From The American Journal of Sports Medicine, July-August 1996
by Merrick J. Wetzler, Toks Akpata, Todd Albert, Timothy E. Foster and Andrew S. Levy)
This article is especially relevant to U.S ruggers - as it makes clear there are safety-related differences between the way we play and the way other nations play. I have highlighted the most interesting passages in red. - Wes
We undertook a retrospective study to document and analyze the occurrence of cervical spinal injuries in rugby in the United States from 1970 to 1994. We studied 59 cases (average, 2.36 per year). Thirty junior-level players (50.8%) (college or high school), 28 (47.5%) men's club players, and 1 (1.7%) woman player were injured. Fifty-seven injuries (97%) occurred during games.
The incidence of cervical spine injuries is well documented in the United Kingdom and South African literature. However, no study in United States literature discusses the incidence or cause of cervical spine injury in rugby. We found that coaching is less consistent in the United States. Players with more weight and less experience are playing positions that require significant skill. Many players in the United States learn skills in games rather than in practice. In our study, 52.5% (31 of 59) of the injured players were junior-level players. Conversely, in world competition junior-level athletes sustained only 30% to 40% of the cervical spine injuries.
Understanding the factors that contribute to cervical spine injuries is paramount in injury prevention. Through this study, we hope to promote change in rugby laws and regulations, as has been done in football, to enhance the safety and pleasure of the sport for players, coaches, and spectators. In the United States, the number of rugby players is increasing. Rugby is a highly competitive, amateur, collision sport played by approximately 1500 teams each year with an estimated 50,000 to 75,000 participants per season.
Rugby is played with 15 players, 8 forwards and 7 backs. The game has three basic phases in which most injuries result.
1. The scrum, which is similar to a hockey face-off, is awarded when play stops because the ball is tied up by the two teams or when there is a minor infraction. The eight forwards (the pack) bind together in a pyramid formation. The two opposing scrums come together (engagement) and the ball is in put in play by the scrum half. The front-row players intertwine their heads with their opponents, with their cervical spines slightly flexed. In a scrum, each team assumes a wedge-shaped configuration and attempts to drive their opponents off the ball, enabling one team to maintain or obtain possession of the ball.
2. A ruck (with the ball on the turf) or maul (with the ball in the hands of a player) is usually formed when a player is tackled. The goal of a ruck or maul is to keep the ball in play by feeding it to the scrum half. The offense forms a platform to protect the ball while the defense attempts to crash through the platform and either gain possession or tie the ball up so a scrum is awarded. Line-outs occur when the ball goes out of bounds. The two opposing forwards line up 1 meter from each other and 5 meters from the boundary where the ball went out of bounds; selected players jump for the ball. Line-outs are included in loose play because usually a ruck or maul is formed once possession is gained by one of the jumpers.
3. The tackle occurs when a player is held by an opponent or brought to the ground. The incidence of injuries in rugby is lower than other full-contact sports such as football.
Garraway and Macleod  demonstrated in a report that 30.8% of the rugby players studied (361 of 1169) sustained injuries in the 1993 to 1994 season. Kauffman  also reported that 11.9% of players (48 of 404) sustained injuries that required play to stop in a United States tournament. These injury percentages were compared with a study by DeLee and Farney  on football injuries that reported 50.6% of the 4399 players were injured during one season in Texas. Authors from Australia, New Zealand, South Africa, and the United Kingdom have all documented the occurrence of cervical spine injuries in rugby during the past 20 years. [2,4,5,9,10,17,18,21,23,24,26] The average incidence of cervical spine injuries in the world, excluding the United States, is approximately 3 per 100,000 athletes [2,4,5,9,10, 17,18,21,23,24,26] We believe our study is the first in the medical literature that examines cervical spine injuries in United States rugby.
MATERIALS AND METHODS
We undertook a retrospective study to document and analyze the occurrence of cervical spine injuries in United States rugby from 1370 to 1994. The data were accumulated from reports collected by one of the authors (TA), as well as from information collected by the American Orthopaedic Rugby Football Association.  We defined a cervical spine injury as any injury to the cervical spine that resulted in a documented fracture or significant ligamentous injury of the cervical spine. Neurologic injury was not an inclusion criterion. Information was compiled from conversations and written descriptions from coaches and officials who witnessed the events, as well as from injured players. We obtained additional information from family members of the injured players, and we reviewed medical records when available.
We reviewed 59 cervical spine injuries with or without neurologic injury that occurred in United States rugby. These cases were collected from 1970 to 1994 (average, 2.36 per year). Among those injured were 30 (60.8%) junior-level players (college or high school), 28 (47.5%) men's club players, and 1 (1.7%) woman player. Those injured were 28 hookers (47.5%) and 7 prop forwards (11.9%), as well as 10 second-row or loose forwards (16.9%) and 12 backs (20.3%). Two other players (3.4%) were listed as injured but their positions were unknown. Significantly more injuries occurred to forwards than backs (P < 0.001), and hookers were injured significantly more often than all other players (P < 0.03). Fifty-seven injuries (97%) occurred during games. Thirty-four injuries (57.6%) occurred during scrummaging. Twenty-one of these 34 injuries occurred during scrum engagements; 13 injuries occurred when the scrum collapsed. Significantly more injuries resulted during scrum engagements than scrum collapses (P < 0.02). During engagement, hookers sustained 19 of the 21 injuries (90.5%), a highly significant majority of the injuries (P < 0.0005). No significant differences were seen in how prop forwards were injured (P< 0.4). Nine injuries (15%) involved a documented mismatch in experience and size between collegiate and men's clubs; 8 of 35 injuries (22.8%) involved forwards. The tackle resulted in a significant percentage of the injuries (72%) that occurred outside the scrum (P < 0.02). Eighteen players (30.5%) were injured during tackles. The seven (11.9%) remaining injuries occurred during rucks and mauls. In addition, 7 of the 25 (28%) injuries that occurred outside the scrum involved some type of "foul" play.
Burry and Calcinai,  Burry and Gowland,  Scher, [14-20] Taylor and Coolican, [25,26] and Williams and McKibbin  have discussed which elements of rugby are responsible for cervical spine injuries. Before 1983, up to 60% of the documented cervical spine injuries occurred during the scrum. [2,9,14,23,27] Milburn states that the scrum epitomizes the physical nature of rugby. Scher  has reported that forces equivalent to 1.5 tons are exerted on a player's cervical spine during a scrum. During scrum engagement, the front-row players intertwine their heads with those of their opponents. At this time, the cervical spines of the opposing players are slightly flexed, which eliminates the normal lordosis. If engagement does not occur properly, or the scrum collapses, the force and energy of the scrum can be transmitted to a player's cervical vertebrae and soft tissue, thus predisposing the neck to injury. Silver, [21-23] Silver and Gill,  Burry et al., [2,3] Taylor and Coolican, [25,26] and others have helped decrease cervical spine injuries in rugby.
Silver  was among the first to report on catastrophic cervical spine injuries in rugby. He documented 63 injuries that occurred from 1956 to 1983 to Rugby Union players in the United Kingdom.  Silver's work resulted in positive law changes by the International Rugby Football Board in 1984. Many changes involved the scrum. These changes aim at preventing barging on scrum engagement and at eliminating tactics that may collapse the scrum, such as rotating the entire scrum after engagement (i.e., wheeling). The changes slowed down the scrum engagement by having the two opposing scrums crouch, touch, and then engage, thus allowing the scrums to come together under more controlled conditions. [2,3,6,12,14,15,25] Further, the Australian Rugby Football Union modified scrummage rules in 1988 by making the forwards crouch, touch, pause, and then engage, further controlling the force of engagement. Since the modification of these rules, there has not been a serious scrum-related cervical spine injury in Australian rugby.  In a New Zealand study, Burry and Gowland  also showed a threefold decrease in the incidence of cervical spine injuries when similar rules were adopted to slow the pace of scrum engagement. Before the rule changes, nine cervical spine injuries were recorded during a 3-year span; after these changes were implemented, the number of cervical spine injuries decreased to three during the next 3 years.
To decrease injury further, Taylor and Coolican [25,26] theorized that "depowering the scrum" by reducing the force of the scrum when the scrum engages (i.e., when the prop forward's or hooker's head strikes the opponent's head) or collapses may reduce injuries. They suggested sequential engagement with the front-row players engaging separately without the rest of the pack. In game situations, this should significantly decrease the force focused on the cervical spines of the front-row players. In addition, sequential engagement will allow engagement to begin under the leadership of the hooker, preventing the second row and the loose forwards from initiating the engagement, thus thrusting unprepared front-row players into their opponents. [25,26] Currently, these concepts are not used in United States rugby, but they have been employed at the junior level in Australia and New Zealand.  As injuries on rugby teams in countries other than the United States decline (from scrum-related rule changes), a heightened awareness of catastrophic events during other phases of play have occurred. In a review of the literature, Miller  reported that 453 (37%) of 1227 catastrophic cervical spine injuries resulted from tackles as compared with 41% from scrums and 22% from loose play. Scher  demonstrated a change in the mechanism of injury in South African rugby, with tackles being responsible for most injuries. Other studies have shown that the remainder of cervical spine injuries (10% to 20%) occur during loose play and many of these involve some type of foul play. [1,9,10,13,18,19, 26, 27] Our study has some limitations because it is retrospective, with data collected and compiled from multiple different sources.  Consequently, the number of cervical spine injuries was probably underestimated. Therefore, we did not attempt to calculate the overall incidence.
Taylor and Coolican  stated in their paper that players recalled the events leading up to their injury as well as the mechanism of injury in extraordinary detail. Williams and McKibbin  also commented on the detailed descriptions of events leading up to the injury from players and from coaches who witnessed the event. In their study, the phase of play and the mechanism of injury were well documented by detailed eyewitness reports as well as from the injured player. Therefore, we believe that valid conclusions can be made from this study.
In the United States, 57.6% of the cervical spine injuries (34 of 59 injuries) we studied occurred during the scrum. This percentage was significantly higher than among teams from other nations (41.5%)  Another disturbing and significant difference between rugby competition in the United States and rugby played in other countries is the incidence of cervical spine injuries among hookers. Hookers sustained 47.5% of the cervical spine injuries we studied among United States players, but, in teams outside the United States, hookers sustained only 18.6% of these injuries.  Props were responsible for 11.7% of United States rugby cervical spine injuries, and their worldwide counterparts were responsible for 20.4% of these injuries. Milburn,  in his research on the biomechanics of the scrum, concluded that more experienced players are able to generate and transmit the force of the scrum and they can better dissipate the forces generated. Although most Americans begin to play rugby in college, rugby players in other countries begin playing as schoolchildren. Our study showed an increase in spinal injuries among forwards in the United States because they weigh more and have more strength; yet, they have less experience than players from other nations. After discussion with players, coaches, and officials, we thought that 8 of the 35 cervical spine injuries (22.8%) that involved front-row players were documented cases of mismatches of experience. Either there was a different caliber or level of player or inexperienced players in the front row matched up against each other. It is difficult to assess how many other injuries occurred because inexperienced players were in skill positions.
Among teams outside the United States, only 30% to 40% of cervical spine injuries involved junior-level players. [2,4,5,9,10,17,18, 21,23,24,26, 27] In this study, 50.8% (N = 30) of the injured players were junior-level players. Alarmingly, 60% (N = 18) of these cervical spinal cord injuries have occurred since 1984. However, only 46.4% (N = 13) of the injuries sustained by men's club players occurred during this same time. This supports the conclusion that United States players of larger mass and less experience are playing skilled positions.
In the United States, rugby is an amateur sport governed by the United States of America Rugby Football Union. All teams, including most collegiate clubs, are run by the players and ex-players. These clubs must support their own activities and supply their own coaches and equipment with little assistance from the United States of America Football Rugby Union. Men's clubs, because of lower personnel turnover, are much more organized than their collegiate counterparts. Many collegiate teams lack institutional support and cannot maintain personnel to form a truly stable governing body. After reviewing collegiate rugby programs, the American Orthopaedic Rugby Football Association data confirmed that many collegiate rugby players receive minimal coaching and have limited facilities to practice scrummaging. Therefore, inexperienced players of significant size and strength in skilled positions (e.g., forwards) are practicing against players with the same or only slightly more experience. In essence, the athletes are learning to scrummage in game situations. Strategies to prevent cervical spine injuries during the scrum include reducing the force of the scrum by having a more controlled engagement, thus reducing the power of the scrum as described in this article. This reduction of force would be most efficacious among less-experienced players and among collegiate players whose coaching and facilities vary extremely.
We further recommend that unskilled players not be allowed to play skilled positions (e.g., prop forward or hooker). During the 1994 Women's World Cup in Scotland, the Scottish Rugby Football Union adopted a new rule. When a skilled player (e.g., forward) is injured and no appropriately skilled player is available for the slot, a scrum, when awarded, is changed to a line-out. In higher-level play, this probably will have little effect. In lower and junior levels, this change could prevent many injuries. Scher [14,15,17,20] drew our focus to the tackle as a cause of cervical spine injury during the scrum. The situation in the United States is complicated because many athletes are former football players who have been taught to use their heads as "weapons" during a tackle or to deliver a blow to the ball carrier. Scher  has described the high tackle as the "black spot" in rugby. Better coaching is paramount to breaking the football mentality of using the head as a weapon. Coaching should focus on safer tackling techniques that allow the tackler to safely tackle below the shoulders, bringing the ball carrier safely to the ground. Coaching should also provide instructions for the ball handler on techniques for warding off the tackler without using his head while keeping the ball in play. In addition, referees should consistently and harshly penalize any players making dangerous or high tackles, late hits, or foul plays. Finally, the use of safety videos developed for football should be mandatory viewing for all club athletes once a year.
Compared with male players, the occurrence of cervical spine injuries in female players are almost nil. With almost 250 current teams and an average of 30 collegiate teams added each year, women's rugby is the fastest-growing form of the sport in the United States. Since 1970, only one cervical spine injury has occurred in women's rugby. This injury resulted when a player fell on the neck of another athlete during loose play. The lower incidence of neck injuries in women's rugby may be attributable to different styles of play. Women do not have the mentality of United States football players, thus they spear less and tackle more safely than their male counterparts. Additionally, barging and high-momentum impacts are extremely rare when the scrum engages. Consequently, women's rugby is safer than men's rugby in terms of risk for catastrophic injury. The medical communities of the British Commonwealth have documented numerous contributing factors of catastrophic cervical spine injuries among rugby players. [5, 9, 18, 25,27] Understanding these factors is paramount to the eventual prevention of these injuries.
This study demonstrates a relatively high incidence of cervical spine injuries in junior-level players. For rugby to increase in popularity, the sport must be made safer, especially for junior level and inexperienced players. With this goal as the objective, the American Orthopaedic Rugby Football Association, with the assistance of the Eastern Pennsylvania Rugby Union, has helped many colleges obtain equipment to practice scrummaging. These groups have also begun a yearly medical and safety clinic for all the collegiate teams in the Eastern Pennsylvania Rugby Union. With this study, we hope to promote rugby law and regulation changes, enhancing the safety and pleasure of the sport for players, coaches, and spectators.
[1.] Akpata T: Spinal Injuries in the U.S. Rugby 16:14-15, 1990 [2.] Burry HC, Calcinai CJ: The need to make rugby safer. Br Med J 296: 149-150, 1988 [3.] Burry HC, Gowland H: Cervical injury in rugby football-A New Zealand survey. Br J Sports Med 15: 56-59, 1981 [4.] Collison D: Rugby injuries. Aust Fam Physician 13: 565-569, 1984 [5.] Danesh JN, Dixon GS, Caradoc-Davies TH: Epidemiology of spinal cord injuries. N Z Med J 104:614-615,1991 [6.] DeLee JC, Farney WC: Incidence of injury in Texas high school football. Am J Sports Med 20: 575-580, 1992 [7.] Garraway M, Macleod D: Epidemiology of rugby football injuries. Lancet 354: 1485-1487, 1995 [8.] Kauffman T: Rugby injuries sustained during tournament play. J Orthop Sports Phys Ther 7: 16-19, 1985 [9.] Kew T, Noakes TD, Kettles AN, et al: A retrospective study of spinal cord injuries in Cape Province rugby players, 1963-1989. Incidence, mechanisms and prevention. S Afr Med J 80: 127-133, 1991 [10.] McCoy GF, Piggot J, MaCafee AL, et al: Injuries of the cervical spine in schoolboy rugby football. J Bone Joint Surg 66B: 500-503, 1984 [11.] Milburn PD: Biomechanics of rugby scrummaging. Technical and safety issues. Sports Med 16: 168-179, 1993 [12.] Milburn PD, O'Shea BP: The sequential scrum engagement: A biomechanical analysis. Aust J Sci Med Sport 26: 32-35, 1995 [13.] Miller B: Cervical spine injuries in rugby. Rugby 20(7): 20-21, 1994 [14.] Scher AT: Catastrophic rugby injuries of the spinal cord: Changing patterns of injury. Br J Sports Med 25: 57-60, 1991 [15.] Scher AT: Paralysis due to the high tackle--A black spot in South African rugby. S Afr Med J 79: 614-615, 1991 [16.] Scher AT: Premature onset of degenerative disease of the cervical spine in rugby players. S Aff Med J 77: 557-558, 1990 [17.] Scher AT: Rugby injuries of the cervical spine and spinal cord--has the situation improved. S Afr Med J 76: 46, 1989 [18.] Scher AT: Rugby injuries to spine and spinal cord. Clin Sports Med 6: 87-99, 1987 [19.] Scher AT: Rugby injuries to the cervical spinal cord sustained during rucks and mauls. S Afr Med J 64: 592-594, 1983 [20.] Scher AT: The high rugby tackle--An avoidable cause of cervical spinal injury? S Afr Med J 53: 1015-1018, 1978 [21.] Silver JR: Injuries of the spine sustained during rugby. Br J Sports Med 26: 253-258, 1992 [22.] Silver JR: Unstable cervical spine injuries in rugby--A 20 year review (Letter). Injury 19: 298, 1988 [23.] Silver JR: Injuries of the spine sustained during rugby. Br Med J 288 (6410):37-43, 1984 [24.] Silver JR, Gill S: Injuries of the spine sustained during rugby. Sports Med 5: 328-334, 1988 [25.] Taylor TK, Coolican MR: Rugby must be safer: Preventive programmes and rule changes. Med J Aust 149: 224, 1988 [26.] Taylor TK, Coolican MR: Spinal-cord injuries in Australian footballers, 1960-1985. Med J Aust 147: 112-118, 1987 [27.] Williams P, McKibbin B: Unstable cervical spine injuries in rugby--A 20 year review. Injury 18: 329-332, 1987 Merrick J. Wetzleritt MD, Toks Akpata,([sections]) Todd Albert,ll MD, Timothy E. Foster,(a) MD, and Andrew S. Levy,(b) MD