The plus sign in FIFA's 11+ warm-up program might well signify plus-sized results.

The exercise regimen developed by the Fédération Internationale de Football Association, soccer's international governing body, (known as FIFA), can reduce overall injuries by one-third and severe injuries by nearly one-half, according to a study published in the British Medical Journal.

[The study] found significantly lower rates of injury in athletes who regularly performed the 20-minute [warm-up] program ...

In a cluster-randomized controlled trial of 1890 Norwegian female youth soccer players, investigators from FIFA's Medical Assessment and Research Centre (F-MARC) and from the Oslo Sports Trauma Research Centre found significantly lower rates of injury in athletes who regularly performed the 20-minute program during an eight-month season.

"The 11+ program should be implemented as a key element of [soccer] training," said Jiri Dvorak, MD, chairman of F-MARC and co-author of the study. "In fact, every coach and team physician needs to be aware of its positive effects and results."

The overall injury rate in the 52 teams randomized to the intervention group was 32% lower than in the 41 control teams that warmed up as usual throughout the season. Athletes in the intervention group also had a 24% lower risk of acute injury, a 53% lower risk of overuse injury, a 46% lower risk of a serious injury (time loss of more than 28 days), a 30% lower risk of any lower extremity injury, and a 45% lower risk of knee injury.

The findings are particularly impressive given that the teams in the intervention group did not actually implement the regimen prior to every training session as they had been instructed to do by the study authors. Compliance with the 11+ program was estimated at 77%.

However, that rate of compliance was a significant improvement over the previous incarnation of the F-MARC warm-up program, which was dubbed "The 11" because it included 10 exercises plus an 11th component of fair play. A cluster-randomized study of "The 11" published in the January 2008 issue of the Scandinavian Journal of Medicine and Science in Sports found no significant effect of that warm-up program, likely because the compliance rate was a poor 52%.

In particular, some coaches felt that "The 11" was not active enough to be an effective warm-up. To address that issue, the 11+ incorporates eight minutes of running at the start of the program and two minutes at the end, a design similar to that used in the Prevent injury and Enhance Performance (PEP) program developed by Santa Monica researchers to prevent anterior cruciate ligament injuries. You can download a poster of the FIFA program from their website: