This article pretty much confirms what our aching joints and limbs tell us: rugby can be dangerous!
Another medical article, this one about American play, can be found here. - Wes
Tackling rugby injuries
(From The Lancet, June 10, 1995 by Michael Edgar, Michael Garraway & Donald Macleod)Rugby Union is on a pinnacle of success and popularity, dominating the sporting media during the World Cup series over the past few weeks. National teams are attracting large sums of commercial sponsorship and the rugby world is about to embark on professionalism with the likelihood of an elite world league. Therefore the paper in this issue by Garraway and Macleod, on the epidemiology of rugby injuries, is well timed. It is also doubly pertinent.
Firstly, the changes in the rules of the game that have raised its profile as a spectator sport were, to a large extent, the result of medical pressure generated to make the game safer. Secondly, Garraway and Macleod have demonstrated the feasibility of a large-scale epidemiological study into rugby injuries; therefore, with the advent of professionalism in Rugby Union, there should be now the opportunity and financial support to set up a comprehensive audit. This will allow not only a longitudinal appraisal of changes in the pattern of rugby injuries but also a comparison with similar studies in other high-risk sports including rugby league, American association football, and various equestrian sports.
To those of us who work in sports trauma clinics, rugby remains the sport with the apparently highest risk per player-hour of injury.[1,2] Paradoxically at the international level, where the game is fastest and most spectacular, evidence shows that fitness and experience considerably reduce the injury rate.[3] From the late 1970s club medical officers became concerned by the increasing numbers of rugby injuries in general and broken necks in particular.[4-6] As a result strong medical representations in several countries influenced the International Rugby Football Board to adopt new rules agreed in 1986.[7] Collapse of the scrum, prolonged rucks or mauls, and spear or high tackles were banned in the interests of safety. [For the uninitiated: a scrum is a set piece in which players pack themselves head-down and try to push opponents off the ball; a ruck is an informal gathering around the ball when it is on the ground; a maul is a loose scrum; and a spear tackle is the use of head or body to knock an opponent to the ground.]
Players in school rugby were to be matched for experience and size rather than for age. [8,9] Although there has been some difficulty in enforcing the rules,[6] the overall effect has been not only a reduction in the prevalence of serious injury but also, almost as a byproduct, a game that flows better and is more open and faster--all important ingredients in attracting spectators.
Inevitably, changes in the rules will alter the pattern of play and hence the spectrum of injury, which itself will require further monitoring. Garraway and Macleod's prospective study of Scottish club rugby players, the largest investigation of its kind, points to a relative reduction in scrum and ruck trauma and an increased risk among those tackling or being tackled. Garraway and Macleod also set out the methods by which the frequency, severity, and consequences of injury can be standardised.
There is now growing acceptance that injury is best measured as the player-injury rate per 1000 player-hours. The current senior Scottish club prevalence is 14, which compares well with a school rugby prevalence in 1980 of 20[10] and a 1990 Australian rugby league prevalence of 45.[11] Garraway and Macleod also subscribe to the consensus that an injury is "notifiable" if it incapacitates the player for more than one week. The other important outcome of their study is that no spinal injuries or neurological disasters were recorded; in agreement with other recent investigations this does indicate that the game is becoming safer,[12,13] though there is still concern in South Africa about a persistently high incidence of cervical spine fractures and quadriplegia.[14]
In an earlier paper Garraway and co-workers[15] called for a national register of rugby injuries to provide a continuous picture of the rugby playing population, and Noakes and Jakoet[14] lately declared that "proper epidemiological studies" are a necessary precursor to a register. This week's paper shows how it can be done. 96% of players and all clubs in the area complied. Certain officials acted as linkmen, liaising with chartered physiotherapists (club medical officers would have perhaps been an alternative) to collate injury details on a manageable proforma. Ideally the reports should include information about the stage of the game, time of the season, phase of play, standard of match, involvement of foul play, weather conditions, and so on, as well as the nature of the injury and the resultant disability in terms of sport and employment. However, the fewer the details the more likely they are to be recorded accurately; in these records game analysis (ie, the relative number of scrums, line-outs, and tackles that lead to injury) will be as important as injury analysis. Long-term follow-up is also important, to clarify late effects, if any, of playing rugby.
Garraway and Macleod's earlier call for such a national register was rebuffed by the English Rugby Union on the grounds that rugby, as an amateur if not minority sport, did not have the professionalism and back-up to collate rugby injuries.[16] Now that the game faces a brighter future, the medical authorities and injury subcommittees of the various rugby football unions must impress on their management that a register is not only practicable and affordable but also vital for the health of players and the game. The Scottish Rugby Union deserve much credit for supporting the current research.
[1] Watters DA, Brooks S, Elton RA, Little K. Sport injuries in an accident & emergency department. Arch Emerg Med 1984; 1:105-11. [2] Bedford PJ, Macauley DC. Attendances at a casualty department for sport related injuries. Br J Sports Med 1984; 18: 116-21. [3] Seward H, Orchard J, Hazard H, Collinson D. Football injuries in Australia at the elite level. Med J Aust 1993; 159: 298-301. [4] Silver JR. Injuries of the spine sustained in rugby. BMJ 1984; 288: 37-43. [5] Barry HC, Calcinai CJ. The need to make rugby safer. BMJ 1988; 296:149-50. [6] Silver JR. Injuries to the spine sustained during rugby. Br J Sports Med 1992;26:253-58. [7] Silver JR, Stewart D. The prevention of spinal injuries in rugby football. Paraplegia 1994; 32: 442-53. [8] Horan FT. Injuries to the cervical spine in schoolboys in playing rugby football. J Bone Joint Surg 1984; 66B: 470-71. [9] McCoy GF, Piggot J, MacAfee AL, Adair IY. Injuries to the cervical spine in schoolboy rugby football. J Bone Joint Surg 1984; 66B: 500-03. [10] Sparks JP. Half a million hours of rugby football. The injuries. Br J Sports Med 198 1; 15: 30-32. [11] Gibbs N. Injuries in professional rugby league. A three-year prospective study of the South Sydney Professional League Football Club. Am J Sports Med 1993; 21: 696-700. [12] Addley K, Farren J. Irish rugby injury survey: Dungannon Football Club (1986-87). Br J Sports Med 1988; 22: 22-24. [13] Ryan JM, McQuillan R. A survey of rugby injuries attending an accident & emergency department. Ir Med J 1992; 85: 72-73. [14] Noakes T, Jakoet I. Spinal cord injuries in Rugby Union players--how much longer must we wait for proper epidemiological studies? BMJ 1995;310:1345-46. [15] Garraway WA, Macleod DAD, Sharp JCM. Rugby injuries--the need for case registers. BMJ 199 1; 303: 1082-83. [16] Bier I. Rugby injuries. BMJ 1991; 303: 1552.
Epidemiology of Rugby Football Injuries.
Michael Garraway; Donald Macleod
Introduction
Interest in rugby football injuries has focused largely on the spinal cord.[1] Although other sorts of injury have been studied at club or regional level,[2-8] the findings are hard to interpret because of differences in reporting criteria and incomplete ascertainment. We report here the frequency, nature, circumstances, and outcome of rugby injuries in a prospective cohort consisting of virtually all players registered with senior rugby clubs in the South of Scotland District of the Scottish Rugby Union (SRU).
Methods
Players were eligible for the survey if members of an SRU-affiliated senior rugby club in the South of Scotland during the 1993-94 season. All 26 clubs agreed to participate and each appointed a linkman responsible for injury notification. These linkmen operated a "cascade" of observers to cover all games played by the club using a standard closed questionnaire to record the circumstances of the injuries. They were visited weekly throughout the season by chartered physiotherapists who ensured that the details of each injury were complete and were applicable to a registered player. All players were contacted at the beginning of the season for information on playing position and physique; permission was also sought for examination of their general-practitioner or hospital medical records should they be injured during the season. The players were also contacted in the middle and at the end of the season and invited to complete a diary of matches played over the previous three months; these diaries were checked against club fixture lists and the injury register for completeness. Playing hours at risk were calculated for each player as number of matches played x 1[multiplied by]33 (each match lasts for 80 min). The outcome of a rugby injury was obtained by contacting the player after an injury episode, as well as from hospital and general-practitioner records. Incapacity was measured as days away from playing or training for rugby and days lost to employment or school/college work.
A rugby injury was defined as an injury sustained on the field during a competitive match, during a practice game, or during other training activity directly associated with rugby football, which prevented the player from training or playing rugby football from the time of the injury or from the end of the match or practice in which the injury was sustained. Rugby injuries sustained during training were those sustained during practice scrums or manoeuvres involving a rugby ball (not circuit training or activities undertaken to achieve fitness). Injuries that necessitated leaving the field of play or practice and missing the remainder of the match or practice, but did not cause the player to miss subsequent matches or practice for at least 7 days, were classified as transient. Rugby injuries were coded according to the International Classification of Diseases (9th revision), and were classified by time to resumption of playing or training: within 28 days, mild; 29-84 days, moderate; more than 84 days, severe.
The 26 clubs fielded 1541 teams involving 1216 players in the 1993-94 season, which lasted from August, 1993, to April, 1994. Complete census and playing records were available for 1169 (96%) eligible players, each of whom participated in an average of 19[multiplied by]8 matches. 361 of these players experienced 512 injury episodes resulting in 584 injuries at matches or during training. In cases of multiple injury, the decision on which injury was primarily responsible for incapacity was a matter of clinical judgment.
Results
Frequency and distribution
Of the 361 players injured, 268 (74%) had 1 injury episode during the season, 61 (17%) had 2, and 32 (9%) had 3 or more. 84% of the 429 injury episodes (290 players) occurred in matches and the remainder (71 players) during training. 442 (86%) injury episodes involved only 1 injury; 70 (14%) involved 2 or more separate injuries. Overall, 1 in every 4 players was injured during the season, with the highest proportion (43%) in the age group 20-24 years--more than five times the incidence rate for players under 16 years. The incidence and period prevalence rates mean that the average team (of 15) can expect to sustain 5[multiplied by]5 new injuries and 1[multiplied by]1 recurrences of old injury during the season.
Nature and site of injury
96 (22%) injury episodes in matches were transient, 164 (38%) mild, 99 (24%) moderate, and 70 (16%) severe. Recurrent injuries were not more severe than new ones; as might be expected, the proportion of recurrent to new injuries increased with age (from 8% in players under 16 years of age to 39% in players aged 30-34). No spinal injuries were recorded in 30 750 playing hours of rugby. Dislocations, strains, and sprains of the knee had the highest incidence and period prevalence rates. For fractures the upper limb was most at risk but the main site of injury (42% of episodes) was the lower limb, with a much greater frequency of dislocations, strains, and sprains. 35% of dislocations, strains, and sprains of the shoulder were recurrent injuries.
Injury association
Injuries were more frequent at the beginning of the season, with a period prevalence of 15[multiplied by]2 per 1000 playing hours in the autumn (September-October) and 12[multiplied by]3 in the spring (March-April). The manoeuvre most strongly associated with injury was the tackle, accounting for 49% of injury episodes in matches; the remainder occurred in the serum (8%), ruck (15%), maul (2%), lineout (12%), while gathering the ball (8%), or away from play in other circumstances (6%). Of the severe injury episodes, 60% occurred while players were tackling or being tackled. 6 out of 11 lower limb fractures and 37% of knee dislocations, ligament, and cartilage tears occurred while players were on the receiving end of a tackle, whereas 45% of shoulder dislocations, strains, and sprains arose in players who were doing the tackling. There were no significant differences in the proportion of injury episodes according to playing position, but injuries to the trunk (mainly back strain and sprain) were three times more frequent in forwards than in backs. In centres and wing threequarters 4 out of every 5 injury episodes were associated with the tackle.
Outcome
19 741 playing days were lost to matches and training during the 1993-94 season. A period prevalence rate of 2[multiplied by]34 per 1000 playing hours together with a mean of 60[multiplied by]4 (SE 9[multiplied by]2) days of lost playing time meant that knee injuries were responsible for 25% of all playing time lost through injury episodes in matches. 28% of primary injuries in matches lost the player time from work, school, or college. Training injuries accounted for 15% (372 days) of time away from employment or education. Injured players lost an average of 18 days' employment or education (table 3). Fractures at all sites caused most absence. Again, the tackle emerged as an important contributor to injury episodes. Tackling in games was associated with 22% of injury episodes and accounted for 18% of absence days from employment or school; being tackled was associated with a further 27% of injury episodes and resulted in 43% of all time lost from employment or education.
Discussion
This study has demonstrated that rugby injuries are an important source of morbidity in young players. The 782 players aged 16-29 years in the survey represented 8% of the male population in this age group resident in the catchment population of the South of Scotland rugby clubs.[9] A player can expect to be injured every 2[multiplied by]7 seasons playing an average of 20 rugby matches per season; and, when injured, he will be out of the game for nearly 6 weeks. On average, each club lost 759 playing days through injury in the season. This must have an important bearing on the coaching, match preparation, results, and completion of fixture lists. Only those acute traumatic injuries that presented on the field of play were addressed. The amount of degenerative disease that might arise in weightbearing joints from injury or chronic overuse can only be established by continuing follow-up of this cohort of players.
A remarkably high response rate was achieved by use of field staff who maintained personal contact with nominated club representatives throughout the season. This is the approach that others must adopt and refutes the view that registration of rugby injuries cannot be enforced because Rugby Union, being an amateur game, relies on the goodwill and enthusiasm of unpaid officials.[10]
Like a more limited study in selected clubs,[11] our investigation has revealed a high level of incapacity due to injury. Apart from time lost from the game or training, this has economic implications. In 28% of injury episodes players lost time from employment or education--a mean of 18 days.
This survey is not the first to highlight the dangers of tackling and being tackled in rugby.[12,13] More needs to be known about the frequency and circumstances of tackling so that players can be coached in tackling techniques that are safe for themselves and their opponents. The overwhelming contribution of the tackle to injury episodes could reflect recent law changes that encourage open play conducted at higher speeds to enhance the game as a flowing spectator sport. The challenge now is to sustain the popularity of the game while lessening the hazard of high-velocity contact in the tackle. A first step is to set up cohort studies in other locations, with the same definitions and methods, to allow comparison of rugby injuries in different playing environments. The International Rugby Football Board is in an excellent position to guide and coordinate this work.
We thank George Murray, district secretary for the South of Scotland; the presidents and linkmen of participating rugby clubs; Gregor Nicholson, administrative secretary, SRU; Sue Davidson, our survey coordinator and the chartered physiotherapists of the Fitness Assessment and Sports Injuries Centre, University of Edinburgh Department of Physical Education; Lyn Chalmers for computing support; Mandy Lee for statistical advice; Ann Cocallis and Caroline Adams for secretarial services; and, finally, the rugby players of the Scottish Borders for their outstanding cooperation.
References
[1] Calcinai C. Cervical spinal injuries. NZ J Sports Med 1992; 20: 14-15. [2] O'Brien C. Retrospective survey of rugby injuries in the Leinster Province of Ireland 1987-1989. Br J Sports Med 1992; 26: 243-44. [3] Addley K, Farren J. Irish rugby injury survey: Dungannon Football Club (1986-1987). Br J Sports Med 1988; 22: 22 24. [4] Myers PT Injuries presenting from rugby union football. Med J Aust 1980; ii: 17-20. [5] Dalley DR, Laing DR, Rowberry JM, Caird MJ. Rugby injuries: an epidemiological survey, Christchuch, 1980. NZ J Sports Med 1982; 10: 5 17. [6] Davies JE, Gibson T Injuries in rugby union football. BMJ 1978; ii: 1759-61. [7] Roy SP. The nature and frequency of rugby injuries. A pilot study of 300 injuries at Stellenbosch. S Afr Med J 1974; 48: 2321 27. [8] O'Connell TCJ. Rugby Union Football injuries and their prevention. A review of 600 cases. J Irish Med Assoc 1954; 34: 20 26. [9] Census 1991 Scotland, Report for Borders Region, General Register Office, Scotland. London: HM Stationery Office, 1993. [10] Beer I. Rugby injuries. BMJ 1991; 303: 1552. [11] Clark DR, Roux C, Noakes TD. A prospective study of the incidence and nature of injuries to adult rugby players. S Afr Med J 1990; 77: 559-62. [12] Scher AT. Catastrophic rugby injuries of the spinal cord: changing patterns of injury. Br J Sports Med 1992; 25: 57-60. [13] Dalley DR, Laing DR, McCartin PJ. Injuries in rugby football, Christchurch 1989. NZ J Sports Med 1992; 20: 205.
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