The 20-Minute Warm Up That Could Save Your Knees

Vermont has become the first place in the U.S. to test out a proven European workout routine aimed at reducing injuries in athletes.

More than 800,000 people experience a lower extremity injury—an injury to the entire leg, foot, ankle, knee, or hip – every year in the United States. That’s troubling because these injuries are often disabling and costly. It is estimated that the cost of providing care for such injuries is nearly $567 million annually.

For athletes, there is another cost: time. It can take weeks to months to recover from ankle and knee ligament injuries. Serious injuries to the knee may be season-ending and often require surgery. Additionally, after the original injury, athletes are at high risk for the developing post-traumatic osteoarthritis.

Other athletes never fully recover and the cost is the end of a career in a sport.

In 2015, Vermont became the first location in the U.S. to test out a proven injury prevention protocol developed in Europe, called FIFA 11+, aimed at reducing these injuries in high school athletes. The program has been used nationwide in Switzerland. When introduced in Norway in 2008, a study found that teams that performed FIFA 11+ at least twice a week had 30 to 50 percent fewer player injuries.

With support from a new three-year grant from the Orthopaedic Research and Education Foundation and a one-year grant from Children’s Miracle Network, James Slauterbeck, M.D., an orthopaedic surgeon at the University of Vermont Robert M.D. College of Medicine and his colleagues are working with teams from 14 local high schools to test it.

Over the last two years, they’ve been observing team warm-up routines, tracking injuries and comparing the effectiveness of traditional injury prevention programs to the FIFA 11+ injury prevention program. The sports followed in the study include football, men’s and women’s soccer, basketball and lacrosse.

“FIFA 11+ was developed by an international group of experts to decrease lower extremity injury in soccer athletes, ages 14 years and up,” says Dr. Slauterbeck, who is an associate professor of orthopaedics and rehabilitation at the Robert Larner College of Medicine at UVM and a team orthopedic surgeon for UVM Athletics. “It’s a pre-practice, warm-up program that is low-cost, time-efficient and is easy for coaches to administer. The 20-minute program consists of exercises to increase strength, improve coordination, and teach running strategy. It must be performed two times per week to be effective.”

The costs to run the program are low as you only need some cones, a ball and a partner. It is also important to have a coach or person observe the training and make helpful cues to ensure new and appropriate neuromuscular skills are created and poor strategies are extinguished. The program can be found on the FIFA 11 + website ( and can be downloaded to an IPhone or android device. The videos demonstrating the exercises are expertly performed by professional athletes.

In 2015, during the first year of the three-year project, former UVM head athletic trainer Rebecca Choquette observed the warm-up routine at the 14 participating high schools (Mount Mansfield Union, Harwood, Milton, South Burlington, U 32, Essex, Missisquoi Valley, Rice, Champlain Valley Union, Colchester, Burlington, Stowe, Spaulding, and Vergennes). All lower extremity injuries among the players that resulted in at least one missed practice or game were recorded.

This year (year two of the grant), the researchers are conducting a prospective, randomized trial where half of the schools follow the FIFA11+ warm-up protocol, while the other half of the schools will follow their regular warm-up pre practice routines.

In addition to tracking lower extremity injuries the group will be tracking sports concussions among the youth athletes, with guidance from UVM neuropsychiatrist James Hudziak, M.D., director of the Vermont Center for Children, Youth and Families. The research team will explore some new evidence that shows concussions may be decreased as a result of pre-practice training programs.

“The third year will give us time to analyze the data, to observe the teams’ continued use of the program and allow for a small pilot study to assist in hopefully gaining further funding,” says Dr. Slauterbeck. “If the FIFA 11+ program is shown effective in reducing injury in our current subset of Vermont high schools we will pursue financial support from NIH and hopefully other private donors to spread the program state- or region-wide.”

UVM’s orthopaedics and rehabilitation research team has a strong track record studying lower extremity injuries. “The ACL injury risk factor research we have completed over the last nine years has really helped us get to know the subset of athletes to pay attention to and hopefully we can begin to target these athletes with injury prevention strategies,” says Dr. Slauterbeck. Athletes at greatest risk for injury are those who have a parent who has torn an ACL, who have loose knees or are very flexible.

He adds that a recent study investigating varsity sports showed that an injury prevention program can significantly reduce related health care costs, so this project could realize a meaningful cost savings for Vermont.

So what has been learned so far? “We are currently in year two of the study and we have observed that Vermont high school teams all warm up with a diverse set of exercises including dynamic stretching, dynamic strengthening, running, and static stretching. Some teams are already using injury prevention warm-ups that are similar to FIFA 11+.  However, the schools involved with the study have really made a great effort to stick with the randomization process in year two so that the study can accurately measure one program against the

Dr. Slauterbeck adds, “We are truly blessed with the support for this project by many athletic trainers, medical students, athletic training and strength and conditioning students and physical therapists that have volunteered to help us teach the FIFA11+ program and collect data at the schools.”

Can it work for adults as well? “The answer is yes,” says Dr. Slauterbeck, “particularly if you play soccer.”


Dr. James Slauterbeck played football at Arizona State and is still active in many sports, especially cycling. He works with many young athletes as part of his practice as an orthopaedic surgeon in South Burlington and an Associate Professor of Orthopaedics in the Department of Orthopaedics & Rehabilitation at the University of Vermont Robert Larner College of Medicine. Jennifer Nachbur is the Communications Director at the UVM Robert Larner College of Medicine. Portions of this article originally appeared on the UVM College of Medicine blog.

Updated on August 21, 2018