Sports Medicine 14 (3): 200-213, 1992 0112-1642/92/0009-0200/$07.00/0 © Adis International Limited. All rights reserved. SP01166

Head and Neck Injuries in Soccer Impact of Minor Trauma A/f Thorvald Tysvaer

Department of Surgery, Central Hospital in Rogaland, Stavanger, Norway

Contents Summary I. Incidence of Head Injuries 2. Neurological Injuries 3. Effect of 'Heading' on Brain Movement 4, Techniques of Heading 4.1 Timing 5, Effect of Ball Impact on the Head 6. Spinal Injuries 7, A Study of Repeated Traumas of the Brain in Soccer 7,1 Results 7.2 Discussion 8, Conclusion

Summary

Head injuries have been shown to account for between 4 and 22% of soccer injuries. Clinical and neuropsychological investigations of patients with minor head trauma have revealed organic brain damage, 69 active football (soccer) players and 37 former players of the Norwegian national team were included in a neurological and electroencephalographic (EEG) study to investigate the incidence of head injuries mainly caused by heading the ball, 3% ofthe active and 30% of the former players complained of permanent problems such as headache, dizziness, irritability, impaired memory and neck pain, 35% of the active and 32% of former players had from slightly abnormal to abnormal EEG compared with 13 and II % of matched controls, respectively. There were fewer definitely abnormal EEG changes among typical 'headers' (\0%) than among 'nonheaders' (27%). The former players were also subjected to cerebral computed tomography (CT). a neuropsychological examination and a radiological examination of the cervical spine, One-third of the players were found to have central cerebral atrophy and 81 % to have from mild to severe (mostly mild to moderate) neuropsychological impairment. The radiological examination of the cervical spine revealed a significantly higher incidence and degree of degenerative changes than in a matched control group.

Head and Neck Injuries in Soccer

Soccer (Association football) is the most common and popular sport in the world, with an organisation of 332 000 clubs, nearly 40 million registered players and more than 0.5 million referees in 150 countries (FIFA News 1982). Today nearly 10% of all traumas treated in hospitals are sports related injuries (Franke 1978; Hitchcock & Karmi 1982; Sandel in et al. 1985; Smodlaka 1979). Injuries may be direct, indirect or due to overuse. The average frequency of sports injuries in an average population is about 2%. The most common lesions are sprains, dislocations and fractures (La Cava 1961). Serious injuries involving fractures, dislocations and internal injuries represent about 15% of the total number of sports injuries (Thorndike 1952).

1. Incidence of Head Injuries Sports related injuries account for 5 to 10% of all head injuries treated in hospitals (Bruce et al. 1984; Franke 1970; Hitchcock & Karmi 1982; Vanderfield 1974). The highest rates of severe head and neck injuries occur in American football, rugby, horseback riding, boxing, gymnastics, baseball, wrestling, diving and hang-gliding (Becker 1959; Burke 1972; Corsellis 1973; Critchley 1957; Danielson & Westlin 1973; Franke 1978; Gonzales 1951; Hitchcock & Karmi 1982; Krissoff & Eiseman 1975; Lehman 1987; Ohry & Rozin 1982; Peterson & Wenker 1968; P0schl & Krieger 1963; Scher 1987; Steinbriick & Paeslack 1978). The incidence is also high in soccer. In an investigation of 1900 head injuries admitted to a neurological unit in Glasgow, Lindsay et al. (1980) found that soccer was the sport most commonly associated with serious head injuries. In Europe, soccer is responsible for about 50% of all sports injuries; 3.5 to 10% of all injuries treated in hospitals (Franke 1978). The most common soccer injuries are to the ankle, knee or groin (Biener 1967; La Cava 1961; McMaster & Walter 1978; Roaas & Nilsson 1977; Sandelin et al. 1985). Head injJ.lries account for 4 to 22% of soccer injuries (Biener 1967; J0rgensen 1984; Maehlum 1984; McCarroll 1984; McMaster

201

& Walter 1978; Nilsson & Roaas 1978) and are of concern as they can be followed by incapacitating neurological damage and even death (Arens 1967; Diehl & Wilke 1957; Eckhardt & Kobbe 1971; Gerchow 1967; Gonzales 1951; Hitchcock & Karrni 1982; Krefft 1955; Matthews 1972; Merrem 1954; Wiillenweber 1962). According to Hughes (1974) 55 English football players have died while playing football since 1931. Of those, 26 had head injuries, including 8 attributed to heading the ball.

2. Neurological Injuries Severe brain injuries can occur at lower levels of impact than are usually required to produce concussion (Reid et al. 1975). Even a single blow, sufficient to stun a person for a short time, may result in minute foci, damage to nerve fibres and capillaries (Oppenheimer 1968). In their experiments using guinea-pigs, Windle et al. (1944) found that the amount of damage to the nerve cells was in proportion both to the number and strength of the blows inflicted. According to Symonds (1962) it is questionable whether the effects of concussion, however slight, are ever completely reversible. The emotional and intellectual problems experienced by patients with severe head injuries, and the great difficulties these patients encounter in their return to society, have been well documented (Brooks 1974; Fuld & Fisher 1977; Ross et al. 1983; van Zomeren 1985). Recent clinical and neuropsychological investigations of patients with minor head trauma have revealed organic brain damage, manifested by neurological deficits, electroencephalographic (EEG) disturbances, and neuropsychological impairment (Barth et al. 1983; Cook 1969; Gronwall & Wrightson 1974; MacFlynn & Montgomery 1984; Rimel et al. 1981; Rutherford et al. 1977, 1979; Wrightson & Gronwall 1980). In an evaluation of patients with minor head trauma, Gronwall & Wrightson (1975) found that they significantly reduce the capacity to process information rapidly, and that deficits in information storage and retrieval were exacerbated by successive injuries.

202

A soccer player receives several thousand blows to the head during his or her football career (Tysvaer & Storli 1981). As the effect of repeated minor head injuries is cumulative (Gronwall & Wrightson 1975; Symonds 1962), it has been suggested that an encephalopathy similar to that seen in boxers (Bruce et al. 1984; Johnson 1969) may occur in other sports, including soccer (Carroll 1936; Lindsay et al. 1980). In 1974, Corsellis (Editorial 1976) asked 165 British neurologists if they had encountered a condition resembling the punch-drunk state among either boxers or sportsmen of any category. Professional soccer was mentioned 5 times with comments on 2 cases: one man was a 'centrehalf much given to heading and able to do so even if the ball were blasted at him from about 6 yards.' Another man had played until he was 40, developed fits, and was considered to belong to the punch-drunk group.

3. Effect of fHeading' on Brain Movement Heading is one of the more difficult skills in soccer. Learning, especially in the early stages, can be a painful experience. Hughes (1974) described 'being hit on the head by a fast-moving soggy ball as little different to the effect of a punch.' The brain is very easily altered in shape, or distorted by rotation of the head about an axis. Sudden rotational acceleration of the movable head emerges as the most dangerous mechanism of injury (Denny-Brown & Russel 1941; Yarnell & Ommaya 1969). The change of velocity which a blow can produce, according to Holbourn (1943), can be analysed into a change in the linear (straightline) velocity together with a change in the rotational velocity about an axis. There is an essential difference between linear and rotational movement. When the skull is moved in a straight line the brain is not compressible and there is no appreciable distortion. Hence, in almost every accident, the linear acceleration can be neglected in comparison with the rotational acceleration (Holbourn 1945). Rotation of the brain within the cranial vault is delayed because of the brain's intrinsic inertia. This

Sports Medicine 14 (3) 1992

lagging movement of the brain leads to stretching of the bridging veins and shearing forces on the nerves (Lampert & Hardman 1984; Strich 1961). The mobility of the head and the direction of the force will influence the degree of inertial motion of the brain. By bracing the neck muscles when heading the ball, the football player decreases the rotation which is, to some extent, insurance against brain damage. It is well known that boxers can tolerate severe direct blows to the head provided their neck muscles are strong and they can keep their head still. Deceleration of the brain occurs when the moving head strikes a stationary object such as an opponent's head or hits the ground in a sudden fall. Furthermore, the inert brain will glide within the cranial cavity, causing small haemorrhage in the cortex and subcortical white matter, as well as subdural haematomas.

4.

Techniq~es

of Heading

In heading the ball, there are 2 main techniques; a standing jump and running jump. Within both techniques the power for heading is derived from a back to front movement starting at the hips (Mawdsley 1978). The initial movement of the trunk, upon leaving the ground, is backward (fig. 1). This is to enable the trunk to move forward with greater velocity at impact. The movements of force at the hip are greater than at the neck as a result of much greater trunk mass. The running jump enables the player to attain greater upward velocity and to use this, together with the forward movement of the trunk, to increase momentum of the ball at impact (fig. I). With the standing jump technique there is no upward velocity of the body at the point of impact. This is the basic difference between the 2 techniques, both of which require careful timing to make maximum use of the body momentum in striking the ball. To absorb the force of the impact of the ball, and to prevent jarring at the neck, the head must be rigid at the impact. By fixating the head, the opposing forces can be considered as an increase in the mass involved at impact (Reid et aI.1975).

203

Head and Neck Injuries in Soccer

b

Fig. 1. The initial backward movement (a) followed by the forward movement (b) enables the header to give a momentum to the ball at impact.

The weight of the head plus the torso must therefore figure in the calculation of the mass. By applying Newton's Law of Motion F = m X a, the same force (F) applied to a greater mass (m) results in less acceleration (a). When fixating the head, the player decreases the risk of rotational acceleration of the head, relative to the trunk, and also the risk of damaging the brain and the cervical spine. 4.1 Timing Timing is an important factor in the correct heading technique both to ensure that the head is rigid and to achieve m·aximum use of the body momentum in striking the ball. To ensure good tim-

ing, the player has to keep his eyes on the ball throughout the movement. In the running jump, timing is more critical since greater velocities are involved and therefore larger forces, and the amount of time from take-off to impact is less than in a standing jump. In the standing jump, rigidity of the head has been shown to be much less than in the running jump but, still well set for impact (Mawdsley 1978). The head is, however, moving backwards relative to the trunk at impact. In this way the player softens the blow by reducing the speed of the ball. The forces involved are demonstrated with another application of Newton's Law of Motion F = m X vlt (where F = force, m = mass, t = time of impact and v = velocity). The

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technique used in the standing jump is easier since there is more time to prepare for the impact. If the timing is poor, the consequences, in terms offorces involved, will be less. The rigidity of the head is, however, also less and the risk for acceleration of the head greater. There is appreciable individual variation in the effect of an impact to the head, and the reasons for such variations are still unclear (Snively & Chichester 1961).

5. Effect of Ball Impact on the Head When mass and velocity are varied, the response from the impact body can be very different. With the same kinetic energy (E = 1/2 mv 2), a bullet of a small mass and great velocity will cause great damage at the site of impact, whereas a large mass with low velocity will cause a velocity change of the whole body, but only little damage at the site of impact (Lindgren 1966). One of the characteristics of impact is the duration of the collision, i.e. the contact time (Snively & Chichester 1961). If one of the bodies is increased in mass, the contact time is prolonged (Lindgren 1966). Changes in the impact velocity of a body with a high coefficient of restitution, for example a football, will however, change the contact time very little (Lindgren 1966). With the same colliding bodies but varying velocity, it is difficult to calculate the result of the impacts. The impact introduces an acceleration pulse, of which the characteristics (rise time, peak value, pulse shape, duration and impulse) are of importance (Lindgren 1966). The scalp (5 to 7mm thick) may be considered as a visco-elastic structure and, like most biological tissues, is a dampening system in which some input energy is dissipated. The skin and the scalp covering the skull probably only reduce the impact impulse transferred to the skull and prolong the rise time and the duration of the impact. The rise time of the acceleration is important for the local effect of the impact and is of no great importance in heading. The increase in contact time is, however, of significance since the force of the football

Sports Medicine 14 (3) 1992

against the head reduces with increasing contact time. The time of the impact has been established to be from 1/64 to 1/125 sec (Schneidewr & Lichte 1975). A plastic-coated football weighs 396 to 453gm with a circumference from 68 to 71 cm, and it has a pressure of 1 kg/cm 2 (I atmosphere at sea level) [Smodlaka 1984]. The speed of the ball can reach nearly 130 km/h (Anzil 1979) and it can hit the head with an impact of more than 2000N (Tysvaer 1990). Three different sizes of soccer balls are in use: No.5 for adults; No.4 for juniors and women; and No.3 for children. The smaller balls are lighter, easier to manipulate and less dangerous. Most of the balls currently used are plastic-coated which are water and mud resistant and stay light during and after rain.

6. Spinal Injuries Acute traumatic lesions of the spine during sports have resulted in a number of severely injured young people (Burke 1984; Danielsson & Westlin 1973; Funk & Wells 1975; Hitchcock & Karmi 1982; Kiwerski & Weiss 1981; Krissoff & Eiseman 1975; Ohry & Rozin 1982; Scher 1987; Sherk & Watters 1984; Steinbruck & Paeslack 1978; Torg et al. 1979). Steinbruck and Paeslack (1978) found that nearly 10% of all para- and tetraplegics treated at Heidelberg University orthopaedic hospital were injured by accidents during sport. They occurred in gymnastics, riding, mountain climbing, skiing, jumping on trampoline and high-tower diving. One of the tetraplegic patients was a soccer player. Hitchcock and Karmi (1982) found about the same percentage of spinal cord injuries due to sports activities as Steinbriick and Paeslack did. Soccer accounted for 6%, whereas rugby football, swimming and riding accounted for nearly 60%. Scoppetta and Vaccario (1978) described a case of central cord syndrome after heading a football. Both a player with subluxation and one with fracture of the cervical spine were reported by Bargon

Head and Neck Injuries in Soccer

(1981). Tysvaer (1985) reported a football player with cervical disc herniation due to heading (fig. 2). After the age of 40, degenerative changes of the cervical spine are a normal finding even in people without any known head or neck injury (Gore et al. 1986). It is generally accepted that traumas to the cervical spine may start and accelerate degenerative changes of the moving segments. Schneider et al. (1962) studied the effect of chronic recurrent cervical spine trauma in 6 highcliff divers of Acapulco, Mexico. The divers had an average of approximately 1000 dives per year from a height of 135 feet. Of the 6 divers 4 had fractures of the cervical spine compared with none in a control group of 10 Mexicans of the same age. The greatest bone changes were found among the divers who dived with their hands spread apart so

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that the impact of striking the water was taken by the head without diminution by the nose-cone effect of the arms. The same 3 divers also had bone bridging anteriorly, which may be due to: tears in the anterior longitudinal ligament; anterior extrusion of the intervertebral discs; or fracture of the anterior portion of a vertebral body with subsequent ossification, resulting in anterior spine fusion. No such changes were found among the 3 divers who dived with locked hands. Except for 1 diver, with minimal bone encroachment of the cervical spine by spurs or bridges posteriorly, no sign of cervical spondylosis was observed. Since scoring with the head or passing the ball with the head is an integral part of the football it is reasonable to think that these traumas may start and accelerate the development of degenerative changes in the

Fig. 2. Myelogram showing a filling defect between C6 and C7 (arrow) and x-ray control 3 months after the operation showing healed fusion between C6 and C7 (from Tysvaer 1985. with permission).

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206

Fig. 3. Slightly abnormal EEG with excess of theta activity in the left temporal region (arrows) [from Tysvaer & Storli 1989a, with permission].

Fig.4. Abnormal EEG with theta activity in the left temporal region (arrows) [from Tysvaer & Storli 1989a. with permission].

cervical spine in the same way as has been seen in high-cliff divers. It has been recognised that forced movement of the head and neck in one direction, with the body as a base, is often followed by a sharp motion in the opposite direction. The various forces that may be transmitted to the neck are compression, distension, bending, shearing, and torsion (Frankel 1959). In acceleration injuries, the force applied to the neck is roughly equivalent to the weight of the head

multiplied by the speed that the head is moving. If the head and neck are turned at the time of impact or if the impact comes from the side, severe torsional forces may then be transmitted to the neck and the structures within (MacNab 1964). The blow of heading is mainly a hyper-extension and compression strain which may result in injury to the vertebral body, the intervertebral joints and the discs in the lower part of the cervical spine (Sortland et aL 1982). A flexion strain may occur if the ball is not headed with the correct technique.

Table I. Age distribution and EEG results in active football players and controls

Players Total Controls Total

No. of players

Age (y)

34 35 69 34 35 59

EEG results normal

slightly abnormal

abnormal

15-24 25-34 15-34

19 (56%) 26 (74%) 45 (65%)

10 (29%) 7 (20%) 17 (25%)

5(15%) 2 (6%) 7 (10%)

15-24 25-34 15-34

28 (82%) 32 (91%) 60 (87%)

3(9%) 2 (6%) 5 (7%)

3(9%) 1 (3%) 4(6%)

207

Head and Neck Injuries in Soccer

Table II. Age distribution and EEG results in former soccer players and controls

Players

Total Controls

Total

No. of players

Age (y)

12 17 8 37 12 17 8 37

EEG results normal

slightly abnormal

abnormal

35-44 45-54 55-64

8 (67%) 12 (71%) 5 (63%)

3 (25%) 2(12%)

35-64

25 (68%)

1 3 3 7

35-44

10 (83%)

45-54 55-64

15(88%) 8 (100%)

35-64

33 (89%)

After heading, particularly in the technique used in the standing jump, the player has to prevent the head from snapping forward following the release of pressure after impact with the ball. He usually does this by correct timing of the impact, by bracing the neck muscles and by keeping the eyes on the ball throughout the movement (Mawdsley 1978).

7. A Study of Repeated Traumas of the Brain in Soccer Although soccer is the most popular and widespread sport in the world, surprisingly little is

(8%) (18%) (38%) (19%)

5 (13%)

2 (17%) 1 (6%)

1 (6%)

3 (8%)

1 (3 %

)

known about the possible late sequelae of repeated traumas to the brain and cervical spine in the participants. In our study of Norwegian football players, 69 active football players from Norwegian first division league clubs, aged 15 to 34 years, and 37 former players of the Norwegian national team, aged 35 to 64 years, underwent a neurological and electroencephalographical examination. Players with a past history of head and neck trauma unrelated to football were excluded from the study (Tysvaer & Storli 1989a,b). The active players, aged 15 to 34 years, had played a total ot 8760 games (average 128; including first and second division and inter-

[100"V r~~·i'/INVv..'Vvvv-.....v.tJW"'I

1

2

3

Fig. 5. After impact of the ball (I) and the eyes closed (2) the EEG-telemetry shows a marked temporary alpha rhythm (3) [from Tysvaer & Storli 1989a, with permission).

208

Sports Medicine 14 (3) 1992

Table III. EEG findings in 'headers' and 'non headers' in active and former soccer players No.

EEG results normal

Active players 'Headers' 'Nonheaders'

slightly abnormal

abnormal

10

7 (70%)

59

38 (64%)

3 (30%) 14 (24%)

7 (12%)

10 27

6 (60%) 19 (70%)

3 (30%) 4 (15%)

1 (10%) 4 (15%)

Former players 'Headers' 'Nonheaders'

national games) and the former players, aged 35 to 64 years, a total of 13 280 games, on average 359. EEG-telemetry recording was performed in 4 players, aged 13, 16, 18 and 23, during and after approximately 10 minutes of heading. Another 2 players underwent a neurological and EEG examination, 1 (a typical header) immediately after a match, and the other shortly after suffering a head trauma during a match (Tysvaer & Storli 1989). The former players were also examined by cerebral computer tomography (CT) [Sortland & Tysvaer 1989], by an extensive battery of psychological tests (Tysvaer & Loechen 1991), and clinically and radiologically for degenerative changes in the cervical spine (Sortland et al. 1982). The EEGs were classified as: normal, slightly abnormal (fig. 3) and abnormal (fig. 4) [Tysvaer & Storli 1989]. 7.1 Results The neurological examination was normal in all but one active player. This player had a slightly reduced abdominal and quadriceps reflex on the right side compared with the left, and a slightly abnormal EEG. Of former players 26 (70%) revealed neurological deficits: 15 had reduced motion of the cervical spine; 5, nystagmus; 2, impaired coordination; 2, impaired hearing; 1, reflex disturbance; 1, unsteadiness. No neurological deficits were observed in controls. 36 active (54%) players and 26 former players

(70%) had been subjected to head trauma during football, including concussion, fracture of nose and maxillae, headache, disorientation, nausea, vomiting and dizziness (Tysvaer & Storli 1989). Two active (3%) and II (30%) former players complained of permanent symptoms commonly attributed to the postconcussion syndrome, namely headache, irritability, dizziness, failure of concentration and memory problems. In most instances the symptoms are due to headings, head to head contact, or a fall with the head hitting the ground or other contacts. All 4 active players examined by EEG-telemetry experienced a headache after about 10 minutes of intense but correct heading. The EEG records of all these players showed an increase in the amplitude of the resting alpha rhythm (fig. 5). No neurological or EEG changes were revealed in experienced headers examined immediately after a football match. Of the active players 24 (35%) had abnormal EEG [slightly abnormal and abnormal (figs 3 and 4)], compared with 9 (13%) of the controls (p < 0.001) [table I]. Of the former players, 12 (32%) had abnormal EEG compared to 4 (11%) in the control group (p < 0.05) [table II]. Although EEG abnormalities were seen in all ages, they occurred most frequently among the youngest players « 24 years). No statistically significant difference was found in the electroencephalograms in experienced headers and 'non headers', neither in active nor former players, but 'non headers' had a higher degree of

Head and Neck Injuries in Soccer

definite abnormal EEG (table III). The examination of the former players by cerebral CT, demonstrated cerebral atrophy with widening of the lateral ventricles in one-third of the players and a number of increased linear measurements (Sortland & Tysvaer 1989) compared to normal controls (Gyldensted 1977; Hahn & Rim 1976; Haug 1977; Messe et al. 1980). The neuropsychological examination demonstrated mild to severe deficits regarding attention, concentration, memory, and judgement in 81% of the former players compared to 40% with only a mild degree of impairment in a control group (p = 0.003) [tables IV and V). A statistically significant correlation was found between EEG disturbances and neuropsychological impairment (p = 0.02) [Tysvaer & Loechen 1991). Of the former players 25 (58%) had reduced motion of the cervical spine, markedly in 18 (42%). Nine (21%) complained of pain and stiffness in the neck, compared with none in the matched control group. 23 (53%) of the players had pronounced degenerative changes in one or several levels of the cervical spine compared to 10 (23%) in the control group. The onset of degenerative changes appeared 10 to 20 years earlier among the football players, and the degree of the degeneration was significantly higher (fig. 6). The greatest difference of degenerative changes between the 2 groups was seen in the intervertebral joints, but a noticeable difference was also found in the intervertebral discs and the uncovertebral joints (Sortland et al. 1982). Ten of 23 former players (43%) with pronounced degenerative changes of the cervical spine, had electroencephalographic disturbances compared to 2 of 12 players (17%) with a less advanced degree of changes. A statistically significant correlation was found between a pronounced degree of degenerative changes in the cervical spine and neuropsychological impairment (p < 0.05). 7.2 Discussion The number of players with permanent complaints was significantly higher among former than

209

among active players. This may partly be explained by the number of games played which was nearly 3 times that of the active players. In boxers, the existence of a correlation between symptoms and the number of matches fought has been shown (Casson et al. 1982, 1984; Ross et al. 1983). The difference in complaints could be because of the larger functional reserve, a normal feature of the young human brain, which masks the effects of small cerebral lesions. When the functional reserve begins to wane with increasing age or if the reserve is reduced by some other concomitant disorder, then symptoms from the lesions may slowly appear. The EEG-telemetry of the 4 players, performed during heading, revealed only slight temporary changes although all suffered headache. The registration of long term electroencephalographic changes in the active football players, who suffered a head trauma during a match but without loss of consciousness, demonstrates the usefulness of the electroencephalogram in the treatment of participants after head trauma. This agrees with Schernikau's (1974) indications for the use of the electroencephalogram in sports. Even without a loss of consciousness, there might be neuronal damage (Windle et al. 1944). No correlation was found between neurological deficits and electroencephalographic changes. This is in accordance with other investigations of sports injuries (Blonstein 1969; Lindsay et al. 1980) and minor head injuries (Denker & Perry 1954; Levin & Grossman 1978). It seems likely that the neurological examination per se is insufficient in detecting cerebral changes after minor head injuries. An EEG may be better in demonstrating neurological abnormalities. Nontypical headers had a higher degree of definite abnormal EEG than typical headers presumably because of difference in technique. A sudden rotation of the head may be sufficient to tear nerve fibres, synapses and even blood vessels (Strich 1961). It would be reasonable to assume that typical headers are more skilful in bracing their neck muscles during heading than 'non headers' and in this way reduce the rotation. The higher incidence of EEG disturbances in the

Sports Medicine 14 (3) 1992

210

Table IV. Occurrence of various symptoms from the neuropsychological examination Symptoms

Number and proportion of cases football players (n: 37)

p-values a

control group (n: 20)

Intellectual impairment

30 (81%)

8 (40%)

0.003

Impaired memory span for digits Reduced visual retention Psychomotor impairment

11 (30%)

1 (5%)

0.04

Impaired function on Trail Making Test Impaired finger identification Dysnomia Dysarthria Construction dyspraxia Unilateral motor impairment Bilateral motor impairment Slight degree of decreased colour vision Righthanded Ambidextrous a

14 (38%) 16(43%) 12 (32%)

0.001 0.0004 0.004 0.04

7 (19%) 3 (8%) 7 (19%) 7 (19%) 6 (16%) 3(8%) 5 (14%) 35 (95%) 2 (5%)

1 (5%)

1.0 0.23 (l.04 0.23 0.38 0.15 0.53 0.53

1 (5%) 1 (5%)

20 (100%)

Fisher exact probability test, two-sided .

1 ''''''''20101030421

younger players is in agreement with findings reported by others (Blonstein 1969; Busse & Silverman 1952; Heppenstall & Hill 1943). The registered predominance may be because (a) the young player has a higher susceptibility to trauma, (b) not all had a full-grown skull, and (c) the young player is the least experienced header. One-third of the former players were found to have a mild to moderate degree of central cerebral atrophy, evaluated by cerebral computer tomography (CT). Since none of the players had had any minor head traumas, it is likely that the cerebral atrophy is a result of repeated small injuries during soccer. The results of the neuropsychological examination, in which 81 % of the football players demonstrated mild to severe neuropsychological impairment regarding attention, concentration, memory, and judgement, strongly indicate the cumulative effect of repeated head traumas. The findings are in accordance with several epidemiological and neuropsychological investigations of minor head trauma (Barth et al. 1983; Gronwall & Wrightson 1974; Levin & Eisenberg 1979; Levin & Grossman 1978; MacFlynn et al. 1984; Rimel et

al. 1981 ; Rutherford et al. 1977, 1979; Wrightson

& Gronwall 1980).

In a study of 538 patients who had suffered minor head trauma (Glasgow Coma Scale of 13 to

7

-

6

50

.

3-

-

2 1

0 9 8 7 &

~

~9

Age

~

SO-S9

groups (y)

60-69

Fig. 6. Total average scores of degeneration and range in football players (_), control group ([il.'J) and headers (-) [from Sortland et al. 1982, with permission].

211

Head and Neck Injuries in Soccer

15), including a significant number of patients with sports related injuries, Rimel et al. (1981) evaluated 424 of them 3 months after the injury. 79% of these complained of persistent headaches, and 59% described memory problems. Although neurological examination was normal in nearly all patients, neuropsychological testing performed among 69 of them demonstrated problems with attention, concentration, memory, or judgement. The result ofthe radiological examination ofthe cervical spine showed that the repeated traumas to the head play an important part in the development of degenerative changes. Scher (1990) has found the same changes in the cervical spine of rugby players. The development of cervical spondylosis is dependent upon wear and tear. The players have multiple strains on their necks, especially during heading, but also in other parts of the play. Movement may exceed the normal mobility of the cervical spine causing lesions of the articulations, capsules and discs. Following disc degeneration, the osteophytic outgrowths, which develop around the uncovertebral joints, may encroach upon the nerve root foramen and compromise the relatively fixed emerging nerve root resulting in cervicobrachial pain (Tysvaer 1985). The spine with degenerative changes is also more susceptible to injury than the normal spine. The frequency of reduced motion, increased degree of degenerative changes and subjective neck complaints in experienced headers compared with 'non headers', indicate that the number of headings is of some importance in causing degenerative changes and symptoms in the cervical spine (Sortland et al. 1982).

8. Conclusion The overall pattern of electroencephalographic disturbances, abnormal findings on computer tomography, high incidence of neuropsychological impairment and increased incidence and degree of degenerative changes in the cervical spine, together with a clear to significant correlation between sev-

Table V. Degree of neuropsychological impairment of various functions in soccer and control groups according to the total diagnostic evaluations Characterisation

Number and proportion of cases football players (n = 37)

7 (19%) No or doubtful evidence of impairment Milder degree of impairment 12 (32%) 1~ (38%) Moderate degree of impairment 3(8%) Severe degree of impairment 1 (3%) Severe to gross degree of impairment

control group (n = 20)

12 (60%) 8 (40%)

eral of the different results, strongly indicate the aetiology and pathogenesis to be the same. The multiple small head and neck injuries, mainly connected to heading during the career of the football player, seem to be the cause of brain damage similar to that seen in people who have sustained minor head injuries. It may also cause the beginning development of cervical spondylosis. Teachers and coaches should, in order to reduce the risk of brain and cervical spine damage, be aware of the most important factors involved. The development of strong neck musculature could reasonably be expected to prevent many brain and neck injuries, and isometric and resistance exercises to develop neck strength should be a part of football training. Most of the results may, however, be considered as minor damage to the brain and cervical spine. None of the players from our study had symptoms and signs similar to those found in boxers with encephalopathia traumatica. The dysfunctions found during the examinations affect neither the players' normal daily activity nor their social adjustment.

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