The prevention of injuries in contact flag football

  • Yonatan Kaplan
  • Grethe Myklebust
  • Meir Nyska
  • Ezequiel Palmanovich
  • Jan Victor
  • Erik Witvrouw
Sports Medicine



American flag football is a non-tackle, contact sport with many moderate to severe contact-type injuries reported. A previous prospective injury surveillance study by the authors revealed a high incidence of injuries to the fingers, face, knee, shoulder and ankle. The objectives of the study were to conduct a pilot-prospective injury prevention study in an attempt to significantly reduce the incidence and the severity of injuries as compared to a historical cohort, as well as to provide recommendations for a future prospective injury prevention study.


A prospective injury prevention study was conducted involving 724 amateur male (mean age: 20.0 ± 3.1 years) and 114 female (mean age: 21.2 ± 7.2 years) players. Four prevention measures were implemented: the no-pocket rule, self-fitting mouth guards, ankle braces (for those players with recurrent ankle sprains) and an injury treatment information brochure. An injury surveillance questionnaire was administered to record all time-loss injuries sustained in game sessions.


There was a statistically significant reduction in the number of injured players, the number of finger/hand injuries, the incidence rate and the incidence proportion between the two cohorts (p < 0.05).


This one-season pilot prevention study has provided preliminary evidence that finger/hand injuries can be significantly reduced in flag football. Prevention strategies for a longer, prospective, randomised-controlled injury prevention study should include the strict enforcement of the no-pocket rule, appropriate head gear, the use of comfortable-fitting ankle braces and mouth guards, and changing the blocking rules of the game.

Level of evidence



Contact flag football Sports injuries Prevention Intervention study 



The authors would like to thank Mrs. Tali Bdolah, MSc, Senior statistician, Hebrew University, Jerusalem, for her assistance with the statistical analysis, as well as Miss Sari Goldstein, BSc, for her editing assistance in preparing this manuscript.


  1. 1.
    Alentorn-Geli E, Myer GD, Silvers HJ, Samiyier G, Romero D, Lazaro-Haro C, Cugat R (2009) Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc 17:705–729PubMedCrossRefGoogle Scholar
  2. 2.
    Bleakley CM, O’Connor S, Tully MA, Rocke LG, Macauley DC, McDonough SM (2007) The PRICE study (protection rest ice compression elevation): design of a randomized controlled trail comparing standard versus cryokinetic ice applications in the management of acute ankle sprain. Musculoskelet Disord 8:125CrossRefGoogle Scholar
  3. 3.
    Burnham BR, Copley GB, Shim MJ, Kemp PA, Jones BH (2010) Mechanisms of flag-football injuries reported to the HQ Air Force Safety Center a 10-year descriptive study, 1993–2002. Am J Prev Med 38(1 Suppl):S141–S147PubMedCrossRefGoogle Scholar
  4. 4.
    Chalmers DJ, Langley JD (1999) New Zealand Injury Research Unit: helping shape injury prevention policy and practice. Inj Prev 5:72–75PubMedCrossRefGoogle Scholar
  5. 5.
    Collins RK (1987) Injury patterns in women’s intramural flag football. Am J Sports Med 15:238–242PubMedCrossRefGoogle Scholar
  6. 6.
    Finch C, Braham R, McIntosh A, McCrory P, Wolfe R (2005) Should football players wear custom fitted mouthguards? Results from a group randomized controlled trial. Inj Prev 11:242–246PubMedCrossRefGoogle Scholar
  7. 7.
    Fuller CW, Ekstrand J, Junge A, Andersen TE, Bahr R, Dvorak J, Hagglund M, McCrory P, Meeuwisse WH (2006) Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Scand J Med Sci Sports 16:83–92PubMedCrossRefGoogle Scholar
  8. 8.
    Gordis L (2009) Epidemiology, 4th edn. Saunders Elsevier Publication, Philadelphia, pp 140–143Google Scholar
  9. 9.
    Handoll HH, Rowe BH, Quinn KM, de Bie R (2001) Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev 3:CD000018PubMedGoogle Scholar
  10. 10.
    Harris DA, Spears IR (2010) The effect of rugby shoulder padding on peak impact force attenuation. Br J Sports Med 3:200–203CrossRefGoogle Scholar
  11. 11.
    Hootman JM, Dick R, Agel J (2007) Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 42:311–319PubMedCentralPubMedGoogle Scholar
  12. 12.
    International Flag Football (2009) 5 on 5/non-contact, Article 1b. Available via:
  13. 13.
    Ivins D (2006) Acute ankle sprain: an update. Am Fam Physician 74:1714–1720PubMedGoogle Scholar
  14. 14.
    Janda DH (1997) Sports injury surveillance has everything to do with sports medicine. Sports Med 42:169–171CrossRefGoogle Scholar
  15. 15.
    Järvinen TA, Järvinen TL, Kääriäinen M, Aärimaa V, Vaittinen S, Kalimo H, Järvinen M (2007) Muscle injuries: optimising recovery. Best Pract Res Clin Rheumatol 21:317–331PubMedCrossRefGoogle Scholar
  16. 16.
    Karlsson J (2002) Ankle braces prevent ligament injuries. Lakartidningen 99:3486–3489PubMedGoogle Scholar
  17. 17.
    Kaplan Y, Myklebust G, Nyska M, Palmanovich E, Victor J, Witvrouw E (2012) The prevention of injuries in contact flag football. Clin J Sport Med, doi: 10.1097/JSM.0b013e3182694870
  18. 18.
    Kerr ZY, Collins CL, Pommering TL, Fields SK, Comstock RD (2011) Dislocation/separation injuries among US high school athletes in 9 selected sports: 2005–2009. Clin J Sport Med 21:101–108PubMedCrossRefGoogle Scholar
  19. 19.
    Martinek V, Friederich NF (1999) To brace or not to brace? How effective are knee braces in rehabilitation? Orthopade 28:565–570PubMedGoogle Scholar
  20. 20.
    Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE, Bahr R (2007) Prevention of noncontract anterior cruciate ligament injuries in elite and adolescent female team handball athletes. Instr Course Lect 56:407–418PubMedGoogle Scholar
  21. 21.
    Navarro RR (2011) Protective equipment and the prevention of concussion—what is the evidence? Curr Sports Med Rep 10:27–31PubMedCrossRefGoogle Scholar
  22. 22.
    Niedfeldt MW (2011) Head injuries, heading, and the use of headgear in soccer. Curr Sports Med Rep 10:324–329PubMedCrossRefGoogle Scholar
  23. 23.
    Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R (2005) Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ 330:449PubMedCrossRefGoogle Scholar
  24. 24.
    Orchard J (1995) Orchard sports injury classification system (OSICS). Sport Health 11:39–41Google Scholar
  25. 25.
    Pasanen K, Parkkari J, Pasanen M, Hiilloskorpi H, Makinen T, Jarvinen M, Kannus P (2008) Neuromuscular training and the risk of leg injuries in female floorball players: cluster randomized controlled study. BMJ 337:a295PubMedGoogle Scholar
  26. 26.
    Pietrosimone BG, Grindstaff TL, Linens SW, Uczekai E, Hertel J (2008) A systematic review of prophylactic braces in the prevention of knee ligament injuries in collegiate football players. J Athl Train 43:409–415PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Rishiraj N, Taunton JE, Lloyd-Smith R, Woollard R, Regan W, Clement DB (2009) The potential role of prophylactic/functional knee bracing in preventing knee ligament injury. Sports Med 39:937–960PubMedCrossRefGoogle Scholar
  28. 28.
    Soligard T, Nilstad A, Steffen K, Myklebust G, Holme I, Dvorak J, Bahr R, Andersen TE (2010) Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med 44:787–793PubMedCrossRefGoogle Scholar
  29. 29.
    Thacker SB (2007) Editorial: public health surveillance and the prevention of injuries in sports: what gets measured gets done. J Athl Train 42:171–172PubMedCentralPubMedGoogle Scholar
  30. 30.
    Wikipedia, the free encyclopedia. Article, Flag Football, Available via:
  31. 31.
    Zebis MK, Bencke J, Andersen LL, Dossing S, Alkjaer T, Magnusson SP, Kjaer M, Aagaard P (2008) The effects of neuromuscular training on knee joint motor control during side cutting in female elite soccer and handball players. Clin J Sport Med 18:329–337PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Yonatan Kaplan
    • 1
    • 5
  • Grethe Myklebust
    • 2
  • Meir Nyska
    • 3
  • Ezequiel Palmanovich
    • 3
  • Jan Victor
    • 4
  • Erik Witvrouw
    • 1
  1. 1.Department of Rehabilitation Sciences and PhysiotherapyGhent UniversityGhentBelgium
  2. 2.Oslo Sports Trauma Research CenterOsloNorway
  3. 3.Department of Orthopedic SurgeryMeir HospitalKfar SabaIsrael
  4. 4.Department of Physical Medicine and Orthopaedic SurgeryGhent UniversityGhentBelgium
  5. 5.Jerusalem Sports Medicine Center, Lerner Sports CenterHebrew UniversityJerusalemIsrael

Personalised recommendations