Available online at www.sciencedirect.

com

Journal of Sport and Health Science 11 (2022) 115 122

Review
Physical exercises for preventing injuries among adult male football players:
A systematic review
omez a, Jos
e Carmelo Adsuar a, Pedro E. Alcaraz b,c, Jorge Carlos-Vivas a,*
Jorge P
erez-G

a
Health, Economy, Motricity and Education (HEME) Research Group, Faculty of Sports Sciences, University of Extremadura, Caceres 10003, Spain
b
UCAM Research Center for High Performance Sport, Catholic University of Murcia, Murcia 30107, Spain
c
Faculty of Sport Sciences, Catholic University of Murcia, Murcia 30107, Spain
Received 22 June 2020; revised 30 August 2020; accepted 17 September 2020
Available online 11 November 2020

2095-2546/Ó 2022 Published by Elsevier B.V. on behalf of Shanghai University of Sport. This is an open access article under the CC BY-NC-ND license.
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Abstract
Background: Football is the most practised sport in the world and is associated with the risk of injuries in the players. Some studies have been
published that identify injury prevention programs, but there is no review of the full body of evidence on injury prevention programs for use by
football coaches. The aim of this article was to carry out a systematic review of published studies on injury prevention programs for adult male
footballers, identify points of common understanding and establish recommendations that should be considered in the design of injury prevention
strategies.
Methods: PubMed and EMBASE databases were used to identify relevant published articles using the following keywords: “soccer” AND
“injury” AND “prevention”.
Results: A total of 2512 studies were identified initially, but only 11 studies met the inclusion criteria, and their outcomes are presented. Results
revealed that injury prevention programs in football have focused on strength training, proprioceptive training, multicomponent programs
(balance, core stability, and functional strength and mobility), and warm-up programs.
Conclusion: Based on results from the studies analyzed, football players can lower the incidence of match and training injuries by participating in
dynamic warm-up programs that include preventive exercises before games or during training sessions, and by adding strength, balance, and
mobility training to the training sessions.
Keywords: Balance; Core stability; Injury prevention programs; Soccer; Warm-up

1. Introduction ranged from 1 to 752 days among professional Dutch football

1 players, with a median of 8 days.9 The time needed to return to
Football is a team sport with a high incidence of injury.
play ranged from 7 to 24 weeks, with an average of 11 weeks,
These injuries are common among both professional2 and non-
among professional football players with serious shoulder inju-
professional football players,3 and some players experience
ries.10 Because having a lower number of injuries has been
extensive time loss associated with an injury.4,5 The average
correlated with team success,11 it is important to reduce them
time to return to play depends on the kind of injury. For
and minimize lost playing time.
instance, obturator muscle injuries need around 12 days of
Injuries in sports have been associated with intrinsic or
recovery for professional football players to return to competi-
extrinsic factors.12 In football, some extrinsic factors are diffi-
tion.2 However, the time needed to return to play after ham-
cult to control, such as contact injuries.13 15 However, it is
string injuries is more variable, ranging from around 14 days6
possible to train for certain predictable intrinsic factors that
to more than 28 days for severe hamstring injuries.7 Specifi-
lead to non-contact injuries.14,16 For example, some epidemi-
cally, an average of 8 to 28 lost playing days were reported for
ology studies have reported on preventable risk factors in pro-
professional Brazilian football players.8 The injury time loss
fessional football players17,18 and highlight the need to
establish injury prevention protocols.5,15,18 To prevent injuries
Peer review under responsibility of Shanghai University of Sport.
* Corresponding author. is extremely important given that a previous injury is a signifi-
E-mail address: [email protected] (J. Carlos-Vivas). cant risk factor for sustaining another injury.19,20 For instance,
https://doi.org/10.1016/j.jshs.2020.11.003
Cite this article: P
erez-G

omez J, Adsuar JC, Alcaraz PE, Carlos-Vivas J. Physical exercises for preventing injuries among adult male football players: A systematic
review. J Sport Health Sci 2022;11:115 22.
116 J. P
erez-G
omez et al.

16% of muscle injuries among professional football players are 3. Results

re-injuries.21 Having a previous groin injury almost doubles
3.1. Search and selection of publications
the risk of having another groin injury,22 and a previous inver-
sion ankle injury can cause persistent symptoms for at least Initially, 2512 studies were identified in the 2 databases.
2 years after the injury.23 All these types of injuries emphasise After duplicates were removed, a total of 1597 articles were
the importance of establishing injury prevention programs. screened. After reading the titles and abstracts, 1505 articles
Risk factors and injury rates are affected by different con- were excluded. The remaining 92 full-text articles were read
siderations: psychosocial,24 psychological,25,26 biomechani- and assessed for eligibility, and 81 studies that did not fulfill
cal,27 field surfaces,28 30 and physical exercise.31 Some injury the eligibility criteria were excluded. Thus, 11 articles were
prevention programs have been effective in reducing the inci- included in our review (Fig. 1).
dence of injuries32 41 and decreasing healthcare costs among The studies were excluded for the following reasons: (1) no
football players.42 Therefore, the purposes of this study were exercise for injury prevention or injury assessment (n = 23),
to (1) focus on physical exercise factors influencing injuries, (2) sample different to soccer players (n = 4), (3) no male par-
(2) identify injury prevention programs and intrinsic factors ticipants were involved (n = 19), (4) the age of participants
related to injuries that have been described in the literature, was less than 18 years old (n = 28), and (5) the intervention did
and (3) establish some recommendations for coaches and phy- not show a significant effect on injury prevention (n = 7).
sical fitness trainers that might reduce the overall number of
injuries among adult male football players.
3.2. Characteristics of studies included

2. Methods Table 1 shows the main characteristics and outcomes of the

included studies. The sample of all studies was composed of
The Preferred Reporting Items for Systematic review and adult male football practitioners aged 18 to 65 years old. The
Meta-Analyses (PRISMA) guidelines43 for search procedures, interventions included training frequencies from 1 to 6 times
study selection, data collection, and data analysis were fol- per week and durations from 10 weeks to a full season. The
lowed in this systematic review. main injury prevention practices included the Nordic ham-
string exercise, YoYo Flywheel Ergometer activity, adductor
2.1. Search strategy and eligibility criteria strengthening activities, proprioceptive activities, a multicom-
A systematic review of studies identified in the PubMed and ponent program and warm-up protocols.
EMBASE electronic databases was conducted up to 24 January
2020. The relevant articles were searched using the terms
3.3. Data organization
“soccer” AND “injury” AND “prevention”. The search and
study selection were performed by 2 independent reviewers For the purposes of our review, the studies were grouped into
(JPG and JCV). Disagreements between the 2 reviewers were 4 broad areas according to the type of physical exercise used in
resolved by discussion; if necessary, a third reviewer (JCA) was the intervention program. These areas include (1) strength train-
consulted to reach a consensus. ing, (2) proprioceptive training, (3) multicomponent programs,
The inclusion criteria for the articles selected included the
following: (1) longitudinal research studies, (2) studies that
showed a reduction in the number of injuries as a consequence
of a physical exercise intervention program, (3) studies that
included professional or amateur male football players as par-
ticipants, (4) original research studies, (5) research conducted
with adults males
18 years old, and (6) studies published in
either English or Spanish.
There were 2 exclusion criteria: (1) protocol studies
(i.e., those that only provided a detailed account of the
hypothesis, rationale and methodology of the study but not
the study outcomes) and (2) studies having only women
participants.

2.2. Methodological quality of studies

Two reviewers (JPG and JCV) independently assessed the
methodological quality of the eligible studies using the Physio-
therapy Evidence Database scale (PEDro).44 The average score
of all included studies for this systematic review was 5 points
on the PEDro scale. Fig. 1. Flow diagram of study selection process.
Physical exercise to prevent injuries in football 117

# overall risk and severity of lower-extremity injury (72%)

Abbreviations: ACL = anterior cruciate ligament; ASP = adductor strengthening programme; FIFA = Federation Internationale de Football Association; NCAA = National Collegiate Athletic Association;
and (4) warm-up programs. Study characteristics are presented

" concentric and eccentric maximal voluntary strength of

# injury rate (46%); decreased time loss to injury (29%)

# incidence of match (12%) and training (25%) injuries

# rate of overall, new and recurrent hamstring injuries

in Table 1.

Preseason: 2 3 times/week 339 semi-professional players 22.0 § 4.3a # prevalence and risk of groin problems (41%)
hamstrings, as well as, maximal speed running
# occurrence of hamstring strain injuries and 3.3.1. Strength training
Most of the studies that involved strength training for the
prevention of injuries focused on eccentric exercises specifi-
cally for the hamstring muscles. The most common eccentric
hamstring exercises used were the Nordic hamstring exercise
(NHE) and the Nordic hamstring lowers.32,38,41

# risk of hamstring injuries

# risk of hamstring strains

# rate of ankle sprains

The NHE has been an effective exercise for both

# rate of ACL injuries

amateur38,41 and professional football players.32,38 In 1 study,
# number of injuries

the inclusion of 27 sessions of NHE during 10 weeks in the

midseason break decreased the rate of new and recurrent ham-
Age (year) Conclusion

string injuries among professional and amateur football play-

ers.38 In another study, fewer sessions of NHE (25) performed
over a longer period of time (13 weeks) and incorporated into
regular amateur football training significantly reduced the
24 26

18 25

14 65

27 28

18 25
18 25
18 40

incidence of hamstring injuries but not the severity of those

injuries.41 Another study combined NHE with a warm-up and
25

23

stretching protocol once or twice per week during both the

942 professionals/amateurs

preseason and regular season and was shown to be effective in

61 NCAA football teams
61 NCAA football teams

reducing hamstring strains among elite football players.32

80 male soccer players
3265 amateur players
41 collegiate players

Another study analyzed a strength training program for the

17 30 elite teams

40 amateur teams
30 elite players

23 elite players

hamstrings that included concentric and eccentric action per-

formed on the YoYo Flywheel Ergometer during the preseason
NHE = nordic hamstring exercise; rep. = repetitions; WU = warm up with stretching; YFE = YoYo Flywheel Ergometer.

for 10 weeks.33 The program was found to be beneficial in that

Sample

it lowered the occurrence of hamstring strain injuries among

elite football players.33
Another study included a strength training protocol called the
In-Season: 1 time/week

Adductor Strengthening Programme (ASP).45 This protocol was

included 2 3 times per week during the preseason (6 8 weeks)
3 sets/8 12 rep., 1 2 seasons 1 3 times/week
1 2 times/week

5 6 times/week

2 3 sets/5 12 rep., 10 weeks 1 3 times/week

2 3 times/week

2 3 sets/5 10 rep., 13 weeks 1 2 times/week

and once per week during the competitive period (28 weeks)
2 times/week

3 times/week
Frequency

Every day

and was shown to be effective in reducing (41%) the prevalence

and risk of groin problems in male football players.45

3.3.2. Proprioceptive training

Only one study involved proprioceptive training.36 This
training employed an ankle disk that was used for 30 min a
Preseason: 6 8 weeks
4 sets/8 rep., 10 weeks

15 20 min, 1 season
In-Season: 28 weeks

day. The training was shown to be effective in reducing the

Main characteristics of the studies included in the systematic review.

20 min, 1 season

20 min, 1 season
30 min,1 season

rate of ankle sprains among football players.36

Exercise program Duration

Multicomponent 1 season

3.3.3. Multicomponent training: balance, core stability, and

20 min

functional strength and mobility

Used during the competitive season, a multicomponent
training program that included a total of 58 sessions (twice
Propioceptive
NHE + WU

weekly) focusing on balance, core stability, and functional

FIFA 11+

FIFA 11+

FIFA 11+
FIFA 11+

strength and mobility exercises produced a significant reduc-

Data were presented as mean § SD.
NHE

NHE
YFE

ASP

tion (43%) in the number of muscle injuries among elite pro-

fessional football players.37
Silvers-Granelli et al. (2017)40
Silvers-Granelli et al. (2015)39
van der Horst et al. (2015)41

3.3.4. Warm-up programs

Petersen et al. (2011)38
Arnason et al. (2008)32

Grooms et al. (2013)34

Askling et al. (2003)33

Mohammadi (2007)36

Warm-up programs used to prevent injuries included the

Harøy et al. (2019)45

Owen et al. (2013)37

Junge et al. (2011)35

“FIFA 11+” program.34,39,40 It has been shown that when the

FIFA 11+ program was implemented correctly, 2 3 times per
week during training sessions, it decreased the rate of anterior
Table 1

cruciate ligament (ACL) injuries among male football players.40

Study

Previous studies have reported that the FIFA 11+ program

a
118 J. P
erez-G
omez et al.

utilized 3 times per week throughout the competitive season In our review, most of the programs in which a reduction in
reduced the injury rate by 46% and time lost to injury by 29% hamstring injuries was observed used the NHE.32,38,41 The
among male competitive collegiate football players.39 Another NHE is a partner exercise; the partner stabilizes the legs of the
study analysed the use of the “FIFA 11+ program” 5 6 times person who is exercising. The exerciser is on his knees, with
per week during a competitive season and found that it reduced the back and hips kept straight, and then leans forward with
the overall rate and severity of lower-extremity injuries by 72% the hamstrings working eccentrically until the exerciser lands
among male collegiate football players.34 on the floor with support from the hands. The NHE has some
In 1 study that analyzed the “11” warm-up program (a advantages for being incorporated into football training
previous version of the “FIFA 11+ program”), amateur foot- because it is easy to perform, is safe, does not require addi-
ball teams whose coaches implemented the 11 program (or tional equipment and does not take very long.
most of it) once or twice a week as part of the warm-up proto- In regard to the optimal time during the training session
col decreased the incidence of match injuries by 11.5% and when the NHE should be performed, some studies found that it
training injuries by 25.3%.35 was left to the coaches to choose when to perform the NHE. It
was sometimes performed before,57 after,41 or even during38
the session. However, some studies found that performing the
4. Discussion
NHE before the training session exacerbated eccentric fatigue
The purpose of this study was to review the physical exer- and could increase the predisposition to hamstring strain inju-
cise training programs that have been effective in lowering the ries.58 Future studies are needed to elucidate the optimal
injury incidence among male football players. Our discussion scheduling of the NHE.
is organized into the same 4 broad areas used in the Results Another important aspect to consider before using the NHE
section: (1) strength training, (2) proprioceptive training, (3) is the potential for muscle damage. It is recommended that an
multicomponent programs, and (4) warm-up programs. introductory period of around 5 weeks be used, during which
the load is increased gradually.55 This helps avoid delayed
onset muscle soreness (DOMS), and some studies in which
4.1. Strength training
this recommendation was followed did not observe any com-
Muscle injuries in male football players constituted 31% of plaint about DOMS from the players.32
all injuries, with the hamstrings being the most affected Exercises using the YoYo Flywheel Ergometer for the ham-
muscles (37%), followed by the adductors (23%), quadriceps string muscles has also been described in the scientific litera-
(19%), and calves (13%).21 This explains why most of the ture.33 A study by Askling et al.33 used this ergometer to
studies on muscle injuries in football have been conducted on generate both concentric and eccentric actions for exercising
the hamstring muscles. the hamstring muscles. In this study, elite football players per-
Several risk factors for hamstring injuries have been formed bilateral knee flexor movements in a prone position
described. These include age, body mass, core stability, and the concentric hamstring action accelerated the flywheel.
delayed recovery, muscle fatigue, muscle flexibility, muscle With the subsequent eccentric hamstring action, the flywheel
activity, playing position, previous hamstring injury, thigh was decelerated. This training not only had positive effects in
muscle imbalance, and hamstring muscle weakness.7,46 50 reducing hamstring injuries but also improved concentric and
Physical exercise programs used to prevent hamstring injuries eccentric maximal voluntary strength in the hamstrings, as
should consider hamstring muscle weakness or imbalance with well as maximal running speed. Unfortunately, most of the
respect to quadriceps strength. players using this method experienced DOMS. Thus, more
Hamstring injuries occur when the load exceeds the strength research is needed on training programs where the YoYo Fly-
of the tissue, and, according to biomechanical studies, hamstring wheel Ergometer is used in order to determine if an introduc-
rupture usually happens in the last part of the swing phase dur- tory period is required to avoid muscle soreness.
ing sprinting.51 53 Hamstring injuries have been linked to insuf- Another important issue in hamstring injury prevention is
ficient eccentric strength in the hamstring.54 Thus, according to related to muscle injury location. Injuries to hamstring muscles
the principle of training specificity and strength training,55 it is are not equally distributed in the muscle group; the biceps fem-
not surprising that using eccentric exercises to train the ham- oris muscle is the most frequently injured (66% of all ham-
string muscles can improve eccentric hamstring strength, string injuries), while the semitendinosus muscle represents
thereby reducing the incidence of hamstring injuries. This is 33% of all hamstring injuries.59 More research is needed in
one explanation for why preventive programs that include order to develop specific hamstring exercises for preventing
exercises in which the hamstring muscles perform eccentric injuries to individual hamstring muscles.
contractions have been effective in reducing hamstring We found only one study45 that focused on injury prevention
injuries.32,33,38,41 In well-trained football players, eccentric exer- strategies for the adductor muscles, despite these muscles being
cises are more effective for developing maximal eccentric ham- the second most injured muscle group in soccer.21 The study by
string strength than comparable hamstring concentric Harøy et al.45 showed that the implementation of ASP could be
contractions.55 It is also known that eccentric exercises produce effective in reducing (41%) the prevalence and risk of groin
a shift in the optimum angle of the muscle, which can be consid- injuries in male football players during the competitive season.
ered as a protective mechanical change that prevents injuries.56 More studies are needed to confirm the findings of Harøy et al.45
Physical exercise to prevent injuries in football 119

4.2. Proprioceptive training consists of 15 exercises performed in 3 different stages. The

first stage (lasting around 8 min) includes slow-speed running
Ankle inversion sprains are a common injury in football,15
exercises and active stretching. The second stage (lasting
with a high probability for reinjury60 or the player experienc-
around 10 min) focuses on exercises designed for agility, bal-
ing persistent symptoms after the injury.23
ance, plyometrics and strength (in the core and legs). The last
Proprioception is a neural process by which the body gets
stage (lasting around 2 min) includes running exercises at
information by sensory input and integrates it in order to deter-
moderate to high speed, combined with changes of direction
mine the body position or movements in space.61 Propriocep-
(cutting movements).72
tion is fundamental for balance control.62 Proprioceptive
Several studies have investigated the implementation of
training is crucial in reducing the risk of ankle sprains or recur-
FIFA 11+ as a warm-up program in the training sessions of
rent injury.63 Proprioceptive training programs usually include
adult male football players, and these studies reported a posi-
exercises using devices such as ankle disks, balance boards,
tive effect in that the program reduced the number of
and tilt boards. These kinds of exercises improve the sensori-
injuries.34,39,40 One possible explanation for why FIFA 11+
motor system’s ability to adapt to the changing environment
reduces the number of injuries is that this warm-up program
and safeguard the body from injury.63 Improvement in proprio-
can improve muscular strength. It has also been shown that
ceptive control can produce better movement control64 during
FIFA 11+ improves the hamstring to quadriceps ratio (H/Q) in
jumping or landing in soccer, which reduces the mechanical
young male professional football players,73 which is important
stress and, consequently, the incidence of injuries in the lower
because low values in the H/Q ratio are considered a risk factor
limbs. The forces applied during the proprioception training
for knee injuries.74
counteracts unbalanced situations and can improve the resi-
FIFA 11+ has some additional benefits apart from injury pre-
lience of ligaments and tendons.65 Ligaments and tendons can
vention. For example, it can prepare football players for compe-
adapt to exercise by changing the cross-sectional area and
tition from a physiological point of view.75,76 One study has
strength due to increased or decreased loading,66 thus allowing
shown that FIFA 11+ is an appropriate warm-up program in,
adaptations in passive structures and the sensorimotor system.
using Level 3 for 20 to 25 min, as that it increased resting oxy-
This explains why proprioceptive balance training has been
gen uptake (14%), core temperature (1%), and lactate levels
effective for the prevention of ankle sprains in adult36 and
(1.5 mmol/L) in amateur male football players.76 It has also
high school football players.67
been shown that the use of FIFA 11+ for 9 weeks improved neu-
romuscular control in male amateur football players.75
4.3. Multicomponent training: balance, core stability, and Some advantages of using FIFA 11+ as a preventive pro-
functional strength and mobility gram for injuries is that, aside from football balls, no other spe-
Some reasons for using strength training (eccentric move- cial material or equipment is needed. The program can also be
ment specifically) and balance training to prevent injuries have implemented in a short time frame, and some coaches have
been explained previously. But strength training involving used a lack of time as a reason why they cannot implement a
concentric movement is also important in order to minimize prevention program.
the strength imbalance between legs. It has been observed that Another injury prevention program is the 11 program,
muscular imbalance between the preferred and non-preferred which was developed before the FIFA 11+ program. The 11
leg in sub-elite football players can be an injury risk factor,68 program includes 10 physical exercises and the promotion of
so it is logical that a multicomponent program that includes fair play. It was developed to reduce the most common football
functional strength would be effective in reducing injuries.37 injuries to the hips, knees and ankles among amateur football
It is known that the number of injuries can be reduced by players. The only materials needed for the 11 program are
improving flexibility.69 Core stability is important for control- football balls. If used, it should be performed during every
ling the position and movement of the trunk over the pelvis in training session for 10 to 15 min.35
order to allow for the efficient transfer of force to the limbs, and Although some studies have shown that the 11 program is
greater core stability can help sports performance by providing effective in preventing injuries among male football players,35
greater force production in the extremities,70 thus reducing the other studies have not observed a reduction in injuries when it
incidence of injuries.70,71 It has been found that training pro- has been used.77 79 One study found that 11 did not reduce the
grams that include mobility and core stability exercises can help injury rate in male amateur football players in one season, but it
to reduce the incidence of muscles injuries.37 significantly reduced injury-related costs per player in favour of
the intervention group, with a mean difference of 201 euros per
player.77 Another study found that the 11 program did not
4.4. Warm-up programs
decrease the overall injury incidence or injury severity among
FIFA 11+ is a complete, dynamic warm-up program that adult male football players; however, the study did find a signi-
includes physical exercises involving agility, plyometrics, pro- ficant reduction in knee injuries.78 A third study of the 11 pro-
prioception, and strength and is designed to prevent or reduce gram found only minor effects on the injury rate among
injuries in football players. It is performed on the field for intermediate-level amateur football players.79 Several reasons
15 20 min before games or training sessions. Developed in could explain these contradictory results: (1) low compli-
2006, the program does not require additional equipment and ance80,81 (it has been shown that players with higher compliance
120 J. P
erez-G
omez et al.
80
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