Knee Surgery, Sports Traumatology, Arthroscopy

https://doi.org/10.1007/s00167-018-4895-5

SPORTS MEDICINE

Higher compliance to a neuromuscular injury prevention program

improves overall injury rate in male football players
Holly J. Silvers‑Granelli1,2 · Mario Bizzini3 · Amelia Arundale1 · Bert R. Mandelbaum4 · Lynn Snyder‑Mackler5,6

Received: 5 July 2017 / Accepted: 8 March 2018

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Abstract
Purpose The 11+ injury prevention program has been shown to decrease injury rate. However, few studies have investigated
compliance and if it is correlated to time loss. The purpose of this study was to (1) analyze how differences in compliance
may impact injury rate and (2) if compliance may impact time loss due to injury.
Methods This study was a Level 1 prospective cluster randomized controlled trial conducted in NCAA men’s football
(soccer) teams that examined the efficacy of the 11+ injury prevention program. The two outcome variables examined were
number of injuries and number of days missed from competition. Twenty-seven teams (n = 675 players) used the 11+ program.
Compliance, injuries and time loss were recorded. There were three compliance categories, low (LC, 1–19 doses/season),
moderate (MC, 20–39 doses/season), and high (HC, > 40 doses/season).
Results There was a significant difference among the groups for injuries, p = 0.04, pη2 = 0.23. The LC group [mean
(M) = 13.25, 95% confidence interval (CI) 9.82–16.68, injury rate (IR) = 10.35 ± 2.21] had a significantly higher injury rate
than the HC group (M = 8.33, 95%CI 6.05–10.62, IR = 10.35 ± 2.21), p = 0.02. The MC group (M = 11.21, 95%CI 9.38–13.05,
IR = 8.55 ± 2.46) was not significantly different than the LC group, p = 0.29, but was significantly greater than the HC group,
p = 0.05. When examined as a continuous variable, compliance was significantly negatively related to injury rate (p = 0.004).
It was also significantly negatively related to number of days missed (p = 0.012).
Conclusions When compliance was high, there was a significant reduction in injury and time loss. This evidence reinforces
the importance of consistent injury prevention program utilization. Clinically, these findings have important implications
when discussing the importance of consistent utilization of an injury prevention protocol in sport.
Level of evidence Level 1—Randomized controlled trial (RCT).

Keywords Injury prevention · Compliance · 11+ · Football (soccer) · Program fidelity

2
* Holly J. Silvers‑Granelli Velocity Physical Therapy, 11611 San Vicente Boulevard,
hollysilverspt@gmail.com GF‑1, Los Angeles, CA 90049, USA
3
Mario Bizzini Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland
mario.bizzini@sportfisio.ch 4
Santa Monica Orthopaedic Group, 1919 Santa Monica
Amelia Arundale Boulevard, 4th Floor, Santa Monica, CA 90404, USA
arundale@UDel.Edu 5
Department of Physical Therapy and Biomechanics
Bert R. Mandelbaum and Movement Science Program, University of Delaware,
bmandelbau@aol.com Newark, DE, USA
6
Lynn Snyder‑Mackler Department of Biomechanical and Movement Sciences,
smack@udel.edu University of Delaware, Newark, DE, USA
1
Biomechanics and Movement Science Program, University
of Delaware, Newark, DE, USA

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 Knee Surgery, Sports Traumatology, Arthroscopy

Introduction Human ethics internal review board approval and informed

consent was obtained through Quorum IRB (Seattle, WA,
Efforts to design and implement effective injury preven- USA). Individual player consent was obtained and a docu-
tion and reduction programs in sport have been researched mentation of coaching understanding was signed by each
in the medical community for several decades [8, 11, 14, institution to ensure that there was a thorough understand-
17, 19, 22, 24, 25, 31]. The success of such community- ing of the expectations of study participation.
based programs is multifactorial and are predicated upon the
identification of the injury risk, analyzing the mechanism of Intervention
injury, education of the coaches and players, the qualitative
content of the injury prevention program, and the fidelity, The 11+ is an injury prevention program designed as a
compliance and adherence to the prescribed evidence-based dynamic warm-up program to address lower extremity injury
program, where compliance refers to an individual conform- incurred in the sport of football for athletes over the age of
ing to a recommended intervention with respect to dosage, 14. It is a 20-min field-based program that consists of 15
frequency and timing and adherence refers to a process exercises divided into three separate components: running
that is influenced by environment, social context, personal exercises (8 min) that encompass cutting, change of direc-
knowledge, motivation, skill and available resources [9, 18, tion, decelerating and proper landing techniques, strength,
20, 30]. Once a program has been scientifically vetted, the plyometric and balance exercises (10 min) that focus on core
sports medicine community is compelled, from a public strength, eccentric control and proprioception, and running
health perspective, to increase awareness that such programs exercises (2 min) to conclude the warm-up and prepare the
do indeed exist. Clinicians must stress the critical nature of athlete for athletic participation. There are three progres-
the inclusion, adoption and adherence to such programs into sions (level 1, level 2, level 3) that increase the difficulty for
the existing sports training repertoire [4, 5, 7]. each respective exercise. This allows for both individual and
Despite the numerous publications that discuss the notion team progression throughout the course of the competitive
of injury prevention and reduction in sport, only a few stud- season. In this specific study, the FIFA 11+ program served
ies have thoroughly discussed how the role of program integ- as the intervention program over the course of one competi-
rity, adherence, and compliance may directly impact the tive collegiate football season [24].
efficacy of such programs [1, 13, 15, 23]. This is a critical
aspect to analyzing the overall fidelity of an injury preven- Participants
tion program. In some research circumstances, if compliance
was not deemed adequate, it is impossible to ascertain sci- Sixty-five institutions were randomly assigned and com-
entifically if it was a failing of the content of the actual pre- pleted the intervention study during one competitive football
vention protocol, or if the compliance to the program was so season (August–December): 34 control institutions (N = 850
inordinately low, that the neuromuscular training benefit of athletes) and 31 intervention institutions (N = 775 athletes)
the prevention program was nullified, respectively [27, 28]. with athletes between the ages of 18–25. Four Division II
The aim of this study was to characterize differences intervention teams discontinued the intervention (N = 100)
in compliance in competitive male football players and to secondary to time and personnel constraints, therefore, a
determine if variability in compliance to a neuromuscular per-protocol analysis was utilized. For the compliance aspect
training program (11+) would impact injury rate. Addition- of the study, only the intervention teams that utilized the
ally, this study assessed if a correlation existed between 11+ program as their dynamic warm-up completed the study
high compliance to the 11+ program and a decrease in time were utilized (27 teams, N = 675) (Fig. 1).
lost due to injury during competitive play and training. This
study is necessary to stress the importance of consistent uti- Operational definitions
lization of injury prevention programs to address the steady
rise in injury associated with sport. The following operational definitions were used during the
injury data entry phase of the study. An injury was reported
if a player was unable to participate fully in a scheduled
game or training session. The player’s return to play date
Materials and methods was entered when the player was fully able to participate
in a game or training session. All injuries were entered by
This study was a prospective cluster randomized con- Certified Athletic Trainers using The International Statisti-
trolled trial, which was conducted in 27 of 61 Division cal Classification of Diseases and Related Health Problems
I and Division II NCAA men’s football (football) teams. (ICD-9) coding system. The severity of injury was defined
utilizing the UEFA injury definition guidelines which was

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Knee Surgery, Sports Traumatology, Arthroscopy

Fig. 1  Description of NCAA

team randomization and study
flow

dictated by the amount of time missed from active participa- and compliance data was entered weekly by the team’s certi-
tion (Table 1) [10]. fied athletic trainer and verified by the research staff. Sixty-
one institutions completed the study during the Fall, 2012
Data collection season (August–December): 34 control institutions (N = 850
athletes) and 27 intervention (N = 675 athletes) institutions.
An internet-based injury surveillance data collection system Only the intervention teams using the 11+ prior to games
was utilized (HealtheAthlete™, Overland Park, Kansas) by and training were analyzed for the compliance phase of the
every enrolled institution in the study. Every athletic expo- study. Upon the completion of the competitive football sea-
sure, injury incurred, utilization of the FIFA 11+ program son, the injury, athletic exposure and compliance data entry

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 Knee Surgery, Sports Traumatology, Arthroscopy

Table 1  Operational definitions used to define the parameters of the injury

Term Operational definition used to identify injury

Reportable injury Any injury sustained by a player during a scheduled game or training session which
caused the athlete to be unable to fully participate and seek treatment by the Certified
Athletic Trainer
Time loss due to injury An injury which caused an athlete to miss a subsequent training session or game
Exposure Participation in a game or training session
Severity of injury The number of days absent from soccer participation; minimal (1–3 days), mild (4–7
days), moderate (8–28 days), or severe (> 28 days)
Return to participation The day the player was able to return to full participation in training and/or game situation

was confirmed by each certified athletic trainer (ATC) and deemed statistically significant with a p value of p < 0.05.
verified with their individual institution’s data collection Tukey’s post hoc analysis was utilized to analyze within
system for accuracy and thoroughness. During the season, group differences when a main effect was identified. χ2 tests
the research team monitored the team and individual com- were used to compare categorical variables within the com-
pliance of the program weekly. If compliance within the pliance subgroups. A GLM regression model was used to
IG was deemed less than optimal, an email was sent by a analyze compliance as a continuous variable with respect to
member of the research team to the individual institution. injury rate and days lost due to injury.
If the institution did not respond within 14 days, a research Cohen’s d effect sizes were calculated and defined when
member contacted the team to encourage improvement in compared to the following: small d = 0.20, medium d = 0.5,
data entry and/or adherence to the program. At the comple- and large d = 0.8. Power calculations were performed, a pri-
tion of the season, compliance was analyzed and stratified by ori, using preliminary data and G*Power software version
utilization consistency into tertile categories and by month 3.1.0 (Universität Düsseldorf, Düsseldorf, Germany). Using
of utilization and on a continuum. a generalized linear model with Tweedie distribution and
Human ethics internal review board approval and logit link function, with p value = 0.05 and power = 0.80, it
informed consent was obtained through Quorum Internal was determined that a relative risk of 1.1 could be detected
Review Board (IRB # 26182/1) (Seattle, WA, USA). with a total sample size of 125.

Statistical analysis
Results
This manuscript is based on an exploratory post hoc analysis
of the data collected from the 11+ Intervention group (IG) Of the thirty-one teams in the intervention cohort, 27 teams
in a larger randomized controlled trial [24]. All statistical (N = 675) completed the research study and, thus, compli-
analyses were conducted utilizing IBM SPSS for Windows ance was analyzed using a per-protocol analysis. Injuries and
version 23 (Armonk, NY). Descriptive and inferential tests time loss due to injury during the entire season were tracked
were used to compare levels of compliance within the IG, within this cohort.
including t tests, χ2 tests, and generalized linear regression
models (GLM), with logit link function and Poisson dis- Team compliance
tribution for injury count data between groups. Descrip-
tive data for compliance, exposures and injury rates (IR) Twenty-seven intervention teams completed the FIFA
are presented as means (M) with standard errors (SE) and 11+ injury prevention program over the course of the season
95% confidence intervals (CI). P values of 0.05 or less were (August through late November or early December, depend-
considered significant. The summary measure for injury ing on the success of the team in the NCAA tournament).
rate (IR) was calculated according to the formula: IR = n/e, The total number of utilizations of the FIFA 11+ equated
where n is defined as the number of injuries during the data to 886 sessions (mean 32.8 ± 12.1 sessions, range 11–64,
collection period and e is the number of exposures expressed median = 32). There were 1304 overall team exposures in the
in number of games or trainings participated in. Relative rate IG (405 games and 899 training sessions) over the course of
ratios (RR), with their associated 95% confidence intervals, the season, translating into an average of 2.2 FIFA 11+ utili-
were calculated using the injury incidence for each compli- zations over the course of the season per week. Compliance
ance group. Analyses of variance (ANOVAs) were utilized was determined to be low for teams using the program ≤ 1
to analyze the main effect of compliance (three levels) on time per week (LC: 1–19 doses/season), moderate for > 1
both injury rate and time loss due to injury. All effects were and < 2 utilizations per week (MC: 20–39 doses/season) or

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Table 2  Tertiles of team Compliance High (n = 9 teams/225 Moderate (n = 14 Low (n = 4 teams/ 100
compliance and utilization of athletes) teams/350 athletes) athletes)
the FIFA 11+ Program
Mean ± SD Range Mean ± SD Range Mean ± SD Range

Teams
1st half of season 26.6 ± 7.7 20–45 17.0 ± 4.2 12–25 8.3 ± 3.3 6–13
2nd half of season 19.2 ± 2.2 18–24 12.4 ± 3.9 9–21 7.5 ± 3.1 5–12
Entire season 45.8 ± 7.5 40–64 29.4 ± 5.9 21–39 15.8 ± 3.6 11–19

The mean values represent the number of FIFA 11+ sessions performed during distinct and in totality for
the competitive season, presented with SD and ranges of utilization

Table 3  Injury risk amongst Compliance # Teams/# athletes Injury count Injury rate (IR) Rate ratio (95% CI) p value
teams stratified into tertiles of (M ± SD)
compliance
High 9/225 athletes 8.3 ± 3.5 6.4 ± 2.7 – –
Moderate 14/350 athletes 11.2 ± 3.2 8.6 ± 2.5 1.3 (1.1–1.7) 0.009
Low 4/100 athletes 13.3 ± 3.2 10.4 ± 2.2 1.6 (1.3–2.1) < 0.001

The data represents number of teams, number of athletes, mean injury count with standard deviation,
injury rate (IR), rate ratio with 95% confidence interval (CI). The high compliance group is the reference
group

high for ≥ 2 utilizations per week (HC: >39 doses per sea- Injury Rate in relationship to compliance
11+ Dose/Season

son,), predicated on a 19.4-week season. Four teams were 50 45.8 14

Injury Rate
categorized in the low tertile (15.8 ± 3.6 doses/season, range 45
40 29.4
12

11–19 days, median = 16.5), 14 teams in the moderate tertile

35 10
30 8
(29.4 ± 5.9 doses/season, range 21–39 days, median = 29.5),
25
20 15.5 6
15
and 9 teams were categorized in the high tertile (45.8 ± 7.5
4
10
5 2
doses/season, range 40–64 days, median = 43) (Table 2). The 0 0
Low (1-19) Mod (20-39) High (>39)
utilization in the first half of the season (August and Sep- Compliance
tember) exceeds that of the utilization in the second half of 11+ Dose/season Injury rate
the season (October, November and December) secondary
to the fact that many teams’ season were concluded in mid-
November after being eliminated from conference tourna- Fig. 2  Injury rates in relationship to compliance with the FIFA
ment play. The decreased dosage of FIFA 11+ in the second 11+ program. The bars represent the level of compliance: Low
half of the season does not necessarily reflect a decrease in compliance = 1–19 utilizations (n = 4 teams), moderate compli-
utilization of the program (Table 2). ance = 20–39 utilizations (n = 14 teams) and high compliance = > 39
utilization (n = 9 teams) of the FIFA 11+ (error bars depict standard
deviation), p = 0.004
Compliance and injury rate

There were 53 injuries in 4 LC teams (M = 13.3, variable, compliance was significantly negatively related
IR = 10.34 ± 2.2, RR = 1.6(1.3–2.1), p < 0.001), 157 inju- to injury rate (b = − 1.6, t = − 3.2, p = 0.004, R2 = 0.029)
ries in 14 MC teams [M = 11.2, IR = 8.6 ± 2.5. RR = 1.3 (Table 3; Fig. 2).
(1.1–1.7), p = 0.009] and 75 injuries in 9 HC teams (M = 8.3,
IR = 6.4 ± 2.7) (Table 2). There was a main effect within the Compliance and time loss due to injury
groups for injury rate, f(2,24) = 3.6, p = 0.043, pη2 = 0.231.
Upon post hoc analysis, the LC group (M = 13.3, 95% Compliance was also significantly negatively related to
CI 9.8–16.7, IR = 10.4 ± 2.2) had a significantly higher number of days missed, which served as a proxy for sever-
injury rate than the HC group (M = 8.3, 95% CI 6.1–10.6, ity of injury (b = − 2.8, t = − 2.7, p = 0.012, R2 = 0.23).
IR = 6.4 ± 2.7), p < 0.001. The MC group (M = 11.2, 95% CI The LC teams reported 9.6 ± 2.8 days lost to injury com-
9.4–13.1, IR = 8.6 ± 2.5) was not significantly different than pared to 11.9 ± 5.7 for the MC teams and 7.6 ± 4.8 days lost
the LC group, p = 0.291, but was significantly greater than for the HC teams (F = 3.35, p = 0.012) (Fig. 3). Within the
the HC group, p = 0.009. When examined as a continuous high compliance group, there was a lower injury rate and a

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 Knee Surgery, Sports Traumatology, Arthroscopy

Team compliance vs. Time lost due to parameters of the data collection). Since we hypothesize that
injury the benefit of performing an injury prevention program is
50
45.8 not realized in the first week of utilization, we performed
a secondary analysis with this one injury removed from
45
40
35
29.4 the dataset. Once removed, there is a significant difference
amongst compliance groups, with the HC having signifi-
30
Days

25
20
15.8 cantly fewer days lost to injury than both LC, p = 0.009, and
MC, p = 0.018 groups, respectively.
15
10
5
9.6 11.9 7.6
0
Low (1-19) Moderate (20-39) High (>39)
Compliance Discussion
11+ Utilization Time lost due to injury

The most important finding of this present study, that cor-

roborated findings by previous researchers, is high compli-
Fig. 3  Team compliance compared to time lost due to injury. Utiliza-
tion of FIFA 11+ stratified by team compliance (low, moderate and
ance to the 11+ injury prevention program demonstrated
high) compared to time lost due to injury. The high compliance teams lower injury rates throughout the competitive season
had significantly fewer days lost due to injury compared to the MC [26–28]. There is an inverse correlation between compliance
and LC compliance groups (p = 0.012) and injury rate and severity of injury; which was reflected
in fewer days lost due to injury. High compliance to the
decreased severity of injury, demonstrated by a decrease in 11+ program resulted in fewer injuries and decreased sever-
time loss due to injury (Table 4; Fig. 3). ity of injury.
There was a significant difference among the compliance
groups on the average number of days missed per injury Compliance and injury risk
by team, f(2,24) = 3.35, p = 0.05, pη2 = 0.218. It should be
noted that the partial eta squared (pη2) was equal to 0.218, The teams with high compliance (HC) completed the FIFA
meaning that the effect for the group differences recorded 11+ nearly three times as frequently as the LC teams and
in days lost due to injury per team accounted for 21.8% of nearly one and one-half times as frequently as the MC teams.
the variance plus error variance. Furthermore, there was When the exposure–response relationship was analyzed, the
a similar pattern noted when analyzing compliance com- preventative impact of the program seemed to improve as the
pared to days lost to injury and compliance compared to number of doses increased throughout the season. The injury
injury rate. The LC group had the second highest number rate was lowest in the HC group compared to the MC and the
of days missed (M = 127.3 ± 54.1, 95% CI 60.0–194.6) and LC groups (Table 2). Thus, a statistically significant inverse
the MC group reported the highest number of days missed relationship exists between compliance and injury rate;
(M = 133.3 ± 76.6, 95% CI 97.3–169.2). The HC group had the more compliant the teams were to utilizing the FIFA
the fewest days missed per team (M = 63.2 ± 46.1, 95% CI 11+ program, the lower the injury rate reported. In addi-
18.4–108.1) and fewest days lost per injury (M = 7.6 ± 4.8, tion, when the entire intervention group was compared to a
95% CI 8.2–12.5) (Table 4). Additionally, there was one control group that did not utilize the 11+ program, there was
potential outlier in the data for the MC group; a contact an overall injury reduction of 46.1% [24]. However, when
ACL/meniscal injury that occurred in the first game of the HC group was compared to the control group, there was
the season resulting in 106 days of time loss (within the a 57.5% decrease in overall injury rate. This supports the

Table 4  FIFA 11+ utilization compared to injury rate and time loss due to injury

Compliance 95% CI Std. Error p value

Low (1–19) Moderate (20–39) High (> 39) Total

11+ Utilization 15.8 ± 3.6 29.4 ± 5.9 45.8 ± 7.5 32.8 ± 12.1 28.0 + 37.6 2.3 < 0.001
Injury rate 13.3 ± 3.2 11.2 ± 3.2 8.3 ± 3.5 10.6 ± 3.6 9.1–12.0 0.7 0.004
Time lost to injury
By team 127.3 ± 54.1 133.3 ± 76.6 63.2 ± 46.1 109.0 ± 70.8 81.0–137.1 13.6 0.01
Per Injury 9.6 ± 2.8 11.9 ± 5.7 7.6 ± 4.8 10.3 ± 5.4 8.2–12.5 1.1 0.01

Data represents mean/standard deviation, 95% confidence interval (CI), standard error (std. error), and p value. Significance (p < 0.05) was
reached for FIFA 11+ utilization, injuries within compliance groups, and time lost due to injury (stratified by team and per injury)

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Knee Surgery, Sports Traumatology, Arthroscopy

notion that as the dosage of the FIFA 11+ increases over the male football teams analyzing the awareness and utilization
course of the season, the preventative benefit also increases. of the FIFA 11+ program, 61% of respondents had heard
The overall utilization of the FIFA 11+ was 32.8 ± 12.1 of the FIFA 11+ program, but only 28% reported using the
doses per season and 2.0 ± 0.7 doses per week. The recom- program in some form (fully or modified versions). Interest-
mended dosage was 2 sessions per week. Despite the LC ingly, when the respondents were queried on who ultimately
and MC teams performing the program fewer times than the holds responsibility for injury prevention efforts, there was
recommended dosage, both groups still experienced a reduc- significant variability in the responses: 35% indicated that
tion in injuries and fewer days lost to injury compared to the the head coach held the ultimate responsibility, 24% the
control group [24]. Recent systematic reviews of the FIFA player, and 24% the fitness coach [21]. Bahr et al. reported
11+ program noted that athletes with high compliance to the that despite the fact that 88% of Champions League and
FIFA 11+ injury prevention program resulted in a 35–39% Norwegian Premier League teams being aware of the exist-
reduction in injury risk [3, 29]. In addition, the athletes using ence of hamstring injury prevention methodology, only 16
the FIFA 11+ program demonstrated significant improve- teams (10.7%) were fully compliant and 9 teams (6%) were
ments in neuromuscular and motor performance when the partially compliant with the proposed intervention. This
structured warm-up was utilized at least 1.5 times per week resulted in a startling 225 teams (83.3.%) of the teams being
[3]. This supports the premise that FIFA 11+ program is deemed completely non-compliant [2]. This research eluci-
indeed an effective manner unto which football-related dates the magnitude of the work that stands before the sports
injury might be prevented. medicine community. This study has important implications
when discussing the importance of consistent utilization of
Compliance and time lost due to injury an injury prevention protocol in sport.
This study was conducted in male football (soccer) play-
The high compliance group experience fewer days lost to ers and only was conducted over the course of one season.
injury per team and fewer days lost to each individual injury The NCAA collegiate football (soccer) season only extends
compared to the low and moderate compliance groups. from August to December, and is significantly shorter than
When compliance was analyzed as a continuous variable, other competitive and professional seasons around the world.
this was also a statistically significant finding. Earlier Unannounced site visits were not conducted during this data
research articles that demonstrated similar findings, have collection due to the vast geographic expanse of the study
corroborated this evidence. In one of the initial studies ana- population (entire United States). Due to the nature of the
lyzing the effectiveness of the FIFA11+ program in young NCAA substitution rule, the researchers analyzed exposure
female football players, there was a significantly lower risk using athletic exposure versus playing hour as a unit of
of injuries overall overuse injuries, and severe injuries in analysis. The researchers were only able to analyze compli-
the IG compared to the CG [25]. In a small cohort study ance by team, and not by individual participant. Individual
conducted in men’s football over one season, the IG dem- compliance to the program was not collected during the data
onstrated a reduction in the relative risk of lower extremity collection phase. The low compliance group was limited to
injury of 72% and time lost due to lower extremity injury four teams and the 11+ utilizations ranged from 11 to 19.
(p < 0.01) [12]. These studies, in addition to others that have This may represent inter-team differences, which can affect
utilized alternative neuromuscular training programs, have the overall comparison between groups. This was overcome
shown proven efficacy in reduction of injury rate, severity by including the analysis of compliance on a continuum.
of injury and time lost due to injury [6, 11, 16, 17, 19].
However, despite very thorough implementation strategies,
compliance continues to be an obstacle in optimal program Conclusions
adherence [4].
The athletes utilizing the FIFA 11+ as their dynamic warm-
The compliance conundrum up program with high compliance demonstrated a signifi-
cant reduction in injury rate and time loss due to injury.
Despite very promising research detailing the efficacy of The higher the consistency in the adherence to the pro-
the FIFA 11+ in male and female football athletes [12, gram, the greater the benefit to the individual athlete with
22, 24, 25], compliance and program adherence by play- respect to decreased injury risk and severity of injury. This
ers and coaches continues to be problematic across sport. corroborates the research finding found in earlier studies
Compliance and adherence to injury prevention protocols conducted in men and women, globally [22, 25–27]. As
has been discussed in the literature, but acceptable levels of researchers continue to revise and improve injury preven-
program adherence in sport continue to elude sports medi- tion and reduction efforts, there should be equal emphasis
cine researchers [18, 26–28]. In a recent survey of youth placed on analyzing optimal strategies to encourage optimal

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 Knee Surgery, Sports Traumatology, Arthroscopy

implementation and utilization by athletes, coaches and 9. Fortington LV, Donaldson A, Lathlean T, Young WB, Gabbe BJ,
medical staffs universally. Lloyd D et al (2015) When ‘just doing it’ is not enough: assessing
the fidelity of player performance of an injury prevention exercise
program. J Sci Med Sport 18:272–277
Funding This study was funded by The Fédération Internationale de 10. Fuller C, Ekstrand J, Junge A et al (2006) Consensus statement
Football Association (FIFA). on injury definitions and data collection procedures in studies of
football (soccer) injuries. Br J Sports Med 40:193–201
Compliance with ethical standards 11. Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers HJ,
Griffin LY et al (2008) A randomized controlled trial to prevent
Conflict of interest One of the authors (HJS-G) received a PhD Re- noncontact anterior cruciate ligament injury in female collegiate
search Grant from Simbex, Inc (less than 10,000 USD); and is a re- soccer players. Am J Sports Med 36:1476–1483
search consultant to Major League Soccer’s M-MARC program (less 12. Grooms DR, Palmer T, Onate JA, Myer GD, Grindstaff T (2013)
than 10,000 USD) unrelated to this work. One of the authors (AA) Soccer-specific warm-up and lower extremity injury rates in col-
received a Grant from the National Institutes of Arthritis and Muscu- legiate male soccer players. J Athl Train 48:782–789
loskeletal and Skin Diseases (R01-AR048212) (less than 10,000 USD) 13. Hagglund M, Atroshi I, Wagner P, Walden M (2013) Superior
and the Foundation for Physical Therapy–Promotion of Doctoral Stud- compliance with a neuromuscular training programme is associ-
ies I Scholarship (less than 10,000 USD). One of the authors (BRM) ated with fewer ACL injuries and fewer acute knee injuries in
received funding from FIFA to support the completion of this study female adolescent football players: secondary analysis of an RCT.
(see below); and is a consultant to Athrex, RTI, Exactech, and DePuy Br J Sports Med 47:974–979
Mitek. The institution (Santa Monica Orthopaedic Group) of one or 14. Hagglund M, Walden M, Atroshi I (2009) Preventing knee injuries
more of the authors (HJS-G, BRM) has received funding from FIFA’s in adolescent female football players—design of a cluster ran-
(Fédération Internationale de Football Association) F-MARC Program domized controlled trial [NCT00894595]. BMC Musculoskelet
(2012) for the initial publication (10,000–100,000 USD). Disord 10:75
15. Heidt RS Jr, Carlonas RL, Traub JA, Tekulve FX (2000) Avoid-
Ethical approval This study received Internal Review Board (IRB) and ance of soccer injuries with preseason conditioning. Am J Sports
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