For 20 minutes after he had sustained what he believes was a concussion, Alex Smith — then a senior defender for an Olympia high-school soccer team — remained on the field. Dazed, he got up and continued running, though he was so disoriented, he could only sprint in circles, he said.

Smith, 21, now a junior studying political science and history at Washington State University, said he felt as if he had “an instant hangover.” But his team, he said, didn’t notice. “I hid it pretty well,” Smith said.

Last year, high-school soccer players suffered more concussions nationally than athletes in basketball, baseball, wrestling, and softball combined, according to estimates from the Center for Injury Research and Policy (CIRP) in Columbus, Ohio. Although media have focused on concussions in football, little has been written about the effects of concussions on soccer players.

“The injury rate [for soccer] probably is lower in the youth sports, but when you get up to a higher skill level, especially high school, the gap between football and soccer narrows significantly,” explained Dr. Jeff Radakovich, a team physician for Washington State University athletics.

Last year, women soccer players suffered 25,953 concussions, and men suffered 20,247 concussions, according to CIRP. By comparison, boys basketball players recorded 11,013 concussions. True numbers are likely higher, experts say: the American Academy of Pediatrics estimates that less than one-tenth of the 3.8 million sports-related concussions each year in the United States are reported.

Researchers say they have found a common cause for many of the soccer injuries: the practice of heading, or advancing the ball by hitting it off a player’s head.

“You see it a lot when two players are going for the same ball,” explained Dr. Kasee Hildenbrand, director of the athletic training education program at Washington State University and an assistant professor in the Educational Leadership and Counseling Psychology department. “It’s not so much the ball coming at your head [that causes a concussion]. It’s someone else’s head.”

Nearly 40 percent of concussions in high-school soccer resulted from heading, according to a 2008 report in the American Journal of Sports Medicine.

“I don’t know if they would ever just get rid of heading to begin with, or if they’re just going to get rid of when you can head it,” said Hildenbrand. “I don’t think it’s out of the question to assume at some point in soccer in the future, there will be rule changes.”

The Washington Interscholastic Activities Association (WIAA), the governing body of high school sports in the state, said there are no plans to remove heading from soccer. Each year, the National Federation of State High School Associations meets to discuss possible rule changes to improve safety.

“I’ve not heard any talk of eliminating heading at the high-school level,” said WIAA assistant executive director John Miller. “It doesn’t mean it couldn’t happen. As more and more data come in, then obviously if there are things that the rules governing body can do to make the game safer, they will certainly look at that.” 

Is heading the problem?

Not everyone agrees that heading leads to concussions. “Those people who don’t understand our sport believe concussions are caused by heading. Concussions are caused by head-to-shoulder, head-to-elbow, head-to-ground” collisions, said Doug Andreassen, president of the Washington State Youth Soccer Association. “Those are the type of injuries that cause concussions. Not necessarily heading the ball.”

Doug Winchell, a longtime Pullman High School soccer coach, also questioned whether the act of heading is related to the number of concussions. “I’ve never seen the act of heading cause a concussion,” Winchell said in an email. “I’ve seen more than a dozen concussions in girls’ soccer during my time at Pullman High School and of all the various reasons, heading in and of itself was never the sole cause.”

When done correctly, researchers say, the play rarely results in an injury. But the attempt can also lead to head-to-head, head-to-elbow collisions, which account for more than 40 percent of concussions in college soccer, according to a 1998 study by Duke University researchers.

A decade ago, the American Youth Soccer Organization considered a ban on heading for younger players. It discourages youth players from heading before age 10. “We don’t teach kids to head at a young age, because of risk of concussions,” said Andreassen. “We also don’t teach soccer so it becomes an aerial game. We say we want to keep the ball on the ground.”

But heading remains an integral part of the game, he said. “I don’t see heading being outlawed by [Washington Youth Soccer],” he said. “If it’s going to be changed, it would have to be changed from the worldwide body called FIFA.”

Dr. Donald Kirkendall, an independent researcher who co-authored the Duke University study and wrote The Complete Guide to Soccer Fitness and Injury Prevention, also argues against a ban on heading. ”Head injuries are the result of accidents,” he said, “and the best way to reduce accidental injury is education about the causes of accidents.”

The risks of concussions

Mike Minick, a 27-year-old former high school soccer player, believes he suffered multiple concussions in games. At one point in a game, a referee asked him how many fingers he was holding up; Minick answered incorrectly but later returned to the game. 

“The concussion was usually just accidental — two people going up to head the ball and hitting heads, or a ball just coming straight at your face,” said Minick, now the director of business development at Health Resources Northwest in Seattle. “I had a lot of concussions, so it was easy for me to get more. My family always joked around — still do — that I should permanently have a helmet on.”

Minick quit playing after a concussion in a soccer game. Other players have quit as well.

One of Winchell’s former players, who’d sustained a number of concussions, quit in 2008 after her doctor prohibited her from heading the ball, he said. “[In high-school soccer], you really have to [head] the ball,” Winchell said. “There were a couple situations where she really should’ve headed the ball, which really hurt the team. If it’s a legitimate medical concern, then I’m not sure playing is the best thing.” 

Casey Curtis, varsity soccer coach at Lewis and Clark High School in Spokane, said he also knows of a prep player who quit soccer because of concern over concussions. The number of concussions, he said, varies from season to season. “This fall, I had three girl teams, and none of them had any concussions,” said Curtis. “Last fall, we had five concussions.”

Some have suggested that players wear helmets. But that may do little to fix the problem, Radakovich said. “If we put a piece of equipment on people, [it might] actually make them more aggressive, now that they feel this sense of protection or invulnerability,” he said.

Hildenbrand agreed, and compared the human head to an egg. “Our brains are basically the yolk floating around in the fluid,” she said. “You can pad the head all you want, but you’re not preventing concussions. The only thing you’re doing is preventing skull fractures.”