Recent Trends in Rugby Union Injuries

John H.M. Brooks, PhD

*
, Simon P.T. Kemp, MA, MBBS
The Rugby Football Union, Rugby House, Rugby Road, Twickenham, TW1 1DS, UK
S
ince its widely accepted origins in Rugby School, England in 1823, and
the subsequent split from rugby league in 1895, rugby union has evolved
into the popular international sport that is played today. More than three
million people across the world in more than 100 countries across ve conti-
nents play the sport annually [1,2], making rugby union one of the worlds
most popular participation team sports. It is played by men, women, boys,
and girls [1] ranging in age from 6 to 60 (there are some players over the
age of 60, although the numbers are very small) [2].
The object of the game is that two teams, each of fteen players, on a eld
measuring a maximum of 100 m by 70 m plus two in goal areas (end zones),
observing fair play, according to the rules governed by the International Rugby
Board (IRB) [3] and in a sporting spirit should, by carrying, passing, kicking,
and grounding the ball, score as many points as possible. There are some
rule variations for players under 19 years old and for seven-a-side rugby union
[3]. The game has evolved greatly since the nineteenth century, primarily as
a consequence of rule modications and events that have invariably changed
the manner in which the game is played; some of these have been summarized
in Table 1. In particular, a large number of rule changes were introduced in the
early 1990s with the aim of optimizing the length of time that the ball is actually
in play.
As with all sport, there is a risk of sustaining injury while playing rugby
union; this risk appears to be higher than in many other sports [4], primarily
because of the contacts and collisions that are an integral part of the game.
In extremely rare circumstances, a rugby union injury can result in catastrophic
injury [5]. In rugby union, a brain or spinal cord injury that results in perma-
nent (>12 months) severe functional disability is referred to as a nonfatal cat-
astrophic injury [6]. From a safety perspective, rules and rule changes have
been focused on reducing the risk of catastrophic or very serious injury. For
example, dangerous tackles, which include the high tackle (a tackle made above
the line of the ball carriers shoulder) and the spear tackle (where the ball car-
rier is upended and driven head rst into the ground), are outlawed. Relatively
recent changes made to the rules have included mandating the use of suitably
*Corresponding author. E-mail address: johnbrooks@rfu.com (J.H.M. Brooks).
0278-5919/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.csm.2007.09.001 sportsmed.theclinics.com
Clin Sports Med 27 (2008) 5173
CLINICS IN SPORTS MEDICINE
trained and experienced front-row forwards in the scrum and controlling the
scrum engagement process (there are separate scrum rules for players under
19 years old that prevent excessive wheeling and pushing). Unfortunately
the inuence of these rules and rule changes on the risk of injury have not
to date been tested objectively.
The most major recent event in the game occurred after the 1995 Rugby
World Cup, when rugby union became professional at the elite level. Profes-
sional full-time training has resulted in increased player skill, strength, power,
and tness, as well as increasing the body mass (Figs. 1 and 2) of the elite
players. Consequently, the speed and force of collisions between players has
increased, as well as the length of time the ball is actually in play for (and there-
fore the time players are exposed to injury). For example, the ball-in-play time
increased from 1603 seconds at the Rugby World Cup in 1995 to 1997 seconds
in 2003 (a 25% increase) [19]. Analysis of Bledisloe Cup matches (contested by
Table 1
Some of the major law changes and events affecting the game
Year Law change/event
1823 William Webb Ellis rst ran with the ball in his hands during a game of
football (soccer).
1871 Rugby Football Union formed and the rst set of laws published
1886 International Rugby Football Board formed (now the IRB)
1877 Number of players per team reduced from 20 to 15
1893 A try is worth 3 points (previously 0, 1, and 2).
1895 Split between rugby union (amateur) and rugby league (professional) is
initiated
1948 Drop goal is worth 3 points (previously 4 points)
1971 A try is worth 4 points.
A goal from mark is abandoned.
1982 Introduction of the 1 m gap between teams in the lineout
1992/1993 A try is worth 5 points.
Referees control (crouch-pause-engage) of the scrum introduced
Replacement of a maximum of four players because of injury
Direct kick to touch outside the 22 m line outlawed
Penalties, free-kicks, and lineouts allowed to be taken quickly
The back-row of the scrum must remain bound until the ball is out.
1994 Use it or lose it law in maul introduced
Tackle law changes: the tackling player has to release the ball and attempt to
move away, the tackled player has to play the ball, and supporting players
have to remain on their feet
1995 Rugby union becomes open, removing restrictions on player payments and
benets
1996 Lineout supporting permitted
1997 Noninjury replacements allowed
2000 Red and yellow cards for misconduct introduced
2001 A scrum is awarded to the opposition if the scrum is wheeled though a 90

angle
2007 Scrum engagement sequence changed to (crouch-touch-pause-engage)
52 BROOKS & KEMP
New Zealand and Australia since the early 1930s) between 1972 and 2004 has
also revealed a number of trends in the match activities since the advent of pro-
fessionalism [20]. Professionalism resulted in an increase in ball in play time by
19% per match, an increase in the number of tries by 72%, and increases in the
number of tackles (51%) and rucks (63%) per match [20]. Simultaneously there
was a reduction in the mean time played by each player per match (16%), and
despite the increase in ball in play time, there were reductions in the number of
kicks during play (30%), mauls (25%), scrums (8%), and lineouts (14%) [20]. It
was suggested that these trends were caused by a number of factors, including
the numerous rule changes that have resulted in a more open game [20]. Nev-
ertheless, the vast majority of the worlds three million plus players are still am-
ateurs, and it is unclear whether these trends have also been seen in the
amateur game.
85
95
105
115
1982 1987 1992 1997 2002
[7]
[9]
[8]
[11]
[10]
[12]
[18]
[17]
[16]
[15]
[14]
[13]
B
o
d
y

M
a
s
s

(
k
g
)
Year of measurement
International
forwards
Senior 1st class
forwards
Fig. 1. The measured body mass of international and senior rst-class forwards.
75
85
95
1982 1987 1992 1997 2002
[7]
[9]
[8]
[11]
[10]
[12]
[18]
[17]

[16]
[15]
[14]
[13]
B
o
d
y

M
a
s
s

(
k
g
)
Year of measurement
International backs
Senior 1st class backs
Fig. 2. The measured body mass of international and senior rst-class backs.
53 RECENT TRENDS IN RUGBY UNION INJURIES
RUGBY UNION INJURY LITERATURE METHODOLOGIES
Rugby union injury literature to date has been dominated by epidemiological
studies [18,2126], case reports [2732], and reports of nonfatal catastrophic
spinal injuries [5]. Prospective epidemiological studies are particularly useful
for identifying injuries of highest incidence and severity, and more importantly,
those of highest risk (a product of incidence and severity) [33,34] in different
cohorts of players. These injuries can be subsequently targeted for prevention
strategies (with the aim of reducing the incidence of injuries) and treatment and
rehabilitation strategies (with the aim of reducing the severity of injuries) to re-
duce the overall injury risk. Epidemiology plays a key role in assessing the ef-
fectiveness of these strategies [35,36].
Since the introduction of professionalism in 1995, the number of rugby
union injury epidemiological publications has increased; a disproportionate
number of these studies have investigated injuries sustained by professional
players [12,25,26,37,38] rather than amateur players [23,3942]. Better resourc-
ing of the medical personnel within the professional game appears to afford
more opportunity for research to be conducted, and for more detailed clinical
coding of injuries to be performed by clinicians. The vast majority of the
worlds three million plus players still play the game without remuneration,
however; therefore the majority of the injury risk is incurred by these players.
Unfortunately there is still a lack of published data available on injuries in am-
ateur rugby union and other discrete cohorts such as the womens game and
players from less developed unions (Table 2), particularly in the past 10 years.
There is a widespread assumption that the ndings of the large number of ep-
idemiological studies of professional players translates to other cohorts of
players in different countries; however, this has yet to be tested.
Despite previous attempts to dene data collection instruments in rugby
union [68,69], major inconsistencies in the methodologies used in epidemiolog-
ical studies make inter-study comparisons very difcult or inaccurate [34]. For
example, a broad spectrum of injury denitions have been employed, from
those injuries resulting in emergency department or sports medicine clinic treat-
ment [44,7074] through those causing absence from a match [26,67] or train-
ing session [18,37], to all physical complaints [41]. An IRB consensus statement
on injury denitions and data collection procedures for studies of injuries in
rugby union has recently been published [6], which should improve the consis-
tency of the methodologies employed in research studies and aid future inter-
study comparability.
INJURIES SUSTAINED DURING MATCHES
Match injuries constitute the largest proportion of the rugby-related injuries re-
ported in epidemiological studies, typically contributing 80% to 90% of all in-
juries [18,23,25,37,45,48], although the proportion depends on a number of
factors, but predominately the ratio of training to match play. The risk of sus-
taining an injury in a rugby union match appears to be higher than in many
other sports [4,41], irrespective of the denition of injury (Figs. 3 and 4);
54 BROOKS & KEMP
Table 2
Prospective rugby union epidemiological publications
Playing population
Studies conducted
pre-professionalism
(up to 1995)
Studies conducted
post-professionalism
(since 1995)
Male senior elite tournaments

Rugby World Cup
qualifying [42]

Rugby World Cup [24]

Rugby World Cup [26]

Male senior elite teams

Australia [21,22]

England [43]

England and Wales [44]

Australia [25]

England [12,18,45]

New Zealand [37]

Scotland [46]

South Africa [38]

Female senior elite
tournaments

None

None
Female senior elite teams

None

England [47]
Male senior non-elite
tournaments

None

None
Male senior non-elite teams

Argentina [39]

England [52]

Ireland [53]

New Zealand [23,50,51]

a

Scotland [48,49]
a

South Africa [54]

Croatia [40]
Female senior non-elite
tournaments

None

None
Female senior non-elite teams

New Zealand [23]
a

None
Students

England [56]

South Africa [55]

None
Male elite U21/U19

None

None
Male non-elite U21/U19

Scotland [48,49]
a

None
School-boy elite tournaments

None

None
School-boy elite teams

None

Australia [57]
School-boy non-elite
tournaments

None

None
School-boy non-elite teams

Australia [6062]

England [63]

New Zealand [23,50,51]

a

Scotland [49]
a

South Africa [58,59]

New Zealand [41,64]

School-girl non-elite
tournaments

None

None
School-girl non-elite teams

New Zealand [23]
a

None
Sevens

None

None
Various teams

Australia [66]

Ireland [65]

Scotland [67]

None
a
Part of a multicohort study.
55 RECENT TRENDS IN RUGBY UNION INJURIES
however, although there has been considerable variation in the exact incidence
of match injuries reported, the incidence is much lower in senior amateur (15
74 injuries per 1000 player hours) [23,48], school-boy (7.028) [41,59,64] and
women (3.67.1) [47,83] players compared with professional players (68218
injuries per 1000 player hours) [12,18,25,26,37,46]. These differences in inci-
dence reported within specic cohorts can be often explained by variations
in the denition of injury employed in each study; nevertheless, injury inci-
dence is consistently reported to rise with age and competitive level
[12,18,23,46,48,58,59,64].
0
50
100
150
200
250
I
n
t
e
r
n
a
t
i
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a
l

r
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l

c
r
i
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e
t
C
l
u
b

c
r
i
c
k
e
t
[12]
[75] [75]
[18]
[78] [78]
[77]
[76]
I
n
j
u
r
i
e
s

(
1
,
0
0
0

h
r
s
)
Fig. 3. The incidence of injury in elite rugby union compared with other elite sports using
a time-loss [6] from training or match play denition of injury.
0
25
50
75
I
n
t
e
r
n
a
t
i
o
n
a
l

r
u
g
b
y

u
n
i
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C
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r
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r
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y

l
e
a
g
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e
C
l
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A
u
s
t
r
a
l
i
a
n

r
u
l
e
s
C
o
l
l
e
g
i
a
t
e

A
m
e
r
i
c
a
n

F
o
o
t
b
a
l
l
I
n
t
e
r
n
a
t
i
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n
a
l

s
o
c
c
e
r
C
l
u
b

s
o
c
c
e
r
[12]
[82]
[76]
[81]
[80]
[79]
[18]
I
n
j
u
r
i
e
s

(
1
,
0
0
0

h
r
s
)
Fig. 4. The incidence of injury in elite rugby union compared with other elite sports using an
absence from subsequent matches denition of injury.
56 BROOKS & KEMP
The introduction of professionalism in 1995 appears to have increased the
incidence of injuries in both the amateur [46] and professional games [25,46].
The greater ball-in-play time and increases in the number of tackles and rucks
demonstrated in the professional game appear to have been mirrored in the
amateur game. Nevertheless, more evidence is required to conrm the change
in proportion of match activities and higher incidence of injuries in amateur
rugby in the professional era.
Injury Prole
Classication systems for recording the injury diagnosis have differed between
studies. For example, the International Classication of Diseases [46,48], the
Orchard Sports Injuries Classication System [12,18,21,45], and the diagnosis
dened by anatomical location and pathology [25,37] have all been used. This
lack of uniformity makes it more difcult to compare differences in the detail of
the injury prole among studies; nevertheless, a number of general trends are
evident.
The lower limb is the most common injury location, with the proportion of in-
juries sustained ranging from 41% to 55% [12,23,25,37]. More specically, the
knee [23,25,37,46,84], the thigh [23,25,85], and the ankle [23,25,37] have been
the most commonly injured lower limb locations reported. As well as being the
most common injury sites in rugby union, injuries to the lower limbs appear to
be disproportionately severe, in particular knee joint injuries [21,25,37,
46,84,86]. Medial collateral ligament (MCL), chondral/ meniscal and patellofe-
moral/extensor mechanisminjuries are the most commonknee injuries; however,
anterior cruciate ligament (ACL) and MCLinjuries cause the greatest proportion
of absence [84]. Thigh hematomas and hamstring muscle injuries are the most
common thigh injuries [18,85]; the impact of hamstring muscle injures in partic-
ular on the overall injury burden may be reduced by appropriate hamstring train-
ing and rehabilitation of these injuries [85]. Lateral ankle ligament injuries are the
most common ankle injury, and together with Achilles tendon injuries make up
the greatest proportion of the absence caused by ankle injuries [18].
Head and noncatastrophic neck injuries frequently represent the next highest
proportion, ranging from 12% to 33% of all injuries [12,23,25,37], although var-
iations in the denition of injury employed can alter these proportions signi-
cantly [87]. Lacerations of the head and face [25,37] and concussions are the
most common head and neck injuries [23,25,37], followed by facial fractures
[87]. The upper limb represents a smaller proportion of the injuries (15%
24%) [12,23,25]; of these, the shoulders receive the greatest proportion
[25,88]. Shoulder injuries also appear to be disproportionately severe [25,88].
Acromioclavicular joint and rotator cuff injuries are the most common shoul-
der injuries, although shoulder dislocations and episodes of shoulder instability
cause the greatest proportion of the absence caused by shoulder injuries [88].
The injury prole in schoolboy players is similar to the prole seen in senior
players, but is characterized by a higher proportion of upper limb injuries
[41,58,62].
57 RECENT TRENDS IN RUGBY UNION INJURIES
Playing Position
In epidemiological studies using smaller cohorts of players (often one team) the
incidence and proportion of injuries has been reported to be higher in both the
forwards [12,25,37] and backs [12]; however, in studies with a larger cohort of
players, the difference in the incidence of injury between forwards and backs is
negligible [18,62,89]. The individual playing position with the highest inci-
dence of injury has varied widely between studies. The number 8s [37], locks
[25,89], and hookers [18] amongst the forwards, and the full backs [37], y-
halves [25], and outside centers [18] amongst the backs have the highest
incidences.
Few studies have investigated the injury prole of both forwards and backs
[18,23], although there does appear to be a difference. In a study of amateur
players, which included a mixture of school children, men, and women in
the cohort [23], the most common injury locations for forwards were the
head (23%), shoulder (10%), neck (9%), and knee (9%) (more commonly upper
body injuries), whereas for backs they were the knee (17%), ankle (10%), thigh
(10%), and shoulder (10%) (more commonly lower limb injuries). In a study of
professional players, differences in the injury prole between forwards and
backs were also identied (Table 3) [18]; for example, with the exception of
calf muscle injuries, lower limb muscle strains were all more common in backs
compared with forwards.
Injury Incident
The majority of rugby union injuries are sustained in contact or collisions with
other players [12,18,23,25,37], and the tackle (involving the ball carrier and
tacklers) accounts for approximately half of all match injuries [23,25,37,46].
Studies distinguishing between tackling and being-tackled as injury events re-
port that similar proportions of injuries occurred during each [23,24], or report
a higher proportion to be sustained while being tackled [18,22,38,46]. Tackles
are also the most common cause of some of the most high-risk rugby union in-
juries, including shoulder dislocations/episodes of shoulder instability [88],
ACL injuries, MCL injuries, chondral or meniscal injuries of the knee [84],
and concussions [87]. After the tackle, the ruck and maul [18,23,25,37] and
open play or running (without contact or collision with another player)
[18,23,25,37] are the most common injury events. A small proportion of in-
juries have been reported to occur in the scrum (2%8%) [18,23,25,37]. These
trends in injury events largely reect the frequency of events during a match,
with the tackle and the ruck being the most common [6] game events. Despite
the introduction of professionalism and a number of rule changes that have al-
tered the frequency of events during matches [20], the injury prole as a func-
tion of inciting event was reported to be similar before these changes
[22,49,50,54]. When the number of events in a match and the number of
days absence caused by injury are taken into account, the propensity for injury
is highest in collisions and the scrum [90].
58 BROOKS & KEMP
INJURIES SUSTAINED DURING TRAINING
Alarge number of rugby union players spend a greater proportion of time taking
part in training activities for rugby than playing matches. Nevertheless, training
injuries typically only constitute between 10% and 20% of all injuries in senior
rugby union [18,23,25,37,45,48], although the proportion appears to be higher
in schoolboy rugby union (21%37%) [41,58,59]. This difference may be be-
cause of the greater proportion of time spent in higher risk game-related training
activities at the schoolboy level. It is more difcult for researchers to collect accu-
rate injury data, and particularly exposure data, during training, especially in am-
ateur cohorts, and consequently much less is known about the detail of training
injuries sustained by rugby union players compared with match injuries.
The incidence of injury in training is signicantly lower than during matches.
This has been reported in all levels. In professional rugby union there were 2.0
training injuries per 1000 player-training hours compared with 91 match injuries
per 1000 player-match hours in senior players [18,45], and 6.1 training injuries
per 1000 player-training hours compared with 218 match injuries per 1000
Table 3
The most common match injury diagnoses for forwards and backs
Forwards Backs
Rank Injury diagnosis
Incidence
(injuries per
1000 hours) Rank Injury diagnosis
Incidence
(injuries per
1000 hours)
1 Hematoma, thigh 7.4 1 Hematoma, thigh 8.7
2 Calf muscle injury
a
5.7 2 Hamstring muscle
injury
a
8.6
3 Lateral ankle
ligament injury
4.5 3 Concussion 4.9
3 Cervical nerve
root injury
4.5 4 Hematoma,
calf/shin
4.0
5 Concussion 4.0 5 Lateral ankle
ligament injury
3.8
6 Acromioclavicular
joint injury
3.6 6 Hip exor/
quadriceps
muscle injury
a
3.2
7 Hematoma,
calf/shin
3.3 7 Adductor muscle
injury
a
3.1
8 MCL injury 3.1 7 MCL injury 3.1
9 Costochondral/
sternal injury
3.0 9 Calf muscle injury
a
3.0
9 Hamstring muscle
injury
a
3.0 10 Acromioclavicular
joint injury
2.1
10 Knee meniscal/
articular cartilage
injury
2.1
a
Excluding hematomas/contusions.
From Brooks, JHM, Fuller, CW, Kemp, SPT, et al. Epidemiology of injuries in English professional rugby
union: Part 1. match injuries. Br J Sports Med 2005;39(10):761; with permission.
59 RECENT TRENDS IN RUGBY UNION INJURIES
player-match hours in senior international players [12]. At the amateur level
there were 1.2 training injuries per 100 player practices compared with 9.9 match
injuries per 100 player matches [23], and 1.3 training injuries per 1000 player-
training hours compared with 45 match injuries per 1000 player-match hours
[22]. In school-boy rugby union there were 1.2 training injuries per 1000
player-training hours compared with 8.4 match injuries per 1000 player-match
hours [58]. The incidence of training injuries also appears to increase with an in-
crease in the age and standard of play [23,58]. Although the incidence of training
injuries is signicantly lower than during matches, training injuries appear to be
of greater severity [18,25,45]. For example, shoulder dislocation/episodes of
shoulder instability, knee meniscal/articular cartilage injuries, and MCL injuries
all have a greater average severity during training [18,45].
Injury Prole
The lower limb is also the most common injury location in training [12,23],
most commonly the thigh and ankle [12,23]. In amateur players, a similar pro-
portion of upper limb (21% and 24%) but fewer head and noncatastrophic neck
injuries (10% and 25%) have been reported in training compared with matches
[23]. The high volume of running, in comparison with contact or collision ac-
tivities (which mimic matches), performed in training may explain the greater
proportion of lower limb injuries seen in training compared with matches.
A higher proportion of injuries reported during training have been muscle
strains and ligament sprains compared with matches [23]; this is most evident
for injuries to the lower limb, where hamstring, calf and hip exor/quadriceps
strains and lateral ankle ligament injuries are all common (Table 4). Muscle
strains and tears occur commonly in non-contact running activities, and there-
fore the high volume of running activities performed in training may explain
the higher incidence of lower limb muscle strains sustained during training
[25,45]. Injuries such as muscle hematomas, lacerations, fractures, dislocations,
and concussions that are more commonly sustained during contact/collision ac-
tivities are less common during training because of the low proportion of train-
ing involving this type of activity [23,45]. The injury prole of forwards and
backs is more similar during training than it is during matches [23] (see Table
4) and this may be as a result of greater similarity in training programs between
forwards and backs [45].
Training Activities and Injury
The incidence [45] and days absent (risk) [91] of injuries sustained during dif-
ferent training activities appears to be activity-specic. Training activities such
as tness testing, defense, and rucking and mauling are identied as high risk,
whereas lower-risk training activities include general play/phase work, set piece
training, and conditioning training [91]. The number of injuries and subsequent
days absent caused by training injuries is therefore dependent on the type and
volume of different training activities performed. The prole of the injuries sus-
tained while performing specic training activities is also variable; for example,
the most common weight training injuries are lumbar disc/nerve root injuries,
60 BROOKS & KEMP
whereas the most common endurance training injuries are hip exor/quadri-
ceps muscle injuries [45].
INJURY SEVERITY, INJURY RISK, AND INJURY RISK FACTORS
Reporting trends in the frequency of injuries in rugby union injury epidemiol-
ogy (the incidence) without taking account of the severity of injuries may fail to
highlight the injuries of greatest concern. Although a large proportion of the
injuries reported in rugby union epidemiology allow a player to return to
play within 7 days [12,18,25,37], it is often the more severe injuries that to-
gether cause the greatest total absence. Therefore a measure of injury risk
that considers the days absent caused by injury per exposure time, a product
of incidence and severity [34,92], is a more pertinent indicator of the impact
of injuries. The injuries causing the greatest total absence from playing and
training are those that should be the primary focus of injury prevention and
best practice treatment plans to reduce the risk of injury (Tables 5 and 6).
These may not necessarily be either the most common or the most severe in-
juries reported [18,45].
In 1991 Meeuwisse [93] emphasized the importance of identifying causal re-
lationships between risk factors and injuries in epidemiological studies, and
some recent studies have been successful in identifying specic intrinsic and ex-
trinsic injury risk factors in rugby union players. Ligament laxity [94], lumbo-
pelvic stability [95], ground and weather conditions [96,97], time of the season
Table 4
The most common training injury diagnoses for forwards and backs
Forwards Backs
Rank Injury diagnosis
Incidence
(injuries per
1000 hours) Rank Injury diagnosis
Incidence
(injuries per
1000 hours)
1 Hamstring
muscle injury
a
0.28 1 Hamstring
muscle injury
a
0.32
2 Lumbar disc/
nerve root
injury
0.19 2 Calf muscle
injury
a
0.18
2 Lateral ankle
ligament injury
0.19 3 Hip exor/
quadriceps
muscle injury
a
0.17
4 Calf muscle
injury
a
0.17 4 Adductor muscle
injury
a
0.10
5 Hip exor/
quadriceps
muscle injury
a
0.15 4 Lateral ankle
ligament injury
0.10
a
Excluding hematomas/contusions.
From Brooks, JHM, Fuller, CW, Kemp, SPT, et al. Epidemiology of injuries in English professional rugby
union: Part 2. training injuries. Br J Sports Med 2005;39(10):771; with permission.
61 RECENT TRENDS IN RUGBY UNION INJURIES
[18,98], previous injury experience [89,98], physical tness or level of activity
[89,98], training volume [91], age or experience [89,98], and physique [89,98]
have all been reported risk factors in rugby union players.
The rugby union epidemiology to date has provided a good level of data on
which to base both preventative and therapeutic interventions (the rst two
stages of the van Mechelen cycle of injury prevention [35]). Investigating the
epidemiology of specic injuries (or injury locations) in detail is particularly
useful for coaches, strength and conditioners and clinicians, allowing them to
target certain high-risk playing groups with injury-specic prevention pro-
grams. For example, the head (including concussions) [87], spine [99,100],
shoulder [88,101], hamstring [85,102], knee [84,86], and ankle [103] have all
been the subject of rugby union specic-injury research papers; however,
much more detailed information is still required on specic injuries, particularly
for non-elite populations, and evidence of the introduction of preventative and
therapeutic interventions and their effectiveness in rugby union is limited to
date (stages 3 and 4) [35].
Table 5
Match injury diagnoses causing the greatest number of days absence for forwards and backs
Forwards Backs
Injury
Total
days
absence
Days
absence/
1000 hrs Injury
Total
days
absence
Days
absence/
1000 hrs
ACL injury 988 110 Hamstring muscle
injury
a
1176 151
Knee meniscal/
articular cartilage
injury
923 103 Dislocation/
instability,
shoulder
957 123
Dislocation/
instability,
shoulder
746 83 MCL injury 870 111
Achilles tendon
injury
726 81 ACL injury 815 104
MCL injury 718 80 Knee meniscal/
articular cartilage
injury
545 70
Calf muscle injury
a
691 77 Wrist/hand fracture 488 62
Cervical nerve root
injury
586 65 Lateral ankle
ligament injury
434 56
Concussion 514 57 Hematoma, thigh 414 53
Acromioclavicular
joint injury
495 55 Concussion 397 51
Rotator cuff/
shoulder
impingement
481 54 Lumbar disc/nerve
root injury
367 47
a
Excluding hematomas/contusions.
From Brooks, JHM, Fuller, CW, Kemp, SPT, et al. Epidemiology of injuries in English professional rugby
union: Part 1. match injuries. Br J Sports Med 2005;39(10):762; with permission.
62 BROOKS & KEMP
PADDED EQUIPMENT AND MOUTH GUARDS
One potential method of reducing injury risk is by the wearing of padded
equipment and mouth guards; although there is no stipulation that this equip-
ment must be worn in the rules of the game. Shoulder pads, headgear, and
chest pads that are worn during matches must be no thicker than 1 cm
when uncompressed (0.5 cm for padding on other areas) and be no denser
than 45 kg per cubic meter [3]. Helmets, padded headgear, and shoulder
pads are used in many other collision and contact sports to prevent head
and shoulder injuries. Research to date, however, both eld and laboratory, in-
dicates that padded headgear does not reduce the incidence of concussion in
rugby union [104106], and that shoulder pads do not reduce the incidence
of shoulder injuries [88], although Jones and colleagues (2004) [107] demon-
strated a reduction in the incidence of supercial scalp and facial injuries in
Table 6
Training injury diagnoses causing the greatest number of days absence for forwards and
backs
Forwards Backs
Injury
Total
days
absence
Days
absence/
1000 hr Injury
Total
days
absence
Days
absence/
1000 hr
Lumbar disc/nerve
root injury
840 7.5 Hamstring muscle
injury
a
502 6.0
Dislocation/
instability,
shoulder
491 4.4 ACL injury 489 5.8
Hamstring muscle
injury
a
478 4.3 Dislocation/
instability,
shoulder
296 3.5
Achilles tendon
injury
402 3.6 Adductor muscle
injury
a
249 3.0
Lateral ankle
ligament injury
332 3.0 Knee meniscal/
articular cartilage
injury
194 2.3
Calf muscle injury
a
322 2.9 Calf muscle injury
a
140 1.7
MCL injury 286 2.5 Hip exor/
quadriceps muscle
injury
a
114 1.4
Tibia/bula fracture 263 2.3 Acromioclavicular
joint injury
101 1.2
Knee meniscal/
articular cartilage
injury
234 2.1 Lumbar disc/nerve
root injury
82 1.0
Acromioclavicular
joint injury
207 1.8 Stress fracture, foot 79 0.9
a
Excluding hematomas/contusions.
From Brooks, JHM, Fuller, CW, Kemp, SPT, et al. Epidemiology of injuries in English professional rugby
union: Part 2. training injuries. Br J Sports Med 2005;39(10):772; with permission.
63 RECENT TRENDS IN RUGBY UNION INJURIES
selected positions when headgear was worn. In fact, most commercially avail-
able IRB-approved rugby headgear fails to meet the impact-testing criteria that
would be typically needed to prevent sport-related concussion [105]. Labora-
tory testing of thicker and denser padded headgear showed that impact atten-
uation could be improved, but possibly not to a level consistent with the
impacts observed to produce concussion in unhelmeted footballers [106].
Mechanisms for shoulder injuries incurred during contact sports have been
described previously [108,109]; tissue damage is attributed to the absorption
and transmission of forces by neuromusculoskeletal structures of the shoulder.
It might be expected that shoulder padding would offer some protection against
these injuries; however, the thickness and density limitations limit their protec-
tion potential, and to date the effectiveness of padding as protection from shoul-
der injuries in rugby union is a matter of contention [88,110].
Mouth guard use, principally to reduce dental injury, is strongly encouraged
but not mandated within rugby union; although a New Zealand Rugby Union
domestic safety rule mandates compulsory wearing of a mouth guard in all
matches below international level in New Zealand. Mouth guard use and den-
tal injuries in rugby union have also been the focus of considerable research
[111119]. There is a commonly held belief that wearing a mouth guard will
also reduce the chance of sustaining a concussion. The evidence for this is
based on a combination of self-reported histories of dental injury before the
use of mouth guards [119,120] and retrospective injury surveys. In a large
cross-sectional survey of university rugby, no signicant protective effect for
any type of injury was shown in mouth guard users [115], although other au-
thors have found different results, particularly with respect to dental injuries
[121]. The current consensus view is that the wearing of mouth guards does
not reduce the incidence of concussion in rugby [122]. Unlike headgear, there
is no international standard for mouth guards, which makes comparison be-
tween studies difcult [122].
CATASTROPHIC SPINAL INJURIES
Little is known about noncatastrophic spinal injuries [99,100]; however, non-
fatal catastrophic (spinal) injuries [6] have received considerable focus in the
medical literature over several decades [5,123143] because of their devastating
consequences. Nevertheless, these injuries are extremely rare (reported to be
around 1 per 10,000 players per season [137]), and the vast majority of them
are sustained in the tackle and the scrum [5]. There have been a number of
changes to the rules of the game in an attempt to reduce the risk of these in-
juries, and it is possible that these changes have reduced the incidence of non-
fatal catastrophic spinal injuries; however, this has not objectively tested.
Because of the rarity of these injuries, the case for an aggregated database or
international case register of catastrophic cervical spine injuries was made some
time ago [144], and continues to be made by medical personnel working in the
game. The challenges that need to be overcome to consistently and accurately
collect such data have been well-described [5]. The theoretical denition of
64 BROOKS & KEMP
nonfatal catastrophic injury was agreed on in the recent injury consensus state-
ment [6], and there are now national case registers in the major rugby playing
nations, but there is no international register of such injuries currently. The
lack of a consistent game-wide operational standard for reporting these injuries
and very signicant difculties in determining player exposure time accurately
have made it very difcult to accurately assess any changes in the incidence of
these injuries over time.
LONG-TERM HEALTH IMPLICATIONS
Few studies have been published and very little is known about the long-term
health impact of rugby union injuries [145148]. In a 4-year follow-up study of
amateur players, it was revealed that 26% of those who had ceased playing had
done so because of a rugby injury (the largest category of retired players), with
the knee (35%), back (14%), and shoulder (9%) the most common injury loca-
tions [148]. Furthermore, 35% of men who sustained an injury in the original
epidemiological study 4 years previously reported signicant effects on educa-
tion, employment, family life, or health [148]. Rugby union has only held
professional status as a sport since 1995, so the possibilities for a long-term fol-
low-up study of professional players is limited at this time; however, a small
preliminary investigation of retired rugby league professionals reported that
29% retired from the sport because of an injury sustained during their rugby
league career, and 14% reported job limitations as a consequence of a rugby
league injury [149]. Possible health sequelae in rugby union may include oste-
oarthritis [150152], and for front-row forwards in particular, premature degen-
erative disease of the cervical spine [145147].
INJURY RESEARCH IN THE FUTURE
The recently published IRB consensus statement on injury denitions and data
collection procedures for studies of injuries in rugby union should allow future
research to be more consistent and comparable than is currently the case [6].
Our understanding of the etiology and epidemiology of rugby union injuries
has improved with the increase in published research post-professionalism;
however, there are still a number of major gaps, and further research is re-
quired to progress our understanding:

The etiology and epidemiology of rugby union injuries sustained by non-elite

players and special populations is limited (see Table 2).

Research examining the propensity for injury by inciting event (for example by
reporting injuries per 1000 events) is still in its infancy [90], and needs to be
expanded to improve the accuracy of injury incident reports.

The reporting of injury incident is often reliant on the retrospective recall of the
medical staff or the player in prospective epidemiological studies. Although
some attempt has been made to investigate the mechanisms sustained in
the tackle [153,154], the greater use of video analysis to gain an insight
into injury mechanism would advance our understanding much further, and
would allow assessment of the validity of medical staff and player retrospec-
tive recall as a method of reporting injury incident.
65 RECENT TRENDS IN RUGBY UNION INJURIES

Injury risk factors and their prevention strategies are multifaceted [33,36];
however, there has been infrequent multifactorial analysis within rugby union
cohorts [89,97] because of difculties in collecting data on multiple risk fac-
tors and the large cohort needed. It is also possible that injury prevention pro-
grams based on research from other sports, such as the prevention of ACL
injuries in handball [155], may not be as successful within rugby union be-
cause of differences in injury mechanism. For example, a recent study of
rugby union knee injuries reported that the majority of ACL injuries were sus-
tained during contact with other players [84]. A number of other potential risk
factors for rugby union injuries have also not been investigated to date, includ-
ing training methods, biomechanics, musculoskeletal measures, player nutri-
tion, and blood markers.

Injury prevention interventions include rule changes, coaching changes, and

player conditioning issues; however, examples of injury prevention interven-
tions in rugby union are rare [156,157], and there is a lack of properly con-
trolled intervention trials. The implementation of prevention strategies in
controlled intervention trials (preferably randomized), would allow the assess-
ment of the inuence of certain risk factors on injury rate. Large community
populations are particularly useful for conducting large scale randomized
controlled trails.

There is a need to better understand the longer-term health implications of

playing rugby union.
SUMMARY
The game of rugby union has evolved over nearly 2 centuries, and is now one
of the worlds most popular participation team sports. Recent drivers for
change in the way the game is played have included rule modications aimed
to both reduce the risk of serious injury and to keep the ball in play longer, and
the advent of professionalism in 1995. Trends from published studies show
a high incidence of injury compared with other team sports; an apparent in-
crease in injury risk since the advent of professionalism in both the professional
and amateur games; a reduction in injury incidence with decreasing age and
competitive level; the shoulder, knee, thigh, ankle and head as the high-risk in-
jury sites; and a very signicantly higher incidence of injuries during matches
compared with training. Approximately half of all match injuries are sustained
in the tackle. Less is known about the prole of training injuries, although there
appear to be clear differences between different activities. Although there is
considerable published rugby union epidemiology, a lack of consistency in
the methodologies used makes inter-study comparisons difcult; this is likely
to be rectied in the future following the recent publication of an IRB injury
denition and data collection process consensus document [6]. There are
a number of clear deciencies in the rugby union research published to date;
for example, there is still a lack of sophistication in our understanding of risk
factors for specic injuries, including the epidemiology of nonfatal catastrophic
injuries, and evidence for the successful implementation of preventative and
66 BROOKS & KEMP
therapeutic interventions to reduce the risk of specic rugby union injuries
remains limited.
Acknowledgement
The authors would like to thank Ed Morrison (Rugby Football Union Elite
Referee Development Ofcer) for his assistance in documenting rugby union
law changes.
References
[1] International Rugby Board (IRB). 2007. IRB organisation. Available at: http://www.irb.
com/EN/IRBOrganisation/. Accessed January 21, 2007.
[2] Rugby Football Union (RFU). 2007. International Rugby Board (IRB) playing charter. Avail-
able at: http://www.rfu.com/index.cfm/fuseaction/RFUHome.WebSite_Detail/storyID/
8147/storytypeID/78/. Accessed January 21, 2007.
[3] International Rugby Board (IRB). Laws of the game rugby union: International Rugby Board.
Available at: http://www.irb.com/lawregulations/laws/index.html.
[4] Nicholl JP, Coleman P, Williams BT. The epidemiology of sports and exercise related injury
in the United Kingdom. Br J Sports Med 1995;29(4):2328.
[5] Quarrie KL, Cantu RC, Chalmers DJ. Rugby union injuries to the cervical spine and spinal
cord. Sports Med 2002;32(10):63353.
[6] Fuller CW, Molloy MG, Bagate C, et al. Consensus statement on injury denitions and data
collection procedures for studies of injuries in rugby union. Br J Sports Med 2007;41(5):
32831.
[7] Maud PJ, Shultz BB. The US national rugby team: a physiological and anthropometric as-
sessment. Phys Sportsmed 1984;12(9):8699.
[8] Carlson BR, Carter JEL, Patterson P, et al. Physique and motor performance characteristics
of US national rugby players. J Sports Sci 1994;12:40312.
[9] Holmyard DJ, Hazeldine RJ. Seasonal variations in the anthropometric and physiological
characteristics of international rugby union players. In: Reilly T, Clarys JP, Stibbe A, editors.
Science and football ii. E & FN Spon; 1993. p. 216.
[10] Tong RJ, Mayes R. The effect of pre-season training on the physiological characteristics of
international rugby union players. J Sports Sci 1995;13:507.
[11] Bell W, Cobner D, Cooper S-M, et al. Anaerobic performance and body composition of
international rugby union players. In: Reilly T, Clarys JP, Stibbe A, editors. Science and foot-
ball ii. E & FN Spon; 1993. p. 1520.
[12] Brooks JHM, Fuller CW, Kemp SPT, et al. A prospective study of injuries and training
amongst the England 2003 rugby World Cup squad. Br J Sports Med 2005;39(5):
28893.
[13] Rigg P, Reilly T. Atness prole and anthropometric analysis of rst and second class rugby
union players. In: Reilly T, Lees A, Davids K, et al, editors. Science and football i. E and F.N.
Spon; 1988. p. 194200.
[14] Nicholas CW, Baker JS. Anthropometric and physiological characteristics of rst and sec-
ond class rugby union players. J Sports Sci 1995;13:15.
[15] Casagrande G, Viviani F. Somatotype of Italian rugby players. J Sports Med Phys Fitness
1993;33:659.
[16] Quarrie KL, Handcock P, Waller AE, et al. The NewZealandrugby injury and performance
project iii. Anthropometric and physical performance characteristics of players. Br J Sports
Med 1995;29(4):26370.
[17] Scott AC, Roe N, Coats AJS, et al. Aerobic exercise physiology in a professional rugby
union team. Int J Cardiol 2003;87:1737.
[18] Brooks JHM, Fuller CW, Kemp SPT, et al. Epidemiology of injuries in English professional
rugby union: part 1 match injuries. Br J Sports Med 2005;39(10):75766.
67 RECENT TRENDS IN RUGBY UNION INJURIES
[19] International Rugby Board(IRB). Rugby World Cup 2003statistical reviewand match anal-
ysis, 2003. Available at: www.irb.com/newsmedia/mediazone/gameanalysis/kind=
20052/index.html. Accessed December 20, 2007.
[20] Quarrie KL, Hopkins WG. Changes in player characteristics and match activities in Bledi-
sloe Cup rugby union from 1972 to 2004. J Sports Sci 2007;25(8):895903.
[21] Seward H, Orchard J, Hazard H, et al. Football injuries in Australia at elite level. Med J
Aust 1993;159:298301.
[22] Hughes DC, Fricker PA. A prospective survey of injuries to rst-grade rugby union players.
Clin J Sport Med 1994;4(4):24956.
[23] Bird YN, Waller AE, Marshall SW, et al. The NewZealand rugby injury and performance
project: V. epidemiology of a season of rugby injury. Br J Sports Med 1998;32:31925.
[24] Jakoet I, Noakes T. A high rate of injury during the 1995 rugby World Cup. S Afr Med J
1998;88(1):457.
[25] Bathgate A, Best JP, Craig G, et al. A prospective study of injuries to elite Australian rugby
union players. Br J Sports Med 2002;36:2659.
[26] Best JP, McIntosh AS, Savage TN. Rugby World Cup 2003 injury surveillance project. Br J
Sports Med 2005;39(11):8127.
[27] Kemp SPT, Targett SGR. Injury to the rst rib synchondrosis in a rugby footballer. Br J Sports
Med 1999;33:1313.
[28] Jeon I-H, Wallace WA. Traumatic humeral articular cartilage shear (THACS) lesion in apro-
fessional rugby player: a case report. Br J Sports Med 2004;38(4):e12.
[29] Walsh AJ, Shine S, McManus F. Paraplegia secondary to fracture-subluxation of the tho-
racic spine sustained playing rugby union football. Br J Sports Med 2004;38(6):e32.
[30] Peek K, Gatherer D. The rehabilitation of a professional rugby union player following
a C7/T1 posterior microdiscectomy. Physical Therapy in Sport 2005;6:195200.
[31] MirzaAH, AlamK, Ali A. Posterior sternoclavicular dislocation in arugby player as acause
of silent vascular compromise: a case report. Br J Sports Med 2005;39(5):e28.
[32] Dearing J, Best J, Henderson N, et al. Soft tissue neck lumps in rugby union players. Br J
Sports Med 2006;40(4):3179.
[33] Fuller CW, Drawer S. The application of risk assessment in sport. Sports Med 2004;34(6):
34956.
[34] Brooks JHM, Fuller CW. The inuence of methodological issues on the results and conclu-
sions from epidemiological studies of sports injuries: illustrative examples. Sports Med
2006;36(6):45972.
[35] van Mechelen W, Hlobil H, Kemper HCG. Incidence, severity, aetiology and prevention of
sports injuries. A review of concepts. Sports Med 1992;14(2):8299.
[36] Meeuwisse WH. Assessing causation in sport injury: a multifactorial model. Clin J Sport
Med 1994;4(3):16670.
[37] Targett SGR. Injuries in professional rugby union. Clin J Sport Med 1998;8(4):2805.
[38] Holtzhausen LJ, Schwellnus MP, Jakoet I, et al. The incidence and nature of injuries in
South African rugby players in the rugby Super 12 competition. S Afr Med J 2006;96:
12605.
[39] Bottini E, Poggi EJT, Luzuriaga F, et al. Incidence and nature of the most common rugby in-
juries sustained in Argentina (19911997). Br J Sports Med 2000;34(2):947.
[40] Babic Z, Misigoj-Durakovic M, Matasic H, et al. Croatian rugby project. Part ii: injuries.
J Sports Med Phys Fitness 2001;41:3928.
[41] Junge A, Cheung K, Edwards T, et al. Injuries in youth amateur soccer and rugby players
comparison of incidence and characteristics. Br J Sports Med 2004;38:16872.
[42] Wekesa M, Asembo JM, Njororai WW. Injury surveillance in a rugby tournament. Br J
Sports Med 1996;30:613.
[43] Durkin TE. A survey of injuries in a 1st class rugby union football club. Br J Sports Med
1977;11:711.
[44] Davies JE, Gibson T. Injuries in rugby union football. Br Med J 1978;2:175961.
68 BROOKS & KEMP
[45] Brooks JHM, Fuller CW, Kemp SPT, et al. Epidemiology of injuries in English professional
rugby union: part 2 training injuries. Br J Sports Med 2005;39(10):76775.
[46] Garraway WM, Lee AJ, Hutton SJ, et al. Impact of professionalism on injuries in rugby
union. Br J Sports Med 2000;34:34851.
[47] Doyle C, George K. Injuries associated with elite participation in womens rugby over
a competitive season: an initial investigation. Physical Therapy in Sport 2004;5:4450.
[48] Garraway WM, Macleod DAD. Epidemiology of rugby football injuries. Lancet
1995;345:14857.
[49] Lee AJ, Garraway WM. Epidemiological comparison of injuries in school and senior club
rugby. Br J Sports Med 1996;30:2137.
[50] Dalley DR, Laing DR, Rowberry JM, et al. Rugby injuries: an epidemiological survey, Christ-
church 1980. New Zealand Journal of Sports Medicine 1982;10:517.
[51] Dalley DR, Laing DR, McCartin PJ. Injuries in rugby football, Christchurch 1989. NewZea-
land Journal of Sports Medicine 1992;20(1):25.
[52] Weightman D, Browne RC. Injuries in association and rugby football. Br J Sports Med
1974;8:1837.
[53] Addley K, Farren J. Irish rugby injury survey: Dungannon football club (198687). Br J
Sports Med 1988;22(1):224.
[54] Clark DR, Roux C, Noakes TD. Aprospective study of the incidence and nature of injuries to
adult rugby players. S Afr Med J 1990;77:55962.
[55] Roy SP. The nature and frequency of rugby injuries. A pilot study of 300 injuries at Stellen-
bosch. S Afr Med J 1974;48:23217.
[56] Reilly T, Hardiker R. Somatotype and injuries in adult student rugby football. J Sports Med
1981;21:18691.
[57] McManus A, Cross DS. Incidence of injury in elite junior rugby union: a prospective de-
scriptive study. J Sci Med Sport 2004;7(4):43845.
[58] Nathan M, Goedeke R, Noakes TD. The incidence and nature of rugby injuries experi-
enced at one school during the 1982 rugby season. S Afr Med J 1983;64:1327.
[59] Roux CE, Goedeke R, Visser GR, et al. The epidemiology of schoolboy rugby injuries. S Afr
Med J 1987;71:30713.
[60] Davidson R, Kennedy M, Kennedy J, et al. Casualty room presentations and schoolboy
rugby union. Med J Aust 1978;1:2479.
[61] Sugerman S. Injuries in an Australian schools rugby union season. Australian Journal of
Sports Medicine and Exercise Science 1983;15(1):518.
[62] Davidson RM. Schoolboy rugby injuries. Med J Aust 1987;147:11920.
[63] Sparks JP. Rugby football injuries, 19801983. Br J Sports Med 1985;19:715.
[64] Durie RM, Munroe AD. Aprospective survey of injuries in a NewZealand schoolboy rugby
population. New Zealand Journal of Sports Medicine 2000;28(4):8490.
[65] OConnell TCJ. Rugby football injuries and their prevention. A review of 600 cases. J Ir
Med Assoc 1954;34(199):206.
[66] Myers PT. Injuries presenting from rugby union football. Med J Aust 1980;2:1720.
[67] Sharp JCM, Murray GD, Macleod DAD. A unique insight into the incidence of rugby in-
juries using referee replacement reports. Br J Sports Med 2001;35:347.
[68] Waller AE, Feehan M, Marshall SW, et al. The New Zealand rugby injury and perfor-
mance project: I. Design and methodology of a prospective follow-up study. Br J Sports
Med 1994;28(4):2238.
[69] McManus A. Validation of an instrument for injury data collection in rugby union. Br J
Sports Med 2000;34:3427.
[70] Adams ID. Rugby football injuries. Br J Sports Med 1977;11:46.
[71] Smithers M, Myers PT. Injuries in sport. A prospective casualty study. Med J Aust
1985;142(8):45761.
[72] Dixon G. Morbidity of rugby union injuries in New Zealand. New Zealand Journal of
Sports Medicine 1993;2:1820.
69 RECENT TRENDS IN RUGBY UNION INJURIES
[73] Yard EE, Comstock RD. Injuries sustained by rugby players presenting to United States
emergency departments, 1978 through 2004. J Athl Train 2006;41(3):32531.
[74] ORourke KP, Quinn F, Mun S, et al. Acomparison of paediatric soccer, gaelic football and
rugby injuries presentingtoanemergencydepartment inIreland. Injury 2007;38:10411.
[75] Lorentzon R, Wedren H, Pietila T, et al. Injuries in international ice hockey: a prospective,
comparative study of injury incidence and injury types in international and Swedish elite
ice hockey. Am J Sports Med 1988;16(4):38991.
[76] Junge A, Dvorak J, Graf-Baumann T. Football injuries during the World Cup 2002. Am J
Sports Med 2004;32(1S):23S7S.
[77] Hawkins RD, Fuller CW. Aprospective epidemiological study of injuries in four English pro-
fessional football clubs. Br J Sports Med 1999;33:196203.
[78] Orchard J, James T, Alcott E, et al. Injuries in Australian cricket at rst class level 1995/
1996 to 2000/2001. Br J Sports Med 2002;36:2705.
[79] Hodgson Phillips L, Standen PJ, Batt ME. The effects of seasonal change in rugby league on
the incidence of injury. Br J Sports Med 1998;32:1448.
[80] Orchard J, Seward H. Epidemiology of injuries in the Australian football league, seasons
19972000. Br J Sports Med 2002;36:3945.
[81] Meyers MC, Barnhill BS. Incidence, causes, and severity of high school football injuries on
eldturf versus natural grass: a 5-year prospective study. Am J Sports Med 2004;32(7):
162638.
[82] Poulsen TD, Freund KG, Madsen F, et al. Injuries in high-skilled and low-skilled soccer:
a prospective study. Br J Sports Med 1991;25(3):1513.
[83] Carson JD, Roberts MA, White AL. The epidemiology of womens rugby injuries. Clin J
Sport Med 1999;9(2):758.
[84] Dallalana RJ, Brooks JHM, Kemp SPT, et al. The epidemiology of knee injuries in English
professional rugby union. Am J Sports Med 2007;35(5):81830.
[85] Brooks JHM, Fuller CW, Kemp SPT, et al. Incidence, risk, and prevention of hamstring mus-
cle injuries in professional rugby union. Am J Sports Med 2006;34(8):1297306.
[86] Levy AS, Wetzler MJ, Lewars M, et al. Knee injuries in women collegiate rugby players. Am
J Sports Med 1997;25(3):3602.
[87] Kemp SPT, Hudson Z, Brooks JHM, et al. The epidemiology of head injuries in English pro-
fessional rugby union. 2007 Under review.
[88] Headey J, Brooks JHM, Kemp SPT. The epidemiology of shoulder injuries in English profes-
sional rugby union. Am J Sports Med 2007;35(9):153743.
[89] Quarrie KL, Alsop JC, Waller AE, et al. The New Zealand rugby injury and performance
project. Vi. A prospective cohort study of risk factors for injury in rugby union football. Br J
Sports Med 2001;35:15766.
[90] Fuller CW, Brooks JHM, Cancea RJ, et al. Contact events in rugby union and their propen-
sity to cause injury. Br J Sports Med 2007;41:8627.
[91] Brooks JHM, Fuller CW, Kemp SPT, et al. An assessment of training volume in professional
rugby union and its impact on the incidence, severity and nature of match and training in-
juries. J Sports Sci 2007, in press.
[92] Drawer S, Fuller CW. Evaluating the level of injury in English professional football using
a risk based assessment process. Br J Sports Med 2002;36:44651.
[93] Meeuwisse WH. Predictability of sports injuries. What is the epidemiological evidence?
Sports Med 1991;12(1):815.
[94] Stewart DR, Burden SB. Does generalised ligamentous laxity increase seasonal incidence
of injuries in male rst division club rugby players? Br J Sports Med 2004;38(4):45760.
[95] Cusi MF, Juska-Butel J, Garlick D, et al. Lumbopelvic stability and injury prole in rugby
union players. New Zealand Journal of Sports Medicine 2001;29(1):148.
[96] Lee AJ, Garraway WM. The inuence of environmental factors on rugby football injuries.
J Sports Sci 2000;18:915.
70 BROOKS & KEMP
[97] Alsop JC, Morrison L, Williams SM, et al. Playing conditions, player preparation and
rugby injury: a case-control study. J Sci Med Sport 2005;8(2):17180.
[98] Lee AJ, Garraway WM, Arneil DW. Inuence of preseason training, tness, and existing
injury on subsequent rugby injury. Br J Sports Med 2001;35:4127.
[99] Brooks JHM, Fuller CW, Kemp SPT. The incidence, severity, and nature of cervical injuries
in professional rugby union [abstract]. Br J Sports Med 2005;39:377.
[100] Fuller CW, Brooks JHM, Kemp SPT. Spinal injuries in professional rugby union: a prospec-
tive cohort study. Clin J Sport Med 2007;17(1):106.
[101] Webb J, Bannister G. Acromioclavicular disruption in rst class rugby players. Br J Sports
Med 1992;26(4):2478.
[102] Upton PAH, Noakes TD, Juritz JM. Thermal pants may reduce the risk of recurrent ham-
string injuries in rugby players. Br J Sports Med 1996;30:5760.
[103] Hume PA, Gerrard DF. Inversion sprains in rugby union and the effectiveness of external
ankle support. Sports Med 1998;25(5):285312.
[104] Finch CF, McIntosh AS, McCrory P. What do under 15 year old schoolboy rugby union
players think about protective headgear? Br J Sports Med 2001;35:8994.
[105] McIntosh AS, McCrory P. Effectiveness of headgear in a pilot study of under 15 rugby
union football. Br J Sports Med 2001;35:1679.
[106] McIntosh A, McCrory P, Finch CF. Performance enhanced headgear: a scientic approach
to the development of protective headgear. Br J Sports Med 2004;38:469.
[107] Jones SJ, Lyons RA, Evans R, et al. Effectiveness of rugby headgear in preventing soft tissue
injuries to the head: a case-control and video cohort study. Br J Sports Med 2004;38:
15962.
[108] Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes.
Am J Sports Med 1998;26(1):13744.
[109] Mair SD, Zarzour R, Speer KP. Posterior labral injury in contact athletes. Am J Sports Med
1998;26(6):7538.
[110] Gerrard DF. The use of padding in rugby union. An overview. Sports Med 1998;25(5):
32932.
[111] Quarrie KL, Gianotti SM, Chalmers DJ, et al. An evaluation of mouth guard requirements
and dental injuries in New Zealand rugby union. Br J Sports Med 2005;39(9):6501.
[112] Chalmers DJ. Mouth guards. Protection of the mouth in rugby union. Sports Med
1998;25(5):33949.
[113] Jennings DC. Injuries sustained by users and non-users of gumshields in local rugby union.
Br J Sports Med 1990;24(3):15965.
[114] Chapman PJ. Players attitudes to mounthguards and prevalence of orofacial injuries in the
1987 U.S. Rugby football team. Am J Sports Med 1989;17(5):6901.
[115] Blignaut JB, Carstens IL, Lombard CJ. Injuries sustained in rugby by wearers and non-
wearers of mouth guards. Br J Sports Med 1987;21:57.
[116] Upson N. Mouth guards, an evaluation of two types for rugby players. Br J Sports Med
1985;19:8992.
[117] Stokes AN, Manseld SG, McNaughton AG. Mouth guardsattitudes and experience of
a group of users. New Zealand Journal of Sports Medicine 1985;15:910.
[118] Hill CM, Crosher RF, Mason DA. Dental and facial injuries following sports accidents:
a study of 130 patients. Br J Oral Maxillofac Surg 1985;23(4):26874.
[119] Chapman PJ. Orofacial injuries and mouth guards: a study of the 1984 Wallabies. Br J
Sports Med 1985;19:935.
[120] Chapman PJ. Orafacial injuries and the use of mouth guards by the 1984 Great Britain
rugby league touring team. Br J Sports Med 1985;19:346.
[121] Maestrella-deMoya M, Primosch R. Orofacial trauma and mouth protector wear among
high school varsity basketball players. J Dent Child 1989;36:369.
[122] McCrory P. Do mouth guards prevent concussion? Br J Sports Med 2001;35:813.
71 RECENT TRENDS IN RUGBY UNION INJURIES
[123] Williams JPR, McKibbin B. Cervical spine injuries in rugby union football. Br Med J
1978;1747.
[124] Burry HC, Gowland H. Cervical injury in rugby footballa New Zealand survey. Br J
Sports Med 1981;15:569.
[125] Scher AT. Serious cervical spine injury in the older rugby player. S Afr Med J 1983;64:
13840.
[126] Taylor TKF, Coolican MRJ. Spinal-cord injuries in Australian footballers, 19601985. Med
J Aust 1987;147:1128.
[127] Scher AT. Rugby injuries of the spine and spinal cord. Clin Sports Med 1987;6(1):8799.
[128] Silver JR, Gill S. Injuries of the spine sustained during rugby. Sports Med 1988;5:32834.
[129] Scher AT. Rugby injuries of the cervical spine and spinal cordhas the situation improved?
S Afr Med J 1989;76:46.
[130] Kew T, Noakes TD, Kettles AN, et al. A retrospective study of spinal cord injuries in Cape
Province rugby players, 19631989. Incidence, mechanisms and prevention. S Afr Med J
1991;80(3):12733.
[131] Silver JR. Injuries of the spine sustained during rugby. Br J Sports Med 1992;26(4):2538.
[132] Wilson SF, Atkin PA, RotemT, et al. Spinal cord injuries have fallen in rugby union players
in New South Wales. Br Med J 1996;13:1550.
[133] Wetzler MJ, Akpata T, Albert T, et al. A retrospective study of cervical spine injuries in
American rugby, 1970 to 1994. Am J Sports Med 1996;24(4):4548.
[134] Armour KS, Clatworthy BJ, Bean AR, et al. Spinal injuries in NewZealandrugby andrugby
leaguea twenty year survey. N Z Med J 1997;110:4625.
[135] Wetzler MJ, Akpata T, Laughlin W, et al. Occurrence of cervical spine injuries during the
rugby scrum. Am J Sports Med 1998;26(2):17780.
[136] Scher AT. Rugby injuries to the cervical spine and spinal cord: a 10-year review. Clin
Sports Med 1998;17(1):195206.
[137] RotemTR. Severe cervical spinal cord injuries related to rugby union and league football in
New South Wales, 19841996. Med J Aust 1998;168:37981.
[138] Maharaj JC, Cameron ID. Increase in spinal injury among rugby union players in Fiji. Med
J Aust 1998;168(8):418.
[139] Noakes TD, Jakoet I, Baalbergen E. An apparent reduction in the incidence and severity of
spinal cord injuries in schoolboy rugby players in the Western Cape since 1990. S Afr
Med J 1999;89(5):5405.
[140] Secin FP, Poggi EJT, Luzurianga F, et al. Disabling injuries of the cervical spine in Argentine
rugby over the last 20 years. Br J Sports Med 1999;33:336.
[141] Haylen PT. Spinal injuries in rugby union, 19702003: lessons and responsibilities. Med J
Aust 2004;181(1):4851.
[142] Carmody DJ, Taylor TKF, Parker DA, et al. Spinal cord injuries in Australian footballers
19972002. Med J Aust 2005;182:5614.
[143] Shelly MJ, Butler JS, Timlin M, et al. Spinal injuries in Irish rugby: a ten-year review. J Bone
Joint Surg Br, 88-B(6) 2006;7715.
[144] Garraway WM, MacleodDAD, Sharp JCM. Rugby injuries. The needfor case registers. Br
Med J 1991;303:10823.
[145] Scher AT. Premature onset of degenerative disease of the cervical spine in rugby players.
S Afr Med J 1990;77:5578.
[146] Broughton H. Premature degeneration of the cervical spine in a rugby union player. New
Zealand Journal of Sports Medicine 1993;21(3):489.
[147] Berge J, Marque B, Vital J-M, et al. Age-related changes in the cervical spines of front-line
rugby players. Am J Sports Med 1999;27(4):4229.
[148] Lee AJ, Garraway WM, Hepburn W, et al. Inuence of rugby injuries on players subse-
quent health and lifestyle: beginning a long term follow up. Br J Sports Med 2001;35:
3842.
72 BROOKS & KEMP
[149] Meir RA, McDonald KN, Russell R. Injury consequences fromparticipation in professional
rugby league: a preliminary investigation. Br J Sports Med 1997;31:1324.
[150] Deacon A, Bennell K, Kiss ZS, et al. Osteoarthritis of the knee in retired, elite Australian
rules footballers. Med J Aust 1997;166:18790.
[151] Turner AP, BarlowJH, Heathcote-Elliott C. Long-termhealth impact of playing professional
football in the United Kingdom. Br J Sports Med 2000;34:3327.
[152] Drawer S, Fuller CW. Propensity for osteoarthritis and lower limb joint pain in retired pro-
fessional soccer players. Br J Sports Med 2001;35(6):4028.
[153] Wilson BD, Quarrie KL, Milburn PD, et al. The nature and circumstances of tackle injuries in
rugby union. J Sci Med Sport 1999;2(2):15362.
[154] Garraway WM, Lee AJ, Macleod DAD, et al. Factors inuencing tackle injuries in rugby
union football. Br J Sports Med 1999;33:3741.
[155] Myklebust G, Engebretsen L, Braekken IH, et al. Prevention of anterior cruciate ligament
injuries in female team handball players: a prospective intervention study over three sea-
sons. Clin J Sport Med 2003;13(2):718.
[156] Chalmers DJ, Simpson JC, Depree R. Tackling rugby injury: lessons learned fromthe imple-
mentation of a ve-year sports injury prevention program. J Sci Med Sport 2004;7(1):
7484.
[157] Gianotti S, Quarrie K, Hopkins W. The prevention of serious injuries in New Zealand
rugby union. Br J Sports Med 2005;39(6):386 [abstract].
73 RECENT TRENDS IN RUGBY UNION INJURIES