How big of an issue are head injuries in soccer?

Posted on July 30, 2018

(Last Updated On: July 30, 2018)

Some background to start

Let’s use American football players as our starting point, since this topic more often revolves around them. I’ve previously written,

Wait, former NFL players are healthier than most people?

One blurb to catch us up,

“The standardized mortality ratio, SMR, is the rate compared to the general U.S. population. At 1.80, NFL players have dementia / Alzheimer’s as an underlying cause of death at 1.8 times the general population. For neurodegenerative causes of death, NFL players are at 2.83, nearly three times the U.S. population.

These numbers seem pretty high, but examining what the relative number, 2.83, comes out to, it’s only 10 causes of death out of 334. Since this was 2.83 times the general population-

10 / 2.83 = 3.53

While NFL players had 10 deaths from neurodegenerative issues in this time period, the general population would have had about 4. The percentage difference is fairly large, but the number of deaths difference is quite small.

Total deaths were 334.

10 / 334 = 0.030 -> NFL neurodegenerative death rate

3.53 / 334 = 0.011 -> Compared to U.S. neurodegenerative death rate

3% risk up from 1.1%. We’ve entered the world of “meh” caring.”

However, despite that debatable-whether-it’s-relevant-increase-in-brain-disease risk, *overall*, NFL players died at half the rate of everyday people. If your sole goal is to live longer than other people, and you only have the option of playing in the NFL or being a (sedentary) everyday person, you’d decide to play in the NFL.

-> I’m aware this is a false dichotomy. It’s only to illustrate a point. I go into more detail about this in the original post and will touch it on it again at the end.



Football has been going through quite a change due to all the brain concern. A fear now trickling into other sports. Soccer being a big one, considering it’s the most popular sport in the world and has the issue of headers.

All causes mortality in male professional soccer players

This study looked at over five thousand players for around 30 years.

First off, soccer players had a 60% less risk of death from cardiovascular issues, and 70% less from cancer. This was considerably better than NFL players.

That’s not surprising. Soccer players run a lot more than football players, and contrary to what many weightlifters want to believe, weightlifting is unlikely to give the health benefits of more aerobic work.

We shouldn’t view strength training as cardio

Exercise and cancer- why it helps and how much is enough? (part 3)

Some exercise advice for former football players (worried about CTE)

However, similar to our NFL study, soccer players did have a higher risk of death from brain disease. ALS represented a whopping 18 times greater risk of death in soccer players than everyday people.

Before we freak out, we need to add a lot of context to that finding.

“The health status of professional soccer players has been of great concern in recent years, because of the anecdotal reports of a large number of cases of Amyotrophic Lateral Sclerosis (ALS), a highly lethal degenerative disease of the motor neuron with very poor prognosis, inconsistently associated with vigorous physical activity, major injuries, the possible use of drugs to improve performance, and the exposure to pesticides sprayed on the playing fields.”

The issue of drugs is a very interesting one. There is some work out there suggesting steroid use can decrease brain size (one hallmark of dementia / Alzheimer’s), as well as make injury to the nervous system worse after a concussion. This is enormously important when you consider how many professional athletes take drugs.

-> Yes, soccer players / endurance athletes too. Lance Armstrong took everything. Steroids and testosterone included. Amongst a plethora of other benefits, it allows you to have more muscle at a lower bodyweight.

The issue of pesticides is one I hadn’t heard of, but makes sense it could be relevant.

Point being, everyone has automatically jumped to the only issue for professional athletes and brain disease being head trauma. It’s obviously a main issue, but it’s extremely unlikely to be the only, and that’s important when you consider whether parents and governments should allow kids to play a sport, as for 99% of people, they will never be at a professional level- we allow damn near everybody to drive a car; we don’t allow many people to drive like they’re in NASCAR. Nor do we shun cars because of NASCAR.


Next, despite having a sample size of 5,389, how many soccer players died of ALS?


Based on the prevalence in the everyday population, we would have expected 0.22. This is where we get our 18 times greater risk:

4 / 0.22 = 18x difference

Time to be a bad guy-

The ice bucket challenge was great and all, and there is no doubt ALS is a brutal disease, but worrying about ALS is like worrying about an asteroid. It is an irrelevant disease in the context what will kill you.

In the United States, there are 2.2 new cases per 100,000 people per year. Something like 5,600 people PER YEAR who are diagnosed with ALS. Two deaths per year, per 100,000 people, or about 6,000 deaths per year.

Meanwhile, 610,000 die of heart disease every year.

Every four days more people die of cardiovascular disease than ALS.

In the soccer study, despite a massive reduction in risk, 34% still died from cardiovascular disease and cancer, compared to 6% for ALS. We’re still way more concerned with the big two.

Furthermore, because the sample size was relatively small, we could only expect 0.22 ALS deaths out of it. That presented a quandary right away. Reason being we were guaranteed to either get 0 or at least one ALS death out of the sample.

That is, we were guaranteed to either get a 100% reduction in ALS deaths i.e. no deaths, or, at minimum, a five fold increase. We were guaranteed to get a big difference no matter what we found.

1 death / 0.2 expected = 5 times more ALS deaths than expected.

-> The next time you read a study with a sample size of only 20, think about this. Excessive interpretation of small sample sizes is a pervasive problem in Exercise Science right now. The bodybuilding and strength training blog boys have been egregious with this.


What about other brain issues?

Soccer players died of suicide at a rate of 20% less than the general population. (Although we’re again still dealing with a relatively small sample size.) And there were ZERO other brain related deaths. No Alzheimer’s, no dementia. Sure, maybe the sample size didn’t get old enough, but in the least then we’re saying if dementia is an issue, it’s still not like a bunch of 30 or 40 year old soccer players are getting it, which is what much of the media stories have been about regarding NFL players- guys shortly after playing who are already having memory and behavior problems.

-> Unfortunately we aren’t going to have any solid data for a long enough follow up period. This study started in the ’70s. At some point, if you keep going further back to get a longer follow up, then the game and environment (drugs / nutrition / healthcare / etc.) has changed so much, it’s hard to compare.

It’s also interesting to note soccer players had a greater incidence of ALS than football players. Are soccer players actually getting more noteworthy head blows than football players? Or are pesticides a true concern on soccer fields?


Don’t forget…

Overall, soccer players died at a rate of 32% less than the regular population.

Interestingly, a lot of the deaths were from car accidents. Which again presents an opportunity to look at the characteristics of the athletes. As the authors hit on, aggressive people are more likely to get in accidents, along with being drug and alcohol users. Soccer players, similar to football, are going to fit here.

College athletes drink more than regular students

-> A consistent finding in alcoholics is brain atrophy. Yet another factor besides head trauma in athletes.

If we merely took half those car accidents away, roughly what’s expected for the general population, and thus focused much more on disease, then similar to NFL players, soccer players died at a rate half that of the general population.


Unintended consequences

Point being- if you want your kid to live longer, viewing the world simply as a matter of play soccer or be an everyday person, then you want them playing soccer.

Or, if you merely had a choice between engage in one of the two most brain traumatic sports -soccer and football- or be a regular person, you would choose brain trauma.

As I’ve repeatedly said, I still don’t want my kid playing football. Soccer I find to be a murkier decision. All sports are going to have negatives. Baseball players are also going to have a greater chance of getting injured by an object hitting their head than everyday people.

But all sports are going to have positives too.

In the grand scheme, we’ve overblown this head trauma issue some, much like we went overboard with ALS. An inordinate amount of attention has been given to what MAY happen due to all the brain trauma. Little attention has been given to what DOES happen: these athletes live longer, healthier lives.

People are acting like playing football is the equivalent of smoking, where there are only downsides. At this point you’d think the NFL was Philip Morris. At the same time there is this thing called heart disease BILLIONS of people are voluntarily heading towards. Parents will do their due diligence with football and act morally superior to other parents, “I care too much about my kid to let them play football,” yet they’ll simultaneously routinely feed their kids fried food after their video game sesh.

Brain diseases are scarier than others. I think just about everybody would rather get cardiovascular disease than Alzheimer’s. As one client put it to me, “I’d rather go out with a bang than drag on in what is essentially a coma for ten years.”

I agree…but you can’t have it both ways. If you want to live the longest, healthiest life, then you can’t throw these activities away.

The fact is, for a lot of people, if they don’t play sports, they aren’t active. It’s the biggest reason activity levels severely drop after high school and college.

After High School, Young Women’s Exercise Rates Plunge

While this could and should be a lot better and different,

Rethinking youth fitness

a big change is not on the immediate horizon. Right now, activists shunning sports like football and soccer may very well be concurrently encouraging heart disease and cancer. Cross country is typically the only other fall sport requiring a lot of cardiovascular activity, and you are definitely not going to get the millions of teenage males engaging in the most violent sports, one being the most popular in America and the other the most popular in the world, to happily switch to running through the forest at 130 pounds.

-> I have greater concern for discouraging soccer than I do football because soccer is a sport people can more or less play forever. It’s much more conducive to rec leagues, pick up games, playing when you’re 50. I’d wager one is much less likely to have a noteworthy decrease in physical activity after high school if they’re a soccer player than a football player.

-> There is an intriguing theory out there that some males need a violent outlet for optimal health. That it’s an innate, evolved need, similar to other social needs, due to how violent a history humans / animals have. It’s the idea behind why Fight Club is so popular.

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