Rescheduling Part 2 of the 11+ reduces injury burden and increases compliance in semi-professional football
Background & Objective
Football (soccer) is the most popular game in the world however injury incidence and burden is an ongoing problem. To address this issue, the 11+ program (formerly known as the FIFA11+) was developed and disseminated to reduce injury incidence. The 11+ program is designed as a 20-25 minute “warm-up”, consisting of three parts; Parts 1 and 3 focus on running-based activity including dynamic actions and accelerations, whereas Part 2 focuses on strengthening and neuromuscular control exercises. Extensive research has shown that injury rates can be reduced by 40% when players complete the 11+ program at least twice per week, with higher 11+ compliance and dose exposure associated with the lowest injury rates, and therefore, better 11+ program effectiveness. However, despite the proven effectiveness of the 11+ program, there continues to be issues with 11+ program implementation and adoption. Some reasons for poor adoption and compliance rates of the 11+ program include:
- The duration of the 11+ program.
- Fatigue and soreness caused by exercises contained in Part 2.
- A lack of support from the coach.
Furthermore, research has shown that the strengthening exercises performed in Part 2 of the 11+ program, are often modified or not performed.
Therefore, our research question:
What would be the impact on injury incidence and player compliance if we combined Parts 1 + 3 of the 11+ program as the “warm-up” and rescheduling Part 2 (strength and balance section) to the end of training?
Methods / What We Did
806 semi-professional football players were randomly allocated to either the standard 11+, with all 3 parts performed at the beginning of training; or a group that performed Part 2 at the end of training (P2post). Both groups performed the 11+, a minimum of 2x/week throughout an entire season. Primary data collectors (PDC) were allocated to each participating club and attended every training session and match. The PDC recorded all injury, exposure and 11+ program compliance in accordance to the Football Consensus statement. To assess the effectiveness of the 11+ program to reduce injuries in this cohort, the total injury incidence and burden for both groups was compared to the previous season (total players included in baseline season = 1041).
A total of 657 time loss injuries were recorded during 54604 hrs of football exposure across both groups. The total injury incidence was the same for both groups (P2post vs Standard 11+ = 11.8 vs 12.3 injuries/1000 h) which was 40% lower than the previous season where no 11+ program was performed (injury incidence = 20 injuries/1000h). Importantly, rescheduling Part 2 significantly increased total 11+ program compliance and dose exposure by 35%. Rescheduling Part 2 resulted in significantly lower:
- Severe injuries (time loss > 28 days)
- Non-contact injury burden
- Hamstring injury burden
- Recurrent injury burden
- Total time lost to injury
When considering specific injury incidence, rescheduling the Part 2 resulted in:
- 40% lower ankle sprain incidence (Clinical inference = Likely Beneficial)
- 30% lower hamstring muscle incidence (Clinical inference = Possibly Beneficial)
- 20% lower sprains incidence (Clinical inference = Possibly Beneficial)
- 30% lower recurrent injury incidence (Clinical inference = Likely Beneficial)
- 10% lower non-contact injury incidence (Clinical inference = Possibly Beneficial)
- 60% lower ACL incidence (Clinical inference = Unclear)
Limitations / Things to Keep in Mind
It is not possible to determine whether the increased compliance observed in the rescheduled group or the fact that the exercises were performed at the end of training were the reason for the findings of this study, with further research required to examine these factors in isolation. Additionally, the power size of the sub-classification analysis (e.g. hamstring injury) may results in some statistical issues, resulting in false positive/negative findings. To overcome this, we determined clinical inferences to allow for practical implications to be drawn from the findings. Finally, the small ACL injury sample size (8 vs 3 injuries) means the results should be approached with caution. However, all 8 ACL injuries in the standard group were non-contact, whilst the ACL injuries in the rescheduled group all involved contact.
Clinical Implications / How This Impacts Clinical Practice
- Performing the exercises contained in Part 2 of the 11+ program at the end of training directly impacts on severe injury incidence and reduces the number of days lost to injury in football.
- Compliance to the entire 11+ program was significantly increased by rescheduling and therefore overcomes some established barriers to the 11+ adoption. Importantly, manipulating the scheduling of the 11+ program did not impact on the effectiveness of the programme.
- The findings of this study provide further evidence to support the use of the 11+ program as an injury prevention program in semi-professional men’s football. In this study, injury incidence was reduced by 40%, equating to ~400 less injuries and ~2500 less days lost to injury when compared to the previous season.
- The simple strategy of rescheduling Part 2 of the 11+ program should be encouraged in practice and included in coaching education and curriculums.
- From a clinical perspective, this study also shows that performing strengthening exercises at the end of training, potentially in a fatigued state, increases the effectiveness of some exercises to reduce the burden and incidence of the most common injuries in football.
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- Thorborg K, Krommes KK, Esteve E, et al. 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 FIFA 11+ programmes. Br J Sports Med 2017;51(7):562-571.
- Silvers-Granelli HJ, Bizzini M, Arundale A, et al. Higher compliance to a neuromuscular injury prevention program improves overall injury rate in male football players. Knee Surg Sports Traumatol Arthrosc, 2018;26(7):1975-1983.
- Bizzini M, Junge A, Dvorak J. Implementation of the FIFA 11+ football warm up program: How to approach and convince the Football associations to invest in prevention. Br J Sports Med 2013;47(12):803-806.
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- Whalan M, Lovell R, McCunn R, et al. The incidence and burden of time loss injury in Australian men’s sub-elite football (soccer): a single season prospective cohort study. J Sci Med Sport 2019;22(1):42-47.
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