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Injury-prevention priorities according to playing position in professional rugby union players

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Abstract and Figures

To examine the match injury profile of professional rugby union players by individual playing position. 4-season prospective cohort design. 14 English Premiership clubs. 899 professional players. Incidence of match injury (recorded as the number of injuries/1000 player-hours of match exposure), severity of injury (recorded as the number of days of absence) and days of absence due to injury per 1000 player-hours of match exposure. Injury diagnosis and individual playing position during a match. 2484 injuries were reported. While there were no significant differences in the total days of absence as a result of injury between different positions in the forwards and the backs, there were a number of significant differences in injury profile for players in individual playing positions. Although three common body locations caused a high proportion of days of absence due to match injury for forwards (shoulder, knee, ankle/heel) and backs (shoulder, hamstring, knee), there were significant differences in injury profile between individual positions. The results clearly demonstrate the need for individual position-specific injury-prevention programmes in rugby union. When devising such programmes, a player's previous injury history should also be taken into account.
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Original article
Brooks JHM, Kemp SP T. Br J Sports Med (2010). doi:10.1136/bjsm.2009.066985 1 of 11
Rugby Football Union,
Twickenha m, U K
Correspondence to
Dr J H M Brooks, Rugby
Football Union, Rugby House,
Rugby Road, Twickenham TW1
1DS, UK ;
johnbrooks@rfu.com
Accepted 24 November 2009
Injury-prevention priorities according to playing
position in professional rugby union players
J H M Brooks, S P T Kemp
ABSTRACT
Objective To examine the match injury pro le of
professional rugby union players by individual playing
position.
Design 4-season prospective cohor t design.
Setting 14 English Premiership clubs.
Participants 899 professional players.
Main outcome measure Incidence of match injury
(recorded as the number of injuries/1000 player-hours
of match exposure), severity of injury (recorded as the
number of days of absence) and days of absence due to
injury per 1000 player-hours of match exposure.
Assessment of risk factors Injury diagnosis and
individual playing position during a match.
Results 2484 injuries were reported. While there
were no signi cant dif ferences in the total days of
absence as a result of injury between different positions
in the forwards and the backs, there were a number
of signifi cant differences in injury profi le for players in
individual playing positions. Although three common
body locations caused a high proportion of days of
absence due to match injury for forwards (shoulder,
knee, ankle/heel) and backs (shoulder, hamstring,
knee), there were signifi cant differences in injury profi le
between individual positions.
Conclusions The results clearly demonstrate the
need for individual position-speci c injury-prevention
programmes in rugby union. When devising such
programmes, a player’s previous injury history should
also be taken into account.
INTRODUCTION
The incidence of injury in professional rugby
union is high in comparison with many other
sports;1 furthermore, the total absence from
playing and training due to these injuries is also
high.1 Reducing this injury burden should be a
central focus for rugby union medical, coach-
ing and conditioning teams; however, time and
training constraints2 typically limit the scope of
injur y-prevention interventions. To counter this,
it is important to focus on injury-prevention pro-
grammes that are most likely to have the great-
est impact on reducing the injuries that cause the
most days of absence .3 4
Playing position is an easily identi able, albeit
non-modifi able, risk factor that can be used to
shape injury-prevention programmes based on
differences in injury profi le by position. Casual
observations as far back as the early 20th cen-
tury highlighted positional differences in injury
profi les.5 These were confi rmed in subsequent
publications,6–8 although there was no statistical
analysis of the results, and the number of injuries
reported in t hese studie s was relatively smal l. Law
modifi cations and the introduction of profession-
alism have signifi cantly changed the nature of
the modern game of rugby union,9 making these
studies less applicable. More recently, studies of
injuries to individual body parts in professional
rugby union have suggested some positional dif-
ferences in injury risk.10–15 However, to optimise
statistical power, these studies have commonly
grouped positions together, such as the front-row
forwards, even though it is recognised that indi-
vidual positions within these positional groups
have subtly different playing roles, are likely to
experience different loads and forces through dif-
ferent parts of their bodies during a match and, as
a result, may exhibit different injury profi les. A n
example of a variation in load is the difference in
the loads absorbed and transmitted by each of the
front-row positions during a scrum.16
Investigation of the injury profi le of players in
individual positions has not been undertaken in
any detail. The purpose of the current study was
to present match injury profi le data as a function
of days of absence and playing position compared
with other forwards or backs.
METHODS
Participants
The study has been described in detail previous-
ly.17 In summary, 899 players (488 forwards and
411 backs) from 14 English Premiership clubs took
part. Players were included or excluded from the
st udy when they bec ame or c eased to be member s
of the club’s fi rst team squad. The average team
squad size was 39 players. Written informed con-
sent was obtained from each subject.
Injury defi nition
The injury defi nition used in the study was: ‘any
injury that prevents a player from taking a full
part in all training and match play activities typ-
ically planned for that day for a period of greater
than 24 h from midnight at the end of the day the
injur y was sustained.’ Injury severity was defi ned
by the number of days of absence before a player
returned to full fi tness; full tness was defi ned as
‘able to take a full part in training activities (typi-
cally planned for that day) and available for match
selection.’ Absences due to illness and non-sport-
related medical conditions were not included in
the study. The injury defi nitions and data-collec-
tion methods utilised in this study are compliant
with the institutional review board consensus
statement on injury defi nitions and data collec-
tion procedures for studies of injuries in rugby
union.18
bjsports66985.indd 1bjsports66985.indd 1 5/10/2010 11:31:57 AM5/10/2010 11:31:57 AM
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(loose-head props: 2952; hookers: 3689; tight-head props:
3254; second-rows: 5916; blind-side fl ankers: 2652; open-side
ankers: 3471; number-8s: 3335) and 21 345 days of absence
to backs (scrum-halves: 3117; fl y-halves: 3017; centres: 6558;
wingers: 5963; full-backs: 2690). In total there were 30 267
h of match exposure reported (forwards: 16 103 h; backs:
14 164 h). There were no signi cant differences in total days
of absence/1000 player-hours due to injury between players
in different positions within the forwards (fi gure 1) and the
backs (fi gure 2).
Loose-head prop’s injury profi le
Absence due to neck injuries was higher for loose-head props
(161 days of absence/1000 player-hours) (p=0.13) because of a
signi cant ly higher absenc e f rom cer vical disc/ner ve root inju-
ries (fi gure 3). The majority of these injuries were sustained
during tackling (57%) and scrummaging (29%). There was
also a signifi cantly higher absence due to shoulder rotator cuff
injuries (scrummaging: 66% (75% of these to the right shoul-
der)) and a signifi cantly higher absence due to chest injuries
(p=0.03) due to a signifi cantly higher absence due to rib frac-
tures and contusions and pneumothoraces.
Hooker’s injury profi le
Absence due to shoulder injuries was signifi cantly higher for
hookers (p=0.01) because of a signifi cantly greater absence
from rotator cuff injuries ( gure 4) (tackling: 57%). Absence
due to neck injuries was higher (p= 0.24) because of a signifi -
cantly greater absence due to cervical disc/nerve root injuries.
The majority of these were sustained during tackling (38%),
collisions (25%) and scrummaging (19%).
Tight-head prop’s injury profi le
Absence due to lumbar spine injuries (p<0.001) because of a
signi cantly greater absence from lumbar disc/nerve root
and soft tissue injuries and absence due to lower leg injuries
(p<0.001) because of a signifi cantly greater absence due to calf
muscle injuries were both signi cantly higher for tight-head
props (fi gure 5). Calf-muscle injuries were predominately sus-
tained during scrummaging (54%) and running (33%), lumbar
Data collection
Medical personnel at each club reported all match injur y epi-
sodes on a weekly basis. They also completed a standard injur y
report form for each injury which detailed the injury diagnosis
using a modifi ed Orc hard Sports I njur y Clas sifi cation System19
and associated injury information including injury event and
playing position at the time of injury. Individual player match
exposure data were recorded every week for each player; this
identi ed the position played and the total time on the fi eld in
competitive matches.
Data analysis
Seven forward playing positions (loose-head prop, hooker,
tight-head prop, second-rows (2), blind-side fl anker, open-side
anker and number-8) and fi ve back positions (scrum-half, fl y-
half, centres (2), wingers (2) and full-back) were used for analy-
sis purposes. Results for each playing position were compared
with data for the remaining forwards or backs. The incidence
of match injury was recorded as the number of injuries/1000
player-hours of match exposure, the average severity of injury
was recorded as the number of days of absence, and the days of
absence due to injur y were recorded as the t otal number of days
of absence/1000 player-hours of match exposure. Differences
in the days of absence due to match injuries between groups
were considered signi cant if the 95% CI of the days of
absence risk ratios for the groups did not include the value of
1.0, and the p value (Z test for the comparison of rates) was less
than 0.05.20 Injury locations causing more than 150 days of
absence/1000 player-hours were classifi ed as injury-prevention
priorities because, in total, they were responsible for 50% or
more of the total days of absence due to match injuries (for-
wards: 50%; backs: 54%).
RESULTS
Number of injuries and days of absence
A total of 1307 injuries to forwards (loose-head props: 157;
hookers: 192; tight-head props: 189; second-rows: 306; blind-
side fl ankers: 150; open-side fl ankers: 153; number-8s: 160)
and 1177 injuries to backs (scrum-halves: 143; fl y-halves: 198;
centres: 356; wingers: 320; full-backs: 160) were reported.
These injuries caused 25 269 days of absence to forwards
0
01
02
03
051001050
(
1000 hours
)ecnedicnI
Average severity (days)
rekooH reknalfedis-nepO 8-rebmuN porpdaeh-thgiT porpdaeh-esooL wordnoceS reknalfedis-dnilB sdrawrofllA
9651
)50.0=p(2531
)11.0=p(9441
)94.0=p(0941
)98.0=p(5851
)43.0=p(3861
)51.0=p(9471
)50.0=p(2971
/1000 hourssbasyaD
)sdrawrofrehtootecnereffid(
Figure 1 Incidence, average severit y and days of absence due to injury for forwards. Bubble size: days of absence/1000 player-hours.
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disc/nerve root injuries and lumbar soft tissue injuries during
scrummaging (67% and 57% respectively).
Second-row’s injury profi le
Absence due to ank le/heel injuries (p=0.14) was higher in sec-
ond-row forwards because of a signifi cantly greater absence
due to ankle lateral ligament injuries (fi gure 6 ). A higher pro-
portion of these injuries were sustained in t he lineout (21%)
compared with other forwards.
Blind-side fl anker’s injury pro le
Absence due to thigh injuries was signifi cantly higher in
blind-side fl ankers (p=0.04) because of a greater absence due
to hamstring muscle injuries (predominately sustained during
running: 86%) (fi gure 7).
Open-side fl anker’s injury profi le
Absence due to neck injuries (p=0.01) was signifi cantly
higher for open-side fl ankers (sustained predominately in
the tackle: 63%) because of a signifi cantly greater absence
due to cervical facet joint injuries (fi gure 8). Absence due to
shoulder injuries (p=0.11) because of a signi cantly greater
absence due to acromio-clavicular joint injuries and absence
due to ankle/heel injuries (p=0.06) because of a signifi cantly
greater absence due to ankle joint capsule sprains/jars were
also higher.
Number-8’s injury profi le
Absence due to arm and hand injuries was signi cantly higher
in number-8s (p<0.001) because of a sign ifi cantly greater
absence due to biceps muscle injuries and wrist /hand fractures
(fi gure 9). Absence due to knee injuries (p=0.16) because of a
signi cantly greater absence due to patella tendon injuries was
also higher.
Scrum-half’s injury profi le
Absence due to lumbar spine injuries was sign ifi cantly
higher in scrum-halves (p<0.001) because of a signi cantly
greater absence from lumbar disc/nerve root and soft tissue
(including muscle strain) injuries ( gure 10). Absence due to
0
01
02
03
051001050
1000/hours)(ecnedicnI
Average severity (days)
sertneC flah-murcS flah-ylF sregniW kcab-lluF skcabllA
7051
)90.0=p(0331
)26.0=p(2741
)67.0=p(7741
)28.0=p(4351
)70.0=p(4361
/1000 hours (difference tosbasyaD )skcabrehto
Figure 2 Incidence, average severit y and days of absence due to injury for backs. Bubble size: days of absence/1000 player-hours.
0 100 200 300 400 500
Head
Neck
Should er
Arm and hand
Ches t
Abdomen and thoracic spine
Lumb ar s pin e
Groin/ hip/ buttock
Thigh
Knee
Lowe r leg
Ankle/ heel
Foot
Days absence (1000/hours)
Loose-head prop All oth er forward s
*
*
0.182.05 (0.72 to 5.83)49Inferior tib-fib syndesmosis
0.930.96 (0.40 to 2.30)69Achilles tendon
0.931.10 (0.15 to 8.04)65
Knee meniscal/ articula r
cartilage
0.870.85 (0.10 to 7.02)92Knee ACL
0.0516.98 (1.06 to 271)25Pneumothorax
0.013.51 (1.35 to 9.15)50Rib fracture/ contusion
0.210.40 (0.09 to 1.69)55
Shoulder dislocation/
instability
0.0043.76 (1.52 to 9.31)128Should er rotator cuff
0.190.53 (0.21 to 1.37)14Cervical facet joint
0.032.33 (1.07 to 5.09)196Cervical d isc/ nerve root
p (Z-test)
Risk ratio to other forwards (95%
CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locati ons with >150 days absence/1000 player-hours or in locations
where absence due to in jury was significantly greater than other forwards
Figure 3 Days of absence injury profi le for loose-head props. *Signifi cantly different from other forwards (p<0.05). ACL, anterior cruciate
ligament.
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0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Chest
Abdomen and thoracic spine
Lumb ar s pi ne
Groin/ hip/ buttock
Thigh
Knee
Lowe r le g
Ankle/ heel
Foot
Days abs en ce (1000/h ours)
Second-row All oth er forwards
*
*
*
0.0022.43 (1.39 to 4.24)62
Ankle lateral ligament
0.861.09 (0.43 to 2.73)76
Achilles tendon injury
0.770.91 (0.48 to 1.72)79Knee MCL
0.372.10 (0.41 to 10.85)176Knee ACL
p (Z-test)
Risk ratio to other forwards
(95% CI)
Days
absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000
player-hours or in locations where absence due to injury was significantly greater than
other forwards
Figure 6 Days of absence injury profi le for second-rows. *Signifi cantly different from other forwards (p<0.05). ACL, anterior cruciate ligament;
MCL, medial collateral ligament.
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Ches t
Abdomen and thoracic spine
Lumb ar s pin e
Groin/ hip/ buttock
Thigh
Knee
Lowe r le g
Ankle/ heel
Foot
Days absence (1000/hours)
Tight-head prop All ot her forward s
*
*
*
*
*
0.921.08 (0.25 to 4.58)76
Achilles tendon
0.001254 (15.92 to 406)91
Ankle instability
0.050.31 (0.10 to 1.00)6
Calf/ shin haematoma
<0.0015.85 (3.64 to 9.40)297
Calf muscle
0.520.73 (0.28 to 1.89)45
Knee meniscal/ articular
cartilage
0.880.85 (0.10 to 7.03)93Knee ACL
<0.00111.08 (4.13 to 29.75)33
Lumbar soft tissue
0.042.86 (1.06 to 7.02)56
Lumbar disc/ nerve root
0.331.57 (0.63 to 3.88)67Shoulder rotator cuff
0.371.93 (0.46 to 8.16)221
Shoulder dislocation/
instability
p (Z-test)
Risk ratio to other forwards
(95% CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player -hours or
in locations where absence due to injury was significantly greater than other forwards
Figure 5 Days of absence injury profi le for tight-head props. *Signi cantly different from other forwards (p<0.05). ACL, anterior cruciate
ligament.
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Ches t
Abdomen and thoracic spine
Lumb ar s pin e
Groin/ hip/ buttock
Thigh
Knee
Lowe r le g
Ankle/ heel
Foot
Days abs enc e (1000/h ours)
Hooker A ll othe r forwards
*
*
0.080.40 (014 to 1.10)15
Ankle lat eral ligament
0.211.87 (0.70 to 4.99)120
Achilles tendon
0.092.25 (0.89 to 5.72)34
Calf/ shin haemat oma
0.151.50 (0.87 to 2.50)116
Calf muscle
0.831.25 (0.15 to 10.41)130Knee ACL
0.013.08 (1.26 to 7.50)146
Knee meniscal/ articular
cartilage
0.0033.75 (1.59 to 8.87)127Shoulder rotator cuff
0.981.01 (0.38 to 2.67)129Shoulder dislocation/ instability
0.230.53 (0.19 to 1.50)14Cervical facet joint
0.021.99 (1.14 to 3.49)173Cervical disc/ nerve root
p (Z-test)Risk ratio to other forwards (95% CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player- hours or in locations
where absence due to injury was significantly greater than other forwards
Figure 4 Days of absence injury profi le for hookers. *Signi cantly different from other forwards (p<0.05). ACL, anterior cruciate ligament.
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Brooks JHM, Kemp SP T. Br J Sports Med (2010). doi:10.1136/bjsm.2009.066985 5 of 11
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Ches t
Abdomen and thoracic spine
Lumb ar s pin e
Groin/ hip/ buttock
Thigh
Knee
Lowe r le g
Ankle/ heel
Foot
Days abs enc e (1000/h ours)
Open-side flanker A ll other fo rwards
*
*
*
<0.00113.25 (3.65 to 48.14)75
Ankle joint sprain/ jar
0.701.49 (0.20 to 10.98)100
Achilles tendon
0.940.93 (0.11 to 7.70)100Knee ACL
0.141.82 (0.82 to 4.05)140Knee MCL
0.0013.89 (1.80 to 8.40)136Acromioclavicular joint
0.701.23 (0.43 to 3.56)153
Shoulder dislocation/
instability
0.450.80 (0.45 to 1.82)81Cervical disc/ nerve root
<0.0018.53 (3.76 to 19.37)106Cervical facet joint
p (Z-test)
Risk ratio to other forwards
(95% CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player-hours or
in locations where absence due to injury was significantly greater than other forwards
Figure 8 Days of absence injury profi le for open-side fl ankers. *Signifi cantly dif ferent from other forwards (p<0.05). ACL, anterior cruciate
ligament; MCL, medial collateral ligament.
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Ches t
Abdomen and thoracic spine
Lumb ar s pin e
Groin/ hip/ buttock
Thigh
Knee
Lowe r le g
Ankle/ heel
Foot
Days absence (1000/hours)
Blind-side flanker All oth er forward s
*
*
*
*
0.472.13 (0.27 to 16.65)59
Patella tendon
0.067.32 (0.94 to 56.69)68
Knee haematoma
0.631.18 (0.61 to 2.26)35Th igh haematoma
0.092.03 (0.90 to 4.55)99Ha mstring muscle
0.240.50 (0.15 to 1.61)136Acromioclavicular joint
0.092.05 (0.90 to 4.68)232
Shoulder dislocation/
instability
p (Z-test)
Risk ratio to other forwards
(95% CI)
Days
absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player-
hours or in locations where absence due to injury was significantly greater than other forwards
Figure 7 Days of absence injury profi le for blind-side fl ankers. *Signifi cantly dif ferent from other forwards (p<0.05).
shoulder injuries was signifi cantly higher in scrum-halves
(0.04) because of a signifi cantly greater absence from acro-
mioclavicular joint injuries. Absence due to thigh injuries
(p<0.001) was signifi cantly lower in scrum-halves due to a
signi cantly lower absence due to hamstring muscle injuries
(p=0.001).
Fly-half injuries
Absence due to thigh injuries (p=0.01) because of signifi cantly
greater absence due to hamstring muscle injuries and absence
due to arm and hand injuries (p=0.001) because of a signifi -
cantly greater absence due to elbow joint injuries were both
signi cantly higher in fl y-halves (fi gure 11).
Centre’s injury profi le
Absence due to head injuries (p<0.001) (tackling: 44%; being
tackled: 39%) because of a signi cantly greater absence due
to concussion, absence due to neck injuries (p=0.005) (being
tackled: 46%; tackling: 42%) because of a signi cantly greater
absence due to cervical disc/ner ve root injuries, absence due
to shoulder injuries (p=0.01) (tackling 68%; being tackled:
18%) because of a greater absence due to shoulder dislocation/
instability and absence due to lower leg injuries (p=0.001)
because of a greater absence due to tibia/fi bula fractures were
all signifi cantly higher in centres (fi gure 12).
Winger’s injury profi le
Absence due t o thigh i njuries (p =0.001) was sig nifi cantly higher
in wingers because of a signi cantly greater absence due to
thigh haematomas (fi gure 13). Absence due to head (p<0.001)
and shoulder (p=0.02) injuries was signifi cantly lower.
Full-back injuries
Absence due to groin /hip/buttock injuries was signi cantly
higher in full-backs (p<0.001) because of a greater absence due
to groin nerve entrapment injuries (fi gure 14). Absence due to
chest injuries was signifi cantly higher in full-backs (p=0.03)
due to a greater absence from costochondral/sternal injuries
and rib fractures/contusions.
Injury-prevention priorities for players by playing position
The injury-prevention priorities for players by playing posi-
tion are summarised in table 1.
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0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Ches t
Abdomen and thoracic spine
Lumb ar s pin e
Groin/ hip/ buttock
Thigh
Knee
Lowe r le g
Ankle/ heel
Foot
Days absence (1000/hours)
Number-8 All other forwards
*
*
*
*
*
0.480.57 (0.12 to 2.66)9
Foot/ toe joint sprain
0.035.49 (1.19 to 25.41)149
Foot fracture
0.015.89 (1.56 to 22.19)115Patella tendon
0.201.69 (0.76 to 3.76)132Knee MCL
0.015.77 (1.56 to 21.32)82Wrist/hand fracture
0.0123.55 (2.13 to 260)93Biceps muscle injury
0.471.37 (0.58 to 3.26)62Acromioclavicular joint
0.390.59 (0.18 to 1.96)79
Shoulder dislocation/
instability
p (Z-test)
Risk ratio to other forwards (95%
CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player -hours or in
locations where absence due to injury was sig nificantly greater than other forwar ds
Figure 9 Days of absence injury profi le for number-8s. *Signifi cantly different from other forwards (p<0.05). MCL, medial collateral ligament.
0.731.22 (0.40 to 3.73)28
Inferior tib-fib syndesmosis
0.081.96 (0.92 to 4.19)96
Ankle lateral ligament
0.352.35 (0.39 to 14.05)108Knee ACL
0.142.23 (0.77 to 6.50)133
Knee meniscal/ articula r
cartilage
0.351.60 (0.60 to 4.25)17
Lumbar soft tissue
0.025.97 (1.27 to 28.11)69
Lumbar disc/ nerve root
0.032.32 (1.09 to 4.96)90Acromioclavicular joint
0.202.08 (0.68 to 6.38)187
Shoulder dislocation/
instability
p (Z-test)
Risk ratio to other forwards (95%
CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player-hours or in
locations where absence due to injury was significantly greater than other backs
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Chest
Abdomen and thoracic spine
Lumbar spine
Groin/ hip/ buttock
Thigh
Knee
Lower leg
Ankle/ heel
Foot
Days absence (1000/hours)
Scrum-half All other backs
*
*
*
*
Figure 10 Days of absence injury profi le for scrum-halves. *Signifi cantly different from other backs (p<0.05). ACL, anterior cruciate ligament.
0.540.72 (0.26 to 2.02)78Kn ee MCL
0.082.19 (0.92 to 5.26)132
Knee menis cal/ articular
cartilage
0.560.86 (0.52 to 1.42)63Thigh haematoma
0.051.65 (1.01 to 2.70)241Hamstring musc le
0.710.75 (0.17 to 3.36)36Wrist/ hand fracture
<0.00143.14 (9.66 to 193)39Elbow joint injury
p (Z-test)
Risk ratio to other forwards (95%
CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locati ons with >150 days absence/1000 player-hours or in
locations where absence due to injury was significantly greater than other backs
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Chest
Abdomen and thoracic spine
Lumbar spine
Groin/ hip/ buttock
Thigh
Knee
Lower leg
Ankle/ heel
Foot
Days absence (1000/hours)
Fly-half All other backs
*
*
*
*
*
0 100 200 400 500
Head
Neck
Shoulder
Arm and hand
Chest
Abdomen and thoracic spine
Lumbar spine
Groin/ hip/ buttock
Thigh
Knee
Lower leg
Ankle/ heel
Foot
Fly-half All other backs
*
*
*
*
*
Figure 11 Days of absence injury profi le for fl y-halves. *Signi cantly different from other backs (p<0.05). MCL, medial collateral ligament.
DISCUSSION
Absence due to match injuries was not signi cantly higher in
any of th e individua l playing pos itions with in the for wards and
backs in the current study. This is consistent with other large
rugby union epidemiological studies where few differences
have also been reported in injury incidence between posi-
tions.17 21 22 Nevertheless, players in every position still missed
a signifi cant number of days of absence due to match injuries
(forwards: 1569 days of absence/1000 player-hours equivalent
to 33 days of absence per match due to forwards injuries; backs
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0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Ches t
Abdomen and thoracic spine
Lumb ar s pin e
Groin/ hip/ buttock
Thigh
Knee
Lowe r le g
Ankle/ heel
Foot
Days absence (1000/hours)
Cent res All other backs
*
*
*
*
*
*
0.940.98 (0.53 to 1.82)46
Calf muscle
0.113.74 (0.76 to 18.54)108
Tibia/fibula fracture
0.00110.81 (2.80 to 41.80)78Knee PC L/ LCL
0.801.08 (0.57-2.05)110Knee MCL
0.020.64 (0.43 to 0.94)51Thi gh haematoma
0.601.12 (0.72 to 1.74)173Hamst ring muscle
0.211.76 (0.73 to 4.24)63Shoulder rotator cuff
0.102.24 (0.87 to 5.81)172
Shoulder dislocation/
instability
25
Spinal cord injury
0.013.09 (1.36 to 6.99)65
Cervical disc/ nerve root
0.182.60 (0.65 to 10.39)19
Head/ facial fracture
<0.0012.54 (1.56 to 4.12)105
Concussion
p (Z-test)
Risk ratio to other forwards (95%
CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player-hours or in
locations where absence due to injury was significantly greater than other backs
Figure 12 Days of absence injury pro le for centres. *Signifi cantly dif ferent from other backs (p<0.05). LCL, lateral collateral ligament; MCL,
medial collateral ligament; PCL, posterior cruciate ligament.
0.311.67 (0.62 to 4.51)33
Inferior tib-fib syndesmosis
0.160.61 (0.30 to 1.23)38
Ankle lateral ligament
0.490.72 (0.29 to 1.81)55
Knee meniscal/ articular
cartilage
0.171.57 (0.82 to 3.01)140Knee MC L
<0.0012.82 (1.88 to 4.22)133Thigh haematoma
0.890.97 (0.67 to 1.42)157Hamstring muscle
0.0024.45 (1.75 to 11.29)28Should er haematoma
0.132.16 (0.79 to 5.90)70Shoulder rotator cuff
p (Z-test)
Risk ratio to other forwards (95%
CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest absence in locations with >150 days absence/1000 player-hour s or in
locations where absence due to injury was significantly greater than other backs
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Chest
Abdomen and thoracic spine
Lumbar spine
Groin/ hip/ buttock
Thigh
Knee
Lower leg
Ankle/ heel
Foot
Days absence (1000/hours)
Wingers All other backs
*
*
*
Figure 13 Days of absence injury profi le for wingers. *Signifi cantly different from other backs (p<0.05). MCL, medial collateral ligament.
1507 days of absence/1000 player-hours equivalent to 28 days
of absence per match due to backs injuries). There is a clear
need to design and implement injury-prevention programmes
for all players to reduce this injury burden.
Three main body locations (the shoulder, knee and ankle/
heel) for forwards and three main body locations (the shoul-
der, hamstring and knee) for backs caused more than 150
days of absence/1000 player-hours; this constituted more
than half of all days of absence due to match injuries. As a
result, injury-prevention strategies for injuries to these four
body regions should be prioritised. Studies implementing
injur y-prevention interventions in other non-collision sports
have been successful at reducing the incidence of injury to all
of these lower-limb locations (hamstrings, knees and ankles)
by utilising exercises designed to improve parameters such as
propriception, core stability and muscle strength.23–30 While
the need for more research into the effectiveness of injury-
prevention interventions in collision sports is recognised, it
is likely that interventional approaches used in other sports
would be transferrable to the rugby union population. Fewer
studies have attempted to prevent shoulder injuries by using
controlled injury-prevention interventions, although reducing
shoulder capsular tightness31 and eccentric resistance train-
ing32 have been highlighted.
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by the greater use of the neck extensors during scrummaging
for loose-head props and hookers. Development of the cervi-
cal musculature may be of benefi t in preventing cervical inju-
ries in these players,38 although the detail of the intervention
needs more investigation.
Shoulder rotator cuff injuries also caused signifi cantly more
absence in loose-head props and hookers. A large propor-
tion of these injuries to loose-heads were due to scrummag-
ing (66%), although the majority of these were to their right
shoulder (75%), which is bound to the hooker rather than the
opposition. None of the rotator cuff injuries to hookers were
sustained during scrummaging. Factors that might result in
these players being more predisposed to rotator cuff injuries14
include rotator cuff weakness,39 fatigue-induced propriception
and skill defi cits40 41 and suboptimal glenhumeral alignment.42
The high impact forces and loads experienced during scrum-
maging16 37 and the repetitive demands placed on hookers from
throwing the ball into the lineout in matches and training may
also increase the risk of injury to these players.
Despite the lack of differences in total absence due to injur y
for each playing position and the identi cation of three prin-
cipal body regions for injury-prevention programmes for the
majority of forwards and backs, signi cant differences in
injury pro le between players in different playing positions
were reported. These can be used to focus further on injury-
prevention programmes.
Loose-head props and hookers both exhibited similar
injury pro les. Cervical injuries, in particular cervical disc/
nerve root injuries, caused signifi cantly greater absence com-
pared with other forwards. It has long been established that
the risk of sustaining a cervical injury is higher in front-row
forwards, in particular during scrummaging;8 11 33– 36 how-
ever, in the current study, tackling was the most common
cause of cervical disc/nerve root injuries for these players.
Nevertheless, the greater impact forces on scrum engagement
and the loads transmitted and absorbed by front-row for-
wards during scrummaging16 37 may have predisposed these
players to cervical injuries. This may have been exacerbated
0.112.58 (0.81 to 8.21)52
Patella tendon
0.412.50 (0.28 to 22.34)113
Knee ACL
0.040.61 (0.38 to 0.99)46Th igh haematoma
0.981.01 (0.58 to 1.73)161Hamstring muscle
0.271.64 (0.68 to 3.95)41
Adductor mu scle
0.001120 (7.51 to 1918)49
Groin nerve entrapment
0.191.93 (0.72 to 5.17)36Rib fracture/ contusion
0.072.27 (0.94 to 5.48)51Costochondral/ sternal injury
0.551.38 (0.48 to 3.95)60Acromi oclavicular joint
0.671.31 (0.38 to 4.54)130
Shoulder dislocation/
instability
p (Z-test)
Risk ratio to other forwards (95%
CI)
Days absence/
1000 hours
Injury diagnosis
The two injuries causing the greatest abse nce in locations with >150 days abse nce/1000 player-hours or in
locations where absence due to injury was sign ificantly greater than other backs
Days absence (1000/hours)
Full-back All other bac ks
*
*
*
*
0 100 200 300 400 500
Head
Neck
Shoulder
Arm and hand
Chest
Abdomen and thoracic spine
Lumbar spine
Groin/ hip/ buttock
Thigh
Knee
Lower leg
Ankle/ heel
Foot
Full-back All other bac ks
*
*
Figure 14 Days of absence injury pro le for full-backs. *Signifi cantly dif ferent from other backs (p<0.05).
Table 1 Injur y locations of highest injury risk for players in each playing position
Playing position Head Neck Shoulder
Arm and
hand Chest
Abdomen and
thoracic spine
Lumbar
spine
Groin/hip/
buttock Thigh Knee Lower leg Ankle/heel Foot
Loose-head prop √√ ––
Hooker √√ –– – –√√ √
Tight-head prop ––––√√ √
Second row
Blind-side fl anker –– √√–– –
Open-side fl anker √√ –– – –
Number-8 √√–– – – ––
Average forward –– – –
Scrum-half ––––
Fly-half – – –– – – √√–– –
Centres √√–– √√––
Wingers –– √√
Full-back ––√√–– –
Average back – – – –
Injur y locations that caused >150 days of abse nce/1000 player-hours or were signi cantly g reater than t he aver age for ward or back ar e liste d as injur y-prevention priorities ().
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is advocated as a possible injury-prevention strategy.44 45
However, the repeated lumbar fl exion and rotation may have
positively conditioned the hamstrings of these players by
increasing hamstring fl exibility53–55 and eccentric strength10 2 4
resulting in the signifi cantly lower absence due to hamstring
muscle injuries observed.
Fly-halves had a signifi cantly greater absence due to thigh
injuries, specifi cally hamstring muscle injuries, compared
with other backs. A high incidence of hamstring muscle inju-
ries in sports that involve a lot of kicking has been previously
reported58 –60 and the frequency wit h which fl y-halves kick the
ball during a match compared with other positions may pre-
dispose them to an increased risk of hamstring muscle injury,
although this has yet to be confi rmed. Greater absence due to
arm and hand injuries was largely as a consequence of injuries
for which injury-prevention strategies are less well validated,
namely elbow joint injuries, while the signi cantly lower
absence from shoulder injuries may be due to fl y-halves mak-
ing fewer tackles in a match compared with other backs.57
The observation that absence due to head injuries, in partic-
ular concussions, was signi cantly higher in centres compared
with other backs has been reported previously.13 Absence due
to neck and shoulder injuries was also signi cantly higher in
centres compared with other backs, and the most common
injur y event was tackling (42–68%). High speed going into
the tackle, high impact force and contact with the tackler’s
head and neck have all been identifi ed previously as signifi -
cant risk factors for tacklers.57 61 Centres tend to make more
tackles in a match than other backs57 and have been signif-
icantly more prone to injur y when tackling than players in
other positions.61
While absence due to thigh injuries was high for the major-
ity of backs, it was signifi cantly higher for wingers compared
with other backs. One might expect that this greater absence
would be due to hamstring muscle injuries because of the
greater number of sprints performed in a match by outside
backs52 and as a consequence of the faster run ning speed of
these players. While absence due to hamstring muscle injuries
was high in wingers, it was the absence due to thigh haemato-
mas that was most signifi cant.
The signi cant differences in the injury profi le of the full-
backs, namely greater absence due to groin/hip/buttock inju-
ries and chest injuries, were largely as a consequence of injur ies
for which injury-prevention strategies are less well validated,
namely groin nerve entrapment injuries, costochondral /sternal
injuries and rib fractures/contusions.
We believe that this study demonstrates the need for injury-
prevention programmes for all players and that playing posi-
tion should be considered as an independent risk factor for
injur y and consequently as a driver for individualised injury-
prevention programmes. While signifi cant absence due to
injur y to three body regions was relatively consistent for all
positions within the forwards (shoulder, knee and ankle/heel)
and the backs (shoulder, hamstring and knee), signifi cant dif-
ferences in the injury profi le between positions demonstrate
the need for injury-prevention programmes to be position-
specifi c. Such programmes should also be player-specifi c and
recognise the importance of focusing on a player’s previous
injur y history because of the signifi cantly greater absence
due to recurrent injuries compared with new injuries.17 In the
future, our understanding of differences in the injury profi le
between different positions could be further en hanced by a
greater understanding of the position-specifi c demands of the
game and the mechanism of injury.
Tight-head props exh ibited a different i njury profi le from the
other front-row positions. Lower leg and lumbar spine injuries
caused signifi cantly more absence compared with other for-
wards due to a signifi cantly greater absence from calf muscle
strains, lumbar disc/nerve root and lumbar sof t tissue injuries;
trends that have been identifi ed previously.11 43 The majority
of all of these injuries were sustained during scrummaging
(54–6 7%). It has been shown that greater loads are transmit-
ted by tight-head props during scrummaging than by all other
forwards.16 The inability of the lumbar spine and calf muscu-
lature of tight-head props to adapt to these high loads there-
fore needs addressing. Improving scrummaging technique
to ensure the lumbar spine is maintained in a strong neutral
position by improving neuromuscular control44 and specifi c
strength training for the lumbar and calf regions are plausi-
ble interventions.45 46 The association between lumbar spine
pathology and calf muscle symptoms or strains should also not
be overlooked.47
Absence due to lateral ank le ligament injuries was signifi -
cantly higher in second-rows, and a higher proportion of these
injuries were sustained in the lineout (21%) compared with
other forwards. This is similar to previous fi ndings15 where
inversion ankle injuries on landing from a lineout lift was felt
to be a signifi cant risk factor. Landing from a jump is a com-
mon cause of ankle injuries in other sports such as soccer48
and volleyball.49 Injury-prevention interventions that have
focussed on adopting the correct lower-limb alignment when
landing have been successful at reducing the incidence of ankle
injuries in other sports.23 27 30
Blind-side fl ankers had more absence due to thigh injuries
than other for wards, in particular due to hamstring muscle
injuries. The majority of these injuries were sustained during
running (86%), typically during sprinting or runn ing at high
speed.28 50 The back-row perform between 1.4 and 2 times as
many sprints in a match compared with other forwards.51 5 2
Eccentric strengthening of the hamstrings,10 24 improving
hamstring fl exibility53–55 and sports-speci c conditioning28
have all been successful at reducing the incidence of hamstring
injuries.
Absence due to neck injuries, in particular cervical facet
joint injuries, was signifi cantly higher in open-side fl ankers.
The tackle is the most common cause of absence due to injur y
largely because it is the most frequent contact event.56 Open
side fl ankers make more tackles than players in other posi-
tions during a match,57 and the majority of open-side neck
injuries were sustained in the tackle (63%). Open-side fl ankers
may benefi t from gains in cer vical musculature strength38 to
improve their ability to adapt to high impact forces on their
neck, as well as improvements in tackling technique previ-
ously advocated.17
The signi cant differences in the injury pro le of the
number-8, namely greater absence due to arm and hand inju-
ries and foot injuries, were largely as a consequence of injuries
for which injury-prevention strategies are less well validated,
namely wrist, hand and foot fractures and biceps muscle
injuries.
While absence due to shoulder and knee injuries was high
in scrum-halves, as with other backs, absence due to lumbar
spine injuries, more specifi cally lumbar disc/nerve root inju-
ries, caused signifi cantly more days of absence for scrum
halves t han for other backs. The repeated lumbar fl exion and
rotation necessary to pass the ball off the ground might pre-
dispose these players to lumbar injury. Optimising global and
local muscular control of this combined lumbar movements
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Brooks JHM, Kemp SP T. Br J Sports Med (2010). doi:10.1136/bjsm.2009.06698510 of 11
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Acknowledgements The authors thank C Fuller (Centre for Sports Medicine,
University of Nottingham) for his key role in initiating and suppor ting the project
(England Rugby Injury and Training Audit). The authors thank the doctors,
physiotherapists, and fi tness, strength and conditioning staff from the following
clubs and teams who have recorded injury and training infor mation throughout the
project: Bath Rugby, Bristol Rugby, Gloucester RFC, England, Leeds Tykes, Leicester
Tigers, London Irish, London Wasps, Harlequins, Newcastle Falcons, Northampton
Saints, Rotherham, Sale Sharks, Saracens and Worcester Warriors. The authors
also thank the Rugby Football Union for their fi nancial support and R Vickers (Rugby
Football Union) and T Clear y (Rugby Football Union) for their help in collecting and
processing the data.
Funding Rugby Football Union.
Competing interests None.
Provenance and peer review Not commissioned; exter nally peer reviewed.
Detail has been removed from this case description or these case descriptions to
ensure anonymity. The editors and reviewers have seen the detailed information
available and are satisfi ed that the information backs up the case the authors are
making.
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10. Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk and preven tion of
hamstring muscle injuries in professional rugby unio n. Am J Spor ts Med
2006;34:1297–306.
What is already known about this topic
Trends in the profi le of injuries sustained in rugby
union matches between different positions have
been reported in the literature on several occasions.
However, the injury profi le has typically only been
reported for grouped playing positions, such as
front-row forwards or mid eld backs, rather than for
individual playing positions.
What this study adds
This study demonstrates that there are individual
position-specifi c differences in match injury profi le
that in conjunction with a player’s past injury history
can be used to design more targeted injury-prevention
programmes in rugby union.
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doi: 10.1136/bjsm.2009.066985
published online May 19, 2010Br J Sports Med
J H M Brooks and S P T Kemp
players unionplaying position in professional rugby
Injury-prevention priorities according to
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... In a game of Rugby, there are 15 players split into forwards (positions No. [1][2][3][4][5][6][7][8] and backs (positions No. [9][10][11][12][13][14][15]. The primary function of forwards is to contest for and regain possession of the ball by participating in tackles, scrums, lineouts, rucks, and mauls. ...
... Shoulder, head, knee, and ankle injuries were the most prevalent, which is consistent with injury profiles in the elite, 20,47 amateur, 37,52 and school game. 1,3,28 Although some data exist for positional trends in match-injury occurrence in the professional game, 9,45 comparable data are lacking in youth Rugby. Forwards by their nature are generally bigger and stronger than backs, as their primary function is to compete for the ball in scrums and lineouts, whereas backs are usually lighter and faster than forwards, as they require skill for kicking, passing, and reading the game. ...
... Forwards by their nature are generally bigger and stronger than backs, as their primary function is to compete for the ball in scrums and lineouts, whereas backs are usually lighter and faster than forwards, as they require skill for kicking, passing, and reading the game. 9,35 The data from the current study clearly demonstrate differences in injury risk and presentation between both positional groups, which has important implications for targeted injury-reduction strategies. ...
Article
Background Concern has been raised over the injury risk to school Rugby union (Rugby) players and the potential long-term health consequences. Despite the increase in studies for this cohort, the influence of playing position on injury incidence and presentation is unclear. Purpose To describe the incidence, nature and severity of match injuries for school Rugby in Ireland overall, and as a function of playing position. Study Design Prospective cohort study. Methods Data were collected from 15 male (aged 16-19 years) school Senior Cup teams across 2 seasons. In total, 339 players participated in season 1, whereas 326 players participated in season 2. Injury data were recorded onto a bespoke online platform. Match exposure was also recorded. Results The incidence rate of match injuries (24-hour time loss) was 53.6 per 1000 hours. Across both seasons, 6810 days were lost from play due to injury. Forwards (65.4 per 1000 hours) sustained significantly more ( P < 0.05) injuries than backs (40.5 per 1000 hours). The head, shoulder, knee, and ankle were the most common injured body regions; however, forwards sustained significantly more ( P < 0.05) head and shoulder injuries than backs. The tackle was responsible for the majority of injuries in both groups. The highest proportion of injuries occurred during the third quarter. Conclusion Clear differences in injury presentation and incidence were evident when comparing forwards versus backs. The high rate of head and shoulder injuries in the forwards suggest the need for more targeted injury-prevention strategies and further research on education and laws around the tackle event. The spike of injuries in the third quarter suggests that fatigue or inadequate half-time warm-up may be a contributing factor warranting further exploration. Clinical Relevance This study demonstrates clear differences in injury presentation according to playing position in school Rugby and highlights the need for a more tailored approach to the design and implementation of injury-prevention strategies. Level of Evidence Level 3
... The term posterior chain injury (PCI) is commonly used in relation to injuries to the posterior musculoskeletal system of the lower limb. 1 2 PCI is commonly observed within athletic populations, with a reported time loss of 10 hours for every 1000 playing hours within elite-level sport. 3 The most prevalent PCIs involve structures within the posterior musculoskeletal system such as the trunk, pelvis, hamstring and calf complexes. [4][5][6][7][8] This has subsequently led to a large amount of research being conducted that focuses on these areas of PCI, particularly during high-velocity activities such as sprinting. ...
... 8 9 Occurrence of PCI is attributed to a failure and a loss of concurrence somewhere within this system. 9 10 Therefore, it is no surprise that PCI prevalence is high in many sports that require sprinting, including rugby union, 3 soccer, 11 American football 12 and athletics. 13 Of the structures within the posterior ...
... Injury surveillance data are missing the last 2 months of the season when injuries may be most prevalent, possibly limiting true findings. 3 Further limitation is also present when looking at the timing of data collection. The study design analyses biomechanics at a single point in time (preseason IRS testing). ...
Article
Full-text available
Objectives Lower limb posterior chain injury (PCI) is common among athletic populations, with multifactorial risk factors including age, previous injury, strength measurements, range of motion and training load. Biomechanics are commonly considered in the prevention and rehabilitation of PCI by performance staff. However, there is no documented testing method to assess for associations between biomechanics and PCI. The aim of this study was to investigate whether there is an association between an easily applicable, novel biomechanical assessment tool and PCI. Methods Fifty male elite-level rugby union athletes (age 22.83±5.08) participating in the highest tier of England were tested at the start of the 2019 preseason period and PCIs (N=48) were recorded over the 2019/2020 playing season. Participants’ biomechanics were analysed using two-dimensional video analysis against an injury risk score (IRS) system in the performance of the combined movement—prone hip extension and knee flexion. Participants’ biomechanics in carrying out this movement were scored against the 10-point IRS, where the more compensatory movement recorded sees an increase in an individual’s IRS. Participants’ IRS was then compared against the number of PCIs sustained and Spearman’s correlation coefficient was used for statistical analysis. Results There is a significant association between IRS and PCI (R=0.542, p<0.001). Linear regression demonstrated that an increase in 1 in IRS was associated with a 35% increase in PCI incidence (R²=0.346). Conclusion A significance between the IRS and PCI provides preliminary support for its use as an injury risk assessment tool.
... 42 É imperativo que os programas de prevenção sejam individualizados, tendo em conta, não só os antecedentes de lesão de cada um, mas também a sua posição de jogo, visto que cada uma tem diferentes padrões de lesão. 28 Direcionar os Avançados para a prevenção das lesões da coluna cervical e os Três-Quartos para as lesões da coxa, seria um exemplo. Em alguns países têm sido discutidas abordagens mais radicais nos escalões jovens, por exemplo, a proibição de placagem em competições infantis devido a este ser o evento mais associado a lesões e pelo possível dano das concussões cerebrais em idades tão jovens. ...
Article
Rugby is one of the team sports with the highest incidence rate of injuries per exposure time. These mainly occur in specific sport movements such as the tackle, ruck, or maul. Therefore, it is important to understand the sports’ specificities and biomechanics and link them with its risk and injury type. The most common reported injuries are musculotendinous and ligament ruptures of the lower limbs, however, we highlight the important incidence of severe head and neck injuries, like cerebral concussion and cervical spine fractures. It is essential to gather data that enable us to characterize the risk and specify of each movement performed by the athlete, to make more effective programs on injury-prevention and rehabilitation of injured athletes, always focusing on their full recovery and reinjure risk reduction.
... These factors were considered in exercise selection, staging progress and RTP clearance. While the length of the surveillance window post-RTP appears to vary due to the impact of intrinsic (age; previous CMSI; other injury history) [8,31,85] and extrinsic (stage of the season; playing position) [86,87] factors, as well as the pathology (muscle involved; index versus recurrent injury [7]), monitoring exposure for ≥ 2 months is likely critical to the ongoing success of managing CMSI [52,53]. ...
Article
Full-text available
Background Despite calf muscle strain injuries (CMSI) being problematic in many sports, there is a dearth of research to guide clinicians dealing with these injuries. The aim of this study was to evaluate the current practices and perspectives of a select group of international experts regarding the assessment, management and prevention of CMSI using in-depth semi-structured interviews. Results Twenty expert clinicians working in elite sport and/or clinician-researchers specialising in the field completed interviews. A number of key points emerged from the interviews. Characteristics of CMSI were considered unique compared to other muscle strains. Rigor in the clinical approach clarifies the diagnosis, whereas ongoing monitoring of calf capacity and responses to loading exposure provides the most accurate estimate of prognosis. Athlete intrinsic characteristics, injury factors and sport demands shaped rehabilitation across six management phases, which were guided by key principles to optimise performance at return to play (RTP) while avoiding subsequent injury or recurrence. To prevent CMSI, periodic monitoring is common, but practices vary and data are collected to inform load-management and exercise selection rather than predict future CMSI. A universal injury prevention program for CMSI may not exist. Instead, individualised strategies should reflect athlete intrinsic characteristics and sport demands. Conclusions Information provided by experts enabled a recommended approach to clinically evaluate CMSI to be outlined, highlighting the injury characteristics considered most important for diagnosis and prognosis. Principles for optimal management after CMSI were also identified, which involved a systematic approach to rehabilitation and the RTP decision. Although CMSI were reportedly difficult to prevent, on- and off-field strategies were implemented by experts to mitigate risk, particularly in susceptible athletes.
... These positional demands directly influence the assessment of activity risk within the returnto-play decision framework following an injury [46], which may also account for the observed difference in the mean days missed per injury between forwards and backs. There are likely to be position-specific differences in match injury profiles, determined by the physical and technical requirements of each position, which may be used to design more targeted injury-prevention programmes [47]. These positionspecific injury profiles warrant an updated investigation, given the changes to game and positional demands that have occurred over recent seasons [3]. ...
Article
Full-text available
Background The most recent meta-analytic review of injuries in elite senior men’s Rugby Union was published in 2013. The demands of the game at the elite level are continually changing alongside law amendments and developments in player preparation. As such, an updated meta-analysis of injury data in this setting is necessary. Objective To meta-analyse time-loss injury data in elite senior men’s Rugby Union between 2012 and 2020. Methods Electronic databases were searched using the keywords ‘rugby’ and ‘inj*’. Nineteen studies met the inclusion criteria. Injury incidence rate data were modelled using a mixed-effects Poisson regression model. Days missed data were modelled using a general linear mixed model. Results The included data encompassed a total of 8819 match injuries and 2801 training injuries. The overall incidence rate of injuries in matches was 91 per 1000 h (95% confidence interval (CI) 77–106). The estimated mean days missed per match injury was 27 days (95% CI 23–32). The overall incidence rate of match concussions was 12 per 1000 h (95% CI 9–15). The overall incidence rate of training injuries was 2.8 per 1000 h (95% CI 1.9–4.0). Playing level was not a significant effect modifier for any outcome. Conclusions The injury incidence rate and mean days missed per injury in the present meta-analysis were higher, but statistically equivalent to, the 2013 meta-analysis (81 per 1000 h and 20 days, respectively). The injury incidence rate for match injuries in elite senior men’s Rugby Union is high in comparison to most team sports, though the training injury incidence rate compares favourably. The tackle event and concussion injuries should continue to be the focus of future preventative efforts.
... These factors were considered in exercise selection, staging progress and RTP clearance. While the length of the surveillance window post-RTP appears to vary due to the impact of intrinsic (age; previous CMSI; other injury history) [8,31,85] and extrinsic (stage of the season; playing position) [86,87] factors, as well as the pathology (muscle involved; index versus recurrent injury [7]), monitoring exposure for ≥ 2 months is likely critical to the ongoing success of managing CMSI [52,53]. ...
Conference Paper
Full-text available
Background Despite being a common cause of time loss, information regarding best practice for calf muscle strain injuries (CMSI) in sport is scarce. Objective To establish best practice for the assessment and management of CMSI. Design Qualitative. Setting In-depth interviews. Patients (or Participants) 20 expert medical professionals working in elite sport and/or researchers specialising in the field; representing seven countries and seven sports. Interventions (or Assessment of Risk Factors) Semi-structured interviews using a schedule of questions canvassing pre-identified topics. Thematic coding to analyse findings. Main Outcome Measurements Data were evaluated in three key areas: (i) injury characteristics, (ii) injury management, and (iii) injury prevention. Results CMSI have unique injury characteristics compared to other common muscle strain injuries (e.g. hamstring), but a criteria-based approach can assist forming the most accurate impression of prognosis. Similarly, a structured approach should be followed to ensure the athlete returns to a high level of performance and the risk of re-injury is minimized, focusing on: re-strengthening, plyometric and ballistic exercises, as well as running-based reconditioning specific to the sport. For the best chance to prevent index CMSI, strategies should span multiple domains of athlete management: screening and monitoring, field-based exposure (e.g. workload data), and off-field interventions (e.g. strengthening). Injury prevention strategies should be tailored to the individual, considering extrinsic (the sport, position played, club culture/coach expectations) and intrinsic (previous injury history, age, training history) factors that may increase susceptibility to CMSI. Conclusions Knowledge about the unique injury characteristics of CSMI can clarify the likely prognosis and best approach to rehabilitation. Practitioners attempting to prevent CMSI should use a multi-faceted approach given that the aetiology of CMSI is complex and often unique to the individual.
Article
Objective This study aimed to systematically review and meta-analyse the incidence and prevalence of hamstring injuries in field-based team sports. A secondary aim was to determine the impact of other potential effect moderators (match vs training; sport; playing surface; cohort age, mass and stature; and year when data was collected) on the incidence of hamstring injury in field-based team sports. Design Systematic review and meta-analysis. Data sources CINAHL, Cochrane Library, MEDLINE Complete (EBSCO), Embase, Web of Science and SPORTDiscus databases were searched from database inception to 5 August 2020. Eligibility criteria Prospective cohort studies that assessed the incidence of hamstring injuries in field-based team sports. Method Following database search, article retrieval and title and abstract screening, articles were assessed for eligibility against predefined criteria then assessed for methodological quality using the Critical Appraisal Tool for prevalence studies. Meta-analysis was used to pool data across studies, with meta-regression used where possible. Results Sixty-three articles were included in the meta-analysis, encompassing 5952 injuries and 7 262 168 hours of exposure across six field-based team sports (soccer, rugby union, field hockey, Gaelic football, hurling and Australian football). Hamstring injury incidence was 0.81 per 1000 hours, representing 10% of all injuries. Prevalence for a 9-month period was 13%, increasing 1.13-fold for every additional month of observation (p=0.004). Hamstring injury incidence increased 6.4% for every 1 year of increased average cohort age, was 9.4-fold higher in match compared with training scenarios (p=0.003) and was 1.5-fold higher on grass compared with artificial turf surfaces (p<0.001). Hamstring injury incidence was not significantly moderated by average cohort mass (p=0.542) or stature (p=0.593), was not significantly different between sports (p=0.150) and has not significantly changed over the last 30 years (p=0.269). Conclusion Hamstring injury represents 10% of all injuries in field-based team sports, with 13% of the athletes experiencing a hamstring injury over a 9-month period most commonly during matches. More work is needed to reduce the incidence of hamstring injury in field-based team sports. PROSPERO registration number CRD42020200022.
Article
Study design and setting Returning rugby players to the sport following musculoskeletal injuries is a multi-factorial and challenging process. A cross-sectional observational study was conducted among health and sport practitioners involved with injured rugby players in South Africa. Objectives and outcome measures The views, current practices and barriers encountered by health and sport practitioners during return to rugby were investigated using a self-developed online survey. Results 64 practitioners participated in the survey including physiotherapists, orthopaedic surgeons, biokineticists and sports physicians. Return to sport (RTS) protocols were considered important, however, participants also indicated that they were slightly more likely to use anecdotal protocols compared to published protocols. Time frames, stages of healing, pain and subjective ratings along with functional outcome measures (such as range of motion, muscle function and proprioception) and sport-specific skills were rated as important and commonly utilised in different RTS phases (i.e., return to non-contact, return to contact and return to matches). The most commonly perceived barriers encountered were related to lack of access and time-constraints. Conclusion Return to rugby guidelines with consideration of a broad range of criteria and common barriers encountered should be developed to facilitate safe, practical and time-efficient return to rugby following musculoskeletal injuries.
Article
Full-text available
Context It is unclear whether playing position influences injury in male academy soccer players (ASP). Objective To determine if playing position is associated with injury in ASP. Design Descriptive Epidemiology Study. Setting English, Spanish, Uruguayan and Brazilian soccer academies. Participants 369 ASP from Under 14 (U14) to U23 age groups, classified as ‘post-peak height velocity' using maturity offset, and grouped as goalkeepers (GK), lateral defenders (LD), central defenders (CD), lateral midfielders (LM), central midfielders (CM) and forwards (FWD). Additional analysis compared central (CENT) with lateral/forward (LAT/FWD) positions. Main Outcome Measures Injuries were recorded prospectively over one season. Injury prevalence proportion (IPP), days missed and injury incidence rate (IIR, injuries per 1000 training/match hours, n=116) were analysed according to playing position. Results No association with playing position was observed for any injury type/location regarding IPP (P≥0.089) or days missed (P≥0.235). The IIR was higher in CD than LD for general (9.30 vs. 4.18 injuries/1000h, P=0.009), soft-tissue (5.14 vs. 1.95 injuries/1000h, P=0.026) and ligament/tendon injuries (2.69 vs. 0.56 injuries/1000h, P=0.040). Regarding CENT vs. LAT/FWD, there were no associations with IPP (P≥0.051) or days missed (P≥0.083), but general IIR was greater in CENT than LAT/FWD (8.67 vs. 6.12 injuries/1000h, P=0.047). Conclusions ASP playing position was not associated with IPP or days missed but the higher general, soft-tissue and ligament/tendon IIR in CD suggests this position warrants specific attention regarding injury prevention strategies. These novel findings highlight the importance of including training/match exposure when investigating the influence of playing position on injury in ASP.
Article
Full-text available
Background: Hamstring strain injuries are one of the most common injuries in Rugby Union, representing up to 15% of all injuries sustained. We aimed to systematically review and summarize the scientific literature that addressed hamstring strain injury incidence, risk factors, injury prevention or strengthening strategies, and strength or asymmetry measures in Rugby Union. Methods: We conducted a systematic search to locate published peer-reviewed articles from PubMed, SPORTDiscusTM, Web of Science®, and Scopus® e-databases. Studies included were original research conducted in Rugby Union that evaluated hamstring strength, hamstring strengthening interventions, and/or hamstring injury outcomes. Included studies were quality assessed using the Newcastle-Ottawa Scale. Results: Twenty-four studies met inclusion and altogether involved 2866 participants. Isokinetic testing was the most common method used to quantify hamstring strength and imbalances in Rugby Union; with data indicating that professionals are stronger than amateurs, and forwards are stronger than backs. Regarding risk factors, we identified playing position, fatigue, previous injuries, between leg strength imbalances, lack of readiness to return to play post injury, and game actions (i.e., running). There is evidence to support the use of Nordic eccentric strength measures to inform practice, with strength and imbalances useful in predicting injuries. Strengthening programs with Nordic exercises significantly increased hamstring strength, increased muscle thickness, and decreased imbalance ratios in female and male players. A significant reduction in injury incidence and severity in professional players has been observed in players performing routines incorporating progressive Nordic exercises. Conclusion: The aetiology of hamstring strain injuries is multifactorial, with playing position, fatigue, previous injuries, leg imbalances, lack of readiness to return to play, and running actions identified as contributing factors across levels. Combining strategies to prevent hamstring injuries and recurrences, and to inform return to play, is likely worthwhile and should include Nordic strength assessment and Nordic exercises.
Article
Full-text available
Objectives: The purpose of the study was to quantify the positional movement patterns of professional Rugby Union players competing in the English Premiership. Design: A cross sectional design was used. Setting: Field based data collection of one professional rugby union club during six league matches. Participants: An incidental sample of 35 professional rugby players with an age range of 20-34 years. Method: Recordings of the positional demands, taken from ten image recognition sensors, were coded for the specified high (HI) and low intensity (LI) tasks. Work-to-rest ratios were also calculated. Statistical assessment used an independent groups one-way ANOVA with post-hoc Scheffe test. Results: For all HI and LI activities there were significant position-related differences (P<0.05). In HI activities there were a range of different post-hoc Scheffe outcomes. The Props sprinted 1±1 time during a game while the Outside Backs sprinted 14±5 times. There were fewer post-hoc differences for the LI activities. For example, the Props jogged 325±26 times and the Outside Backs jogged 339±45 times. There was no significant position-related difference in the work-to-rest ratios for the quantity of HI and LI activities (P>0.05). There was, however, a significant positional difference when comparing the work to rest ratio for time spent in HI and LI activities (P<0.05). The Loose Forwards had the least amount of recovery with a work to rest time ratio, in seconds, of 1:7.5 s. The Outside Backs had the most amount of recovery, 1:14.6 s. Conclusions: There were clear positional differences in the quantity and time spent in rugby specific demands. These differences are most obvious in the HI activities of the game and included position-specific differences within both the Forward and Backs units.
Article
Full-text available
Rugby Union is a popular international sport [Bathgate, A., Best, J., Craig, G., & Jamieson, M. (2002) with a high incidence of cervical injury. A prospective study of injuries to elite Australian rugby union players. British Journal of Sports Medicine36, 265–269.] with a high incidence of cervical injury. The purpose of this case study was to explore the rehabilitation of a professional rugby union player following a cervical disc injury affecting the C8 nerve root and subsequent microdiscectomy. The isometric strength of the cervical musculature was measured using Repetition Maximum (1RM). A 10-week rehabilitation programme was then commenced whereby the player performed periodised upper limb and Maximal Isometric Voluntary Muscle Contraction (IVMCmax) neck exercises with a graduated return to contact training and playing. Re-tests of the cervical musculature were performed after Phases 1, 2, 3 and 4 of the 10-week rehabilitation programme. The results show a dramatic improvement in the strength of the cervical musculature acting in the four directions of movement tested (cervical flexion, extension and left and right side flexion). The player returned to professional club rugby 16 weeks post-operation and returned to International duty 2 weeks later. At the time of writing this case study, the player had not missed any game time due to cervical symptoms.