The World Cup starts Thursday in Brazil, and Cristiano Ronaldo, Lionel Messi, Diego Costa, Luis Suarez and Neymar are just a few of the players who could soon become household names. There is one less-known name who could have a much greater impact on the sport of soccer in the coming years – Patrick Grange.Soccer header

Grange played soccer collegiately at Illinois-Chicago and New Mexico as well as several semi-professional leagues and the Chicago team in the Premier Development League. He also coached and played indoor soccer in Albuquerque.

What Grange did for soccer isn’t what could affect future generations of players. It’s what soccer might have done to him.

Patrick Grange is the first soccer player confirmed to have developed chronic traumatic encephalopathy (CTE).

Grange died in 2012 at the age of 29. Months earlier, he was diagnosed with amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrig’s disease. While ALS usually develops among people in their 50s and 60s, Grange started having symptoms as a young adult. He initially noticed a sore calf, but quickly he could not walk or feed himself. Dr. Ann McKee, the neuropathologist who studied Grange’s brain after his death, found extensive damage that she believes led to his ALS.

Also read:
Injuries likely to impact the World Cup
Recognize that concussions occur in sports other than football

What is CTE?

CTE is a degenerative brain condition characterized by the abnormal deposition of tau protein within the brain. Some researchers believe a single traumatic blow can lead to CTE, while others believe it results from repetitive subconcussive blows over time. Former athletes can manifest the disease anywhere from 8 to 20 years after retirement from sports.

Clinically CTE is characterized by psychiatric, cognitive and behavioral changes, such as depression, mood swings, impulsiveness, attention deficits and memory loss. In a February interview with The New York Times, Grange’s parents recalled that some of those symptoms appeared as early as high school. He experienced long bouts of depression. He had trouble balancing a checkbook. He left quickly for a soccer tryout without asking for time off from his job and was fired.

What makes Grange’s case more tragic is how it might have developed. His parents noted how he loved to head the ball, from as early as age 3 all the way to his days in college and pro soccer. When McKee performed her exam, she found extensive damage to his brain’s frontal lobes. While the damage corresponded with the parts of his head that would be involved in heading the ball, McKee could not definitively conclude that heading caused Grange to develop CTE.

Also read:
Repetitive heading in soccer: Does it cause brain damage after all?
Are Abby Wambach’s headers dangerous to emulate?

Can heading in soccer cause CTE?
Heading soccer ballWhether or not heading a soccer ball can cause brain injury is the subject of increasing scrutiny, but we know soccer balls can deliver significant impacts. Scientists at Imperial College London measured the forces from soccer balls traveling 18 meters per second, the average speed of a ball kicked by a nonprofessional player. The forces of the soccer headers were similar to those of punches thrown by amateur boxers.

Given these forces, we must then determine if repetitive headers over time increase the chances of long-term brain damage. A 2013 study found changes in the white matter of the brains of players who headed the ball more than 885 to 1550 times per year. The researchers found that players who headed a ball more than 1800 times per year had poorer memory scores than did players who headed the ball less often.

While 1800 headers per year might sound high, year-round soccer players who practice several times per week can reach that number quickly.

Also read:
Are soccer headers equal to punches to the head?
Would neck strengthening prevent brain damage in young soccer players?

Should headers be eliminated in soccer?

For the more than 265 million people playing soccer worldwide, Pat Grange’s death might lead to more questions than answers. Was his an isolated case of CTE? Or will more soccer players develop CTE years after their playing careers are over?

Likewise, at the youth level, we might soon need to ask whether soccer leagues should remove heading and at what age. Coaches might have to consider significantly cutting down on heading drills in practice. And much like many already do in football, parents might start weighing the risks of their children playing soccer.

Note: A modified version of this post appears as my sports medicine column in the June 12, 2014 issue of The Post and Courier.

Shawn Love and Gary S. Solomon. Talking With Parents of High School Football Players About Chronic Traumatic Encephalopathy: A Concise Summary. Am J Sports Med. Published online June 6, 2014.

Brain Trauma Extends to the Soccer Field. By John Branch. The New York Times. February 26, 2014.