FIFA neuromuscular training programs on ankle injuries in football players: A meta-analysis with emphasis on evidence gaps

Abstract

Background

Football causes over 4 million injuries each year, making injury prevention a priority. To mitigate the risks, FIFA neuromuscular programs (FIFA 11 +, FIFA 11 + Kids, and FIFA 11) are implemented to reduce injury risk. Nevertheless, their efficacy varies across populations and implementation protocols.

Methodology

Databases such as PubMed, Web of Science, Cochrane Library, and EMBASE (2006–2025) were searched for randomized controlled trial (RCT) studies comparing FIFA programs to standard warm-ups. Risk of bias was assessed using the Cochrane RoB 2.0 tool. Pooled relative risk (RR) with 95 % CIs were calculated using random-effects models. Prespecified subgroups were analyzed according to program version, sex, sample size, and training parameters (frequency/duration).

Results

Nine RCTs (n = 11,687) found that FIFA programs, in general, reduced ankle injury risk by 38 % (RR=0.62, 95 % CI: 0.50–0.78; P < 0.001). Version-specific analyses revealed significant effects for FIFA 11 + (RR=0.57) and FIFA 11 + Kids (RR=0.56), but no effect for FIFA 11 (RR=0.94). Sex-specific analysis showed a 44 % reduction in males (RR=0.56) but no significant effect in females (RR=0.87). Exploratory subgroup analysis revealed small-study effects: smaller trials (n < 500) demonstrated greater efficacy (RR=0.33) than larger trials (n ≥ 1000; RR=0.73). Neither training frequency (1–2 vs. >2 sessions/week; P = 0.91) nor intervention duration (20–26 vs. ≥27 weeks; P = 0.09) modified efficacy. The quality of evidence was rated as moderate according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

Conclusion

FIFA programs significantly reduce ankle injury risk in football players. However, efficacy differences primarily reflect program version (FIFA 11 ineffective) rather than biological sex, with insufficient female-specific data and diminished effects in larger trials. Future large-scale trials should confirm effectiveness in female and youth athletes, addressing limitations from small-trial bias.

1

Introduction

Today, football has approximately 270 million registered players and 400 million global participants , , generating over 4 million annual injuries. The resultant economic burden exceeds 1.8 billion euros in direct medical costs, with indirect costs, including productivity loss and long-term rehabilitation, accounting for 70 % of the total burden , . Ankle injuries are among the most common musculoskeletal injuries in sports, accounting for up to 40 % of all sports-related injuries , . Incidents related to this injury often occur during dynamic maneuvers such as jumping, landing, cutting, and collisions, where deficits in neuromuscular control predispose athletes to inversion sprains and ligament damage , .

To address this public health challenge, the FIFA Medical and Research Centre (F-MARC) developed structured prevention programs. The original FIFA 11 program (hereafter the ‘11’), introduced in 2006, comprised 10 running, plyometric, and balance exercises during 15-minute warm-ups but demonstrated inconsistent ankle protection, particularly among female athletes . Its successor, FIFA 11 +, expanded to 15 exercises across three progressive phases (dynamic warm-ups, strength/balance/plyometrics, and agility drills), explicitly enhancing ankle stability through core control, eccentric strength, proprioception, and landing mechanics . Further adaptation resulted in FIFA 11 + Kids, which transformed neuromuscular training into age-appropriate motor skill development and gamified coordination for children aged 7–12 years , addressing growth-related injury risks during puberty .

Empirical evidence reveals significant yet heterogeneous efficacy: FIFA 11 + reduces lower extremity injury risk by 30–35 % through biomechanical mechanisms that augment anterior talofibular ligament (ATFL) stabilization and peroneal muscle strength , , while FIFA 11 + Kids significantly mitigates youth ankle injury risk . With ≥ 2 weekly sessions, this protective effect is amplified through enhanced neuromuscular control of the ankle joint , . Despite these benefits, critical methodological limitations challenge the consistency of these findings.

The FIFA 11 failed to demonstrate statistically significant ankle injury reduction . Meanwhile, even though FIFA 11 + demonstrated variable efficacy across populations, particularly under low compliance (<70 %) or in cohorts including participants over 40 years old with overweight, such heterogeneity compromises outcome generalizability . Sex-specific analysis confirms the efficacy of FIFA 11 + in reducing ankle injuries in males, while female-specific ankle injury data remain inconclusive due to underpowered trials . Persistent methodological limitations compromise the validity of injury prevention research, manifesting in three core deficiencies. First, inadequate monitoring of intervention adherence persists, with pivotal studies reporting compliance below the 70 % efficacy threshold required for reliable outcomes . Second, insufficient stratification of anatomical outcomes leads to conflated pathology metrics, such as aggregated knee and ankle injury data, obscuring joint-specific intervention effects. Third, some influential systematic reviews rely on weaker study designs, including observational studies and poorly controlled trials, which increase the risk of bias . Collectively, these limitations directly contribute to quantifiable analytical noise, as evidenced by substantial statistical heterogeneity .

Despite more than two decades of updates, FIFA programs continue to exhibit methodological limitations, resulting in inconsistent evidence. Some foundational meta-analyses have combined results from different program generations, such as FIFA 11 and FIFA 11 +, even though these differ substantially in neuromuscular training intensity, a factor likely responsible for variations in efficacy , . In addition, the exclusion of FIFA 11 + Kids further limits the generalizability of the findings . Narrow participant sampling, such as the exclusive focus on NCAA Division I athletes, fails to represent amateur populations, which experience 23 % lower effectiveness . Additionally, unaccounted biological confounders, such as growth velocity differentials during puberty, significantly alter biomechanical responses to prevention protocols due to muscle-bone length mismatches .

The contrasting approaches of interventions delivered once or twice weekly versus those administered multiple times per week suggest conclusive evidence regarding the relative efficacy of low-frequency versus high-frequency training in preventing ankle injuries , . Furthermore, while the preventive mechanism relies critically on enhanced muscular strength, the intervention duration across studies varied substantially, ranging from 6 to 9 months. This heterogeneity in training period impedes definitive evaluation of the impact of program length on improvements in ankle functional capacity.

This study establishes the first meta-analytic framework to resolve the longstanding controversies through three core innovations: (1) version-specific efficacy profiling, (2) rigorous sex-stratified analysis, and (3) validity tiers to correct for small-study bias, supplemented by exploratory dose-response modelling (accounting for exercise frequency, duration, and program length). This approach is expected to redefine best practices for FIFA program generations by matching them to athlete demographics, reporting sex-subgroup efficacy separately, deriving clinical inferences only from adequately powered trials, and incorporating dose parameters into future program design and evaluation

2

Data source and literature search

2.1

Data sources and literature search

This meta-analysis was prospectively registered with PROSPERO (CRD42024627670) and adhered to the PRISMA 2020 guidelines . A systematic search was conducted across four electronic databases (PubMed, Web of Science, Cochrane Library, and EMBASE), covering publications indexed from 1 January 2006–30 June 2025. Search strategies combined Medical Subject Headings (MeSH) and free-text terms using Boolean operators. A representative search query was: (“injury prevention” OR “FIFA 11” OR “FIFA 11 +” OR “FIFA 11 + Kids” OR “neuromuscular training”) AND (“football” OR “soccer”). The complete search syntax for each database is provided in Appendix A Table A1.

Duplicate records were identified and removed using EndNote software (Version 21; Clarivate, Philadelphia, PA, USA). Two independent reviewers screened titles, abstracts, and full texts against predefined eligibility criteria. Discrepancies were resolved by consensus or third-reviewer adjudication. To minimize selection bias, the reference lists of included studies and relevant systematic reviews were hand-searched for additional eligible publications.

2.2

Inclusion and exclusion criteria

2.2.1

Inclusion criteria

The inclusion criteria were based on the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework. Eligible participants must be competitive football athletes of any sex, aged 12–35 years, with at least one year of training experience. The interventions consisted of complete FIFA injury prevention programs (FIFA 11, FIFA 11 +, or FIFA 11 + Kids) delivered as standardized warm-up protocols. Control groups performed conventional dynamic stretching or running-based warm-ups without structured neuromuscular training components. The primary outcome was ankle injuries, such as ligament sprains or fractures, reported as risk ratios (RRs) with 95 % confidence intervals (CIs). Eligible study designs included randomized controlled trials (RCTs) published in peer-reviewed journals

2.2.2

Exclusion criteria

Studies were excluded if they involved non-FIFA injury prevention programs (such as modified versions of FIFA 11, FIFA 11 +, or FIFA 11 + Kids), included control groups that incorporated any injury prevention elements (such as balance drills), or failed to report ankle-specific injury data. Studies employing non-randomized designs, non-peer-reviewed publications, or non-English texts with untranslatable data were also excluded.

2.3

Data extraction

Data extraction was performed by two independent reviewers using a pre-piloted template, with discrepancies resolved by a third reviewer. Extracted data included study characteristics (author, year, study design), participant details (age, sex, competitive level, and sample size), and intervention parameters (training frequency, intervention duration, and total duration). The primary outcomes were ankle injury RRs with 95 % CIs. Risk of bias for individual studies was assessed using the Cochrane Risk of Bias 2.0 tool (RoB 2). Disagreements were resolved by consensus or, when necessary, by adjudication from a third reviewer.

2.4

Grading of recommendations, assessment, development, and evaluation (GRADE) evidence quality evaluation

In this study, the quality of the evidence was rigorously assessed using the GRADE approach, which systematically evaluates the quality of evidence and the strength of recommendations . The evidence was categorized into four levels: high, moderate, low, and very low quality. This evaluation involved an analysis across five critical domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias. Each domain was examined to determine the robustness and reliability of the evidence, ensuring a rigorous and transparent assessment process.

2.5

Data analysis

A comprehensive meta-analysis was performed using RRs with 95 % CIs as the primary effect size metric for binary outcomes. Statistical heterogeneity was assessed using the I² statistic and τ² estimates , with a random-effects model applied when substantial heterogeneity was observed (I²≥50 %) ; otherwise, fixed-effects models were employed. Pooled estimates were derived through inverse-variance weighting. Additionally, sensitivity analysis using leave-one-out methodology was performed to evaluate the disproportionate influence of individual studies. Publication bias was assessed through funnel plot symmetry, Egger’s regression test, and Begg’s rank correlation test (significance threshold: p < 0.05). Moreover, stratified random-effects models were used to explore heterogeneity and assess the consistency of effects across predefined subgroups. All statistical analyses were conducted in Review Manager 5.4, while publication bias testing was carried out in R (v4.4.3) using the metafor and meta packages .

3

Result

3.1

Literature search results

A total of 1052 records were identified from four databases (PubMed, Web of Science, Embase, and Cochrane). After removing 346 duplicates, 706 records were screened, with 676 excluded (508 non-RCTs, 50 animal studies/reviews, 118 interventions failing criteria), leaving 30 for full-text review. Of these, 10 were unretrievable and 1 was excluded due to incomplete data (n = 3), non-convertible data (n = 3), or ineligible subjects (n = 5), resulting in 9 studies included in the meta-analysis, as shown in Fig. 1 .

Fig. 1

PRISMA 2020 flow diagram of the study selection process.

3.2

Characteristics of included studies

As detailed in Table 1 , this meta-analysis synthesized nine RCTs involving 11,687 football athletes across developmentally distinct cohorts, with participants’ ages ranging from 7 to 35 years. Six studies exclusively enrolled male athletes, two focused on female-only groups, and one included mixed-gender participants ,,,,,,,, . The intervention protocols varied in several aspects: session durations ranged from 15 to 20 min (median: 20 min); training frequencies ranged from 1 to 4 sessions per week (≥2 sessions: 7 studies); and intervention periods ranged from 20 to 39 weeks (median: 26 weeks; >24 weeks: 6 studies). The studies employed FIFA 11 +, FIFA 11 + Kids, and FIFA 11. Specifically, FIFA 11 + was used in 7 studies, FIFA 11 + Kids in 2 studies, and FIFA 11 in 1 study. Outcome assessments were centered on ankle injury incidence within FIFA-structured prevention programs, with results reported using RR under binary outcome classification (injured vs. non-injured).

Table 1

Data Extraction From Included Articles.

Author (Year) Intervention Type Session Duration (min) Training Frequency (sessions/week) Intervention Period (weeks) Age Range Group (M/F) Sample Size (IG/CG)
Al Attar et al. (2017) FIFA 11 + 20 2–3 26 14–35 Male 144/136
Lopes et al. (2020) FIFA 11 + 20 2 20 27.7 ± 5.0 Male 31/34
Nuhu et al. (2021) FIFA 11 + 20 3–4 30 19.9 ± 0.2 Male 309/317
Owoeye et al. (2014) FIFA 11 + 20 1–2 26 14–19 Male 212/204
Rössler et al. (2018) FIFA 11 + Kids 15–20 2 39 7–13 Mixed (M/F) 2066/1829
Silvers-Granelli et al. (2015) FIFA 11 + 15 2 22 18–25 Male 675/850
Soligard et al. (2008) FIFA 11 + 20 3 35 12–18 Female 1055/837
Steffen et al. (2008) FIFA 11 15 1 30 13–16 Female 1079/947
Zarei et al. (2019) FIFA 11 + Kids 20 2 39 7–14 Male 443/519

EG = experimental group; CG = control group; M = male; F = female.

3.3

Methodological quality

The results of the risk of bias assessment of 9 studies are presented in Fig. 2 . These figures offer a clear and concise overview of the methodological quality of each study, with low risk indicated by green, some concerns in yellow, and high risk in red. For the randomization process, all 9 studies were assessed as having low risk of bias. Regarding deviations from the intended interventions, 1 study was rated as high risk, and the others raised some concerns. In the domain of missing outcome data, 7 studies were rated as low risk, and 2 studies raised some concerns. For outcome measurement, 7 studies were rated as low risk, and 2 studies raised some concerns. Similarly, in the selection of the reported result, 7 studies were classified as low risk, and 2 studies raised some concerns. Overall, 3 studies were rated as low risk, Rössler et al. (2018) was rated as high risk, and 5 studies raised some concerns.

Fig. 2

Risk of Bias Summary and Graph (Created using the Robvis Tool).

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Sep 5, 2026 | Posted by in ORTHOPEDIC | Comments Off on FIFA neuromuscular training programs on ankle injuries in football players: A meta-analysis with emphasis on evidence gaps

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