See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/283326964

Efficacy of the FIFA 11+ Injury Prevention Program in the Collegiate Male
Soccer Player

Article in The American Journal of Sports Medicine · September 2015

DOI: 10.1177/0363546515602009

CITATIONS READS

281 2,065

9 authors, including:

Holly Silvers-Granelli Mario Bizzini

Major League Soccer Schulthess Klinik, Zürich
84 PUBLICATIONS 8,045 CITATIONS 191 PUBLICATIONS 8,990 CITATIONS

SEE PROFILE SEE PROFILE

Ryan T Pohlig Astrid Junge

University of Delaware Medical School Hamburg
150 PUBLICATIONS 2,598 CITATIONS 240 PUBLICATIONS 21,904 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Mario Bizzini on 04 July 2016.

The user has requested enhancement of the downloaded file.

 The American Journal of Sports
Medicine http://ajs.sagepub.com/

Efficacy of the FIFA 11+ Injury Prevention Program in the Collegiate Male Soccer Player
Holly Silvers-Granelli, Bert Mandelbaum, Ola Adeniji, Stephanie Insler, Mario Bizzini, Ryan Pohlig, Astrid Junge, Lynn
Snyder-Mackler and Jiri Dvorak
Am J Sports Med published online September 16, 2015
DOI: 10.1177/0363546515602009

The online version of this article can be found at:

http://ajs.sagepub.com/content/early/2015/09/15/0363546515602009

Published by:

http://www.sagepublications.com

On behalf of:
American Orthopaedic Society for Sports Medicine

Additional services and information for The American Journal of Sports Medicine can be found at:
Published online September 16, 2015 in advance of the print journal.

P<P
Email Alerts: http://ajs.sagepub.com/cgi/alerts

Subscriptions: http://ajs.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> OnlineFirst Version of Record - Sep 16, 2015

What is This?

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

 AJSM PreView, published on September 16, 2015 as doi:10.1177/0363546515602009

Efficacy of the FIFA 111

Injury Prevention Program in the
Collegiate Male Soccer Player
Holly Silvers-Granelli,*yz§ MPT, Bert Mandelbaum,y§ MD, Ola Adeniji,y MS,
Stephanie Insler,y BA, Mario Bizzini,|| PT, PhD, Ryan Pohlig,{ PhD, Astrid Junge,|| PhD,
Lynn Snyder-Mackler,z# PT, ATC, ScD, and Jiri Dvorak,|| MD
Investigation performed at Santa Monica Sports Medicine Foundation,
Santa Monica, California, USA, and the University of Delaware, Newark, Delaware, USA

Background: The Fédération Internationale de Football Association (FIFA) 111 program has been shown to be an effective injury
prevention program in the female soccer cohort, but there is a paucity of research to demonstrate its efficacy in the male
population.
Hypothesis: To examine the efficacy of the FIFA 111 program in men’s collegiate United States National Collegiate Athletic
Association (NCAA) Division I and Division II soccer.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: Before the commencement of the fall 2012 season, every NCAA Division I and Division II men’s collegiate soccer team
(N = 396) was solicited to participate in this research study. Human ethics review board approval was obtained through Quorum
Review IRB. Sixty-five teams were randomized: 34 to the control group (CG; 850 players) and 31 to the intervention group (IG; 675
players). Four teams in the IG did not complete the study, reducing the number for analysis to 61. The FIFA 111 injury prevention
program served as the intervention and was utilized weekly. Athlete-exposures (AEs), compliance, and injury data were recorded
using a secure Internet-based system.
Results: In the CG, 665 injuries (mean 6 SD, 19.56 6 11.01) were reported for 34 teams, which corresponded to an incidence
rate (IR) of 15.04 injuries per 1000 AEs. In the IG, 285 injuries (mean 6 SD, 10.56 6 3.64) were reported for 27 teams, which cor-
responded to an IR of 8.09 injuries per 1000 AEs. Total days missed because of injury were significantly higher for the CG (mean 6
SD, 13.20 6 26.6 days) than for the IG (mean 6 SD, 10.08 6 14.68 days) (P = .007). There was no difference for time loss due to
injury based on field type (P = .341).
Conclusion: The FIFA 111 significantly reduced injury rates by 46.1% and decreased time loss to injury by 28.6% in the com-
petitive male collegiate soccer player (rate ratio, 0.54 [95% CI, 0.49-0.59]; P \ .0001) (number needed to treat = 2.64).
Keywords: injury prevention; epidemiology; neuromuscular training; FIFA 111

Soccer (football) is the most widely played sport among Collegiate Athletic Association (NCAA) soccer.46 The num-
both men and women, with approximately 300 million reg- ber of participants is increasing annually, imparting a mul-
istered players globally.10,20,25 The growth of the sport in titude of positive effects with respect to emotional and
the United States (US) has been unprecedented. It is cur- physical wellness and health, and is influential in decreas-
rently the third most popularly played sport, with over ing the onset of illness and systemic disease. However, the
13 million Americans participating at the youth and adult risks associated with soccer participation have been well
levels.57 Major League Soccer (MLS) is currently in its documented.** In the past 2 decades, numerous attempts
20th season and has grown to 20 professional teams within have been made to gain a fuller understanding about the
the US and in Canada since its inception, with further mechanism of these injuries and how researchers can
expansion on the horizon.42 In addition, there are approx- reduce the incidence of such injuries.yy
imately 412,000 high school male and 23,000 collegiate Soccer-related injuries are not uncommon. There have
male soccer players participating in US National been numerous research studies published elucidating
the incidence and prevalence of soccer-related injuries in

The American Journal of Sports Medicine, Vol. XX, No. X **

References 1, 4-8, 13, 15, 17, 22, 36, 41, 43.
DOI: 10.1177/0363546515602009
yy
Ó 2015 The Author(s) References 12, 14, 16, 18, 22, 29, 30, 33, 34, 39-41, 44, 48, 50-52.

1
Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015
2 Silvers-Granelli et al The American Journal of Sports Medicine

both male and female players; recreational, amateur, perspective, prepare the athlete for competition.9,31,35,49,58
and professional players; and youth and adult play- The program has also demonstrated the ability to improve
ers.11,12,21,28,32,37,48 Researchers have also focused on var- muscular strength that may be deemed integral to injury
iations in the injury rate occurring on artificial turf prevention.18,45,50
versus grass and during tournament play versus regular- The aim of this research study was to describe the use of
season play.7,22,24,36,48 However, there is a growing body the FIFA 111 program in competitive male soccer athletes
of evidence validating the notion that injury prevention in the collegiate setting. We hypothesized that the teams
programs have the inherent ability to decrease the inci- who participated in the FIFA 111 intervention program
dence of soccer-related injuries and the time loss associated would have a lower rate of injuries and incur a reduction
with such injuries.31,49,52-55 In the past 2 decades, many in time loss due to injury in comparison to the control group.
injury prevention efforts were focused solely on female ath-
letes, namely, on anterior cruciate ligament (ACL) injury
prevention.24,29,30,33,40 Recent publications have focused METHODS
on the injury mechanisms related to male soccer players, Study Design and Recruitment
but most of the injury prevention interventions have
focused on women and girls.2,3,23,37,39,50 A prospective, cluster randomized controlled trial was con-
The rate of injuries in soccer depends on several factors: ducted in NCAA Division I and Division II men’s soccer
age, level of competition, position on the field, environmen- teams. Every athletic director, head soccer coach, and
tal setting, location of injury, time of injury, and sex. These head athletic trainer from each institution with a men’s
injuries most commonly involve the lower extremities and college Division I or II soccer program (N = 396) was con-
typically consist of mild to moderate sprains, strains, or tacted via a formal letter, an email that reiterated the writ-
contusions.27,36,56 In studies analyzing the injury rates of ten letter, and a direct telephone call. The letter and email
professional male soccer athletes, researchers have found included a hyperlink for video clips that featured former
an overall injury rate ranging from 6.2 to 13.2 injuries and current prominent US soccer players and a coach
per 1000 athlete-exposures (AEs).7,22,43 In a collegiate who discussed the nature and importance of injury preven-
analysis of male soccer injuries, the game injury rate was tion in the sport of soccer (http://vimeo.com/25708967 and
21.92 per 1000 AEs in Division I and 20.43 per 1000 AEs http://vimeo.com/25708960). The inclusion criteria included
in Division II; the practice injury rate was 4.60 per 1000 current student athletes who were participating in an
AEs in Division I and 4.40 per 1000 AEs in Division II.1 NCAA Division I or Division II member institution and, to
The Fédération Internationale de Football Association avoid participant contamination, who had not participated
(FIFA) and its Medical Assessment and Research Centre in an injury prevention program in the past 4 competitive
(F-MARC) developed injury prevention programs such as seasons. Sixty-five institutions consented to participate; par-
the ‘‘11’’ and the ‘‘FIFA 111’’ in an effort to improve ticipants from each institution ranged in age from 18 to 25
strength and reduce the incidence of all injuries incurred years. Human ethics internal review board approval was
as a result of soccer participation.10,52,55 These programs obtained through Quorum Review IRB. Before randomiza-
have been evaluated in both sexes; in recreational, amateur, tion, player consent was obtained, and a document of coach-
and semiprofessional soccer; and in court-based sports (bas- ing comprehension was signed by each institution to ensure
ketball in the study by Longo et al38).31,49,52,55,58 To address that there was a thorough understanding of the expectations
the compliance issue and perhaps some of the inadequacies of study participation. The randomization of each club was
of the therapeutic exercises initially selected for the ‘‘11’’ conducted utilizing a random number generator once every
protocol, an international group of researchers reconvened enrolled team had been identified. Upon randomization of
and restructured the ‘‘11’’ program and developed a dynamic the enrolled institutions, the intervention group (IG) received
warm-up program that addressed the major deficiencies an instructional FIFA 111 DVD, an injury prevention man-
that were deemed to be ubiquitous to soccer athletes, ual, and explanatory placards describing the FIFA 111 inter-
renamed as the ‘‘FIFA 111’’ program. The program effec- vention at length (www.f-marc.com/11plus). The control
tively reduced soccer-related injuries in multiple studies group (CG) received the identical study materials as the IG
and has been shown to optimally, from a physiological at the end of the data collection process.

*Address correspondence to Holly Silvers-Granelli, MPT, Santa Monica Sports Medicine Foundation, 11611 San Vicente Boulevard, GF-1, Los Angeles,
CA 90049, USA (email: [email protected]).
y
Santa Monica Sports Medicine Foundation, Santa Monica, California, USA.
z
Department of Biomechanical and Movement Sciences, University of Delaware, Newark, Delaware, USA.
§
Institute for Sports Sciences, Los Angeles, California, USA.
||
Fédération Internationale de Football Association (FIFA) Medical Assessment and Research Centre (F-MARC), Zurich, Switzerland.
{
Biostatistics Core Facility, College of Health Sciences, University of Delaware, Newark, Delaware, USA.
#
Department of Physical Therapy and Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA.
This article is in partial fulfillment of the doctoral dissertation for H.S.-G. at the University of Delaware.
Presented at the 40th annual meeting of the AOSSM, Seattle, Washington, July 2014.
One or more of the authors has declared the following potential conflict of interest or source of funding: H.S.-G., B.M., O.A., and S.I., as affiliates of the
Santa Monica Sports Medicine Foundation, received a grant from FIFA in the amount of $150,000 to run this large study. A large proportion of the funding
was utilized for the injury surveillance database (HealtheAthlete) and the honorariums provided to each athletic trainer at each National Collegiate Athletic
Association institution to assist in data collection.

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

Vol. XX, No. X, XXXX FIFA 111 in Male Collegiate Soccer 3

eccentric control, and proprioception; and lastly, running

Enrollment

Assessed for eligibility: N = 396 teams

• 204 NCAA Division I Teams exercises (2 minutes) to conclude the warm-up and prepare
• 192 NCAA Division II Teams the athlete for athletic participation. There are 3 levels for
Excluded (n = 331 teams)
each specific exercise (levels 1-3) that increase the diffi-
• Not meeting inclusion criteria culty for each respective exercise. This allows for both indi-
(n = 32 teams)
• Refused to participate
vidual and team progression throughout the course of the
(n = 299 teams) competitive season26 (http://f-marc.com/11plus/home/) (see
Appendix 1, available in the online version of this article
Randomized
(n = 65 teams)
at http://ajsm.sagepub.com/supplemental). In this specific
study, the FIFA 111 program served as the intervention
program over the course of 1 competitive collegiate soccer
Allocation

Allocated to intervention group Allocated to control group

(n = 31 teams) (n = 34 teams) season. The warm-up was suggested to be utilized 3 times
Received allocated intervention Followed during course of season per week for the duration of the season. In comparison,
(n = 775 athletes) (n = 850 athletes) typical soccer warm-up programs are quite heterogeneous
and typically encompass running exercises, static and/or
Follow-up

Lost to follow-up (n = 4) Lost to follow-up (n = 0)

dynamic stretching, movements involving change of direc-
Discontinued intervention: 4 Division II All control teams remained in
teams (100 players) due to time and completed the study tion, and short passing. They typically average from 5 to 45
constraints during training minutes in duration. The average warm-up program does
not typically emphasize qualitative movement.9,10
Analysis

Intervention group Control group

Analyzed: 27 teams (675 players) Analyzed: 34 teams (850 players)
Division I: 16 teams (400 players) Division I: 17 teams (425 players)
Division II: 11 teams (275 players) Division II: 17 teams (425 players) Exposure, Injury Data Entry, and Compliance
Upon consenting to participate in the study, each team
Figure 1. Description of National Collegiate Athletic Associ- provided a roster to be entered into the HealtheAthlete
ation team randomization and study flow. injury surveillance system. The surveillance system was
a web-based system that was a data-secured, Health
An Internet-based injury surveillance system (Health- Insurance Portability and Accountability Act (HIPAA)–
eAthlete) was utilized by every enrolled institution. Every compliant site that utilized the Verisign secure second-
AE, incurred injury, utilization of the FIFA 111 program, factor logon feature. The injury and exposure data for
and compliance data were entered weekly by the team’s each player on the roster were entered by the team’s
certified athletic trainer (ATC) and verified by the research ATC. All injuries were entered weekly by the ATC and
staff. Sixty-one institutions completed the study during the were verified and crosshatched with his or her institu-
fall 2012 season (August-December): 34 control institu- tional injury surveillance system at the end of the compet-
tions (n = 850 athletes) and 27 intervention institutions itive season. The ATC indicated on which days the FIFA
(n = 675 athletes) (Figure 1). Demographic information, 111 program was completed and which athletes partici-
including age, position played, and leg dominance, was pated in the training. The NCAA calendar was entered
also collected. Upon the completion of the season, the for each respective club to delineate the full soccer sched-
injury data entry was confirmed by each ATC and batched ule, which commenced in August 2012 and ended in
with his or her individual institution’s data collection sys- December 2012 (contingent upon the success of the institu-
tem for accuracy and thoroughness. During the course of tion in the NCAA playoff tournament). No unique identi-
the season, the individual compliance of the program was fiers that would reveal the identity of the team or the
monitored by the research team weekly. In the event athlete were visible to any of the research staff.
that compliance within the IG was deemed less than opti- The operational definition for an AE was participation
mal, a member of the research team contacted the team to in any team practice or game during preseason or in-
encourage improvements in compliance. season. We decided to use AEs over hours of playing time
secondary to the NCAA substitution rules.47 An injury
was defined as any physical complaint sustained by
a player that resulted from a football match or football
Intervention Program training, irrespective of the need for medical attention or
time loss from football. An injury resulting in a player
The FIFA 111 is an injury prevention program designed as
receiving medical attention was referred to as a ‘‘medical
an alternative warm-up program to address lower extrem-
attention’’ injury and an injury that resulted in a player
ity injuries incurred in the sport of soccer for athletes older
being unable to take full part in future football training
than 14 years.10 It is a 20-minute program that is utilized
or match play as a ‘‘time-loss’’ injury.27
on the field without any additional or onerous equipment
necessary, and it consists of 15 exercises divided into 3 sep-
arate components: running exercises (8 minutes) that Statistical and Data Analyses
encompass cutting, change of direction, decelerating, and
proper landing techniques; strength, plyometric, and bal- All statistical analyses were conducted utilizing SPSS for
ance exercises (10 minutes) that focus on core strength, Windows version 22. Descriptive and inferential tests

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

4 Silvers-Granelli et al The American Journal of Sports Medicine

TABLE 1
Player and Injury Characteristics for the Control and Intervention Groupsa

Control Group (n = 34 Teams) Intervention Group (n = 27 Teams)

No. of players 850 675

Division I 425 (17 teams) 400 (16 teams)
Division II 425 (17 teams) 275 (11 teams)
Age, mean 6 SD, y 20.68 6 1.46 20.40 6 1.66
No. of AEs
Total 44,212 35,226
Games 13,624 10,935
Practices 30,588 24,291
Injuries by position, n (%)
Defender 204 (30.68) 92 (32.28)
Forward 132 (19.85) 67 (23.51)
Midfielder 256 (38.50) 101 (35.44)
Goalkeeper 73 (10.98) 25 (8.77)
Total injuries, n (mean 6 SD) 665 (19.56 6 11.01b) 285 (10.56 6 3.64b)
Division I injuries, n (% of total) 355 (53.4) 198 (69.5)
Mean 6 SD 22.19 6 12.0 9.9 6 3.11
Division II injuries, n (% of total) 310 (46.6) 87 (30.5)
Mean 6 SD 17.22 6 10.03 12.43 6 4.61
Game injuries, n (%) 392 (58.9) 185 (64.9)
Mean 6 SD 11.53 6 5.84b 6.85 6 3.17b
Practice injuries, n (%) 273 (41.1) 100 (35.1)
Mean 6 SD 8.03 6 6.24b 3.70 6 2.13b
IR per 1000 AEs
Total 15.04 8.09
Games 28.77 16.92
Practices 8.93 4.01
Days lost to injury
n (mean 6 SD) 8790 (13.20 6 26.6b); 2944 (10.08 6 14.68b);
SE = 1.09 SE = 0.96
Time loss, n (% of injuries)
No time loss 201 (30.2) 104 (36.5)
1-3 d 126 (18.9) 31 (10.9)
4-7 d 94 (14.1) 43 (15.1)
8-29 d 164 (24.7) 81 (28.4)
30 d 80 (12.0) 26 (9.1)

a
AE, athlete-exposure; IR, incidence rate.
b
P \ .001.

were used to compare the CG and IG, including t tests, x2 (44%) who had 35,226 (44%) AEs (games: 10,935; practices:
tests, and generalized linear regression models, with a logit 24,291). The CG had a significantly higher number of inju-
link function and Poisson distribution for count data. Two ries per team (mean 6 SD, 19.56 6 11.01) compared with
generalized linear regression models (Biostatistics Core that of the IG (mean 6 SD, 10.56 6 3.64) (t(59) = 4.07; P
Facility, University of Delaware) were used to test if there \ .001; Cohen d = 1.16). The number of participants who
was a significant difference in the number of days missed needed to be exposed to the intervention to reduce 1 injury
because of injuries between the IG and CG and, secondly, in the IG (number needed to treat [NNT]) was 3. The mean
to test if the number of days missed because of injuries utilization of the FIFA 111 in the IG was 32.78 6 12.13
was different for athletes who had used the FIFA 111 on doses over the course of the season. There was no signifi-
the day of the injury. All injuries that occurred throughout cant difference between the age of the injured athletes
the fall 2012 soccer season were analyzed by location, dura- (IG: 20.40 6 1.66 years; CG: 20.68 6 1.46 years), nor was
tion, and turf type (grass vs artificial turf). there a difference in the number of injured athletes based
on player position (Table 1).
When the data were stratified by division of play (I or II)
RESULTS and for game and practice, the Division I CG had a signifi-
cantly higher number of game injuries (n = 200 [56.3%];
The CG consisted of 850 athletes (56%) in 34 teams (56%) mean 6 SD, 12.5 6 5.51; incidence rate [IR], 29.36) com-
who had 44,212 (56%) AEs (games: 13,624; practices: pared with Division I IG game injuries (n = 122 [61.6%];
30,588). The IG consisted of 675 athletes (44%) in 27 teams mean 6 SD, 6.13 6 2.47; IR, 18.83) (P = .000038) (see

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

Vol. XX, No. X, XXXX FIFA 111 in Male Collegiate Soccer 5

TABLE 2
Total Injury Counts for the Control and Intervention Groupsa

Control Group (n = 850) Intervention Group (n = 675)

No. of IR per % of Total No. of IR per % of Total Rate Ratio
Area Injuries 1000 AEs Injuries Injuries 1000 AEs Injuries (95% CI) NNT

Ankle 115 2.601 17.3 59 1.675 20.7 0.65 (0.48-0.87) 21

Knee 102 2.307 15.3 34 0.965 11.9 0.42 (0.29-0.61) 14
Head 61 1.380 9.1 31 0.880 10.9 0.64 (0.4203-0.9743) 39
Hamstring 55 1.244 8.3 16 0.454 5.6 0.37 (0.21-0.63) 24
Foot 49 1.108 7.4 22 0.625 7.7 0.57 (0.35-0.93) 40
Groin 48 1.086 7.2 23 0.653 8.1 0.60 (0.37-0.98) 45
Hip 45 1.018 6.8 16 0.454 5.6 0.45 (0.26-0.79) 34
Quadriceps 44 0.995 6.6 25 0.710 8.8 0.72 (0.44-1.16) 68
Leg 39 0.882 5.9 25 0.710 8.8 0.08 (0.49-1.32) 113
Shoulder 30 0.679 4.5 6 0.170 2.1 0.25 (0.1054-0.6016) 38
Spine 30 0.679 4.5 9 0.255 3.2 0.38 (0.18-0.79) 46
Hand 10 0.226 1.5 6 0.170 2.1 0.76 (0.28-2.07) 348
Torso 10 0.226 1.5 9 0.255 3.2 1.13 (0.46-2.77) 638
Elbow 9 0.204 1.4 2 0.057 0.7 0.25 (0.05-1.15) 114
Wrist 7 0.158 1.1 0 0.000 0.0 0.01 (0.001-0.017) 121
Neck 6 0.136 0.9 1 0.028 0.4 0.21 (0.025-1.73) 179
Chest 3 0.068 0.5 0 0.000 0.0 0.004 (0.0026-0.01) 283
Arm 1 0.023 0.2 1 0.028 0.4 1.26 (1.179-20.1) 3279
Forearm 1 0.023 0.2 0 0.000 0.0 1.25 (0.078-20.1) 3279
Total 665 100.0 285 100.00

a
AE, athlete-exposure; IR, incidence rate; NNT, number needed to treat.

Appendix 2, available online). There was a similar outcome 3

for Division I and Division II practices. There was a signif- IR Control
icant difference between the Division I CG practice injuries 2.5
Injury Rate per 1000 AEs

IR Intervenon
(n = 155 [43.7%]; mean 6 SD, 9.69 6 7.6; IR, 10.13) com-
2
pared with Division I IG practice injuries (n = 76
[38.4%]; mean 6 SD, 3.44 6 1.86; IR, 5.146) (P = .0027). 1.5
There was also a significant difference between the Divi-
sion II CG practice injuries (n = 118 [38.1%]; mean 6 SD, 1
6.56 6 4.42; IR, 7.72) compared with Division II IG practice
0.5
injuries (n = 24 [27.6%]; mean 6 SD, 3.14 6 1.57; IR, 2.36)
(P = .0457). There was no significant difference found 0
est
kle

ow
s
ad i p

rm
ine

ck
ee
Ha ead

Fo m
oin
ot
ng

nd

ist
rso

between the CG and IG in Division II game injuries (see

Sh eg
r
ep

lde
H

Ar
Ne
Fo

Wr
Kn

tri

Ha
An

Ch

rea
Elb
Sp
Gr

To
ric
H

ou
ms

Appendix 2).
Qu

The injury rates were significantly lower in the IG when Injury Type
stratified for type of injury as well (Table 2 and Figure 2).
The highest number of reported injuries in both the CG Figure 2. Injury rate per 1000 athlete-exposures (AEs) clas-
and IG were ankle injuries. The CG reported 115 ankle sified by type and stratified by group.
injuries, accounting for 17.3% of the total CG injuries
(IR, 2.601), compared with 59 ankle injuries in the IG
(20.7% of total injuries; IR, 1.675; rate ratio [RR], 0.65 injuries. There were 55 hamstring injuries reported in
[95% CI, 0.48-0.87]). Knee-related injuries were the second the CG (8.3%; IR, 1.244) compared with 16 in the IG
highest reported injury for both groups. The CG reported (5.6%; IR, 0.454), accounting for a 2.74-fold reduction in
102 total knee injuries (15.3%; IR, 2.307) compared with the likelihood of incurring a hamstring injury (RR, 0.37
34 in the IG (11.9% of total injuries; IR, 0.965; RR, 0.42 [95% CI, 0.21-0.63]; NNT = 24; P \ .001).
[95% CI, 0.29-0.61]; NNT = 14). When the data were strat- A Poisson regression was used to compare the total
ified for type of knee injury, there were 16 ACL injuries number of days missed between groups, IG versus CG,
reported in the CG (2.4%; IR, 0.362) and 3 ACL injuries and for field types (grass vs turf) because the number
in the IG (1.1%; IR, 0.085), accounting for a 4.25-fold of days missed is a count variable and normality was vio-
reduction in the likelihood of incurring an ACL injury lated for both groups. The overall model was significant
(RR, 0.236 [95% CI, 0.193-0.93]; NNT = 70; P \ .001). A (likelihood ratio [LR] x2(2) = 263.06; P \ .001). There
similar trend was seen with respect to acute hamstring was a significantly higher number of days missed in the

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

6 Silvers-Granelli et al The American Journal of Sports Medicine

associated with the sport of soccer. In this study, the prin-

12
Injury Rate per 1000 AEs

cipal finding in this randomized controlled trial was that,

10
by virtue of utilizing the FIFA 111, there was an overall
8
reduction of injuries in the IG by 46.1%, demonstrating
6 the decreased likelihood of an athlete in the IG being
4 injured (RR, 0.54 [95% CI, 0.49-0.59]; P \ .0001; NNT =
2 2.64). This is consistent with other studies that have
0 elucidated the efficacy of the 111 in similar popula-
Low (1-19) Moderate (20-39) High (>40)
tions.31,49,52,55 There was a statistically significant reduc-
Compliance (ulizaons during season) tion in injuries with respect to individual injuries (IR,
15.04/1000 AEs [CG] vs 8.09/1000 AEs [IG]; P \ .001)
Figure 3. Injury rates in relationship to compliance with the and in relation to injuries per team (mean injuries/team:
FIFA 111 program. AE, athlete-exposure. 19.56 [CG] vs 10.56 [IG]; P \ .001). This reinforces the
findings of other authors, elucidating the protective benefit
CG (mean 6 SD, 13.20 6 26.6 days) than in the IG of the FIFA 111 program for both men and women.
(mean 6 SD, 10.08 6 14.68 days) (Wald x2(2) = 7.35; b = When the data were analyzed for division of play (Divi-
0.34; SE = 0.12; P = .007); for each day missed in the IG, 1.4 sion I or II), there were significant reductions in the IG for
days were missed in the CG (odds ratio [OR], 1.40). The total Division I game (IR, 29.36 [CG] vs 18.83 [IG]; P = .000038)
number of days missed because of injuries was 8790 in the CG and practice injuries (IR, 10.13 [CG] vs 5.146 [IG]; P =
compared with 2944 in the IG. There was no difference in .0027) and Division II practice injuries. There was no sta-
either group for days missed based on field type (Wald x2(2) tistical difference in Division II game injuries, but a trend
= 0.91; b = 0.13; SE = 0.14; OR, 1.15; P = .341). for injury reduction in this cohort was apparent (P = .3762)
A second Poisson regression was used for those who (see Appendix 2). This injury distribution with respect to
were in the IG to compare the number of days missed if level of play and game versus practice injury is consistent
the injury occurred on a day when the intervention was with the existing literature.1,21,23,31
used. The model was significant (LR x2(2) = 6.02; P \ The FIFA 111 program was first tested in female soccer
.049). There was a significantly higher number of days players in Norway. Soligard et al52 conducted a cluster
missed when the intervention was not used on the day of randomized controlled trial in 125 female youth soccer
injury (mean 6 SD, 10.65 6 15.35 days) than when it clubs in Norway (aged 13-17 years): 65 teams in the IG
was used (mean 6 SD, 6.56 6 10.44 days) (Wald x2(1) = (n = 1055) and 60 teams in the CG (n = 837) followed the
4.26; b = 4.08; SE = 1.98; P = .039). There was no difference protocol for 1 season (8 months). During the season, 264
in the number of days missed in the IG based on field type players had relevant injuries: 121 players in the IG and
(Wald x2(1) = 0.90; b = 2.10; SE = 2.21; P = .343). 143 in the CG (RR, 0.71 [95% CI, 0.49-1.03]). In the IG,
there was a significantly lower risk of injuries overall
(RR, 0.68 [95% CI, 0.48-0.98]), overuse injuries (RR, 0.47
Compliance [95% CI, 0.26-0.85]), and severe injuries (RR, 0.55 [95%
CI, 0.36-0.83]). This indicates that a structured warm-up
Compliance of the intervention was analyzed and stratified
program can prevent injuries in young female soccer
by utilization consistency. Compliance was determined to
players.
be low (LC: 1-19 doses/season), moderate (MC: 20-39
In a small cohort study conducted of men’s collegiate
doses/season), or high (HC: .40 doses/season). The mean
soccer in the US, Grooms et al31 utilized the FIFA 111
(6SD) utilization per team was 30.47 6 12.16 FIFA 111
intervention for 1 Division III soccer team (N = 41; aged
sessions. There were 54 injuries in 4 teams reported in
18-25 years). The first season served as the referent sea-
the LC group (mean, 13.5 doses/season [range, 10-19
son, and the second season served as the intervention
doses/season]; IR, 10.353 6 2.21), 156 injuries in 14 teams
assessment. The injury rate in the referent season was
in the MC group (mean, 11.14 doses/season [range, 21-39
8.1 injuries per 1000 AEs with 291 days lost and 2.2 inju-
doses/season]; IR, 8.545 6 2.46), and 75 injuries in 9 teams
ries per 1000 AEs and 52 days lost in the intervention
in the HC group (mean, 8.33 doses/season [range, 40-64
assessment season. The intervention assessment season
doses/season]; IR, 6.39 6 2.71). There was a statistically sig-
demonstrated reductions in the relative risk of lower
nificant difference reached, and an inverse relationship
extremity injuries of 72% (RR, 0.28 [95% CI, 0.09-0.85])
between the utilization compliance of the FIFA 111 and
and time lost to lower extremity injuries (P \ .01). Despite
the injury rate was identified (P = .034). The greater the
the small sample size, there was a statistically significant
team compliance to the program, the lower the injury rate
reduction in the injury rate and time lost to injury. The
within that respective cohort (Figure 3).
researchers noted excellent compliance and adherence to
the program and benefited from direct oversight from an
ATC at every exposure.
DISCUSSION A recent study investigated the efficacy of the FIFA 111
in a male soccer cohort in the African Laos Junior League.
The FIFA 111 was designed as a concise and comprehen- Owoeye et al49 utilized the FIFA 111 intervention in a clus-
sive warm-up program to address lower extremity injuries ter randomized trial in 20 teams (N = 416 players:

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

Vol. XX, No. X, XXXX FIFA 111 in Male Collegiate Soccer 7

intervention = 212 players, control = 204 players) over the intervention teams [223 players] and 12 control teams
course of 6 months. In total, 130 injuries were recorded, [233 players]) showed a significant difference in the
affecting 104 (25%) of the 416 players. The FIFA 111 pro- incidence of knee injuries but not in overall injuries (9.6
gram significantly reduced the overall rate of injuries in injuries/1000 athlete-hours [95% CI, 8.4-11.0] for the inter-
the intervention group by 41% (RR, 0.59 [95% CI, 0.40- vention and 9.7 injuries/1000 athlete-hours [95% CI, 8.5-
0.86]; P = .006) and all lower extremity injuries by 48% 11.1] for the control), despite having good compliance
(RR, 0.52 [95% CI, 0.34-0.82]; P = .004). However, the (73% compliance rate for teams and 71% for players).58
rate of injury reduction based on secondary outcomes ‘‘The 11’’ program was subsequently revamped into ‘‘The
mostly did not reach the level of statistical significance. 111’’ to address the inadequacies in the former program’s
The FIFA 111 program has been shown to be an effi- components.
cient means of achieving optimal physiological readiness
for sport.9,35 The program has also been shown to increase
muscle activation in the rectus abdominis, gluteus medius, Compliance
and gluteus minimus immediately after completing the
A variable worthy of discussion, which may positively or
program, corroborating its effect on core activation.45
negatively affect the efficacy of a neuromuscular injury
Daneshjoo et al18 analyzed the effect of the FIFA 111 on
prevention intervention, is the role of compliance. It has
knee strength in male competitive soccer players. Quadri-
been demonstrated that compliance is inversely corre-
ceps and hamstring strength was assessed after 24 ses-
lated with the injury rate; the more regularly the neuro-
sions of utilizing the FIFA 111 program in U-21 male
muscular training programs are implemented, the lower
soccer players (N = 36); concentric quadriceps peak torque
the reported injury rate.52 High adherence to injury pre-
increased by 27.7% at 300 deg/s in the dominant leg (P \
vention programs, specifically the FIFA 111, resulted in
.05), and concentric hamstring peak torque increased by
lower injury rates in a Canadian youth female soccer
22%, 21.4%, and 22.1% at 60, 180, and 300 deg/s, respec-
cohort (incidence rate ratio, 0.28 [95% CI, 0.10-0.79]).53
tively, in the dominant leg and by 22.3% and 15.7% at 60
In contrast, when compliance and adherence to a program
and 180 deg/s, respectively, in the nondominant leg com-
are diminished, the propensity of the prevention program
pared with the control group.
to be effective is limited as well.55 In this current study,
The results in the aforementioned articles suggest that
there was an inverse relationship between the injury
consistent utilization of a neuromuscular training pro-
rate and compliance; as compliance increased, injury
gram, such as the FIFA 111, may impart a protective ben-
rates subsequently decreased with statistical significance
efit to the soccer athlete by achieving an optimal state of
(P = .034) (Figure 3). It is critical to effectively communi-
physiological preparedness for soccer competition and suf-
cate the importance of the regularly scheduled implemen-
ficient biomechanical training to offset the risk of injuries
tation of programs such as the FIFA 111 to fully impart
associated with soccer participation.
their benefits to the soccer community at large.

Evolution of the Program Program Dissemination

Steffen et al55 attempted to reduce the incidence of ACL The NCAA FIFA 111 program was delivered without
injuries by using a set of exercises known as ‘‘The 11.’’ It direct contact to the ATC at each respective institution
was a cluster randomized controlled trial to test the effi- because of the wide geographic expanse of the randomized
cacy of the ‘‘11’’ on the injury risk in female soccer players groups. The researchers relied solely on video, DVD, and
(IA, 59 teams; n = 1091) compared with a control group printed materials to ensure proper implementation of the
(CA, 54 teams; n = 1001). A total of 396 players (20%) sus- program with a proper biomechanical technique. The fact
tained 483 injuries. There was no difference in the overall that the ATC was the point person for FIFA 111 delivery
injury rate between the IA (3.6 injuries/1000 athlete-hours as well as injury collection is a strength of the study, as
[95% CI, 3.2-4.1]) and CA (3.7 injuries/1000 athlete-hours ATCs are highly qualified and well-educated members of
[95% CI, 3.2-4.1]; RR, 1.0 [95% CI, 0.8-1.2]; P = .94), nor the multidisciplinary medical team. The subject of pro-
was there a difference in the IR for type of injury. The gram delivery has been the source of debate in the litera-
training program was utilized during 60% of the soccer ture.10,29,51,52,54,55 Steffen et al53 examined the effect of
training sessions in the first half of the season, but only different delivery methods on compliance and injury rates
14 of 58 intervention teams completed more than 20 pre- in youth soccer. Teams that had supervision and had
vention training sessions throughout the course of the sea- access to a coach-focused workshop demonstrated greater
son. The researchers noted no effect of the injury adherence to the FIFA 111 program compared with the
prevention program on the injury rate perhaps because control teams, who only had access to the educational web-
of the exercises not being specific enough to address the site (85.6% and 81.3%, respectively; control, 73.5%). Play-
biomechanical deficiencies present in this population. Fur- ers with high adherence to the FIFA 111 program had
thermore, the low compliance rates among the interven- a 57% lower injury risk, but this was not statistically sig-
tion teams could have negatively affected the prevention nificant. This research demonstrates that despite financial
benefit. However, a study analyzing the efficacy of ‘‘The and geographic limitations associated with the multicul-
11’’ in adult male amateur players (N = 23 teams; 11 tural and global appeal of the sport of soccer, the factor

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

8 Silvers-Granelli et al The American Journal of Sports Medicine

that remains critical to optimal injury prevention outcomes found a statistically significant difference between compli-
is imploring coaching and training staff to regularly utilize ance groups in relation to the injury rate. Even in the LC
such programs on a weekly basis. IG teams (n = 4; range, 10-19 doses), the athletes demon-
Another factor to consider with implementation is the strated an injury rate significantly lower than that of the
timing of the intervention during the course of training. CG teams (IR, 10.353 6 2.21 [LC], 8.545 6 2.46 [MC],
The PEP program and the FIFA 111, among others, have 6.39 6 2.71 [HC] vs 15.04 6 11.01 [control]; P = .034). In
been designed as dynamic warm-up programs to be utilized continents with extensive geographic expanse, such as
before training.10,40,52 The rationale behind this method of North and South America, Africa, and Australia, research-
delivery is to increase compliance, as warm-ups are consis- ers may often depend on the electronic dissemination
tently utilized in the sport of soccer, and to neuromuscularly of medical information and program implementation.
prepare the athlete for training in a nonfatigued state. Although the authors contend that direct contact with
When a neuromuscular training program is delivered, it coaches and players is optimal, electronic educational dis-
should be performed with a proper biomechanical tech- semination has been shown to be effective and cost effi-
nique. If the exercises are performed in a fatigued state, cient. In spite of the anonymous delivery system utilized
or with a poor or inconsistent biomechanical technique, in this study, the program was initiated during the presea-
a pathokinematic motor pattern may be neuromuscularly son portion of the season and continued throughout the
reinforced. A study that utilized an injury prevention pro- duration of the season with significant reductions in inju-
gram after training, in a fatigued state, and devoid of ries and time loss due to injury. The authors contend,
a strength element was largely unsuccessful in reducing from a public health perspective, that the ease and gener-
the rate of ACL injuries across 3 sports.51 alizability of the program and the ability to deliver and dis-
seminate the injury prevention message meaningfully and
effectively over a vast geographic area are strengths of the
Limitations program.

There are several factors to consider with respect to the

methodological limitations of the study. The study was Future Directions
only conducted over the course of a single NCAA competi-
tive season (August-December 2012). The average Division There have been several research studies that have illumi-
I and II teams have 18 and 18 games and 51 and 52 prac- nated the protective benefit of utilizing the FIFA 111 pre-
tices, respectively, throughout the course of the season.1,19 vention program as a viable alternative to an existing
Because of the truncated nature of the collegiate season, it warm-up protocol. There have been notable reductions in
is often challenging to impart the full neuromuscular ben- injury rates in both male and female soccer players, and
efit of such a program because of the short duration of the time loss due to injury had been significantly reduced by
season compared with domestic professional and European virtue of utilizing the FIFA 111 program. To fully under-
leagues (9- to 10-month season). In addition, training stand the biomechanical changes imparted by the FIFA
for the study was accomplished remotely via a website 111 through the kinematic chain, a thorough biomechani-
(www.f-marc.com/11plus), an educational video clip cal motion analysis before and after utilization among men
(Vimeo), an instructional DVD, a manual, and a PDF post- and women in various age groups and levels of competition
er detailing the elements and progression of the FIFA 111. would be warranted and is being conducted at the present
There was no direct contact or training with each individ- time.
ual institution or the team ATC because of the wide geo-
graphical expanse of the study population. However, the
ATC was responsible for initiating each session at his or CONCLUSION
her respective institution and for entering the injury
data in a medical database. The ATC served as a highly The FIFA 111 was shown to reduce injury rates and time
qualified medical professional who vastly improved the loss due to injury in the competitive male collegiate soccer
quality of the data entered into the HealtheAthlete secure player in a statistically significant manner. The more con-
system.19 In a recent study, various FIFA 111 implemen- sistently the program was utilized, the greater the injury
tation strategies were investigated in a cluster randomized prevention benefit imparted to the athlete. The benefits
controlled trial. The study compared (1) unsupervised, of sport participation are numerous and far outweigh the
website-directed FIFA 111 implementation with a compre- risks associated with such. However, the likelihood of
hensive coach-focused workshop (2) with and (3) without incurring an injury by virtue of participating in soccer
regular supervision by a physical therapist. The research- should not be underestimated. As clinicians, it is integral
ers found that teams in the comprehensive and regular to our collective ethos to recognize the risks associated
interventions demonstrated greater compliance, which with sport and to profess the merits of prevention protocols
was not statistically significant. Players with higher com- that have been presented in the peer-reviewed literature.
pliance to the program showed lower injury rates, which This information may successfully reduce the incidence of
were not shown to be statistically significant either.54 sport-related injuries in a meaningful way. As researchers,
However, this may speak to the overall effectiveness and we will continue to set our sights higher to improve the
generalizability of the program. In this current study, we quality and efficacy of the prevention programs available

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

Vol. XX, No. X, XXXX FIFA 111 in Male Collegiate Soccer 9

to the athletic community. We recognize and embrace the 13. Brophy R, Silvers HJ, Gonzales T, Mandelbaum BR. Gender influen-
need for program compliance and further randomized con- ces: the role of leg dominance in ACL injury among soccer players.
Br J Sports Med. 2010;44(10):694-697.
trolled trials to elucidate the epidemiology, mechanism of
14. Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention of anterior
injury(s), and ultimate reduction and prevention of sport- cruciate ligament injuries in soccer: a prospective controlled study of
related injuries. proprioceptive training. Knee Surg Sports Traumatol Arthrosc.
1996;4(1):19-21.
15. Centers for Disease Control and Prevention. Nonfatal sports- and
ACKNOWLEDGMENT recreation-related injuries treated in emergency departments: USA,
July 2000-June 2001. MMWR. 2000;51:736-740.
The researchers would like to thank all of the NCAA Divi- 16. Cerulli G, Benoit DL, Caraffa A, Ponteggia F. Proprioceptive training
and prevention of anterior cruciate ligament injuries in soccer. J
sion I and Division II certified athletic trainers, coaching
Orthop Sports Phys Ther. 2001;31(11):655-660.
staff, and players who participated in this study. They 17. Chandy TA, Grana WA. Secondary school athletic injury in boys and
are incredibly appreciative of the time, dedication, and girls: a three year comparison. Phys Sportsmed. 1985;13:106-111.
compliance of these participants to this important body of 18. Daneshjoo A, Mokhtar AH, Rahnama N, Yusof A. The effects of injury
research. The authors also thank Conrad Von Grebel prevention warm-up programmes on knee strength in male soccer
(Von Grebel Motion AG, Zurich, Switzerland) for his gener- players. Biol Sport. 2013;30(4):281.
ous assistance in filming the video necessary for partici- 19. Dick R, Agel J, Marshall SW. National Collegiate Athletic Association
Injury Surveillance System commentaries: introduction and methods.
pant recruitment, and Dennis Granelli for his statistical
J Athl Train. 2009;42(2):173-182.
assistance in the refinement of this manuscript. 20. Dvorak J, Junge A. F-MARC Football Medicine Manual: 1994-2005.
Zurich: Fédération Internationale de Football Association; 2005:81-93.
21. Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccer injuries:
REFERENCES supervision by doctor and physiotherapist. Am J Sports Med.
1983;11(3):116-120.
1. Agel J, Evans TA, Dick R. Descriptive epidemiology of collegiate 22. Ekstrand J, Hägglund M, Fuller CW. Comparison of injuries sustained
men’s soccer injuries: National Collegiate Athletic Association Injury on artificial turf and grass by male and female elite football players.
Surveillance System, 1988-1989 through 2002-2003. J Athl Train. Scand J Med Sci Sports. 2010;21(6):824-832.
2007;42(2):270-277. 23. Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Pre-
2. Alentorn-Geli E, Mendiguchı́a J, Samuelsson K, et al. Prevention of vention of injuries among male soccer players: a prospective, ran-
anterior cruciate ligament injuries in sports, part I: systematic review domized intervention study targeting players with previous injuries
of risk factors in male athletes. Knee Surg Sports Traumatol Arthrosc. or reduced function. Am J Sports Med. 2008;36(6):1052-1060.
2014;22(1):3-15. 24. Faude O, Junge A, Kindermann W, Dvorak J. Injuries in female soc-
3. Alentorn-Geli E, Mendiguchı́a J, Samuelsson K, et al. Prevention of cer players: a prospective study in the German national league. Am J
non-contact anterior cruciate ligament injuries in sports, part II: sys- Sports Med. 2005;33:1694-1700.
tematic review of the effectiveness of prevention programmes in 25. Fédération Internationale de Football Association. 270 million people
male athletes. Knee Surg Sports Traumatol Arthrosc. 2014;22(1):16- active in football. 2006. Available at: http://www.fifa.com/mm/docu
25. ment/fifafacts/bcoffsurv/bigcount.statspackage_7024.pdf. Accessed
4. Arendt E, Dick R. Knee injury patterns among men and women in col- October 25, 2014.
legiate basketball and soccer: NCAA data and review of the literature. 26. Fédération Internationale de Football Association. FIFA 111 website.
Am J Sports Med. 1995;23(6):694-701. 2014. Available at: http://f-marc.com/11plus/home/. Accessed Octo-
5. Azubuike OS, Okojie HO. Epidemiology of soccer injuries in Benin ber 25, 2014.
City, Nigeria. Br J Sports Med. 2009;43(5):382-386. 27. Fuller C, Ekstrand J, Junge A, et al. Consensus statement on injury
6. Bailey R, Erasmus L. Incidence of injuries among male soccer players definitions and data collection procedures for studies of injuries in
in the first team of the University of the Free State in the Coca Cola football (soccer) injuries. Clin J Sport Med. 2006;16(2):97-106.
League: 2007/2008 season. SA J Sports Med. 2009;21(1):3-6. 28. Fuller C, Junge A, DeCelles J. ‘‘Football for Health’’: a football-based
7. Bengtsson H, Ekstrand J, Hägglund M. Muscle injury rates in profes- health-promotion programme for children in South Africa. A parallel
sional football increase with fixture congestion: an 11-year follow-up cohort study. Br J Sports Med. 2010;44:546-554.
of the UEFA Champions League injury study. Br J Sports Med. 29. Gilchrist J, Mandelbaum B, Melancon H, et al. A randomized con-
2013;47(12):743-747. trolled trial to prevent noncontact anterior cruciate ligament injury
8. Beynnon BD, Vacek PM, Newell MK, et al. The effects of level of in female collegiate soccer players. Am J Sports Med. 2008;36(8):
competition, sport, and sex on the incidence of first-time noncontact 1476-1483.
anterior cruciate ligament injury. Am J Sports Med. 2014;42(8):1806- 30. Griffin LY, Albohm MJ, Arendt EA, et al. Understanding and prevent-
1812. ing noncontact anterior cruciate ligament injuries: a review of the
9. Bizzini M, Impellizzeri FM, Dvorak J, et al. Physiological and perfor- Hunt Valley II Meeting, January 2005. Am J Sports Med. 2006;34(9):
mance responses to the ‘‘FIFA 111’’ (part 1): is it an appropriate 1512-1532.
warm-up? J Sports Sci. 2013;31(13):1481-1490. 31. Grooms DR, Palmer T, Onate JA, Myer GD, Grindstaff T. Soccer-
10. Bizzini M, Junge A, Dvorak J. Implementation of the FIFA 111 foot- specific warm-up and lower extremity injury rates in collegiate male
ball warm up program: how to approach and convince the football soccer players. J Athl Train. 2013;48(6):782-789.
associations to invest in prevention. Br J Sports Med. 2013;47(12): 32. Hägglund M, Waldén M, Ekstrand J. Lower reinjury rate with a coach-
803-806. controlled rehabilitation program in amateur male soccer: a random-
11. Blatter S. FIFA’s Injuries to Women. Health and Fitness for the Female ized controlled trial. Am J Sports Med. 2007;35(9):1433-1442.
Football Player: A Guide for Players and Coaches. Zurich: Fédération 33. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of
Internationale de Football Association; 2007. neuromuscular training on the incidence of knee injury in female ath-
12. Bollars P, Claes S, Vanlommel L, Van Crombrugge K, Corten K, Bel- letes: a prospective study. Am J Sports Med. 1999;27(6):699-706.
lemans J. The effectiveness of preventive programs in decreasing the 34. Hewett TE, Myer GD, Ford KR. Reducing knee and anterior cruciate
risk of soccer injuries in Belgium: national trends over a decade. Am J ligament injuries among female athletes: a systematic review of neu-
Sports Med. 2014;42(3):577-582. romuscular training interventions. J Knee Surg. 2005;18(1):82-88.

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

10 Silvers-Granelli et al The American Journal of Sports Medicine

35. Impellizzeri FM, Bizzini M, Dvorak J, Pellegrini B, Schena F, Junge A. 47. National Collegiate Athletic Association. Rules of the game: NCAA
Physiological and performance responses to the FIFA 111 (part 2): soccer officiating center circle. Available at: http://ncaasoccer.arbi
a randomised controlled trial on the training effects. J Sports Sci. tersports.com/front/106254/Site/Area/Rules-of-the-Game. Accessed
2013;31(13):1491-502. October 29, 2014.
36. Junge A, Dvorak J. Soccer injuries: a review on incidence and pre- 48. Östenberg A, Roos H. Injury risk factors in female European football:
vention. Sports Med. 2004;34(13):929-938. a prospective study of 123 players during one season. Scand J Med
37. Junge A, Rösch D, Peterson L, Graf-Baumann T, Dvorak J. Preven- Sci Sports. 2000;10:279-285.
tion of soccer injuries: a prospective intervention study in youth ama- 49. Owoeye OB, Akinbo SR, Tella BA, Olawale OA. Efficacy of the FIFA
teur players. Am J Sports Med. 2002;30(5):652-659. 111 warm-up programme in male youth football: a cluster rando-
38. Longo UG, Loppini M, Berton A, Marinozzi A, Maffulli N, Denaro V. mised controlled trial. J Sports Sci Med. 2014;13(2):321-328.
The FIFA 111 program is effective in preventing injuries in elite 50. Petersen J, Thorborg K, Nielsen MB, Budtz-Jørgensen E, Hölmich P.
male basketball players: a cluster randomized controlled trial. Am J Preventive effect of eccentric training on acute hamstring injuries in
Sports Med. 2012;40(5):996-1005. men’s soccer: a cluster-randomized controlled trial. Am J Sports
39. Malinzak RA, Colby SM, Kirkendall DT, Yu B, Garrett WE. A compar- Med. 2011;39(11):2296-2303.
ison of knee joint motion patterns between men and women in 51. Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee liga-
selected athletic tasks. Clin Biomech. 2001;16(5):438-445. ment injury prevention program on the incidence of noncontact ante-
40. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of rior cruciate ligament injury. J Bone Joint Surg Am. 2006;88:1769-
a neuromuscular and proprioceptive training programme in prevent- 1774.
ing anterior cruciate ligament injuries in female athletes: 2-year 52. Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up
follow-up. Am J Sports Med. 2005;33:1003-1010. programme to prevent injuries in young female footballers: cluster
41. McLean SG, Huang X, Su A, Van Den Bogert AJ. Sagittal plane bio- randomised controlled trial. BMJ. 2008;337:a2469.
mechanics cannot injure the ACL during sidestep cutting. Clin Bio- 53. Steffen K, Emery CA, Romiti M, et al. High adherence to a neuromuscu-
mech. 2004;19(8):828-838. lar injury prevention programme (FIFA 111) improves functional balance
42. MLSsoccer.com. Expansion, refs, Cascadia: MLS Commissioner and reduces injury risk in Canadian youth female football players: a clus-
Don Garber covers it all in annual address. February 27, 2013. ter randomised trial. Br J Sports Med. 2013;47(12):794-802.
Available at: http://www.mlssoccer.com/news/article/2013/02/27/ 54. Steffen K, Meeuwisse WH, Romiti M, et al. Evaluation of how different
expansion-refs-cascadia-commissioner-garber-covers-it-all-march- implementation strategies of an injury prevention programme (FIFA
soccer-addre. Accessed October 27, 2014. 111) impact team adherence and injury risk in Canadian female
43. Morgan B, Oberlander M. An examination of injuries in Major youth football players: a cluster-randomised trial. Br J Sports Med.
Soccer League: the inaugural season. Am J Sports Med. 2001;29: 2013;47:480-487.
426-430. 55. Steffen K, Myklebust G, Olsen OE, Holme I, Bahr R. Preventing inju-
44. Myklebust G, Engebretsen L, Braekken IH, Skjølberg A, Olsen OE, ries in female youth football: a cluster-randomized controlled trial.
Bahr R. Prevention of anterior cruciate ligament injuries in female Scand J Med Sci Sports. 2008;18(5):605-614.
team handball players: a prospective intervention study over three 56. Torg JS, Stilwell G, Rogers K. The effect of ambient temperature on
seasons. Clin J Sport Med. 2003;13(2):71-78. the shoe-surface interface release coefficient. Am J Sports Med.
45. Nakase J, Inaki A, Mochizuki T, et al. Whole body muscle activity dur- 1996;24(1):79-82.
ing the FIFA 111 program evaluated by positron emission tomogra- 57. US Census Bureau. Participation in selected sports activities: 2009.
phy. PLoS One. 2013;8(9):e73898. Available at: http://www.census.gov/compendia/statab/2012/tables/
46. National Collegiate Athletic Association. Estimated probability of 12s1249.pdf. Accessed November 2014.
competing in athletics beyond the high school interscholastic level. 58. van Beijsterveldt AM, van de Port IG, Krist MR, et al. Effectiveness
Available at: https://www.ncaa.org/sites/default/files/Probability-of- of an injury prevention programme for adult male amateur soccer
going-pro-methodology_Update20123.pdf. Accessed October 28, players: a cluster-randomised controlled trial. Br J Sports Med.
2014. 2012;46(16):1114-1118.

For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav

Downloaded from ajs.sagepub.com by HOLLY SILVERS on September 17, 2015

View publication stats