Milton High School sophomore Maddie Search immediately recognized the feeling when a soccer ball slammed into her head during a September game.
It was a concussion - the third of her soccer career.
“I remember thinking: Oh no,” recalled the 16-year-old Search, who was ordered off the field by referees.
Soccer is hot in these parts. Atlanta United led Major League Soccer attendance for the third straight year, averaging more than 50,000 fans a game at Mercedes-Benz Stadium. Arthur Blank, United’s owner, is mulling bringing a National Women’s Soccer League franchise to Atlanta.
The sport also has been pitched as a safer alternative to football amid growing evidence of football’s physical toll on participants, including neurological damage.
But when it comes to concussions, at least, soccer isn't that different from football if you're a teenage girl, according to a study of 20 high school sports published in the November issue of Pediatrics, a peer-reviewed medical journal.
University of North Carolina researchers found football had the highest concussion rate, with 10.4 concussions per 10,000 athletic exposures, followed by girls soccer with 8.19 concussions. Boy soccer players had a much lower rate of 3.57 concussions.
UNC researchers looked at injuries per athletic exposure for U.S. high schoolers during the 2013-2014 to 2017-2018 school years. For every athlete, one practice or competition is counted as one exposure. Overall, 9,542 concussions were reported during the study period, or 4.17 concussions per 10,000 exposures. The data came from the National High School Sports-Related Injury Surveillance Study database, which is based on reporting from athletic trainers.
Experts speculate that girls have smaller, weaker necks than boys, making their heads more susceptible to trauma. Hormones also could play a role. And girls might be more likely to report a concussion - a traumatic brain injury caused by a bump, blow or jolt to the head or body that causes the brain to move rapidly inside the skull.
Soccer is the most popular sport for girls in Georgia, with close to 10,500 girls playing at 400 schools, slightly fewer than boys, according to the latest Georgia High School Association participation study. Football remains king, with 31,904 boys playing across the state, although football isn’t growing as fast.
A growing body of research has linked football players to a degenerative brain disease, chronic traumatic encephalopathy, or CTE, caused by repetitive impacts to the brain. The disease, which can develop into dementia, has been found in male football players, but little is known about the long-term effects of head impacts on girl soccer players.
Boston University researchers are launching a first-of-its-kind study looking at the consequences of such repeated hits on former professional female soccer players. The study, called "The Soccer, Head Impacts and Neurological Effects," will examine 20 former female players at least 40 years old.
Search, the Milton high schooler, started playing soccer when she was 3 years old. She’s a member of the competitive United Futbol Academy and on her varsity team, making the squad her freshmen year.
“It’s all I do,” she said. “Mainly I love being part of a team.”
She had her first concussion when she was in fourth grade, and then a second one two years later. All three concussions involved a kicked ball accidentally hitting her in the head - the most recent one from a teammate’s unexpected pass as Search ran toward the goal.
"When they were younger, they weren't overly aggressive and I didn't think much about it," said Kristin Search, Maddie's mother. "But as they started getting older, I certainly became much more aware."
A new Georgia law in 2014 known as the Return to Play Act requires coaches, trainers and others who work with student-athletes to learn the signs of concussion, establish a concussion management plan, and provide concussion education to parents and students. It also requires students who show concussion symptoms — such as headache, nausea and dizziness — to be cleared by a health professional before returning to play.
Marietta resident Sharon Loughran, a soccer player for 28 years, and a coach for 33 years, said there's no question coaches, school officials and referees take concussions more seriously than they have in the past.
“It’s extreme – and I mean extreme in a good way,” said Loughran about The Westminster Schools, where she is an assistant coach for the boys varsity soccer team, and Walton High School, where she was a longtime girls soccer coach.
Loughran said protocols include making sure young athletes undergo a baseline test, and getting approval from a doctor and a school’s athletic trainer before returning to play. Young athletes who experience a concussion can be out of the game for months, she said.
But Loughran, a former coach for the Olympic Development Program, believes there needs to be more emphasis on preventive techniques, including core strength exercises and conditioning. She also teaches her players alternatives to heading the ball, such as using the upper body and shoulders. And while one’s instinct is to use hands to break a fall, the key is to roll with it to lessen impact, she said.
The UNC study found heading the ball is responsible for about 25% of concussions among girls. But close to 50% were associated with collisions among players. Another common way a girl gets a concussion is by hitting her head on the turf.
After Search's second and third concussion, the Milton soccer player and her parents met with Dr. David Marshall, medical director of the Sports Medicine Program at Children's Healthcare of Atlanta. After the latest concussion, the mother said, "I asked him when we reach the point when she can't play anymore."
Marshall told them there is no magic number - or set recovery time.
The hospital no longer prescribes a week or longer of complete cognitive rest with quiet time in a dimly lit or dark room. The goal now, he said, is to make kids’ lives “as normal as possible” because having them miss too much school and cutting them off from their friends was causing emotional stress.
He recommends children miss no more than two or three days of school, then return for half days, and be able to rest in the nurse’s office as needed. There should also be accommodations such as avoiding loud noises in the cafeteria and gym.
But one constant remains: Young athletes should be free of all concussion symptoms before resuming even light aerobic activity such as a walk in the neighborhood, gradually increasing intensity, and only return to sports after getting the OK from a doctor. Marshall said the key to recovery is making sure a young athlete’s brain has healed before resuming the sport.
And if symptoms linger and a recovery is taking three months, added Marshall, “a family has to think is it really worth risking another concussion.”
Search’s symptoms subsided after a few weeks, with the headache lasting the longest. Recently, she began playing competitive soccer again.
“It has been so fun to be back on the field,” said the high schooler. “But I don’t take concussions lightly. The thing with concussions is it’s your brain, and you only have one.”
The UNC study looked at 20 high school sports and found the following to have the highest concussion rates:
• Boys’ football, with 10.4 concussions per 10,000 athletic exposures
• Girls’ soccer, with 8.19 per 10,000 athletic exposures
• Boys’ ice hockey, with 7.69 per 10,000 athletic exposures
• Boys’ lacrosse, with 4.92 per 10,000 athletic exposures
The sports with the lowest concussion rates:
• Boys’ cross country, with 0.06 per 10,000 athletic exposures, and boys’ track and field, with 0.17 per 10,000 exposures
• Girls’ cross country, with 0.13 per 10,000 athletic exposures, and girls’ track and field, with 0.29 per 10,000 exposures
• Boys’ swimming, with 0.37 per 10,000 athletic exposures
• Girls’ swimming, with 0.66 per 10,000 athletic exposures
NOTE: For every athlete, one practice or competition is counted as one exposure.
Other findings in the UNC study
Football game-day concussion rates rose during the study from 33.19 to 39.07 per 10,000 athletic exposures. But football practice concussions became less common, dropping from 5.47 to 4.44 per 10,000 AEs.
And across all high school sports in the study, repeat concussion rates declined from 0.47 to 0.28 per 10,000 AEs, when comparing 2017-2018 and 2013-2014 statistics.
About CTE
Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in people with a history of repetitive brain trauma (often athletes), including symptomatic concussions as well as asymptomatic subconcussive hits to the head that do not cause symptoms. CTE has been known to affect boxers since the 1920s (when it was initially termed punch drunk syndrome or dementia pugilistica).
In recent years, reports have been published of neuropathologically confirmed CTE found in other athletes, including football and hockey players (playing and retired), as well as in military veterans who have a history of repetitive brain trauma.
The repeated brain trauma triggers progressive degeneration of the brain tissue. These changes in the brain can begin months, years, or even decades after playing a sport. The brain degeneration is associated with common symptoms of CTE including memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, suicidality, parkinsonism, and eventually progressive dementia.
There remains several gaps in scientific and medical knowledge about the disease. One such gap is a clear understanding of the clinical manifestations of the underlying brain changes. Also, at this time, CTE can only be diagnosed after death through careful neuropathological examination of the brain.
