Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 24, Issue 6, pp 2002–2008 | Cite as

Injuries can be prevented in contact flag football!

  • Yonatan KaplanEmail author
  • Grethe Myklebust
  • Meir Nyska
  • Ezequiel Palmanovich
  • J. Victor
  • E. Witvrouw
Sports Medicine



This original prospective cohort study was conducted in an attempt to significantly reduce the incidence and the severity of injuries in an intervention cohort as compared to a two-season historical cohort, and to provide recommendations to the International Federation of Football (IFAF) pertaining to prevention measures to make the game safer.


A total of 1,260 amateur male (mean age: 20.4 ± 3.9 years) and 244 female (mean age: 18.5 ± 1.7 years) players participated in the study. 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. All time-loss injuries sustained in game sessions were recorded by the off-the-field medical personnel and followed up by a more detailed phone injury surveillance questionnaire.


There was a 54 % reduction in the total number of injuries and a significant reduction in the incidence rate and incidence proportion between the intervention cohorts as compared to the historical cohort (p < 0.001). There was no statistically significant reduction in the number of injuries in any of the body parts, except for in hand/wrist injuries related to the use of pockets (p < 0.001), as well as the severity of mild-moderate injuries (p < 0.05).


This study provided evidence that hand/wrist injuries can be significantly reduced in flag football. Recommendations to the IFAF include strict enforcement of the no-pocket rule, the use of soft headgear, comfortable-fitting ankle braces and mouth guards and additionally, to change game rules concerning blocking.

Level of evidence



Contact flag football Sports injuries Prevention Intervention 



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 Mrs Sari Diament BSc, for her editing assistance in preparing this manuscript.

Conflict of interest

The authors declare that no organization sponsored the research and there is no conflict of interest.

Supplementary material

167_2014_3266_MOESM1_ESM.xlsx (17 kb)
Supplementary material 1 (XLSX 17 kb)


  1. 1.
    Aaltonen S, Karjalainen H, Heinonen A et al (2007) Prevention of sports injuries: systematic review of randomized controlled trials. Arch Intern Med 167(15):1585–1592CrossRefPubMedGoogle Scholar
  2. 2.
    Barbic D, Pater J, Brison RJ (2005) Comparison of mouth guard designs and concussion prevention in contact sports: a multicenter randomized controlled trial. Clin J Sport Med 15(5):294–298CrossRefPubMedGoogle Scholar
  3. 3.
    Bleakley CM, O’Connor S, Tully MA et al (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. BMC Musculoskelet Disord 8:125CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Burnham BR, Copley GB, Shim MJ et al (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(suppl 1):S141–S147CrossRefPubMedGoogle Scholar
  5. 5.
    Chalmers DJ, Langley JD (1999) New Zealand Injury Research Unit: helping shape injury prevention policy and practice. Inj Prev 5:72–75CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Collins RK (1987) Injury patterns in women’s intramural flag football. Am J Sports Med 15:238–242CrossRefPubMedGoogle Scholar
  7. 7.
    Finch C, Braham B, McIntosh A, McCrory P, Wolfe R (2005) Should football players wear custom-fitted mouthguards? Results from a group-randomized controlled trial. Inj Prev 11:242–246CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Fuller CW, Ekstrand J, Junge A et al (2006) Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Scand J Med Sci Sports 16:83–92CrossRefPubMedGoogle Scholar
  9. 9.
    Gordis L (2009) Epidemiology, 4th edn. Publication, Philadelphia PA Saunders Elsevier, pp 140–143Google Scholar
  10. 10.
    Handoll HH, Rowe BH, Quinn KM et al (2001) Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev 3:CD000018Google Scholar
  11. 11.
    International Flag Football Rules: 5 on 5/non-contact. International Federation of American Football (IFAF) (2009) article 1b
  12. 12.
    International Flag Football Rules: 5 on 5/non-contact. International Federation of American Football (IFAF) (2011). Rule 1, section 3
  13. 13.
    Janda DH (1997) Sports injury surveillance has everything to do with sports medicine. Sports Med 42:169–171CrossRefGoogle Scholar
  14. 14.
    Järvinen TA, Järvinen TL, Kääriäinen M et al (2007) Muscle injuries: optimising recovery. Best Pract Res Clin Rheumatol 21:317–331CrossRefPubMedGoogle Scholar
  15. 15.
    Kaplan Y, Myklebust G, Nyska M et al (2012) The epidemiology of injuries in contact flag football. Clin J of Sport Med 23:39–44CrossRefGoogle Scholar
  16. 16.
    Kaplan Y, Myklebust G, Nyska M et al (2014) The prevention of injuries in contact flag football. Knee Surg Sports Traumatol Arthrosc 22(1):26–32CrossRefPubMedGoogle Scholar
  17. 17.
    Karlsson J (2002) Ankle braces prevent ligament injuries. Lakartidningen 99:3486–3489PubMedGoogle Scholar
  18. 18.
    Knowles SB, Marshall SW, Guskiewicz KM (2006) Issues in estimating risks and rates in sports injury research. J Athl Train 41(2):207–215PubMedPubMedCentralGoogle Scholar
  19. 19.
    Meeuwisse WH (1994) Assessing causation in sport injury: a multifactorial model. Clin J Sport Med 4:166–170CrossRefGoogle Scholar
  20. 20.
    Myklebust G, Skjolberg A, Bahr R (2013) ACL injury incidence in female handball 10 years after the Norwegian ACL prevention study: important lessons learned. Br J Sports Med 47(8):476–479CrossRefPubMedGoogle Scholar
  21. 21.
    Niedfeldt MW (2011) Head injuries, heading, and the use of headgear in soccer. Curr Sports Med Rep 10:324–329CrossRefPubMedGoogle Scholar
  22. 22.
    Orchard J (1995) Orchard Sports Injury Classification System (OSICS). Sport Health 11:39–41Google Scholar
  23. 23.
    Pasanen K, Parkkari J, Pasanen M et al (2008) Neuromuscular training and the risk of leg injuries in female football players: cluster randomised controlled study. BMJ 337:a295PubMedPubMedCentralGoogle Scholar
  24. 24.
    Schneider S, Seither B, Tönges S et al (2006) Sports injuries: population based representative data on incidence, diagnosis, sequelae, and high risk groups. Br J Sports Med 40(4):334–339CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Soligard T, Nilstad A, Steffen K et al (2010) Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med 44:787–793CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  • Yonatan Kaplan
    • 1
    • 5
    Email author
  • Grethe Myklebust
    • 2
  • Meir Nyska
    • 3
  • Ezequiel Palmanovich
    • 3
  • J. Victor
    • 4
  • E. Witvrouw
    • 1
  1. 1.Department of Rehabilitation Sciences and PhysiotherapyGhent UniversityGhentBelgium
  2. 2.Oslo Sports Trauma Research CenterNorwegian School of Sport SciencesOsloNorway
  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