Heading in football and concussion have become increasingly important issues for professional footballers.

In Australia, the PFA has advocated for a range of initiatives to better protect players and address growing concerns related to concussion and its side effects in footballers. Each season, the PFA provides its members with comprehensive concussion education.

Ahead of the last A-League season, the PFA requested independent spotters be included in stadiums and encouraged clubs to procure digital devices to provide club medical representatives with the opportunity to review incidents that may have involved a concussion in real time.

From the 2021/22 A-League season Australian-based footballers will have an additional preventative measure to address concussion injury, following the introduction of concussion substitutes for the FFA Cup and the forthcoming A-Leagues campaigns. 

However, there remains a key differential between ‘concussion’ injuries and head injuries accrued through repetitive heading of the ball, which remains a core part of the game. 

The PFA spoke with Dr. Kerry Peek, a researcher in the prevention of head injuries in football from the University of Sydney, about the need for football to adopt a multifaceted approach to address head and concussion injuries.

Q. Concussion and head injury remain an area of acute focus for global football. What do you believe to be the most important areas of focus to reduce concussion, head injury and injury from heading right now in football?

Dr. Kerry Peek: Firstly, it is important to understand the different context of concussion and other head injuries in football, as well as the risks associated with heading. Heading itself where players intentionally use their head to redirect the ball rarely leads to the clinical signs and symptoms of concussion. 

Where heading and concussion risk overlap is via ‘heading duels’. Two players competing for an aerial ball are more likely to be exposed to head-head  or elbow-head contact. This is a common mechanism for concussion injury. It is also a risk factor for dental injuries and other head injuries including facial fractures. Concussion and other dental and head injuries in football are relatively low compared to other contact or collision sports but as with all head injuries the risk of harm is high so it is important that football’s governing bodies do what they can to mitigate or reduce the risk of harm to players.

Q. Is it a case of a multi-pronged approach such as adopting strength training, reducing heading in training, teaching heading technique, introducing concussion substitutes, independent spotters in stadiums on match days?

KP: When we are assessing risk, we need to first identify the risk: what is it, who might be harmed and how, what is the likelihood that harm will occur, what is the severity of any potential harm. Then we need to design and implement strategies which can eliminate or reduce the risk, and finally we need to evaluate these risk-reduction strategies. In relation to heading and heading-related injury (including concussion from heading duels etc) we can minimise the risk of harm by eliminating heading from the game completely (across all levels including at the professional level). 

This is unlikely to occur at least for the foreseeable future for many legitimate reasons, therefore, in the immediate term we should focus on risk reduction strategies. How can we reduce the risk of harm to players from heading-related injury, using a multi-pronged approach? 

In terms of primary risk reduction this includes the laws of the game (such as education and enforcing rules around deliberate elbow to head contact), teaching good heading technique which includes body positioning, tracking ball trajectory, timing of runs and jumps (which can all be practised in part without ball-head contact), introducing neuromuscular neck training to improve head-neck-body stability and reduce head impact magnitude on ball contact as well as reducing ball pressure. 

We should also implement secondary risk reduction strategies which may include temporary or permanent substitutions, independent medical assessment, and enhanced return to play policies following a concussion. 

Q. While separate from heading technique, concussion substitutes will provide a level of security (and incentive) for players and clubs to remove a player who is suspected to be concussed. What is your position on this new regulation being introduced in Australia?

KP: This is an important discussion, and it is great that the A-Leagues are going to be part of the IFAB trial. We must go into this trial with an open mind and ensure that the implementation of permanent substitutions is properly evaluated following the trial; this means assessing whether the introduction of permanent substitutions has had the intended outcome without any unintended consequences. 

Q. Is gradual introduction of different measures, or a complete overhaul and reform of the game the best way to address this growing issue?

KP: The answer lies in developing well thought out strategies to minimise the risk of harm based on the age, sex and playing level and experience of players and making sure we evaluate each strategy. 

I cannot emphasise this second part enough as it is often missed. Risk assessment should be a cyclical process which is constantly being refined based on new information. 

Rugby Union is a perfect example. One study demonstrated that reducing tackle height in elite rugby reduced concussion incidence in the ball carrier but led to an increased concussion incidence in the tackler. Changing any aspect of football may have unintended consequences so evaluation is key but that shouldn’t prevent us from exploring and implementing strategies to make football safer. We just need to ensure that we complete the process and be open to the fact that some strategies may not have the desired effect despite our best intentions.

Q. What are the biggest risks for players when it comes to injury from heading and general concussion injuries?

KP: The unknown risk of heading is related to whether there is an accumulative dose effect; in other words, do repetitive head impacts which do not result in clinical signs and symptoms of concussion lead to long-term changes in the brain and increase the risk of developing neurodegenerative disease such as dementia. This research is still on-going and may take years. Therefore, it is prudent for football governing bodies to explore both primary and secondary risk reduction strategies that can be implemented and evaluated in the short-term to reduce the risk of harm to our current and future players. 

Q. How can PFA members better prepare for this season by reducing their heading (bearing in mind this may be out of their control given clubs and national teams will have specific training exercises that obligatory in match preparation)?

KP: Part of our evaluation of heading incidence in Australia is to assess the key components of heading such as which players head the ball and under what circumstances. If we can identify these patterns, then we can inform players and coaches about the critical type of headers for that player and position. 

The Football Association in England has placed heading restrictions in training right up to the professional level. If, for example, a player is only able to practice 10 headers per week then it is important that they prioritise the heading relevant to them and ignore all the unnecessary heading drills that are not relevant to them (i.e. why expose players to unnecessary ball-head impacts if these do not translate to a common game scenario for that player or position). 

Each type of header is different and requires different technique. For example, a defensive header is very different from an attacking header. Teaching heading technique is very important and does not always need to include ball-head contact. I am also a strong advocate for neuromuscular neck training which we have demonstrated in a recent published study can reduce head impact magnitude during heading in high-level football players aged 12-17 years. 

What we need to remember is that the best way to protect our future professional players is to protect our young players. The biggest risk factor for concussion is a previous concussion. In the first 90 days of return to play following a concussion, players are also at greater risk of sustaining a lower limb injury. If we can maintain a reduced risk in our young players, then we will better protect them as adults.

The opinions and information reflected in this article are not necessarily the views or policy of the PFA, but are expressed with the intention of providing PFA members with a greater understanding of the issue impacting them, their health and their careers.