The Concern Over ‘CTE’

First, what is ‘CTE‘? This stands for Chronic Traumatic Encephalopathy. You have heard of football players, that have died, leaving their brains to science for research. Many famous players, Jr. Seau being the most famous, have been found to have developed CTE over their playing career.

This is a progressive brain disease that occurs over a period of time, due to repetitive concussive and sub-concussive hits to the brain. The condition can exhibit itself during a player’s career at any point where there have been accumulated hits to trigger the disease (there is no currently estimated trigger number at this point), or can manifest itself progressively, after a player has stopped playing.

The first stage of brain degeneration is initially associated with memory loss, confusion, impaired judgment, impulse control problems, dizziness, depression, attention span deterioration, vertigo, disorientation, speech impediment, tremors, and headaches. Victims, in the second stage, may show symptoms of  erratic behavior, problems socializing, memory loss, and Parkinson’s disease.  Third stage victims may demonstrate progressive dementia, physical aggression, deafness,   suicidal tendencies, and deterioration of muscle movement (facial expressions affected and speech affected).

This condition has caused some youth athletes, and many NFL players, to eventually take their life. The discussion over CTE in soccer has centered on heading of the ball. There is much debate and inconclusive research on if heading the ball causes sub-concussive damage to the brain. Some theorists do claim research that does appear to indicate that heading can cause accumulation of sub-concussive hits. The picture is cloudy in this area at the moment.

What actually is a sub-concussive hit? This is a hit which causes an injury to the brain, but does not manifest itself into a diagnosable concussion. It causes minute damage to the brain. It becomes more apparent later in an athletes life, after the brain is affected by the accumulation of degraded brain tissue areas. This slow deterioration of brain tissue causes symptoms of CTE to start appearing in an individual.

There have been athletes that played their entire career, without being diagnosed with an actual concussion, but yet started showing signs of CTE later in life.  In 2017, Dr. Ann McKee, a neuropathologist took part in a Boston University study of deceased football players brains.  The study found that 110 out of 111 brains showed CTE symptoms.

The Boston University study was published in the July, 2017, ‘Journal of The American Medical Association‘.  The study concluded that ” In a convenience sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of CTE, suggesting that CTE may be related to prior participation in football.”

As for soccer,  Ann McKee stated “Soccer has repetitive impacts, from player to player and players heading the ball”.  Ann McKee further stated “It doesn’t matter how you do it, just that you do it and do it repetitively.”

This question of repetitive hits could an important one for soccer players, who had started playing at an early age, and continued playing for a long period of time.  The question to ask would be what may have subconcussive hits, and under/not reported concussions done to a players brain.  Rules for not allowing younger players to head the ball may be seemingly reinforced by the studies comment “...it is unclear if symptomatic hits (concussions) are more important than asymptomatic hits resulting in subconcussive injury. As with other neurodegenerative diseases, age may be related to risk and pathological severity in CTE.“.

What worries researchers is that CTE has started appearing in young athletes. The causative factor is the number of sub-concussive blows that an athlete has received in their playing career.

The basis for this concern is that their head and neck muscles are not ready to handle this task, and the developing nature of their young brain. This concern is stronger for young girls, who do not have the same muscular strength in their necks as boys do.

With the head being the focal point for headers, which is basically a blow to the head, researchers are carefully researching this. The accumulation of header hits to an athletes head from practicing and games can add up over the years. This is especially true for a player that started playing competitive soccer at an early age and routinely did soccer headers. This also applies to players who may take years of hits to the body, or hard falls to the ground (linear & rotational acceleration forces come into play).

Heading the ball has been identified as a leading cause for collisions between players. This is amplified as most challenges for balls, while attempting to head it, occur when the player jumps into the air. It is not pretty if a hard collision happens with two players jumping forcefully into the air to head a ball. Both players receive an initial collision in mid-air, with no means of support, and may receive another hard collision from falling to the ground.

There is also the danger of being struck by an elbow, or out-stretched arm, when a player accentuates a header. The brain is directly affected by acceleration forces. If no hit to the head occurs, the collision of the players with themselves, or the ground, can be dismissed by a viewing party, if no bones, or other obvious visible injury is apparent. What is totally missed is the internal brain action of smashing into the skull.

What is agreed upon is that improper heading techniques can contribute to subconcussive brain injury and the stress is upon the teaching of proper heading techniques. There is also considerable agreement that female athletes are prone to subconcussive damage, due to weaker neck/back muscles, especially when combined with improper heading techniques (see ‘Soccer Headgear’ section below).

The important point to keep in mind is that if a player has never been diagnosed with a concussion, they still could have built up a collection of subconcussive hits, causing CTE to start occurring.  US Youth Soccer addressed this issue by banning heading in age groups 11 years old and down.  This helps to reduce the accumulation of subconcussive hits for younger players, doing heading.

There is considerable discussion happening concerning the heading of balls by young children. The majority opinion has been leaning to banning heading for players aged 10 and down. US Soccer set a policy that heading could not occur in games for age groups U11 and down.  Other soccer organizations have set a policy not allowing heading in games for U12 and down.

The concern is that due to the immature development of their brain at their age, and the impact that a concussion could have on a young developing brain. There is also the belief that the neck muscles are not developed in strength for heading

Until January, of 2018, CTE was solely thought to be the result of ties to  concussions.  In January, 2018, Boston University published a study which attributed CTE to occur, due to the physical hits that the brain incurred over time.  The report minimizes ties to diagnosed concussions and focusses on the number of physical trauma that a brain has received.  This leads back into sub-concussive hits that a player has received.

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