Shoulder injuries in soccer goalkeepers: review and development of a FIFA 11+ shoulder injury prevention program

Abstract

Benno Ejnisman,1 Gisele Barbosa,1 Carlos V Andreoli,1 A de Castro Pochini,1 Thiago Lobo,2 Rodrigo Zogaib,2 Moises Cohen,1 Mario Bizzini,3 Jiri Dvorak3 1Department of Orthopaedics, Federal University of São Paulo, 2Sports Medicine Department, Santos FC, São Paulo, Brazil; 3FIFA-Medical Assessment and Research Centre, Schulthess Clinic, Zurich, Switzerland Abstract: In the last years, shoulder injuries have represented an increasing health problem in soccer players. The goalkeepers are more exposed to shoulder disorders than other field players. Injury prevention exercises for upper limbs were cited in few studies involving throwing athletes, but we know that goalkeepers need a specific program. The purpose of this study is to describe the development of an adapted Fédération Internationale de Football Association (FIFA) 11+ program, namely the FIFA 11+ shoulder, which targets the prevention of shoulder injuries in soccer goalkeepers. The FIFA 11+ shoulder program is structured into three parts: general warming-up exercises, exercises to improve strength and balance of the shoulder, elbow, wrist, and finger muscles, and advanced exercises for core stability and muscle control. The exercises were selected based on recommendations from studies demonstrating high electromyographic activity. Keywords: goalkeeper, shoulder, injury prevention, prevention program

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Shoulder injuries in soccer goalkeepers: review
and development of a FIFA 11+ shoulder injury
prevention program
Benno Ejnisman1
Gisele Barbosa1
Carlos V Andreoli1
A de Castro Pochini1
Thiago Lobo2
Rodrigo Zogaib2
Moises Cohen1
Mario Bizzini3
Jiri Dvorak3
1Department of Orthopaedics,
Federal University of São Paulo,
2Sports Medicine Department, Santos
FC, São Paulo, Brazil; 3FIFA-Medical
Assessment and Research Centre,
Schulthess Clinic, Zurich, Switzerland
Correspondence: Benno Ejnisman
Department of Orthopaedics, Federal
University of São Paulo, Rua Estado de
Israel 636, Cep 04022-002, São Paulo, SP,
Brazil
Email bennoale@uol.com.br
Abstract: In the last years, shoulder injuries have represented an increasing health problem in
soccer players. The goalkeepers are more exposed to shoulder disorders than other field players.
Injury prevention exercises for upper limbs were cited in few studies involving throwing athletes,
but we know that goalkeepers need a specific program. The purpose of this study is to describe
the development of an adapted Fédération Internationale de Football Association (FIFA) 11+
program, namely the FIFA 11+ shoulder, which targets the prevention of shoulder injuries in
soccer goalkeepers. The FIFA 11+ shoulder program is structured into three parts: general
warming-up exercises, exercises to improve strength and balance of the shoulder, elbow, wrist,
and finger muscles, and advanced exercises for core stability and muscle control. The exercises
were selected based on recommendations from studies demonstrating high electromyographic
activity.
Keywords: goalkeeper, shoulder, injury prevention, prevention program
Introduction
Soccer is the most popular sport worldwide, and participation in this sport can be
associated with injuries.1 On average, an elite soccer player suffers from 1.5 to 7.6
injuries each 1,000 hours of training and 12 to 35 injuries each 1,000 hours of match.2,3
Kirkendall and Dvorak4 reported that the most common injured site was the lower limb
(67.7%), followed by the upper limb (13.4%).
In the last years, shoulder injuries have represented an increasing health problem
in soccer players.5 The modern soccer has been characterized by high speed, pressing,
and marking.5 Many researchers have reported that goalkeepers are more exposed to
upper limb lesion than other field soccer players.6,7
The percentage of shoulder damage that occurred during Athens 2004 and EURO
2004 was 3.8% and 4.4%, respectively.8 Junge et al9 reported shoulder injuries between
2% and 13% during a 4-year period (from 1998 to 2001) of international tournaments.
The Fédération Internationale de Football Association (FIFA) collected data during
Japan/Korea World Cup (2002) and Germany World Cup (2006) and reported higher
percentages of upper extremity injury (4.6% and 8.2%, respectively).
A third of shoulder injuries (28%) sustained by professional soccer players are
severe because of which participation in training and games is stopped for $28 days.10
In a study of the UEFA European Championships, a total of 34 severe injuries were
recorded, two of which were shoulder dislocation.11 Hart and Funk12 reported that a
previous shoulder injury is a significant risk factor of more or repeated injuries than
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other soccer injuries in general. A majority of serious soccer
shoulder injuries affect the glenoid labrum (84%), and a
smaller number are labral injuries with associated rotator
cuff involvement (8%). A minority (8%) are isolated rotator
cuff injuries.
Prevention of soccer injuries: what
about the upper extremity?
Since the launch of FIFA 11+, key publications have
confirmed the preventive effects of the program and have
evaluated its performance-improving effects in female as
well as male amateur soccer players.13 Considerable reduc-
tions in the number of injured players, ranging between
30% and 70%, have been observed among the teams that
implemented the FIFA 11+ program.14 This program has been
mainly developed to prevent lower limb injuries – there is
no specific program in the current literature to prevent upper
limb lesions in soccer players.
Wilk et al15 developed the Advanced Throwers Ten Exer-
cise Program. This program consists of exercises that restore
muscle balance and symmetry in the overhead throwing ath-
lete, which is necessary for the symptom-free return to sports
after lesion. Injury prevention exercises for upper limbs are
cited in few studies involving throwing athletes,16,17 but we
know that soccer goalkeepers need a specific program.
McCall et al18 cited that the “five” most common injury
risk-screening tests used by national soccer teams were
the evaluation of flexibility (dynamic and static), physical
fitness, joint mobility, balance/proprioception, and muscle
endurance and peak strength. In the same study, the authors
reported the exercise-based injury prevention strategies that
were not specific for upper or lower limb injuries. The key
preventive exercises used by national teams were similar to
those reported for premier league clubs, albeit in a slightly
different order of importance.18 For example, core, balance/
proprioception, and eccentric exercises also feature in the
“Top five” of national teams’ exercises. At the time of this
review, there was no direct scientific evidence that core
exercises can reduce injury risk in top-level soccer players,
although evidence from other sports suggests some preven-
tive capacity.19
Despite being supported for shoulder rehabilitation by
some studies, eccentric exercise has a weak level of evidence
in the scientific literature20 as it cannot be ascertained whether
its beneficial effects on injury are specifically from the eccen-
tric component.21,22 Finally, while flexibility is an important
exercise for practitioners, two systematic reviews23,24 have
shown that there is no conclusive evidence to support
stretching to prevent injuries. Both reviews, however, also
highlight that there is no sufficient reason to discontinue
flexibility exercises in the training program.
The aim of this paper is to describe the development of an
adapted FIFA 11+ program, namely the FIFA 11+ shoulder
(FIFA 11+S), which targets the prevention of shoulder injuries
in soccer goalkeepers.
Development of the FIFA 11+S
program
The FIFA 11+S program is structured into sections according
to the FIFA 11+ program already successfully used to prevent
lesions.25 The exercises were selected based on recommen-
dations from studies demonstrating high electromyographic
activity,26–32 including additional exercises to provide varia-
tion and progression.
The program was developed by an international group
of experts, including orthopedics expert in shoulder lesions,
physiotherapists with experience in soccer lesion, and
specialists in sports rehabilitation. For all the exercises,
correct performance is of great importance. Therefore, the
coach should supervise the program and correct the players
if necessary.
The program consists of three parts: general warming-up
exercises (part I), exercises to develop strength and balance
of the shoulder, elbow, wrist, and finger muscles (part II),
and advanced exercises for core stability and muscle control
(part III). The FIFA 11+S takes ∼20–25 minutes to complete
and replaces the usual warm-up before training (Figure 1).
All exercises focus on core stability, neuromuscular control,
eccentric rotator strength, and agility.
These exercises should be performed three times per
week and should be added to the training taken by the soccer
goalkeeper. Part I exercises should be done for 7 minutes as
a general warm-up. Part II exercises should be performed
for 9–10 minutes in a low-resistance (light tubing strength
or 2–3 kg), high-repetition format (three sets of 15–20 rep-
etitions), in order to improve strength and local muscular
endurance.33 Exercise should be changed according to the
tolerance of the athlete (to A instead of B and C exercises,
Figure 1). In part III, the athlete must do the exercises at
high velocities with five or six sets of 15–20 repetitions not
exceeding 9–10 minutes; these exercises are performed to
increase local muscular endurance.33
The emphasis is given to the strengthening of some
muscle groups such as the shoulder rotator cuff. The external
and internal concentric rotation power balance ratio must be
maintained between 0.6 and 0.8.34 Regarding athletes with
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Ejnisman et al

instability, Ellenbecker and Davies35 suggested as a preventive
measure an increase of 10% in the normal strength relation
(from 66% to 76%), altering the rotator’s relation from 2/3 to
3/4. Internal rotator is an important component of the throw-
ing movement; on the other hand, the antagonist (external
rotator) must be strong enough to decelerate the throwing
movement and to stop the ball when grabbing it.
Other important muscles that should be focused on are
the anterior serratus and lower and medium trapezium to
prevent the scapular dyskinesia. The power of these muscles
and superior trapezium keeps the correct scapulohumeral
rhythm.32,36–39
Open kinetic chain exercises with ball-throwing move-
ments are included, in addition to closed kinetic chain
1 Run
Relaxed walking or running.
the speed can be
progressively increased.
5 min
2 Throw the ball in the chest
line
Ask for help from a partner.
With both hands in front
of the body, throw and catch
the ball, first with your elbows
flexed and then with your
arms over your head. 1 min
3 Spinning movements with
the hands
Interlace the fingers and make
spinning movements with the
hands. 1 min
1A External rotation
Initial position: Standing with
the elbow flexed at 90° to the
side
Exercise: Rotate the arm
from neutral to external
rotation.
.
1B External rotation
Initial position: standing with
the elbow flexed at 90° and
45° abducted
Exercise: Rotate the arm
from the neutral to external
rotation.
2B Internal rotation
Initial position: standing with
the elbow flexed at 90° and
45° abducted
Exercise: Rotate the arm
from neutral to internal
rotation.
2A Internal rotation
Initial position: standing with
the elbow flexed at 90° to the
side
Exercise: Rotate the arm
from neutral to external
rotation.
1C External rotation
Initial position: standing with
the elbow flexed at 90° and
90° abducted
Exercise: Rotate the arm
from the neutral to external
rotation.
2C Internal rotation
Initial position: standing with
the elbow flexed at 90° and
90° abducted
Exercise: Rotate the arm
from neutral to internal
rotation.
3B Scaption
Rise the arm with external
rotation in the scapular plane
(30° in the frontal plane) to
shoulder height. Hold heavier
weight than the previous level.
3A Scaption
Rise the arm with external
rotation in the scapular plane
(30° in the frontal plane) to
shoulder height. Hold a weight.
3C Scaption
Rise the arm with external
rotation in the scapular plane
(30° in the frontal plane) to
shoulder height. Hold heavier
weight than the previous level.
4B Push-up-plus
In the same position. Place an
anklet of 5 kg on your back.
Exercise: Rise the body and
then lower the body
4A Push-up-plus
In the prone position. The
hands should be placed at a
distance corresponding to the
width of the shoulders.
Exercise: Rise the body and
then lower the body
4C Push-up-plus
In the same position but on
one foot. Place an anklet of
more than 5 kg on your back.
Exercise: Rise the body and
then lower the body
5B Inferior and mid trapezius
In the prone position, arms In
90° abduction. After changing
the arms to 120° of abduction.
Exercise: Hold heavier weight
than the previous level and
bring the arm back slightly.
5A Inferior and mid trapezius
In the prone position, arms in
90° abduction. After changing
the arms to 120° of abduction.
Exercise: Hold a weight and
bring the arm back slightly.
5C Inferior and mid trapezius
In the prone position, arms in
90° abduction. After changing
the arms to 120° of abduction.
Exercise: Hold heavier weight
than the previous level and
bring the arm back slightly.
6B Biceps
Position: Arms at your sides,
palms facing inwards. Hold
heavier weight than the
previous level.
Exercise: Bend your elbows,
turning the palms upward.
6A Biceps
Position: Arms at your sides,
palms facing inwards. Hold a
weight.
Exercise: Bend your elbows,
turning the palms upward.
6C Biceps
Position: Arms at your sides,
palms facing inwards. Hold
heavier weight than the
previous level.
Exercise: Bend your elbows,
turning the palms upward.
Part I – Warm-up exercises*
Part II – strength and balance of the shoulder, elbow, wrist, and finger muscles**
Figure 1 (Continued)
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FIFA 11+S upper extremity prevention program

exercises that simulate falls and movements on the ground.
In both cases, the CORE activation is needed to maintain
the correct muscular activation sequence, and transfer and
dissipate energy in the kinetic chain.29,40
The diagonal exercises are used to strengthen the
muscles. The diagonal D1 in the flexor pattern (accelera-
tion) and extension (deceleration) activates the rotator cuff,
scapular waist, and deltoid muscles, which is important
to improve the co-activation of the intra-articular power
couples.37,41
The sensory-motor training is an important part of the
program. The lack of shoulder stability increases the need
of the sensory-motor system for neuromuscular control.
The feed forward and feedback mechanisms are considered
7A Wrist flexors
Position: Support the forearm,
palm of the hand upward. Hold a
weight.
Exercise: Lower the weight as
far as possible and then lift it
up.
7B Wrist flexors
Position: Support the forearm,
palm of the hand upward. Hold
heavier weight than the previous
level.
Exercise: Lower the weight as
far as possible and then lift it up.
7C Wrist flexors
Position: Support the forearm,
palm of the hand upward.Hold
heavier weight than the previous
level.
Exercise: Lower the weight as
far as possible and then lift it up.
8A Wrist extensors
Position: Support the forearm,
palm of the hand down. Hold a
weight.
Exercise: Lift up weight as far as
possible and then lift it up.
8B Wrist extensors
Position: Support the forearm,
palm of the hand down. Hold
heavier weight than the previous
level.
Exercise: Lift up weight as far as
possible and then lift it up.
8C Wrist extensors
Position: Support the forearm,
palm of the hand down. Hold
heavier weight than the previous
level.
Exercise: Lift up weight as far as
possible and then lift it up.
9A Finger flexors
Position: Supported forearm and
palm of the hand down on an
elastic.
Exercise: Close the hand,
pulling the elastic.
9B Finger flexors
Position: Supported forearm and
palm of the hand down on an
elastic. Increase the resistance
of the elastic.
Exercise: Close the hand,
pulling the elastic.
9C Finger flexors
Position: Supported forearm and
palm of the hand down on an
elastic. Increase the resistance
of the elastic.
Exercise: Close the
hand, pulling the elastic.
.
10A Finger extensors
Position: Supported forearm and
palm of the hand upward on an
elastic. The other hand holds the
elastic.
Exercise: Open the hand,
stretching the elastic.
10B Finger extensors
Position: Supported forearm and
palm of the hand upward on an
elastic. The other hand holds the
elastic. Increase the resistance
of the elastic.
Exercise: Open the hand,
stretching the elastic.
10C Finger extensors
Position: Supported forearm and
palm of the hand upward on an
elastic. The other hand holds the
elastic. Increase the resistance
of the elastic.
Exercise: Open the hand,
stretching the elastic.
2 Throw the ball over the head
with an arm
Ask for help from a partner. With
the elbow extended and arm
above the level of the head,
throw and catch the ball with an
arm.
3 Throw the ball to the sides
With the elbow extended, throw
and catch the ball one arm at a
time. Make the movement with
the arm by the body’s side and
lift it up over the head.
Part III – Core stability and muscle control with advanced exercises***
1 Jump and throw the ball over
the head
Ask for help from a partner. Jump
and with the elbow extended
and arm above the level of the
head, throw and catch the ball.
4 Jump with your hands on the
mini trampoline
In prone position, firming
yourself with the feet on the
ground and the palms of the
hands on the mini trampoline.
“jump” with your hands, keeping
the elbows straight.
5 Walking on hands
Ask for a partner to hold your
legs and, in prone position,
“walk” using your hands. Move
forward, backward and to the
sides.
5 Plyometric external rotation
Flexed elbow in 90° and flexed
and abducted arm in 90°. Hold
the elastic and make
movements from neutral to
lateral rotation quickly.
Figure 1 The FIFA 11+ shoulder injury prevention program.
Notes: *Part I should be performed for 7 minutes. **Part II should be performed in 9–10 minutes at 3 sets of 15 repetitions. Exercises should be changed according to the
tolerance of the athlete (to A for B and C exercises). ***Part III, the athlete must do the exercises at high velocities with 5 or 6 sets of 15 to 20 repetitions, not exceeding
9–10 minutes.
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Ejnisman et al

as critical points of the kinetic chain, making their training
extremely important for the prevention of lesions.42
Plyometric training is also included, which facilitates
the increase of excitability of the neural system and the
reactive capacity of the neuromuscular system of healthy
athletes’ shoulders. This training includes the eccentric
movement that produces elastic energy and transforms this
accumulated energy into kinetic energy which is transferred
to the concentric phase using the shortening–strengthening
cycle.30–32,43
Conclusion and future perspectives
We would like to recommend scientists and clinicians to
also consider researching upper extremity injury in soccer
goalkeepers. Considering favorable results from the previ-
ously published research on FIFA 11+ with soccer athletes,
we hypothesize the following benefits of FIFA 11+S: fewer
injuries, fewer costs, and better performance by soccer
goalkeepers.
One of the strengths of this study is the type of athletes
involved, who have not been discussed in the literature,
considering the difficulties in obtaining a program specific
for goalkeepers. The lack of results about the use of this
preventive program is the limitation of this paper.
Future research should investigate the effects of FIFA
11+S to prevent injuries of the upper limbs and improve
performance of the soccer goalkeepers.
Disclosure
The authors report no conflicts of interest in this work.
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