preventing injuries in soccer players by conducting a by lindash


									type=editorial in-section=editorial id=broj612234 in-journal=bmj elocation-id=a2381
Warm-up programmes in sport
John H M Brooks(A1)
rugby football union injury risk analyst
Samuel J Erith(A2)
head of sports science
      Rugby Football Union, Twickenham TW1 1DS
    Tottenham Hotspur Football Club, Chigwell, Essex IG7 5AB
Research, doi:10.1136/bmj.a2469
Can reduce injury, and should be recommended at all levels of participation
  Injuries sustained by participants in team sports place a considerable burden on medical
services,(1)   (2)
                     and they often disrupt the lives of those injured. Evidence based strategies to
prevent injury should therefore be encouraged. Sports teams often perform a warm-up routine
with the dual purpose of improving performance and reducing the risk of injury. Although the
theory that warming up effectively will reduce the risk of injury makes sense, data from the
sports medicine literature are equivocal, and this theory has rarely been proved through
randomised control trials.(3)
     In the linked study (doi:10.1136/bmj.a2469), Soligard and colleagues report a cluster
randomised controlled trial of an injury prevention programme in young female football
players in Norway.(4) A 20 minute warm-up intervention was conducted before training
sessions and matches. The warm-up routine consisted of a series of exercises focusing on
awareness and neuromuscular control during active movements. The routine is referred to as
the “11+” and is a development of the “11” series of exercises devised by the medical
department of FIFA (Fédération Internationale de Football Association).(5) The control group
warmed up as usual and did not report using similar exercises to those incorporated in the
11+. Although the primary outcome of injuries to the lower extremity was not significantly
different between groups, overall injuries (rate ratio 0.68), overuse injuries (0.47), and severe
injuries (0.55) were all significantly lower in the intervention group than in the control group.
     An important finding from this study was that teams using the 11+ warm-up reported a
significantly lower incidence of severe injuries (>28 days’ absence from soccer). These
injuries cause the greatest total absence from sport of all injuries,(6) interfere with people’s
normal lives, and place a greater burden on scarce medical resources than more minor
injuries do. The average participant performed only 12 sessions of the 11+ warm-up during

the study, so the programme may reduce the injury rate even more with prolonged and
regular use.
   Previous studies investigating the effect of warming up on the risk of injury have focused
on key warm-up elements—raising the core temperature, stretching the muscles used, and
conducting movement specific exercises—but the effect on injury has been inconclusive.(3)
The 11+ incorporates these key warm-up elements plus additional training exercises with
progressions for competent athletes. These exercises aim to improve the players’ core
stability, strength, and proprioception. Other randomised controlled trials in female football
players that used similar elements of the 11+ training programme have shown significant
reductions in injuries,(7) specifically injuries to the anterior cruciate ligament.(8)   (9)

Consequently, these additional training elements in the 11+ programme probably contributed
to the reduced injury rate in the intervention group.
   Adherence to the 11+ programme in this study was no doubt helped by the comprehensive
resource package, including step by step diagrams and DVDs. The variety of exercises and
progressions in the 11+ also helps maintain the interest of participants, as shown by the high
rate of compliance (77%). The generic nature of this material make it suitable for use in other
sports, although its effectiveness would need to be investigated. This study focused on
football among young female players, which is rapidly growing in popularity. Female players
have similar injury rates to male players, although the risk of serious injury may be higher,(10)
making this study highly relevant to this population.
   The health benefits of undertaking regular physical activity are clear, but participation in
any sport carries the risk of injury. One vital aspect of sports medicine is to reduce morbidity
and the burden of sports injuries on medical services worldwide. A comprehensive warm-up
routine is a recognised but unproved component in sports injury prevention and is widely
used by sportspeople throughout the world.
   Practical and effective warm-up and training routines such as the 11+ should be brought to
the attention of the wider sporting population—clinicians should encourage people working
within sport and participants themselves to engage in such preventative initiatives. The
current study shows that a 20 minute comprehensive warm-up with training elements can
significantly reduce injury risk during sport and should be used by participants at all levels.
Increasing awareness and evidence of the benefits of such strategies will increase their
widespread use and effectiveness.

Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.
   1 Nicholl JP, Coleman P, Williams BT. The epidemiology of sports and exercise related
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  3 Fradkin AJ, Gabbe BJ, Cameron PA. Does warming up prevent injury in sport? The
      evidence from randomised controlled trials? J Sci Med Sport 2006;9:214-20.
  4 Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini M, et al.
      Comprehensive warm-up programme to prevent injuries in young female footballers:
      cluster randomised controlled trial. BMJ 2008;337:a2469.
  5 Dvorak J, Junge A. Football medicine manual. Zurich: F-MARC, 2005.
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  7 Heidt RS, Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX. Avoidance of soccer
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      Effectiveness of a neuromuscular and proprioceptive training program in preventing
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  9 Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers HJ, Griffin LY, et al. A
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  10 Bjordal JM, Arnoy F, Hannestad B, Strand T. Epidemiology of anterior cruciate
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Cite this as: BMJ 2008;337:a2381


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