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

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.