Laird Harrison

June 02, 2016

BOSTON — A short warm-up can reduce the risk for sports-related knee injuries in teenage girls, a new head-to-head trial shows.

A program called FIFA 11+ was developed in response to a spiraling rate of anterior cruciate ligament tears in teenage girls by the Fédération Internationale de Football Association (FIFA). It takes teams about 20 minutes to work their way through the series of exercises before each practice.

Multiple randomized controlled trials have shown that FIFA 11+ can reduce lower-extremity injuries by 50% or more in both male and female athletes, as previously reported by Medscape Orthopedics.

But less than 20% of high-school coaches report adopting the program, said Jessica Martinez, PhD, from Northern Illinois University in DeKalb. "Athletes are saying 20 minutes is too long," and some coaches can't perform the exercises so they feel they can't teach them, she explained.

Dr Martinez and her colleagues wanted to know whether similar benefits could be achieved with a shorter exercise program. She presented the study results here at the American College of Sports Medicine 2016 Annual Meeting.

A Shorter Program in Half the Time

The researchers recruited 76 healthy girls 14 to 16 years of age who played field hockey, soccer, or volleyball.

One-third of the girls were randomly assigned to the focused 10-minute program. Like FIFA 11+, it consisted of flexibility, core, agility, plyometric, strengthening, and balance exercises in three planes of motion. And also like FIFA 11+, it included feedback about proper form and provided instruction such as bend your knees, keep your knees over your toes, keep your toes pointed straight ahead, and keep your hips square.

One-third of the girls were assigned to a control warm-up program, which consisted of movements similar to what they were already performing at team practices, such as high knees, inchworms, butt kicks, and lunges.

And one-third of the girls were assigned to FIFA 11+.

In the fall of 2014, Dr Martinez and her colleagues videotaped the girls as they jumped at baseline, before the 8- to 10-week sports season began, and at follow-up, after the season ended. They used the Landing Error Scoring System — which lists 20 possible landing errors, such as failing to bend knees, bending at the waist, and abducting knees — to rate the girls.

The reduction in errors was greater in the FIFA 11+ group than in the focused 10-minute group or the control group, but the difference was not significant (P = .32).

There were more injuries in the control group than in the other groups, but this was also not significant, Dr Martinez reported.

The 21 girls who made at least five errors at baseline were classified as high risk on the basis of previous studies showing a correlation between a high number of errors and an increased incidence of injury.

The reduction in errors was significantly greater in the high-risk girls than in the other girls (P < .001). However, the reduction in the number of errors was not significantly different among the three groups.

Table. Number of Landing Errors Over the Sports Season

Group Baseline, n Follow-up, n Reduction, n
Focused 7.22 5.33 1.89
FIFA 11+ 6.79 4.92 1.87
Control 7.05 5.00 2.05
Overall 7.00 5.06 1.94


The study was not blinded because all the warm-ups took place at central locations, which is a limitation, the researchers acknowledge.

Still, it shows the promise for short warm-up programs, Dr Martinez said. Despite the lack of a statistical differences in the study, she said she advises athletes to do a combination of plyometric, stretching, strengthening, and agility exercises in multiple planes. "It's been shown you can't just do one of them," she pointed out.

"The take-home message is that you need to do warm-up," she told Medscape Medical News.

This study shows that warm-up programs do improve landing patterns in athletes, said Blaise Dorsey Williams, PhD, from Virginia Commonwealth University in Richmond, who was not involved in the study.

But it also illustrates the difficulty of researching injury-prevention exercises. "They did not have a true control group," he pointed out. "They couldn't because they were working with teams that already had a warm-up program."

Dr Williams told Medscape Medical News that he is currently testing such exercises as a way of reducing injuries in runners.

The study was funded by the National Athletic Trainers Association. Dr Martinez and Dr Williams have disclosed no relevant financial relationships.

American College of Sports Medicine (ACSM) 2016 Annual Meeting: Abstract 1003. Presented June 2, 2016.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: