Is heading the ball safe enough for professional footballers?

For decades, coaches have strategised how to win the aerial battle in football. Centre-backs have been, and continue to be, selected based on their pace, strength and of course, their ability to win headers. After all, a centre-half that cannot win a header can be a crucial weakness. Yet many forget the long-term danger of heading the ball in football, which is not restricted to players in the back line.

During the 2020-21 campaign, the Premier League had trialled the use of concussion substitutions from Matchweek 23 until the end of the season. It featured on-pitch clinical assessments and gave a tunnel doctor the opportunity to review video footage of the incident. At the same time, teams were able to apply to replace the injured player, without losing one of their (at the time) three available transfers. However, in January 2023, the International Football Association Board rejected a new temporary concussion substitute trial in the Premier League for the 2023-24 season, despite the request from Fifpro, the world player’s union, and the World Leagues Forum. The decision left the Professional Footballers’ Association’s head of brain health, Dr Adam White, feeling that it was “extremely disappointing”. The tide of player and health professional opinion may well be turning on heading the ball in favour of greater protection of players.

Research substantiates that the quality of footballs used in the professional game had an adverse effect on players’ long-term health

At the end of November 2022, the Scottish FA announced new guidelines to protect players’ long-term cognitive health. Following new research from Glasgow University which suggested that footballers were three-and-a-half times more likely to die from brain disease, professional footballers playing in Scotland have been banned from heading the ball during training sessions the day before and the day after a match. Clubs have also been told to limit the number of exercises that require heading the ball to just one session a week, as a consequence of the new research. With this decision in mind, is it now time for all football associations to impose stringent regulations on heading the ball?

Research substantiates that the quality of footballs used in the professional game had an adverse effect on players’ long-term health. Footballs have not always been the same size, weight or pressure. It was not until 1863 that specifications for footballs were implemented by the FA, before which pig bladders were used as balls. Charles Goodyear’s patenting of vulcanisation as a technique to make rubber more elastic and durable made footballs more resistant to heat and cold, but it did not address a fatal flaw in footballs: water saturation. Balls at this time were extremely susceptible to water and retained it well, making them heavier as games went on. The repetitive heading of a ball may now have been identified as detrimental to brain health, but doing so for 90 mins with a waterlogged ball was all the more dangerous.

The BBC documentary Alan Shearer: Dementia, Football and Me shared the story of former West Bromwich Albion footballer Jeff Astle, who died at the age of 59. Consultant neuropathologist Dr Derek Robson concluded that Astle’s degenerative brain condition had likely been exacerbated by his repetitive heading of the ball. The BBC documentary made a point to note that the fact that the footballs were so susceptible to water will have increased the risk of developing degenerative neurological conditions, like the illness which led to Astle’s death.

It is widely known that repetitive head trauma can lead to or certainly increase the risk of developing CTE, which is heavily associated with dementia

In 1989, Tysvaer published three articles which documented the neurologic and electroencephalographic (EEG) data of 69 active and 44 retired footballers. Although normal EEGs were recorded in 65% of active players, there was an alarming number of abnormalities found in younger players. What was all the more shocking was that 70% of the 44 retired players who were examined presented with a history of head trauma. Symptoms ranged from anything from impaired coordination to reduced cervical spine motion in more serious cases. Moreover, Tysvaer discovered that there were higher frequencies of cortical atrophy — a gradual but progressive degeneration of the cortex, the outer layer of the brain — in players who typically headed the ball. This, of course, demonstrated further neurological impairment, but was also suggestive of a heightened risk of developing chronic traumatic encephalopathy (CTE), a progressive disease of the brain linked to repetitive head trauma.

It is widely known that repetitive head trauma can lead to or certainly increase the risk of developing CTE, which is heavily associated with dementia. The symptoms of the condition and of dementia are very similar: memory loss, behavioural changes and confusion. Every time a forceful impact occurs, the nerve cells in the brain become more fragile to the point that they can break, which happens during concussions. Constant repetition of this action over the course of 90 minutes can have a significant impact on the brain and, indeed, on its function.

The MLS has also taken great strides towards protecting players. In 2016, players under the age of 10 were prohibited from heading the ball during training sessions in Major League Soccer youth teams as part of the US Soccer Concussion Initiative. In a similar way to rugby, players who had suffered a suspected concussion during a match were permitted to leave the pitch to be assessed without the team being penalised for being a player down. In their absence, the team was able to make a ‘concussion substitution’ which would not count against the team’s total number of substitutions. Such precautions have been implemented astutely and with player safety at their core. It is a wonder why such a prudent measure could have been continued following the Premier League’s 2021 trial and could not be trialled fully next season in England’s top flight, in spite of the permanent introduction of five substitutions this season.

heading the ball is a staple part of football, but we cannot ignore the wealth of research that concludes that it puts players in danger

Scotland’s measures are an excellent step in the right direction for player safety in football. It is not just about heading the ball, but also the implicated danger of going up for a header. Ryan Mason’s clash of heads with Gary Cahill in 2017 left the Hull City player with 14 metal plates in his head due to a fractured skull. In 2018, he was forced to retire from football aged just 26 — the prime years in a football career — for fear of the risks associated with him continuing to play. Wolves’ Raul Jimenez also suffered a fractured skull in November 2020 after a clash of heads with David Luiz left him unconscious. How long is it before these injuries, which are extremely serious in themselves, become even more serious?

Yes, of course, heading the ball is a staple part of football, but we cannot ignore the wealth of research that concludes that it puts players in danger. To remove heading altogether from football would currently be a mistake for the game. There are too many tactical and strategic uses of heading the ball, without which the very essence of the game would be in peril. Thus, we must look to mitigate the risk that heading can pose. Football must introduce head injury assessments, just like in rugby, and bring in concussion substitutions. Measures like this must be implemented across the world of football and not be confined to the boardrooms of national governing bodies. The Scottish FA’s new guidelines on heading the ball in training are also invaluable and put player safety above all else. It is time, now more than ever, to adapt the game to make it safer for all players. A simple change in guidelines in training or on a match day could easily save a life on the pitch or in the years after a player hangs up their boots. If football is to find the compromise between its competitiveness and player safety, there is no better time to do it than the present.