Implementation of the FIFA 11+ Injury Prevention Program by High School Athletic Teams Did Not Reduce Lower Extremity Injury

Sluaterbeck J, Cohquette R, Tourville TW, Krug M, Mandelbaum BR, Vacek P, & Beynnon B.  Am J Sports Med. 2019; 47(12): 2844-2852. DOI:10.11111/sms.13532

Take-Home Message

The FIFA 11+ program failed to reduce lower extremity injury rates versus a standard warm-up among high school athletes, probably because 2 out of 3 teams failed receive the recommended number of training sessions/week. We need better implementation strategies to ensure compliance with injury prevention programs.


The FIFA 11+ program can reduce the number of injuries among elite soccer and basketball athletes (see related posts below). However, we know little about well the FIFA 11+ works among athletes in various high school sports. Therefore, the authors conducted a cluster randomized trial to investigate the efficacy of the FIFA 11+ program across multiple sports at the high school level.  These authors recruited 14 out of 15 high schools across the northern portion of New England that employed an athletic trainer for at least 25 hours/week, were near the research facility, and had at least 6 out of 7 sports of interest (football and men’s and women’s soccer, basketball, and lacrosse).  During the year prior to the study, the authors trained 44 volunteers to observe warm-ups to note if any teams performed exercises that were part of the FIFA 11+ program. The authors also collected injury exposure risk, time loss, and types of injuries sustained during this year.  Next, half of the schools completed the FIFA 11+ as instructed by their coach and half continued to perform their usual warm-up programs.  The research team met with athletic trainers, athletic directors, and coaches to educate them on implementation of the program.  Each school was also paired with a research volunteer within a related field who could help address questions.  Coaches and athletic trainers were contacted weekly to assess FIFA 11+ implementation, compliance, and athletic exposures and lower extremity injuries.  The coaches were asked to use the full program at every practice; except the day before a game when they could implement a modified program. The athletic trainer at each school recorded details on any lower extremity injury.   

Coaches reported completing the full FIFA 11+ ~1.45 times per week. More specifically, 62% of the coaches reported that their team completed the FIFA 11+ once/week, while only 32% reported completing the program at least twice a week. The authors found no differences between the FIFA 11+ and control groups for injury rates (1.6 versus 1.5 injuries per 1000 athlete exposures). These findings were supported when the authors looked at each specific body location of injury, sport, level of play or sex.


Overall, the authors found that the FIFA 11+ program failed to prevent injuries among high school athletes competing in football, soccer, or lacrosse. The program likely failed because only 32% of teams met the recommendations to complete prevention training programs at least 2 times per week. We previously reported that compliance is critical to the success of the FIFA 11+.  Ultimately, this study should remind clinicians that we need to find strategies to optimize the implementation of preventive training programs by modifying the FIFA 11+ program or allowing coaches to tailor a program to their team. For example, another research team found that completing part 2 of the FIFA 11+ after practice improved compliance. Alternatively, the Osteoarthritis Action Alliance is developing an injury prevention toolkit, “Remain in the Game”, which will help coaches develop an injury prevention program tailored to their needs.  The authors also noted that logistical issues may have hindered compliance. For example, many high school athletes change sports, teams, or coaches during an academic year because the average high school season is 12 weeks long while a 10 week training program is recommended.  This also supports the idea of implementing injury prevention programs during physical education classes. While these researchers found that the FIFA 11+ program failed to reduce the risk of lower extremity injury probably because of poor compliance this should be a reminder to sports medicine clinicians that we need to work with our coaches to find an injury prevention program that works for them to ensure better compliance. .

Questions for Discussion

What specific barriers have you seen to injury prevention program compliance?  Are there any strategies that you have found to be effective at creating buy-in for injury prevention programs?

Written by: Nicole M. Cattano
Reviewed by: Jeffrey Driban

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What if I told you… compliance is key to reducing injuries