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
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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The largest barrier I have seen to program compliance is buy in from the head coach, strength coach, and players. The athletes that I have encountered are usually more open and accepting to the idea of an injury prevention program that is utilized as a dynamic warmup. However, most of my student athlete contact is with injured athletes, so my experience is skewed. Strength coaches I have encountered are typically hesitant to give up control their warmup and want to utilize their own concepts for warmups. If the strength coach is not in control of the warmup the team coach typically runs the athletes through the routine. From my experience and observation coaches want to control the on-field sporting activities. By relinquishing control of the field to the ATC, for activity unrelated to acute injury I believe head coaches would feel threatened unless they were educated and had significant buy in.
Since my experience is limited, I have yet to see any strategies that have been effective in creating buy-in for injury prevention. The one strategy I could foresee as having a large positive impact would be an educational presentation at the beginning of every calendar year to the coaching staff, athletes, and strength and conditioning coach. If you could educate the coaching staff on the benefits of a prevention program and quantify games saved from injury, I believe they would see the value in the program. If you quantify the economic value, and time lost to injury to the student athlete and Athletic director I also believe there would be significant by in from both the school, university, coaching staff, and athlete.
I strongly agree with the authors summary that failure of the program to prevent injury was due to compliance. Recent research conducted by Thorborg K,Krommes KK, Esteve E,et al. Br J Sports Med 2017;51:562–571 placed the injury prevention rates near 40%. I also agree with the viewpoint that we need to find methods to increase compliance. Whether compliance is improved it’s through education, manipulation (such as splitting the program into two sessions), or sport specialization further research must be conducted to improve athlete compliance if the impact is as severe as it appears.
A major barrier to implementing injury prevention program compliance it due to the rejection from coaches and players. A lot of coaches are very set in their ways especially if season has already started. They do not like change or implementing new things. Even if the student athletes are open to the idea of implementing an injury prevention program, ultimately the coaches have the final say on whether or not it occurs. I agree with the author on the idea that compliance is a large issue with reducing risk of injury. Research is constantly brining light to new ideas, however these old time coaches are going to implement the same things they have been doing every year. I haven’t really found any strategies that have been effective to get players, coaches, etc to buy into new things.
As an ATS who has primarily done clinical hours in different high schools, compliance is a HUGE issue. Especially with young athletes and strict coaches. Through my experiences, coaches are very strict methods to how they run practices and how they optimize the time they have with their athletes to get the best results. Although it should be quite obvious that implementing an injury prevention program for their athletes would only be beneficial, we would be “interrupting” the time coaches have with their athletes. I have found that trying to com up with an extra 30 minutes into their practice time instead of trying to take over the time they already have preset. I have seen that students are very willing to take the extra step to try to prevent any injuries because of their dedication to sport and not wanting to miss any game time, but ultimately their loyalty is to there coaches. These programs are worth then fight to get students to comply and getting coaches on board as well. I strongly agree that the failure of the Fifa 11+ was to compliance.
At WABAdevelopment.com we have implemented our own WABA Dynamic 12 warm up. We are seeing 90%+ self compliance as we expect athletes to show up early to execute. We have developed it to be done in a 6’x12’ space or larger, without a partner, and the last 3 exercises are with ball. It takes 6-8 minutes and is suggested to double the exercise time for U15 and older. Our goal is compliance and habit building at U9-U14. We teach proper form and highlight how each exercise dovetails into game play. This helps with athlete buy in.