New Study Finds Link Between Injury Prevention and Winning

Bert R. Mandelbaum, MD, DHL (Hon)

November 19, 2015

You Can't Win With an Injured Team

Injury prevention works.

A study my colleagues and I published this month in the American Journal of Sports Medicine shows that the Fédération Internationale de Football Association (FIFA) 11+ warm-up program can cut injuries—not just knee or ankle injuries but all injuries—by about half.^[1] It can cut missed days by one third.

Moreover, from unpublished data, presented in this column for the first time, we know that teams using this program win more games.

What coach wouldn't want to put a program like this in place? As it turns out, most of them. Coaches across the country are shirking their responsibilities.

For this study, we wrote to every National Collegiate Athletic Association (NCAA) Division I and II men's soccer team to solicit their participation. We emailed them. We called them. We told them we had strong evidence already that the program was working in women and that the preliminary evidence in men was extremely positive as well.

Tepid Response From Coaches

I had a lot of those conversations myself, and the responses broke down into three categories:

"Thank you for calling. We're using the program. It's the best in the world."
"I don't know what you're talking about. We have a short season. I don't have time."
"Let me get our trainer to call you."

The trainers seldom called. In the end, only one in six teams took the opportunity we were offering.

A Game-Changing Program

To understand what the opportunity is, we need a little context: Back in the 1990s, many of us who practice sports medicine began noticing a spike in the rate of knee injuries. The injuries seen in my practice went from 80% male to 80% female as a surge of girls began playing competitive sports—and blowing out their anterior cruciate ligaments (ACLs) at a shocking rate.

The number of ACL injuries more than tripled in NCAA soccer players from 1990 to 2000.^[2]

I and other researchers from around the world watched many hours of video to determine how these injuries were happening. Again and again, we documented that they were most likely to take place when knees are in dynamic valgus alignment.^[3]

In force-plate studies, we confirmed that a stiff valgus landing delivers more force to the joint.^[3]

The problem was most striking in adolescent female soccer players, but we have also observed it in males playing basketball, team handball, and American football.^[4]

In addition, there is evidence that athletes whose hamstrings are relatively weak in relation to their quadriceps are also more likely to sustain ACL injuries.^[5]

From these observations, we developed programs to strengthen the relevant muscles, teach athletes better movement techniques, and improve proprioception.

After years of testing, these efforts culminated in the FIFA 11+ warm-up program. The just-published study on its effectiveness mentioned earlier is only the latest validation of the program. The program has proved itself not only in boys' and girls' soccer but in basketball as well.^[6] I believe that the same program could help athletes in just about any sport where knee injuries are a problem.

And not only injuries to knees. In the new study, we were able to show a reduction in injuries to almost every body part—including the head, wrist, and hand.^[1]

Why Adoption Has Been Slow

We've been sharing such results from our previous studies for years. Our group has won NCAA awards. We have published articles and books. But we still have failed to convey our points about players' safety to a great many coaches. Why aren't teams eagerly embracing this approach?

There appear to be several reasons. Many teams don't have medical staff. Recreational teams often have no access even to a professional trainer. That means that everything falls on the coach. Coaches feel intense pressure to satisfy their constituents—athletic directors, parents, alumni, and fans—who too often think only of winning. For too many coaches, winning means a tunnel-vision focus on strategy and skills.

If coaches had to choose between preventing injuries and winning games, I'd still argue that safety should come first. What most young athletes learn about how to tackle, throw, or run in team competition won't matter a few years from now when high school and college are behind them. But knowledge of fitness and safety will serve them for a lifetime.

But we now know that programs like the FIFA 11+ meet both goals. Analyzing the win/loss ratio, our research group—led by physical therapist Holly Silvers-Granelli at the University of Delaware—found that NCAA Division I teams using the FIFA 11+ program had an average record of 9.86 wins, 5.71 losses, and 2.43 ties, while the control teams had an average record of 7.6 wins, 8.48 losses, and 2.57 ties (Silvers-Granelli H, Mandelbaum B, Adeniji O, et al, unpublished data, 2015). The difference in wins and losses was statistically significant, and when we looked at Division II teams, we found a similar pattern.

Recommendations for Coaches

Of course, safety goes far beyond the FIFA 11+ program. At FIFA, we're trying to raise awareness about coaches' responsibilities by disseminating a number of key points. We recommend that coaches:

Coordinate with physicians, trainers, biomechanists, nutritionists, and other experts to acquire and implement the best safety and performance information available;
Maintain constant and complete communication with the medical team;
Insist on electrocardiogram screening before athletic participation to ensure that all team members have healthy hearts;
Obtain baseline psychoneurologic data on team members by using instruments that I discussed in a previous column, such as the ImPACT® and King-Devick tests for diagnosing concussion or the Sports Concussion Assessment Tool (SCAT 3);
Use an evidence-based program like FIFA 11+ to strengthen and train athletes to avoid injury;
Teach players about healthy food choices;
Be aware of the limits to training imposed by the climate in which players train and offer them ample opportunity for hydration;
Teach players how to play hard without hurting each other;
Be aware that players' needs will vary depending on their level of fitness, age, body mass index, the nature of the sport in which they're participating, and the climate in which competition occurs;
Honor the gradual steps by which players can return to sports after injuries; and
Insist that players avoid the nonmedical use of performance-enhancing and other drugs.

Injury Prevention: A Licensing Requirement?

Many coaches will shake their heads when they see this list. I might have had the same reaction when I was the lacrosse coach at Johns Hopkins University. Whatever you read about the outsized salaries of a handful of elite coaches, most do their essential work for too little compensation.

As a society, we don't value our coaches and other teachers enough. I'd like to see injury prevention included in licensing requirements—and higher pay for those coaches who obtain the licenses.

Many families can afford to chip in—say, $100 each—for a program like FIFA 11+. Philanthropists or public health programs could also lend financial support.

The investment would pay off on many levels. If we can create safe, competitive sports opportunities for disadvantaged kids, with coaching that addresses issues of health and character, such kids will be less likely to join gangs, have children before they are ready, or become addicted to drugs. They will be more likely to build balanced lives.

In addition to creating financial incentives for coaches, we need our opinion leaders to speak out. We must implore the Surgeon General, sports celebrities, and physician celebrities like Dr Oz to provide practical, evidence-based information on preventing sports injuries.

As sports physicians, let's all begin by reaching out to the coaches in our orbits and by taking every opportunity to speak in public about the powerful opportunities available to protect and instruct young athletes. With these kinds of initiatives, I believe that we will see a dramatic reduction in the rate of injuries in every sport.

Dr. Mandelbaum Discusses New Study with Medscape that Finds Link Between Injury Prevention and Winning

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