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The Prevention of Soccer-Related Injuries: an Exploration of the 11+ Injury Prevention Program and its Implementation

 

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The Prevention of Soccer-Related Injuries: an exploration of the 11+ injury prevention program and its implementation 

Created by: Mollie Pathman, SPT

Background:

My passion for the prevention of soccer-related injuries began during my experience as a collegiate and professional soccer player. As a player, I witnessed countless soccer injuries and saw first hand the devastating consequences of these injuries. My interest in the prevention of soccer-related injuries grew over the past six years through my work as a one-on-one soccer coach.  The players themselves and their parents have expressed concern regarding soccer-related injuries and the lack of prevention available to them. 

Throughout the UNC DPT curriculum, we have discussed the importance and value of preventative medicine. Given my passion for soccer, I was motivated to explore the literature on injury prevention for soccer players. For the Evidence-Based Practice II course, I completed a critically appraised topic regarding the efficacy of an injury prevention program, the 11+, in preventing anterior cruciate ligament injuries. I expanded on this as part of the advanced orthopedic assessment class, where I reviewed the evidence regarding the prevention of ACL injuries in soccer players, focusing on common mechanisms of ACL injuries. 

This coursework and my passion for soccer drew me to seek a deeper understanding of the research regarding the prevention of soccer-related injuries as well as potential barriers to adoption, implementation, and compliance with existing protocols. It also served as motivation to conduct a free injury prevention clinic for local coaches and players. 

Statement of Need:

Soccer is one of the most popular sports in the world with an estimated 265 million people participating globally.1 It is one of the most widely growing sports in the United States.2 Over 17 million people in the US alone participate in organized soccer.2 Playing soccer places an athlete at an increased risk of injury. Soccer is associated with a rate of injury of between 14-35 injuries per 1,000 game hours or 2-8 injuries per 1,000 practice hours.2 High-school aged athletes are at elevated risk of injury.5 One injury of particular interest for soccer players is anterior cruciate ligament (ACL) injuries. ACL injuries account of roughly 1.3% of injuries in male soccer players and 3.7% in female soccer players.1  Soccer-related injuries are associated with significant financial and psychological costs as well as time missed from competition, increased risk of re-injury and poor team performance.5-9 Khodaee et al. evaluated the injury rates among US high school players and concluded that attention to and implementation of injury prevention programs is critical given the high rates of non-concussion injuries among their studied population.3

The high school aged players that I coach have identified a lack of injury prevention strategies implemented as part of their club and school soccer training routines.  They have expressed interest in learning about actions they can take decrease their risk of injury. I also spoke with one of the directors of a local soccer club, North Carolina FC. He corroborated the present issue with soccer-related injuries and identified a need for prevention strategies implemented at a larger scale.

Overview/Purpose:

The “11+” injury prevention program was developed by the FIFA Medical Assessment and Research Center (F-MARC) in response to the alarming rates of injuries among soccer players.4 It was released as a free educational tool for coaches, players, trainers and medical staff.4 It is designed as a warmup progression for amateur players 14 years and older, and its recommended to be utilized at least twice a week.4 F-MARC reports that “Teams that performed the ’11+’ regularly at least twice a week had 37% fewer training injuries and 29% fewer match injuries, and severe injuries were reduced by almost 50%.”4 The warmup system is predicated on the correct performance of each the 15 exercises, and takes approximately 20 minutes to complete.4 A shortened version with just the running exercises (12 minutes) should be performed before games.4

The primary focus of this capstone project was to determine the efficacy of the 11+ on reducing the rate of soccer-related injuries generally and to quantify the impact compliance has on the effectiveness of the program. Additionally, I aimed to identify facilitating factors and potential barriers to compliance through the review of the literature and direct feedback from local coaches and players. The aim of this project is to provide a framework for soccer future injury prevention clinics for coaches and youth players. The capstone project also is intended for physical therapists and physical therapy students as a model for implementing injury prevention using the RE-AIM framework.

Products:

  • 11+ Evidence Table addressing the following research questions: 1) What is the efficacy of the “11+” injury prevention program in reducing soccer-related injuries in amateur soccer players? 2) Does compliance impact the efficacy of the “11+”  program? 3) What are potential barriers to the implementation of “11+”? This evidence table was designed for health care providers who work with amateur soccer players.
  • PowerPoint presentation designed to serve as a clinical resource for physical therapists, physical therapy students, and athletic trainers who work with high school level soccer players. The presentation consolidates the information gathered from the evidence appraisal, outlined in the evidence table, and feedback I received from youth players and coaches following an injury prevention clinic.
  • Free injury prevention clinic for local high school aged players and coaches. The injury prevention program included a PowerPoint presentation outlining the risk of soccer-related injuries, the efficacy of the 11+ and importance of compliance to maximizing these effects. This PowerPoint presentation is designed to supplement player/coach education on the 11+ injury prevention protocol. Players and coaches were also instructed in the 11+ protocol. Coaches had the opportunity to instruct players through the program. This presentation also includes a  summary handout of the 11+ protocol and additional resources

Evaluation:

Throughout the process of developing my evidence table and PowerPoint presentations, I utilized feedback from my committee members to improve each of my products. Following the injury prevention clinic, I sought feedback from the players and coaches (Feedback form for 11+ Clinic ) regarding the achievement of presentation objectives and general perceptions of the 11+ injury prevention program. This feedback was compiled and provided a framework for modifying the injury prevention clinic in future renditions. The feedback regarding the facilitators and barriers to compliance with the 11+ was consistent with the literature. I summarized this feedback in my presentation designed for health care providers.

I plan to present my PowerPoint as an inservice presentation during my last clinical rotation at a sports physical therapy practice. I developed a feedback form (inservice PT feedback form) to help determine if my learning objectives were met, the relevance of the information provided and the quality of the delivery of the information. I anticipate this feedback will help me improve my products and my skills as a presenter.

Self-Reflection:

Through this project, I have expanded my knowledge of the 11+ injury prevention program and its efficacy in the prevention of soccer-related injuries. I have also developed a better understanding of the risk and consequences of soccer-related injuries. I feel prepared to educate players, coaches, parents and health care providers regarding injury prevention in youth soccer. I have also gained a better understanding of the multiple factors impacting reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of the 11+ protocol and injury prevention programs more generally. This understanding came from the appraisal of research and feedback from my 11+ injury prevention clinic. 

I have developed a framework for soccer injury prevention clinics which I hope to continue running after graduation. Through this project, I gained valuable feedback about conducting injury prevention clinics and ways to improve my presentation in future iterations. Based on the feedback I received, in future models of the 11+ injury prevention clinic, I will instruct the players and coaches separately, use video demonstrations, and have a follow-up on the field session. Through this experience, I learned concrete ways that health care providers, coaches, and soccer administrators could work within the RE-AIM framework to increase the effectiveness of the 11+ and ultimately reduce the risk of injuries for amateur soccer players. 

Overall, I am very excited about the final products created through my capstone project. I am thankful for the personal learning experience this project has provided. I developed skills in finding and appraising evidence and implementing evidence into practice. This experience also helped me to build invaluable connections with clinicians who specialize in the management and treatment of soccer players and local coaches and players. 

Acknowledgments:

I would like to express my appreciation, and gratitude to everyone who assisted me with the development of this project. I would like to personally thank my committee advisor Michael Gross, PT, PhD for your expertise and professional guidance throughout this project. Thank you for providing direction and feedback through every step of the process. I would also like to thank my committee members, Michael Messer, PT, DPT, SCS, and Brian Diaz, PT, CSCS for volunteering your time, and sharing your clinical expertise in the prevention and management of soccer-related injuries. Your experiences as soccer players, coaches and physical therapists were invaluable. Thank you for sharing your passion for soccer and for your commitment to providing the highest quality preventative care. I cannot thank you three enough for your willingness to share your knowledge and experiences. I would also like to thank the players and coaches who attended the 11+ injury prevention clinic for your time, effort and feedback. Your feedback served as a crucial learning experience. 

References:

  1. Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc 2009;17(7):705-729. doi:10.1007/s00167-009-0813-1.
  2. Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum 2004;50(10):3145-3152. doi:10.1002/art.20589.
  3. Khodaee M, Currie DW, Asif IM, Comstock RD. Nine-year study of US high school soccer injuries: data from a national sports injury surveillance programme. Br J Sports Med 2017;51(3):185-193. doi:10.1136/bjsports-2015-095946.
  4. FIFA Medical Assessment and research centre, Bizzini M. A complete warm-up programme to prevent injuries.
  5. Pfirrmann D, Herbst M, Ingelfinger P, Simon P, Tug S. Analysis of injury incidences in male professional adult and elite youth soccer players: A systematic review. J. Athl. Train. 2016;51(5):410-424. doi:10.4085/1062-6050-51.6.03.
  6. Marshall DA, Lopatina E, Lacny S, Emery CA. Economic impact study: neuromuscular training reduces the burden of injuries and costs compared to standard warm-up in youth soccer. Br. J. Sports Med.2016;50(22):1388-1393. doi:10.1136/bjsports-2015-095666.
  7. Padaki AS, Noticewala MS, Levine WN, Ahmad CS, Popkin MK, Popkin CA. Prevalence of posttraumatic stress disorder symptoms among young athletes after anterior cruciate ligament rupture. Orthop. J. Sports Med. 2018;6(7):2325967118787159. doi:10.1177/2325967118787159.
  8. Silvers-Granelli H, Mandelbaum B, Adeniji O, et al. Efficacy of the FIFA 11+ injury prevention program in the collegiate male soccer player. Am J Sports Med 2015;43(11):2628-2637. doi:10.1177/0363546515602009.
  9. Hägglund M, Waldén M, Magnusson H, Kristenson K, Bengtsson H, Ekstrand J. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. Br. J. Sports Med. 2013;47(12):738-742. doi:10.1136/bjsports-2013-092215

Photo by Jeffrey F Lin – https://images.unsplash.com/photo-1528162841823-9e55a8cc2f58?ixlib=rb-1.2.1&q=80&fm=jpg&crop=entropy&cs=tinysrgb&w=1152&fit=max&ixid=eyJhcHBfaWQiOjk4MDV9

5 Responses to “The Prevention of Soccer-Related Injuries: an Exploration of the 11+ Injury Prevention Program and its Implementation”

  1. Mollie Pathman

    Kelly, David, Elise, and Debbie, thank you all for your encouraging feedback. I appreciate you taking the time to look through my project. Thank you for the well wishes.
    Kelly – glad to hear that you had some experience with injury prevention being administered at the high school level. Seems like your experience is similar to many others with a lack of buy-in from stakeholders. Still promising to hear that it was something people were considering. Hopefully, the recent advances in research and dissemination of programs such as the 11+ can help increase compliance and adoption of injury prevention across youth sports.
    David – I think you identified one of my main takeaways from performing this project. There are so many people involved when considering injury prevention and education needs to be directed at multiple levels.
    Elise – Sorry to hear about the conflicting information you received while recovering and returning to sport after your injuries. I am hoping that I can use this project in the future to help direct the focus of prevention towards evidence-based practice. One aspect that I like about the 11+ is how easy it can be to implement and instruct. It puts a lot of the burden on the players and coaches, who are directly being affected by the injuries.

    Thank you all again – I have enjoyed reading all your posts and have learned so much. It is so inspiring to see everyone’s unique interests and how they plan to build on their knowledge in the service of the profession or public.

    Reply

  2. Debbie Thorpe

    Mollie
    A wonderful project with great resources for PTs and coaches! Good luck with your in service. This is such important information for coaches, especially so that they can work on injury prevention at earlier ages.

    Reply

  3. Elise Widman

    Mollie overall this project is excellent and as David mentions addresses the needs of so many stakeholders in the process. With the risk of injury falling on adolescents, the need for education and evidence to convince those overseeing training and development programs is essential in order to prevent injury and this project is well suited to meet that need. As someone who worked with a large number of doctors, therapists, coaches, and athletic trainers after each of my injuries I can speak to the variability in treatment methods and advice on prevention, exercise and causes that were communicated to me which resulted in a confusing and I’m sure less than optimal recovery process. Its clear that your exposure to the population and prevalence of the condition drove your motivation and I hope you meet a receptive audience when communicating the value of prevention programs. Your work clearly makes a case for valuing the evidence over theoretical intervention or guru techniques based in isolated instances of success, which is an important theme in the world of athletics. Congratulations on your work and good luck in your last clinical, where ever you end up will be so lucky to have you!

    Reply

  4. David Morse

    Mollie,
    You have done such a good job with your Capstone! I really enjoyed reading it after talking to you about it a bit during PT advocacy day. I think that you have identified a really important and timely preventative approach to knee injury in female athletes in particular who are at such high risk for knee injury in sport. Your analysis and implementation of existing guidelines is great certainly needed, as an often-neglected aspect of sport training. You had mentioned that this is a known issue that has not been addressed for several issues by various stakeholders for various reasons. One of which is the reluctance to take practice time to perform these activities. I know you have identified key components to the knee injury exercise regimen which are most effective at reducing players likelihood of experiencing a knee injury. I think that your work at identifying these components is key to your successful implementation of these programs giving you the best change to prevent knee injury. I think that it is wonderful that you are going to try and carry this work forward after graduation through continued implementation of the 11+ injury prevention clinic. I know your last rotation is in a sports orthopedics location and am so excited by the prospect of you practicing in this field. I think that your interest in sports is going to make you a great therapist and a wonderful advocate for athletes participation in injury prevention.
    David

    Reply

  5. kadams17

    Mollie,
    Wow! It is clear that you put a lot of time and effort into implementing this capstone project. Your finished products were completed in a clear, concise manner that highlight the importance of injury prevention in this population and important factors to consider when presenting this program to sports teams. Reading your site reminded me of injury prevention programs that I performed in high-school through my soccer club. In theory, the program administered by my club was a good idea, but participation was optional and it basically just consisted of 30 minutes of plyometrics. As your project states, compliance is a huge factor in decreasing the rate of injury, requiring coaches, parents, and players to be dedicated to performing the program at the correct frequency in order to benefit. Your passion for soccer and connectedness to the local soccer community is perfect for executing your project, which could be continued for years. Through the information presented in your product, it is my hope that coaches will begin taking injury prevention more seriously. In addition, younger players with collegiate level and beyond aspirations in soccer could understand the potential repercussions associated with orthopedic injuries such as ACL injuries, and see the benefit of this program. Best of luck to you in all of your endeavors! Your commitment to education and success (and soccer!) has been evident throughout the program, and I know you will be victorious in whatever your future holds.

    Reply

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