Anticipating the Problem
Professional rugby union players are increasingly large, powerful, fit and skilful. England international forwards and backs in 2003 weighed, on average, 109 kg and 90 kg respectively, compared with 100 kg and 83 kg for their counterparts in 1991. A greater proportion of this weight is lean body mass, so more force is generated in the collisions. There has also been a 30% increase in the ball-in-play time between 1995 and 2003; therefore there is a significantly greater chance of injury per match.

The incidence of injury is higher in professional rugby union than in amateur rugby union but information about the nature and profile of the injuries sustained within the elite game has been very limited to date.

The England Rugby Injury and Training Audit - Its Scope and the People Involved
The England Rugby Injury and Training Audit was introduced across the Premiership and England teams in 2002 and covered the 2002–03 and 2003–04 seasons.  It was a partnership amongst the Premiership clubs, the RFU and the University of Leicester. The lead researcher was Dr. John Brooks in collaboration with Dr Colin Fuller, an expert in injury risk management at the University of Leicester; Dr Simon Kemp, Head of Sports Medicine at the RFU; Dave Reddin MBE, England Fitness Coach and the Premiership medical and fitness staff. The audit comprises the world’s largest study of professional rugby union injuries and is unique in that it includes an analysis of training injuries and practices. 

Executive Summary – What the Numbers Say

• Over 2,000 injuries at Premiership clubs were recorded: this equated to an average of 92 injuries per team per season.
• 263 injuries causing 5,161 days absence were also sustained while playing and training for England international teams (England, A, U21 and 7s).
• The chance of sustaining an injury in a club match was 12.5% (1 in 8 chance), with an average 18 days absence. The incidence of injury in international matches was higher at 29% (1 in 4) with an average 14 days absence but this included a higher proportion of injuries resulting in less than 72 hours absence (34% compared with 23%). Furthermore, the number of match injuries sustained causing a subsequent match to be missed was similar during club (0.8 per match) and international (1.1) matches.
• On average, 9 out of 38 players at every club required treatment and rehabilitation each day for the injuries reported. In addition, there would have been players who required treatment and rehabilitation for injuries that did not prevent their playing or training and were therefore not reported in the audit.
• On average, each player spent 19% of the calendar year injured.
• 72% of match injuries occurred in contact, 51% of them in the tackle situation.
• A disproportionate number of injuries occurred in the final quarter of a match and during this period the incidence of injury was higher for players starting a match than for replacement players.
• 50% of injuries were not considered at the time of injury to be severe enough for the players to be removed from the field of play and these injuries were typically the least severe (12 days).
• Those injured players who were removed from play immediately following injury (25%) were suffering injuries that were of greater average severity (32 days).
• 24% of injuries were sustained during training (rugby: 68%; conditioning: 32%). Overall, training injuries were significantly more severe (24 days) than injuries sustained during competition (18 days)

Definition and Recording of Injuries
An injury was recorded if it prevented a player from taking a full part in all training activities and match play for more than 24 hours, from midnight at the end of the day the injury was sustained. For example, if a player injured on Saturday was unavailable for all training activities planned for the following Monday, his injury was included. Absences due to illness and non-sport-related medical conditions were excluded. Medical personnel at each club and the England teams reported the details of every injury using a standard Injury Report Form and team fitness coaches recorded players’ training schedules and exposure times on a weekly basis, utilising a standard Training Report Form. The audit only included 1st team RFU registered players.

Injury Risk – Explanation and Definition
The overall “injury risk” to a club is defined as the total number of days absent from playing and training. Independent reporting of just the number or the severity (number of days absent from training or playing as a result of any particular injury) of injuries does not expose the true level of risk.

Number of injuries x Severity (days absent as a consequence) = total “RISK”

The England Rugby Injury and Training Audit – Support from the Players
Players involved in the English Premiership during the 2002-03 and 2003-04 seasons (98 weeks) agreed to take part and gave their written consent to be included in the study. Unique registration numbers were used to identify players throughout the study in order to maintain anonymity and confidentiality of medical information.  The Professional Rugby Players Association gave its full support to the study.

Playing Injuries

Injury Profile
The most commonly reported injuries are displayed in Table 1. However, Table 2 highlights the injuries causing most lost time – ie the greatest number of days absence due to injury.

Injury mechanism
The most common cause of injury during matches was being tackled (22%) and tackling (15%). The majority of injuries sustained from being tackled were from side-on (51%) and head-on (34%) tackles. Head-on tackles caused the majority of injuries sustained when ‘tackling’ (56%), followed by side-on tackles (38%). Foul play was responsible for only a small proportion (6%) of the injuries reported. There were no significant differences in injury severity as a function of injury mechanism.

The Way Forward – Joint Initiative
Injury Risk Management Plan

England Rugby Limited has put in place the basis of a long term injury risk management plan. It was important that elite rugby recognised the risk, not only in a sporting perspective, but in the wider standards applied to industry.
 
The number of days lost through injury can be reduced by implementing prevention strategies to reduce the number of injuries and introducing treatment and rehabilitation strategies to reduce the severity of injuries. To be able to develop effective strategies, objective injury data is required both before and after strategy implementation.

Initial steps in the Injury Risk Management Plan have already been undertaken and include:-

• An independent application for International Rugby Board (iRB) funding has been submitted for detailed research into the mechanics of injuries relating to the tackle. The project is designed to run over an 18 month period. Further studies will be commissioned, targeting highest risk injuries initially.
• The Premiership clubs and the RFU jointly will recommence match and training injury and exposure data collection with pre-season data in June 2005.
• A policy addressing the issues of Hepatitis B immunisation will be introduced for the start of the 2005-06 season
• New requirements for the standards of training in pitch side immediate trauma care have been introduced and will apply to all medics attending athletes on the field of play from the start of the 2006-07 season
• New minimum standards for emergency medical equipment and facilities have been introduced. Funding will be made available to all clubs to address their needs.
• The inaugural ERL Medical Conference was attended by medical teams from across the Premiership and the England elite teams. A significant amount of additional ongoing work into determining minimum standards for the Premiership criteria and creating best practice guidelines is underway.
• A group of medical practitioners have been tasked with assessing the level of medical provision offered throughout the elite game on a player:practitioner ratio.

Sources of information
Details of England injuries and training were published in the British Journal of Sports Medicine (BJSM) in May 2005. An abstract of the England injuries paper up to and including RWC2003 is available free on http://bjsm.bmjjournals.com/cgi/content/abstract/39/5/288.  The full article requires a subscription but can be obtained via http://bjsm.bmjjournals.com/cgi/reprint/39/5/288

1st June 2005