A review of football safety procedures over twenty years for child and adolescent play. The review includes research experiments, expert opinion, and pediatric guidelines for the prevention and treatment of concussions.

1. Football Heading Risk
and Safety
Expert Conclusions over Twenty Years
Safia Fatima Mohiuddin, Researcher and Scientific Writer
Based on Global Studies of Child and Adolescent Play

2. The Physics of Heading a Football
High kicks
Collisions
Head Ball
Contact
Section 1
An Early Answer to the Question: Why do
football and soccer players have deficits in
concentration, memory, planning, and alertness
overtime?
Charles Babbs’ Model to
Assess Brain Injury Risk from
Heading (2001)
Babbs’ Experiment
Falling

3. Head-ball contact may be a possible cause of head injury.
Babbs’ study to understand whether heading in
football was safe or harmful: 🔻
Heading is an essential aspect of competition, a controversial research topic. Yet, it is
important to analyze the risk of cumulative injury related to brain acceleration
A small percentage of permanent brain injury implies serious public health consequences
A Mathematical Model
Newton’s Second law of Motion
A meter stick
A stopwatch
A balance
➔ The Player
➔ The Ball
➔ Flight of the ball
prior to impact
➔ Effects of variables
on intensity and
duration of head
acceleration
The Variables
Measured
Two Masses

4. Horizontal Head
Acceleration
(Dependencies)
Player’s
Effective
Body Mass
Horizontal
speed of
ball
Size of
ball
Inflation
Pressure of
the ball
Speed of
Player
Force = Mass * Acceleration Estimation of Acceleration
for many game scenarios -
The Data
Corner
kicks
Goal
Kicks
Crosses
Clearances
Shots
Large and
small players
Poor or good
technique
Mass of
Ball
The Forces

5. Trajectories of Lofted Balls (The Data)
Estimating the Horizontal Speed
of the Ball (The Variables)
Air
Resistance
Drag of
Motion
Spring Constant (Function
of Inflation Pressure of the
ball)
Damping Coefficient
(Height to which ball
bounces initially when
dropped from a height)
Players between the
ages 10 and 14
Amateur and
professional levels
Adult men and
women
Equations of motion for
spherical projectiles
slowed by air resistance
The Variables

6. Ratio of horizontal force to horizontal
acceleration (depending on angle of
inclination of player to the ground)
Effective Body Mass
The Ideal Heading Technique
➔ Strong, stiff neck muscles
➔ Head does not wobble
backwards
➔ Entire body mass connected to
the ball
➔ Effective body mass is one half
body mass for grounded and
jumping player
Player Unaware of the Ball
➔ Mass of the head alone is used
➔ Head is susceptible to acceleration
during head - ball contact
Mediocre Technique
➔ Head wobbles slightly
➔ Effective body mass is
intermediate between head and
one half of total body mass
Higher Effective Body Mass Results in
Smaller Head Acceleration
When the Ball Collides with the Forehead
The Biomechanics of Heading

7. Overall range of possible accelerations in legally inflated balls is
greater in youth compared to adults. What Makes Heading Safer?
⚽ Reducing inflation
pressure (softer
rather than hard
over-inflated balls) is
a good strategy for
safer heading
⚽ Reduced bounce
increases heading safety
⚽ Greater contact area
and greater contact time
mean greater control of
the ball - greater touch
⚽ Higher accelerations were recorded for youth
with unfavorable conditions: bad technique, high
ball velocity, high inflation pressure
⚽ Smaller ball size does NOT compensate for
smaller effective body mass of young players
⚽ Loose Neck & Wobbling Head (accidental
hit / half-hearted effort) causes Effective
Body Mass to Reach Mass of Head, Leading
to Highest Dangerous Accelerations.
⚽ Low pressure balls cause less head
acceleration over longer contact times, and
Lower Head Injury Criterion (HIC) values
⚽ Diving headers are better for the brain as
they muster greater effective body mass in
the horizontal direction
⚽ Repeated Subconcussive Blows have
Significant Cumulative Impact

8. Dr. Babbs lauded Ronaldo
for “both effectiveness and safety”
“It was perfect in more ways than one”
-- Physicist and scientist, Dr. Charles Babbs on Cristiano Ronaldo diving bullet header in 2018
FIFA pantheon between Portugal and Morocco
News Reference: Won, A.S., Perone, B., Friend, M., & Bailenson, J.N. (2016). Identifying Anxiety Through Tracked
Head Movements in a Virtual Classroom. Cyberpsychology, behavior and social networking, 19 6, 380-7 .
Ronaldo became the second-highest goal scorer in men’s
international soccer
Babbs’ Recent Observation

9. A Nurse Explains
Concussions
Information for Young Football Players
Section 2
The Value of Safety from a Nurse’s
Perspective: What children, adolescents,
caregivers, and coaches need to know about
Chronic Traumatic Encephalopathy (CTE)
Perspective of Linda Hepler,
BSN, RN (2016)

10. What is a Concussion and How is it Treated
Whiplash along the
Sagittal Plane
Whiplash along the
Axial Plane
Whiplash along
the Coronal Plane
Image Reference: Won, A.S., Perone, B., Friend, M., & Bailenson, J.N. (2016). Identifying Anxiety Through Tracked
Head Movements in a Virtual Classroom. Cyberpsychology, behavior and social networking, 19 6, 380-7 .
The Brain Shifts Rapidly within the Skull
A Force is Transmitted to the Brain
⚽ Concussions
in children
under 19 are on
the rise
⚽ Helmet-to-helmet
concussions may go
undetected

11. CTE was first recorded by forensic
pathologist, Bennet Omalu in 2002
from the autopsy of the deceased
football player, Mike Webster
Advanced neurocognitive and
radiological studies in children can
provide evidence of brain damage at
cellular level even without any
symptoms or reported concussions
Advocates advice exposure to
non-impact football, accompanied by
strengthening exercises (core and
neck strengthening) during practice. Concussion: 2015 Book and Film
Omalu’s Discovery of Chronic Traumatic Encephalopathy (CTE)

12. Nurse Recommendations for Young Football Players
Identifying Common Symptoms
➔ Sleep disturbances
➔ Problems with Concentration
➔ Headache, dizziness
➔ Irritability, Nausea
Diagnosis and Care
➔ Diagnosed using Neurocognitive Testing
and Imaging
➔ Treated with Physical and Cognitive Rest
➔ Break from Screen Time and Homework
for 7-10 days
➔ Concomitant migraine or ADHD may
require longer recovery times
Nurse Recommendations for Youth
➔ Mandatory education for coaches on
concussion symptoms
➔ Implementing age-appropriate laws
➔ Sports medicine professionals
recommend head up tackling to
reduce risk
➔ Pre-season neurocognitive testing
➔ Following physician
recommendations for concussions
for prompt recovery

13. Stanford Team Studies
Head Impact Kinematics
MiG2.0 Mouthguards to Measure Brain Strain
Measuring Sub-Concussive Brain Strain:
How well did instrumented mouthguards
(mouthguards with accelerometers) measure
sub-concussive brain strain and concussions in
head impact?
Section 3
Finite Element (FE) Analysis
of Liu’s team (2021).

14. ⚽ The link between head kinematics and
deformation of the brain is used as a predictor of
risk of brain injury.
⚽ Finite element head models were used to
calculate brain strain and ascertain the risk of
mild traumatic brain injury (mTBI) - a type of
brain injury that causes cognitive deficits and
changes in neurological function.
⚽ 118 head impacts were recorded by
video and compared to those collected by
Stanford Instrumented Mouthguard
(MiG2.0 devices).
⚽ All 118 impacts were found to be
subconcussive (neither recorded nor
diagnosed)
Experimental Setup Results
⚽ A wearable device (instrumented
mouthguards) to collect data related to head
impact kinematics measurements during a
specific period of time
⚽ Finite element (FE) analysis was used
to calculate peak brain strains (rotation)
MiG2.0 Mouthguards Successfully Detect Subclinical Concussions

15. Safety Equipment may
not Reduce Risk of CTE
Camarillo’s Padded Helmet Test
Section 4
Protective Equipment Ineffective in
Preventing CTE: How Dr. David Camarillo’s
team experimented in their lab, and discovered
that padded helmets failed to soften blows.
Dr. David Camarillo’s
Experiment on Helmets (2023)

16. ⚽ Researchers pounded the head at different
speeds and angles using a battering device to
measure the force of blows
⚽ Experts fitted mouthguards with the same
motion sensor technology on the field (real
scenario) on five players during a practice season,
with and without soft caps.
⚽ The soft cap that shifted like a loose wig
over the helmet provided 15% to 20% more
protection (probably due to redirection in
some of the impact energy when the
impact was received at the right angle).
⚽ Researchers identified 97 head-to-head
collisions, which they matched to the
sensor data from the mouthguards. The
cap did not seem to provide protection
against the blows.
Experimental Setup Results
⚽ Camarillo tested a padded helmet using a
crash test with a dummy head using motion
sensors on the head
⚽ Head impact in the absence of a
concussion contributed to CTE.
Dr. David Camarillo’s Enquiry into the Effectiveness of Padded Helmets

17. Dealing with Pediatric
Concussions
RTS Clearance Guidelines + Evidence-Based Prevention
Section 5
Protecting Children with and without a
History of Concussion: What factors increase
risk of recurrent concussion? How can
Evidence-Based prevention and RTS Guidelines
help?

18. Incidence of Concussions in Children
➔ Collision sports have the highest risk of concussion
➔ Incidence of concussion per 1000 exposures is 0.5 to 4.2 concussions.
➔ Recurrent concussion among youth happen due to
⚽ lack of knowledge of concussion signs and symptoms
⚽ fear of being removed from the game
⚽ not thinking the concussion was serious enough to seek medical attention
⚽ not wanting to let down teammates.
1-2 million children under 18 sustain sports-related
concussions per year
Increased Risk of Concussion in Children and Adolescents

19. Risks of Concussions in Children and Adolescents
➔ Prior history of concussion increased risk of concussion and injury, as well
as lower extremity musculoskeletal injury.
➔ Factors contributing to greater vulnerability and delayed recovery were
⚽ thinner cortical skull bones ⚽ neurological immaturity ⚽ weaker
supportive neck musculature.
➔ Adolescents are more susceptible to second impact syndrome, with
catastrophic consequences, on returning to high-risk activity while still
symptomatic from previous concussion
➔ Increased cerebral vulnerability may be due to exacerbated symptoms of
index injury or a reinjury.
Overall risk of sustaining a concussion with a prior history
was four times greater.
Increased Risk of Concussion in Children and Adolescents

20. Reducing Risk of Concussion Recurrence (For Clinicians)
➔ Preventing concussion through neuromuscular training
➔ Individualized vestibular and cervical physiotherapy to decrease
return-to-sport clearance
➔ Educate youth and parents about increased risk
➔ Understand biomarkers of recovery to predict recurrence of concussion
➔ Learn about functional disturbances and microstructural injury
➔ Follow a conservative approach in treating children and adolescents,
considering increased vulnerability, recovery times, and adverse long-term
consequences, given the sensitive neurodevelopment growth period.
Ensure that consensus guidelines for RTS following
concussion are evidence-based, sex-specific, and age-specific
Increased Risk of Concussion in Children and Adolescents

21. Examining, Diagnosing, and Managing Concussions
➔ Injuries in football can go undetected, cause transient functional impairment,
or lead to life-threatening structural lesions. Most physicians find it
challenging to assess injury severity on-field and off-field.
➔ The clinical symptoms of brain injury may develop after minutes, hours, or
days after the injury, and a standardized approach for physician
decision-making is required with regard to player removal from play.
➔ Current international guidelines consist of examination and management
procedure within 72 hours after the injury accompanied by a “graduated
return-to-football” program.
➔ Seven stages are required to be completed from on-pitch examination to
return-to-play. These stages cover several criteria for removal of play,
emergency management, and specialist referral.
Ensure consensus guidelines for RTS following concussion are
evidence-based, sex-specific, and age-specific
Sports Medicine Guidelines

22. Sports Medicine Guidelines
Seven Stages from On-Pitch Examination to Return-to-Football
TBI care is administered in line with European Federation of Neurological Societies (EFNS)
guidelines for mTBI, National Institute of Health and Care Excellence (NICE) guidelines
Stage 1 - On-pitch exam of
head injury: checking acute
signs, Glasgow Coma Scale,
Maddocks questionnaire for
memory and orientation
Stage 2 - Off-field assessment:
Ocular motor function test,
treating minor injuries
Stage 3 - Treatment in a quiet area
using latest concussion assessment tool
with detailed neurological examination.
Players return to play when they have
no symptoms after Phase 2 and 3.
Players with TBI symptoms complete
graduated return-to-football
program.
Stage 4 - Team physician
continues to observe player
until end of play, directing
player to emergency
management for worsening
symptoms. Players are
re-examined before leaving
facility and may require
driving clearance.
Stage 5 - Player is observed for
24 hours by team physician,
directing to emergency when
required.
Stage 6 - Re-evaluation:
Physician performs physical and
cognitive tests; players advised
to avoid electronic devices;
return-to-play in case of
absence of symptoms;
reevaluation after 18-72 hours
Stage 7 - Return-to-football
graduated program based on
McCrory’s Protocol: Medical exam for
abnormal diagnostic signs on day of
injury, persisting symptoms, and
developing symptoms under increasing
cognitive and physical training load

23. More on the Graduated Program Based on McCrory’s Protocol
Sports Medicine Guidelines
➔ The graduated program requires a multidisciplinary approach
➔ The program consists of six stages including graduated increase in physical
demand, risk of contact, football-specific exercises, and head impact, spread
over training sessions
➔ Younger players with risk factors and history of concussive injuries require a
conservative approach
➔ Specific guidelines exist on the initiation of the graduated return-to-football
program
➔ Physicians must perform a differential diagnosis using available guidelines
for all domains (consciousness, sleep, vision, etc.) following head injury
Future guidelines must include impact severity (threshold), time course of metabolic and
pathophysiological changes, as these signs may cause energy crisis & delayed symptoms

24. Important Information
Brain Injury Blog:
https://tbisequelae.wordpress.com/
Edited by:
Safia Fatima Mohiuddin
Researcher and Scientific Writer
Email: safia_fatima@yahoo.com
Disclaimer:
The enclosed content is for information and discussion only. It is not a substitute for medical or
professional advice. It is not an offer to buy or sell any product or service. Facts and opinions are
summarized and available as per date of writing indicated. The editor does not accept any
responsibility or liability for any damage caused by following advice mentioned in the document.
The editor holds no responsibility for the content summarized or linked in the document. The
inclusion of authors and links does not imply any sort of endorsement.

25. References
Babbs, C. F. (2001). Biomechanics of Heading a Soccer Ball: Implications for Player Safety. The Scientific World
JOURNAL, 1, 281–322. https://doi.org/10.1100/tsw.2001.56
Cook, N. E., Gaudet III, C. E., Van Patten, R., Kissinger-Knox, A. M., & Iverson, G. (2022). Clinical Outcome
Following Sport-Related Concussion Among Children and Adolescents with a History of Prior Concussion: A
Systematic Review. Journal of Neurotrauma. https://doi.org/10.1089/neu.2022.0078
Erickson, M. (2023). Padded helmet cover shows little protection for football players. Scope.
https://scopeblog.stanford.edu/2023/03/28/padded-helmet-cover-shows-little-protection-for-football-player
s/
Feddermann‐Demont, N., Chiampas, G., Cowie, C. M., Meyer, T., Nordström, A., Putukian, M., Straumann, D., &
Kramer, E. (2020). Recommendations for initial examination, differential diagnosis, and management of
concussion and other head injuries in high‐level football. Scandinavian Journal of Medicine & Science in Sports,
30(10), 1846–1858. https://doi.org/10.1111/sms.13750
Hepler, L. (2016). Football & Concussion: Worth the Risk?. CHOC Children’s.
https://www.choc.org/news/football-concussion-worth-risk/
Liu, Y., Domel, A. G., Cecchi, N. J., Rice, E., Callan, A. A., Raymond, S. J., Zhou, Z., Zhan, X., Zeineh, M., Grant, G.,
& Camarillo, D. B. (2021). Time Window of Head Impact Kinematics Measurement for Calculation of Brain Strain
and Strain Rate in American Football. Annals of Biomedical Engineering, 49, 2791–2804.
https://doi.org/10.1007/s10439-021-02821-z
Van Ierssel, J., Osmond, M., Hamid, J., Sampson, M., & Zemek, R. (2020). What is the risk of recurrent concussion
in children and adolescents aged 5–18 years? A systematic review and meta-analysis. British Journal of Sports
Medicine, bjsports-2020-102967. https://doi.org/10.1136/bjsports-2020-102967