Welcome to another edition of the Learn.Physio Journal Club!

Welcome to Issue #2 of Mick Hughes' Research Reviews, and thanks once again for signing up to our fortnightly reviews! If you're new to The Learn.Physio Journal Club, and you missed Issue #1, you can catch up by clicking here 

In Issue #2 Mick covers 2 recent studies led by Physiotherapist Matt Whalan PhD. First off, Mick share his findings of reducing severe injuries in football/soccer, and increasing 11+ program compliance by simply modifying how the 11+ program is conducted. Secondly, Mick reviews his research team's fascinating findings of "injury niggles" and how they can impact on a future "time-loss" injury.

For those of you are interested, Matt Whalan, along with Matilda's Physio Jaclyn Benz, will be joining Mick Hughes tomorrow night for Episode 2 of our Careers in Health and Sport Webinar Series. Come along and ask Matt and Jaclyn questions about their careers as Sports Physios! You can register for this FREE event here 

We hope you are enjoying Mick's reviews and are learning something new!
Injury prevention programs in soccer/football, such as the 11+, have been well researched over the last 20-30 years. It has been recently found that injury rates in soccer/football can be reduced by at least 40% by regularly performing the 11+ program at least 2x per week (Thorborg et al 2017).

Despite such positive numbers, awareness of the 11+ program and compliance/adoption of the 11+ is still quite low; with 1 study alone showing that only 1/3 of high school coaches delivered the 11+ to the recommendation of 2x per week (Slauterbeck et al 2019, Bizzini et al 2013, Silvers-Granelli et al 2015, O'brein et al 2017).

Barriers in the adoption of injury prevention programs (not just the 11+) have been previously identified in previous studies; with “lack of time”, “takes too long” “increased fatigue and soreness from doing part 2 of the program” being a consistent theme across those players and coaches who have been surveyed (Benjaminse et al 2018 & Donaldson et al 2017, O’Brien et al 2016, O’Brien et al 2017, Marshall et al 2015).

To overcome these barriers in adoption of the 11+ program, “thinking outside the square” is needed to increase compliance to these very important injury prevention programs.

And that is exactly what Matt Whalan and colleagues did recently in their study of 25 semi-professional football teams. To address 2 major barriers of “lack of time” and “increased fatigue” they re-scheduled parts of the 11+ and observed not only 11+ compliance over a competitive season in 25 teams, but also injury rates and injury burden over a competitive soccer/football season in the same 25 teams.
For those unaware, the 11+ program is broken down into 3 sections:

Part 1 – A series of 6 running and mobility exercises aimed at increasing heart rate, increasing lower limb mobility and neuromuscular activity (8mins)
Part 2 – 3 different levels of strength, plyometrics, balance exercises ranging from beginner, to intermediate to advanced with each level having 6 different exercises to be performed (10mins)
Part 3 – A series of 3 higher intensity running drills that are performed just prior to commencing team training (2mins)

The authors randomised 398 players to receive either the “usual” scheduling of the 11+ program (Part1, then Part 2, then Part 3) or a modified version of the 11+ program where the athletes would do Part 1 and Part 3 prior to team training, and then they would complete Part 2 after training (408 players). Injuries were recorded for both training and games across both groups.

The results of this innovative study were quite fascinating:
  • Compared to the 2016 season injury data that the authors had previously obtained, the 11+ (regardless of how it was implemented) reduced injury rates in the 2017 season by 37%
  • Total injury burden was significantly lower in the modified 11+ group
  • A significantly lower number of “severe injuries” (time loss >28 days) and were observed in the modified 11+ group
  • A significantly lower number of ankle injuries and recurrent injuries were observed in the modified 11+ group
  • A significantly lower incidence of non-contact ankle injuries in the modified 11+ group
  • Compliance, adoption and ultimately dosage of the 11+ over a competitive season was higher in the modified 11+ group than the “usual” 11+ delivery.
In summary, this is a perfect example of listening to the “consumer” and thinking outside the box to continue to deliver high quality healthcare. By simply modifying the 11+ program to match the players and coaches value on time and perceptions of fatigue, it ultimately lead to a tremendous impact on lower injury rates and higher levels of player availability which are huge assets to the high performance of a team and club. Bravo Matt Whalan and colleagues!
  1. Whalan M, Lovell R, Steele JR, Sampson JA. Rescheduling Part 2 of the 11+ reduces injury burden and increases compliance in semi-professional football. Scand J Med Sci Sports. 2019 Dec;29(12):1941-1951. doi: 10.1111/sms.13532. Epub 2019 Aug 22. PMID: 31376194.
  2. Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med. 2017 Apr;51(7):562-571. doi: 10.1136/bjsports-2016-097066. Epub 2017 Jan 13. PMID: 28087568.
  3. Slauterbeck JR, Choquette R, Tourville TW, Krug M, Mandelbaum BR, Vacek P, Beynnon BD. Implementation of the FIFA 11+ Injury Prevention Program by High School Athletic Teams Did Not Reduce Lower Extremity Injuries: A Cluster Randomized Controlled Trial. Am J Sports Med. 2019 Oct;47(12):2844-2852. doi: 10.1177/0363546519873270. Epub 2019 Sep 17. PMID: 31526276.
  4. Bizzini M, Junge A, Dvorak J. Implementation of the FIFA 11+ football warm up program: how to approach and convince the Football associations to invest in prevention. Br J Sports Med. 2013 Aug;47(12):803-6. doi: 10.1136/bjsports-2012-092124. Epub 2013 Jun 27. PMID: 23813485; PMCID: PMC3717809.
  5. Silvers-Granelli H, Mandelbaum B, Adeniji O, Insler S, Bizzini M, Pohlig R, Junge A, Snyder-Mackler L, Dvorak J. Efficacy of the FIFA 11+ Injury Prevention Program in the Collegiate Male Soccer Player. Am J Sports Med. 2015 Nov;43(11):2628-37. doi: 10.1177/0363546515602009. Epub 2015 Sep 16. PMID: 26378030; PMCID: PMC4839291.
  6. O'Brien J, Young W, Finch CF. The delivery of injury prevention exercise programmes in professional youth soccer: Comparison to the FIFA 11. J Sci Med Sport. 2017 Jan;20(1):26-31. doi: 10.1016/j.jsams.2016.05.007. Epub 2016 Jun 1. PMID: 27293086.
  7. Benjaminse A, Otten B, Gokeler A, Diercks RL, Lemmink KAPM. Motor learning strategies in basketball players and its implications for ACL injury prevention: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017 Aug;25(8):2365-2376. doi: 10.1007/s00167-015-3727-0. Epub 2015 Aug 11. PMID: 26259551; PMCID: PMC5522510.
  8. Donaldson A, Lloyd DG, Gabbe BJ, Cook J, Finch CF. We have the programme, what next? Planning the implementation of an injury prevention programme. Inj Prev. 2017 Aug;23(4):273-280. doi: 10.1136/injuryprev-2015-041737. Epub 2016 Jan 19. PMID: 26787739; PMCID: PMC5537515.
  9. O'Brien J, Finch CF. Injury prevention exercise programmes in professional youth soccer: understanding the perceptions of programme deliverers. BMJ Open Sport Exerc Med. 2016 Jan 4;2(1):e000075. doi: 10.1136/bmjsem-2015-000075. PMID: 27900158; PMCID: PMC5117035.
  10. Marshall PW, Lovell R, Knox MF, Brennan SL, Siegler JC. Hamstring Fatigue and Muscle Activation Changes During Six Sets of Nordic Hamstring Exercise in Amateur Soccer Players. J Strength Cond Res. 2015 Nov;29(11):3124-33. doi: 10.1519/JSC.0000000000000966. PMID: 25886019.
Speak to any athlete, coach, sports physio, sports doctor or S&C coach involved in sport and they will say that over the course of a season – especially late in the season – most players are playing with “niggles” or are carrying some form of minor injury through each week towards the end of the season.

But a big question lingers for those working in sporting circles is “do these “niggles”, or non-time loss injuries, expose the athlete to a higher risk of sustaining a future “time-loss” injury?”. In other words, do these “niggles” evolve into an actual injury that will prevent the athlete from participating in a training session or a competitive match?

Once again Matt Whalan and his clever team of researchers set out to answer this very interesting question in a group of 25 semi-professional soccer/football teams over a competitive season. The key aims of their paper were to:
  1. Determine relative risk of sustaining a time-loss injury within 7 days of reporting the presence (or absence) of a non-time loss injury
  2. Examine whether the presence of a non-time loss injury is linked to injury occurrence
In total, 25 teams volunteered to be part of this study during the 2016 season, with all players participating in a minimum of 3 football-based sessions per week. Data was collected by a “primary data collector” who was allocated to each club, and they recorded injury data (injury location etc) as well as exposure minutes (training and match minutes).

Time loss injury was defined as an “inability to fully participate in football training of matches”.

Non-time loss injury data was assessed weekly (over 35 weeks) using the Oslo Sports Trauma Research Centre (OSTRC) Questionnaire on Health Problems, with athletes instructed to complete the questionnaire prior to the first training session of the same week. A non-time loss injury was recorded when a player self-reported on the OSTRC “full participation but with health problems” (minor) or “reduced participation due to health problems” (moderate).
Link to the OSTRC Questionnaire on Health Problems can be found

Note: Illness (cold, flu etc.) were recorded by OSTRC, but not included in the data analysis.
A total of 218 male players (average age 24yrs, ave height 177cm, ave weight 75kg) participated in this study with a 45% compliance rate in answering the surveys each week.

Despite the low compliance rate in answering surveys, the authors did discover in those that responded some fascinating insights to how a “niggle” can build into a time loss injury in the ensuing week that ultimately has an impact on player performance, overall participation and volume or training/playing.

The authors found that the risk of sustaining a time loss injury within 7 days of self reported “minor” health problems was 3.3x greater than no health problems; with the risk increasing of sustaining a time loss injury within 7 days of a self-reported “moderate” health problem being 6.5x greater than no health problems.
These findings are the first of its kind and could potentially be an important factor for coaches, players, medical and high performance staff in determining whether or not an athlete - who is reporting a “niggle” - will participate in team training that week, how much they will participate, and ultimately will they be named in the next match.

Before we start ruling out players from training sessions and games based on “niggles” however, we must remember that “risk does not equal rate”; and just because someone has an elevated risk of injury, does not guarantee that they will go on to sustain a time-loss injury. In fact, being available to train and play will allow the player to adapt to the physical qualities required to play their sport – and if we are too cautious in our approach, these niggles can persist for too long throughout a season.

A more sensible approach would be to base player availability for training and games in a shared environment that includes not only the coach, medical staff and high performance staff but also the player within the context of the season (pre-season vs early season, mid-season vs late-post season) and the player in front of you (eg. younger vs older age, chronic injury history vs low injury history etc). Plenty of work has been done in this space by Tim Gabbett and colleagues and I have shared some reference links below for you to read wider on this topic.

In summary these findings are another tool for sports physio toolkit. By giving the OSTRC questionnaire to your group of athletes it may allow you to identify those players who are carrying “niggles” throughout the competitive season and allow you to mitigate risk of injury burden to your athletes and club. The OSTRC questionnaire can also open up lines of communication between you and the player and the coach in regards to training availability, team selection and allow you to intervene with injury risk reduction strategies.
  1. Whalan, Matthew & Lovell, Ric & Sampson, John. (2019). Do Niggles Matter? -Increased injury risk following physical complaints in football (soccer). Science and Medicine in Football. 4. 10.1080/24733938.2019.1705996.
  2. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016 Mar;50(5):273-80. doi: 10.1136/bjsports-2015-095788. Epub 2016 Jan 12. PMID: 26758673; PMCID: PMC4789704.
  3. Gabbett TJ. Debunking the myths about training load, injury and performance: empirical evidence, hot topics and recommendations for practitioners. Br J Sports Med. 2020 Jan;54(1):58-66. doi: 10.1136/bjsports-2018-099784. Epub 2018 Oct 26. PMID: 30366966.
  4. Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player's risk of subsequent injury. Br J Sports Med. 2016 Apr;50(8):471-5. doi: 10.1136/bjsports-2015-095445. Epub 2015 Dec 23. Erratum in: Br J Sports Med. 2019 Sep;53(18):e6. PMID: 26701923.
  5. Gabbett TJ, Nielsen RO, Bertelsen ML, Bittencourt NFN, Fonseca ST, Malone S, Møller M, Oetter E, Verhagen E, Windt J. In pursuit of the 'Unbreakable' Athlete: what is the role of moderating factors and circular causation? Br J Sports Med. 2019 Apr;53(7):394-395. doi: 10.1136/bjsports-2018-099995. Epub 2018 Nov 13. PMID: 30425045.
  6. Gabbett TJ. How Much? How Fast? How Soon? Three Simple Concepts for Progressing Training Loads to Minimize Injury Risk and Enhance Performance. J Orthop Sports Phys Ther. 2020 Oct;50(10):570-573. doi: 10.2519/jospt.2020.9256. Epub 2019 Nov 15. PMID: 31726926.
  7. Malone S, Hughes B, Doran DA, Collins K, Gabbett TJ. Can the workload-injury relationship be moderated by improved strength, speed and repeated-sprint qualities? J Sci Med Sport. 2019 Jan;22(1):29-34. doi: 10.1016/j.jsams.2018.01.010. Epub 2018 Feb 2. PMID: 30057364.

Thanks for reading and staying up to date. I look forward to sharing more in the future.

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