England Rugby acts to reduce injury risk.

In a press conference at Twickenham today, the partnership of the Rugby Football Union, Premier Rugby Limited and the Professional Rugby Players Association, announced details of the England Rugby Injury and Training Audit, a unique project commissioned in 2001 to address the risk of injury in rugby union.   The vision for how the sport plans to learn from and use the findings was then outlined in the group’s Injury Risk Management Plan.  

The extensive study includes an analysis of injuries and training practices, covering international and club matches in the 2002-3 and 2003-4 seasons. It defines an injury as something that prevented a player from taking a full part in all training activities and match play for more than 24 hours.   

The study recorded over 2,000 injuries at Premiership clubs, which translated 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, England A, U21 and 7s).

 Key Findings

• Players had a 1 in 8 chance of sustaining an injury in a club match (12.5%), resulting in an average 18 days absence.
• Players had a 1 in 4 chance of sustaining an injury in an international match (29%), resulting in an average 14 days absence.
• 34% of England injuries (compared to 23% of club injuries) resulted in less than 72 hours absence.
• The number of match injuries sustained causing a subsequent match to be missed was 0.8 per club match and 1.1 per international match
• On average, 9 players at every club required treatment and rehabilitation each day for the injuries reported.
• 72% of match injuries occurred in contact, 51% of them in the tackle situation

 The Way Forward - Injury Risk Management Plan

The findings have enabled the RFU, PRL and PRA to work together, as England Rugby, on an Injury Risk Management Plan, to manage injury risk at the elite level of the game.

The plan, presented to England Rugby Limited in May 2005, includes policies for Hepatitis B immunisation, training in pitch-side immediate trauma care, minimum standards for medical and also prehab and rehab equipment and facilities. As a result, Premier Rugby has raised the level of the minimum standards criteria for medical equipment and training at all Premiership clubs and has provided funds to help clubs comply with the criteria.  

This month the Premiership clubs and the RFU, with the support of the PRA, will jointly return to match and training injury data collection.

To help further reduce the risk of players suffering injuries and the number of days lost through injury, an application for funding has been made to the International Rugby Board, for detailed research over an 18 month period, into injuries relating to the tackle.

Roy Headey, the RFU’s Head of Elite Support said: 

“For the first time, we are now able to plan to manage the risk of injury in elite rugby from a base of evidence.  We’ve always known and understood that rugby union is a game in which injuries occur. It’s an inevitable aspect of a collision sport. But now we know quantifiably where to focus our attention in order to reduce the time elite players spend injured. 

“The audit will start again from today, in order to assess the impact of the injury risk management plan as it is rolled out. 

“Our aim in this respect must be excellence as an industry, not just as a sport, so we’ve retained Dr Colin Fuller, an expert in industrial risk management, to work with us for this next importance stage.”  

Phil Winstanley , Rugby Manager for PRL added:

 “As a body we must define industry standards for injury prevention and management and the audit has informed that approach.

“Based on the specific findings of this report Premier Rugby has already raised the minimum standards required for medical facilities at club grounds and minimum qualifications for club medics for next season, with funding to ensure compliance being provided centrally.

“As employers we have a duty of care to our players and, working in partnership with the RFU, PRA and our clubs, we will ensure the Injury Risk Management Plan delivers the highest standards of both prevention and care”.  

Damian Hopley , Chief Executive of the PRA said:  

"Whilst there has long been anecdotal evidence to support the information gathered through this survey, this positive piece of work from all the stakeholders within the English game provides us with a platform to better manage our elite players, and ensure that the industry encourages best practice in terms of quality and quantity of medical support and injury risk management.

“It is encouraging that, after years of lobbying, the sport is now working together to ensure that player welfare is the number one priority."

Injury risk management - press briefing

Wednesday 1 June 2005

 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 1^st 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 PRA 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.

 Table 1. The most common injuries (matches and training combined)

	Forwards	Backs
1	Calf muscle injury	Hamstring muscle injury
2	Haematoma thigh	Haematoma thigh
3	Ankle lateral ligament injury	Ankle lateral ligament injury
4	Hamstring muscle injury	Calf muscle injury
5	Cervical nerve root injury	Concussion

  

Table 2. Injuries causing most lost time (matches and training combined)

	Forwards	Backs
1	Lumbar disc nerve or canal injury	Hamstring muscle injury
2	Knee cartilage/ degenerative injury	ACL injury
3	Dislocation/ instability shoulder	Dislocation/ instability shoulder
4	Achilles tendon injury	MCL injury
5	Calf muscle injury	Knee cartilage/ degenerative 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 pitchside 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