Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes
Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Br J Sports Med. 2017 Apr;51(7):562-571. doi: 10.1136/bjsports-2016-097066. Epub 2017 Jan 13.
Take Home Message: The FIFA 11+ program reduces injury rates in recreational and sub-elite soccer players.
There are a variety of training programs to prevent injury in athletics, particularly in soccer. Many of these programs target anterior cruciate ligament (ACL) injury prevention but these programs are also able to reduce the risk of injury in general. The FIFA Medical Assessment and Research Centre (F-MARC) created the FIFA 11 and 11+ programs to reduce injury and allow for continued participation in soccer. While various investigators have implemented these programs, their effects on injury have been conflicting. Therefore, the authors conducted a meta-analysis to pool data from individual studies to increase our ability to precisely estimate the possible effects of these programs. Initially, the authors identified 4,842 results and screened them for eligibility. Six studies met the inclusion criteria of being randomized control trials or cluster randomized control trials that compared FIFA injury prevention programs with a control (no intervention or sham intervention). Two of the studies used the FIFA 11 program and four studies used the revised FIFA11+ program, which is expanded and more detailed regarding exercise inclusion and progression. The pooled results of all six studies showed that the programs offered a 25% reduction in injury. The authors also looked at the studies with the FIFA 11 and 11+ separately. Trials with the FIFA 11+ program resulted in a 39% decrease in injury compared with the FIFA 11 program that resulted in no decrease in injury. Specifically, the FIFA 11+ program reduced the number of injuries at the hamstrings by ~60%, hip/groin by ~41%, knee by ~48%, and ankle by 32%. These positive effects on injury reduction were achieved even though < 15% of teams completed the recommended frequency of at least two sessions per week.
The FIFA 11+ program is a more complete program from several perspectives than the original FIFA 11. The 11+ program offers greater detail with a variety of strength, plyometric, running and agility drills, as well as exercise progression. While it is not surprising that the more complete FIFA 11+ is more effective it is interesting that the magnitude of change between the FIFA 11 and FIFA 11+ programs was so large. While these authors show that implementing the FIFA 11+ program can be beneficial in reducing soccer-related injuries the study did not examine effects on specific types of injury. This limitation is important as ACL injury prevention is often thought of when looking at injury prevention programming due to the large expenses and time lost from these injuries as well as modifiable risk factors of non-contact injuries. Regardless, the authors definitively show positive effects on injury and the benefits of FIFA 11+. The program is beneficial even though only a few teams met the recommended frequency of twice per week for the program. Hence, we may be underestimating the amount of injury reduction that we could achieve with improved compliance. Ultimately the results of the meta-analysis provide strong evidence that FIFA 11+ programming should be widely adopted. The vast numbers of youth and adolescents participating in soccer provides a great opportunity for implementation of this program and the ability to successfully impact injury and prolong participation.
Questions for Discussion: What effect does the program instructor have on compliance, exercise performance, and effectiveness; i.e. does implementation by sport coach/parents have the same effect as direction from professionals (AT, PT, Strength Coach)? Can future studies with improved compliance show an even larger reduction in injury?
Written by: Adam Lake
Reviewed by: Jeffrey Driban