U.S. Soccer’s New Player Safety Campaign Leaves Many Questions Unanswered

By Doug Fuglsang. Mr. Fuglsang is a licensed attorney in Illinois and Wisconsin with a Sports Law Certificate from the National Sports Law Institute. He can be reached at doug.fuglsang@gmail.com.

Is the U.S. Soccer Federation doing enough to protect players from concussions and shield itself from legal liability? (Photo by Kansas City Legal Examiner)

Starting January 1, 2016 U.S. Soccer Federation’s new rules banning headers for players 10 and under, while also limiting the amount of exposure to headers in practice for players between the ages of 11 and 13, went into effect — at least I think they did.

There was much acclaim for the new rules. A few thought U.S. Soccer overreacted to the threat of litigation over youth concussions; but upon closer examination, I’m not really sure much was changed, other than limiting the liability for U.S. Soccer.

Youth soccer is facing a similar crisis to that of youth football; parents are beginning to question whether the benefits of permitting their children to play sports that carry a higher risk of head injury, like football and soccer, outweigh the risks of future health complications due to concussions and repetitive sub-concussive hits. Youth football has already seen a decline in participation and it’s not outlandish to think a similar trend could hit youth soccer as more information becomes available to parents.

So why does the U.S. Soccer Federation now care so much about concussions? Look to the lawyers.

The U.S. Soccer Federation was the latest target of a lawsuit for failure to be proactive in concussion management. In August 2014 a group of players and parents sued U.S. Soccer and FIFA, among others, in the U.S. District Court of Northern California. At issue was whether U.S. Soccer and FIFA failed to enact policies and rules to protect players from unnecessary risk of head injury. The judge dismissed the case against FIFA because the plaintiffs had no standing, but allowed an amended complaint to be filed against U.S. Soccer. The plaintiffs sought no monetary damages, merely rules changes, and on November 2, 2015 U.S. Soccer announced a settlement with the plaintiffs in a joint statement and unveiled new player safety initiatives that will serve as a resolution to the lawsuit.

Following the settlement agreement, U.S. Soccer pledged to:

(a) improve concussion awareness and education among youth coaches, referees, parents and players;

(b) implement more uniform concussion management and return-to-play protocols for youth players suspected of having suffered a concussion;

(c) modify the substitution rules to insure such rules do not serve as an impediment to the evaluation of players who may have suffered a concussion during games; and

(d) eliminate heading for children 10 and under and limit heading in practice for children between the ages of 11 and 13.

Additionally, U.S. Soccer plans to unveil a comprehensive “player safety campaign,” the details of which have yet to be explained. According to U.S. Soccer, the new “player safety campaign” would be unveiled within 30 days of the announcement; but in a follow up, meant to clarify the joint statement, U.S. Soccer stated the plan would be rolled out in the coming months.  Even more confusing, in the FAQs about the player safety initiative U.S. Soccer announced the new rules will take effect January 1, and merely reiterates the rules announced in the November statement. U.S. Soccer did not respond to questions seeking clarification about this new campaign, so all I have to go off of is the U.S. Soccer website.

Aside from the legal liability of not adopting a uniform and proactive stance to curb concussions, there is also medical support behind concussion-driven fears when it comes to soccer.  

A 2007 study looked at the rates of concussions among high school and collegiate athletes. They found the incidence of concussions in soccer is second only to football. At the high school level girls had a higher rate of concussion than boys; among both boys and girls, the activity most frequently associated with concussions was heading the ball — 64.1% of injuries sustained while heading the ball were concussions. Contact with another person resulted in a greater proportion of concussions in boys (85.3%), than in girls (58.3%). However, contact with the ground and contact with the soccer ball were related to a significantly greater proportion of concussions in girls than in boys.

A recent 2015 study published in JAMA Pediatrics, a peer-reviewed medical journal published by the American Medical Association, explored soccer specific mechanisms by which players sustain concussions and had similar findinfs. The study explained that “Heading was the most common soccer-specific activity, responsible for 30.6% of boys’ concussions and 25.3% of girls’ concussions. Contact with another player was the most common type of injury in heading-related concussions among boys (78.1%) and girls (61.9%).” The study concluded that although banning heading would likely prevent some concussions, reducing athlete-athlete contact across all phases of play would likely be a more effective way to prevent concussions.

On the other hand, the evidence is limited and the research into head injuries and lasting effects are in their infancy, researchers are just beginning to understand the link between head trauma sustained playing sports and later development of A.L.S., dementia, or other neurological disease. Even Dr. Robert Cantu, chief of neurosurgery at Emerson Hospital and co-director of Boston University’s Center for the Study of Traumatic Encephalopathy, acknowledges the science is limited on the connection between soccer and brain injuries. He admits other genetic or environmental factors may contribute to why a certain group of people, subjected to the same degree of head trauma as somebody else, go on to develop chronic traumatic encephalopathy. In an interview with PBS, Dr. Cantu discussed the limited amount of information we do know about the connection of heading the ball and brain trauma. In one particular study cited, there was a magic number of 885 headers a year that produced changes in the brain and if you got up to 1,800 headers, the people experienced cognitive problems.

According to Dr. Cantu “[i]n the last year alone, there have been 13 studies that I’m aware of…that have shown sub-concussive hits in sports that take a lotta brain trauma, like soccer in some cases, football in other cases, have shown abnormalities on DTI MRI, have shown abnormalities on functional MRIs…and also breakdown of the blood-brain barrier. And that’s happened without a recognized concussion, just from repetitive trauma. And they found the individuals with the highest degree of abnormalities were those individuals that took the highest number of hits over the course of a season.” There is still a lot we don’t know because CTE can only be diagnosed by looking at someone’s brain post-mortem, compounded by the fact the changes in the brain can begin months, years, or even decades after the last brain trauma. It’s also important that people understand the majority of people recover from concussions without any future complications, however there are also tragic examples of young athletes being affected by neurological disease. The evidence is pointing to the less we hit our heads at a younger age the better.

With all of this new medical evidence, U.S. Soccer’s new rules are both laudatory and necessary. However, the rules are still vague and perplexing. The first thing that stands out is the fact these new rules are only recommendations for the majority of youth leagues because U.S. Soccer does not have direct authority at the local level, this is due to the nature and scope of authority reserved for individual state athletic associations. Essentially, these rules only apply to U.S. Soccer’s Youth National Teams and the U.S. Soccer Development Academy. The academy consists of 94 U-13/14 clubs, with minimum rosters of 16 to 23 players, so we are talking about 2,162 players out of the roughly 4-6 million youth that play soccer annually.  Affiliates are encouraged to adopt these rules but it isn’t required.

I’m going to assume some, if not all, of the affiliates will adopt some form of these new rule proposals in order to limit exposure to lawsuits. To recap, U.S. Soccer is going to prohibit heading the ball for children 10 and under and limit the activity in practice only for ages 11 to 13. Most associations across the nation already ban headers children under 10, so this really didn’t change anything for them. The limit in practice for 11-13 year olds is an interesting decision, the evidence, while not conclusive, supports we limit the amount of potential trauma to young developing brains. Generally, around high school the neck muscles are strong enough to prevent the bobble-head effect that contributes to the higher rate of concussions sustained from heading the ball among youth soccer players.

While a good intentioned rule I imagine this is going to be an administrative nightmare. There is no information about how this ban will be enforced or how practice limits will work: will players be given a yellow card for heading in a U-10 game? Will there be a free kick awarded? Additionally, what is the threshold for 11-13 year old heading the ball in practice? Will it be a number of headers, or an hourly limit? Who will keep track of header exposure? There is still a lot to be explained and it may be more complicated than envisioned.

Additionally, U.S. Soccer is modifying substitution rules to allow players who may have suffered a concussion to be evaluated without penalty during the game. This is perhaps the most important modification to the game: If a player suffers a blow to the head and is removed for evaluation of a suspected concussion, that substitution will not count against a team’s total number of allowed substitutions. If the player with the suspected head injury gets clearance to return to the game, the player may re-enter at any stoppage of play but must replace the player’s original substitute. The player that was temporarily substituted into the game will still be considered an available substitute and permitted to re-enter the game as a standard substitute per Development Academy rules. This is extremely beneficial to young players because they can report a potential head injury and take proper precaution without the fear of being unable to return to play. It will reduce the incentive for young players to try and play through a potential head injury. A small caveat, the U.S. Soccer Youth National Teams will continue to be bound by the substitution rules of the events in which they participate, so this rule will rarely be used in Youth National games and will only affect those 2,162 Development Academy players.

Lastly, U.S. Soccer intends to improve concussion awareness and education among youth coaches, referees, parents and players based on the recommendations of the U.S. Soccer medical committee. The only information I could find about U.S. medical committee research was a 2001 study performed by exercise physiologist and U.S. Soccer medical advisory committee member, Donald Kirkendall aimed at studying the effects of heading on the brains of national youth team players. That study was never published. Kirkendall explained the tests meant to track the subjects’ cognitive functions were too hard to administer in the noisy conditions of training camp and the youth teams frequently changed players, further complicating efforts to collect long-term data. I’m assuming more information will be available in the player safety campaign but again; it’s not out yet. That hasn’t stopped U.S. Soccer from boasting about the “player safety campaign” which they claim being developed “long before the lawsuit was filed … and [it] was developed with the help of medical experts to provide coaches, players, parents and referees with information, guidance and additional educational materials to improve the management of injuries, including concussions.” If this was in the works prior to, and not the result of litigation, why have we received essentially zero information about it? I guess we’ll just have to take their word for it.

U.S. Soccer also partnered with the Centers for Disease Control and Prevention “Heads Up” program in attempt to spread awareness of the issue. The “Heads Up” program has its flaws, but they do a respectable job of spreading awareness and providing parents with information about the issue.

I generally cringe when I hear about organizations spending money on “spreading awareness,” usually because I prefer to see money spent towards research, however in this case it’s likely the only solution to the problem. Head injuries are a part of sports, they are unavoidable, unless you fundamentally change the games and I’m not sure anyone wants that, I know I don’t. But, this is strictly anecdotal evidence, most people I encounter aren’t educated about concussions and more importantly the impact of repetitive subconcusive hits. The GQ article “Brain Game” was published in 2009, yet when the movie “Concussion” came out, even people who cover the sport of football for a living acted like it was groundbreaking new information. “Head’s Up” provides an easy way for parents to get educated and keep up with current research through the CDC.  Sports provide far too many benefits to be avoided completely, so educating coaches, parents, and players about the potential dangers and letting them make informed decisions is about the only thing that can be done.

All in all, U.S. Soccer has taken a positive step, whether it was induced by litigation and self-preservation or not, protecting young athletes from unnecessary risk is a noble end. U.S. Soccer successfully limited their liability by implementing modest rule changes that do little to change the fundamentals of the game. At the very least every soccer association should follow U.S. Soccer and adopt their substitution rules regarding suspected head injuries. Only time will tell about the U-13/14 practice limitations.

My personal opinion is that the rule is mistake, but I don’t have any skin in the game when it comes to turning U.S. Soccer into a international powerhouse. Taking into account the research available, potential exposure to liability, and understanding this is an essential skill for U.S. Soccer players; I would probably ban headers in games for all players U-14 and limit headers to practice time only for 12-14 year olds, this way they can develop the proper technique under coach controlled conditions.

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