Injury prevention works – and improves functional balance! ~ Kathrin Steffen, PhD

To our knowledge, an international joint study recently published online by the BJSM is the first to show that a neuromuscular training program can not only reduce injury risk, but also improve performance.1

The four-month randomized controlled trial in Canadian female adolescent football corroborates the original FIFA 11+ works of Soligard et al.2,3 and also supports the extensive effort of Myklebust´s more than 10 years of implementation work in Norwegian handball.4 The message is clear  –injury prevention training works!

Kathrin Steffen_CSM blog 170413

Good news for players and coaches

And the news gets better. In the Canadian project, better functional balance was found for those players who highly adhered to the prescribed exercises during season compared to those with fewer exercises even though the latter also displayed a lower injury risk.1

For football players, proper functional balance and body control are essential to efficiently position themselves in relation to the opponent and to control and pass the ball before being challenged by the opposing player.5 The current investigation has a clear message: twenty minutes of regular structured warm-up exercises improves your balance performance and helps you to stay healthy.

The coach is crucial to the implementation of successful injury prevention strategies

The study also sends another strong message: “you have to take the ‘medicine’, if you want to see an effect.” Adherence is key!  The challenge is that winning and performance are prime factors for coaches and players and it can be difficult to convince them to spend twenty minutes on injury prevention warm-up exercises.  We all have heard the arguments for not doing these exercise programs: “takes too long”, “is boring”, “has no performance benefits”, “is too difficult”, and there are easily more barriers to add.

This reluctance is a crucial barrier to overcome in the realization of injury prevention training as best practice warm-up routines.6,7 Motivating coaches and players to follow exercise programs, such as the FIFA 11+,2 the Swedish “Knäkontroll” (knee control)8 or the PEP program,9 is more likely easier if they are seen as providing direct performance benefits and not just preventing injuries.

Proper coach education is key.6,7,10

Coaches are integral to the successful implementation of injury prevention warm-up exercises; and now that we know that the FIFA 11+ study also improves players´ performance this should be an easy buy-in: convince coaches to use structured warm-up exercises regularly. It is a cheap and easy investment in player´s health and performance!

For more information on the principles of injury prevention turn to Chapter 9 in Clinical Sports Medicine.

Kathrin is a senior researcher at the Oslo Sports Trauma Research Center (OSTRC) in Norway. Her primary research field is sports injury prevention, with focus on community sports and ACL research. Presently, she leads the outreach activities of the OSTRC. Kathrin is also the Assistant Editor for the IOC journal British Journal of Sports Medicine Injury Prevention and Health Protection and involved in other IOC driven research projects.


1) Steffen K, Emery CA, Romiti M, et al. High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in Canadian youth female football players: a cluster randomised trial. Br J Sports Med 2013 Apr 4. [Epub ahead of print]

2) Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ 2008 Dec 9;337.

3) Soligard T, Nilstad A, Steffen K, et al. Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med 2010;44(11):787-93.

4) Myklebust G, Skjølberg A, Bahr R. ACL injury incidence in female handball 10 years after the Norwegian ACL prevention study: important lessons learned. Br J Sports Med 2013 Feb 12. [Epub ahead of print]

5) Soligard T, Grindem H, Bahr R, et al. Are skilled players at greater risk of injury in female youth football? Br J Sports Med 2010;44(15):1118-23.

6) Saunders N, Otago L, Romiti M, et al. Coaches’ perspectives on implementing an evidence-informed injury prevention programme in junior community netball. Br J Sports Med 2010;44(15):1128-32.

7) Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br J Sports Med 2010;44(13):973-8.

8) Waldén M, Atroshi I, Magnusson H, et al. Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. BMJ 2012 May 3;344.

9) Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33(7):1003-10.

10) Steffen K, Meeuwisse WH, Romiti M, et al. Evaluation of how different implementation strategies of an injury prevention programme (FIFA 11+) impact team adherence and injury risk in Canadian female youth football players: a cluster-randomised trial. Br J Sports Med 2013 Mar 13. [Epub ahead of print]

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