Background Epidemiological studies in American Flag Football have revealed a high incidence of injuries. No previous study has attempted to prevent injuries.

Objective 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.

Design Prospective cohort study.

Setting Kraft Stadium, Jerusalem, Israel.

Participants A total of 1 260 amateur male (mean age: 20.4±3.9 yrs) and 244 female (mean age: 18.5±1.7 yrs) players participated in the study.

Interventions 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.

Main outcome measures 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.

Results There was an 88% reduction in the total number of injuries, and a significant reduction in the incidence rate and incidence proportion between the intervention cohort as compared to the historical cohort (P<.001). There was a trend towards a reduction in the number of injuries in all body parts, reaching statistical significance in hand/wrist injuries related to the use of pockets (P<.001), as well as the severity of mild-moderate injuries (P<.05).

Conclusions 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.