Activate, as trialledEmerging evidence
In 40 independent schools in England (3,188 boys aged 14 to 18, of whom 2,452 were analysed, over one season), coaches swapped the usual warm-up for balance, whole-body strength, jumping, landing and cutting drills, done as the first 20 minutes of every training session and match warm-up, with new phases every 4 weeks. The comparison teams did a running and stretching warm-up. Across all teams, the effect on match injuries was unclear: 26 against 30 per 1,000 match hours, with the trial's uncertainty range running from 39% fewer to 17% more. Concussions were 6 against 8 per 1,000 match hours, a likely but uncertain difference.
Teams that did it 3 or more times a week had 72% fewer match injuries and 59% fewer concussions than comparison teams doing their warm-up as often. But only 12 of 63 teams managed 3 sessions a week (the average was 1.9), so these figures rest on a small group.
In English men's community clubs (81 clubs randomised over the 2015 to 2016 season), the warm-up ran in seven 6-week phases, at training twice a week and before matches, with neck exercises in every phase. There was no clear effect on injuries overall. Concussions were 60% lower, 1.2 against 3.4 per 1,000 match hours, with the trial's uncertainty range running from 30% to 80% lower, and lower-limb injuries were about 40% lower, though that range reached no difference. But 40 of the 81 clubs dropped out or sent incomplete data, and shoulder injuries weren't lower.
Both trials reported 90% rather than the usual 95% uncertainty ranges, and the biggest effects came from small groups that did it most often, so we grade Activate as emerging.
Sources 8, 9, 39
What Activate involvesStrong evidence
Activate comes in versions for under-15s, under-16s, under-18s and adults. Each session has 4 parts: running preparation and change of direction; balance (youth) or range of movement, strength and balance (adults); strength (youth) or strength, stability, agility and power (adults); and landing and jumping (youth) or repeated sprints and neck strength (adults). It takes 15 to 20 minutes for young players and 20 to 25 for adults.
Everyone starts at the first phase and moves on after 6 to 8 weeks, or 12 to 16 sessions at twice a week, and injured players restart at their own phase. Adults use a separate match-day phase before matches, without Nordic hamstring exercises, which "can tire the hamstring muscles". The online programme lists the same versions as levels: four for each youth age group, and seven plus a match-day session for adults.
The manual says the best results come from 3 sessions a week, and that teams doing it once or twice a week still saw fewer injuries. The trials were in schoolboys aged 14 to 18 and adult men, so it asks coaches to adapt it for younger players and women.
Sources 39, 40
Doing it often enough is the hard partEmerging evidence
In a real-world study of schoolboy teams, 16 of 25 teams took Activate up, and only one used it 3 times a week with the full phases. Players who did it 3 or more times a week had fewer training and match injuries than those who did it less than once a week. In the men's clubs that kept to it best, the injuries the programme targets were about 60% lower. As with football's 11+, the benefit follows how often teams do it.
Sources 8, 41, 9
Hamstrings: the Nordic exerciseEmerging evidence
Across 15 studies of 8,459 athletes of both sexes in several sports, programmes that included the Nordic hamstring exercise were linked with about half as many hamstring injuries, and two large football trials found big falls, but when only properly randomised trials are pooled the effect is uncertain. In professional union, players who added Nordics to their usual strengthening and stretching had fewer and less severe hamstring injuries, though that study wasn't randomised. A review of 24 rugby studies lists playing position, fatigue, a previous injury, strength differences between the legs, returning too soon and running as risk factors.
The 10-week build and the weekly upkeep from the football trials are in our hamstring and groin injury prevention workout.
Sources 12, 13, 14, 15, 16, 17, 36
ShouldersMixed evidence
No shoulder prevention programme has been tested in rugby, and in the adult Activate trial, which included shoulder exercises, shoulder injuries weren't lower. Tackle technique is the practical lever (see the tackle section below).
After a dislocation, our shoulder dislocation guide explains why young players in collision sports should ask about surgery: repeat dislocations are common. After surgery, collision athletes still dislocate again more often than other athletes, and in contact and collision athletes, open repair was followed by fewer repeats than keyhole (arthroscopic) repair, 7% against 18%, with similar returns to play. The NHS says getting back to some sports can take up to 16 weeks.
Sources 34, 9, 42, 43, 44
What hasn't workedEmerging evidence
Padded headgear didn't reduce concussion in a randomised trial. Neck strengthening hasn't been shown to reduce it. Lowering the tackle height in elite men didn't reduce concussions, and tacklers were concussed more often. In schoolboys, Activate done less than 3 times a week showed much smaller effects.
Sources 45, 11, 46, 8