Putting players first with world leading injury audit

The England Rugby Injury & Training Audit 2008-09, the world's largest continuous injury study in professional rugby union, was unveiled today and maps the frequency and risk of injuries at Guinness Premiership and England level.

The sixth season of the study (2008-9) recorded 769 match injuries from the Guinness Premiership, EDF Energy Cup and European competitions and 258 training injuries. An injury is defined as preventing a player from training and/or playing for more than 24 hours.

The results show that the likelihood of sustaining a match injury increased in the 2008-9 season, reversing the downward trend that had been established since the 2002-3 season.

Elite players suffered an extra 119 injuries over the course of the 2008-9 season - an increase of 20 per cent or 0.3 injuries per club per match from the 2007-08 season. In the England Senior team, match injuries fell to 23 from 55 although the small number of matches make it difficult to draw any statistical assumptions in this area.

The average numbers of days' absence as a result of each match injury, at the professional club level, increased from 19 to 23 days.

Consequently, the total number of days absence as a result of match injury increased to 2285 days/1000hrs in 2008-9 compared with 1613 days absence/1,000 hrs in 2007-8 - the highest level reported since the study began in 2002-3.

However, the total number of training injuries decreased from 318 to 258 - a reduction of 19%.

Dr Simon Kemp, RFU Head of Sports Medicine, said: "This audit is pivotal in both providing the baseline data needed to assess trends in injury and in guiding further investigation into injuries that are common, severe or increasing in incidence. It generates robust high-quality data with which to inform risk management.

"What we saw last season was an increase in both the likelihood of a match injury and the length of time an injury keeps a player out.

"It's difficult to be sure as to the precise reasons for this increase but a small increase in two uncommon injuries (anterior cruciate ligament ruptures and foot fractures) both of which typically keep a player out for more than 84 days were responsible for 50 per cent of this increase.

"We now need to integrate the injury audit with a video analysis of the structure of the elite game and of game injury events. This will give us a better understanding of the relationship between changes in the frequency and nature of game events (tackles, rucks, mauls, scrums, lineouts, restarts) i.e. the overall shape of the game and injury risk.

"We have based our recommendations on an accepted injury risk management process. This involves not only improving the quality of the data we collect but also looking to develop how we evaluate and then mitigate risk by involving a multi-disciplinary group, rather than just medics, in the processes. Players, coaches, conditioners, referees, law makers, the disciplinary process all have key roles to play.

"We will be commissioning specific studies into knee anterior cruciate ligament and medial collateral ligament injuries, as well as hamstring injuries which are a continuing source of days lost, so that we can better understand why these injuries occur, how they might be prevented and what we can do to treat them better."

Phil Winstanley, Rugby Director at Premier Rugby, said: "The injury audit is a world leading study that asks when injuries occur, as they will in rugby, why they happen and how we can avoid them in the future. It is another example of the extensive medical work that currently goes on at the Elite level in England, alongside programmes like the Pitchside Immediate Trauma Care course, CogSport and the development of minimum medical provision at all clubs.

"The specific studies into knee ligament and hamstring injuries borne out of this latest report, as well as the monitoring of the impact of the IRB law change at the breakdown, are designed to further improve practice in England and ensure that as the game grows and changes, player welfare remains our primary concern."

Damian Hopley, Chief Executive of the Rugby Players' Association, said: "The increased number of injuries reported in this invaluable audit are of significant concern to the RPA and our members, and the findings reinforce the requirement for further research into acceptable levels of workload and demands made of rugby players by the modern elite game.

"This commitment to further research, seeking to investigate the underlying causes of the rise in injuries, will be crucial in ensuring we continue to optimally manage our players' health, protection and welfare effectively."

Key findings

Match injuries

• 769 match injuries at Guinness Premiership clubs were reported - an average of two injuries per club per match

• Likelihood of sustaining a match injury increased by 20% in 2008-09 compared with 2007-08, but was the same level as the 2002-3 season. This equates to an extra 0.3 injuries per club per match or 119 extra injuries compared with 2007-8

• Average numbers of days absence as a result of each match injury increased from 23 days in 2008-9 compared with 19 in 2007-8

• Consequently, the total number of days absence as a result of match injury increased by 42% to 2285 days/1000hrs in 2008-9 compared with 1613 days absence/1,000 hrs in 2007-8 - the highest level reported since the study began in 2002-3.

• Significant rise in the number of days lost as a result of match knee anterior cruciate ligament (ACL) injuries (117 to 232 days lost/1,000 hrs), match knee medial collateral ligament (MCL) injuries (88 to 154 days lost/1,000 hrs) and match hamstring injuries (74 to 138 days lost/1,000 hrs).

Training injuries

• 258 training injuries at Guinness Premiership clubs reported - an average of 22 training injuries per club per season.

• The likelihood of sustaining an injury during both rugby skills and strength and conditioning training was reduced in 2008-09 by 19% compared with 2007-08

• The total day's absence from playing and training as a result of a training injury sustained during rugby skills and strength and conditioning remained similar to 2007-08

England Senior side

Note: The study includes data from the Elite squad training camp, Autumn Internationals, Six Nations and Argentina summer tour. However the relatively small number of senior England training sessions in the study makes the differences seen in this group much more likely to have arisen by chance rather than to be the result of a true difference.

• In a match situation there were a total of 23 injuries in the senior England side compared to 55 in 2007/8 but given the smaller numbers involved there is no statistical change in risk year on year.

• The likelihood (162/1,000 hrs → 96/1,000 hrs), the average severity of injury (24 days → 8 days) and the total days absence as a result of injury sustained whilst playing for the England Senior side (3876/1,000 hrs → 813/1,000 hrs) all reduced significantly in 2008-09 compared to 2007-08 and was the lowest since the study began in 2002-3

• Compared to 2007-08, there was a reduction from 7.3/1,000 hrs to 6.5/1,000 hrs in the incidence of rugby skill training injuries for the England Senior side but an increase in strength and conditioning incidence from 2.5/1,000 hrs to 12.1/1,000 hrs.

• Largely as a result of two severe injuries which skewed the numbers, the average severity and total day's absence for both England Senior rugby skills training injuries and strength and conditioning injuries increased.

Actions resulting from the 2008-9 audit

Risk estimation

• Injury audit data collection will be integrated with the enhanced electronic player medical record keeping system (EPAS Medical), whose use will be mandatory for all elite players, for the season 2011-12. This will allow both more comprehensive and injury specific data capture and will also allow illnesses also to be reported. This enhanced system of data collection will be piloted during the 2010-11 season prior to implementation for 2011-12.

• Integration of the injury audit with a structured video analysis of the structure of the elite game and game injury events is needed to provide a better understanding of the relationship between changes in the frequency and nature of contact events, the overall shape of the game and injury risk.

Risk evaluation, treatment and prevention

• A multidisciplinary working group will be created representative of all stakeholders across all rugby disciplines within the Elite Game (to include players, elite coaches, medical staff, S&C, referees, discipline, law makers and administrators) in England to accept, consider and evaluate research and injury data and risk, consider injury risk mitigation approaches and to monitor and make proposals to the Professional Game Board on the shape of the elite game

• A multidisciplinary working group will be tasked to:

- minimise the nature of match injury risk by systematic review and analysis of existing laws. This will involve working closely with the existing Laws Group to scope any proposals to potentially amend the laws of the game from a safety perspective

- review how best to optimise players' skills and techniques from a safety perspective by refining coaching practices whilst maximising performance

- optimise the extent players are exposed to the risk of injury to plan appropriate training and playing commitments and ensure adequate recovery

- use injury audit data and evidence from projects to minimise injury risk by ensuring that the laws of the game are consistently applied. This will involve close liaison with the IRB

• Integrated conditioning and medical programmes will be designed to protect players from injury. Priority will be given to developing prevention, treatment and rehabilitation strategies for the highest risk match injuries - shoulder dislocation and instability, ACL injury, MCL injury, hamstring muscle injury, knee meniscal cartilage/articular cartilage injury

• Undertake a structured analysis using video footage to assess the injury mechanism of match Knee Anterior Cruciate Ligament (ACL) injuries and Knee Medial Collateral Ligament injuries (MCL) injuries and in particular establish the extent to which these injuries are contact or non contact injuries. This will inform prevention initiatives.

• Undertake a detailed analysis of current elite game medical and strength and conditioning staff practices regarding hamstring injury prevention, diagnosis, treatment and rehabilitation should now be undertaken

• Continue to improve diagnosis, treatment and rehabilitation processes to reduce days lost from the injuries that cause the longest absences

• Ensure appropriate resources to include facility and personnel resources to develop and deliver injury risk management on the ground at clubs.

• Extending the use of Global Positioning System (GPS) technology already use by the RFU for fitness evaluation into the area of training and match workload and the prevention of injury.