Michael England

The epidemiology of injuries in English youth community rugby union

Introduction Recent studies report the incidence and epidemiology of injury in professional rugby union; however, there is limited research in amateur and youth rugby. Injuries in youth rugby may have consequences for sports participation and physical development. The authors performed a prospective cohort study of injuries during youth community rugby. Methods An injury surveillance programme was established for the 2008–2009 season (9 months, 1636 player-hours) of an English community rugby club. The study included 210 players, all males, in Under 9 to Under 17 (U9–U17) age groups. These were categorised into mini, junior, pubertal and school participation age groupings. Injuries were defined according to the International Rugby Board consensus statements. Results There were 39 injuries reported (overall injury rate 24/1000 player-hours). Injury rates ranged from 0 to 49.3/1000 player-hours. More injuries occurred in junior (34.2/1000 player-hours) than in minis (11.9/1000 player-hours) (p<0.025). Higher numbers of moderate (20.6/1000 player-hours, p<0.005) and severe (9.5/1000 player-hours, p<0.05) injuries occurred in the U16–U17 age groups compared with younger age groups (U9–U10) where only minor injuries were reported. Most injuries occurred in the tackle (59%). The knee (4.9/1000 player-hours), shoulder (4.9/1000 player-hours) and head (4.3/1000 player-hours) were the most commonly affected areas. Concussion (1.8/1000 player-hours) affected half of the head injuries. Conclusions Injuries in youth rugby occur infrequently and are lower than in adult series. The risk of injury and severity of injury increases with age. This study highlights the need for further research into injury risk factors around puberty and the need for first aid provision.

Match injuries in English youth academy and schools rugby union: an epidemiological study.

Background: Numerous injury epidemiology studies have reported injury patterns in senior rugby union, but investigations in youth rugby are limited. Purpose: To describe the nature of injuries resulting from match play within the English youth rugby union, including a comparison between 2 levels of play within the same age group: professional academy versus school rugby. Study Design: Cohort study; Level of evidence, 2. Methods: A 2-season (2006-2007 and 2007-2008) study obtained information on injuries sustained in male youth rugby union players (age, 16-18 years) from 12 English Premiership academies (n = 250) and 7 schools (n = 222). Match exposure (player-hours) and injury details were recorded. Results: Match injury incidence was 47 per 1000 player-hours for the academy and 35 per 1000 player-hours for the school groups; these rates were statistically different (P = .026). The most common injury site was the lower limb and the most common injury type was a ligament sprain, with injuries to the knee and shoulder region resulting in the greatest burden of injury for both groups. The tackle event was the most common cause of match injury for both academy (51% of injuries) and school (57% of injuries) groups. Conclusion: Overall, the incidence of injury for youth rugby was lower than for previous studies in senior rugby, but injury patterns (location, type) and causes were similar. The study confirmed that match injury incidence was significantly greater in elite academy youth rugby union than schools rugby. The results suggest that the specific focus for injury risk management in youth rugby should be on players’ tackle technique and prevention strategies for knee and shoulder injuries.

Injury and biomechanical perspectives on the rugby scrum: a review of the literature

As a collision sport, rugby union has a relatively high overall injury incidence, with most injuries being associated with contact events. Historically, the set scrum has been a focus of the sports medicine community due to the perceived risk of catastrophic spinal injury during scrummaging. The contemporary rugby union scrum is a highly dynamic activity but to this point has not been well characterised mechanically. In this review, we synthesise the available research literature relating to the medical and biomechanical aspects of the rugby union scrum, in order to (1) review the injury epidemiology of rugby scrummaging; (2) consider the evidence for specific injury mechanisms existing to cause serious scrum injuries and (3) synthesise the information available on the biomechanics of scrummaging, primarily with respect to force production. The review highlights that the incidence of acute injury associated with scrummaging is moderate but the risk per event is high. The review also suggests an emerging acknowledgement of the potential for scrummaging to lead to premature chronic degeneration injuries of the cervical spine and summarises the mechanisms by which these chronic injuries are thought to occur. More recent biomechanical studies of rugby scrummaging confirm that scrum engagement forces are high and multiplanar, but can be altered through modifications to the scrum engagement process which control the engagement velocity. As the set scrum is a relatively ‘controlled’ contact situation within rugby union, it remains an important area for intervention with a long-term goal of injury reduction.

A modified prebind engagement process reduces biomechanical loading on front row players during scrummaging:a cross-sectional study of 11 elite teams.

Aim Biomechanical studies of the rugby union scrum have typically been conducted using instrumented scrum machines, but a large-scale biomechanical analysis of live contested scrummaging is lacking. We investigated whether the biomechanical loading experienced by professional front row players during the engagement phase of live contested rugby scrums could be reduced using a modified engagement procedure. Methods Eleven professional teams (22 forward packs) performed repeated scrum trials for each of the three engagement techniques, outdoors, on natural turf. The engagement processes were the 2011/2012 (referee calls crouch-touch-pause-engage), 2012/2013 (referee calls crouch-touch-set) and 2013/2014 (props prebind with the opposition prior to the ‘Set’ command; PreBind) variants. Forces were estimated by pressure sensors on the shoulders of the front row players of one forward pack. Inertial Measurement Units were placed on an upper spine cervical landmark (C7) of the six front row players to record accelerations. Players’ motion was captured by multiple video cameras from three viewing perspectives and analysed in transverse and sagittal planes of motion. Results The PreBind technique reduced biomechanical loading in comparison with the other engagement techniques, with engagement speed, peak forces and peak accelerations of upper spine landmarks reduced by approximately 20%. There were no significant differences between techniques in terms of body kinematics and average force during the sustained push phase. Conclusions Using a scrum engagement process which involves binding with the opposition prior to the engagement reduces the stresses acting on players and therefore may represent a possible improvement for players’ safety.

Engagement techniques and playing level impact the biomechanical demands on rugby forwards during machine-based scrummaging

Objectives This cross-sectional study investigated the factors that may influence the physical loading on rugby forwards performing a scrum by studying the biomechanics of machine-based scrummaging under different engagement techniques and playing levels. Methods 34 forward packs from six playing levels performed repetitions of five different types of engagement techniques against an instrumented scrum machine under realistic training conditions. Applied forces and body movements were recorded in three orthogonal directions. Results The modification of the engagement technique altered the load acting on players. These changes were in a similar direction and of similar magnitude irrespective of the playing level. Reducing the dynamics of the initial engagement through a fold-in procedure decreased the peak compression force, the peak downward force and the engagement speed in excess of 30%. For example, peak compression (horizontal) forces in the professional teams changed from 16.5 (baseline technique) to 8.6 kN (fold-in procedure). The fold-in technique also reduced the occurrence of combined high forces and head-trunk misalignment during the absorption of the impact, which was used as a measure of potential hazard, by more than 30%. Reducing the initial impact did not decrease the ability of the teams to produce sustained compression forces. Conclusions De-emphasising the initial impact against the scrum machine decreased the mechanical stresses acting on forward players and may benefit players’ welfare by reducing the hazard factors that may induce chronic degeneration of the spine.

Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial

Background Injury risk in youth rugby has received much attention, highlighting the importance of establishing evidence-based injury reduction strategies. Aim To determine the efficacy of a movement control exercise programme in reducing injuries in youth rugby players and to investigate the effect of programme dose on injury measures. Methods In a cluster-randomised controlled trial, 40 independent schools (118 teams, 3188 players aged 14–18 years) were allocated to receive either the intervention or a reference programme, both of which were to be delivered by school coaches. The intervention comprised balance training, whole-body resistance training, plyometric training, and controlled rehearsal of landing and cutting manoeuvres. Time-loss (>24 hours) injuries arising from school rugby matches were recorded by coaches and medical staff. Results 441 time-loss match injuries (intervention, 233; control, 208) were reported across 15 938 match exposure-hours (intervention, 9083; control, 6855). Intention-to-treat results indicated unclear effects of trial arm on overall match injury incidence (rate ratio (RR)=0.85, 90% confidence limits 0.61 to 1.17), although clear reductions were evident in the intervention arm for concussion incidence (RR=0.71, 0.48 to 1.05). When trial arm comparisons were limited to teams who had completed three or more weekly programme sessions on average, clear reductions in overall match injury incidence (RR=0.28, 0.14 to 0.51) and concussion incidence (RR=0.41, 0.17 to 0.99) were noted in the intervention group. Conclusion A preventive movement control exercise programme can reduce match injury outcomes, including concussion, in schoolboy rugby players when compared with a standardised control exercise programme, although to realise the greatest effects players should complete the programme at least three times per week.

Training Activities and Injuries in English Youth Academy and Schools Rugby Union

Background: All rugby training activities carry an injury risk, but in the training environment these injury risks should be more controllable than during matches. Purpose: To (1) describe the incidence, severity, anatomic location, and type of youth rugby training injuries; (2) determine the injury events and type of training activities associated with injuries; and (3) compare 2 levels of play (professional academy vs school) within English youth rugby union. Study Design: Cohort study; Level of evidence, 2. Methods: A 2-season (2006-2007 and 2007-2008) study recorded exposure to training activities and time-loss injuries in male youth rugby union players (age range, 16-18 years) from 12 English Premiership academies (250 player-seasons) and 7 schools (222 player-seasons). Players from the Premiership academies, associated with the top-level professional clubs in England, represented the elite level of youth rugby; the school players were from established rugby-playing schools but were overall considered at a lower level of play. Results: There was a trend for training injury incidence to be lower for the academy group (1.4/1000 player-hours; 95% CI, 1.0-1.7) compared with the school group (2.1/1000 player-hours; 95% CI, 1.4-2.9) (P = .06). Injuries to the ankle/heel and thigh were most common in academy players and injuries to the lumbar spine and ankle/heel region most common in school players. The training activities responsible for injury differed between the 2 groups: technical skills (scrummaging) for school players and contact skills (defense and ruck/maul drills) for academy players. Conclusion: For injury risk management in youth rugby, coaches of school players should focus on the development of the correct technique during practice of technical skills such as scrummaging, weight training, and skills training, and coaches of academy players should consider the extent to which contact drills are necessary during training.

Concussions and Head Injuries in English Community Rugby Union Match Play

Background: Previous research has described general injury patterns in community-level rugby union, but specific information on time-loss head injuries has not been reported. Purpose: To establish the incidence and nature of significant time-loss head injuries in English community rugby match play, and to identify the injury risk for specific contact events. Study Design: Descriptive epidemiology study. Methods: Over 6 seasons, injury information was collected from 46 (2009-2010), 67 (2010-2011), 76 (2011-2012), 50 (2012-2013), 67 (2013-2014), and 58 (2014-2015) English community rugby clubs (Rugby Football Union levels 3-9) over a total of 175,940 hours of player match exposure. Club injury management staff reported information for all head injuries sustained during match play whereby the player was absent for 8 days or greater. Clubs were subdivided into semiprofessional (mean player age, 24.6 ± 4.7 years), amateur (24.9 ± 5.1 years), and recreational (25.6 ± 6.1 years) playing levels. Contact events from a sample of 30 matches filmed over seasons 2009-2010, 2010-2011, and 2011-2012 provided mean values for the frequency of contact events. Results: The overall incidence for time-loss head injuries was 2.43 injuries per 1000 player match hours, with a higher incidence for the amateur (2.78; 95% CI, 2.37-3.20) compared with recreational (2.20; 95% CI, 1.86-2.53) (P = .032) playing level but not different to the semiprofessional (2.31; 95% CI, 1.83-2.79) playing level. Concussion was the most common time-loss head injury, with 1.46 per 1000 player match hours. The tackle event was associated with 64% of all head injuries and 74% of all concussions. There was also a higher risk of injuries per tackle (0.33 per 1000 events; 95% CI, 0.30-0.37) compared with all other contact events. Conclusion: Concussion was the most common head injury diagnosis, although it is likely that this injury was underreported. Continuing education programs for medical staff and players are essential for the improved identification and management of these injuries. With the majority of head injuries occurring during a tackle, an improved technique in this contact event through coach and player education may be effective in reducing these injuries.

The efficacy of a movement control exercise programme to reduce injuries in youth rugby: a cluster randomised controlled trial.

Background Injuries to youth rugby players have become an increasingly prominent health concern, highlighting the importance of developing and implementing appropriate preventive strategies. A growing body of evidence from other youth sports has demonstrated the efficacy of targeted exercise regimens to reduce injury risk. However, studies have yet to investigate the effect of such interventions in youth contact sport populations like rugby union. Objective To determine the efficacy of an evidence-based movement control exercise programme compared with a sham exercise programme to reduce injury risk in youth rugby players. Exercise programme compliance between trial arms and the effect of coach attitudes on compliance will also be evaluated. Setting School rugby coaches in England will be the target of the researcher intervention, with the effects of the injury prevention programmes being measured in male youth players aged 14–18 years in school rugby programmes over the 2015–2016 school winter term. Methods A cluster-randomised controlled trial with schools randomly allocated to either a movement control exercise programme or a sham exercise programme, both of which are coach-delivered. Injury measures will derive from field-based injury surveillance, with match and training exposure and compliance recorded. A questionnaire will be used to evaluate coach attitudes, knowledge, beliefs and behaviours both prior to and on the conclusion of the study period. Outcome measures Summary injury measures (incidence, severity and burden) will be compared between trial arms, as will the influence of coach attitudes on compliance and injury burden. Additionally, changes in these outcomes through using the exercise programmes will be evaluated. Trial registration number ISRTCNN13422001.

Pre-binding prior to full engagement improves loading conditions for front row players in contested rugby union scrums

We investigated the effect of a “PreBind” engagement protocol on the biomechanics of contested Rugby Union scrummaging at different playing levels. “PreBind” requires front‐row props to take a bind on opposing players prior to the engagement, and to maintain the bind throughout the scrum duration. Twenty‐seven teams from five different playing levels performed live scrums under realistic conditions. Video analysis, pressures sensors, and inertial measurement units measured biomechanical outcomes as teams scrummaged following different engagement protocols: the CTPE (referee calls “crouch‐touch‐pause‐engage”), the CTS (“crouch‐touch‐set”), and the PreBind (“crouch‐bind‐set”) variants. PreBind reduced the set‐up distance between the packs (−27%) and the speed at which they came into contact by more than 20%. The peak biomechanical stresses acting on front rows during the engagement phase were decreased in PreBind by 14–25% with respect to CTPE and CTS, without reducing the capability to generate force in the subsequent sustained push. No relevant main effects were recorded for playing level due to within‐group variability and there were no interaction effects between playing level and engagement protocol. Pre‐binding reduced many mechanical quantities that have been indicated as possible factors for chronic and acute injury, and may lead to safer engagement conditions without affecting subsequent performance.