It is probable that many young players progress into adulthood with compromised brains due to soccer. We must do more to protect their brains from long-term damage.

Hockey Luddites and Trauma

As with soccer, the brain changes leading to CTE begin early in a hockey career. Eventually, repetitive brain traumas, which devastate our neurons, could lead to various brain problems such as CTE, ALS, Parkinson’s, and dementia—among others. Because brain trauma to the developing nervous system results in significant loss of brain function, these young hockey players might struggle for 60 or 70 years saddled by a lower IQ. By delaying checking until age 13, we could minimize the impact of early head traumas.

NHL fighters and enforcers often endure headaches, depression, dementia, and other neurological problems. As with many ex-NFL players, they may turn to alcohol and drugs, and suicide is frequently the result. It’s simply not worth the money and glory.

As a kid, I watched Bobby Hull fly up the ice at the old Chicago Stadium. Using his heavy wooden stick, he would wind up and unleash a fierce slapper past a frightened, maskless goalie. Stan Mikita was a 1960s version of the great Wayne Gretzky and a skilled magician with the puck. As these magnificent players demonstrated, the majestic beauty of hockey lies in the passing, stick handling, shooting, and goaltending. We could do without the thuggery.

The easiest change would be to eliminate fighting. It exists primarily to entertain fans. An enforcer’s role supposedly includes protecting the star players. But the referees and league should be protecting the players, not relying upon enforcers. The NHL has a long history of inadequately punishing thuggish goons. Skilled hockey players are much more entertaining than are clumsy fighters. The NHL has instituted a number of rule changes, but these have not yet resulted in significantly fewer injuries. And if little is done, players will keep suffering and lawyers will continue to sue.

Many concussions occur when a larger man hits a smaller player. Studies have indicated that forwards bear the brunt of the violence and injuries. The “big men” from 1965 were 6 feet and 180 lb.; now they have grown to 6’5”, 230 lb. As the players have increased in size and brawn, serious injuries have also increased.

How important is hitting to hockey? In the NFL, hitting is an integral part of the game. Hockey is very different. Imagine a game patterned after the women’s version, where bodychecking was not allowed (or was minimized). The incredible speed and breathtaking skill would be a beautiful thing to watch. We would not have to cringe every time a defenseman gave up the puck, knowing some big lug was going to crash into him (which rarely occurred in the 1960s). Our favorite players might continue playing into their ‘40s, having suffered fewer injuries. They might actually go on to enjoy life, without requiring multiple joint replacements, and, of course, the neurologic devastation would be far less.

The NHL overtime 3-on-3 game is exhilarating to watch. The high-skill players go head to head, with magical displays of passing and shooting. It’s hockey at its finest, without the unnecessary crushing body and head blows.

Minimizing checking would not eliminate head injuries. NCAA women hockey players do not bodycheck, yet they suffer higher rates of concussions than the men. The women’s concussion rates even exceed those of football players. Reasons for this include the fact that women have weaker neck musculature (strong neck muscles help protect the brain), and without checking, women are less apt to anticipate being hit, not bracing themselves for a collision.

It’s unlikely that we will see an end to checking. But at least prohibiting bodychecking in one zone, such as between the blue lines, would cut down on injuries. Most injuries occur in the offensive or defensive zone, and eliminating hitting in the middle (neutral) portion of the ice would least affect the game.

If hitting were restricted, other aspects of the game would need to be tweaked. The nets could be made a bit smaller so that every game did not have 30 goals scored, or goalies could go back to slightly larger pads. What would be so terrible if the average game ended with a score of 8 to 7? Fans like scoring; the last time I checked, the NBA enjoyed huge ratings.

The NHL could easily crack down on thuggish play. Previously the league would assess a paltry 1- or 2-game suspension (if at all) if a player intentionally injured another. While the suspensions have lengthened, they remain inadequate. Fining the coach and team could also help to minimize the superfluous violence. During the 2012 playoffs, the popular Chicago Blackhawks star Marian Hossa was knocked out by a vicious hit. Raffi Torres, a repeat offender, had launched himself at Hossa’s head. This ended the Blackhawks’ chances, and could, quite possibly, lead to permanent neurologic problems for Hossa. As usual, the NHL allowed Torres to remain in the league, and he has continued to injure other players.

In 2012 I wrote an article, “Stop Football (Under Age 18), Save Brains.” Hockey is not football, and all ages should be able to participate. However, hockey remains a rough, physical game, often resulting in devastating injuries. We could minimize the violence without materially affecting the game.

Last updated on: May 17, 2016
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Preventing Chronic Overuse Sports Injuries

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