Theme 1: the understanding of the 11+ injury prevention warm-up

In each of the focus groups, participants believed that a warm-up and injury prevention strategies were important. There appeared to be a general willingness to participate in these programmes and the majority of participants reported having used the 11+ programme.

Coach: Yes, I think so. I think on most coaching licenses I’ve been on that have had someone for football have come along and talked everyone through it. I think the coaches come away with some semblance of an understanding of what they should be delivering.

Player: I really like it as a warmup, I think it’s super easy and basically I like the fact that I know that it’s proven to reduce injuries.

Many of the participants either had little understanding of the ‘Part 2’ strength exercises or did not think that these exercises should be included in a football warm-up. As a result, these elements were rarely done or delivered by study participants.

Strength and Conditioning (S+C): I always thought it was interesting because you’re doing a lot of those movements [Part Two exercises] in your gym sessions anyway, so I usually just take them out.

Coach: I’ve never seen Part Two. So I’ve only ever seen, I think it’s six, eight minutes at the start, two groups in a line, two lines going around the cones, doing the running movements and all that, opening the gates and stuff. I’ve never seen 10 minutes of planks and things like that, nor whatever it is that I don’t understand.

Player: We just do the running things with the cones and it only takes a few minutes and then it’s done.

There was good understanding of the potential of the programme to reduce the risk of injury. Participants believed those participating at a community level were less likely to complete a warm-up and to know about the 11+ due to a range of issues including a lack of time and the feeling that it was not ‘cool’.

Player: I’d say just changing that for social teams just that social stigma around warming up, quite often you turn up and if you’re the one person warming up you kind of look like a dick, you look like you’re out there as a pro. And I’d say that’s probably one of the number one reasons people don’t warm up on a social team is because you look like an idiot if you’re going to warm up before you play five a side at futsal.

Theme 2: content of an ideal injury prevention programme

There was universal agreement that the ‘physiological’ element of the warm-up (the ability to increase the players’ heart rate, warm up muscles and to get the players moving) was an essential element of a football warm-up. There was a desire to retain the proprioceptive elements, especially among the strength and conditioning (S+C) and medical participants. This was generally regarded as being an essential element, alongside the running activities.

Medical: The shoulder bump exercise in the 11+ to me is one of the most important preparatory drills, especially before a game.

S+C: I think, looking at it, the things that you get plenty of in the game are the top block [Part One] and the bottom block [Part Three], the things that are most important for that injury prevention side of things, which especially at the community level, people won’t be as accustomed to doing, is definitely the plyometric stuff, the balance stuff, the hamstring strengthening exercises.

S+C: I think that plyo component and the progression of those plyos, and then especially those landing mechanics, all that sort of stuff, is invaluable.

There were mixed views about whether the warm-up was the best place to deliver strengthening exercises. This type of training was felt to be of importance, but some participants felt this is better delivered outside of the football training session as they were less enjoyable and harder to include in a prefootball session. The S+C participants reported the exercises were difficult to implement in a football session due to the varying needs and abilities of individual players, and expressed concerns whether these exercises could be delivered safely.

S+C: …a community-based player, I’d get them through the running. I’d get them through the quick stuff at the end, get them through some change of direction. And I'd probably bomb off the middle, if I’m being honest. If they’re going to do it poorly.

Coach: Yeah. You look at some movement of Part Two like the single leg stands and vertical jumps and things like that, again, lend itself to that, we’re stood up, ball each, whatever it may be, we’ve just done a run and then we go into our sprints and then we’re away. There’s something in my mind which still says, yep, this is all related, this links to this. We’re away. As soon as we get on the floor and start doing planks and things like that, I’m not sure….

Theme 3: structure of the programme

All of the study participants commented on the rigidity of the current 11+ programme. This was generally felt to be a limitation of the 11+. The fixed structure was felt to have some benefit for those with less experience and to have some value with regard to mental preparation, especially on match days.

Player: I think the fact that we do it at the start of every training or whatever that almost mentally prepares me as well. I know it’s physically supposed to warm you up, but I kind of get to the end of the warmup and I’m like, okay, you’re ready to go.

Participants expressed a desire to add more variability and to incorporate activities and movements that were more directly related to football. Incorporating the elements of the current 11+ programme into the tactical elements of a session, using a ball or integrating the warm-up intervention into the entire training session, rather than seeing the programme as a stand-alone warm-up, was suggested. Involving high-profile coaches to develop session plans was also recommended.

S+C: I can see really good opportunities if you’ve got a coach and an S+C working together to deliver the nuts and bolts of this, but with the inclusion of the tactical or skill components of the warmup.

Player: I think with the sprinting part you could definitely get it out of a game with the ball involved and I think socially that’s probably what most people want when they’re warming up.

Medical: [Senior national team coach, name removed], devises a session plan about defending and shows community coaches and players how to deliver it. That includes some injury prevention messages and themes throughout the program.

There was a feedback that, where possible, it would be good to individualise the delivery of prevention strategies to a player’s needs. When considering a more generic programme, however, the majority of the S+C, coach and medical participants felt that there might be some value in adding elements that were specific for individual target groups, for example, female players, younger players or those who have been injured before. The player group appeared less certain about the need for gender-specific strategies.

S+C: I reckon it’s a great call if you show the athletes their individual work ons, strengths, weaknesses etc., the buy-in from my experience is far greater than the delivery of a generic program.

Player: Having two programs [male and female] is probably a bit woke. I don’t really see the difference. Running is running sort of thing, we all have groins and we all have hamstrings, I don’t really know if it’s really going to be much different.

Player: I would think if you’re going to have separate ones you would have to have quite a clear evidence that there is difference in the injuries and sell that story and quite clearly for people then to accept the different ones.

Theme 4: education, adherence and dissemination

Participants felt there was scope to improve adherence by changing the structure and delivery of the programme. Suggestions included providing variability, incorporating football-specific movements and considering the delivery of the strength elements.

Each of the individual focus groups recognised the importance of the coach for the successful implementation of injury prevention strategies. As a result, engagement with coaches in the development and implementation of any new injury prevention initiative was felt essential. At the recreational level, where teams often do not have coaches, it is felt that a different strategy will be needed.

Player: Yeah, I think it would be virtually impossible [to do the 11+ or other injury prevention initiative] without coach buy in. They have complete ownership of what warm up we do, so if they weren’t invested or if they want to do something different then we could give feedback on that, but ultimately the buck stops with them on what we’re doing for the warmup and that’s their job.

Player: I think it’s hard at the social level to get an organized delivery because generally you don’t have a coach.

There was a desire to make the programme less ‘medical’ and to get input from a variety of stakeholders about how to approach warming up and the delivery of injury prevention strategies. Each of the groups identified a need to focus on enjoyable football experiences (at a community level) and on enhancing performance (at higher levels) rather than on preventing injury.

Medical: One of the things we’ve tried to do is really work closely with the coach education sort of departments, and go look, this here, this is a coach’s program. It’s not a medical program. This is your warmup. It’s not a physio’s warmup. So then we can essentially, once you give them ownership, we’ve found that they actually make it. They, then grab it and they take it.

Coach: Mine would be around messaging folks. So I think if we were to concentrate on the performance element of it, that’s what switches more people on is performance levels as opposed to reducing injury.

While participants had good awareness of the 11+ there was a belief that many stakeholders within football had not engaged well with the programme. Integrating injury prevention messages into coaching material, developing a clear communications strategy (involving social media, educational resources and through other non-medical channels) and recruiting high-profile coach or player ambassadors/endorsers were all though to be of value. Mandating a warm-up as part of a competition structure was also discussed.

Coach: I think kids will be more likely to follow the role model player than follow the coach that’s harping on at them every day of the week. So that would be huge. I think the message from athletes to younger athletes is so much more powerful than the coaches’ message.

S+C: So I don’t know if there’s an opportunity in there, bringing some sort of education into the mix in terms of teaching people how to do this and creating a feedback loop, using some online tools, perhaps.

Player: A lot of people use apps, I use an app in the gym most days to find my program or whatever, if you’ve got it on there or somewhere you can just access it, fine.

Player: The [existing] videos are just so dry.

Online supplemental table 4 demonstrates the key themes, subthemes and some of the relevant quotes that emerged during the thematic analysis.