Sports Medicine Research: In the Lab & In the Field: The Effectiveness of “The 11” in Preventing Injuries among Male Amateur Soccer Players (Sports Med Res)
Wednesday, September 26, 2012

The Effectiveness of “The 11” in Preventing Injuries among Male Amateur Soccer Players

Effectiveness of an injury prevention programme for adult male amateur soccer players: a cluster-randomized controlled trials trial

van Beijsterveldt AMC, van de Port IGL, Krist MR, Schmikli SL, Stubbe JH, Frederiks JE, Backx FJ. Br J Sports Med. 2012, Epub Ahead of Print.

Incidence of injuries in soccer is among the highest of all team sports. FIFA developed an exercise program, called the 11, that focuses on injury prevention. This program has been tested among younger soccer players but not among male adults, which represents a large number of soccer players. Therefore, van Beijsterveldt and colleagues completed a cluster-randomized controlled trial to investigate the effectiveness of The 11 program to reduce the incidence and severity of injuries among adult male amateur soccer players. High-level amateur soccer teams from two regions in the Netherlands were invited to participate in the study. The included players were male and between 18 and 40 years old. In general, all teams had 2-3 practices and 1 match per week. A total of 487 players (on 23 teams) were randomized by team (241 players among 11 teams in the intervention (The 11 program) group, 246 players among 12 teams in control group). During the 2009-10 season all of the coaches, whose team was in the intervention group, were instructed to incorporate The11 into the warm-ups of practices at least twice a week. Exercises took approximately 10-15 minutes for the teams to perform and the exercises included core stability exercises, eccentric exercises for the thigh muscles, proprioceptive training, dynamic stabilization, and plyometric exercises. Coaches were trained in applying The 11 by the research staff, received various supplemental materials (DVD’s, posters, etc.), and attended a familiarization session prior to the start of the season. Throughout the season, researchers visited each team every month to monitor the implementation of the program. During the 2009-10 season, each individual’s exposure to soccer was recorded by the coaches and any injuries were recorded by that team’s medical coverage. Following the intervention season, a total of 31 players (18 intervention, 13 control) were lost to follow-up. The investigators analyzed the data from the remaining players and reported a total exposure time of 44,252 hrs and 427 injuries during the season. Overall, the total injury incidences between the two groups were not significantly different (intervention group: 9.6 injuries per 1000 hrs, control group: 9.7 injuries per 1000 hrs). There was also no difference between groups in regards to injury severity. There was some evidence that the incidence of knee injuries may have been lower in the intervention than the control group.

Overall, this study presents an interesting view into injury prevention among soccer players.  While this study showed that implementing The 11 program into the warm-ups of high-level amateur male soccer players did little to affect the injury incidence or severity, it had some evidence of decreasing the number of knee injuries. Unfortunately, no study has shown a similar affect among a female population, which is interesting in itself. Why has this program not had an effect on the female soccer population? Conceivably, The 11 should show some injury prevention in this population as it encompasses the type of exercises which are used in female anterior cruciate ligament (ACL) injury prevention programs (proprioception, plyometrics, etc.). If this program does not work among females, this would be particularly important for clinicians to know. Perhaps a study comparing The 11 to an ACL rupture prevention program would also be clinically helpful. It would also be interesting to record more detail regarding specific diagnosis of injuries occurred rather than categorizing by anatomic location or severity by time lost to injury. Do you have any experience with The11? Have you noticed less knee injuries after implementing an injury prevention warm-up program like The 11?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

Related Post:

van Beijsterveldt AM, van de Port IG, Krist MR, Schmikli SL, Stubbe JH, Frederiks JE, & Backx FJ (2012). Effectiveness of an injury prevention programme for adult male amateur soccer players: a cluster-randomised controlled trial. British Journal of Sports Medicine PMID: 22878257

8 comments:

Bethany said...

I do not have any experience with The11, but I am a bit surprised at these findings. The activities that The11 includes are quite similar to a number of (ACL-specific) injury prevention programs that have shown positive effects. Although these programs were specifically for the ACL, balance training, plyometrics/jump landing training, and/or a combination of these types of programs have shown increased ability to land in biomechanically advantageous positions (in terms of not injuring the ACL following the program compared to without the program).

I think that it is interesting to note, however, that while these programs show biomechanical advantages, there are mixed results on whether an actual decrease in incidence rates exists following implementation of a program like The11. More research is warranted that is applicable to more varied populations and that will shed some light on what types/combinations of exercises are most useful in injury prevention overall.

Kyle Harris said...

Bethany,

Thanks for the post! You bring up some excellent points. While I do agree that more research on various populations is needed, I would also like to see this study performed again but with a larger researcher presence. While the coaches were instructed on how to properly implement the program, this still opens the door to the possibility that the protocol was not followed in its entirety. Another option could be to utilize the medical staff of the team in question. The text suggested that each team had some type of medical coverage. Perhaps having them as observers could decrease the likelihood that the protocol would be implemented differently or incorrectly. Thanks for the post!

Natalie Reigh said...

I also found it surprising that using a preventative program had no significant effect on injury prevalence in these athletes. The article mentioned that it was effective in preventing injuries in male junior soccer players. Do you think it is possible that their is a ceiling effect involved here? I would assume that higher level athletes are already involved in strength training and conditioning programs, whereas lower level athletes may not be. Is it possible that a preventative program like this might show results in lower level athletes but not higher level athletes simply due to physical fitness level and training intensity?

Kyle said...

Natalie,

Thanks for the comment. I think you make a very good point. Perhaps there is some type of ceiling effect. One can also assume that as the athletes reach a higher level of competition, they have access to better facilities and training which could also effect injury prevention. I personally believe that the issue with this particular study was more the recording, detailing of injuries and the training of the coaches. Because researchers were not present at all practices and events, and the fact that coaches were "trained" to implement The 11, a lot of inconsistency could exist with the quality and consistency of implementing this program. I believe that the next step in truly assessing the effectiveness of this program would be to preform this study again but with a more consistent researcher presence. What do you think? Could this also explain the surprising results you noticed?

Chip W. said...

I too am surprised by these findings somewhat. However, maybe these exercises were all similar to exercises done during conditioning or in the weight room, so the benefit may be diminished. Benefits may not be seen if the warm-up that was previously done addressed these issues. Now that I read through the comments a little more, I see that Natalie addressed this. I think that through the age of 14 or so, where strength training and conditioning isn't nearly as emphasized, greater effects would be seen.

Kyle said...

Chip,

I think you bring up a good point. It is difficult in the current study to look at a specific age group with a sample that has such a wide age range. This could be very interesting to see in the future if someone could look at the differences in specific age group and how well they would react to this program. I would also imagine the training that they have done in their previous experiences would also affect the findings. If their youth coaches/clubs had them perform The 11 or even a modified version, this would greatly impact the results. The study did mention that the subjects included in this study were "high-level" soccer players so it is not out of the question to assume that they were given the best possible instruction (including injury prevention techniques). Great comment! Thank you for posting it.

Becca Burkhart said...

Like most I also found that The 11 prevention program had no significant effect on injury prevention. This study only had the teams doing the prevention program twice a week. I wonder if The 11 was preformed more frequently would it have a greater effect on injury prevention. This study showed that there was a lower amount of knee injuries in the experimental group compared to the control group. I wonder even though there is no study on whether The 11 program is beneficial for female athletes if it would still decrease the number of knee injuries?

Jeffrey Driban said...

Becca: The FIFA 11 program seems to be effective among females:
http://www.sportsmedres.org/2013/05/high-adherence-to-fifa-11-decreases-injuries.html
http://www.sportsmedres.org/2013/04/coaches-influence-adherence-injury-prevention-programs.html

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