Tori Bellucci steadied her balance, dizzied by climbing a flight of stairs at Huntingtown High in 2012. She couldn’t remember the next class on her schedule — one she'd had for two months — so she ducked into the bathroom to take a look at her schedule.
Math. Of course.
In the days after she suffered her third concussion on the soccer field in the fall of 2012, doubts, fears and confusion joined the aches inside Bellucci’s skull.
“It changes the way you think and feel,” Bellucci, now 18, said. “I was just like really sad, really kind of desperate type of feeling. I couldn’t do anything because of my head, so I would just be in my room with the shades drawn. I was like, ‘I don’t want to live like this anymore.’ ”
By the time her high school and club soccer careers ended in 2013, Bellucci, an All-Met, had suffered five concussions. And the effects knocked her priorities into perspective. She walked away from the game she loved, turning down a scholarship to play at Towson, because for her, playing soccer wasn’t worth all the hours spent in rooms with lights and screens off and her memory sputtering.
Bellucci is one of thousands of female soccer players with similar experiences. According to High School RIO (reporting information online), an injury surveillance system built by Dr. Dawn Comstock of the Colorado School of Public Health, only football and boys’ hockey players report concussions at a higher rate than girls’ soccer players. Since 2008, high school girls’ soccer players have reported an average of 14 concussions per 10,000 games played (a game is equal to one game played by one player). The figure is nearly twice the average for boys’ soccer (7.30), and only football (27) and boys’ hockey (18) have reported more concussions than girls’ soccer.
As defined by the National Athletic Trainers’ Association, a concussion is a “trauma-induced alteration in mental status that may or may not involve loss of consciousness,” and results from “the rapid acceleration or deceleration” of the brain within the skull. The force behind the brain’s change in velocity is often from direct contact to the head, but can also come from indirect forces like whiplash — as could result from a car accident or being blindsided by a hit on a soccer field.
The particularly high concussion incidence rate in girls’ soccer can be partially explained by the fact that girls are more susceptible to concussions across all sports played by both genders, despite rules in lacrosse and hockey aimed at diminishing contact, according to multiple studies.
Comstock and Dr. Kevin Crutchfield, director of the Comprehensive Sports Concussion Program at the Sandra and Malcolm Berman Brain & Spine Institute at LifeBridge Health, agree there is no data to explain the increased numbers in women.
“We don’t know definitively why,” Comstock said, “but the true answer is probably a combination of reasons.”
Crutchfield said women’s increased susceptibility to migraine headaches is a factor. Migraines resemble post-concussive headaches, and so women may report more symptoms immediately after the injury and throughout recovery. Comstock theorized that hormonal differences may cause variation of energy transfer within the male and female brains. Both suggested weaker muscles and tighter ligaments in female necks relative to boys’ as another potential cause.
In soccer, a particular source of concussion concern is heading the ball. A recent study published in the medical journal Radiology showed that repeated heading of the ball resulted in brain damage and weakened cognitive performance in adult amateur players with a median age of 31.
But according to Comstock and Crutchfield, it’s not head-to-ball contact that poses the greatest concussion danger for younger players, but rather player-to-player or player-to-ground contact that can result from a heading attempt.
“It’s all the other injuries associated with that activity, rather than hitting the ball itself — at least at a high, elite level,” said Crutchfield, who helped develop the NFL’s concussion protocol. “Though when you talk about just kids who are younger and playing, they have poor technique. Then the head hitting the ball is a problem.”
Like many youth coaches, Haroot Hakopian, girls’ coach at Churchill High and for youth teams at Bethesda Soccer Club, believes shying away from heading is causing more head injuries than it’s preventing.
“The teaching of the skill, it keeps getting passed along, passed along, passed along and they get to high level high school and high level club, they haven’t really practiced it,” Hakopian said. “So they start doing it, they start doing it incorrectly.”
According to former University of Miami soccer player Sam Sanderson, the co-founder of Concussion Connection, an online support station for college athletes with traumatic brain injuries, incorrect technique often causes awkward head-to-opponent contact.
Sanderson, whose career ended because of concussions, said she was taught to go up strong with arms out both for propulsion through the ball and to protect her head from player-to-player contact. But “there were times where you’d get your arms out and elbow someone because they don’t have their arms out and aren’t doing it correctly,” Sanderson said.
In the 2012 Maryland state playoffs, Bellucci leapt to head a ball, missed, and knocked heads with a defender. When she fell to the ground, her neck snapped back and her head bounced hard off the turf, a jolt after which she needed a few seconds to understand her situation.
“It all came back pretty quickly,” Bellucci remembered. “And then I was like, ‘I’ve got to keep playing’ — it was like a big game, of course.”
That inclination to return to play endangers players further, as a player’s risk of suffering another concussion becomes 1.5 times greater after a first concussion and 3.5 times higher after a second, according to the Journal of Athletic Training.
Concussion education is mandatory for coaches in D.C., Maryland and Virginia public schools, and educating parents and players on the symptoms and implications of concussions has become a priority. In Fairfax County, parents and students must complete an online concussion education course before the students are eligible to participate in sports.
The Maryland Public School Athletic Association’s protocol, like in most states, calls for a player’s immediate removal from the game if a coach or referee suspects any type of head injury. That increased responsibility to pull players from games has forced coaches to reevaluate their approach to injuries.
Sanderson says athletes will never answer honestly when asked “are you okay,” and Hakopian agrees. He says he believes player self-evaluation should be removed from the head injury equation entirely. Instead, players should be told simply: “You’re not playing.”
Some players opt for newly developed protective devices. Some are made of foam and worn around the head to protect the forehead from the impact of headed balls and to soften the blow of player-to-player contact.
But according to Comstock, no studies or data exist to support the efficacy of products in reducing the risk of head injury.
As Sanderson put it, “if football helmets haven’t stopped concussions, it’s hard to believe these will.”
Despite the heightened awareness around traumatic brain injuries in recent years, Comstock said her data shows leveling off of concussion rate curves that had been shooting skyward over the past five years, though she’s not sure whether to attribute that to efficacy of prevention policies or an increase in injury reporting.
But while she and others emphasize the gravity of concussions, Comstock finds statistics showing decreased participation upsetting.
“We don’t want to scare any parent into thinking sports are too dangerous to play,” Comstock said. “They have too many positive attributes for kids not to participate.”
Lauren Long, co-founder of Concussion Connection and a former college soccer player, said she suffered 10 concussions and continues to deal with emotional and cognitive consequences. She says she hopes parents will remember that not all players who suffer concussions experience the same consequences, and that often those who do suffer long-term effects ignored the first signs of trouble.
“I play soccer, so concussions — it’s not a matter of if, but when it happens,” Long said. “I use the analogy: I live in Oklahoma City, tornado alley, so there it’s not a matter of if a tornado is going to come through, it’s when. When it does, what are you going to do to be safe? In our house, we know what we’re going to do. It should be the same for concussions.’”