Injury Prevention in Young Athletes

Can the FIFA 11+ program reduce injury rates among high school competitors?

That experience inspired Dr. Each year, high school athletes account for 2 million injuries, 500,000 doctor visits, and 30,000 hospitalizations. And with 70 percent of individuals showing signs of post-traumatic osteoarthritis 15 years after a serious sports-related injury to a lower extremity, the impact lasts long after the initial injury has healed. With more than 30 million children and adolescents participating in youth sports in the United States, total youth injuries and rates of injury are increasing. Individual events have only served to highlight the crisis. In one instance, James R. Slauterbeck, MD, witnessed a high volume of injured young athletes firsthand when five players tore their anterior cruciate ligaments (ACLs) during one women’s soccer season at the University of California, Los Angeles.

Slauterbeck to begin researching knee ligament injuries, a topic he has continued to investigate throughout his career. In 2004, he received an Orthopaedic Research and Education Foundation (OREF) Clinician Scientist Grant to support his investigation into why knee ligament injuries occurred more frequently in female athletes. The study, which began as basic science investigations of hormone differences, progressed to research on mechanical differences and eventually led to studies of risk factors for ACL injuries among female athletes and for lower extremity injuries in general. As Dr. Slauterbeck began to publish his conclusions, he realized that his next investigation should focus on the prevention of such injuries.

Preventing lifelong injuries

“I take care of so many kids that tear one ACL in their freshman year [of high school], tear their next ACL in their sophomore year, then retear one of them in their senior year,” said Dr. Slauterbeck, now an orthopaedic surgeon and professor at the University of Vermont Medical Center, professor at the Larner College of Medicine, and head team orthopaedic surgeon for the University of Vermont Catamounts athletic teams. “Their knees are often injured for life, though we get them back to their sports. The long-term implication of these injuries, with the risk of osteoarthritis, can be huge.”

As he considered potential injury-prevention strategies, Dr. Slauterbeck learned of one potential program that incorporated the Fédération Internationale de Football Association (FIFA) 11+ injury-prevention program—a dynamic warm-up program consisting of running, strengthening and conditioning, and sprinting drills—into professional sports. Upon reviewing the literature, he noticed a downward trend in injuries when a prevention program was incorporated into warm-ups—but that injuries rose again if athletes went back to methods of training without the injury-prevention program. In fact, several studies of professional sports teams that employed the FIFA 11+ program showed decreased injury rates. Dr. Slauterbeck wondered whether the same would be true if high schools incorporated the program into their team warm-ups.

Because FIFA 11+ does not require extra equipment or a significant amount of added time, Dr. Slauterbeck thought that high school coaches would be more likely to try it, thus making FIFA 11+ the ideal injury-prevention program for the study. In 2015, Dr. Slauterbeck received the OREF Prevention of Musculoskeletal Youth Sports Injuries Grant to conduct a three-year study on whether incorporating the FIFA 11+ program into high school teams’ warm-ups would reduce the rate of injuries in high school athletes. Funded by OREF’s James R. Andrews, MD, Mentor Campaign, the grant provides funding for clinical and social research in the prevention of musculoskeletal youth sports injuries.

“What I want to do is make sure that kids can play their sports, maximize their performance, not get injured, and have a good time. That’s really why most of them play—to bond with their friends, develop their bodies, and hopefully not get hurt,” said Dr. Slauterbeck.

Studying school sports

Dr. Slauterbeck and his team recruited 14 schools based on location (within a 50-mile radius of the University of Vermont), sports offered, and the presence of a certified athletic trainer on campus. In all, the study observed 200 warm-up programs in football, men’s and women’s soccer, basketball, and lacrosse across a cohort of nearly 4,000 student athletes. Dr. Slauterbeck received additional funding from the Children’s Miracle Network and the University of Vermont Department of Orthopaedics and Rehabilitation Departmental Research Fund to support the 50 medical students, strengthening and conditioning students, athletic training students, and physical therapy student volunteers who would make the observations.

For the first year of the study, volunteers observed the teams’ regular warm-ups to learn and record what they were already doing—running, jogging, strength training, and stretching. They also recorded injuries on a FIFA 11+ injury data sheet. The goal was to ensure that none of the schools had already incorporated FIFA 11+ exercises into their programs, as well as to establish a control for their study and a baseline for injuries. Observers noted that only a few teams incorporated any FIFA 11+ components, and no teams used the full program.

In the second year of the study, researchers randomized schools to get an equal distribution of those that would use the FIFA 11+ program in their warm-ups and those that would continue with their regular warm-ups (control group). During the summer before the next school year, volunteers taught the program to the coaches who would be using it. The FIFA Medical and Research Center provided exercise booklets and posters to aid in the effort.

FIFA 11+

The FIFA 11+ program is a dynamic warm-up program consisting of three parts that take about 15 to 20 minutes to complete:

  1. running (six exercises that should take about eight minutes)
  2. strength, plyometrics, and balance (six exercises, with three levels, that should take about 10 minutes)
  3. sprinting (three exercises that should take about two minutes)


High school football teams warm up with FIFA 11+ strength, plyometrics, and balance exercises.
Courtesy of James R. Slauterbeck, MD

Although the volunteers remained available to answer questions or help if a team struggled with an exercise, once they taught the program, their main objective was to observe what was happening at schools assigned to the FIFA 11+ program versus the control group. For both groups, they recorded lower extremity, back, pelvis, and concussion injuries on the FIFA injury form, categorizing each as minimal (one to three days not able to play due to injury), mild (four to seven days), moderate (eight to 28 days), or severe (greater than 29 days).

Now in the third year of the study, the researchers have recorded almost 400 injuries, about half of which occurred during games. Observations of injury patterns may be reported in a paper this year.

“We are excited about the findings and importance that the paper will bring to injury-prevention strategies in high schools,” Dr. Slauterbeck said. “We have learned a lot about how to implement injury-prevention programs in high schools and are finding that the strategies for injury prevention might be different than they are for elite soccer programs. High school athlete injuries are occurring in alarming numbers, and hopefully injury-prevention strategies can reduce them.”

Warm-up trends in high school sports

Dr. Slauterbeck and his team published an article related to this research in the November 2017 issue of Sports Health about the pre-practice exercises of high school athletic teams. Using 644 observations from an early part of their FIFA 11+ study, Dr. Slauterbeck and colleagues found that only about 8.7 percent of teams included at least one FIFA 11+ exercise, 69.9 percent did not include any FIFA 11+ exercise, 5.9 percent included only jogging, and 10.6 percent included only sport-specific activities. The researchers also were surprised to find that, due to competition for gym time, athletes from about 15 percent of the teams were asked to warm up on their own, rather than during a team practice.

Dr. Slauterbeck said that he likes this type of research because it allows him to search for the answer to a clinically relevant question. “Research for me started with an observation of ACL injuries being more common in females and looking at sex difference in the risk factors for ACL injury. I think, over my entire career, it’s been a very nice question that has branched off into many areas, and now I’m working on injury-prevention strategies,” he said. According to Dr. Slauterbeck, this study was the first to take a look at high school sports rather than professional.

Amy Kile is the manager of marketing communications for OREF. She can be reached at kile@oref.org.

© Orthopaedic Research and Education Foundation (OREF)

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