Physical activity is associated with specific health benefits, including prevention of chronic diseases [38]. Injuries are indeed a common consequence of physical activity, and their management in sports, such as football (soccer), is difficult in terms of costs and time loss for the athlete, for the team and for the society as well [22]. It is known and well accepted that severe injuries take time to recover or can lead to an early retirement and to long-term consequences. For example, a majority of athletes sustaining an ACL injury will develop early osteoarthritis [23]. A variety of injury prevention exercise programmes (IPEPs) have been shown to be effective in reducing the injury rate [5, 16, 19, 20, 24, 29, 37]. Typically, these programmes consist of exercises focusing on balance, core stability, muscle strength and stretching. Examples of recent neuromuscular training (NMT) include a 5-phase 15 min programme [25], a 15-minute neuromuscular warm-up programme [37], the Prevent Injury and Enhance Performance programme (PEP) [24], The 11 [34] and The 11+ [29]. Although the effectiveness of these programmes has been demonstrated, compliance may be a critical factor in decreasing injuries [8]. To really prevent injuries and to have a significant public health impact, IPEPs need to be accepted, adopted and complied with by athletes, coaches, sports bodies and clubs [8]. Many studies demonstrated that players with high adherence/compliance had significantly lower injury risk [13, 30, 32]. In a recent meta-analysis, for example, Sugimoto et al. found that the incidence of ACL injury was lower in studies with good adherence to NMT [35].

Implementation of injury prevention programmes represents a real challenge in sports medicine [9]. The key point for future sports injury prevention is to reduce the “research to practice” gap [15]. It is mandatory to translate evidence into practice to establish the real effectiveness of these programmes.

As an example, we will discuss what the Fédération Internationale de Football Association (FIFA) has done in the past years and what it keeps on doing.

Prevention programmes are thought to be applied in the same way to very different athlete groups. This approach is the one presented in the most part of articles. Whether or not a preseason evaluation based on movement analysis and athlete’s clinical history will be useful has to be determined in further studies. Hewett et al. evaluated a large number of young female athletes in the preseason and built a predictive model for ACL injury risk based on a drop-jump analysis [17]. So the most logic approach may be to split in two the prevention concept: general prevention (through the well-known neuromuscular programmes) and tailored prevention (based on the player’s risk profile) (Fig. 11.4).

In terms of general prevention, we strongly advice to implement prevention programmes on the two main categories of athletes: the recreational athletes and the young athletes.

If we really want to implement prevention and have a strong impact on public health, we need to target the recreational athletes (99 % of the 300 million football players worldwide). For recreational athletes we mean the competitive players of lower divisions (all sports) and the non-competitive recreational, maybe playing once a week without training. This is a hard challenge to be pursued. Regarding the first group, it is easiest to introduce prevention exercise as they play in a structured team with a dedicated staff or at least a coach, which has to be targeted for education. For the second group, public education programmes should be taught and implemented together with physical activity prescription. Moreover, in case of injury, a specific reinjury prevention programme should be learned.

Most researchers and doctors recommend starting prevention strategies as soon as possible. Generally, injury risk is low under the age of 12 [11]. The incidence of injury increases with age, and studies have shown that the injury rate among players aged 16 years or older approaches that of adult players [3, 6]. The focus on young athletes ideally brings two main advantages. First of all, having a good prevention strategy at a young age means improving the young athlete’s health also from a musculoskeletal perspective. Moreover, a proper education of the youngest means having a higher compliance of the future adult athletes. To reach the youngest, it is very important to involve the family and educate, first of all, their parents. Regarding the responsibility for implementing measures to reduce the risk of injury in the young population, Emery et al. argued that there is a hierarchy of responsibility with the lowest level of responsibility assigned to the child and the highest to those organisations (sports groups and government) that could potentially make the most change [4]. For example, an Australian legislation increased the helmet-wearing from 31 to 75 % in a year. This means that government regulation can make more changes compared to parent and child behaviour.

First of all, the aim of an injury prevention research group is to check the effectiveness of the proposed NMT throughout prospective studies and subsequently share the findings with the scientific community. Among the 45 papers we reviewed during the writing of this chapter, we found that the most represented types of articles are prospective randomised controlled trial (RCT), prospective intervention study and statements. Prospective studies, possibly randomised, are the gold standard. An intervention and a control group need to be created. The control group may consist of a real group of different players without intervention or the same group of players in previous seasons.

Once the effectiveness of the NMT has been demonstrated, the scientific community has to deliver the programme to the public audience and to the sports community. This is what the international organisations, and in general all the sports bodies, are doing nowadays. Ways of “practical” publication have changed through the years, so, Web-based and app-based channels have to be carefully considered. Moreover, the organisation of workshops and courses for coaches and athletic trainers is still very important to spread out the message. The delivery of posters, DVD and pamphlets is fundamental as well. We need to use the right message to the right goal. For example, the right message to convince and motivate them is “injury prevention programme will reduce the risk by at least 50 %” instead of “injury prevention programme may reduce the risk” [26]. One of the keys while conducting a workshop or a course is “proposing” rather than “imposing” FIFA11+. After increasing the motivation of the coach and raising awareness of injury prevention, the exercises should be briefly explained and demonstrated. The participants should then perform the exercises and be corrected by the instructor(s), therefore appreciating the challenges (i.e. neuromuscular control!) behind each exercise. In the second half of the workshop, each of the participants should teach at least one of the exercises to the group and get feedback on this from the instructor. It is important to stress that regular and correct performance of the exercises is crucial for the preventive effect.

Maybe the most important player on which we need to do prevention is the public audience. The sports medicine community needs the power of media and Web-based communication. Communication is evolving and the community is evolving too. Media can maximise the effort of a single man or organisation; the message may spread to the entire world and modify the way people think. This is what FIFA did during the World Cup in 2010 (Fig. 11.5), and they keep doing it through “The 11+” video sharing. Simple messages have to be transmitted to the audience.