England Professional Rugby Injury Surveillance Project Season Report February 2015

Transcription

1 England Professional Rugby Injury Surveillance Project Season Report February 215

2 The overall risk of match and training injury in the Premiership remained stable during the season

3 Executive summary Contents The England Professional Rugby Injury Surveillance Project (PRISP) has reported on injury risk since 22, is the most comprehensive injury dataset in Professional Rugby Union and provides objective analysis of trends in injury risk in the English professional game. In the Project team successfully integrated existing surveillance processes with the Rugby Squad player electronic medical record, creating greater opportunities for injury and illness analysis. The key findings from the season were: The overall risk (incidence and absence) of match and training injury in the Premiership remained stable during the season and was again within the expected range of season by season variation seen since the study began in 22. The incidence of training injury, although falling within the expected limits of variation, was one of the highest seen during the study period. There should be continued focus on injury prevention efforts in this potentially more controllable environment. Concussion was, for the third consecutive season, the most commonly reported Premiership match injury (1.5/1 player-hours) constituting 12.5% of all match injuries. Improving concussion awareness amongst players, coaches, referees and medical staff and the standardisation of concussion management has been the major medical focus of the English professional game since 212 and is likely to have contributed significantly to this continued rise in concussion reporting. There was a continued decrease in the incidence of recurrent injuries, continuing the trend seen since 27-8 and a consequence of the continued delivery of effective Authored by the England Professional Rugby Injury Surveillance Project Steering Group rehabilitation of injuries by club medical and conditioning teams. Match hamstring injuries reduced by 5% to their lowest level since 22 again suggesting increasingly effective injury prevention approaches across the league for this common injury. The incidence of time loss injury in matches played on artificial turf (Allianz Park) in professional rugby was compared with those played on natural turf for the first time. The injury risk on artificial turf was similar to that on natural turf. However, continued surveillance is required before inferences regarding differences in the risk of specific injuries can be made. Skin abrasions were substantially more common on artificial turf than natural grass, although the majority of these were minor and only two resulted in any reported time-loss. The incidence of match injuries associated with scrums under the new engagement sequence (crouch, bind, set) introduced in (3.9/1, hrs) was similar to the mean incidence for the study period and fell within the expected limits of variation. The incidence of injury resulting from non-accidental collisions (where a tackler illegally impedes or attempts to stop the ball carrier without the appropriate use of his arms) was 5.5/1 hours. This constitutes a significant proportion of all match injuries and was the highest incidence reported since The consistency with which these illegal tackles are penalised by referees warrants further investigation Time lost as a result of illness and retirements as a result of injury and illness are reported for the first time. Chaired by Dr Simon Kemp (Chief Medical Officer RFU) and comprising Dr John Brooks (Injury Risk Analyst and Ex Harlequins and England Saxons), Matthew Cross (PhD Student and Injury Surveillance Project Research Assistant, University of Bath), Phil Morrow (Performance Director, Saracens RFC), Sean Williams (PhD Student, University of Bath), Dr Tim Anstiss (RPA Medical Advisor), Dr Andy Smith (Consultant in Emergency Medicine, Mid Yorkshire NHS Trust and Premiership Rugby Clinical Governance Advisor), Aileen Taylor (Physiotherapist), Dr Grant Trewartha (Senior Lecturer, University of Bath), Dr Julian Widdowson (Sports Physician, Bath RFC) and Dr Keith Stokes (Injury Surveillance Project Principal Investigator, University of Bath) Executive Summary Definitions Key findings Time-loss illness Injuries leading to retirement Concussion Scrum injuries and scrum engagement trial Training injury event Training volume Most common match injuries Most common training injuries England Senior side Training injuries RFU injury surveillance project methods Supplementary data contents Background Match injury incidence and severity Training injury incidence and severity Injury recurrence Match Injury event Artifical surface Hamstring injuries Injury diagnosis Highest risk match injuries Highest risk training injuries Match injuries Current publications Supplementary data The content of the report is based on data collected and analysed by Matthew Cross (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 4 5

4 Background Introduction The Rugby Football Union (RFU) and Premier Rugby Ltd (PRL) first commissioned an injury surveillance study across the Premiership and England teams in 22 that remains driven and directed towards the improvement of player welfare in elite rugby. This report presents Premiership-wide key findings from the season comparing them longitudinally with the results from 1 previous seasons. The England Professional Rugby Injury Surveillance Project (PRISP) 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. The methods for PRISP can be found towards the end of this report. Supporting tables and figures are included in the supplementary data file alongside this report, the contents of this file are summarised at the end of this report. Developments The season was the first time that an electronic data collection method was used for PRISP. Injury details were captured through Rugby Squad (a whole league electronic player medical record system developed by the Sports Office). The PRISP processes were integrated with the player medical record with a consequent reduction in the time demand on club medical staff and increased analysis opportunities. Because of the recognised season to season variability in the number of injuries reported, it is difficult, without using both methods simultaneously, to definitively determine whether changing the data collection method used will lead to changes in injury reporting behaviours. Nevertheless, when comparing the season with the season, there was no clear difference between the two systems of data capture when considering the mean number of injuries reported per club (Table 1). Feedback regarding the new PRISP processes from club medical staff has been positive and data collection through Rugby Squad will continue in Table 1: Mean number of injuries per club comparing the periods (paper reporting) and (online reporting) Mean injuries per club (match) Mean injuries per club (training) Illness The new electronic data collection method through Rugby Squad allowed the project to begin to survey illnesses for the first time in These data are summarised briefly in this report. It is planned that we will continue to integrate and build upon the initial work in this important area of player welfare. Recovery following concussion In line with a desire to understand more about recovery after concussion, the season saw the continuation of a specific concussion audit across all 12 Premiership clubs. This was introduced to improve our understanding of the time course of resolution of concussion in professional rugby union and includes an audit of return to play practices. While the detailed study results will be released separately to this report, a summary of concussion incidence and risk for is included in this report. Training and match load In a pilot study aligned with the injury surveillance project, individual training and match intensity and load was captured from players at four Premiership clubs during the season. The aim of this study is to investigate the relationship between training intensity and load and injury risk, an area that has not yet been explored by PRISP. The findings from this study will be published in next season s report. Scrum Engagement saw the trial law amendment of the crouch, bind, set scrum engagement sequence. It is likely that further global analysis will be provided in the near future, however this report highlights the incidence of time-loss injuries attributed to the scrum in the English Premiership since 22 and including the season. Looking Forward to Artificial Turf From , two English Premiership teams will play their home fixtures on an artificial playing surface, and it is expected that the use of such surfaces by teams across all levels of the game will increase in the future. Our understanding of the influence that the new generation artificial turf has upon injury risk and perceptions of muscle soreness is still developing. To address this, a study was commissioned by the RFU, PRL and the Rugby Players Association. This report gives a short summary of the results from but the study will continue in Non-time loss injury The use of Rugby Squad makes it possible for PRISP to analyse non-time loss injuries (injuries for which the player receives treatment but that do not cause more than 24 hours of absence from training or match play). These injuries have a significant impact on player welfare and are likely to be risk factors for subsequent injury. Next season s report will include, for the first-time an overview of non-time loss injuries from the season. Definitions 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. Injury severity Injury severity was measured as time () lost from competition and practice and defined as the number of 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. 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. Injury incidence and 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 1, 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 injury severity and is measured in absence. Illness Any illness (classified using the Orchard sports injury classification system OSICS 1.1) for which the player sought consultation at his club that prevented the player from participating in training or match play for a period greater than 24hrs after the onset of symptoms. 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 2. In this report statistical analysis has been performed for the match and training injury incidence and absence. SPC charting has been used to show the expected limits of the system with upper and lower limits set at +/- 2 standard deviations from the mean. NB: The vertical line on each figure denotes the change in data collection methods (move to electronic capture) prior to the season. Time lost as a result of illness and retirements as a result of injury and illness are reported for the first time 6 7

5 Key findings Match injury incidence and severity Summary of match injury risk Match injury risk remains within the expected limits of natural season-to-season variation based on the data since 22 (For a breakdown of incidence and severity by season see table S1). Likelihood or incidence of injury 739 match injuries that led to time lost from training and/or match play were reported in the season compared with a mean of 676 injuries during the period The match injury incidence in was 91/1 hours. This is similar to the mean incidence of 87/1 hours since team matches were included in the analysis during equating to an average of 62 match injuries per club for the season and 1.8 injuries per club per match. This is around 13 injuries per club more for the season than in Severity of injuries and absence from playing and training as a result of match injuries The average severity of 26 for an injury before return to availability for match selection also falls within expected natural variation based on data since 22. As a consequence of the increase in number and severity of injuries, the total number of absence as a result of match injuries for was higher than in and the mean across the study period. The average absence per club per match due to injuries in was 45. Figure 1a: Incidence rates of match injuries over the study period with mean ± 2 x standard deviation shown. Vertical line denotes change in data collection methods to electronic capture.. Note - For a normal distribution, 95% of all data should fall between (Mean - 2 x standard deviation) and (Mean + 2 x standard deviation). 12 Figure 1b: Severity of match injuries over the study period with mean ± 2 x standard deviation shown. Vertical line denotes change in data collection methods to electronic capture. Severity ( absence) Severity Mean Lower limit-2sd Upper limit-2sd : 26 Mean: 22 Figure 1c: Days absence/1hrs from match injuries over the study period with mean ± 2 x standard deviation shown. Vertical line denotes change in data collection methods to electronic capture. Days abscence/1hrs Days abscence Mean Lower limit-2sd Upper limit-2sd : 2247 Mean: 1872 Training injury and incidence and severity Summary of the Training injury risk 414 training injuries (rugby skills and strength and conditioning combined) that led to time lost from training and/or match play were reported in the season. This equated to an incidence rate of 2.9/1 player hours or around 35 injuries per club per season (a season by season breakdown can be seen in table S3). The incidence of injury from training fell within the expected limits of natural season-to-season variation based on the data since 22, although it is one of the highest seen during the study period. The severity of training injuries (25 ) also returned within expected natural variation after falling outside of these limits for the first time in It should be noted that the severity of these injuries remains high when compared to earlier seasons. In general it is the more severe injuries that contribute to the high severity in , with the incidence of injuries in the and day severity categories the highest seen since the study began (table S4). Days absence/1hrs remained within the expected natural season-to-season variation, but was higher than in any other year apart from due to the incidence and severity of training injuries being relatively high in Figure 2a: Incidence rates of training injuries over the study period with mean ± 2 x standard deviation shown. Vertical line denotes change in data collection methods to electronic capture. Incidence/1hrs : 2.9 Mean: 2.5 Severity () Days abscence/1hrs Figure 2b: Severity of training injuries over the study period with mean ± 2 x standard deviation shown. Vertical line denotes change in data collection methods to electronic capture Severity Mean Lower limit-2sd Upper limit-2sd : 25 Mean: 21 Figure 2c: Days absence/1hrs for training injuries over the study period with mean ± 2 x standard deviation shown. Vertical line denotes change in data collection methods to electronic capture Days abscence Mean Lower limit-2sd Upper limit-2sd : 74 Mean: 53 Incidence/1hrs : 91 Mean: Incidence Mean Lower limit-2sd Upper limit-2sd Incidence Mean Lower limit-2sd Upper limit-2sd 8 9

6 Time-loss illness Incidence and severity of time-loss illness A total of 112 time-loss illnesses were reported through Rugby Squad in 9 players during This meant that of the 585 players that consented to the study, 15% reported an illness to their club doctor during the season. The incidence of reported illness for was 191/1 athletes. This is likely to be an underestimate of the total number of illnesses as illnesses in players presenting to general practitioners who do not use Rugby Squad will not have been captured. The mean severity of time-loss illness in was 8 (95% CI: 6-1) absence. Seventy percent of illnesses led to 7 or less absence from training and match play. Most common time-loss illnesses The top 5 illnesses by occurrence were; Upper respiratory tract infection (excluding tonsillitis) (2 cases), diarrhoea (19 cases), gastroenteritis (15 cases), tonsillitis (7 cases) and other ear, nose and throat illness (excluding tonsillitis) (5 cases). Respiratory illness combined accounted for 29 cases, 26% of all illnesses, this proportion is similar to that found in previous studies in other team sports. Both the proportion of players that reported an illness and the incidence of illness was higher than that seen at the 212 London Olympics but less than that observed in Super 14 Rugby Union tournament in 21 (incidence could not be directly compared because of the difference in illness incidence definition). The nature of the illnesses reported was similar to these previous studies. Additional seasons of data collection are required in order to present these data in further detail and to allow the monitoring and comparison of illness incidence and severity across seasons. Injury recurrence Summary of recurrent injury risk Recurrent injury risk for match and training in remains within the expected limits of natural season-to-season variation based on the data since 22 (although season 22-3 falls outside of what is expected). The decrease in reported recurrent injuries since 27-8 that was mentioned in last season s report continues. The incidence rate for recurrent match injuries (4.3/1 player hours) was below the mean incidence of 9.2/1 player hours for the period The most commonly reported recurrent match injuries for season were hamstring muscle injury (3 injuries) and ankle syndesmosis injury (3 injuries). These injury types are similar to those reported in season More detail of the most common recurrent match injuries can be seen in table S6. NB: Concussion was not included in the analysis of recurrent injury as subsequent concussions are considered to be repeat injuries rather than a recurrence of an index injury. 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. Recurrent Match Injuries Figure 3a: Incidence rates of recurrent match injuries over the study period with mean ± 2 x standard deviation shown. Vertical line denotes change in data collection methods to electronic capture Incidence/1hrs Incidence Mean Lower limit-2sd Upper limit-2sd Mean: : 4.3 Recurrent Training Injuries Figure 3b: Incidence rates of recurrent training injuries over the study period with mean ± 2 x standard deviation shown Incidence/1hrs Severity Mean Lower limit-2sd Upper limit-2sd Mean: :.1 Injuries leading to retirement The injury surveillance steering group would like to thank the Rugby Players Association (RPA) for its assistance with the data on players who retired as a result of injury or illness. Previously this report has only presented the number of players who retired with an unresolved (i.e. open) time-loss injury sustained in the season being studied, rather than the total number of players retiring during the season as a result of injury or illness. During the season, 23 players retired through injury and 2 as a result of illness. The injuries that led to retirement were the following body locations: Head & neck - 7 Upper limb - 3 Thoracic and lumbar spine - 2 Lower limb - 11 The average age of the players was 31 Match injury event The profile of injury causation leading to match time-loss injury remains very similar when compared to the period The tackle remains the most common match event associated with injury. The most common injuries as a result of the tackle in were (in order): Ball Carrier Concussion MCL Injury Quadriceps haematoma Inferior Tibiofibular syndesmosis Injury Tackler Concussion Quadriceps haematoma Cervical stinger/burner Acromioclavicular joint sprain Whilst these findings remain largely similar to the past three seasons, for the first time concussion has become the most common match injury for both the ball carrier and the tackler. Injuries caused by player collisions (accidental and nonaccidental combined) were significantly higher in than for the period The incidence injury resulting from nonaccidental collisions (where a tackler impedes/stops ball carrier without the use of his arms) was 5.5/1 hours which constitutes a significant proportion of all match injuries and the highest incidence reported since 29-1 when collisions were first divided into accidental and non-accidental collisions (Figure 6). There are recognised limitations to the non-video based analysis of injury events used in PRISP but non-accidental collisions are illegal under the laws of the game and consistent penalisation by the referee is likely to be an effective control measure. Further evaluation of this area is warranted. Injuries associated with running were significantly lower in than (Figure 5). Whilst it is not possible to draw any strong conclusions yet on why these changes may have occurred, it is important to monitor these events in season Figure 5: Incidence rates of match injuries by injury event. Error bars show 95% CI s Incidence/1hrs Incidence/1hrs Tackled Tackling 29-1 Collision Ruck Maul Scrum Figure 6: Incidence of non-accidental match collisions by season. Error bars show 95% CI s Lineout Other contact Non-accidental collisions Other non-contact Running Not known 1 11

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8 Concussion During there were 86 reported match concussions (62 Premiership, 12 European Competition & 12 National cup competition) and 8 training concussions. 13% of players included in the study sustained 1 or more match concussions with 1 players sustaining 2 separate concussive events within the season. No player sustained more than 2 reported concussions during Figure 7: Incidence per 1 player hours of reported match concussions by season with mean ± 2 standard deviations. Vertical line denotes change in data collection methods to electronic capture Incidence/1hrs Incidence Mean Lower limit-2sd Upper limit-2sd The incidence of reported concussions (1.5/1 hours) during matches is considerably higher than has been reported in previous seasons and is outside of the expected natural variation based on the data from all seasons combined. During the season 91% of reported concussions occurred in match play and 9% in training; these proportions are identical to those observed in season Eighty-seven percent of players went through the season without reporting a concussion (9% in season ). The group believes that this significant increase in reported concussion incidence is most likely to reflect increased awareness and behavioural change amongst players, medical staff, coaches and referees as a result of RFU, PRL, RPA and World Rugby education initiatives and media exposure. A number of previously published studies have suggested that concussion has historically been under-reported in rugby union and it remains to be seen whether the concussion incidence reported for yet represents a true reflection of concussion risk or whether under-reporting is : 1.5 Mean: 5.2 still an issue. It is not possible to separate improvement in reporting practice from the possibility of an inherent increase in the risk of concussion in recent years, but given the rate of change in incidence it seems likely that the biggest change is in reporting rather than true risk. Figure 8: Severity ( absence) of reported match concussions by season with mean ± 2 standard deviations. Vertical line denotes change in data collection methods to electronic capture Severity ( absence) Severity Mean Lower limit-2sd Upper limit-2sd The mean severity of reported match concussions in was 11. It should be noted that the guidelines for return to play after concussion changed for the season. Before the minimum recommended stand-down time was 21 (unless cleared by a neurological specialist). From onwards, players progressed through a graduated return to play protocol dependent on their individualised recovery with a minimum return to play time of 6. In around a third of players with a reported concussion did not report any symptoms or show any signs of cognitive impairment after the day of injury or during the graduated return to play period and were therefore able to return to play in : 11 Scrum injuries and scrum engagement trial During the season a trial law amendment was introduced for the scrum engagement ( crouch, bind, set ). Currently, only one season s worth of injury data exists for this law amendment and therefore, the data must be interpreted with caution. The incidence of match injuries associated with scrums under the new engagement sequence in was 3.9/1 hours. This figure was similar to the mean incidence for the study period and fell within the expected limits of variation (Figure 9). The new scrum engagement process has been shown in previously published research to reduce the impact force at engagement by approximately 2%, thus hopefully leading to a reduction in chronic injuries caused by scrummaging. Further longitudinal research is required to ascertain the full impact of this law variation. The injury surveillance research group will continue to monitor injuries in this aspect of the game in future seasons. Figure 9: Incidence per 1 player hours of match injuries associated with the scrum with mean ± 2 standard deviations Incidence /1hrs Severity Mean Lower limit-2sd Upper limit-2sd Mean: : 3.9 Artificial surface Time-loss injuries (from 39.5 matches) and abrasions (from 27 matches) were compared between matches played on artificial turf and natural grass. The incidence values for match injuries on each surface were; natural grass: 73/1 hours 9% CI 59-9 and artificial turf: 66/1 hours 9% CI: Thus, injury risk on artificial turf was not different to that on natural turf however continued surveillance is required before inferences regarding risk of specific injuries can be made. Abrasions were substantially more common on artificial turf (119/1 hours 9% CI ) than natural grass (15/1 hours 9%CI 9-26), although the majority of these were minor and only two resulted in any reported time-loss. Muscle soreness was reported over the four following a match played on each surface by 95 visiting players (i.e., players who normally play on natural grass surfaces). Muscle soreness was consistently higher over the four following a match on artificial turf in comparison with natural grass, although the magnitude of this effect was small. A full analysis of this area has been accepted for publication in the Scandinavian Journal of Medicine and Science in Sport

9 Training injury event When compared to the period there was no significant change in the incidence rates for any training modality (a breakdown of incidence by severity grouping can be seen in table S4). In , during conditioning non weights training sessions, most injuries were as a result of running related activities (56%). During rugby skill contact sessions, most injuries (24%) resulted from running related activities, with the tackle being the second most common cause of injury (13%). Figure 1: Incidence rates of training injuries by session type. Error bars show 95% CI s Incidence/1hrs Rugby skills - contact Hamstring injuries Hamstring injuries remain the most common and highest risk training injury across the study period. Hamstring injury incidence in matches however reduced by around 5% in from the previous three seasons, which might reflect a focussed injury reduction effort in clubs. There was no change in the incidence of hamstring training injuries in when compared to (.4/1 hours for both and 22-13). A season by season breakdown can be seen in table S1. Training volume Rugby skills - non-contact Conditioning weights Conditioning non-weights Training volume for rugby skills practice specifically was also similar to that seen in the period (3.3 vs. 3.7 hours/ week) while training volume for strength and conditioning in was identical to (2.7 hours/week). A similar proportion of time spent in contact and non-contact training means that any change in training injury incidence is unlikely to be related to a change in type of training. A season-byseason breakdown can be seen in table S9. The risk of injury during training is a function of the content/ activity, the volume and the intensity. It is hoped that the training load pilot study that is in progress will give additional insight into the role of training intensity and load on injury risk. Injury diagnosis Summary of the most common and highest risk match injuries For the third consecutive season, concussion was the most common match injury (12.5% of all match injuries) with the incidence of this injury continuing to increase. This rise in incidence is likely due to a combination of increased education and awareness from national and international governing body initiatives. The season saw the incidence of match-related hamstring muscle injuries reduce by 5%, to their lowest level since 22. This is a reduction of around 25 injuries over the season. While it was commented earlier that the profile of hamstring injuries in training has remained similar, it is important that we continue to monitor hamstring muscle injuries in matches to see if the incidence remains lower across multiple seasons. Match injury risk expressed as absence per 1 player hours decreased for a number of injuries in This reduction in risk has resulted in medial collateral ligament (MCL) injuries to the knee becoming the highest risk match injury in even though the risk of MCL injury is actually less than seen in when it was ranked 2nd. 9% of MCL injuries occurred in contact and consequently are likely to be difficult to prevent. Concussion, for the first time during the study period appeared in the top 5 highest risk ( absence) match injuries. This is due to the high incidence of concussion when compared to all other injuries rather than severity. Overall there has been very little change in the highest risk match injuries over the study period, with the exception of concussion

10 Most common match injuries Highest risk match injuries Thigh haematoma 5.4 ACL AC joint Concussion Ankle syndesmosis MCL Tib/fib fracture AC joint 92 Concussion 5.1 ACL Thigh haematoma MCL Shoulder dislocation MCL 4. PCL/LCL 92 Concussion 6.7 Ankle syndesmosis Syndesmosis MCL MCL ACL Thigh haematoma 3.3 Clavicle fracture 95 Concussion 1.5 MCL Thigh haematoma MCL Ankle lateral ligament ACL Concussion Ankle syndesmosis 96 Figure 11a. Ranking of the top 5 most common match injuries each season for with the associated incidence rates (injuries/1 hours) Figure 11b. Ranking of the top 5 highest risk match injuries each season with the associated absence/1hours 18 19

11 Summary of the most common and highest risk training injuries The profile of the most common training injuries is very similar to that seen since 22. The only change in is the increase in incidence/rank of hip flexor/quadriceps muscle injury and a decreased rate of adductor muscle injuries. injuries (57 injuries) remained the most common training injury throughout the study., calf muscle and lumbar disc/nerve root injuries are the highest risk training injuries throughout the study period. Shoulder dislocations in training entered the highest risk injuries for the first time in Most common training injuries Highest risk training injuries Hip flexor/quad muscle Abductor muscle ACL Ankle lateral ligament Ankle lateral ligament.11 Knee cartilage Hip flexor/quad muscle Abductor muscle Lumber disc/nerve root Ankle lateral ligament Ankle lateral ligament.9 Tib/fib fracture Abductor muscle Ankle lateral ligament ACL Lumber disc/nerve root Hip flexor/quad muscle.9 Lumber soft tissue Hip flexor/quad muscle Ankle lateral ligament Lumber disc/nerve root Ankle lateral ligament Abductor muscle.9 Shoulder dislocation 1.9 Figure 12a. Ranking of the top 5 most common training injuries each season with associated incidence rates 2 Figure 12b. Ranking of the top 5 highest risk training injuries each season with associated absence/1hours 21

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13 England Senior side England match and training injury risk No statistically significant change in injury risk (match or training) was seen for when compared with previous seasons for players on England Senior squad duty. The average severity of match injuries decreased for the second season. Training injury severity also decreased for those injuries attributed to rugby skills sessions but severity increased for injuries sustained in strength and conditioning based sessions. 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 Match Injuries Table 3: England match injury incidence, average severity & absence since 22-3 Total number of injuries Injuries / 1 hrs (95% CI) Injuries per match severity, Days absence / 1 hrs (95% CI) ( ) ( ) 85 Days absence per match Training injuries Table 4: England training injury incidence, average severity & absence since 22-3 Injuries / 1 hrs (95% CI) Rugby skills severity, Days absence / 1 hrs (95% CI) Injuries / 1 hrs (95% CI) Strength and conditioning severity, (2.6-8.) 15 69(6-8) 4.( ) 4 16(8-32) ( ) 12 89(8-99) 6.3( ) 13 79(68-9) (.1-4.) 4 2(1-6) ( ) ( ) ( ) 9 74(46-13) 2.5(.5-4.6) 12 34(7-61) Days absence / 1 hrs (95% CI) (3.-1.) 2 135(62-29) 12.1(4.2-2.) (81-385) ( ) 8 46(3-73) 4.(2.-8.6) 6 26(12-55) (.8-3.5) 7 12(5.7-26) 4.4( ) 5 22( ) ( ) 22 7(31-11) 2.8(.4-5.3) 18 51(6-95) (1.6-9.) 2 58(24-139) 1.1 (.2-7.8) 9 1(1-71) ( ) 11 87(52-147) 3.9( ) 14 57(18-177) ( ) ( ) (95-195) ( ) (95-195) ( ) (119-25) ( ) (57-135) ( ) (52-125) ( ) (37-119) ( ) (31-92) ( ) (78-158) ( ) (55-135) ( )

14 RFU injury surveillance project methods Current publications Further detailed information on injury risk in this cohort of players can be obtained from the following peer reviewed publications that have been produced as part of the surveillance project CW Fuller, JHM Brooks, RJ Cancea, J Hall, & SPT Kemp Contact events in rugby union and their propensity to cause injury. British Journal of Sports Medicine, Dec 27; 41: Publications CW Fuller, AE Taylor,& M Raftery. Epidemiology of concussion in men s elite Rugby-7s (Sevens World Series) and Rugby-15s (Rugby World Cup, Junior World Championship and Rugby Trophy, Pacific Nations Cup and English Premiership). British Journal of Sports Medicine 214; /bjsports J Headey, JHM Brooks & SPT Kemp. The epidemiology of shoulder injuries in English professional rugby union. American Journal of Sports Medicine, Sep 27; 35: RJ Dallana, JHM Brooks, SPT Kemp & AW Williams. The epidemiology of knee injuries in English professional rugby union. American Journal of Sports Medicine, May 27; 35: AE Taylor, SPT Kemp, G Trewartha & KA Stokes. Scrum injury risk in English professional rugby union. British Journal of Sports Medicine 214; 48(13) CW Fuller, JHM Brooks & SPT Kemp. Spinal injuries in professional rugby union: a prospective cohort study. Clinical Journal of Sport Medicine, 27; 17 (1): 1-16 S Williams, G Trewartha, SPT Kemp & KA Stokes. A meta-analysis of injuries in senior men s professional rugby union. Sports Medicine 213; 43(1) JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. Incidence, risk and prevention of hamstring muscle injuries in professional rugby union. American Journal of Sports Medicine, 26; 34: Written informed consent was obtained from 585 registered Premiership squad players for the season. No players formally refused consent. A total of 48 games were included in the analyses for the season. Injuries sustained in training and in all matches in the Aviva Premiership, LV Cup and European Competitions (Heineken and Amlin Cup) were included. Injuries sustained while players represented England were reported and analysed separately. Match and training injury data, and training exposure data, were provided by all 12 Premiership clubs in A complete set of data were collected from all 12 premiership clubs and the England senior side. Medical personnel at each Premiership club and the England senior team reported the details of injuries and illnesses sustained by a player at their club/team that were included in the study group together with the details of the associated injury event using an online medical record keeping system. Strength and conditioning staff recorded the squad s weekly training schedules and exposure on a password protected online system. Team match were also recorded by strength and conditioning staff. Injury and illness diagnoses were recorded using the Orchard Sports Injury Classification System (OSICS) version 1.1. This sports specific injury classification system allows detailed diagnoses to be reported and injuries to be grouped by body part and injury pathology. The definitions and data collection methods utilised in this study are aligned with the IRB Consensus statement on injury definitions and data collection procedures for studies of injuries in rugby union. CW Fuller, AE Taylor JHM Brooks & SPT Kemp Changes in the stature, body mass and age of English professional rugby players: A 1-year review, Journal of Sports Sciences 212 DOI:1.18/ SC Cheng, ZK Sivardeen, WA Wallace, D Buchanan, D Hulse, KJ Fairbairn, SP Kemp & JH Brooks. Shoulder instability in professional rugby players-the significance of shoulder laxity. Clinical Journal of Sports Medicine 212 Sep; 22(5): CJ Pearce, JHM Brooks, SP Kemp & JD Calder. The epidemiology of foot injuries in professional rugby union players Foot & Ankle Surgery. 211 Sep; 17(3): Epub 21 Mar 5. JHM Brooks & SPT Kemp Injury prevention priorities according to playing position in professional rugby union players. British Journal of Sports Medicine 211 Aug;45(1): Epub 21 May 19 RA Sankey, JHM Brooks, SPT Kemp & FS Haddad The epidemiology of ankle injuries in professional rugby union players. American Journal of Sports Medicine Dec 28; 36: CW Fuller, T Ashton, JHM Brooks, RJ Cancea, J Hall, & SPT Kemp Injury risks associated with tackling in rugby union. British Journal of Sports Medicine 21; 44(3): JHM Brooks, CW Fuller, SPT Kemp & DB Reddin An assessment of training volume in professional rugby union and its impact on the incidence, severity and nature of match and training injuries. Journal of Sports Sciences 28 26:8, SPT Kemp, Z Hudson, JHM Brooks & CW Fuller. The epidemiology of head injuries in English professional rugby union. Clinical Journal of Sports Medicine 28; 18: JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. Epidemiology of injuries in English professional rugby union: part 1 match injuries. British Journal of Sports Medicine, Oct 25; 39: JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. Epidemiology of injuries in English professional rugby union: part 2 training injuries. British Journal of Sports Medicine, Oct 25; 39: JHM Brooks, CW Fuller, SPT Kemp & DB Reddin A prospective study of injuries and training amongst the England 23 Rugby World Cup squad British Journal of Sports Medicine, May 25; 39: Abstracts/Presentations JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. The Incidence, Severity and Nature of Injuries Caused by Tackling in Professional Rugby Union Competition. Presented (poster) at The American College of Sports Medicine Annual Meeting, 1st June 26. Published in: Medicine and Science in Sports and Exercise 26: 38(5) S JHM Brooks, CW Fuller, SPT Kemp. The Incidence, Severity and Nature of Groin Injuries in Professional Rugby Union. Presented at The American College of Sports Medicine Annual Meeting, 1st June 26. Published in: Medicine and Science in Sports and Exercise 26: 38(5) S351. JHM Brooks, CW Fuller, SPT Kemp & DB Reddin. The incidence, severity and nature of injuries caused by being tackled in professional rugby union. Presented (oral) at The Faculty of Sports and Exercise Medicine, Royal College of Physicians Ireland (RCPI) and Royal College of Surgeons, Ireland (RCSI) Annual Scientific Meeting, Dublin, 5th September 25 JHM Brooks, CW Fuller, SPT Kemp. The incidence, severity, and nature of scrummaging injuries in professional rugby union. Presented (poster) at 1st World Congress of Sports Injury Prevention, Oslo, Norway 23rd-25th June 25. Published in: Br J Sports Med 39:

15 Supplementary data contents Table S1 Match injury incidence, severity and absence since 22-3 Table S2 Match injury severity since 22-3 Table S3 Training injury incidence, severity and absence since 22-3 Table S4 Training injury incidence in severity classifications since 22-3 Recurrent Injuries Further Detail Table S5 New vs. recurrent match injury incidence, average severity and absence Table S6 The four most common match injury recurrences during Table S7 New vs. recurrent training injury incidence, average severity and absence Time of match injury - Summary Time in season - Summary Figure S8. Incidence rates of match injuries by month of the season. Table S9 - player training hours per week Table S1 Hamstring training injuries, incidence and absence per 1hrs Table S2 : Match injury severity since 22-3 Season Incidence /1 hrs > 84 All Supplementary data Table S1 : Match injury incidence, average severity and absence since 22-3 Table S3 : Training injury incidence, average severity and absence since 22-3 Season Total number of match injuries Injuries / 1 hrs (95% CI) Injuries per club per match severity, (95%CI) Days absence / 1 hrs (95% CI) (92-17) 2. 16(15-17) 1556( ) 31 Days absence per club per match Season Total number Injuries / of training 1 hrs injuries (95% CI Rugby skills severity, Days absence / 1 hrs (95% CI) Injuries / 1 hrs (95% CI Strength and conditioning severity, Days absence / 1 hrs (95% CI) (82-95) 1.8 2(19-22) 1773( ) (68-82) (19-23) 1591( ) (84-97) (2-23) 1879( ) (77-89) (18-21) 1613( ) (93-17) 2. 23(21-25) 2285( ) (73-86) (2-24) 1722( ) (86-99) (2-23) 1917( ) (76-88) (25-29) 2222( ) (67-79) (23-27) 1784( ) (85-98) (24-28) 2247( ) (2.7-4.) (9-97) 2.3 (1.7-3.) (27-31) (1.4-2.) (42-45) 1.3 ( ) (22-24) ( ) (47-51) 1.5 ( ) (22-25) ( ) (35-38) 1.6 (1.3-2.) (24-27) ( ) 19 6 (51-68) 2.7 ( ) (36-52) ( ) (53-73) 2.4 (2.-2.9) (34-49) ( ) (5-67) 2.1 ( ) (3-43) ( ) (66-87) 2.6 (2.1-3.) (34-48) ( ) (59-78) 2.2 ( ) (32-46) ( ) (93-121) 2. ( ) (41-6) ( ) 27 84(75-95) 2.1( ) 2 4(34-47) 28 29

16 Table S4 : Training injury incidence in severity classifications since 22-3 Table S6 : The five most common match injury recurrences during Incidence / 1 hrs > 84 All Diagnosis Number of injuries Severity injury 3 3 Ankle syndesmosis injury 3 3 Grade 1 MCL injury 2 21 Lumbar facet joint pain/stiffness Table S7 : New vs. recurrent training injury incidence, average severity and absence Injuries / 1 hrs New injuries severity, day Days absence / 1 hrs Injuries / 1 hrs Recurrent injuries severity, Days absence / 1 hrs Recurrent Injuries Of recurrent injuries in , 5% occurred within one month of return to play, 32% within 1-6 months, % greater than a year and 18% were not specified. Overall, these proportions are similar to those reported in previous seasons with in particular, a similar proportion of reported recurrent injuries occurring within one month of return to play when compared to previous seasons (61% in the period , 52% in season ). Between 27-8 and there was a decrease in the incidence of recurrent training injuries. Since the incidence has remained the same, a theme that continues in season The incidence of recurrent training injuries in (.1/1 player hours) was below that observed during the period (.26). In addition the severity of new vs. recurrent training injuries can be seen in table S Table S5 : New vs. recurrent match injury incidence, average severity and absence Injuries / 1 hrs New injuries severity, day Days absence / 1 hrs Injuries / 1 hrs Recurrent injuries severity, Days absence / 1 hrs Time of Injury The profile for the timing of injuries within a match remained similar to the period The percentage of injuries for which no precise time of injury was known was far lower than that reported in previous seasons. In less than 1% of match injuries had an unknown time of event. The number of match injuries than were associated with an unknown injury event in remains similar to previous seasons at 14%. Time in Season There has been no significant change over the study period in the time during the season when injuries occur. For the second successive season, saw a significant difference in the incidence of injuries reported in November. Injuries were sustained throughout the season with a peak in injury incidence seen in March. 3 31

17 Table S8 : Incidence rates of match injuries by month of the season. Error bars show 95% CI s Incidence/1hrs May April March February January December November October September August Table S9 : player training hours per week Table S1 : Hamstring training injuries, incidence and absence per 1hrs Training Hrs per week Year Rugby Skills Strength & Conditioning Total Year Incidence/1hrs Days Absence/1hrs

18 Notes Notes 34 35

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