Injury Prevention Programmes in Male Soccer Players: An Umbrella Review of Systematic Reviews

Background: The incidence of lower-extremity injuries in soccer is high, with effective injury prevention programmes shown to reduce injury rates. Over the past decades, an exponential growth has occurred in the number of scientific publications including review articles on injury prevention programmes in male soccer. Accordingly, it is timely to summarise findings from potential systematic reviews and meta-analyses in the form of an umbrella review. Objective: This umbrella review was conducted to review, synthesise and appraise the findings of the published systematic reviews and meta-analyses that investigated the effects of injury prevention programs in male soccer players. Methods: Following pre-registration on the International Platform of Registered Systematic Review and Meta-analysis Protocols (https://inplasy.com/inplasy-2021-9-0066/) and according to PRISMA guidelines, a search of databases (Web of Science, Sco-pus, SPORTDiscus and PubMed) was conducted for studies published before June 2021. Studies were eligible if they included male (amateur to professional) soccer players, included studies that incorporated injury prevention programs with a control and intervention group(s), and adopted the form of a systematic review (with or without a meta-analysis). The methodological quality of the evidence was assessed using the AMSTAR 2 tool. Results: Eight systematic reviews (no meta-analyses) were included in the umbrella review. The review articles retained for analyses primarily focused on the prevention of injuries in the lower limbs, with primary focus on the hamstrings. Prevention programs principally incorporating strengthening, proprioception and multi-component protocols (balance, core stability, functional strength and mobility) revealed positive effects on injury incidence and severity. Implementing eccentric hamstring protocols demonstrated efficacy in decreasing hamstring injury and proprioception exercises reduced the risk of ankle sprains. It was also revealed that dynamic warm-ups were effective in reducing incidence, but not severity of injuries. Conversely, the evidence from the current umbrella review suggests that programs focusing on static stretching showed inconclusive injury preventative effects. Articles were of mixed methodological quality with one demonstrating high quality, two indicating low quality and five were of critically low quality. Conclusions: The systematic reviews in this area suggests that prevention programs developing muscle strength and propri-oception are effective in reducing the incidence and severity of injury (time out). Dynamic movements performed before a match are effective in reducing injury incidence, whilst the effects of warm-ups incorporating static stretching are unclear. Future original studies on this topic with improved methodological quality and consistency among experimental study designs should be conducted to evaluate the benefits of different programs over longer periods in male soccer players.

football; effectiveness; methodological quality; synthesis

[1] Konefał M, Chmura P, Kowalczuk E, Figueiredo AJ, Sarmento H, Rokita A, et al. Modeling of relationships between physical and technical activities and match outcome in elite German soc-cer players. The Journal of Sports Medicine and Physical Fit-ness. 2019; 59: 752–759.

[2] Julian R, Page RM, Harper LD. The Effect of Fixture Conges-tion on Performance during Professional Male Soccer Match-Play: a Systematic Critical Review with Meta-Analysis. Sports Medicine. 2021; 51: 255–273.

[3] Pérez-Gómez J, Adsuar JC, Alcaraz PE, Carlos-Vivas J. Physi-cal exercises for preventing injuries among adult male football players: a systematic review. Journal of Sport and Health Sci-ence. 2022; 11: 115–122.

[4] Ekstrand J. Preventing injuries in professional football: thinking bigger and working together. British Journal of Sports Medicine. 2016; 50: 709–710.

[5] Hägglund M, Waldén M, Magnusson H, Kristenson K, Bengts-son H, Ekstrand J. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Cham-pions League injury study. British Journal of Sports Medicine. 2013; 47: 738–742.

[6] Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. British Journal of Sports Medicine. 2011; 45: 553–558.

[7] Ekstrand J, Lundqvist D, Davison M, D’Hooghe M, Pensgaard AM. Communication quality between the medical team and the head coach/manager is associated with injury burden and player availability in elite football clubs. British Journal of Sports Medicine. 2019; 53: 304–308.

[8] Eirale C, Tol JL, Farooq A, Smiley F, Chalabi H. Low injury rate strongly correlates with team success in Qatari professional football. British Journal of Sports Medicine. 2013; 47: 807–808.

[9] Small K, Mc Naughton L, Matthews M. A Systematic Review into the Efficacy of Static Stretching as Part of a Warm-up for the Prevention of Exercise-Related Injury. Research in Sports Medicine. 2008; 16: 213–231.

[10] Ayala F, Calderón-López A, Delgado-Gosálbez JC, Parra-Sánchez S, Pomares-Noguera C, Hernández-Sánchez S, et al. Acute effects of three neuromuscular warm-up strategies on sev-eral physical performance measures in football players. PLoS ONE. 2017; 12: e0169660.

[11] Machado AF, Ferreira PH, Micheletti JK, de Almeida AC, Lemes ÍR, Vanderlei FM, et al. Can Water Temperature and Immersion Time Influence the Effect of Cold Water Immersion on Muscle Soreness? A Systematic Review and Meta-Analysis. Sports Medicine. 2016; 46: 503–514.

[12] Meyer T, Wegmann M, Poppendieck W, Fullagar HHK. Regen-erative interventions in professional football. Sport-OrthopäDie - Sport-Traumatologie - Sports Orthopaedics and Traumatology. 2014; 30: 112–118.

[13] Ribeiro J, Sarmento H, Silva AF, Clemente FM. Practical Pos-texercise Recovery Strategies in Male Adult Professional Soccer Players: a Systematic Review. Strength and Conditioning Jour-nal. 2021; 43: 7–22.

[14] Junge A, Dvorak J. Soccer Injuries. Sports Medicine. 2004; 34: 929–938.

[15] McCunn R, aus der Fünten K, Fullagar HHK, McKeown I, Meyer T. Reliability and Association with Injury of Movement Screens: a Critical Review. Sports Medicine. 2016; 46: 763–781.

[16] van Beijsterveldt AMC, van der Horst N, van de Port IGL, Backx FJG. How Effective are Exercise-Based Injury Prevention Pro-grammes for Soccer Players? Sports Medicine. 2013; 43: 257–265.

[17] Olsen L, Scanlan A, MacKay M, Babul S, Reid D, Clark M, et al. Strategies for prevention of soccer related injuries: a systematic review. British Journal of Sports Medicine. 2004; 38: 89–94.

[18] Rogan S, Wüst D, Schwitter T, Schmidtbleicher D. Static stretching of the hamstring muscle for injury prevention in football codes: a systematic review. Asian Journal of Sports Medicine. 2013; 4: 1–9.

[19] Shadle IB, Cacolice PA. Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: a Critically Ap-praised Topic. Journal of Sport Rehabilitation. 2017; 26: 573–577.

[20] van Dyk N, Behan FP, Whiteley R. Including the Nordic ham-string exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes. British Journal of Sports Medicine. 2019; 53: 1362–1370.

[21] Al Attar WSA, Soomro N, Sinclair PJ, Pappas E, Sanders RH. Effect of Injury Prevention Programs that Include the Nordic Hamstring Exercise on Hamstring Injury Rates in Soccer Play-ers: a Systematic Review and Meta-Analysis. Sports Medicine. 2017; 47: 907–916.

[22] Impellizzeri FM, McCall A, van Smeden M. Why methods mat-ter in a meta-analysis: a reappraisal showed inconclusive injury preventive effect of Nordic hamstring exercise. Journal of Clin-ical Epidemiology. 2021; 140: 111–124.

[23] Al Attar WSA, Soomro N, Pappas E, Sinclair PJ, Sanders RH. How Effective are F-MARC Injury Prevention Programs for Soccer Players? A Systematic Review and Meta-Analysis. Sports Medicine. 2016; 46: 205–217.

[24] Arnason A, Andersen T, Holme I, Engebretsen L, Bahr R. Pre-vention of hamstring strains in elite soccer: an intervention study. Scandinavian Journal of Medicine & Science in Sports. 2008; 18: 40–48.

[25] Petersen J, Thorborg K, Nielsen MB, Budtz-Jørgensen E, Hölmich P. Preventive Effect of Eccentric Training on Acute Hamstring Injuries in Men’s Soccer: a cluster-randomized con-trolled trial. The American Journal of Sports Medicine. 2011; 39: 2296–2303.

[26] Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 2: a review of preven-tion programs aimed to modify risk factors and to reduce injury rates. Knee Surgery, Sports Traumatology, Arthroscopy. 2009; 17: 859–879.

[27] Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, et al. Effectiveness of a Neuromuscular and Pro-prioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. The American Journal of Sports Medicine. 2005; 33: 1003–1010.

[28] Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini M, et al. Comprehensive warm-up programme to prevent in-juries in young female footballers: cluster randomised con-trolled trial. British Medical Journal. 2008; 337: a2469.

[29] Lemes IR, Pinto RZ, Lage VN, Roch BAB, Verhagen E, Bolling C, et al. Do exercise-based prevention programmes reduce non-contact musculoskeletal injuries in football (soccer)? A system-atic review and meta-analysis with 13 355 athletes and more than 1 million exposure hours. British Journal of Sports Medicine. 2021; 55: 1170–1178.

[30] Kiani A, Hellquist E, Ahlqvist K, Gedeborg R, Byberg L. Pre-vention of Soccer-Related Knee Injuries in Teenaged Girls. Archives of Internal Medicine. 2010; 170: 43–49.

[31] 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. British Journal of Sports Medicine. 2017; 51: 562–571.

[32] Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mul-row CD, et al. PRISMA 2020 explanation and elaboration: up-dated guidance and exemplars for reporting systematic reviews. British Medical Journal. 2021; 372: n160.

[33] Ryan R, Horey D, Oliver S, McKenzie J, Prictor M, Santesso N, et al. Cochrane Consumers and Communication Group Standard protocol text and additional guidance for review authors. CCCG. http://cccrg.cochrane.org/author-resources (Accessed: date).

[34] Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of health-care interventions, or both. British Medical Journal. 2017; 358: j4008.

[35] Cruz-Ferreira A, Marujo A, Folgado H, Gutierres P, Fernandes J. Exercise programs in the preventing injuries in football players: a systematic review. Revista Brasileira De Medicina Do Esporte. 2015; 21: 236–241.

[36] Porter T, Rushton A. The efficacy of exercise in preventing in-jury in adult male football: a systematic review of randomised controlled trials. Sports Medicine - Open. 2015; 1: 4.

[37] Fanchini M, Steendahl IB, Impellizzeri FM, Pruna R, Dupont G, Coutts AJ, et al. Exercise-Based Strategies to Prevent Mus-cle Injury in Elite Footballers: a Systematic Review and Best Evidence Synthesis. Sports Medicine. 2020; 50: 1653–1666.

[38] Rosado-Portillo A, Chamorro-Moriana G, Gonzalez-Medina G, Perez-Cabezas V. Acute Hamstring Injury Prevention Programs in Eleven-a-Side Football Players Based on Physical Exercises: Systematic Review. Journal of Clinical Medicine. 2021; 10: 2029.

[39] Espinosa GdA, Pöyhönen T, Aramendi JF, Samaniego JC, Knörr JIE, Kyröläinen H. Effects of an eccentric training programme on hamstring strain injuries in women football players. Biomed-ical Human Kinetics. 2015; 7.

[40] Kraemer R, Knobloch K. A Soccer-Specific Balance Training Program for Hamstring Muscle and Patellar and Achilles Ten-don Injuries: An Intervention Study in Premier League Female Soccer. The American Journal of Sports Medicine. 2009; 37: 1384–1393.

[41] Fredberg U, Bolvig L, Andersen NT. Prophylactic Training in Asymptomatic Soccer Players with Ultrasonographic Abnor-malities in Achilles and Patellar Tendons: The Danish Super League Study. The American Journal of Sports Medicine. 2008; 36: 451–460.

[42] Croisier J, Ganteaume S, Binet J, Genty M, Ferret J. Strength Imbalances and Prevention of Hamstring Injury in Professional Soccer Players: A Prospective Study. The American Journal of Sports Medicine. 2008; 36: 1469–1475.

[43] Elias SR, Roberts WO, Thorson DC. Team Sports in Hot Weather: guidelines for modifying youth soccer. The Physician and Sportsmedicine. 1991; 19: 67–78.

[44] Athanasiou M, Stergioulas A. Hamstring Strains in Football. Prevention and Rehabilitation Rules. Systematic Review. Biol-ogy of Exercise. 2016; 12: 121–148.

[45] McCall A, Carling C, Davison M, Nedelec M, Le Gall F, Berthoin S, et al. Injury risk factors, screening tests and pre-ventative strategies: a systematic review of the evidence that underpins the perceptions and practices of 44 football (soccer) teams from various premier leagues. British Journal of Sports Medicine. 2015; 49: 583–589.

[46] Ghareeb DM, McLaine AJ, Wojcik JR, Boyd JM. Effects of Two Warm-up Programs on Balance and Isokinetic Strength in Male High School Soccer Players. Journal of Strength and Condition-ing Research. 2017; 31: 372–379.

[47] Naclerio F, Larumbe-Zabala E, Monajati A, Goss-Sampson M. Effects of two different injury prevention resistance exercise protocols on the hamstring torque-angle relationship: a random-ized controlled trial. Research in Sports Medicine. 2015; 23: 379–393.

[48] Naclerio F, Faigenbaum AD, Larumbe E, Goss-Sampson M, Perez-Bilbao T, Jimenez A, et al. Effects of a Low Volume In-jury Prevention Program on the Hamstring Torque Angle Rela-tionship. Research in Sports Medicine. 2013; 21: 253–263.

[49] Daneshjoo A, Mokhtar AH, Rahnama N, Yusof A. The effects of injury prevention warm-up programmes on knee strength in male soccer players. Biology of Sport. 2013; 30: 281–288.

[50] Daneshjoo A, Mokhtar AH, Rahnama N, Yusof A. The effects of injury preventive warm-up programs on knee strength ratio in young male professional soccer players. PLoS ONE. 2012; 7: e50979.

[51] Verrall GM, Slavotinek JP, Barnes P. The effect of sports spe-cific training on reducing the incidence of hamstring injuries in professional Australian Rules football players. British Journal of Sports Medicine. 2005; 39: 363–368.

[52] Sebelien C, Stiller C, Maher S, Qu X. Effects of implementing Nordic hamstring exercises for semi-professional soccer players in Akershus, Norway. Orthopaedic Practice. 2014; 26: 90–97.

[53] Ekstand J, Gillquist J. Prevention of Sport Injuries in Foot-ball Players. International Journal of Sports Medicine. 1984; 5: S140–S144.

[54] Askling C, Karlsson J, Thorstensson A. Hamstring injury oc-currence in elite soccer players after preseason strength training with eccentric overload. Scandinavian Journal of Medicine and Science in Sports. 2003; 13: 244–250.

[55] Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Prevention of Injuries among Male Soccer Players: a prospec-tive, randomized intervention study targeting players with previ-ous injuries or reduced function. The American Journal of Sports Medicine. 2008; 36: 1052–1060.

[56] van Beijsterveldt AMC, van de Port IGL, Krist MR, Schmikli SL, Stubbe JH, Frederiks JE, et al. Effectiveness of an injury prevention programme for adult male amateur soccer players: a cluster-randomised controlled trial. British Journal of Sports Medicine. 2012; 46: 1114–1118.

[57] Hölmich P, Larsen K, Krogsgaard K, Gluud C. Exercise pro-gram for prevention of groin pain in football players: a cluster-randomized trial. Scandinavian Journal of Medicine and Science in Sports. 2010; 20: 814–821.

[58] Mohammadi F. Comparison of 3 Preventive Methods to Reduce the Recurrence of Ankle Inversion Sprains in Male Soccer Players. The American Journal of Sports Medicine. 2007; 35: 922–926.

[59] Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. The American Journal of Sports Medicine. 1985; 13: 259–262.

[60] de Hoyo M, Pozzo M, Sañudo B, Carrasco L, Gonzalo-Skok O, Domínguez-Cobo S, et al. Effects of a 10-Week in-Season Eccentric-Overload Training Program on Muscle-Injury Preven-tion and Performance in Junior Elite Soccer Players. Interna-tional Journal of Sports Physiology and Performance. 2015; 10: 46–52.

[61] Harøy J, Clarsen B, Wiger EG, Øyen MG, Serner A, Thorborg K, et al. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. British Journal of Sports Medicine. 2019; 53: 150–157.

[62] Silvers-Granelli HJ, Bizzini M, Arundale A, Mandelbaum BR, Snyder-Mackler L. Does the FIFA 11+ Injury Prevention Pro-gram Reduce the Incidence of ACL Injury in Male Soccer Play-ers? Clinical Orthopaedics and Related Research. 2017; 475: 2447–2455.

[63] Silvers-Granelli H, Mandelbaum B, Adeniji O, Insler S, Bizzini M, Pohlig R, et al. Efficacy of the FIFA 11+ Injury Prevention Program in the Collegiate Male Soccer Player. The American Journal of Sports Medicine. 2015; 43: 2628–2637.

[64] van der Horst N, Smits D, Petersen J, Goedhart EA, Backx FJG. The Preventive Effect of the Nordic Hamstring Exercise on Hamstring Injuries in Amateur Soccer Players: a random-ized controlled trial. The American Journal of Sports Medicine. 2015; 43: 1316–1323.

[65] van de Hoef PA, Brink MS, Huisstede BM, van Smeden M, de Vries N, Goedhart EA, et al. Does a bounding exercise program prevent hamstring injuries in adult male soccer players? - A cluster‐RCT. Scandinavian Journal of Medicine & Science in Sports. 2019; 29: 515–523.

[66] Elerian AE, El-Sayyad MM, Dorgham HAA. Effect of Pre-training and Post-training Nordic Exercise on Hamstring Injury Prevention, Recurrence, and Severity in Soccer Players. Annals of Rehabilitation Medicine. 2019; 43: 465–473.

[67] Owen AL, Wong DP, Dellal A, Paul DJ, Orhant E, Collie S. Ef-fect of an Injury Prevention Program on Muscle Injuries in Elite Professional Soccer. Journal of Strength and Conditioning Re-search. 2013; 27: 3275–3285.

[68] Melegati G, Tornese D, Gevi M, Trabattoni A, Pozzi G, Schon-huber H, et al. Reducing muscle injuries and reinjuries in one Italian professional male soccer team. Muscles, Ligaments and Tendons Journal. 2013; 3: 324.

[69] Izzo R, Giovannelli M, D’Isanto T. The injury prevention pro-gram WTA functional primitive movement in professional foot-ball players: A case study. Journal of Physical Education and Sport. 2019; 19: 1885–1889.

[70] Grooms DR, Palmer T, Onate JA, Myer GD, Grindstaff T. Soccer-Specific Warm-up and Lower Extremity Injury Rates in Collegiate Male Soccer Players. Journal of Athletic Training. 2013; 48: 782–789.

[71] Junge A, Lamprecht M, Stamm H, Hasler H, Bizzini M, Tschopp M, et al. Countrywide Campaign to Prevent Soccer Injuries in Swiss Amateur Players. The American Journal of Sports Medicine. 2011; 39: 57–63.

[72] Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention of anterior cruciate ligament injuries in soccer. Knee Surgery, Sports Traumatology, Arthroscopy. 1996; 4: 19–21.

[73] Lehnhard RA, Lehnhard HR, Young R, Butterfield SA. Moni-toring Injuries on a College Soccer Team: the effect of strength training. Journal of Strength and Conditioning Research. 1996; 10: 115–119.

[74] Dadebo B. A survey of flexibility training protocols and hamstring strains in professional football clubs in England. British Journal of Sports Medicine. 2004; 38: 388–394.

[75] Cross KM, Worrell TW. Effects of a static stretching program on the incidence of lower extremity musculotendinous strains. Journal of Athletic Training. 1999; 34: 11.

[76] Caldwell AR, Vigotsky AD, Tenan MS, Radel R, Mellor DT, Kreutzer A, et al. Moving Sport and Exercise Science Forward: a Call for the Adoption of more Transparent Research Practices. Sports Medicine. 2020; 50: 449–459.

[77] Erickson LN, Sherry MA. Rehabilitation and return to sport af-ter hamstring strain injury. Journal of Sport and Health Science. 2017; 6: 262–270.

[78] Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. British Journal of Sports Medicine. 2016; 50: 731–737.

[79] Nédélec M, McCall A, Carling C, Legall F, Berthoin S, Dupont G. Recovery in Soccer. Sports Medicine. 2012; 42: 997–1015.

[80] Rhodes D, McNaughton L, Greig M. The temporal pattern of recovery in eccentric hamstring strength post-soccer specific fa-tigue. Research in Sports Medicine. 2019; 27: 339–350.

[81] Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. British Journal of Sports Medicine. 2006; 40: 40–44.

[82] Sherry MA, Johnston TS, Heiderscheit BC. Rehabilitation of Acute Hamstring Strain Injuries. Clinics in Sports Medicine. 2015; 34: 263–284.

[83] Comin J, Malliaras P, Baquie P, Barbour T, Connell D. Re-turn to Competitive Play after Hamstring Injuries Involving Dis-ruption of the Central Tendon. The American Journal of Sports Medicine. 2013; 41: 111–115.

[84] Sherry MA, Best TM. A Comparison of 2 Rehabilitation Pro-grams in the Treatment of Acute Hamstring Strains. Journal of Orthopaedic and Sports Physical Therapy. 2004; 34: 116–125.

[85] Silder A, Sherry MA, Sanfilippo J, Tuite MJ, Hetzel SJ, Hei-derscheit BC. Clinical and Morphological Changes Following 2 Rehabilitation Programs for Acute Hamstring Strain Injuries: a Randomized Clinical Trial. Journal of Orthopaedic and Sports Physical Therapy. 2013; 43: 284–299.

[86] Daneshjoo A, Mokhtar AH, Rahnama N, Yusof A. Effects of the 11+ and Harmoknee warm-up programs on physical perfor-mance measures in professional soccer players. Journal of Sports Science and Medicine. 2013; 12: 489–496.

[87] Sarmento H, Manuel Clemente F, Marques A, Milanovic Z, David Harper L, Figueiredo A. Recreational football is medicine against non‐communicable diseases: A systematic review. Scandinavian Journal of Medicine & Science in Sports. 2020; 30: 618–637.