A warm-up program that focuses on improving strength, balance, core stability and muscular awareness cuts injury in female footballers by a third and severe injuries by almost a half, according to research published on bmj.com today.

In an accompanying editorial, John Brooks an injury expert for the Rugby Football Union, says that people participating in any sport at all levels should adopt a warm-up program like this to reduce injury. Previous studies investigating the effect of warming up on the risk of injury have focused on key warm-up elements — raising the core temperature, stretching the muscles used, and conducting movement specific exercises — but the effect on injury has been unclear until now.

Torbjørn Soligard and colleagues recruited 1,892 female footballers from Norway between the ages of 13 and 17 and randomized them to perform either traditional warm-up exercises (1, 055) or the "11+" 20 minute warm-up intervention (837).

The "11+" 20 minute warm-up program consists of slow and speed running, key exercises to improve strength and balance, and movements that focus on core stability, hip control and knee alignment. The whole program emphasizes the importance of internal muscular awareness.

The researchers reported no significant difference in the number of lower leg injuries between the groups, but substantially fewer severe injuries, overuse injuries and overall injuries were found in the intervention group.

Two examples of strength exercises. Top: side plank exercise. Bottom: the "Nordic hamstring lower"

Compliance with the study was boosted by providing coaches and players with a DVD showing all the exercises, posters and exercise cards, and step by step cards.

The authors conclude by calling for the program to be implemented as a key element of coaching, education and training in football.

In the editorial, Brooks points out that one of the most important findings of this study is that teams using the "11+" program sustained a lower incidence of severe injuries—it is these severe injuries which cause the most absence from sport, interfere with people's lives and place the greatest burden on scarce medical resources.

Not every participant in the study performed the "11+" throughout the season as recommended, so the program may reduce the injury even more with regular use. Health professionals should encourage anyone involved in sport to participate in similar warm-up programs, Brooks concludes.

Article: Torbjørn Soligard, Grethe Myklebust,Kathrin Steffen, Ingar Holme, Holly Silvers, Mario Bizzini, Astrid Junge,Jiri Dvorak, Roald Bahr,Thor Einar Andersen, 'Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial', BMJ 2008;337:a2469, doi:10.1136/bmj.a2469