Epidemiology of rugby football injuries
Summary
With the exception of spinal cord injuries, the frequency
and consequences of rugby injuries are not clearly
understood. We therefore conducted a prospective cohort
study involving all the senior rugby clubs in the Scottish
Borders. 1169 (96%) of 1216 eligible players provided
personal details and recorded all 15-a-side matches they
played in the 1993-94 rugby season. Physiotherapists
visited the clubs weekly to liaise with volunteer linkmen
who were appointed to notify the circumstances of all new
or recurrent injuries occurring in matches or rugby-related
training.
361 players experienced 584 injuries in 512 injury
episodes, 84% of which arose in matches. The period
prevalence rate of match injuries was 13·95 (95% Cl
12·64-15·26) per 1000 playing hours, the equivalent of an
injury episode every 1·8 rugby matches. An injury episode
took the player away from the game for an average of 39
days. 28% of injury episodes resulted in absence from
employment or school/college work, for an average of 18
days.
Rugby injuries are an important source of morbidity in
young men. They need to be better understood if their
frequency and consequences are to be reduced.
Lancet 1995; 345: 1485-87
See Commentary page 1452
Department of Public Health Sciences, Medical School, Edinburgh
EH8 9AG, UK (Prof W M Garraway MD); and Department of Surgery,
St John’s Hospital, Livingston, West Lothian (D A D Macleod FRCSE)
Correspondence to: Prof W M Garraway
Introduction
Interest in rugby football injuries has focused largely on
the spinal cord.’ Although other sorts of injury have been
studied at club or regional level, 2-8 the findings are hard to
interpret because of differences in reporting criteria and
incomplete ascertainment. We report here the frequency,
nature, circumstances, and outcome of rugby injuries in a
prospective cohort consisting of virtually all players
registered with senior rugby clubs in the South of
Scotland District of the Scottish Rugby Union (SRU).
Methods
Players were eligible for the survey if members of an SRU-
affiliated senior rugby club in the South of Scotland during the
1993-94 season. All 26 clubs agreed to participate and each
appointed a linkman responsible for injury notification. These
linkmen operated a "cascade" of observers to cover all games
played by the club using a standard closed questionnaire to
record the circumstances of the injuries. They were visited weekly
throughout the season by chartered physiotherapists who ensured I
that the details of each injury were complete and were applicable
to a registered player. All players were contacted at the beginning
of the season for information on playing position and physique;
permission was also sought for examination of their general-
practitioner or hospital medical records should they be injured
during the season. The players were also contacted in the middle
and at the end of the season and invited to complete a diary of
matches played over the previous three months; these diaries
were checked against club fixture lists and the injury register for
completeness. Playing hours at risk were calculated for each
player as number of matches played X I - 33 (each match lasts for
80 min). The outcome of a rugby injury was obtained by
contacting the player after an injury episode, as well as from
hospital and general-practitioner records. Incapacity was
measured as days away from playing or training for rugby and
days lost to employment or school/college work.
A rugby injury was defined as an injury sustained on the field
during a competitive match, during a practice game, or during
other training activity directly associated with rugby football,
which prevented the player from training or playing rugby
football from the time of the injury or from the end of the match
or practice in which the injury was sustained. Rugby injuries
sustained during training were those sustained during practice
scrums or manoeuvres involving a rugby ball (not circuit training
or activities undertaken to achieve fitness). Injuries that
necessitated leaving the field of play or practice and missing the
remainder of the match or practice, but did not cause the player
to miss subsequent matches or practice for at least 7 days, were
classified as transient. Rugby injuries were coded according to
the International Classification of Diseases (9th revision), and
were classified by time to resumption of playing or training:
within 28 days, mild; 29-84 days, moderate; more than 84 days,
severe.
The 26 clubs fielded 1541 teams involving 1216 players in the
1993-94 season, which lasted from August, 1993, to April, 1994.
Complete census and playing records were available for 1169
(96%) eligible players, each of whom participated in an average
of 19.8 matches. 361 of these players experienced 512 injury
episodes resulting in 584 injuries at matches or during training.
In cases of multiple injury, the decision on which injury was
1485
Table 1: Frequency and distribution of injury episodes
primarily responsible for incapacity was
judgment.
Results
Frequency and distribution
Of the 361 players injured, 268 (74%) had 1 injury
episode during the season, 61 (17%) had 2, and 32 (9%)
had 3 or more. 84% of the 429 injury episodes (290
players) occurred in matches and the remainder (71
players) during training. 442 (86%) injury episodes
involved only 1 injury; 70 (14%) involved 2 or more
separate injuries. Table 1 summarises the age-specific
incidence and period prevalence rates of injury. Overall, 1
in every 4 players was injured during the season, with the
highest proportion (43%) in the age group 20-24 years-
more than five times the incidence rate for players under
16 years. The incidence and period prevalence rates mean
that the average team (of 15) can expect to sustain 5-5
new injuries and 1 1 recurrences of old injury during the
season.
Nature and site of injury
96 (22%) injury episodes in matches were transient, 164
(38%) mild, 99 (24%) moderate, and 70 (16%) severe.
Recurrent injuries were not more severe than new ones; as
might be expected, the proportion of recurrent to new
injuries increased with age (from 8% in players under 16
years of age to 39% in players aged 30-34). No spinal
injuries were recorded in 30 750 playing hours of rugby.
Dislocations, strains, and sprains of the knee had the
highest incidence and period prevalence rates (table 2).
iuu coamgs Tor tne site ana nature or eacn injury can oe oolamea Trom tne autnors.
Table 2: Site and nature of primary injuries sustained in matches
1486
occurring in matches
a matter of clinical For fractures the upper limb was most at risk but the
main site of injury (42% of episodes) was the lower limb,
with a much greater frequency of dislocations, strains,
and sprains. 35% of dislocations, strains, and sprains of
the shoulder were recurrent injuries.
Injury association
Injuries were more frequent at the beginning of the
season, with a period prevalence of 15.2 per 1000 playing
hours in the autumn (September-October) and 12.3 in
the spring (March-April). The manoeuvre most strongly
associated with injury was the tackle, accounting for 49%
of injury episodes in matches; the remainder occurred in
the scrum (8%), ruck (15%), maul (2%), lineout (12%),
while gathering the ball (8%), or away from play in other
circumstances (6%). Of the severe injury episodes, 60%
occurred while players were tackling or being tackled. 6
out of 11I lower limb fractures and 37% of knee
dislocations, ligament, and cartilage tears occurred while
players were on the receiving end of a tackle, whereas
45% of shoulder dislocations, strains, and sprains arose in
players who were doing the tackling. There were no
significant differences in the proportion of injury episodes
according to playing position, but injuries to the trunk
(mainly back strain and sprain) were three times more
frequent in forwards than in backs. In centres and wing
threequarters 4 out of every 5 injury episodes were
associated with the tackle.
Outcome
19 741 playing days were lost to matches and training
 overuse can only be established by continuing follow-up
of this cohort of players.
A remarkably high response rate was achieved by use of
field staff who maintained personal contact with
nominated club representatives throughout the season.
This is the approach that others must adopt and refutes
the view that registration of rugby injuries cannot be
enforced because Rugby Union, being an amateur
game, relies on the goodwill and enthusiasm of unpaid
officials. 10
Like a more limited study in selected clubs," our
investigation has revealed a high level of incapacity due to
injury. Apart from time lost from the game or training,
this has economic implications. In 28% of injury episodes
players lost time from employment or education-a mean
of 18 days.
This survey is not the first to highlight the dangers of
tackling and being tackled in rugby.12.13 More needs to be
known about the frequency and circumstances of tackling
so that players can be coached in tackling techniques that
are safe for themselves and their opponents. The
overwhelming contribution of the tackle to injury episodes
could reflect recent law changes that encourage open play
conducted at higher speeds to enhance the game as a
flowing spectator sport. The challenge now is to sustain
*Mean (SE); tno (%). the popularity of the game while lessening the hazard of
Table 3: Loss of playing time and length of absence from high-velocity contact in the tackle. A first step is to set up
employment or education cohort studies in other locations, with the same
definitions and methods, to allow comparison of rugby
during the 1993-94 season. Table 3 shows the loss of
rugby-playing days for each group of primary injuries. A injuries in different playing environments. The
International Rugby Football Board is in an excellent
period prevalence rate of 2-34 per 1000 playing hours
together with a mean of 60-4 (SE 9-2) days of lost playing position to guide and coordinate this work.
time meant that knee injuries were responsible for 25% of We thank George Murray, district secretary for the South of Scotland; the
all playing time lost through injury episodes in matches. presidents and linkmen of participating rugby clubs; Gregor Nicholson,
28% of primary injuries in matches lost the player time administrative secretary, SRU; Sue Davidson, our survey coordinator and
the chartered physiotherapists of the Fitness Assessment and Sports
from work, school, or college. Training injuries accounted
Injuries Centre, University of Edinburgh Department of Physical
for 15% (372 days) of time away from employment or Education; Lyn Chalmers for computing support; Mandy Lee for
education. Injured players lost an average of 18 days’ statistical advice; Ann Cocallis and Caroline Adams for secretarial
services; and, finally, the rugby players of the Scottish Borders for their
employment or education (table 3). Fractures at all sites outstanding cooperation.
caused most absence. Again, the tackle emerged as an
important contributor to injury episodes. Tackling in
games was associated with 22% of injury episodes and References
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