Injury Surveillance Project

England Professional Rugby
Injury Surveillance Project
2014-15 Season Report
March 2016
Authored by the England Professional Rugby Injury Surveillance Project Steering Group
Chaired by Dr Simon Kemp (Chief Medical Officer, RFU) and comprising;
Dr John Brooks (Injury Risk Analyst and Ex Harlequins and England Saxons),
Matthew Cross (Injury Surveillance Project Research Assistant, University of Bath and Professional Rugby Medical Research Officer, RFU),
Phil Morrow (Performance Director, Saracens RFC),
Dr. Sean Williams (Lecturer, University of Bath),
Dr Tim Anstiss (Medical Advisor, RPA),
Dr Andy Smith (Consultant in Emergency Medicine, Mid Yorkshire NHS Trust and Premiership Rugby Clinical Governance Advisor),
Aileen Taylor (Physiotherapist),
Corin Palmer (Head of Rugby Operations, Premiership Rugby),
Richard Bryan (Rugby Director, RPA),
Grant Trewartha (Senior Lecturer, University of Bath) and
Dr Keith Stokes (Injury Surveillance Project Principal Investigator, University of Bath).
The content of the report is based on data collected and analysed by Matthew Cross (University of Bath).
This report was designed by Jo Church (RFU Studio).
The authors would like to acknowledge with considerable gratitude, the work of the doctors, physiotherapists and strength and conditioning
staff from the Premiership clubs and England teams who have recorded injury and training information throughout the project.
EXECUTIVE SUMMARY
The key findings from the 2014-15 season:
•
The 2014-15 Professional Rugby Injury Surveillance
Project (PRISP) is the most comprehensive and longest
running injury surveillance project in Professional
Rugby Union. It monitors the injury risk in the English
Premiership over time and allows for the investigation of
specific areas of injury risk.
•
The overall incidence of match and training injury
(the likelihood of a player sustaining an injury) in the
Premiership remained stable during the 2014-15 season
and was again within the “expected range” of variation
seen since the study began in 2002.
•
The severity of match injuries (the time taken to return
to play) for the 2014-15 season was the highest reported
since 2002 and although from a statistical perspective
the average severity of 29 days still falls within the
expected limits of variation, there is a trend for an
increasing severity of match injuries. Specifically, there
was an increase in the number of injuries that led to
> 84 days absence with the incidence of Anterior Cruciate
Ligament (ACL) and Medial Collateral Ligament (MCL)
injuries to the knee in 2014-15 twice that reported in
2013-14. These are rare injuries with a prolonged recovery
time. Other factors that may be contributing to this trend
include an increase in the severity of specific injuries
and more prolonged and comprehensive return to play
protocols.
•
Due to this high severity, there is a trend for an increase
in the overall risk of match injury (a combination of both
incidence and severity).
•
There were no clear differences in the incidence, severity
or overall injury burden of time-loss and non-timeloss injuries between matches played on artificial turf
(Allianz Park and Kingston Park) and natural grass.
•
In a similar fashion to match injuries, there also
appeared to be an increasing trend for the severity of
training injuries. However, the overall risk of training
injuries remained within the expected limits of variation
and was lower than reported in the previous two seasons.
•
There was a decrease in the incidence of recurrent match
injuries, continuing the trend seen since 2007-8. This
is a likely consequence of the continued delivery of
effective rehabilitation of injuries by club medical and
conditioning teams. This more conservative approach
may have impacted on the overall higher severity of
match injuries.
•
Concussion was, for the fourth consecutive season, the
most commonly reported Premiership match injury
(13.4/1000 player-hours) constituting approximately
17% of all match injuries. Ninety-five percent of all
concussions occurred in matches. It is likely that the
continued focus on improving concussion awareness
among players, coaches, referees and medical staff and
the development of more inclusive and specific criteria
that lead to a diagnosis of concussion as part of the Head
Injury Assessment (HIA) process have both contributed
to this continued rise in concussion incidence.
•
The mean severity of reported match concussions in
2014-15 remained stable at 12 days. Compliance with
mandatory return to play protocols after concussion was
excellent.
•
Changes to the nature of the professional game (e.g.
more powerful players and/or an increasing frequency
of contact events) have been suggested as factors
underpinning the increase in concussion incidence.
However, it should be noted that the risk of all other
(non-concussion) match contact injuries in the
Premiership has remained stable. Concussion prevention
is currently a key focus for the game. World Rugby,
supported by the RFU, are presently undertaking a video
analysis study investigating risk factors for concussion.
This analysis will provide insight into the potential of a
range of factors (e.g. the laws of the game and coaching
and refereeing initiatives) to reduce concussion
incidence. Data recorded in the PRISP study is being
used in this analysis.
•
In 2014-15, 11 players retired as a result of injury and
one retired as a result of illness. In the previous season,
23 players retired as a result of injury and two players
retired through illness.
CONTENTS
00
EXECUTIVE SUMMARY
1
Introduction
4
Updates: 2014-15
4
Looking Forward
5
Project Definitions
06
KEY FINDINGS
6
Match Injury Incidence & Severity
9
Training Injury Incidence & Severity
12
Injury Recurrence
14
Match Injury Event
16
Time in the Season
16
Injuries Leading to Retirement
18
Concussion
20
Injuries at the Scrum
21
Artificial Turf
23
Training Volume
24
Injury Diagnosis
26
Other Projects
28
England Senior Side
22
Training Injury Event
22
Hamstring Injuries
23
Time-Loss Illness
RFU INJURY SURVEILLANCE
PROJECT METHODS
30
CURRENT PUBLICATIONS &
PRESENTATIONS
31
32
SUPPLEMENTARY DATA
INTRODUCTION
The Rugby Football Union (RFU) and Premiership Rugby
Ltd (PRL) first commissioned an injury surveillance study
across the Premiership and England teams in 2002 that
remains driven and directed towards the improvement of
player welfare in professional Rugby Union. This report
presents the Premiership-wide key findings from the 2014-15
season and compares them longitudinally with the results
from 11 previous seasons. The Professional Rugby Injury
Surveillance Project (PRISP) is pivotal in both providing
the baseline data needed to assess trends in injury and in
guiding further investigation into injuries that are common,
severe or increasing in incidence.
The data collection methods for PRISP can be found towards
the end of this report. Supporting tables and figures are
included in the supplementary data file at the end of this
report.
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2014-
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UPDATES: 2014-15
Return to play following concussion
In line with a desire to understand more about the return to
play following concussion, 2014-15 saw the continuation for
a third season of the RFU concussion surveillance project
across all 12 Premiership clubs. This was introduced to
improve our understanding of the time course of resolution
of concussion in professional Rugby Union and includes an
audit of return to play practices. These findings have been
released separately to this report via an open access (freely
available to all) publication in the British Journal of Sports
Medicine, however a summary of the key findings of this
study and also of the concussion incidence, severity and risk
of concussion during 2014-15 are included in this report.
Training load and injury risk
In a pilot study aligned with the injury surveillance project,
individual training and match intensity and load were
captured from players at four Premiership clubs during the
2013-14 season (data collection continued in 2014-15 but
are currently being analysed). The aim of this study was to
investigate the relationship between training intensity and
load and injury risk, an area that has not yet been explored
by the Premiership injury surveillance project. A summary of
the key findings are included in this report.
Scrum engagement
2013-14 saw the continuation of the “crouch, bind, set” scrum
engagement sequence throughout the game. It is likely that
further global analysis will be provided in the near future,
however this report continues to highlight the incidence
of time-loss injuries attributed to the scrum in the English
Premiership since 2002 and including the 2013-14 and 2014-15
seasons for which the most recent engagement sequence was
in operation.
LOOKING FORWARD: 2015-16
Game events and concussion risk
As part of the Rugby Football Union’s continued focus
on concussion, and in conjunction with research being
conducted by World Rugby, a study investigating the
mechanisms of time-loss match concussion in professional
Rugby Union is in progress. Footage of match events
associated with a concussion will be analysed from the 201314, 2014-15 and 2015-16 Premiership seasons.
Artificial turf
During 2014-15, two English Premiership teams played
their home fixtures on an artificial playing surface. Our
understanding of the influence that the new generation
artificial turf has upon injury risk and perceptions of
muscle soreness is still developing. To address this, a study
was commissioned by the RFU, Premiership Rugby and
the Rugby Players Association. This report gives a short
summary of the results from 2013-14 and 2014-15. The
study will continue in 2015-16 and will include additional
information including the collection of training exposure by
surface type and association with training injury risk.
Training load and injury risk
In order to further progress our initial work in this area
(as mentioned above, a summary of the current key findings
are included in this report), we have expanded the collection
of training load data to form a much bigger sample of
Premiership clubs and the inclusion of the England 7s team.
An update regarding the development of this study and any
new findings will be included in the 2015-16 annual report.
04
PROJECT DEFINITIONS
Time-loss injury
A time-loss injury was defined as ‘any injury that prevents
a player from taking a full part in all training activities
typically planned for that day and/or match play for more
than 24 hours from midnight at the end of the day the injury
was sustained’. For example, if a player was injured during
a match on Saturday and he was able to take a full part in
training on Monday, the incident would not be classed as
a time-loss injury. If the player’s training was restricted on
Monday due to the injury received on Saturday, the incident
would be classed as a time-loss injury and reported.
Injury severity
Injury severity was measured as time (days) lost from
competition and practice and defined as the number of
days from the date of the injury to the date that the player
was deemed to have regained full fitness, not including the
day of injury or the day of return. A player was deemed to
have regained full fitness when he was ‘able to take a part in
training activities (typically planned for that day) and was
available for match selection.’
Recurrent injury
An injury of the same type and at the same site as an index
(original) injury and which occurs after a player’s return to
full participation from the index (original) injury.
Injury incidence and days absence
The likelihood of sustaining an injury during match play
or training is reported as the Injury incidence. The Injury
incidence is the number of injuries expressed per 1,000
player-hours of match exposure (or training exposure).
Equally important to the player and/or his team is how long
players are absent. This is known as injury severity and is
measured in days absence.
Illness
Any illness (classified using the Orchard Sports Injury
Classification System – OSICS 10.1) for which the player
sought consultation at his club that prevented the player
from participating in training or match play for a period
greater than 24 hours after the onset of symptoms.
Statistical significance
A result is considered to be statistically significant if the
probability that it has arisen by chance is less than 5% or 1 in
20. In this report statistical analysis has been performed for
the match and training injury incidence and days absence.
Statistical Process Charting (SPC) has been used to show the
expected limits of the system with upper and lower limits set
at +/- 2 standard deviations from the mean.
NB: The vertical line on each figure denotes the change in data collection methods (from paper to electronic data capture) prior to the start of the 2013-14 season.
05
KEY FINDINGS
MATCH INJURY INCIDENCE & SEVERITY
Likelihood or incidence of match injury
The incidence of match injury remained stable in 2014-15
(Figure 1a). Six hundred and forty-five match injuries that led
to time lost from training and/or match play were reported
in the 2014-15 season, this number is similar to the mean of
674 injuries per season observed for the whole study period.
The match injury incidence in 2014-15 was 79/1000 hours or
approximately 54 match injuries per club during the season.
This incidence is similar to the mean incidence of 86/1000
hours for the period 2002-15. Four hundred and ten team
matches (1 game = 2 team matches if both clubs are involved
in the injury surveillance project) were included in the
analysis during 2014-15 equating to an average of 1.6 injuries
per club per match.
Severity of match injuries
The severity of match injuries for the 2014-15 season was
the highest seen since 2002. From a statistical perspective
the average severity of 29 days still falls within the expected
limits of variation however, there appears to be an increasing
trend for the severity of match injuries with the season
average severity higher than the overall mean for the last four
seasons (Figure 1b).
rare but are associated with a prolonged recovery time (for
a breakdown of match injury incidence and severity by
season see Table S1). The last three seasons have also seen
a reduction in the number of 2-3 day match injuries being
reported, which may also increase the average severity of
injury.
For some injuries, more tightly defined diagnostic criteria
have developed over the study period which is likely to have
resulted in changes in the identification and management
of these injuries. For example, in the last three seasons
(2012-15), there has been a very significant increase in
the average severity of ankle syndesmosis injuries when
compared to the average for the period 2002-12 (72 days vs
34 days). Additionally, the average days absence of 114 days
in 2014-15 was the highest seen for this injury type during
the study, suggesting that more conservative return to play
strategies are being employed by club medical staff to aim to
ensure a more complete rehabilitation and a reduction in the
risk of early recurrence for this injury.
Increases in mean severity may represent a) an actual
increase in the severity of selected injuries, b) more
conservative return to play protocols employed by medical
staff or c) a small number of severe injuries having a large
effect on the mean. Table 1 provides a breakdown of match
injuries by severity group and highlights an increase in
those injuries that lead to greater than 84 days absence.
This increase in >84 day injuries has likely contributed to
the increase in average severity of match injuries this season.
Specifically, the incidence of Anterior Cruciate Ligament
(ACL) and Medial Collateral Ligament (MCL) injuries to
the knee in 2014-15 was twice that reported in 2013-14 (ACL
injuries went from 4 to 8 occurrences). These injuries are
06
Summary of match injury risk
Due to the higher severity of injury in 2014-15, the overall
risk of match injury (a combination of both incidence and
severity; Figure 1c) was also the highest seen since the start
of the surveillance project, equating to approximately 47 days
absence per club per match. The overall risk of match injury
remains within the expected limits of season-on-season
variation, but there appears to have been an increase in the
overall risk (total days lost) of match injuries since 2002.
Figure 1a
INCIDENCE/1000HRS
120
100
Upper limit
80
Lower limit
60
Mean
40
Incidence
20
0
03
2-
0
20
04
3-
0
20
2
6
-0
5
00
2
7
-0
6
00
11
10
13
15
09
08
14
12
2- 1347- 08- 09- 10- 111
1
0
0
0
0
0
0
2
2
2
2
2
2
20
0
20
Figure 1a: Incidence rates of match injuries over the study period
with mean ± 2 x standard deviation shown. Vertical line denotes
change in data collection methods to electronic capture.
Note - For a normal distribution, 95% of all data should
FIG 1B(Mean - 2 x standard deviation) and
fall between
(Mean + 2 x standard deviation).
Figure 1b
35
DAYS ABSENCE
30
25
Upper limit
20
Lower limit
15
Mean
10
Severity
5
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
20
20
20
20
20
20
20
20
20
20
20
2
2
00
Figure 1b: Severity of match injuries over the study period with
mean ± 2 x standard deviation shown. Vertical line denotes change
in data collection methods to electronic capture.
07
FIG 1C
Figure 1c
DAYS ABSENCE/1000 HRS
3000
2500
Upper Limit
2000
Lower Limit
1500
Mean
1000
Days absence
500
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
20
20
20
20
20
20
20
20
20
20
20
2
00
2
Figure 1c: Days absence/1000 hrs from match injuries over the
study period with mean ± 2 x standard deviation shown. Vertical line
denotes change in data collection methods to electronic capture.
Table 1:
Match injury incidence by severity grouping 2002-15
INCIDENCE /1000 HRS
SEASON
2-7
DAYS
8 - 28
DAYS
29 - 84
DAYS
> 84
DAYS
ALL
2002-03
57
30
9
3
100
2003-04
45
26
14
4
88
2005-06
29
29
13
3
75
2006-07
47
28
11
5
90
2007-08
39
30
10
4
83
2008-09
48
31
14
6
100
2009-10
36
29
10
4
80
2010-11
44
32
11
5
93
2011-12
34
28
13
7
82
2012-13
26
30
13
4
73
2013-14
38
33
14
6
91
2014-15
33
25
12
9
79
08
TRAINING INJURY INCIDENCE & SEVERITY
Summary of training injury risk
of variation (Figure 2b). The severity of training injuries
has been higher than the mean severity for the last three
seasons and requires careful monitoring. In common with
the previous two seasons, as well as the match injury data, it
is the most severe injuries that appear to contribute to this
higher severity in 2014-15. The incidence of injuries in the
29-84 and >84 day severity categories remained high when
compared with previous seasons (Table 2).
A total of 325 training injuries (34% of the total injury count
for 2014-15) led to time lost from training and/or match play
were reported in the 2014-15 season. This equated to an
incidence rate of 2.3/1000 player hours or approximately 27
injuries per club per season (a season-by-season breakdown
can be seen in Table S2).The incidence of injury from
training was within the expected limits of natural season-toseason variation and is very similar to the mean incidence
seen during the study period (Figure 2a).
Despite this high severity, the overall risk of training injuries
(days absence/1000 hours) remained within the expected
limits of season-to-season variation and was lower than seen
in the previous two seasons (Figure 2c).
The severity of training injuries during season 2014-15 was
28 days and there appears to be a trend for increased severity
of injuries, although the data are within the expected limits
FIG 2A
Figure 2a
3.5
INCIDENCE/1000HRS
3.0
Upper limit
2.5
Lower limit
2.0
1.5
Mean
1.0
Incidence
0.5
0.0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
2
2
20
20
20
20
20
2
2
00
Figure 2a: Incidence rates of training injuries over the study period
with the mean ± 2 x standard deviation shown. Vertical line denotes
change in data collection methods to electronic capture.
09
Figure 2b
35
DAYS ABSENCE
30
25
Upper limit
20
Lower limit
15
Mean
10
Days absence
5
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
2
20
20
20
20
20
20
2
00
2
Figure 2b: Severity of training injuries over the study period with
mean ± 2 x standard deviation shown. Vertical line denotes change
in data collection methods to electronic capture.
FIG 2C
Figure 2c
DAYS ABSENCE/1000HRS
90
80
70
Upper limit
60
Lower limit
50
Mean
40
30
Days absence
20
10
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
2
2
2
2
2
2
2
2
2
00
Figure 2c: Days absence/1000hrs for training injuries over the
study period with mean ± 2 x standard deviation shown. Vertical line
denotes change in data collection methods to electronic capture.
10
Table 2: Training injury incidence by severity grouping 2002-15
INCIDENCE /1000 HRS
SEASON
2-7
DAYS
8 - 28
DAYS
29 - 84
DAYS
> 84
DAYS
ALL
2002-03
1.13
1.29
0.42
0.18
3.0
2003-04
0.61
0.63
0.30
0.08
1.6
2005-06
1.04
0.70
0.35
0.10
2.2
2006-07
0.99
0.61
0.20
0.07
1.9
2007-08
1.26
1.08
0.38
0.07
2.8
2008-09
1.00
0.94
0.31
0.10
2.4
2009-10
1.09
0.89
0.34
0.07
2.4
2010-11
1.24
1.12
0.32
0.13
2.8
2011-12
0.87
0.97
0.30
0.14
2.3
2012-13
0.90
0.98
0.49
0.21
2.6
2013-14
0.94
1.25
0.52
0.18
2.9
2014-15
0.87
0.82
0.44
0.19
2.3
11
INJURY RECURRENCE
Summary of recurrent injury incidence
The incidence of recurrent injuries in match (Figure 3a)
and training (Figure 3b) remains within the expected limits
of variation in 2014-15 (although season 2002-03 now falls
outside of what is expected for recurrent match injuries).
The decrease in reported recurrent injuries since 2007-08
continues. The 2014-15 incidence rate for recurrent match
injuries was 3.0/1000 player hours and was well below the
mean incidence of 8.7/1000 player hours for the period 200214. More detailed data regarding the incidence, severity and
overall risk of new vs recurrent injuries can be seen in Tables
S3 and S4 for match and training respectively.
This may indicate that on average players are undertaking a
more comprehensive and conservative rehabilitation, which
may have impacted the overall severity of match and training
injuries.
The most commonly reported recurrent match injuries
during the 2014-15 season were hamstring, soleus and
quadriceps muscle injuries (three injuries each) and ankle
syndesmosis injury (two injuries). These injury types are
similar to those reported in season 2013-14. The severity of
the most common recurrent match injuries can be seen in
Table S5.
NB: Concussion was not included in the analysis of recurrent injury for consistency with data reported in previous years.
A separate section on concussion is presented opposite.
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CONCUS
“
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12
FIG 3A
Figure 3a
20
INCIDENCE/1000HRS
18
16
14
Upper limit
12
10
Lower limit
Mean
8
6
Incidence
4
2
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
2
2
2
2
2
2
2
2
00
2
Figure 3a: Incidence rates of recurrent match injuries over the
study period with mean ± 2 x standard deviation shown. Vertical line
denotes change in data collection methods to electronic capture.
FIG 3B
Figure 3b
0.7
INCIDENCE/1000HRS
0.6
0.5
Upper limit
0.4
Lower limit
0.3
Mean
0.2
Incidence
0.1
0.0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
20
20
20
20
20
20
20
20
20
20
20
2
2
00
Figure 3b: Incidence rates of recurrent training injuries over the
study period with mean ± 2 x standard deviation shown. Vertical line
denotes change in data collection methods to electronic capture.
13
MATCH INJURY EVENT
The proportional profile of the type of match events leading
to match time-loss injury remains similar to that observed
throughout the duration of the injury surveillance project
(Figure 4). It is important to note that for the second season
in succession: 1) the proportion of injuries associated with
running were significantly lower (8% of all injuries) and 2)
the proportion of injuries associated with player-on-player
(accidental or non-accidental) collisions (15% of all injuries)
were significantly higher when compared with the average
The most common injuries
as a result of the tackle in
2014-15 were (in order):
for the whole period 2002-14. There was also an increase
in the number of injuries attributed to a not-known event.
It is important to note that of these “not-known” events, a
proportion are injuries with a non-specific time of onset (e.g.
they have developed over time) rather than acute injuries that
are directly attributable to a match event. The tackle remains
the match event most commonly associated with injury,
accounting of 36% of all injuries in 2014-15.
Ball Carrier
Tackler
Concussion
Ankle syndesmosis injury
Quadriceps haematoma
MCL injury
Concussion
Quadriceps haematoma
Cervical stinger/burner
Brachial plexus stinger/burner
incidence of these injuries going forward in 2014-15. Nonaccidental collisions are illegal under the laws of the game
and consistent penalisation by the referee is likely to be an
effective control measure. Although the proportion of injuries
attributed to collisions (accidental and non-accidental
combined) increased (Figure 4), specifically, the incidence
of injuries attributed to non-accidental collisions reduced to
3.1/1000 hours (similar to the mean for the whole period of
2.9/1000 hours) from 5.5/1000 hours in 2013-14 (Figure 5).
Once again, these findings remain largely similar to the past
four seasons, and for the second time, concussion was the
most common match injury for both the ball carrier and the
tackler.
Last season’s annual report highlighted an increase in the
incidence of injury resulting from non-accidental collisions
(where a tackler impedes/stops the carrier without the
use of his arms) and the importance of monitoring the
NB: The differentiation of accidental versus non-accidental collisions started in 2009-10 therefore, no data are available before this date.
14
Figure 4: Incidence rates of match injuries by injury event. Error bars show 95% CIs
25
Incidence /1000 hours
20
15
10
Lin
eo
ut
um
Ma
ul
Ot
Ru
2002-2014
Sc
r
he
r
ck
ns
isi
o
Co
ll
N
No ot k
n- now
sp
ec n/
ifi
c
ing
nn
Ru
Ta
ck
Ta
ck
led
lin
g
5
2014-2015
Figure 5: Incidence of injury associated with non-accidental match collisions by season. Error bars show 95% CI’s.
8
6
5
4
3
2
1
14
-15
20
13
-14
20
15
20
-13
12
1112
20
-11
10
20
09
-10
0
20
Incidence/1000 hours
7
TIME IN THE SEASON
In 2014-15, the peak injury incidence was seen in September (more detail can be found in Figure S6). There has been no
significant change over the study period regarding the monthly distribution of injuries.
INJURIES LEADING TO RETIREMENT
The Injury Surveillance Steering Group would like to thank
the Rugby Players Association (RPA) for its assistance with
compiling data on players who retired as a result of injury or
illness.
The injuries that led to retirement in 2014-15 were sustained
at the following body locations:
Prior to 2013-14, the PRISP annual report only presented the
number of players who retired with an unresolved (i.e. open)
time-loss injury sustained in the season being studied, rather
than the total number of players retiring during the season
as a result of injury or illness. From 2013-14 onwards, the total
number of retirements where injury was cited as the reason
for the retirement are presented.
Lower Limb – 5
Thoracic and Lumbar Spine – 3
Upper Limb – 2
Head and Neck – 1
During 2014-15, 11 players retired due to injury and one player
retired as a result of illness. In 2013-14, 23 players retired
through injury and two players retired through illness.
16
11
T
L
U
S
E
R
A
S
A
D
PLAYERS RETIR0E14-15 COMPARED
OF INJURY IN 2
WITH 23 IN 2013-14
17
CONCUSSION
Prevalence, incidence and severity
During 2014-15 there were 110 reported match concussions
(70 Premiership, 23 European Competition and 17 National
Cup) compared with 86 in 2013-14. Six concussions occurred
in training (compared with 8 in 2013-14). Overall, 95% of
concussions occurred in match play and 5% in training.
During 2014-15, 83% of players did not have a diagnosed
concussion. Of the 17% of players (13% in 2013-14) for whom
a concussion was reported by medical staff, 87 players
sustained 1 concussion. 8 players sustained 2 concussions,
1 player sustained 3 concussions and 1 player was reported
as having sustained 4 concussions. The Rugby Football
Union and Premiership Rugby currently recommends that a
specialist neurological opinion should be sought for players
following a second diagnosed concussion during a 12 month
period.
For the fifth consecutive season, the incidence of reported
concussions increased (Figure 6). In 2014-15, the reported
incidence of concussion was 13.4/1000 hours, and is the
highest observed since the start of the surveillance project in
2002. For the second season in succession, the incidence of
reported concussions rose above the upper limit of expected
variation.
The mean severity of reported match concussions in 2014-15
was 12 days and remains stable (Figure 7). If the current
graduated return to play protocol is followed correctly, the
minimum time to return to play is six days from the day of
injury. In 2014-15, the number of players returning to play
earlier than the recommended guidelines continued to fall,
with only one player returning in less than six days. This
finding highlights the excellent compliance with concussion
FIGto6play guidelines in 2014-15.
return
Figure 6
16
INCIDENCE/1000HRS
14
12
Upper limit
10
Lower limit
8
Mean
6
Incidence
4
2
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
2
2
20
20
20
20
20
2
00
2
Figure 6: Incidence per 1000 player hours of reported match concussions by season with mean ± 2
standard deviations. Vertical line denotes change in data collection methods to electronic capture.
Verticle dark red line denotes introduction of PSCA/HIA.
18
Figure 7
20
18
DAYS ABSENCE
16
Upper limit
14
12
10
Lower limit
Mean
8
6
Severity
4
2
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
2
2
20
20
20
20
20
2
00
2
Figure 7: Mean severity (days absence) of reported match concussions by season with mean ± 2
standard deviations. Vertical line denotes change in data collection
methods to electronic capture.
FIG 8
Verticle dark red line denotes introduction of PSCA/HIA.
Figure 8
70
INCIDENCE/1000HRS
60
50
Upper limit
40
Lower limit
30
Mean
20
Incidence
10
0
7
3
9
8
6
4
1
0
3
5
-0 3-0 5-0 6-0 7-0 8-0 9-1 0-1 1-12 2-1 3-14 4-1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
2
20
20
20
20
20
20
2
00
2
Figure 8: Incidence rates of match contact injuries (excluding concussion) over the study period with mean ± 2 x
standard deviation shown. Vertical blue line denotes change in data collection methods to electronic capture.
It is not possible for the PRISP study to separate changes in
reporting practice from any inherent changes in the risk of
concussion in this competition. However, the steering group
believes that the significant increase in the incidence of
reported match concussion most likely reflects the continued
increase in concussion awareness and behavioural changes
among players, medical staff, coaches and match officials as
a result of RFU, Premiership Rugby, RPA and World Rugby
education initiatives and the recent media focus on this injury.
consequence of changes to the World Rugby Head Injury
Assessment (HIA) process. The steering group believes that
it is likely that this change has also led to more cases being
reported. Specifically, during 2012-13 the criteria for immediate
and permanent removal from play after a head injury event (and
an automatic diagnosis with concussion) consisted of three
criteria: confirmed loss of consciousness, tonic posturing and
concussive convulsions. In 2013-14 these criteria were expanded
to also include: suspected loss of consciousness, ataxia and
observable disorientation. Before the start of the 2014-15, three
further additional criteria were added: being clearly dazed or
“dinged”, definite confusion and definite behavioural change.
It is also important to note that the operational definition
of concussion in the elite adult game has widened as a
19
INJURIES AT THE SCRUM
The 2013-14 season saw the introduction of a new scrum
engagement sequence (“crouch, bind, set”). The 2013-14
annual report presented the first season of data regarding
the incidence of injury at the scrum and highlighted the
importance of continued monitoring of injury rates in future
seasons to understand the impact of this change upon acute
injury risk. The new scrum engagement process has been
shown in previously published research to reduce the impact
force at engagement by approximately 20% and improve the
stability of the scrum, thus hopefully leading to a reduction
in chronic and catastrophic injuries caused by scrummaging.
Further longitudinal research is required to ascertain the full
impact of this law variation.
incidence before the law change (2002-13: 4.3/1000 hours
versus 2013-15: 3.3/1000 hours; Figure 9), although the
relatively small number of injuries mean that this is not
statistically significant. Continued surveillance will be
required to determine whether injury risk related to the
scrum has reduced substantially as a result of the new
scrum engagement sequence. The average severity of
injuries sustained at the scrum was 52 days highlighting a
greater severity of injury at the scrum when compared with
the average for all match injuries. The severity of match
injuries associated with the scrum has remained stable
throughout the study period. The most common injury
types at the scrum are medial Gastrocnemius muscle strain,
Costochondral joint sprain and Lumbar muscle strain (all
four injuries each), there were no catastrophic spinal injuries
reported in 2014-15 in the professional game. The overall risk
of scrum injuries in 2014-15 was 133 days/1000 hours.
A total of 21 match injuries were attributed to the scrum
during 2014-15 giving rise to an incidence of 2.6/1000
hours. There has been a reduction in the reported
incidence of injury at the scrum when compared to the
Figure 9:
5
4
3
2
1
Po
ch st la
an w
ge
0
P
ch re la
an w
ge
Incidence/1000 hours
6
Figure 9: Incidence per 1000 player hours of match injuries
associated with the scrum with mean ± 2 standard deviations.
20
ARTIFICIAL TURF
The Rugby Football Union (RFU), Premier Rugby Ltd (PRL)
and the Rugby Players Association (RPA) first commissioned
a study to investigate the impact of artificial playing surfaces
in this setting during the 2012-13 season, when the first
artificial surface for match play was installed in the English
Premiership (two English Premiership teams now play their
home fixtures on third-generation artificial playing surfaces).
This report provides a summary of the key findings from the
most recent 2014-15 season.
•
There were no clear differences in the incidence, severity or overall injury burden of
time-loss injuries between matches played on artificial turf and natural grass.
•
There were no clear differences in the incidence of non-time loss injuries between
playing surfaces.
•
Overall, players reported a small increase in muscle soreness (particularly the lower
back) and players reported a lower ‘readiness to return to training’ score following a
match on artificial turf, compared with natural grass.
The findings from the study to-date conclude that: playing
professional Rugby Union on artificial turf does not appear
to substantially alter match overall acute injury risk, in
comparison with matches played on natural grass surfaces.
artificial turf pitches. What this survey cannot monitor is the
extent to which players are not selected to play on artificial
pitches on specific medical/player management advice within
clubs and the strategies of club medical and conditioning
teams in managing the effects of playing on artificial pitches.
It is intended to capture this information during the 2015-16
season.
It is important to note that currently this study considers
responses from those who have taken part in matches on
“
PLAYINGCIAL TURF
ON ARTIFI APPEAR TO
T
O
N
S
E
O
ER
T
D
L
A
Y
L
L
A
I
T
N
TA
SUBS
K
S
I
R
Y
R
U
J
N
I
MATCH
21
”
TRAINING INJURY EVENT
grouping can be seen in Table 2).
When compared with the period 2002-14 fewer injuries
occurred as a result of conditioning non-weights sessions
in 2014-15 (3.2/1000 hours vs. 5.1/1000 hours; Figure 10).
Clearly this reduction is encouraging and hopefully reflects
improved practice and player management but the exact
reason for this difference in 2014-15 remains unknown. The
incidence of all other training categories in 2014-15 remained
similar to 2002-14 (a breakdown of incidence by severity
In 2014-15, during conditioning non-weights and rugby
skill training sessions, most injuries occurred as a result of
running related activity (71% and 36% respectively). During
rugby skills sessions, the tackle was the cause of 11% of
training injuries over the course of the season.
Figure 10: Incidence rates of training injuries by session type. Error bars show 95% CIs.
Incidence/1000 hours
6
5
4
3
2
1
0
Rugby Skills
Contact
Rugby Skills
Non-Contact
2002-2014
Conditioning
Weights
2014-2015
HAMSTRING INJURIES
Hamstring injuries remain the most common
and highest risk training injury across the
study period. After a reduction in hamstring
match injury incidence of around 50% in
2013-14 to 2.5/1000 hours, the incidence of
hamstring injury in 2014-15 increased to
4.4/1000 hours, suggesting that the reduction
observed last season was likely due to seasonal
variation rather than a change due to the
success of injury prevention efforts. There
were 15 fewer hamstring training injuries
sustained in 2014-15 compared with 2013-14
equating to an incidence of 0.3/1000 hours.
This is less than the mean incidence for the
period 2002-14 of 0.4/1000 hours. The overall
risk (days absence/1000 hours) of hamstring
injuries remained stable in 2014-15. A season
by season breakdown can be seen in Table S7.
22
Conditioning
Non-Weights
TIME-LOSS ILLNESS
Incidence and severity of time-loss illness
The Premiership injury surveillance project has collected
time-loss illness data for two seasons (2013-14 and 201415). During 2014-15, a total of 155 time-loss illnesses were
reported compared with 112 time-loss illnesses in 2013-14.
The incidence of time-loss illness this season was 1.0/1000
player days (0.8/1000 player days for the two season period;
N.B. The incidence of illness is not directly comparable
with the incidence of injury due to the different incidence
denominator). Over the two seasons, the mean severity of
time-loss illness was 12 days, with 15% of players reporting at
least one time-loss illness. Overall, in 2014-15, illness led to a
total of 2701 days lost from training and match play equating
to approximately 225 squad days of unavailability per club
during the season. Additional seasons of data collection and
a better understanding of illness procedures in each club are
required in order to present these data in further detail and
to allow the monitoring and comparison of illness incidence
and severity across multiple seasons.
Most common time-loss illnesses
The most commonly affected systems during the last two
seasons (2013-14 and 2014-15) were; Respiratory, Digestive
and Dermatological accounting for 31%, 23% and 17% of all
reported time-loss illness, respectively. Specifically, upper
respiratory tract infections and diarrhoea were the most
common diagnoses, each accounting for 12% of all illnesses.
Although the comparison of these data is difficult due to a)
the lack of scientific literature regarding illness in Rugby
Union b) the lack of a scientific consensus regarding the
reporting of illness, it would appear that the incidence of
time-loss illness in this cohort is lower than in Super Rugby
competition. It should be noted however that it is likely that
the increased travel demand and as a consequence, exposure
to varied environmental conditions increases the risk of
illness in the Super Rugby competition.
TRAINING VOLUME
The total training volume per player at Premiership clubs in
2014-15 was similar to that for the period 2002-14 (6.0 hours/
week vs. 6.5 hours/week, respectively). A similar proportion
of time spent in contact and non-contact training means
that any change in training injury incidence is unlikely to be
related to a change in type of training. A season by season
breakdown can be seen in Table S8.
23
INJURY DIAGNOSIS
Summary of the most common and highest risk match injuries
average severity for all match injuries (Figure 2b). ACL
injuries carried the highest risk of any injury with an equal
number occurring in contact and non-contact events (Figure
11b). While these injuries are not common (eight ACL
injuries were sustained in 2014-15) the average severity was
246 days. For the second season in succession, concussion
appears in the top five highest risk (days absence/1000 hours)
match injuries. This is due to the increasing incidence of
concussion when compared with all other contact injuries
(Figure 8) rather than changes to the severity of the injury,
which has remained stable throughout the surveillance period
(Figure 7).
For the fourth consecutive season, concussion was the most
common match injury (17% of all match injuries; Figure 11a)
with the incidence of this injury continuing to rise (Figure 6).
It is hoped that the aforementioned video analysis study
investigating the mechanisms for concussion from match
events will provide further understanding of the potential
to reduce concussion incidence in the future. The 201415 incidence value again highlights that concussion was
previously significantly under-reported (along with the more
inclusive sign/symptom checklist to indicate diagnosis and
removal from play) and as such the reported incidence for
the 2014-15 season should serve as a minimum estimate. In
addition, injuries to the AC joint entered the five most common
injuries for the first time since 2010-11.
Overall, the profile of the most common and highest risk
match injuries has remained similar throughout the injury
surveillance project with the exception of concussion.
The overall risk of specific match injuries (days absence per
1000 player hours) increased in 2014-15 due to the higher
The most common match injuries
Figure 11a:
Match
2011-12
2012-13
2013-14
2014-15
Concussion 5.1
Concussion 6.7
Concussion 10.5
Concussion 13.4
Hamstring
muscle 5.0
Thigh
haematoma 4.9
Hamstring
muscle 4.9
Ankle
syndesmosis 3.8
Thigh
haematoma 4.2
MCL 3.7
Hamstring
muscle 4.4
Thigh
haematoma 3.4
Calf muscle 4.8
MCL 3.6
Ankle lat. lig. 2.9
MCL 3.3
MCL 4.0
Thigh
haematoma 3.3
Hamstring
muscle 2.5
AC joint 2.9
The highest risk match injuries
Figure 11b:
Figure 11a: Ranking of the top five most common match injuries each
season for 2011-15 with the associated incidence rates (injuries/1000 hours).
2011-12
2012-13
2013-14
2014-15
ACL 186
Ankle
syndesmosis 145
MCL 130
ACL 240
MCL 148
MCL 141
ACL 116
Concussion 189
Hamstring
muscle 119
Shoulder
dislocation 108
Hamstring
muscle 130
Concussion 105
Hamstring
muscle 153
Ankle
syndesmosis 142
PCL/LCL 92
Hamstring
muscle 104
Ankle
syndesmosis 96
ACL 108
Clavicle
fracture 95
Figure 11b: Ranking of the top five highest risk match injuries for each
season 2011-15 with the associated days absence/1000hours.
24
MCL 139
Summary of the most common and highest risk training injuries
The profile of the most common and highest risk training
injuries is very similar to that seen since 2002. Hamstring
muscle injuries (42 injuries) remained the most common
training injury throughout the study (Figure 12a). The only
change in 2014-15 was the introduction of lumbar facet joint
injuries into the top five most common training injuries
for the first time. Hamstring muscle, calf muscle and ACL
injuries were the highest risk training injuries (Figure 12b).
The most common training injuries
Figure 12a:
Training
2011-12
2012-13
2013-14
2014-15
Hamstring
muscle 0.42
Calf
muscle 0.24
Hip flexor/quad
muscle 0.11
Abductor
muscle 0.10
Hamstring
muscle 0.39
Calf
muscle 0.29
Abductor
muscle 0.18
Hamstring
muscle 0.40
Calf
muscle 0.22
Hip flexor/quad
muscle 0.18
Hamstring
muscle 0.30
Calf
muscle 0.26
Hip flexor/quad
muscle 0.12
Ankle lat. lig. 0.10
Ankle lat. lig. 0.13
Ankle lat. lig. 0.11
Hip flexor/quad
muscle 0.09
Abductor
muscle 0.09
Lumbar facet
joint 0.09
Ankle lat. lig. 0.09
The highest risk training injuries
Figure 12b:
Figure 12a: Ranking of the top five most common training injuries each
season 2011-15 with associated incidence rates.
2011-12
2012-13
2013-14
2014-15
Hamstring
muscle 7.3
Lumbar disc/
nerve root 6.5
Calf
muscle 3.4
Hamstring
muscle 9.5
Hamstring
muscle 8.2
Calf
muscle 4.5
Lumbar disc/
nerve root 3.9
Hamstring
muscle 7.2
Calf
muscle 6.3
Ankle lat. lig. 2.1
Ti/Fib fracture 2.1
ACL 6.3
Lumbar disc/
nerve root 5.3
Calf
muscle 4.9
Lumbar soft
tissue 4.5
Ankle lat. lig. 2.4
Shoulder
dislocation 1.9
ACL 5.3
Lumbar disc/
nerve root 5.0
Ankle lat. lig. 4.6
Figure 12b: Ranking of the top five highest risk training injuries each season
2011-15 with associated days absence/1000hours.
25
OTHER PROJECTS
Return to play from concussion
During the 2012-13 and 2013-14 seasons, the Rugby Football Union and Premiership Rugby undertook a study of 810 Premiership
players in order to explore the short and medium term clinical outcomes and subsequent injury risk following return to play from
concussion (Click here). The key findings and practical recommendations are summarised below:
•
In agreement with recent findings in other sports, this study found that players were at an increased risk of injury
following return to play from concussion. In this study, there was a 60% increase in the risk of sustaining an injury
(of any type) after returning from concussion compared with those players who had not reported a concussion but
other injuries (Figure 13).
•
Thirty-eight percent of players reported a recurrence of symptoms or failed to match their baseline neurocognitive
(CogState Sport) test during their graduated return to play protocol (specifically during stages 2-6 of that
protocol).
•
The majority (~90%) of players that had reportable data in the study were managed in accordance with current
best-practice guidelines.
•
Return to play after concussion is not straightforward. Whether the process can be improved with specialist
support (e.g. neurological, vestibular or psychological) remains unclear.
•
More conservative return-to-play protocols with a greater focus on active rehabilitation of the systems likely
impacted by a concussive injury (including vestibular and autonomic) may prove helpful – this study was not
designed to answer this question.
Figure 13:
160
Incidence/1000 hours
140
HR = 1.6
*
120
100
HR = 1.1
80
60
40
20
0
Not Concussed
Concussed - Pre
Concussed - Post
Figure 13: Match incidence rates in players with a diagnosed concussion (pre and post incidence
rates shown) and those that did not have a diagnosed concussion. Hazard ratios (HR) were used to
determine effect size. * Shows significant difference versus the non-concussed group.
26
Training load and injury risk
The risk of injury during training is a function of the content/activity, training duration (volume) and also training intensity.
Previously, the intensity of training has not been reported by the injury surveillance project however, in order to fully understand
the risk of injury during training, training load (a product of volume and intensity) is clearly an important measure to consider.
During 2013-14, four clubs participated in a study in order to explore the association between training load measures and
injury risk in professional Rugby Union. Each player was asked to report their RPE (using the modified Borg CR 10 RPE Rate
of Perceived Exertion scale) for each session confidentially to the strength and conditioning coach without knowledge of other
players’ ratings. Session RPE in arbitrary units (AU) for each player was then derived by multiplying RPE and session duration/
volume (min). The key findings that can be made from the 2013-14 data are presented below:
•
Players had an increased risk of injury if they had high one-week cumulative loads or large week-to-week changes
in load.
•
A ‘U-shaped’ relationship was observed for four-week cumulative loads, with an apparent increase in risk
associated with higher loads (>8651 AU) and a reduction in risk with higher intermediate loads (5932 to 8651 AU).
•
Team coaches should monitor a player’s weekly load, week-to-week changes in load and four-week cumulative
load, when planning and implementing training to optimise performance whilst minimising injury risk.
•
Given that these findings suggest that a high weekly load and a large absolute change in load increase the risk
of injury in professional Rugby Union players, trying to periodise training schedules with alternating heavy and
light training weeks is not recommended (as opposed to alternating heavy and light days which requires further
investigation). One way that this may be achieved in practice is for coaches to prescribe stable and consistent
weekly loads throughout the season in order to prevent any spikes in acute workload.
•
Professional players may have a four-week cumulative training load limit, and that exceeding this threshold is
associated with a substantial increase in injury risk. These findings should provide a starting point for planning
and monitoring individual player training thresholds.
NB: From 2015-16 onwards, this study has been expanded to include data collection for all 12 Premiership clubs. It is therefore
anticipated that more detailed findings regarding the training load-injury relationship in the English Premiership will be
presented in future PRISP annual reports.
27
ENGLAND SENIOR SIDE
Summary of England match and training injury risk
No statistically significant change in injury risk (match or training) was seen for 2014-15 when compared with previous seasons
for players on England senior squad duty (Tables 3 and 4). The average severity of match (23 days) and training injuries (rugby
skills; 25 days, strength and conditioning; 2 days) remained stable during 2014-15 (Tables 3 and 4). It is important to note that
this report includes injuries sustained during the period 1st June 2014 to 31st May 2015. Therefore, injuries sustained during
the Rugby World Cup are not included and will be included in next season’s report.
NB: The relatively small number of senior England training sessions included in the study each season means that the training
injury risk for England should be interpreted with caution. The small sample size means that any differences in risk are much
more likely to have arisen “by chance” rather than to be the result of a “true” difference, reflected in the wide 95% confidence
intervals and the lack of statistical significance in the results.
Match
Table 3:
SEASON
TOTAL
NUMBER OF
INJURIES
INJURIES/1000
HOURS
INJURIES PER
MATCH
AVERAGE
SEVERITY
DAYS
ABSENCE/1000
HOURS
DAYS
ABSENCE
PER MATCH
2002-03
53
221 (169-289)
4.4
19
4264 (4010-4533)
85
2003-04
83
207 (167-256)
4.1
11
2371 (2225-2527)
47
2005-06
30
136 (95-195)
2.7
10
1391 (1243-1556)
28
2006-07
30
136 (95-195)
2.7
28
3836 (3586-4104)
77
2007-08
55
162 (119-205)
3.2
24
3876 (2852-4901)
78
2008-09
23
96 (57-135)
1.9
8
813 (480-1145)
16
2009-10
23
88 (52-125)
1.8
19
1712 (1012-2411)
34
2010-11
14
78 (37-119)
1.5
23
1789 (852-2726)
36
2011-12
16
62 (31-92)
1.2
29
1754 (894-2613)
35
2012-13
31
111 (78-158)
2.2
24
2618 (1841-3722)
52
2013-14
19
86 (55-135)
1.7
20
1509 (963-2366)
34
2014-15
27
113 (78-164)
2.3
23
2604 (1786-3797)
52
Table 3: England match injury incidence, average severity and risk since
2002-03 (95% confidence intervals shown in brackets where appropriate).
28
Training
Table 4:
DAYS
INJURIES/1000
ABSENCE/1000
HOURS
HOURS
AVERAGE
SEVERITY
DAYS
ABSENCE/1000
HOURS
4.0 (1.0-15.9)
4
16 (8-32)
89 (80-99)
6.3 (3.8-10.3)
13
79 (68-90)
4
2 (1-6)
-
-
-
9.8 (5.9-16.3)
15
149 (131-169)
-
-
-
2007-08
7.3 (4.5-10.1)
9
74 (46-103)
2.5 (0.5-4.6)
12
34 (7-61)
2008-09
6.5 (3.0-10.0)
20
135 (62-209)
12.1 (4.2-20.0)
18
233 (81-385)
2009-10
5.3 (3.4-8.3)
8
46 (30-73)
4.0 (2.0-8.6)
6
26 (12-55)
2010-11
1.7 (0.8-3.5)
7
12 (6-26)
4.4 (1.8-10.5)
5
22 (9-53)
2011-12
3.2 (1.4-5.1)
22
70 (31-110)
2.8 (0.4-5.3)
18
51 (6-95)
2012-13
3.7 (1.6-9.0)
20
58 (24-139)
1.1 (0.2-7.8)
9
10 (1-71)
2013-14
7.9 (4.7-13.3)
11
87 (52-147)
3.9 (1.3-12.1)
14
57 (18-177)
2014-15
3.3 (1.6-6.9)
25
85 (50-145)
2.3 (0.6-9.2)
2
3 (1-80)
SEASON
INJURIES/1000
HOURS
AVERAGE
SEVERITY
2002-03
4.5 (2.6-8.0)
15
69 (60-80)
2003-04
7.6 (5.3-11.0)
12
2005-06
0.6 (0.1-4.0)
2006-07
Table 4: England training injury incidence, average severity and risk since
2002-03 (95% confidence intervals shown in brackets where appropriate).
UED
N
I
T
N
O
C
A
S
A
W
THERE
OF
D
O
O
IH
L
E
K
I
L
E
H
DECREASMEATICNHTINJURIES RECURRING,
F
A LIKELY CONSEQUENCE OLUB MEDICAL
THE EFFECTIVENESS OF C G TEAMS.
AND CONDITIONIN
“
”
29
RFU INJURY SURVEILLANCE PROJECT METHODS
Written informed consent was obtained from 577 registered Premiership squad players for the 2014-15 season, there were three
players that formally refused consent. A total of 410 team games were included in the analyses for the 2014-2015 season.
Injuries from consented first team squad (including academy players that trained regularly with the first team) players sustained
in training and in all matches in the Aviva Premiership, LV Cup and European Competitions (Champions and Challenge Cup)
were included. Injuries sustained while players represented England were reported and analysed separately.
Match and training injury data, and training exposure data, were provided by all 12 Premiership clubs in 2014-2015. A complete
set of data were collected from all 12 Premiership clubs and the England senior side.
Medical personnel at each Premiership club and the England senior team reported the details of injuries and illnesses sustained
by a player at their club/team that were included in the study group together with the details of the associated injury event using
an online medical record keeping system. Strength and conditioning staff recorded the squad’s weekly training schedules and
exposure on a password protected online system. Team match days were also recorded by strength and conditioning staff.
Injury and illness diagnoses were recorded using the Orchard Sports Injury Classification System (OSICS) version 10.1. This
sports specific injury classification system allows detailed diagnoses to be reported and injuries to be grouped by body part and
injury pathology.
The definitions and data collection methods utilised in this study are aligned with the IRB (now World Rugby) Consensus
statement on injury definitions and data collection procedures for studies of injuries in Rugby Union.
30
CURRENT PUBLICATIONS & PRESENTATIONS
Further detailed information on injury risk in this cohort of players can be obtained from the following peer reviewed publications
that have been produced as part of the Premiership injury surveillance project.
Publications
RJ Dallana, JHM Brooks, SPT Kemp & AW Williams. The epidemiology
of knee injuries in English professional rugby union. American Journal of
Sports Medicine, May 2007; 35: 818 – 830.
MJ Cross, G Trewartha, A Smith, SPT Kemp & KA Stokes. Professional
Rugby Union players have a 60% greater risk of time loss injury after
concussion: a 2-season prospective study of clinical outcomes, 2015. British
Journal of Sports Medicine pp.bjsports-2015.
CW Fuller, JHM Brooks & SPT Kemp. Spinal injuries in professional rugby
union: a prospective cohort study. Clinical Journal of Sport Medicine, 2007;
17 (1): 10-16.
MJ Cross, S Williams, G Trewartha, SPT Kemp & KA Stokes. The influence
of in-season training loads on injury risk in professional rugby union, 2015.
International Journal of Sports Physiology and Performance.
JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. Incidence, risk and
prevention of hamstring muscle injuries in professional rugby union.
American Journal of Sports Medicine, 2006; 34: 1297-1307.
S Williams, G Trewartha, SPT Kemp, JHM Brooks, CW Fuller, AE Taylor,
MJ Cross & KA Stokes. Time-loss injuries compromise team success in elite
Rugby Union: A 7-year prospective study, 2015. British Journal of Sports
Medicine bjsports-2015.
JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. Epidemiology of injuries
in English professional rugby union: part 1 match injuries. British Journal of
Sports Medicine, Oct 2005; 39: 757 - 766.
CW Fuller, AE Taylor & M Raftery. Epidemiology of concussion in men's
elite Rugby-7s (Sevens World Series) and Rugby-15s (Rugby World Cup,
Junior World Championship and Rugby Trophy, Pacific Nations Cup and
English Premiership). British Journal of Sports Medicine 2014; 10.1136/
bjsports-2013-093381.
JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. Epidemiology of injuries
in English professional rugby union: part 2 training injuries. British Journal
of Sports Medicine, Oct 2005; 39: 767 – 775.
JHM Brooks, CW Fuller, SPT Kemp & DB Reddin A prospective study of
injuries and training amongst the England 2003 Rugby World Cup squad
British Journal of Sports Medicine, May 2005; 39: 288 – 293.
AE Taylor, SPT Kemp, G Trewartha & KA Stokes. Scrum injury risk in
English professional rugby union. British Journal of Sports Medicine 2014;
48(13) 1066-1068.
Abstracts/Presentations
S Williams, G Trewartha, SPT Kemp & KA Stokes. A meta-analysis of injuries
in senior men's professional rugby union. Sports Medicine 2013; 43(10) 10431055.
MJ Cross, SPT Kemp, A Smith, G Trewartha & KA Stokes. Injury risk after
returning from concussion in elite Rugby Union players. Presented at: The
8th World Congress on Science and Football, Copenhagen, 2015.
CW Fuller, AE Taylor JHM Brooks & SPT Kemp Changes in the stature,
body mass and age of English professional rugby players: A 10-year review,
Journal of Sports Sciences 2012 DOI:10.1080/02640414.2012.753156.
S Williams, G Trewartha, SPT Kemp, JHM Brooks, CW Fuller, A Taylor, MJ
Cross, & KA Stokes. Association between injuries and team success in elite
Rugby Union. Presented at: The World Congress on Science and Football,
Copenhagen, 2015.
SC Cheng, ZK Sivardeen, WA Wallace, D Buchanan, D Hulse, KJ Fairbairn,
SP Kemp & JH Brooks. Shoulder instability in professional rugby players-the
significance of shoulder laxity. Clinical Journal of Sports Medicine 2012 Sep;
22(5):397-402.
JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. The Incidence, Severity
and Nature of Injuries Caused by Tackling in Professional Rugby Union
Competition. Presented (poster) at The American College of Sports
Medicine Annual Meeting, 1st June 2006. Published in: Medicine and Science
in Sports and Exercise 2006: 38(5) S351-352.
CJ Pearce, JHM Brooks, SP Kemp & JD Calder. The epidemiology of foot
injuries in professional rugby union players Foot & Ankle Surgery. 2011 Sep;
17(3):113-8. Epub 2010 Mar 5.
JHM Brooks, CW Fuller, SPT Kemp. The Incidence, Severity and Nature
of Groin Injuries in Professional Rugby Union. Presented at The American
College of Sports Medicine Annual Meeting, 1st June 2006. Published in:
Medicine and Science in Sports and Exercise 2006: 38(5) S351.
JHM Brooks & SPT Kemp Injury prevention priorities according to playing
position in professional rugby union players. British Journal of Sports
Medicine 2011 Aug;45(10):765-75. Epub 2010 May 19.
RA Sankey, JHM Brooks, SPT Kemp & FS Haddad The epidemiology of
ankle injuries in professional rugby union players. American Journal of
Sports Medicine Dec 2008; 36:2415-2424.
JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. The incidence, severity
and nature of injuries caused by being tackled in professional rugby union.
Presented (oral) at The Faculty of Sports and Exercise Medicine, Royal
College of Physicians Ireland (RCPI) and Royal College of Surgeons, Ireland
(RCSI) Annual Scientific Meeting, Dublin, 5th September 2005.
CW Fuller, T Ashton, JHM Brooks, RJ Cancea, J Hall, & SPT Kemp Injury
risks associated with tackling in rugby union. British Journal of Sports
Medicine 2010; 44(3): 159-167.
JHM Brooks, CW Fuller, SPT Kemp. The incidence, severity, and nature of
scrummaging injuries in professional rugby union. Presented (poster) at
1st World Congress of Sports Injury Prevention, Oslo, Norway 23rd-25th June
2005. Published in: Br J Sports Med 39: 377.
JHM Brooks, CW Fuller, SPT Kemp & DB Reddin An assessment of training
volume in professional rugby union and its impact on the incidence, severity
and nature of match and training injuries. Journal of Sports Sciences 2008
26:8, 863-873.
SPT Kemp, Z Hudson, JHM Brooks & CW Fuller. The epidemiology of head
injuries in English professional rugby union. Clinical Journal of Sports
Medicine 2008; 18:227-234.
CW Fuller, JHM Brooks, RJ Cancea, J Hall, & SPT Kemp Contact events in
rugby union and their propensity to cause injury. British Journal of Sports
Medicine, Dec 2007; 41: 862 - 867.
J Headey, JHM Brooks & SPT Kemp. The epidemiology of shoulder injuries
in English professional rugby union. American Journal of Sports Medicine,
Sep 2007; 35: 1537 - 1543.
31
SUPPLEMENTARY DATA
Table S1:
Match
SEASON
TOTAL NUMBER
OF MATCH
INJURIES
INJURIES/
1000 HRS
(95% CI)
INJURIES PER
CLUB PER
MATCH
AVERAGE
SEVERITY
(DAYS) (95%CI)
DAYS ABSENCE DAYS ABSENCE
/1000 HRS
PER CLUB PER
(95% CI)
MATCH
2002-03
748
100 (92-107)
2.0
16 (15-17)
1556 (1444-1667)
31
2003-04
653
88 (82-95)
1.8
20 (19-22)
1773 (1637-1909)
35
2005-06
482
75 (68-82)
1.5
21 (19-23)
1591 (1449-1733)
32
2006-07
755
90 (84-97)
1.8
21 (20-23)
1879 (1745-2013)
38
2007-08
660
83 (77-89)
1.7
19 (18-21)
1613 (1490-1736)
32
2008-09
769
100 (93-107)
2.0
23 (21-25)
2285 (2123-2446)
46
2009-10
636
80 (73-86)
1.6
22 (20-24)
1722 (1588-1856)
34
2010-11
746
93 (86-99)
1.9
21 (20-23)
1917 (1779-2054)
38
2011-12
655
82 (76-88)
1.6
27 (25-29)
2222 (2052-2392)
44
2012-13
588
73 (67-79)
1.5
25 (23-27)
1784 (1645-1936)
35
2013-14
739
91 (85-98)
1.8
26 (24-28)
2247 (2091-2415)
46
2014-15
645
79 (73-85)
1.6
29 (27-31)
2369 (2193-2560)
47
Table S1: Match injury incidence, severity and risk 2002-15.
Training
Table S2:
RUGBY SKILLS
STRENGTH AND CONDITIONING
SEASON
TOTAL
NUMBER OF
TRAINING
INJURIES
INJURIES
/1000 HRS
(95% CI)
AVERAGE
SEVERITY
(DAYS)
DAYS ABSENCE
/1000 HRS
(95% CI)
INJURIES
/1000 HRS
(95% CI)
AVERAGE
SEVERITY
(DAYS)
DAYS ABSENCE
/1000 HRS
(95% CI)
2002-03
159
3.3 (2.7-4.0)
28
93 (90-97)
2.3 (1.7-3.0)
13
29 (27-31)
2003-04
217
1.7 (1.4-2.0)
26
44 (42-45)
1.3 (1.1-1.6)
17
23 (22-24)
2005-06
203
2.2 (1.9-2.6)
22
49 (47-51)
1.5 (1.2-1.9)
16
24 (22-25)
2006-07
209
2.1 (1.7-2.5)
18
37 (35-38)
1.6 (1.3-2.0)
16
25 (24-27)
2007-08
318
3.2 (2.7-3.7)
19
60 (51-68)
2.7 (2.2-3.1)
15
44 (36-52)
2008-09
258
2.5 (2.1-2.9)
26
63 (53-73)
2.4 (2.0-2.9)
17
41 (34-49)
2009-10
298
2.8 (2.4-3.2)
21
59 (50-67)
2.1 (1.7-2.4)
18
37 (30-43)
2010-11
340
3.1 (2.7-3.5)
25
76 (66-87)
2.6 (2.1-3.0)
17
41 (34-48)
2011-12
323
2.7 (2.4-3.1)
26
68 (59-78)
2.2 (1.8-2.6)
18
39 (32-46)
2012-13
335
3.2 (2.9-3.6)
33
106 (93-121)
2.0 (1.7-2.4)
24
49 (41-60)
2013-14
414
3.1 (2.7-3.5)
27
84 (75-95)
2.1 (1.7-2.4)
20
40 (34-47)
2014-15
325
2.7 (2.4-3.1)
29
71 (61-82)
1.9 (1.6-2.3)
23
44 (38-51)
Table S2: Training injury incidence, severity and risk since 2002-15.
32
Match
Table S3:
NEW INJURIES
RECURRENT INJURIES
SEASON
INJURIES
/1000 HRS
AVERAGE
SEVERITY
(DAYS)
DAYS ABSENCE
/1000 HRS
INJURIES
/1000 HRS
AVERAGE
SEVERITY
(DAYS)
DAYS ABSENCE
/1000 HRS
2002-03
79
14
1084
19
23
438
2003-04
72
18
1333
13
33
435
2005-06
67
20
1372
10
29
279
2006-07
76
21
1574
8
33
261
2007-08
74
19
1444
9
20
169
2008-09
85
21
1800
14
34
485
2009-10
72
21
1515
8
29
207
2010-11
87
21
1776
6
25
141
2011-12
77
27
2106
5
23
116
2012-13
68
25
1659
5
26
125
2013-14
87
25
2157
4
25
90
2014-15
78
29
2300
3
31
69
Table S3: New vs. recurrent match injury incidence, severity and risk 2002-15.
Training
Table S4:
NEW INJURIES
RECURRENT INJURIES
SEASON
INJURIES
/1000 HRS
AVERAGE
SEVERITY
(DAYS)
DAYS ABSENCE
/1000 HRS
INJURIES
/1000 HRS
AVERAGE
SEVERITY
(DAYS)
DAYS ABSENCE
/1000 HRS
2002-03
2.5
21
54
0.5
34
16
2003-04
1.3
21
27
0.3
36
12
2005-06
1.8
19
35
0.4
21
8
2006-07
1.7
17
30
0.2
15
3
2007-08
2.3
17
39
0.5
23
11
2008-09
2.0
21
41
0.4
27
11
2009-10
2.2
20
44
0.2
21
4
2010-11
2.7
20
53
0.1
58
8
2011-12
2.2
22
49
0.1
46
4
2012-13
2.6
29
69
0.1
33
4
2013-14
2.8
25
70
0.1
25
4
2014-15
2.2
28
61
0.1
33
3
Table S4: New vs. recurrent training injury incidence, severity and risk 2002-15.
33
Table S5:
DIAGNOSIS
NUMBER OF INJURIES
AVERAGE SEVERITY
(DAYS)
Hamstring muscle injury
3
40
Soleus muscle injury
3
49
Quadriceps muscle injury
3
16
Ankle syndesmosis
2
71
Figure S5: The four most common match injury recurrences during 2014-15.
Table S6:
160
140
Incidence/1000 hours
120
100
80
60
40
20
0
pt
Se
r
be
em
er
Oc
b
to
r
r
be
be
m
m
e
e
c
v
De
No
ry
a
nu
Ja
2002-2014
ry
b
Fe
a
ru
ch
ar
M
ril
Ap
ay
M
2014-2015
Figure S6: Incidence rates of match injuries by month of the season. Error bars show 95% CI’s.
34
Table S7:
SEASON
INCIDENCE/1000 HOURS
DAYS ABSENCE/1000 HOURS
2002-03
0.45
6.4
2003-04
0.21
4.2
2005-06
0.36
4.6
2006-07
0.32
5.1
2007-08
0.59
9.5
2008-09
0.36
5.0
2009-10
0.38
6.1
2010-11
0.45
6.9
2011-12
0.42
7.3
2012-13
0.39
9.5
2013-14
0.40
10.7
2014-15
0.30
7.2
Table S7: Hamstring training injury incidence and risk 2002-2015.
Table S8:
TRAINING (HOURS PER WEEK)
SEASON
RUGBY SKILLS
STRENGTH & CONDITIONING
TOTAL
2002-03
3.9
2.5
6.4
2003-04
5.0
3.7
8.7
2005-06
4.3
3.1
7.4
2006-07
4.1
3.1
7.2
2007-08
3.0
2.7
5.7
2008-09
3.2
2.6
5.8
2009-10
3.2
2.9
6.1
2010-11
3.1
2.8
5.9
2011-12
3.6
2.8
6.4
2012-13
3.1
2.7
5.9
2013-14
3.3
2.9
6.2
2014-15
3.4
2.6
6.0
Table S8: Average player training volume (hours) per week 2002-15.
35
Rugby Football Union. The RFU Rose and the words ‘England Rugby’ are official registered trade marks of the Rugby Football Union.