Do exercise-based prevention programmes reduce non-contact musculoskeletal injuries in football (soccer)? A systematic review and meta-analysis with 13355 athletes and more than 1 million exposure hours

Key points

1. 0110 RCTs with 13,355 players and over 1 million exposure hours found a 23% reduction in non-contact injuries (IRR 0.77, 95% CI 0.61 to 0.97) with exercise-based programmes
2. 02Focused hamstring programmes (Nordic Hamstring Exercise, Bounding Exercise) reduced non-contact hamstring injuries by 35% (IRR 0.65, 95% CI 0.44 to 0.97) with low-quality evidence
3. 03General programmes (e.g., FIFA 11+) did not show a statistically significant effect on non-contact hamstring injuries specifically (IRR 0.63, 95% CI 0.19 to 2.12)
4. 04You would need to expose 148 players to an intervention programme to prevent one non-contact injury; for focused hamstring programmes the number needed to treat was 31
5. 05All evidence was rated very low to low quality; more high-quality RCTs are needed before firm clinical recommendations can be made

How it was conducted

Design

Systematic review and meta-analysis of randomised controlled trials (PRISMA guidelines; PROSPERO CRD42020173017)

Databases searched

MEDLINE, EMBASE, CENTRAL, CINAHL, PEDro, SPORTDiscus, earliest record to January 2021

Participants

Football players aged 13 years or older, all amateur, including male and female and youth and adult players across 8 countries

Intervention types

General programmes (FIFA 11+, FIFA 11, PEP, Knäkontroll neuromuscular training) and focused programmes (Nordic Hamstring Exercise, Bounding Exercise Programme)

Primary outcome

Number of non-contact musculoskeletal injuries per 1000 hours of exposure

Study length

12 weeks to 9 months across included trials

What they found

• Pooled IRR for all exercise-based programmes vs control: 0.77 (95% CI 0.61 to 0.97), n=13,355, I2=30%; very low-quality evidence (23% risk reduction)
• Focused programmes for non-contact hamstring injuries: IRR 0.65 (95% CI 0.44 to 0.97), n=1238, I2=0%; low-quality evidence (35% risk reduction)
• General programmes for non-contact hamstring injuries: IRR 0.63 (95% CI 0.19 to 2.12), n=2573, I2=51%; very low-quality evidence (not statistically significant)
• Sensitivity analysis - male athletes only: IRR 0.68 (95% CI 0.48 to 0.96), n=3444, I2=20%; significant effect
• Sensitivity analysis - female athletes only: IRR 0.85 (95% CI 0.63 to 1.16), n=9911, I2=38%; not statistically significant
• Number needed to treat (NNT) for overall programmes: 148; for focused programmes: 31; for men: 118; for women: 181
• Overall non-contact injury incidence in control groups: 0.54 per 1000 hours (95% CI 0.47 to 0.60); for overall non-contact injuries specifically: 0.96 per 1000 hours (95% CI 0.79 to 1.13)
• Non-contact ACL injury incidence: 0.87 per 1000 hours (95% CI 0.70 to 1.05); non-contact hamstring injury incidence: 0.41 per 1000 hours (95% CI 0.32 to 0.50)

Limitations

• All evidence rated very low to low quality by GRADE; 4 of 10 studies had high risk of bias and only 30% used concealed allocation
• Most included studies focused on specific injury subtypes (hamstring, knee, ACL) rather than all non-contact injuries, likely underestimating true effect
• Participants were predominantly young, amateur, and female, limiting generalisability to adult professional or elite players
• 90% of studies did not separate training from match injuries, preventing incidence reporting by context

Why it matters

For patients

Amateur football players can expect a modest reduction in their risk of non-contact injuries by consistently following an exercise prevention warm-up programme, with the strongest benefit for hamstring injury prevention using targeted exercises.

For clinicians

Hamstring-focused eccentric programmes (NNT=31) offer the most actionable evidence for reducing specific non-contact injuries, while general programmes like FIFA 11+ are easier to implement with good adherence (~85%) despite weaker evidence for non-contact injury specifically.

For readers

This meta-analysis fills a gap by focusing exclusively on non-contact injuries in football, but the very low evidence quality means these promising findings need confirmation from larger, better-designed trials before definitive guidelines can be set.