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Soccer Heading Is Associated with White Matter Microstructural and Cognitive Abnormalities
Open accessAbstract
PURPOSE: To investigate the association of soccer heading with subclinical evidence of traumatic brain injury. MATERIALS AND METHODS: With institutional review board approval and compliance with HIPAA guidelines, 37 amateur soccer players (mean age, 30.9 years; 78% [29] men, 22% [eight] women) gave written informed consent and completed a questionnaire to quantify heading in the prior 12 months and lifetime concussions. Diffusion-tensor magnetic resonance (MR) imaging at 3.0 T was performed (32 directions; b value, 800 sec/mm(2); 2 × 2 × 2-mm voxels). Cognitive function was measured by using a computerized battery of tests. Voxelwise linear regression (heading vs fractional anisotropy [FA]) was applied to identify significant regional associations. FA at each location and cognition were tested for a nonlinear relationship to heading by using an inverse logit model that incorporated demographic covariates and history of concussion. RESULTS: Participants had headed 32-5400 times (median, 432 times) over the previous year. Heading was associated with lower FA at three locations in temporo-occipital white matter with a threshold that varied according to location (885-1550 headings per year) (P < .00001). Lower levels of FA were also associated with poorer memory scores (P < .00001), with a threshold of 1800 headings per year. Lifetime concussion history and demographic features were not significantly associated with either FA or cognitive performance. CONCLUSION: Heading is associated with abnormal white matter microstructure and with poorer neurocognitive performance. This relationship is not explained by a history of concussion.
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“Recently, soccer players who head the ball more than 1,800 times per year were found to have microstructural abnormalities in the temporo-occipital white matter on DTI that correlated with poorer memory scores [111].”
From The neuropathology of sport (2014) · cites this paper as [111]
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Self-citationOrbitofrontal Gray-White Interface Injury and the Association of Soccer Heading With Verbal Learning
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“In the context of this evidence, our results suggest that impaired re-myelination, due to presence of the Met allele, is a potential pathological substrate of functional deficits, which are associated with high levels of sub-concussive heading (8, 9).”
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“Headers are associated with a decrease in the parameter of fractional anisotropy (FA) in temporo-occipital white matter, which also suggests changes in diffusion (52 – 54).”
Neuropsychophysiological Aspects of Soccer Performance: A Bibliometric Analysis and Narrative Review
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“Frequent heading has been associated with cognitive dysfunctions, impacting players ’ decision-making and tactical awareness (Lipton et al., 2013; Matser et al., 2001; Zhang et al., 2013).”
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Wahlquist, V. E., Buckley, T. A., Caccese, J. B., Glutting, J. J., Royer, T. D., & Kaminski, T. W. (2024) · Sports · doi:10.3390/sports12120342 · Cited by 4
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Concussions in young adult athletes: No effect on cerebral white matter
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“Using diffusion-tensor imaging, one group reported that the number of headers a soccer player performed within the last year was associated with the degree of axonal injury for specific regions of interest.(5) Another study revealed that elite male soccer players show evidence of increased radial and axial diffusivity…”
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“Soccer heading frequencies are associated with microstructural alterations in brain white matter and cognitive abnormalities (Lipton et al., 2013).”
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“22 However, these observations remain controversial and the recent meta-analysis by Kontos does not establish a link between heading and persistent cognitive impairment, mainly due to the existence of numerous biases and different methodologies that do not allow for comparison be-tween studies.”
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“12 RHHs after a collegiate football season have been linked to reductions in brain white matter (WM) integrity, 13 – 18 similar to those detected after sports-related concussion, 19 which are considered to result from traumatic axonal injury.”
Hamel, R., Waltzing, B. M., Massey, T., Blenkinsop, J., McConnell, L., Osborne, K., Sesay, K., Stoneman, F., Carter, A., Maaroufi, H., et al. (2024) · PLoS ONE · doi:10.1371/journal.pone.0306560 · Cited by 4
“…studies should investigate how the subjective symptoms of sub-concussive head impacts interact with their associated cognitive function impairments (as in Di Virgilio et al., 2016; ref [24]), increased wet pro-inflammatory biomarker expression (see ref [58]), and brain structural insults [4, 5].”
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“3 Therefore, pathological evidence of traumatic brain injury is mixed, and, if detectable, it is likely to present prior to the onset of overt symptoms or disability.”
Predicting brain acceleration during heading of soccer ball
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“A recent study has revealed that repetitive heading occasions experienced by soccer players could lead to degeneration of brain cells [8].”
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“While some studies have failed to detect any “clinically meaningful” SHI-related changes on concussion assessment batteries [6–8], others have revealed transient vestibular deficits [9], lingering ocular-motor impairment [10–12], acute and chronic elevations in blood biomarkers of neural injury [13–15], and changes in…”
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INVESTIGATION OF PITUITARY DYSFUNCTION IN RETIRED PROFESSIONAL SOCCER PLAYERS
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Logan, K., Yuan, W., Foss, K. D. B., Diekfuss, J. A., DiCesare, C. A., Leach, J. L., Altaye, M., Lloyd, R. S., & Myer, G. D. (2021) · Journal of Science in Sport and Exercise · doi:10.1007/s42978-020-00101-1 · Cited by 2
Preparedness during Head Impacts in Intercollegiate Men’s and Women’s Soccer Athletes
Jackson, B. C., Rogerson, C. E., Bradney, D. A., Breedlove, K. M., & Bowman, T. G. (2023) · Biomechanics · doi:10.3390/biomechanics3010004 · Cited by 2
Liu, Y., Mao, H., Chen, S., Wang, J., & Ouyang, W. (2024) · Journal of Visualized Experiments · doi:10.3791/66440 · Cited by 2
Heading in Female Soccer: A Scoping Systematic Review
Shen, Y., Chen, S., Liu, Q.-G., & Cicchella, A. (2024) · Sports · doi:10.3390/sports12120327 · Cited by 2
Dahlén, S. C., Bjørneboe, J. A., Sandmo, S. B., Bache‐Mathiesen, L. K., Filipčík, P., Howe, E. I., Høgestøl, E. A., Selbæk, G., Straume-Næsheim, T. M., Westlye, L. T., et al. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-092456 · Cited by 2
“There appears to be an association between long-term head impact exposure and white matter abnormalities in footballers, 44–47 and head impact frequency and type appear to be linked to white matter integrity in selected brain regions.”
Proceedings From the Ice Hockey Summit III: Action on Concussion
Smith, A. M., Alford, P. W., Aubry, M., Benson, B. W., Black, A. M., Brooks, A., Burke, C. J., D’Arcy, R. C. N., Dodick, D. W., Eaves, M., et al. (2019) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000745 · Cited by 2
“Accurate imaging techniques to detect mTBI and subsequently to confirm recovery are important steps forward in the care of SRC [80-83].”
BackgroundKindliches Schädel-Hirn-Trauma – Gehirnerschütterung
Gänsslen, A., Neubauer, T., Hartl, C., Rickels, E., Schmehl, I., Moser, N., & Krutsch, W. (2021) · Springer Reference Medizin · doi:10.1007/978-3-642-54673-0_229-1 · Cited by 2
Assessment of Cognitive Functioning in Mixed Martial Arts Athletes
Heath, C. (2014) · Journal of Athletic Enhancement · doi:10.4172/2324-9080.1000162 · Cited by 2
Haller, S. (2017) · European Journal of Neuroscience · doi:10.1111/ejn.13643 · Cited by 2
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Heading in the right direction
Stewart, W. B., Jr., & Carson, A. J. (2022) · Nature Reviews Neurology · doi:10.1038/s41582-022-00712-y · Cited by 2
Jack, J., Woodgates, A., Smail, O., Brown, F., Lynam, K., Lester, A. B., Williams, G., & Bond, B. (2022) · Frontiers in Neurology · doi:10.3389/fneur.2022.1021536 · Cited by 2
“Consideration needs to be given to the fact that amateur players may accumulate several thousands of headers over their years of playing the game (4).”
BackgroundThe Effect of Wearing Soccer Headgear on the Head Response in Soccer Heading
Tan, F. Y., Hassan, M. H. A., Johari, N. H., Omar, M. N., & Hasanudin, I. (2022) · International Journal of Automotive and Mechanical Engineering · doi:10.15282/ijame.19.4.2022.08.0782 · Cited by 2
“A study on 37 amateur soccer players has found that repetitive heading could result in abnormal white matter microstructure as well as poor neurocognitive performance [20].”
BackgroundA Biomechanical Assessment of Direct and Inertial Head Loading in Rugby Union
Tierney, G. J. (2018) · Arrow@dit (Dublin Institute of Technology) · Cited by 2
Dementia in Sport: Causation, Management and Prevention
Williams, D. D. R. (2023) · Medical Research Archives · doi:10.18103/mra.v11i8.3921 · Cited by 1
Assessment of the brain impact of soccer heading using pupillary light reflex
Nakao, J., Muroi, A., Marushima, A., Tasaki, K., Inoue, Y., Matsumaru, Y., & Ishikawa, E. (2025) · Frontiers in Neurology · doi:10.3389/fneur.2025.1603033 · Cited by 2
Change in Head Impact Exposure following Return to Sport in Concussed Football Athletes
MUENCH, J. R., Sinson, G. P., Glaeser, B., Shah, A. S., Rowson, S., Duma, S. M., Mihalik, J. P., Brooks, A., CAMERON, K., Giza, C. C., et al. (2025) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000003833 · Cited by 1
Video analysis of head impacts in top-level female football players: a cohort study
Dahlén, S. C., Bjørneboe, J. A., Sandmo, S. B., Bache‐Mathiesen, L. K., & Andersen, T. E. (2025) · Science and Medicine in Football · doi:10.1080/24733938.2025.2548209 · Cited by 1
“While there is limited evidence that heading alone compromises brain health, studies have demonstrated associations between repetitive head impacts and short-term cognitive impairment (Lipton et al. 2013; Ye et al. 2022).”
Soccer heading and white matter microstructural changes: a two-year longitudinal cohort study
DeMessie, B., Charney, M. F., Fleysher, R., Ye, K. Q., Kim, M., Stewart, W. F., Zimmerman, M. E., Kaminski, T. W., Lipton, R. B., & Lipton, M. L. (2026) · Brain Imaging and Behavior · doi:10.1007/s11682-026-01134-w · Cited by 1
“…of active adult amateur soccer players suggest that soccer-related RHI is associated with alterations in white matter microstructure (Michael L. Lipton et al., 2013; Rubin et al., 2018), while studies of former professional players show structural brain changes including cerebral atrophy…”
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Brain Motion, Deformation, and Potential Injury During Soccer Heading
Babbs, C. F. (2018) · Sports Injuries & Medicine · doi:10.29011/2576-9596.100033 · Cited by 1
Red Flags erkennen – zwei ähnliche Verletzungen mit unterschiedlichen Folgen
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“Neurosurgery 2004; 55: 649–655 [13] Lipton ML, Kim N, Zimmerman ME, Kim M, Stewart WF, Branch CA, Lipton RB.”
BackgroundThe effect of foam padding on the head response in soccer heading
Tan, F. Y., Hassan, M. H. A., Johari, N. H., Omar, M. N., & Hasanuddin, I. (2022) · Malaysian Journal of Movement Health & Exercise · doi:10.4103/mohe.mohe_37_22 · Cited by 1
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Les têtes répétées au football : pourquoi et comment protéger le cerveau ?
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Meaningful Play, Meaningful Pain: Learning the Purpose of Injury in Sport
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Addressing head injury risk in youth football: are heading guidelines the answer?
Gilbert, A. W., Bering, J. M., & Anderson, L. C. (2021) · Science and Medicine in Football · doi:10.1080/24733938.2021.1967435 · Cited by 1
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Metadata
- Authors
- Lipton, M. L., Kim, N., Zimmerman, M. E., Kim, M., Stewart, W. F., Branch, C. A., & Lipton, R. B.
- Affiliations
- Albert Einstein College of Medicine (US)
- Sutter Health (US)
- ORCID
- Venue
- Radiology
- Published
- 2013-09
- Volume
- 268
- Issue
- 3
- Pages
- 850-857
- ISSN
- 0033-8419 (ISSN-L)
- 1527-1315
- PMC
- PMC3750422
- OpenAlex
- W2170100452
- Cited by
- 376
- References
- 30
- Citations by year
- 2026: 20 · 2025: 20 · 2024: 20 · 2023: 30 · 2022: 30 · 2021: 30 · 2020: 47 · 2019: 40 · 2018: 37 · 2017: 27 · 2016: 36 · 2015: 15 · 2014: 18 · 2013: 5
- FWCI
- 17.97
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Radiology (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Dana Foundation
- Yeshiva University
- National Institutes of Health (5k23ns051409-02, 5r01ag025119-05, K23NS05140901A1, AG03949, RO1AG025119, RO1AG12101, PO1 AG03949, PO1AG027734)
- Albert Einstein College of Medicine, Yeshiva University
- National Institute on Aging (R01-AG025119, R01AG022374, P01AG03949, P01AG027734, P01AG003949, R01AG034119, R01AG012101, K23AG030857, R01-AG-12101)
- National Institute of Neurological Disorders and Stroke (K23NS047256, R01NS082432, K23 NS47256, K23NS051409-01A1)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Advanced Neuroimaging Techniques and Applications
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports injuries and prevention
- Keywords
- soccer heading, white matter microstructure, fractional anisotropy, diffusion tensor imaging, cognitive performance, memory, amateur football players, concussion
- MeSH terms
- Adult, Brain Injuries, Cognition Disorders, Female, Humans, Magnetic Resonance Imaging, Male, Nerve Fibers, Myelinated, Sensitivity and Specificity, Soccer, Wounds, Nonpenetrating, Reproducibility of Results
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