England Professional Rugby

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1 England Professional Rugby Injury Surveillance Project Season Report MARCH 2013

2 MARCH 2013 ı 3 Contents Authored by the England Professional Rugby Injury Surveillance Project Steering Group Chaired by Dr Simon Kemp (Head of Sports Medicine RFU) and comprising Dr John Brooks (Ex Injury Risk Analyst and Ex Harlequins and England Saxons), Dr Colin Fuller (Risk Management Consultant IRB and FIFA), Dr Tim Anstiss (RPA Medical Advisor), Mr Andy Smith (Consultant in Emergency Medicine, Mid Yorkshire NHS Trust and Premiership Rugby Clinical Governance Advisor), Aileen Taylor (Physiotherapist and Injury Audit Research Assistant, University of Bath), Dr Grant Trewartha (University of Bath) and Dr Keith Stokes (University of Bath) The content of the report is based on data collected and analysed by Aileen Taylor (University of Bath) The authors would like to acknowledge with considerable gratitude, the work of the doctors, physiotherapists and strength and conditioning staff from the Premiership clubs and England teams who have recorded injury and training information throughout the project 1 executive Summary Introduction Scope of the Research Definitions9 4.1 injury injury severity Recurrent injury injury incidence and days absence Statistical significance KEY Results Premiership clubs Match injuries training injuries injury Severity Match injury SEVERITY training injuries injuries leading to Retirement in Recurrence of Injury Match injuries training injuries time of Injury during match during SEASON injury Event Match Injury Event training Injury Event TRAINING VOLUME HAMSTRING TRAINING INJURIES INJURY DIAGNOSIS MOST COMMON MATCH INJURIES HIGHEST RISK MATCH INJURIES MOST COMMON TRAINING INJURIES HIGHEST RISK TRAINING INJURIES Results England Senior Side Match injuries training injuries Publications current APPENDICES appendix A - SEVERITY OF INJURY appendix B - RECURRENT INJURIES - MATCH appendix B - TRAINING appendix C - TIME OF INJURY DURING MATCH appendix C - TIME OF INJURY DURING SEASON appendix D - MATCH - INJURY EVENT appendix D - TRAINING - INJURY EVENT...48

3 MARCH 2013 ı 5 1 Executive Summary The overall risk (incidence and days absence) of match and training injury in Aviva Premiership Rugby remained stable during the season and was within the normal range of season by season variation seen since the study began in Whilst the incidence or likelihood of sustaining a match injury reduced by 12% (93 82 injuries per 1,000 hrs) compared to , this was counterbalanced by an increase in average match injury severity from 21 to 27 days, although this increase was still within the range attributable to season by season variation. The increase in average severity was largely as a result of an increase in the number of injuries resulting in 3-6 months out of the game. This group of injuries comprised a broad range of injury types affecting a range of body locations and no firm conclusions about changes in risk profile can be drawn at the present time. This specific group of injuries will be monitored in training injuries were reported. Therefore, one third of all reported injuries are occurring in a potentially controllable environment and this again highlights the need for coaches and medical and conditioning staff to continue to balance team preparation and performance optimisation with injury risk minimisation. Hamstring muscle injuries, lumbar disc and nerve root injuries, and calf muscle injuries were responsible for 32% of the total days absence for training injuries. Concussion was, for the first time, the most common Aviva Premiership Rugby match injury in This reflects a decrease in the incidence of other injuries rather than an increase in the risk of concussion, but highlights the importance of a co-ordinated concussion management policy. The Premiership is currently trialling a new Pitch Side Concussion Assessment (PSCA) process and specifically auditing Concussion match injuries. Hamstring injuries remain the most common and highest risk training injuries, and the third highest risk match injury. 92% of all hamstring injuries are running related and remain an injury with significant potential for further injury risk reduction. The medical/injury elements of the data collection for the surveillance project will be integrated into the new RugbySquad electronic medical record database for the start of the season. This will provide new opportunities to survey illness and non timeloss injuries, deliver bespoke, diagnosis specific questionnaires and better correlate training load and match injury risk. England England Professional Rugby Premiership Rugby Injury Injury Surveillance and Training Project Audit Season Report

4 MARCH 2013 ı 7 2 introduction The Rugby Football Union and Premier Rugby Ltd first commissioned an injury surveillance study across the Premiership and England teams in The study is now conducted annually and The England Rugby Injury and Training surveillance study is the world s largest study of professional rugby union injuries and training practices. Injury surveillance is now considered to be an important obligation for professional sporting bodies. However, the degree to which it is successfully undertaken varies substantially between different sports. The England Rugby Injury and Training surveillance study is unique in the way that it measures both the risk of injury sustained during training and matches. The England Rugby Injury and Training surveillance study is admired for its robust methodology, the high level of compliance from respondents and for the number of scientific publications it has generated. The consistent methodology and mandated data collection by club medical and strength and conditioning staff has led to annually consistent results enabling the results from each season to be compared with each other. The England Rugby Injury and Training surveillance study 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. This report presents the high level findings from the England Rugby Injury and Training surveillance study and compares them with the results from the 8 previous Injury and Training surveillance seasons ( , , , , , , and ). These results are intended to inform discussion about the direction of the injury risk management programme for elite rugby in England. In line with the international interest in concussion management, during the and seasons there will be a focus on understanding the time course of symptom resolution of concussion injuries. In addition, for the first time we will examine the influence of training practice and prior injury, alongside other risk factors, on the risk of sustaining an injury. The goal of this aspect of the work is to improve the ability to predict injury. OVERALL RISK OF INJURY IN THE PREMIERSHIP HAS REMAINED STABLE

5 MARCH 2013 ı 9 3 SCOPE OF THE res each 4 definitions Aviva Premiership Rugby first team squad members who were registered with the RFU were invited to participate in the study. Written informed consent was obtained from each player. The total number of consented players for the season was 572. Two players did not give consent and as such their data has not been collected and is not reported here. For the season, all matches in the Aviva Premiership Rugby, LV Anglo-Welsh Cup and European competitions (Heineken and European Challenge Cup) were included. Injuries sustained while players represented England are reported separately. Match and training injury data, and training exposure data, were provided by all 12 Premiership clubs in A complete set of data was collected (as in , , ,). RFU unique player registration numbers were used to identify players throughout the study in order to maintain anonymity and medical confidentiality. Medical personnel at each Premiership club and the England senior team reported the details of every injury to their players who were included in the study group together with the details of the associated injury event using a standard injury report form. Strength and conditioning staff recorded the squad s weekly training schedules and exposure on a standard training report form. Team match days were also recorded and by the strength and conditioning staff. Injury diagnoses were recorded using the Orchard codes (OSICS). This sports specific injury classification system allows detailed diagnoses to be reported, and injuries to be grouped by body part and injury pathology. The injury definitions and data collection methods utilised in this study are compliant with the IRB Consensus statement on injury definitions and data collection procedures for studies of injuries in rugby union. LARGEST STUDY OF PROFESSIONAL RUGBY UNION INJURIES AND TRAINING PRACTICES 4.1 injury An injury was defined as any injury that prevents a player from taking a full part in all training activities typically planned for that day and/or match play for more than 24 hours from midnight at the end of the day the injury was sustained. For example, if a player was injured during a match on Saturday and he was able to take a full part in training on Monday, the incident would not be classed as an injury. If the player s training was restricted on Monday due to the injury received on Saturday, the incident would be classed as an injury and reported. 4.2 Injury severity Injury severity was measured as time (days) lost from competition and practice and defined as the number of days from the date of the injury to the date that the player was deemed to have regained full fitness, not including the day of injury or the day of return. A player was deemed to have regained full fitness when he was able to take a part in training activities (typically planned for that day) and was available for match selection. 4.3 Recurrent injury An injury of the same type and at the same site as an index injury and which occurs after a player s return to full participation from the index injury. 4.4 Injury incidence and days absence The likelihood of sustaining an injury during match play or training is reported as the injury incidence. The injury incidence is the number of injuries expressed per 1000 player-hours of match exposure (or training exposure). Equally important to the player and/or his team is how long players are absent. This is known as the days absence and is also expressed per 1000 player-hours of match exposure (or training exposure). 4.5 Statistical significance A result is considered to be statistically significant if the probability that it has arisen by chance is less than 5% or 1 in 20. In this report statistical analysis has been performed for the match and training injury incidence and days absence. 95% Confidence intervals (CI) have been reported and a significant difference between the values for incidence and days absence with previous seasons was assumed if the 95% confidence intervals for the parameters did not overlap.

6 MARCH 2013 ı 11 5 KEY results Premiership clubs 5.1 Match Injuries Table 1 > Match injury incidence, average severity and days absence since Season Total number of match injuries Injuries (95% CI) Injuries per club per match Average severity, days (95%CI) (95% CI) (92-107) (15-17) 1556 ( ) 31 per club per match figure 1b > Comparison of the average severity of match injury over the study period with mean ± 2 x standard deviation shown. SEVERITY UPPER LIMIT 2SD MEAN LOWER LIMIT 2SD SEVERITY (DAYS) Note - for a normal distribution, 95% of all data should fall between (mean - 2 x standard deviation) and (mean + 2 x standard deviation) (82-95) (19-22) 1773 ( ) (68-82) (19-23) 1591 ( ) (84-97) (20-23) 1879 ( ) (77-89) (18-21) 1613 ( ) (93-107) (21-25) 2285 ( ) (73-86) (20-24) 1722 ( ) (86-99) (20-23) 1917 ( ) (76-88) (25-29) 2222 ( ) 44 There were 399 team games included in the match analysis for figure 1a > Comparison of the incidence of match injury over the study period with mean ± 2 x standard deviation shown. UPPER LIMIT 2SD incidence / 1000 hrs MEAN LOWER LIMIT 2SD Note - for a normal distribution, 95% of all data should fall between (mean - 2 x standard deviation) and (mean + 2 x standard deviation).

7 MARCH 2013 ı 13 figure 2 > Comparison of days absence/1000hrs from match injuries over the study period with mean ± 2 x standard deviation shown. days absence mean LOWER LIMIT 2SD UPPER LIMIT 2SD days absence / 1000 hrs Note - for a normal distribution, 95% of all data should fall between (mean - 2 x standard deviation) and (mean + 2 x standard deviation). Summary of the Match Injury risk There was a decrease in match injury incidence in compared to ; however, there was an increase in overall match injury risk (days absence per 1000 hrs) due to increased average injury severity. It is important to note that the season-to-season variation is within the limits of what we would expect based on the data since Likelihood or incidence of injury 655 match injuries that led to time lost from training and/or match play in a Premiership, European competition or National knockout cup match were reported in the season. This equates to an average of 55 match injuries per club and 1.6 injuries per club per match. The likelihood of sustaining an injury decreased by 12% (93 82 injuries per 1000 hrs) in compared with The decrease compared to was not statistically significant (i.e. the probability that it has arisen by chance is more than 5%) and represents a decrease of 0.3 injuries per club per match or 91 injuries for all clubs over the course of the season. Average severity of injury and days absence from playing and training as a result of match injuries The average severity of injuries (days before return to fitness/ availability for match selection) sustained in a Premiership, European competition or National knockout cup match showed a statistically significant increase from 21 days in to 27 days in As a consequence of the increase in average severity of match injury, the total number of days absence as a result of match injury increased by 16% to 2222 days absence per 1000hrs in compared with 1917 days absence per 1000 hrs in The average days absence per club per match in was 44 compared with 38 in Summary on trend of incidence, severity and risk of match injury since 2002 Since the study began in 2002, the likelihood of sustaining a match injury has varied between a lower limit of 75 injuries per 1000 hours (2005-6) and an upper limit of 100 injuries per 1000 hours ( and ), with an average severity of injury between 16 (2002-3) and 27 ( ) days and the total days absence per 1000 hours between 1556 (2002-3) and 2285 days (2008-9). 655 MATCH INJURIES & 323 TRAINING INJURIES IN SEASON

8 MARCH 2013 ı training Injuries figure 3 > Comparison of the incidence and severity of training injury sustained during rugby skills and conditioning sessions over the study period 8 30 Table 2 > Training injury incidence, average severity and days absence since Season Total number of training injuries Injuries (95% CI) 3.3 ( ) 1.7 ( ) Rugby Skills Average severity, days Days absence (95% CI) (90-97) (42-45) Injuries (95% CI) 2.3 ( ) 1.3 ( ) Strength and conditioning Average severity, days Days absence (95% CI) (27-31) (22-24) incidence / 1000 hrs severity (days) ( ) (47-51) 1.5 ( ) (22-25) ( ) (35-38) 1.6 ( ) (24-27) ( ) (51-68) 2.7 ( ) (36-52) - rugby skills - conditioning ( ) (53-73) 2.4 ( ) (34-49) average Severity - rugby skills average Severity - conditioning ( ) (50-67) 2.1 ( ) (30-43) figure 4 > Comparison of days absence per 1000hrs of training injuries over the study period ( ) (66-87) 2.6 ( ) (34-48) ( ) (59-78) 2.2 ( ) (32-46) Total number of training injuries for only includes the injuries occurring in weeks where training exposure data were provided by clubs days absence / 1000 hrs days absence - rugby skills days absence - conditioning

9 MARCH 2013 ı 17 1 Executive Summary Summary of the Training injury risk No statistically significant change in risk was seen in compared to Likelihood or incidence of injury 323 training injuries (rugby skills and strength and conditioning) that led to time lost from training and/or match play were reported in the season. This equates to an average of 27 injuries per club per season. The likelihood of sustaining an injury during training decreased from 2.8 injuries per 1000 hrs in to 2.3 injuries per 1000 hrs in This equates to a decrease of 1.4 injuries per club or 17 fewer training injuries over the course of the season compared with Note: There was an increase of 15% in the total training exposure reported. The increase in the number of players in the study group, slight increase in training volume and increased accuracy of reporting active recovery/cool down, contributed to this increase. The likelihood of sustaining an injury during rugby skills and strength and conditioning decreased slightly by 13% ( injuries per 1000 hrs) and 15% ( injuries per 1000 hrs) respectively, in compared with average severity of injury, the total days absence as a result of these injuries decreased slightly; 68 days absence per 1000 hrs in compared with 76 days absence per 1000 hrs in This was similar to the incidence of training injuries sustained during strength and conditioning sessions, although days absence per 1000 hrs for strength and conditioning did not change appreciably (39 days absence per 1000 hrs in compared with 41 days absence per 1000 hrs in ). Summary on trend of incidence, severity and risk of training injury since 2002 Since the study began in 2002, the likelihood of sustaining a training injury during rugby skill sessions has varied from a lower limit of 1.7 injuries per 1000 hours to an upper limit of 3.3 injuries per 1000 player hours, with an average severity of injury between 19 and 28 days and total days absence per 1000 hours between 37 and 93 days. Since the study began in 2002, the likelihood of sustaining a training injury during strength and conditioning sessions has varied from a lower limit of 1.3 injuries per 1000 hrs to an upper limit of 2.7 injuries per 1000 hours, with an average severity of injury between 13 and 18 days and total days absence per 1000 hours between 23 and 44 days. Average severity of injury and days absence from playing and training as a result of training injuries The average severity of injuries sustained during training (rugby skills and strength and conditioning) remained similar in when compared to As a consequence of the decrease in the incidence of training injuries sustained during rugby skill sessions and a similar 1/3 OF ALL INJURIES OCCUR DURING TRAINING A CONTROLLABLE ENVIRONMENT?

10 MARCH 2013 ı 19 Table 4 > Comparison of the days absence/1000hrs in each severity grouping for and INJURY SEVERITY Season /1000hrs 2-3 days 4-7 days 8-21 days days days >84 days Grand Total Match injury severity Table 5 > Comparison of the average severity of injury in each severity grouping for and Injury severity was measured as time (days) lost from competition and practice. Injuries are grouped as 2 to 3 days, 4 to 7 days, 8 to 21 days, 21 to 28 days, 28 to 84 days and > 84 days lost. Season Average severity of Injury (days) 2-3 days 4-7 days 8-21 days days days >84 days Grand Total Table 3 > of match injuries broken down by injury severity since Season days 4-7 days 8-21 days days days >84 days All Table 6 > Comparison of the number of injuries resulting in >84 days absence in and Season Number of injuries months 6-12 months >12 months A decrease in the incidence of injury was seen in the 2-3 days, 4-7 days, 8-21 days categories; however, there was an increase in the incidence of injuries resulting in days, days, and >84 days abscence compared with the season. The increase in the incidence of injuries of greater severity will have a significant impact on the average severity of all injuries and on the total number of days lost through injury. The proportional increase in injury risk (days absence per 1000 hours) in severity groupings in when compared with was a 32% increase in the injuries resulting in days absence, a 22% increase in the injuries resulting in days absence, and a 37% increase in the injuries resulting in >84 days absence (See table 4, opposite). The rise in these severity categories explains the increase in days absence per 1000 hours seen in match injuries in (See table 1, page 10) Injuries resulting in >84 days absence and days absence contributed to 46% and 29%, respectively, of the total days absence in matches in Note - this table is number of injuries not incidence The increase in incidence of the more severe injuries appears to be the reason for the increase in the overall average severity of injury. There has been a slight rise in the average severity of injuries resulting in days absence, but a fall in the average severity of injuries resulting in >84 days absence. The main rise in the number of injuries in the >84 days absence appears to be due to the rise in the injuries resulting in 3-6 months out, rather than in injuries leading to greater than 6 months absence. This combined with more injuries resulting in days absence and their corresponding slight rise in average severity has the effect of pushing the average severity of injury upwards especially as there have been fewer injuries reported in the less severe categories. In the profile of injuries resulting in the most days absence in the >84 days category changed when compared to In , there were five ACL ruptures resulting in a total of 1458 days absence, five shoulder dislocation/ instability injuries resulting in a total of 617 days absence and three dislocated patellas resulting in a total of 530 days absence. Combined these 13 injuries resulted in 15% of the total days absence of all match injuries. The profile of injuries resulting in the most days absence in the days category in were Knee - MCL injury, resulting in a total of 601 days absence, hamstring muscle injury resulting in a total of 462 days absence, and wrist/hand fracture, resulting in a total of 344 days absence. All these injuries saw a rise in total days absence as the result of injury when compared to Knee - MCL injury was the only one of these injuries also in the top three in

11 MARCH 2013 ı training Injuries The overall severity of training injuries increased in when compared to % of the total days absence due to both match and training injuries were as a result of training injuries. The greatest proportion of the total days absence due to training injuries were still due to training injuries resulting in >84 days absence (39%). Hamstring muscle, lumbar, disc, nerve or canal, and calf muscle injuries resulted in the most days absence, irrespective of injury severity category. (See later in the report in table 10). Combined, they resulted in 32% of the total days absence due to training injuries. For the detail on the incidence in of injury in each severity grouping for the study period, see Appendix A. (See table A2, page 42) 6.3 Injuries leading to retirement in Six players retired in the season as a result of injuries sustained (either during 1st team competitive matches, training or that were cumulative) that did not resolve during the season. The numbers of players retiring through a reportable injury from which a player did not return to full fitness have been collected each season. The number of retirements as a result of injury from which the player had been deemed to have returned to full fitness before retirement are not reported in the audit and therefore are not included in this report. The figures in this report therefore do not reflect the total number of players who retired as a result of injury. Since the season, injuries to the knee (7 of 33), shoulder (8), lumbar spine (7), cervical spine (8), ankle (2) and elbow (1) have caused the most retirements. For a table listing the injuries leading to retirement in see Appendix A. (See table A3, page 42)

12 MARCH 2013 ı 23 7 recurrence of injury 7.1 match Injuries Summary of the risk of a recurrence of injury The incidence of recurrence of injury in matches and days absence resulting from recurrent injuries (overall risk) in was similar to For details of the incidence of injury for new and recurrent injuries for the study period, see Appendix B. (See table B1, page 43) Work defining practical tools to help medical teams and coaches evaluate when a player is appropriately rehabilitated from common and high risk injuries should continue. The study uses the IRB consensus definition of what constitutes a recurrent injury (an injury of the same type and at the same site as an index injury and which occurs after a player s return to full participation from the index injury)., severity and days absence as a result of recurrent injury The incidence of recurrent injury decreased from 6 5 injuries per 1,000hrs in compared to The average severity and days absence for recurrent injuries also decreased further in compared with Of the recurrent injuries in , 75% occurred within one month of return to play, 13% within 1-6 months, 5% greater than a year and 8% were not specified. This is a similar proportion of reported recurrent injuries occurring within one month of return to play when compared to season (74%) and slightly higher than the past 4 seasons. ( %, % and % occurred within one month of injury). The distribution of recurrent injuries in , as a function of location and type, revealed the highest percentage of recurrent injuries were to the lower limb (70%). Of these 33% were muscle, a slightly higher percentage when compared to season (22%), 10% joint and ligament, a lower percentage when compared to season (22%), and 10% tendon injuries, a higher percentage when compared with season (4%). Of the most common recurrent match injuries in when compared to , only hamstring muscle injury and calf muscle injury were present in both seasons. The percentage of all match injuries to the hamstring that were recurrent increased in when compared to (18% c/w 9%), whereas the percentage of calf muscle injuries that were recurrent declined (6% c/w 11%). For a table of the five most common match injury recurrences during and seasons see Appendix B. (See table B2 and B3, page 43) 7.2 TRAINING Injuries The incidence of recurrent training injuries remained the same in compared to , whilst the incidence of new training injuries declined. The average severity of recurrent injuries and days absence per 1000hrs decreased. For detail of the incidence, severity and days absence for new and recurrent injuries for the study period, see Appendix B. (See table B4, page 44)

13 MARCH 2013 ı 25 8 TIME OF INJURY 8.1 During match In , there was a rise in the percentage of injuries sustained during the 3rd quarter of the match when compared with The 3rd quarter was also the quarter in which the most match injuries were seen to occur. In comparison there was a decrease in the number of injuries sustained in the 2nd quarter. The percentage of injuries for which no precise time of injury was identified was similar to , at 10% of all match injuries. This remains similar to the proportion of injuries for which no known associated event is recognised. For detail of the percentage of injury in specific time periods see Appendix C. (See figure C1, page 45) 8.2 During season There has been no significant change over the study period in the timing of injuries during the season. Injuries were sustained throughout the season with small peaks of injury incidence seen in September and January in For detail of the incidence of injury during the months of the season see, Appendix C. (See figure C2, page 46)

14 MARCH 2013 ı TRAINING INJURY EVENT 9 injury event FIGURE 5 > of training injury and associated training sessions injury event in match injury event FIGURE 5 > of match injury and associated match injury event in /1000hrs incidence / 1000 hrs Conditioning - non-weights Rugby skills - contact Rugby skills - non-contact Conditioning - weights The most common training session resulting in injury in was conditioning non-weight sessions, the second being rugby skill contact sessions. This is the same as seen in There was a decrease in incidence of injury in all types of training sessions in when compared to The percentage decreases in when compared to in each type of training session were 18% in conditioning nonweight sessions, 14% in rugby contact sessions, 7% in rugby skills non contact sessions and 5% in conditioning weights sessions. 0 Tackled Tackling Running Collision Not known Ruck Scrum Maul Lineout Other - contact During conditioning non-weights training sessions, the most injuries were as a result of running-related activities (89%), a rise when compared with (78%). The most common injuries sustained during conditioning non-weights sessions in remained the same as , with a small rise in the percentage of hamstring and calf muscle injuries. They were hamstring muscle injury (29% v 24%), calf muscle injury (16% v 13%), and hip flexor/ quadriceps muscle injury (7% v 11%). Other - non-contact During rugby skill contact sessions the most injuries (32%) resulted from running-related activities, with the tackle being the second most common cause of injury (26%). The tackle remains the most common match event resulting in injury. However, the incidence of injuries as a function of injury event saw a drop in the incidence of injury as a result of the tackle (being tackled and tackling) in The most common injuries as a result of the tackle in were thigh haematoma, MCL injury, knee joint sprain, Inferior tibiofibular syndesmosis injury, and costo-chondral/sternal injury to the ball carrier, and acromio-clavicular joint injury, concussion and cervical nerve root injury to the tackler. These findings are similar to the past two seasons. Running remains the second most common match event resulting in injury (13% of all match injury events). The most common match injuries as a result of running are calf muscle injury, hamstring muscle injury and adductor muscle injury, which combined make up 58% of all running related match injuries. The incidence of injury associated with the collision (accidental or illegal tackle) was similar in when compared to Of the total number of injuries resulting from collisions, the proportion of those resulting from perceived accidental collision was 83% in , the same as The incidence of injuries for which the associated event was not identified was similar in to (10% compared with 11%). For details of incidence of injury and associated match event for the whole study period, see Appendix D. (See figure D1, page 47) The proportion of injuries caused by a contact event in rugby skill contact sessions reduced in when compared to (61 v 68%); however, when combined, contact events still result in the most injuries in rugby skill contact sessions. There was a rise in the proportion of injuries caused by a non-contact event in (34%) compared with (25%). There were a smaller proportion of injuries for which the associated event was unknown in (5%) compared with (7%). The most common injuries sustained during contact rugby skill sessions in compared with were hamstring muscle injury, (11% v 11%), calf muscle injury (10% v 7%) and Knee MCL injury (5% v 3%) There was a similar percentage of acromioclavicular joint injury (4% v 6%) and ankle lateral ligament injury sustained during training (4% v 3%). For details of incidence of injury and associated training session for the study period see Appendix D. (See figure D2, page 48) Despite a reduction in the incidence of training injury, the average severity of training injuries sustained during conditioning nonweight sessions and rugby skill contact sessions increased in when compared to by 15% and 6% respectively. For comparison of the average severity of injury during training sessions for and , see Appendix D. (See table D3, page 49)

15 10 Training Volume 11 Hamstring Training Injuries Hamstring muscle injuries continue to remain the most common and highest risk training injury (see tables 9 & 10). The incidence of hamstring injuries decreased slightly in when compared to , however, the injury risk associated with these injuries increased. Biceps femoris muscle injuries remain the most common hamstring injury, at 59% of all hamstring training injuries. Posterior thigh pain of neural origin made up 7% of all hamstring training injuries. Running related activities were the cause of 92% of all hamstring training injuries in For detail of the incidence of hamstring training injuries per 1,000hrs, days absence per 1000hrs each season over the study period and the profile of hamstring injuries in training see Appendix D. (See tables D5 and D6, page49/50) The total training volume per player at Premiership clubs increased in for rugby skill training sessions but was similar for strength and conditioning when compared to the period In there was an increase in training volume in rugby skill sessions when compared to , but a decrease in incidence of injury in these sessions. The proportion of training volume spent doing rugby skill contact sessions/rugby skill non-contact sessions was the same in as The risk of injury during training is a function of the content/ activity, the volume and the intensity. The injury and training study does not currently capture the intensity of the training session (or the player s response to the intensity of the session). The decrease in rugby skill training injury incidence, taken with a similar proportion of time spent in contact and non contact sessions means that the reduction in incidence does not appear to be related to change in type of training. There was, however, a slightly greater proportional reduction in incidence of injury in rugby skill contact sessions in compared with rugby skill non contact sessions. The observed decrease in incidence of injuries in as a result of strength and conditioning training was mainly due to the decrease in conditioning non-weights sessions. The proportion of training volume spent in conditioning non weights sessions was similar to that in , suggesting that it is not the volume of training, but rather the difference in content and intensity of the sessions that may have resulted in the decrease in injury incidence. For comparison of the training volume per player per week over the study period, see Appendix D. (See table D4, page 49)

16 MARCH 2013 ı Injury Diagnosis 12.1 Most common match injuries The most common match injuries in were: 1. Concussion 2.= Thigh haematoma 2.= Hamstring muscle injury (excluding haematomas) 4. Calf muscle injury 5. Knee - MCL injury 6. Acromio-clavicular joint injury The highest ranked match injuries in the period were: 1. Thigh haematoma 2. Hamstring muscle injury (excluding haematomas) 3. Concussion 4. Calf muscle injury 5. Knee MCL injury 6. Ankle lateral ligament injury Injuries have been included in each table if they were one of the 8 most common or greatest risk (total days absence) injury diagnoses during previous seasons. Knee MCL injuries were seen in the top 5 most common match injuries in again. The rise in ranking of these injuries resulted in them being amongst the most common match injuries throughout the study period. Thigh haematomas, hamstring muscle injuries, ankle lateral ligament, concussion and calf muscle injuries remained among the most common match injuries throughout the study Injury - (region and diagnostic category) Head/neck Concussion 5.6 (3) 3.3 (5=) 3.1 (5) 4.4 (5) 4.6 (2) 4.9 (4) 3.9 (4) 4.7 (4) 5.1 (1) Cervical nerve root injury 3.4 (7) 2.6 (8) 2.1 (9=) 3.0 (7=) 1.5 (15=) 2.5 (10) 0.9 (20=) 2.1 (11=) 2.0 (11) Shoulder Acromioclavicular jt injury 3.6 (5) 2.1 (12=) 2.0 (12=) 2.5 (10) 2.9 (8) 3.6 (7) 1.9 (10=) 4.8 (3) 3.0 (6) Chest/low back Costochondral/sternal injury 2.4 (12=) 2.5 (9=) 2.7 (6) 2.8 (9) 3.1 (6) 2.2 (11=) 3.5 (6) 3.3 (8) 2.9 (7) Rib fracture/contusion 1.3 (19=) 2.1 (12=) 2.4 (7) 1.4 (17) 2.5 (9) 0.9 (30=) 1.9 (10=) 0.9 (24=) 1.1 (24=) Thigh Haematoma, thigh 9.8 (1) 6.2 (1) 5.6 (1) 7.7 (1) 5.8 (1) 6.6 (1) 4.9 (1) 7.4 (1) 5.0 (2=) Hamstring muscle injury* 6.3 (2) 4.9 (3) 4.0 (3) 5.5 (2) 4.4 (3) 6.3 (2) 4.6 (2) 5.8 (2) 5.0 (2=) Knee MCL injury 2.9 (9=) 3.3 (5=) 3.7 (4) 3.9 (6) 3.6 (5) 4.7 (5) 3.4 (7) 3.7 (7) 4.0 (5) Knee meniscal/articular cartilage injury 2.4 (13) 2.0 (17) 2.1 (9=) 1.6 (12=) 1.9 (13=) 3.4 (8) 1.8 (13) 2.1 (11=) 0.8 (31=) Lower leg Haematoma, calf/shin 3.5 (6) 3.8 (4) 1.5 (18) 3.0 (7=) 2.4 (10) 1.8 (14) 1.5 (14=) 2.1 (11=) 1.8 (14=) Calf muscle injury* 3.3 (8) 5.5 (2) 4.5 (2) 4.5 (3=) 4.1 (4) 5.0 (3) 3.8 (5) 4.7 (4) 4.5 (4) Ankle/heel/foot Lateral ligament injury-ankle 5.2 (4) 3.2 (7) 2.3 (8) 4.5 (3=) 3.0 (7) 4.1 (6) 4.0 (3) 4.2 (6) 2.4 (8) Inf tib-fib syndesmosis injury 2.4 (8) 3.1 (9) 1.8 (14=) table 7 > Most common match injuries (* Excluding haematomas/contusions)

17 MARCH 2013 ı Highest risk match injuries table 8 > Highest risk match injuries (* Excluding haematomas/contusions) Injury (region and diagnostic category) Head/neck Concussion 57 (8) 52 (12) 66 (5) 55 (10) 40 (10=) 62 (10) 28 (18) 45 (15) 64 (9) Cervical disc injury 4 (41) 12 (32) 49 (9) 19 (23) 15 (25) 77 (8) 36 (14) 25 (24) 12 (30) Shoulder Dislocation/instability 108 (2) 95 (2) 176 (1) 118 (4) 90 (2) 86 (7) 114 (2) 66 (9) 108 (4) Acromioclavicular joint injury 66 (6) 30 (22) 48 (11) 64 (8) 40 (10=) 55 (15) 39 (12) 92 (5) 43 (19) Rotator cuff injury/impingement 83 (4) 11 (32) 15 (24) 33 (18) 48 (15) Arm/elbow/wrist/hand Fracture arm 28 (22) 79 (7) Wrist/hand fracture 27 (17) 70 (8) 25 (21) 40 (15) 54 (8) 105 (6) 36 (15) 46 (13) 55 (12) Thigh Haematoma, thigh 53 (9) 38 (17) 33 (15) 74 (7) 39 (13) 35 (21) 50 (10) 47 (12) 21 (25) Hamstring muscle injury* 103 (3) 84 (3) 93 (3) 132 (2) 74 (5) 138 (3) 102 (4) 90 (6) 119 (3) Adductor muscle injury* 83 (6) Knee MCL injury 83 (5) 106 (1) 129 (2) 110 (5) 88 (3) 154 (2) 97 (5) 108 (3) 148 (2) ACL injury 134 (1) 81 (81) 24 (24) 168 (1) 117 (1) 232 (1) 90 (6=) 184 (1) 186 (1) Meniscal/articular cartilage injury 101 (4) 74 (7) 52 (7) 121 (3) 67 (7) 113 (5) 124 (1) 66 (10) 18 (26) PCL/LCL injury 41 (16) 92 (5) Patella dislocation or tendon injury 6 (38=) 76 (8) Lower leg Calf muscle injury* 32 (14) 77 (6) 66 (4) 80 (6) 50 (9) 51 (17) 60 (9) 46 (13) 56 (11) Tibia/fibula fracture 43 (10) 40 (16) 24 (22=) 58 (9) 37 (14=) 32 (22) 79 (8) 97 (4) 41 (20) Achilles tendon injury 11 (29) 80 (5) 53 (6) 10 (32) 26 (18=) 75 (9) 37 (13) 87 (7) 46 (16) Ankle/heel/foot Lateral ankle ligament injury 63 (7) 37 (18) 42 (13) 50 (13) 37 (14=) 57 (12) 33 (16) 70 (8) 27 (22) Inf. tib-fib syndesmosis injury 17 (22) 28 (23) 50 (8) 50 (14) 70 (6) 60 ( (6=) 131 (2) 58 (10) Fractured foot 133 (4) 104 (3) 29 (20) 44 (18) The match injuries of highest risk in were: 1. Knee - ACL injury 2. Knee - MCL injury 3. Hamstring muscle injury (excluding haematomas) 4. Shoulder dislocation/instability 5. Knee - PCL/LCL injury The highest ranked match injuries in the period were: 1. Knee - ACL injury 2. Knee - MCL injury 3. Shoulder dislocation/instability 4. Hamstring muscle injury (excluding haematomas) 5. Knee meniscal/articular cartilage injury ACL injury was once again the highest risk match injury in and shoulder dislocation/instability featured in top five after dropping out in Conversely, Inferior tibiofibular syndesmosis injuries dropped out of the top 5 highest match risk injuries in after being the second highest ranked in There has been very little change in the highest risk match injuries over the study period.

18 MARCH 2013 ı Most common training injuries table 9 > Most common training injuries (* Excluding haematomas/contusions) Injury (region and diagnostic category) Head/neck Concussion 0.07 (8=) 0.04 (11=) Cervical nerve root inj (11=) 0.01 (27=) 0.01 (29=) 0.06 (6) (27) 0.02 (18=) 0.03 (21=) 0.04 (11=) Shoulder Acromioclavicular jt inj (5) 0.04 (8=) 0.07 (8=) (10=) 0.03 (17=) 0.06 (7) 0.07 (8=) 0.04 (11=) Rotator cuff injury/impinge (9) 0.02 (21=) 0.02 (18=) 0.07 (8=) 0.01 (27=) Thoracic/lumbar spine Lumbar facet joint inj (7=) 0.02 (16=) 0.07 (8=) 0.05 (9) 0.04 (10=) 0.08 (8) 0.05 (12=) 0.05 (15=) 0.06 (7=) Lumbar disc/nerve root inj (6) 0.14 (3) 0.10 (3=) 0.04 (10=) 0.16 (4) 0.12 (6) 0.08 (6) 0.07 (8=) 0.08 (6) Lumbar soft tissue inj (7=) 0.04 (8=) 0.10 (3=) 0.06 (7) 0.09 (8) 0.09 (7) 0.06 (7=) 0.07 (8=) 0.04 (11=) Groin/hip/buttock Adductor muscle inj.* 0.04 (16=) 0.09 (6) 0.10 (3=) 0.07 (5=) 0.18 (2=) 0.14 (5) 0.11 (4) 0.14 (4) 0.10 (4) Thigh Haematoma, thigh 0.02 (21=) 0.01 (20=) 0.06 (11=) 0.04 (10=) 0.11 (7) 0.05 (11=) 0.03 (15=) 0.05 (10) Hip flexor/quads muscle inj.* 0.18 (4) 0.15 (2) 0.07 (8=) 0.12 (4) 0.12 (6) 0.19 (2) 0.09 (5) 0.15 (3) 0.11 (3) Quadriceps muscle inj (6=) 0.06 (7=) Hamstring muscle inj.* 0.45 (1) 0.21 (1) 0.36 (1) 0.32 (1) 0.59 (1) 0.36 (1) 0.38 (1) 0.45 (1) 0.42 (1) Knee MCL injury 0.09 (7=) 0.03 (11=) 0.06 (11=) 0.07 (5=) 0.04 (10=) 0.05 (11=) 0.03 (15=) 0.06 (7=) Meniscal/articular cartilage inj 0.05 (11=) 0.03 (11=) 0.08 (6=) 0.02 (20=) 0.03 (20=) 0.07 (9=) 0.06 (7=) 0.08 (6=) 0.01 (27=) Knee joint sprain/jar 0.06 (7=) 0.07 (8=) 0.04 (11=) Lower leg Calf muscle inj.* 0.33 (2) 0.11 (5) 0.16 (2) 0.13 (3) 0.14 (5) 0.17 (3=) 0.20 (2) 0.30 (2) 0.24 (2) Achilles tendon inj (7=) 0.04 (7) 0.06 (11=) 0.02 (20=) 0.04 (10=) 0.07 (9=) 0.06 (7=) 0.03 (21=) 0.04 (11=) Ankle/heel/foot Lateral ankle ligament inj (3) 0.12 (4) 0.08 (6=) 0.16 (2) 0.18 (2=) 0.17 (3=) 0.12 (3) 0.11 (5) 0.09 (5) Inf tib-fib syndesmosis inj (8=) 0.03 (17=) 0.01 (26=) 0.02 (23=) 0.02 (21=) 0.05 (12=) 0.04 (17=) 0.02 (19=) The most common training injuries in were: 1. Hamstring muscle injury (excluding haematomas) 2. Calf muscle injury 3. Hip flexor/quadriceps muscle injury (excluding haematomas) 4. Adductor muscle injury (excluding haematomas) 5. Lateral ankle ligament injury The highest ranked training injuries in the period were: 1. Hamstring muscle injury (excluding haematomas) 2. Calf muscle injury 3. Lateral ankle ligament injury 4. Hip flexor/quadriceps muscle injury (excluding haematomas) 5. Adductor muscle injury (excluding haematomas) There was no change in the most common training injuries in when compared with Hamstring muscle injuries remained the most common training injury throughout the study.

19 MARCH 2013 ı Highest risk training injuries table 10 > Highest risk training injuries (* Excluding haematomas/contusions) Injury (region and diagnostic category) (rank) Head/neck Cervical disc inj (24) 1.8 (5) 2.2 (5=) 0.2 (24) 0.2 (27=) 1.4 (15) 0.1 ( 31=) Shoulder Dislocation/instability 8.2 (1) 2.4 (5) (32) 1.4 (10) (12) 2.1 (7) 0.7 (17) Acromioclavicular joint inj. 3.4 (8) 0.8 (12) 1.4 (11) (27=) 1.0 (13) 1.8 (9) 1.6 (11=) 1.4 (10=) Rotator cuff/impingement (14) 2.9 (4) 0.4 (15) 1.7 (8=) 0.7 (16) 0.2 (27=) 1.6 (11=) 0.1 (31=) Arm/elbow/wrist/hand Wrist/hand fracture 0.9 (16) 0.7 (13) 1.0 (13) 1.2 (7) 0.8 (14=) 1.1 (12) 0.8 (14) 1.3 (16=) - Thoracic/lumbar spine Lumbar disc/nerve root inj. 2.4 (9) 5.7 (1) 1.8 (9) 1.8 (4) 2.5 (3=) 7.3 (1) 2.8 (4) 1.7 (8=) 6.5 (2) Groin/hip/buttock Adductor muscle inj.* 0.5 (21) 2.4 (4) 0.8 (19) 1.2 (8) 1.9 (7) 1.3 (11) 1.1 (11) 1.7 (8=) 1.0 (13) Thigh Hip flexor/quads muscle inj.* 2.0 (10) 1.1 (11) 2.1 (8) 0.8 (11) 1.2 (11) 2.7 (5) 0.7 (15=) 1.3 (16=) 1.7 (8) Hamstring muscle inj.* 6.4 (2) 4.2 (2) 4.6 (1) 5.1 (1) 9.5 (1) 5.0 (3) 6.1 (1) 6.9 (1) 7.3 (1) Quadriceps muscle inj. 1.7 (8=) 0.9 (14) Knee MCL inj. 4.9 (3) 0.6 (17) 2.9 (3) 1.1 (9) 0.7 (16=) 2.1 (6) 0.7 (15=) 0.5 (24=) 2.0 (6) ACL inj. 4.6 (4) 1.7 (7) 4.1 (2) 1.7 (6) (4) 2.1 (7) 6.8 (2) 1.9 (7) PCL, LCL inj. 2.5 (3=) 0.1 (27=) 0.02 (40) 0.2 (32=) 0.6 (18) Meniscal/articular cartilage inj. 1.5 (12) 2.4 (3) 2.8 (5) 0.1 (30) 2.2 (5=) 6.2 (2) 3.8 (2) 3.1 (5) 1.3 (12) Knee joint sprain/jar 1.3 (9=) 0.7 (15=) 0.3 (28=) 0.4 (20=) Lower leg Calf muscle injury* 4.4 (5) 1.5 (8) 2.7 (6) 2.5 (3) 1.7 (8=) 1.8 (8) 2.0 (8) 3.8 (3) 3.4 (3) Tibia/fibula fracture 2.0 (11) 1.3 (10) 2.4 (7) (15) 2.2 (6) 0.9 (19=) 2.1 (4=) Achilles tendon injury 4.2 (6) 1.7 (6) 1.5 (10) 0.1 (25=) 1.1 (12) 1.3 (9=) 3.3 (3) 3.0 (6) 1.6 (9) Inferior tib-fib syndesmosis 2.6 (5) 1.5(14) 0.5 (19) Ankle/heel/foot Lateral ankle ligament inj. 3.7 (7) 1.4 (9) 0.9 (17) 3.0 (2) 2.7 (2) 2.0 (7) 1.7 (10) 3.8 (4) 2.1 (4=) The training injuries of highest risk in were: 1. Hamstring muscle injury (excluding haematomas) 2. Lumbar disc/nerve root injury 3. Calf muscle injury 4= Tibia/fibula fracture 4= Ankle lateral ligament injury The highest ranked training injuries over the period were: 1. Hamstring muscle injury (excluding haematomas) 2. Lumbar disc/nerve root injury 3. ACL injury 4. Calf muscle injury 5. Knee meniscal/articular cartilage Hamstring muscle, lumbar disc/nerve root and ACL injuries remain the highest risk training injuries throughout the study period.

20 MARCH 2013 ı results England Senior Side 13.2 Training injuries TABLE 12 > England training injury incidence, average severity and days absence since Rugby skills Strength and conditioning The data includes the 2011 Rugby World Cup and 2012 Six Nations competition. Injuries (95% CI) Average severity, days (95% CI) Injuries (95% CI) Average severity, days (95% CI) ( ) (60-80) 4.0 ( ) 4 16 (8-32) 13.1 Match injuries table 11 > England match injury incidence, average severity and days absence since ( ) (80-99) 6.3 ( ) (68-90) ( ) 4 2 (1-6) ( ) ( ) ( ) 9 74 (46-103) 2.5 ( ) (7-61) Total number of injuries Injuries (95% CI) Injuries per match Average severity, days (95% CI) per match ( ) (62-209) 12.1 ( ) (81-385) ( ) 8 46 (20-73) 4.0 ( ) 6 26 (-3-55) ( ) ( ) ( ) ( ) (95-195) ( ) (95-195) ( ) ( ) ( ) (57-135) ( ) (52-125) ( ) (37-119) ( ) (31-92) ( ) ( ) 7 12 ( ) 4.4 ( ) 5 22 ( ) ( ) (31-110) 2.8 ( ) (6-95) England Match and Training Injury risk No statistically significant change in risk was seen in The likelihood of sustaining an injury whilst playing for England senior side reduced again in , however the average severity of injury increased. These changes were not statistically significant. There was an increase in the incidence of rugby skill training injuries, whilst the incidence of injury sustained in strength and conditioning sessions reduced when compared to These changes were not statistically significant. Note: 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, reflected in the wide 95% confidence intervals and the lack of statistical significance in the results. CONCUSSION IS THE MOST COMMON MATCH INJURY