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Effective Injury Prevention in Soccer

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 Clinical features

Effective Injury Prevention in Soccer

Donald T. Kirkendall, PhD; Jiri Dvorak, MD

Abstract: Sports participation is accompanied by risk of injury, and each specific sport has its own unique injury profile.
One of the goals of a sports medicine professional is injury prevention, and the past decade has seen numerous reports
on the outcomes of injury-prevention studies. Health care professionals have been particularly vigilant in attempting to
reduce common injuries in soccer, beginning with work in the early 1980s to the rigorous randomized trials of today. The
use of a structured, generalized warm-up program has been shown to be effective in preventing common soccer injuries,
reducing overall injury rates by approximately 30%. Given the number of individuals who play soccer worldwide, any injury
reductions will likely have an impact on public health. It is an important goal of the sports medicine community to inform
physicians and other sports medicine professionals about the effectiveness of prevention programs to increase use and
compliance.
Keywords: soccer; injury prevention; randomized trials; ligament sprains; muscle strains

Donald T. Kirkendall, PhD 1 Introduction

Jiri Dvorak, MD 1
Soccer is unquestionably the most popular participant and spectator sport in the world. The statistics
FIFA Medical Assessment
1
representing soccer’s influence and outreach are impressive:1
and Research Center
(F-MARC), Schulthess Clinic,
Zürich, Switzerland • There are > 250 million registered players worldwide.
• The international governing body of soccer, the Fédération Internationale de Football Associa-
tion (FIFA), has more member nations than the United Nations.
• The FIFA World Cup Web site received 4.2 billion Web page views during the 1-month com-
petition in 2006.
• The 2006 FIFA World Cup Germany was broadcast in 214 countries.
• The estimated cumulative number of television viewers for the entire 2006 FIFA World Cup
Germany was 26.29 billion.
• 715 million viewers watched Italy’s overtime win over France in the 2006 final.

No other single sport or event comes close to the impact soccer has worldwide. In June 2010, the
world’s attention will again be riveted on soccer for the 2010 FIFA World Cup South Africa. Although
the world’s attention will be focused on a single tournament involving a few hundred professional
players, professionals account for only a few hundred thousand of this massive number of participants.
Like all other sports, playing soccer carries the risk of injury. Every sport has its unique profile of
injuries, many of which are preventable. One of the goals of the sports medicine professional is injury
prevention, and sports physicians should be doing everything possible to minimize the risk of injury
to keep players in the competitive arena.
In the past, sports physicians and coaches had to apply general concepts of prevention to any
particular sport. Many of the methods may have made sense intuitively, but there continues to be
debate on issues, such as the preventive benefits of pre-event stretching.2–4 In the past 10 years, great
Correspondence: strides have been made by the research community to provide strong evidence for the effective-
Donald T. Kirkendall, PhD,
1103 Winwood Drive, ness of prevention programs. Most prevention trials follow a model proposed by van Mechelen5
Cary, NC 27511. that follows 4 conceptual steps (Figure 1): 1) establish the incidence of injury; 2) determine the
Tel: 919-624-0663
Fax: 919-681-6357
mechanism of injury; 3) devise prevention programs; and 4) test the program by gathering new
E-mail: donald_kirkendall@yahoo.com incidence data.

© THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, April 2010, No. 1, Volume 38 1
 Clinical features
Donald T. Kirkendall and Jiri Dvorak
Figure 1. Prevent research model.
1. Establish the extent
of the injury problem:
– Incidence
– Severity
4. Assess effectiveness
by repeating step 1
Reproduced with permission from Sports Med.5
Methods of Injury Prevention Research
in Soccer
Injury Incidence in Soccer
Soccer is classified as a contact sport. Many consider soccer to
be relatively safe because of the low incidence of serious injury.6
However, it is difficult to measure soccer’s ranking in terms of
overall injury rate compared with other sports because of different
study methods used in defining injury and severity, reporting of
rates, and comparing different ages, genders, and performance
levels. Although there is consensus on the methods of conduct-
ing injury surveillance research,7 earlier research (which focused
primarily on professionals) was difficult to compare, and there are
few papers that have studied injuries in which there is the highest
level of participation: recreational youth.
One of the most reliable data sets on a large number of athletes
in various sports is the National Collegiate Athletic Association
(NCAA)’s Injury Surveillance System. This rigorous survey proj-
ect, sponsored by the NCAA, includes almost 20 years worth of
collected injury statistics, at all levels of 15 intercollegiate sports.8
A summary of the NCAA injury rates is shown in Table 1, with
soccer ranked in the upper one-third of all sports observed. Since
2 © THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, April 2010, No. 1, Volume 38
2. Establish the etiology
and mechanisms
of sports injuries
3. Introduce preventive
measures
1998, FIFA’s Medical Assessment and Research Center (F-MARC)
has been conducting an injury surveillance program at all FIFA
competitions.9,10 These data are gathered by each team physician at
every match and reported to the research team. Over time, injury
rates of 88.710 and 67.49 injuries per 1000 match hours have been
reported for men and women, respectively, and most of these
injuries are considered minor ( 7 days lost).11 Most injuries
involve contact during tackling,12,13 and a little less than one-half10
and one-third9 of all injuries in men and women, respectively, are
due to foul play. As data collected at world championship events
come from the highest level of competition, the rates are higher
than that reported for lower levels of play.6,14
Common Injuries in Soccer
Because of the nature of the game, in which the lower extremities
are primarily used to control and advance the ball, the most com-
mon injuries are to the lower extremity. A common soccer injury
is a contusion; however, a contusion rarely results in days lost
from training or competition. Most studies report that the top
time-loss injuries, regardless of level of play or gender, are ankle
sprains, knee sprains, hamstring strains, and groin strains,14–19
 Clinical features

Preventing Common Soccer Injuries

Table 1.  Overall Rates of Injury per 1000 Athlete Exposures for and length of high-speed sprints at top-level competition has
National Collegiate Athletic Association Sports resulted in hamstring strains increasing from 2.3 injuries per
Game Practice team in the inaugural season of the Major Soccer League,18
Men’s football 35.9 3.8 to 5 per club in the English Football Association (FA),11 and
Men’s wrestling 26.4 5.7 from 9% of all injuries in Swedish professionals29 to 28% of all
Men’s soccer 18.8 4.3
injuries in the Italian Serie A.19 The mechanism of a muscle
Women’s soccer 16.4 5.2
strain is well described (high muscle tension during muscle
Men’s ice hockey 16.3 2.0
Women’s gymnastics 15.2 6.1 stretch30), with the biceps femoris being the most frequently
Women’s ice hockey 12.6 2.5 injured of the 3 hamstrings.11,31
Men’s lacrosse 12.6 3.2
Men’s basketball 9.9 4.3 Groin Strains
Women’s field hockey 7.9 3.7 The basic mechanism of this muscle strain is the same as
Adapted from J Athl Train et al.8 described for a hamstring strain—a strong contraction during
Table sorted on game injury rate. Data averaged over 16 years.
stretch. In soccer, a player reaches far to the side with his or
her leg, usually in an attempt to tackle or deflect a ball. When
which account for between one-half and two-thirds of all soccer contacting the ground with the lead leg, a groin muscle (usually
injuries. The order changes by level of play, with ankle sprains the adductor longus) in the push-off leg tears when it contracts
being more common in youth and lower levels of play,20,21 and to help maintain balance, resulting in an injury in the trailing
hamstring strains being a leading cause of time loss in higher leg (W.E. Garrett, personal communication 2009).
levels of play.11,19,22
Method of Injury Prevention Research
Mechanism of Common Soccer Injuries Although injury prevention has a long history of discussions,
Ankle Sprain evidence-based research has become more commonplace in
Noncontact ankle sprains can occur when stepping on uneven the past 10 to 15 years. A search of PubMed was conducted
ground, landing on another player’s foot after jumping, or while using “injury prevention” and “sport” as primary keywords
cutting. A mechanism that is specific to soccer occurs during (n = 2910). This list was limited to “clinical trial” or “random-
tackling: a player can be dribbling the ball with the right foot ized controlled trial” (n = 202). The list was then narrowed to
when an opponent attempts a tackle from the opposite side, studies on “all children (0–18)” and “adults (18–44)” (n = 172).
usually by sliding. Contact with the medial aspect of the drib- The list was limited further to studies on preventing common
bler’s shin at the time of ground contact can force an inversion soccer injuries (ankle sprain, knee sprains, muscle strains).
stress on the right ankle, spraining the lateral ankle ligaments.23,24 Each title and abstract was then reviewed to ensure that, after
random assignment, injuries in a control group and interven-
Knee Sprain tion group were compared. Studies that used a prophylactic
The other main ligament injury in soccer is a noncontact intervention (eg, taping, bracing) were excluded because only
anterior cruciate ligament (ACL) tear—a particular problem training programs were of interest. Finally, while soccer was
in the female player. It is believed that cutting or landing on a the sport of interest, other team sports (basketball, volley-
nearly straight hip and knee,25 coupled with perturbations at the ball, team handball, and Australian Rules football) were also
trunk,26 places enough tension on the ACL to tear the ligament. included. In total, there were 3 trials on ankle sprains, 3 trials
The ACL injury rate in female soccer players is reported to be on knee sprains, 3 trials on muscle strains, and 7 general injury
about 3 times that of males.27,28 prevention trials. Table 2 summarizes the trials that met the
inclusion criteria.
Hamstring Strain Ekstrand et al32–34 conducted the first serious investigation
Higher levels of play can be accompanied by increased speed in soccer injury prevention in the early 1980s. Many factors
of running. For many, a hamstring strain is thought of as a and interventions were studied using a medically supervised
sprinting injury (ie, a track injury). The higher frequency on-field program for Swedish professionals. The final tally was

© THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, April 2010, No. 1, Volume 38 3
 Clinical features

Donald T. Kirkendall and Jiri Dvorak

Table 2.  Summary of Randomized Control Trials on Injury Prevention in Sport

Study Joint Focus Sex Group Membership

Hupperets et al41 Ankle Prevent recurrent ankle sprains Males and females Intervention 256 (120 females),
controls 266 (128 females)
Mohammadi42 Ankle Prevent recurrent ankle sprains Males 80 males randomly assigned to
in soccer 1 of 3 interventions or control
Holme et al63 Ankle Prevent recurrent ankle sprains Males and females 92 subjects matched for age, sex,
level of play
Myklebust et al53 Knee ACL injury prevention in team Females Control season 942, 2 interven-
handball tion seasons of 855 and 850
Gilchrist et al52 Knee Prevent ACL injury in collegiate Females Intervention 583; control 852
soccer

Mandelbaum et al51 Knee Injury prevention in youth soccer Females Year 1: intervention, 1041; control,
1905;Year 2: intervention 844,
control 1913
Gabbe et al58 Muscle Hamstring injury prevention in Males 220 males randomly assigned to
amateur Australian Rules Football control or intervention group

Askling et al60 Muscle Hamstring injury prevention in Males 30 players randomly assigned
professional soccer to hamstring specific eccentric
training or control
Fredberg et al64 Muscle Prevent Achilles and patellar Males 209 (9 teams randomly assigned
tendon injury in professional to intervention or control)
soccer
Scase et al65 Overall Injury prevention in junior Males Intervention 114, control 609
Australian Rules Football
Soligard et al36 Overall Injury prevention in youth soccer Females Intervention 1055, control 837

Steffen et al54 Overall Injury prevention in youth soccer Females Intervention 1091, control 1001

Emery et al66 Overall Injury prevention in youth bas- Males Intervention 494, control 426
ketball

Junge et al61 Overall Injury prevention in youth soccer Males Intervention 194, controls 101

Ekstrand et al33 Overall Multifactorial study of professional Males 12 teams (180 players)
male soccer randomly assigned to control or
intervention groups
Emery et al67 Overall Home-based balance training to Males and females Intervention 66, controls 81
prevent sports-related injury in
adolescents

4 © THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, April 2010, No. 1, Volume 38
 Clinical features

Preventing Common Soccer Injuries

Age Intervention Outcome

Middle school-aged to 8-wk home-based proprioception program 35% risk reduction of recurrent ankle sprain
adult
Adult Proprioceptive training, strength training, Significant reduction in recurrent sprains in
orthosis, control proprioceptive training group vs control
Adult Balance training program Recurrent ankle sprain in 29% of control vs 7%
of intervention
Adult Balance, neuromuscular control, planting ACL injury risk was reduced in players who
and landing strategies complied with the program
College-aged Guided warm-up program focused on 41% reduction in ACL injuries, 70% reduction
neuromuscular control in noncontact injuries. Significant reduction in
recurrent ACL injury.
High school-aged Guided warm-up: stretching, strengthening, 88% reduction in ACL injury in year 1, 74%
plyometrics, agility reduction in year 2.

Adult Stretching (control) vs eccentric hamstring No group differences in injury rates because of
strengthening poor compliance. In those who complied with
the program, the RR was 0.3 (P  0.1)
Adult Mechanical eccentric overload of ham- Hamstring strains in 10 of 15 in control group
strings vs 3 of 15 in intervention group

Eccentric training and stretching of the Intervention reduced risk of developing

Achilles and patellar tendons ultrasonic evidence of abnormalities, but no
differences in injury rate
High school-aged Landing and falling strategies 28% reduction in injuries in intervention group

High school-aged Progressive warm-up program for
strength, awareness, neuromuscular
control
High school-aged Exercises to improve core stability,
lower extremity strength, neuromuscular
control, agility
Middle school- to high Guided warm-up program and home-based
school-aged balance program
High school-aged Exercises to improve core stability,
lower extremity strength, neuromuscular
control, agility
Adult Numerous interventions, including training
correction, prophylactic measures,
controlled rehabilitation, etc.
High school-aged Daily wobble board training (6 wks), then
6-month, home-based program
32% reduction in overall injury rate, 43%
reduction in overuse injuries, 45% reduction in
severe injuries
No difference in injury rate, possibly due to
poor compliance by intervention teams
29% reduction in acute injuries. Reported 20%
reduction in all injuries, 17% reduction in lower
extremity injuries, and 29% reduction in ankle
sprains were not significant. There was poor
compliance to the home-based program
36% injury reduction in intervention group,
especially for mild, overuse, training injuries.
Greater effect in low- vs high-skilled players
75% injury reduction in intervention group,
particularly in ankle/knee sprains and muscle
strains.
Balance training had a protective effect of injury
(RR = 0.2)

Abbreviations: ACL, anterior cruciate ligament; RR, relative risk.

© THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, April 2010, No. 1, Volume 38 5
 Clinical features
Donald T. Kirkendall and Jiri Dvorak
a 75% reduction in injuries,33 and a number of observations
(eg, role of the training/match ratio to injuries34) have become
a renewed topic of interest.35 The designs of the projects and the
number of interventions implemented, however, made it difficult
to determine which prevention methods were the most critical.
As previously mentioned, van Mechelen5 outlined a protocol
for conducting injury-prevention research (Figure 1). In a
research setting, a large number of teams are randomly assigned
to a control (no intervention) or an experimental group (the
prevention program), and the injury rates of the 2 groups over
a full competitive season are compared. A good example of such
a study is the cluster randomized trial by Soligard et al.36 These
studies require a very large numbers of subjects (most involve
 1000 players), are very time consuming, labor intensive, costly,
and are conducted at a limited number of research centers. Some
studies have been performed on limited numbers (Table 2).
Many prevention studies and randomized controlled trial
designs have been conducted on specific injuries. Ankle sprains
are one of the most common ligament injuries in sports and
require aggressive treatment to avert future disability.37 This
common injury is a primary target for prevention research.38–44
The hypothesis is that if the muscles can be strengthened and
proprioceptive function around the ankle can be improved, the
athlete will be better positioned to respond to forces that attempt
to force the ankle into inversion. Prevention activities include
various exercises and protocols using an unstable platform
(eg, cushioned pillows, various types of wobble boards) and
strengthening of muscles that cross the ankle. In a recent trial, the
rate of ankle sprains was reduced from 0.9 to 0.5 injuries/1000
player hours44 in Dutch volleyball players. Notably, there was
a 60% reduction in ankle injury in players with a history of a
prior ankle sprain.44 No prevention trial to date has been able
to prevent the first ankle sprain. The only projects that have
been shown to prevent the first ankle sprain are those that use
external supports (eg, tape, braces, orthoses).45
Prevention of ACL injuries, particularly in females, has
come under intense scrutiny and has been the subject of several
reviews that discuss the factors behind the gender inequity in
ACL injury rates.46–48 Although there are many risk factors of
interest,49 the prevention programs have primarily focused on
basic motor skills, strength, balance, and proprioception, all of
which are incorporated in the warm-up. These methods have
been shown to improve neuromuscular power and control,50
which should reduce ACL injury rates. Reduced ACL injury
rates have been reported in the 2-year intervention trial at the
6 © THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, April 2010, No. 1, Volume 38
Santa Monica Orthopaedic and Sports Medicine Foundation (A
FIFA Medical Center of Excellence) by Mandlebaum et al,51 who
reported 88% and 74% reductions in years 1 and 2, respectively,
in ACL injury rates in female soccer players aged 14 to 18 years.
Gilchrist et al52 demonstrated a 70% reduction in noncontact
ACL injuries in collegiate female soccer players.
When performed regularly, there are reports of significant
reductions in ACL injury rates. However, compliance is critical
because these programs can be ineffective if not performed on
a consistent basis.53,54 Further, the effectiveness may be sport-
specific, with reduced injury rates being reported in soccer but
not in basketball.49 The risk of an overuse injury of the knee is
increased in a player with a prior ACL tear,55,56 making primary
prevention of the first injury a major goal.
The traditional way to prevent hamstring strains is by static
stretching during warm-up (a practice that has come into
question).2 While the risk of this injury is greatly increased in
players with a history of a previous injury (odds ratio [OR],
7.457), age57,58 and thigh muscle strength imbalance59 have also
been identified as risk factors.22 Strength can be increased by
strength training in the weight room. In professional male soccer
players, a 10-week strength training program (1–2 days/week)
that emphasized an eccentric overload reduced the incidence of
hamstring strains from 67% in the control group to 20% in the
intervention group.60 Like many other sports injuries, a history
or a prior injury greatly increases the risk of a recurrent injury;
thus, primary prevention of the first hamstring strain is critical.
Generalized Warm-Up to Decrease
Soccer Injuries
In the spring of 2003, F-MARC brought together a group
of international injury-prevention experts and developed a
prevention program for amateur players based on their knowl-
edge. The “11” is a program of 10 simple, catchy, and time-effi-
cient exercises plus the promotion of fair play to reduce injuries
from fouls. The previous version of this prevention program61
was studied in males (aged 14–19 years), in which the overall
injury rate was reduced by 36%. When the results were reported
as injuries per player, there were 43% fewer mild injuries, 41%
fewer overuse injuries, 42% fewer noncontact injuries, 55%
fewer training injuries, and 80% fewer groin injuries.61 “The 11”
has been successfully implemented in countrywide campaigns
in Switzerland and New Zealand.
A new, more advanced version of this program called
“The 11+” is a complete generalized warm-up program.
 Clinical features

Preventing Common Soccer Injuries

Figure 2 shows that The 11+ program has 3 parts: running Table 3. Injury Rate Ratios Between Teams with Traditional
exercises and dynamic stretching (part 1) followed by 6 exercises Warm-up and Teams Performing “The 11+” Prevention Program
(part 2), each with 3 levels of increasing difficulty to improve Rate Ratiob

strength, balance, motor control, and core stability. This is then All injuries 0.68
followed by further running exercises (part 3). Coaches and   Match injuries 0.71
players can individually adapt the program as fitness improves.   Training injuries 0.63
The entire warm-up takes about 20 minutes to complete.   Severe injuriesa 0.54
A cluster randomized trial of The 11+ conducted by research- All overuse injuries 0.44
ers at the Oslo Sports Trauma Research Center (a FIFA Medi-   Severea overuse injuries 0.30
cal Center of Excellence) was recently published and reports   All acute injuries 0.76
evidence substantiating the effectiveness of the program at   Severea acute injuries 0.65
reducing common soccer injuries.36 The research group col-   Contact injuries 0.64
lected information on all injuries, both acute and overuse. The Severe injuries = ≥ 28 days time loss.
a

11+ was used in every training session instead of a traditional Rate ratio = intervention group injury rate/control group injury rate.
b

Adapted with permission from BMJ.36

warm-up. Prior to a match, only parts 1 and 3 (the running
exercises) were performed in advance of more soccer-specific,
pre-match warm-up activities.
This trial followed nearly 1900 female players (aged
13–17 years) from 125 Norwegian clubs that were randomly
assigned to either a traditional warm-up (control group) or
The 11+ (intervention group). Each coach and team captain
of the intervention teams received face-to-face instruction and
then introduced the program to their respective team. Injury
incidence for the entire 8-month season was documented in
each group.
The overall risk of injury in the teams that performed The
11+ was about 30% less than that of the control group. Other
rate ratios can be found in Table 3. According to the authors, “...
the overall rate of injuries, as well as the rate of match injuries,
training injuries, overuse injuries, and acute injuries differed
significantly. The rate of severe injuries, severe overuse injuries,
and severe acute injuries was significantly lower in the interven-
tion group.”36 The research paper,36 videos of all the exercises,
the poster, and more are available at the FIFA 11+ Web site.62
Furthermore, fewer players in the intervention group had  2
injuries. There was an inverse relationship between compliance
and injury rate: the teams that performed the program the most
had the lowest injury rates.
Summary
Based on results from current randomized controlled trials,
there is good evidence that prevention programs are effective
at preventing common soccer injuries. The data show that
significant reductions in ankle and knee ligament sprains as
well as muscle strains are possible when complying with such
a program. Although there are protocols for specific injuries,
a generalized warm-up plan that incorporates aspects of the
injury-specific programs, like The 11+, addresses many of
the common injury problems in soccer. The sports medicine
community needs to be diligent in promoting simple and
effective injury prevention programs to the teams under their
care. Educating the on-the-field coach on how such programs
are effective at reducing the time lost to injury should encour-
age coaches to incorporate injury prevention as an essential
component of their team’s training program.
Conflict of Interest Statement
Donald T. Kirkendall, PhD, and Jiri Dvorak, MD disclose no
conflicts of interest.
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