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JPHYS-363; No. of Pages 8

Journal of Physiotherapy xxx (2017) xxx–xxx

Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys

Research

Adding a post-training FIFA 11+ exercise program to the pre-training

FIFA 11+ injury prevention program reduces injury rates among
male amateur soccer players: a cluster-randomised trial
Wesam Saleh A Al Attar a,b,c, Najeebullah Soomro d, Evangelos Pappas b,
Peter J Sinclair a, Ross H Sanders a
a
Discipline of Exercise and Sport Science, Faculty of Health Sciences, The University of Sydney, Australia; b Discipline of Physiotherapy, Faculty of Health Sciences, The University of
Sydney, Australia; c Department of Physiotherapy and Rehabilitation Sciences, Faculty of Applied Medical Sciences, Umm Al Qura University, Makkah, Saudi Arabia; d Broken Hill
University Department of Rural Health, The University of Sydney, Australia

K E Y W O R D S A B S T R A C T

Soccer Question: Does adding a post-training Fédération Internationale de Football Association (FIFA) 11+
Injury prevention programs exercise program to the pre-training FIFA 11+ injury prevention program reduce injury rates among male
FIFA 11+ program amateur soccer players? Design: Cluster-randomised, controlled trial with concealed allocation.
Pre-training exercises
Participants: Twenty-one teams of male amateur soccer players aged 14 to 35 years were randomly
Post-training exercises
assigned to the experimental group (n = 10 teams, 160 players) or the control group (n = 11 teams,
184 players). Intervention: Both groups performed pre-training FIFA 11+ exercises for 20 minutes. The
experimental group also performed post-training FIFA 11+ exercises for 10 minutes. Outcome measures:
The primary outcomes measures were incidence of overall injury, incidence of initial and recurrent
injury, and injury severity. The secondary outcome measure was compliance to the experimental
intervention (pre and post FIFA 11+ program) and the control intervention (pre FIFA 11+ program).
Results: During one season, 26 injuries (team mean = 0.081 injuries/1000 exposure hours, SD = 0.064)
were reported in the experimental group, and 82 injuries were reported in the control group (team
mean = 0.324 injuries/1000 hours, SD = 0.084). Generalised Estimating Equations were applied with an
intention-to-treat analysis. The pre and post FIFA 11+ program reduced the total number of injuries (x2
(1) = 11.549, p = 0.001) and the incidence of initial injury (x2 (2) = 8.987, p = 0.003) significantly more
than the pre FIFA 11+ program alone. However, the odds of suffering a recurrent injury were not different
between the two groups (x2 (1) = 2.350, p = 0.125). Moreover, the severity level of injuries was not
dependent upon whether or not the pre and post FIFA 11+ program was implemented (x2 (1) = 0.016,
p = 0.898). Conclusion: Implementation of the FIFA 11+ program pre-training and post-training reduced
overall injury rates in male amateur soccer players more than the pre FIFA 11+ program alone. Trial
registration: ACTRN12615001206516. [Al Attar WSA, Soomro N, Pappas E, Sinclair PJ, Sanders RH
(2017) Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+ injury
prevention program reduces injury rates among male amateur soccer players: a cluster-randomised
trial. Journal of Physiotherapy XX: XX–XX]
© 2017 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction 2011–2012 season), 24 soccer teams from nine European countries

Soccer (football) is the most popular sport worldwide, with
almost 300 million male and female participants.1 It is also the
most played outdoor team sport in Australia.2 The medical
treatment of soccer injuries can have remarkable social and
economic implications in terms of healthcare costs. In the
Australian Professional League (A-League), the total number of
time-loss injuries and matches missed increased from 129 in
2008 to 1110 in 2011.3 Over five A-League seasons (2008–2009
season to 2013–2014 season), the total time-loss injuries and
matches missed led to high costs (up to AUD37 million in the 2012–
2013 season).3 Moreover, in the Union of European Football
Associations (UEFA) Champions League (2001–2002 season to
reported 7792 injuries and 8029 time-loss injuries during matches
and training.4,5
The Fédération Internationale de Football Association (FIFA)
Medical and Research Centre (F-MARC) together with the Santa
Monica Orthopaedic and Sports Medicine Research Foundation
(SMSMF) and the Oslo Sports Trauma Research Centre (OSTRC)
developed the F-MARC, FIFA 11, and FIFA 11+ injury prevention
programs.6,7 The FIFA 11+ program, with a total of 15 exercises, is
used before training. The exercises are based on three main
exercise modules: a running and active stretching session; a core
and leg strengthening session; and a high-speed planting and
cutting session. The main focus of these exercises is to strengthen
the core and leg muscles, and to improve coordination, balance,

http://dx.doi.org/10.1016/j.jphys.2017.08.004
1836-9553/© 2017 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Al Attar WSA, et al. Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+
injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. (2017),
http://dx.doi.org/10.1016/j.jphys.2017.08.004
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JPHYS-363; No. of Pages 8
2 Al Attar et al: Pre and post-training FIFA 11+ program
agility, and static, dynamic, and reactive neuromuscular control.
Numerous studies in different countries have assessed the efficacy
of the FIFA 11+ program, including Canada,8 Germany,9 Nigeria,10
Norway11 and the USA.12,13 Moreover, Al Attar and colleagues14
conducted a meta-analysis to evaluate the effectiveness of the F-
MARC injury prevention programs in soccer. The results showed
that teams complying with F-MARC programs (particularly the
FIFA 11+ program) could reduce injury rates by up to 50% compared
with teams that did not follow the program recommendations. The
FIFA 11+ program led to a statistically significant reduction in
injuries. The pooled injury risk ratio (IRR) was 0.65 (95% CI 0.54 to
0.80) for all injuries and 0.61 (95% CI 0.48 to 0.79) for lower-
extremity injuries.
The effects of the FIFA 11+ protocol when used both before and
after training sessions have not been investigated and may be
important. Participating in the FIFA 11+ program before and after
soccer training sessions may further challenge and expose the
athlete to physiological conditions known as ‘game-like’ condi-
tions. Muscle injuries frequently occur just before the end of each
half, and this has been linked to fatigue.15,16 Therefore, the effect of
injury prevention training under fatigued conditions has been
examined. Malliou and colleagues17 investigated the incidence
of injuries in dance aerobics instructors based on the duration of
pre-training and post-training exercises. They found that partici-
pants who completed post-training exercises had a lower injury
rate than those who did not. The rate of injury was even lower
among those who performed both pre-training and post-training
exercises.
In the long term, teams involved in the injury prevention
program may gain some competitive advantages. The FIFA 11+
program was designed to be a pre-training ‘warm-up’ before soccer
training sessions, with the intention of ensuring proper technique
and improved neuromuscular coordination. However, it could
be hypothesised that training in a fatigued state (post-training)
might help players learn to control their movements while in
this fatigued state, thereby providing a mechanism for reducing
injury.18 A prospective study by Verrall and colleagues19 indicated
that increasing the amount of anaerobic interval training,
stretching while the muscle is fatigued, and implementing
sport-specific training drills resulted in a significant reduction in
the number and consequences of hamstring injuries per
1000 hours of playing time (RR 0.267, 95% CI 0.076 to 0.764).
The findings from Small and colleagues20 demonstrated that
performing post-training, as well as pre-training, eccentric
hamstring strengthening exercises (a part of the FIFA 11+ program)
during soccer practice sessions assisted in maintaining eccentric
hamstring strength and preserved the functional strength ratios.
The study showed a significant reduction in the negative influence
of fatigue on hamstring strength. Moreover, Gioftsidou and
colleagues21 investigated whether the effectiveness of a balance
program was affected by its performance before and after soccer
training. They found that the balance program significantly
increased the balance ability when performed before and after
soccer training, compared with no intervention. Moreover, the
improvement in balance ability was significantly greater when the
balance program was performed after soccer training.
There is some evidence that a post-training exercise program
increases muscle flexibility more than if performed as pre-training,
and thereby assists in reducing muscle injury and improving
performance.17,19,20,22 However, many soccer players and coaches
do not include post-training exercises as part of their training
sessions.23 Although post-training exercises can be similar to pre-
training exercises, they differ only by having a lower level of
intensity and can be completed in approximately 10 minutes.17,19,22
Injury rates during match time are usually higher than those
during training, and this may be attributed to fatigue, which can
cause functional neuromuscular decline. If players perform
neuromuscular strengthening exercises after being exposed to a
match-like workload, it may condition their bodies to physical
activity under a fatigued state, which may reduce their injury risk.
Please cite this article in press as: Al Attar WSA, et al. Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+
injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. (2017),
http://dx.doi.org/10.1016/j.jphys.2017.08.004
Based on this hypothesis, research conducted to investigate the
benefits of a post-training exercise program among soccer players
is appropriate.14
Therefore, the research question for this randomised trial was:
Does adding post-training FIFA 11+ exercises (in addition to the
traditional pre-training FIFA 11+ exercises) reduce the incidence
of injuries among male amateur soccer players?
Method
Design
This study was a cluster-randomised, controlled trial comparing
the effectiveness of the FIFA 11+ program used before training
versus before and after training in preventing injury among male
amateur soccer players. The unit of randomisation was the soccer
team, with the intervention delivered at the team level. After
coaches and players agreed to participate, their teams were
randomly allocated to either the experimental or control group by
an online research randomiser. The randomisation process was
undertaken after every enrolling team had been identified, thus
achieving concealed allocation. Coaches and players were aware of
implementing an injury prevention program but unaware of the
difference in the program that had been allocated to the alternate
group. The purpose and methods of this trial were explained to the
coaches and medical staff (the team physician and physiotherapist)
of the participating teams. Individual players within teams were
tracked and the number of injuries recorded for each player. The
reporting of this study followed the Consolidated Standards of
Reporting Trials (CONSORT) guidelines.24
Participants, therapists and teams
Teams competing at either of two levels (Amateur Premier
Leagues and State League) in New South Wales, Australia were
invited to participate. These teams generally play one or two
matches per week and have two or three training sessions per
week. The invitation letters were sent through Football New South
Wales to the registered soccer clubs. Teams of male amateur soccer
players within the age range of 14 to 35 years were eligible for
inclusion. Three exclusion criteria were applied to players within
teams: commencing participation in a team after the start of the
trial; a medical history of lower extremity injury that required
medical attention in the past 6 months; and systemic disease,
cardiovascular disease, neurological disorders, bone fractures, or
surgery in the previous year. No anthropometric data were
collected. Before randomisation, all participants were asked to
read and sign an informed consent form that explained in detail:
the purpose of the study; what participation in the study would
involve; protection of privacy and confidentiality; expected
outcomes; and further use of the results.
Intervention
The experimental group was instructed to perform the FIFA 11+
program as pre-training exercises for 20 minutes before training
sessions and for 10 minutes as post-training exercises after
training sessions, two to three times per week for one season
(6 months). To investigate the effect of adding post-training
FIFA 11+ exercises to the pre-training FIFA 11+ exercises on the
incidence of injuries, the control group was instructed to perform
the FIFA 11+ program as pre-training exercises for 20 minutes
before training sessions only. The investigator visited one team
selected randomly from each group each week throughout the
study period (once a week for the control group and twice a
week for the experimental group) to motivate the teams and to
ensure that the program was being followed conscientiously and
correctly. The post FIFA 11+ exercise program included three
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Research 3

Table 1
Pre-training exercises (used by both intervention groups) and post-training exercises (used by the experimental group only).

FIFA 11+ pre-training exercises Sets FIFA 11+ post-training exercises Sets
20 min 10 min

Part 1 Running exercises Part 1 Jogging exercises

8 min 4 min

1 Running, straight ahead 2 1 Jogging, straight ahead 1

2 Running, hip out 2 2 Jogging, hip out 1
3 Running, hip in 2 3 Jogging, hip in 1
4 Running, circling partner 2 4 Jogging, circling partner 1
5 Running, jumping with shoulder contact 2 5 Jogging, jumping with shoulder contact 1
6 Running, quick forwards and backwards 2 6 Jogging, forwards and backwards 1

Part 2 Strength, plyometric and balance exercises Part 2 Strength, plyometric and balance exercises
10 min 5 min

7.1 The bench, static 3 7.1 The bench, static 1

7.2 The bench, alternate legs 3 7.2 The bench, alternate legs 1
7.3 The bench, one leg lift and hold 3 7.3 The bench, one leg lift and hold 1
8.1 Sideways bench, static 3 8.1 Sideways bench, static 1
8.2 Sideways bench, raise and lower hip 3 8.2 Sideways bench, raise and lower hip 1
8.3 Sideways bench, with leg lift 3 8.3 Sideways bench, with leg lift 1
9.1 Nordic hamstring, beginner 1 9.1 Nordic hamstring, beginner 1
9.2 Nordic hamstring, intermediate 1 9.2 Nordic hamstring, intermediate 1
9.3 Nordic hamstring, advanced 1 9.3 Nordic hamstring, advanced 1
10.1 Single-leg stance, hold the ball 2 10.1 Single-leg stance, hold the ball 1
10.2 Single-leg stance, throwing ball 2 10.2 Single-leg stance, throwing ball 1
10.3 Single-leg stance, test your partner 2 10.3 Single-leg stance, test your partner 1
11.1 Squats, with toe raise 2 11.1 Squats, with toe rise 1
11.2 Squats, walking lunges 2 11.2 Squats, walking lunges 1
11.3 Squats, one-leg squats 2 11.3 Squats, one-leg squats 1
12.1 Jumping, vertical jumps 2 12.1 Jumping, vertical jumps 1
12.2 Jumping, lateral jumps 2 12.2 Jumping, lateral jumps 1
12.3 Jumping, box jumps 2 12.3 Jumping, box jumps 1

Part 3 Running exercises Part 3 Jogging exercises

2 min 1 min

13 Running, across the pitch 2 13 Jogging, across the pitch 1

14 Running, bounding 2
15 Running, plant and cut 2

major categories similar to the pre FIFA 11+ exercises, but included
jogging activity rather than running activity. These categories
were: jogging exercises (4 minutes); strength, plyometric and
balance exercises (5 minutes); and jogging exercises (1 minute).
The pre-training FIFA 11+ exercises were comprised of 15 sub-
categories while the post-training FIFA 11+ exercises were
comprised of 13 subcategories, to avoid excessive fatigue. Table 1
shows the pre-training FIFA 11+ exercises used by both groups and
the post-training FIFA 11+ exercises used by the experimental
group. During the pre-competition season (January to March
2016), both groups were informed about the positive results of
using the FIFA 11+ program, which included reduced incidence of
injury during practice sessions. Prior to the competition season
(April to September 2016), teams were randomly allocated to the
experimental and control groups. Coaches and players from each
team in the experimental group were instructed to apply the
program before and after each training session in their soccer field.
Coaches delivered the prescribed program (three times per week
during the season) and recorded players’ weekly participation in
training sessions and matches. In addition, coaches in both the
experimental and control groups reported injuries during training
and matches by filling in forms once per week and submitting
the information using the Sports Injury Tracker injury reporting
form (Sports Medicine Australia). The team coach or the team
physiotherapist monitored the exercise program and was also
responsible for reporting all injuries. Injuries were defined
according to a consensus statement on injury definitions and data
collection procedures in soccer studies; an injury was recorded if it
caused the player to be unable to completely participate in the
following match or training session.25
Exposure time
Exposure time in hours was calculated for each team over a
6-month period. Match exposure was calculated as (NMPMDM)/60,
where NM was the total number of matches played, PM was the
number of players on the team (normally 11), and DM was the
duration of the match in minutes (90 minutes in a full game).
Training exposure was calculated as (PTDT)/60 for every training
session throughout the study, where PT was the total number of
players who attended per training session and DT was the duration
of the training session in minutes (mostly 2 hours per session).25
The pre-training FIFA 11+ program (20 minutes per session) and
the pre- and post-training FIFA 11+ program (30 minutes per
session) were recorded and added to calculate training exposure.
Outcome measures
The primary outcomes that were registered were: incidence of
overall injuries; incidence of initial and recurrent injuries; and
injury severity. Injury rates were summarised as number of
injuries per 1000 player-hours for both matches and training.
Injury severity was defined as time loss in days: minor (1 to 7 days
lost), moderate (8 to 21 days lost), or severe (>21 days lost). The
secondary outcome measure was compliance to the experimental
and control interventions. Program compliance was evaluated
according to the players’ rate of participation.
Data analysis
Data were imported into an electronic spreadsheeta for basic
calculations of exposure time and incident rate. The data were then
exported for analysis to commercial statistical analysis softwareb
for advanced analysis. A General Estimating Equation (GEE)
Poisson regression with an intention-to-treat (ITT) analysis was
performed to compare the effect of the interventions on the
number of total injuries incurred for each player. A GEE binary
logistic regression with ITT analysis was used for initial and
recurrence injury rates analysis. A GEE cumulative logistic
regression with ITT analysis was used for injury severity analysis.

Please cite this article in press as: Al Attar WSA, et al. Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+
injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. (2017),
http://dx.doi.org/10.1016/j.jphys.2017.08.004
G Model
JPHYS-363; No. of Pages 8

4 Al Attar et al: Pre and post-training FIFA 11+ program

A GEE binomial regression with ITT analysis was used for age group
analysis. This method accommodates the fact that players are
nested within teams (clusters) and they are therefore not
independent units. The GEE methods are also less dependent
upon assumptions relating to normality of distribution. The ITT
analysis includes all data that were obtained from each team and
analysed each team’s data in the group to which that team was
randomised, regardless of whether that team received the
allocated intervention.26
A power analysis was performed to retrospectively check that
the sample size was adequate. The number needed to treat was
used as a measure to assess the effectiveness of the intervention.
The number needed to treat is commonly used in healthcare
research to report the impact of a new intervention on a
dichotomous outcome.27 In this trial, the number needed to treat
was the average number of players who needed to be prescribed
the pre- and post-training FIFA 11+ program to prevent one injury
that would have occurred among players prescribed the pre-
training FIFA 11+ program. The number needed to treat is the
inverse of absolute risk reduction, which is calculated as the
difference between one treatment comparison group’s event rate
and another comparison group’s event rate. The effect size was
computed from the Coefficient of Determination (R2).28 The IRR,
which is now considered a new standard for analysing the efficacy
of injury prevention programs,14,29–31 was calculated as:
IRR ¼ ðnumber of injuries in the experimental group=
hours of total exposureÞ=ðnumber of injuries in the
control group=hours of total exposureÞ:
Results
Flow of participants, therapists and teams through the study
From January 2016 to March 2016, during the pre-competition
season, 45 teams were assessed for eligibility; however, 24 teams
declined to participate. Prior to the competition season, from
April 2016 to September 2016, 21 teams were randomly assigned
to the experimental or control group. The description of team
randomisation, the flow of participants through the study, reasons
for ineligibility and follow-up are presented in Figure 1.
Compliance with the trial protocol
One experimental team and three control teams withdrew from
the study due to limited training time. However, all their available
data were included (ie, before they withdrew) to ensure an ITT
analysis. Complete data were available from 17 teams: nine teams
in the experimental group (144 players) and eight teams in the
control group (136 players). The ITT analysis included 160 players
in the experimental group and 184 players in the control group.
Characteristics of participants
The characteristics of the teams and players that participated in
the trial are summarised in Table 2. The experimental and control
groups were similar in their age distribution, level of competition,
and personnel available to manage injuries. Match and training
exposure times were similar between the groups, as presented in
Table 3.
Effect of intervention
Injury rate per 1000 player-hours
Among the 136 players in eight teams in the control group,
44 reported a total of 82 injuries in approximately 31 540 exposure
hours (2.6 injuries/1000 exposure hours). Among the 144 players
in nine teams in the experimental group, 19 reported a total of
26 injuries in approximately 35 620 exposure hours (0.73 injuries/
1000 exposure hours) (Table 4). These injuries are presented
according to body location, mechanism of injury and severity in
Tables 5 and 6, where the data are also presented for the teams who
withdrew during the monitoring period. The de-identified
individual participant data are presented in Table 7 (see eAddenda
for Table 7). For further transparency, a detailed statistical analysis
report is presented in Appendix 1 and the data and syntax files
used in the analysis are presented in Appendices 2 and 3 (see
eAddenda for Appendices 1 to 3).

Assessed for eligibility

(n = 45 teams)

Excluded (n = 24 teams)
• declined (n = 24 teams)

Randomised (n = 21 teams, 344 players)

Month 0
(n = 10 teams, 160 players) (n = 11 teams, 184 players)

Experimental group Control group

Lost to follow-up (n = 1 • pre-training FIFA Lost to follow-up (n = 3
• pre-training and
team, 16 players) post-training FIFA 11+ program teams, 48 players)
11+ program • 2 to 3 sessions
• 2 to 3 sessions per week
per week • 6 months
• 6 months

Measured injury occurrence, injury severity, and compliance

(n = 9 teams, 144 players) (n = 8 teams, 136 players)

Month 6
Intention-to-treat analysis of all data collected during participation

(n = 10 teams, 160 players) (n = 11 teams, 184 players)

Figure 1. Design and flow of participants through the trial.

FIFA = Fédération Internationale de Football Association.

Please cite this article in press as: Al Attar WSA, et al. Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+
injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. (2017),
http://dx.doi.org/10.1016/j.jphys.2017.08.004
G Model
JPHYS-363; No. of Pages 8

Research 5

Table 2 Table 5
Baseline characteristics of the participating teams and players. Injury rates by body location, mechanism of injury, and severity (defined as time
loss in days) for the experimental and control groups that completed the study.
Characteristic Exp Con
(n = 160) (n = 184) Injury Exp Con
(n = 9 teams, (n = 8 teams,
Teams (n) 10 11
144 players) 136 players)
Players per team (n), mean (SD) 16 (1) 17 (1)
Age of players (yr), mean (SD) 18 (6) 16 (4) Injuries Incidence Injuries Incidence
Level of competition, n (%) of teams (n) (injuries/1000 h) (n) (injuries/1000 h)
Amateur Premier Leagues 7 (70) 10 (91)
Body location
State League 3 (30) 1 (9)
head/neck 1 0.028 2 0.063
Medical personnel, n (%) of teams
shoulder 1 0.028 2 0.063
Doctor 1 (8) 1 (6)
arm 1 0.028 1 0.032
Physiotherapist 2 (15) 4 (25)
elbow 1 0.028 1 0.032
Trainer 10 (77) 11 (69)
forearm 0 0.000 1 0.032
Con = control group, Exp = experimental group. wrist 1 0.028 2 0.063
chest 2 0.056 2 0.063
trunk/abdomen 1 0.028 8 0.253
lower back/pelvis/sacrum 4 0.112 8 0.253
Table 3 hip/groin 1 0.028 6 0.189
Player-hours of exposure among the teams that completed the study. quadriceps 1 0.028 6 0.189
hamstring 2 0.056 9 0.284
Exposure variables Total Mean (SD) Mean diff
knee 4 0.112 13 0.411
(hr) per team (95% CI)
lower leg/Achilles tendon 1 0.028 6 0.189
(hr)
ankle 4 0.112 12 0.379
Exp Con Exp Con Exp minus Con foot/toe 1 0.028 3 0.095
(9 teams) (8 teams) Mechanism of injury
contact 21 0.586 55 1.739
Match exposure 7722 6864 858 (15) 858 (15) 0 (–15 to 15)
non-contact 5 0.139 27 0.854
Training exposure 28 080 24 752 3120 (13) 3094 (8) 964 (953 to 975)
Type of injury
Overall exposure 35 802 31 616 3978 (16) 3952 (17) 26 (9 to 43)
initial 24 0.670 75 2.372
Con = control group, Exp = experimental group. recurrent 2 0.056 7 0.221
Time loss (d)
1 to 7 19 0.530 64 2.024
8 to 21 4 0.112 11 0.347
The IRR was 0.28, which was statistically significant (95% CI >21 3 0.084 7 0.221
0.18 to 0.44). The IRR of 0.28 indicated a 72% reduction in injuries in All injuries 26 0.726 82 2.593
the experimental group compared with the control group. A power Con = control group, Exp = experimental group.
analysis revealed that the power of the test was nearly 1.0,
indicating that the sample size was sufficient. The number needed getting an injury in the control group were significantly greater
to treat was calculated to be five; meaning that for every five than in the experimental group, OR = 2.47 (95% CI 1.37 to 4.46).
players that received the experimental intervention, one injury
was prevented.
Incidence of recurrent injury
The GEE binary logistic regression with an ITT approach
Total number of injuries sustained by players indicated that the odds of suffering a recurrent injury were not
The Poisson GEE logistic regression with an ITT approach significantly different between the two groups, x2 (1) = 2.350,
showed that the pre- and post-training FIFA 11+ program reduced p = 0.125. The odds of a player in the experimental group suffering
the number of injuries sustained by players more than the pre- a recurrent injury were 0.320 times those of a player in the control
training FIFA 11+ program alone, x2 (1) = 11.549, p = 0.001. The group (95% CI 0.075 to 1.373).
mean number of injuries per player was 2.77 times higher for
players in the control group than the experimental group (95% CI
Injury severity
1.54 to 4.98).
Severity was classified into one of three categories, depending
upon the recommended length of time that a player should refrain
Incidence of initial injury
Table 6
The GEE binary logistic regression with an ITT approach Injury rates by body location, mechanism of injury, and severity for the lost to
indicated that the pre- and post-training FIFA 11+ program follow-up experimental and control group teams.
reduced the incidence of initial injury more than the pre-training
Injury Lost to follow-up Exp Lost to follow-up Con
FIFA 11+ program alone, x2 (2) = 8.987, p = 0.003. The odds of (n = 1 teams, 16 players) (n = 3 teams, 48 players)

Injuries Incidence Injuries Incidence

Table 4 (n) (injuries/1000 h) (n) (injuries/1000 h)
Injury rates by teams for the control and experimental group teams that completed Body location
the study. hip/groin 0 0.000 1 0.628
hamstring 0 0.000 1 0.628
Exp teams Injuries Incidence Con Injuries Incidence
knee 0 0.000 2 1.256
(n) (injuries/1000 h) teams (n) (injuries/1000 h)
ankle 1 1.485 0 0.000
1 6 0.167 1 6 0.189 Mechanism of injury
2 6 0.167 2 10 0.316 contact 0 0.000 2 1.256
3 5 0.139 3 10 0.316 non-contact 1 1.485 2 1.256
4 3 0.084 4 9 0.284 Type of injury
5 2 0.056 5 10 0.316 initial 1 1.485 4 2.512
6 2 0.056 6 9 0.284 recurrent 0 0.000 0 0.000
7 0 0.000 7 14 0.442 Time loss (d)
8 0 0.000 8 14 0.442 1 to 7 1 1.485 3 1.884
9 2 0.056 8 to 21 0 0.000 1 0.628
All injuries 26 0.726 All injuries 82 2.593 >21 0 0.000 0 0.000
All injuries 1 1.485 4 2.512
Con = control group, Exp = experimental group.

Please cite this article in press as: Al Attar WSA, et al. Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+
injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. (2017),
http://dx.doi.org/10.1016/j.jphys.2017.08.004
G Model
JPHYS-363; No. of Pages 8
6 Al Attar et al: Pre and post-training FIFA 11+ program
Figure 2. Profile plot showing the difference in the effect of the intervention across
three different age groups of players.
Con = control group, Exp = experimental group.
from practising in order to allow for sufficient time to heal. For a
player that received multiple injuries, the maximum length
recommended for any injuries to heal was used to determine
the category into which he was classified. The GEE cumulative
logistic regression analysis with an ITT approach showed that there
was no evidence that the severity level of injuries was dependent
upon whether the pre and post FIFA 11+ program or the pre
FIFA 11+ program was implemented, x2 (1) = 0.016, p = 0.898.
Age group
The players participated with teammates in their own age up
until the age of 17 years. Players aged 18 year participated
together with no age restrictions. For the purposes of this study,
three age groups were created: 14 to 15 (n = 179), 16 to 17 (n = 119),
and >18 (n = 46). This factor variable was added to the GEE
binomial regression with an ITT analysis. The full factorial model
revealed that the interaction between intervention and age group
was highly significant, x2 (2) = 9.268, p < 0.001. In the control
group, the rate of initial injuries rose with age, while in the
experimental group it fell. This effect is clearly illustrated in the
profile plot shown in Figure 2.
Compliance with the programs
The nine teams in the experimental group performed the pre
and post FIFA 11+ program in 65 out of 78 (83%) training sessions.
The eight teams in the control group performed the FIFA 11+
program in 60 out of 78 (77%) training sessions. The GEE binary
logistic regression with an ITT analysis showed that the odds of
compliance were not significantly different between the two
groups, x2 (1) = 0.851, p = 0.356. The odds of compliance by a player
on a team in the control group were 0.315 lower than the odds
of compliance by a player on a team in the experimental group.
However, with a 95% CI of 0.027 to 3.671, that difference was not
statistically significant.
Discussion
The FIFA 11+ program was designed as an effective, adequate,
and complete warm-up program to minimise injuries on the soccer
field. However, the pre- and post-training FIFA 11+ program
resulted in a further decrease in the risk of overall injuries for
soccer players aged 14 to 35 years compared with the traditional
pre-training FIFA 11+ program. This conclusion was supported by
the main results of this randomised trial. It is important to indicate
that this is a novel study because no prior studies have evaluated
the effectiveness of the FIFA 11+ program when used both before
and after training in soccer, while the traditional FIFA 11+ program
has shown its efficacy in many previous studies.8–14
Please cite this article in press as: Al Attar WSA, et al. Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+
injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. (2017),
http://dx.doi.org/10.1016/j.jphys.2017.08.004
The findings of this randomised trial indicated that using the
FIFA 11+ program before and after training had a greater impact on
reducing injuries than the traditional FIFA 11+ program among
male amateur soccer players aged 14 to 35 years. However, there
was no strong evidence of a significant decrease in the rate of
recurrent injuries for players participating in the pre- and post-
training FIFA 11+ program. Also, for players suffering an initial
injury, there was no evidence that the pre- and post-training
FIFA 11+ program affected the severity of the injury. Moreover,
the pre- and post-training FIFA 11+ program showed a larger drop
in injury rate among older players (ie, the 16 to 17 year and
>18 year subgroups) than the younger ones (14 to 15 year
subgroup). That could be because of the effect of maturation.
Many studies32–36 have reported that the stage of maturation was
associated with the occurrence of sports injuries.
The pre- and post-training FIFA 11+ program showed potential
benefits with two to three training sessions per week for soccer
players. Grooms and colleagues12 indicated that performing the
FIFA 11+ program five to six times per week could reduce lower
extremity injuries by 82%, while Hammes and colleagues9 did not
show these benefits with one session per week. The efficacy of the
pre- and post-training FIFA+ injury prevention program is related
to the degree of compliance; that is, the greater the compliance, the
greater the reduction in injuries.8,37 For instance, several studies
have shown that the more frequently neuromuscular training
programs are implemented, the lower the reported injury
rate.8,11,12 This was obvious in two studies conducted by Steffen
and colleagues,8,38 in which compliance was 52% with the FIFA
11 program versus 85% with the FIFA 11+ program. The low number
of sessions per week and compliance in the FIFA 11 program were
significant limiting factors. Moreover, Steffen and colleagues8
found that the risk of injury was inversely associated with the
degree of compliance (IRR = 0.32, 95% CI 0.11 to 0.95). Therefore,
when compliance to a pre- and post-training injury prevention
program is neglected, the potential of the program to be effective is
limited. Thus, the pre- and post-training FIFA 11+ program in the
experimental group was monitored by this study’s investigator for
the purpose of ensuring full implementation of the program’s steps
among participants of the experimental group.
In a randomised trial, Impellizzeri and colleagues39 investigated
the long-term training effects of the FIFA 11+ program. The results
showed that performing the FIFA 11+ program improved neuro-
muscular control, time to stabilisation, and knee flexor strength.
Furthermore, other studies40–43 have found improvements in
static/dynamic balance and thigh muscle strength in male soccer
and futsal players after performing the FIFA 11+ program.
Gioftsidou and colleagues21 found that the balance program
significantly increased the balance ability when performed before
and after soccer training; the improvement in balance ability was
significantly greater when the balance program was performed
after training. The pre- and post-training FIFA 11+ program,
compared to the traditional FIFA 11+ program, may provide extra
focus on core stability, balance, and neuromuscular control as well
as hip control and knee alignment that avoids excessive knee
valgus during both static and dynamic movements. These factors
are likely key mechanisms for explaining the injury prevention
effects of the new pre- and post-training FIFA 11+ program.
Therefore, this significant result should encourage implementation
of the post-training FIFA 11+ exercises as an extra phase to the
traditional program.
This research had some limitations. First, the study’s investiga-
tor monitored compliance with the allocated intervention among
the experimental group teams more frequently than among the
control group teams. This was done to ensure full implementation
of the program’s steps among participants of the experimental
group after training. Close monitoring of the post-training use of
the intervention was deemed necessary, due to the players being
unaccustomed to having a cool-down and therefore a possible
tendency, particularly when fatigued, to not comply fully on
every occasion. In contrast, players are accustomed to having a
G Model
JPHYS-363; No. of Pages 8
Research
pre-training warm-up and recognise the need to prepare the body
for the rigours of the forthcoming training session. Indeed, the
random monitoring of the control group pre-training compliance
was shown to be sufficient to achieve a high level of compliance to
the pre-training FIFA 11+ program. A second limitation was that the
analysis did not factor in engagement in other sports or playing
soccer outside the team. Factoring in all physical activity may vary
injury rates, as the exposure time data change.
This randomised trial provides evidence that implementation
of the pre- and post-training FIFA 11+ program can reduce overall
injury rates in amateur male soccer players more than the pre-
training FIFA 11+ program alone, and this may lead to a reduction in
the financial burden of injury-related health costs. This is the first
randomised trial to report the efficacy of the pre- and post-training
FIFA 11+ program in preventing injuries among male amateur
Australian soccer players. These results suggest that teams using
the pre- and post-training FIFA 11+ injury prevention program can
reduce injury rates in the long term compared with teams using
the pre-training FIFA 11+ program alone. Moreover, the increased
exposure to the FIFA 11+ program that comes with adding the
post-training component translates (perhaps via improving the
strength and function of the neuromuscular system) into a
reduction in injuries.
What is already known on this topic: The FIFA 11+ injury
prevention program is a highly effective program that reduces
overall injury risk among soccer players. Meta-analysis of
existing data indicates that use of the FIFA 11+ program before
training sessions significantly reduces the pooled injury risk
ratio for all injuries, and specifically for lower-extremity inju-
ries.
What this study adds: Compared to use of the FIFA 11+
program before training sessions only, use of the program
before and after training sessions reduced the rate of injuries in
male amateur soccer players. On average, for every five players
who use the program before and after training sessions, one
injury will be prevented that would have occurred with use of
the program only before training sessions. The severity of the
injuries that occurred was not reduced by the additional use of
the FIFA 11+ program after training sessions.
Footnotes: a Microsoft Excel 2010, Microsoft Corporation,
Redmond, Washington, USA. b Statistical Package for the Social
Sciences (SPSS) version 24.0, SPSS Inc, Chicago, Illinois, USA.
eAddenda: Table 7 and Appendices 1, 2 and 3 can be found
online at: http://dx.doi.org/10.1016/j.jphys.2017.08.004
Ethics approval: The study received ethical approval from the
University of Sydney Human Research Ethics Committee, Project
No. 2015/94. Informed consent was obtained from each participant
in the study before data collection began.
Competing interests: Nil.
Source of support: Nil.
Acknowledgements: The authors would like to acknowledge
Philip Brown, Head of Football New South Wales, for distributing
the study invitation to soccer clubs registered with Football New
South Wales and encouraging them to participate. Thanks to the
coaches and players who participated in this project.
Provenance: Not invited. Peer reviewed.
Correspondence: Wesam Saleh A Al Attar, Discipline of Exercise
and Sport Science, Faculty of Health Sciences, The University of
Sydney, Australia. Email: wala3431@uni.sydney.edu.au
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Websites
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Please cite this article in press as: Al Attar WSA, et al. Adding a post-training FIFA 11+ exercise program to the pre-training FIFA 11+
injury prevention program reduces injury rates among male amateur soccer players: a cluster-randomised trial. J Physiother. (2017),
http://dx.doi.org/10.1016/j.jphys.2017.08.004