Injuries in Rugby Union football

THE GAME

Aggression is an essential ingredient of many sports, particularly those involving bodily contact. Aggression in man is arguably a biological necessity but it is not necessarily synonymous with violence or malice prompted by motives of revenge or hatred. In rugby football the presence of aggression and resultant violence has been the subject of an on-going debate for a considerable time. They can be manifested in most aspects of rugby including running, jumping, tackling, scrummaging, rucking and mauling. It is possible, however, to possess an aggressive attitude towards the game without the use of violence. Nevertheless injuries are an unavoidable consequence of aggression especially when it does generate violence.

It is well recognised that fitness can help to reduce the risk of injury. The fittest man on the field however, if trapped in a ruck, can be severely injured by an unscrupulous player with a disregard for the laws of the game. Invariably acts of violence come within the scope of Law 20 which relates to charging, obstruction, foul play and misconduct. Most offences against this law tend to occur in the scrum, the line-out, the ruck and the maul. These particular phases of the game constitute focal points where possession of the ball is contested, aggression is generated, violence ensues and injuries occur. These and other phases of the game require summary explanation.

Kick-offs occur at the start of each half of the game and after each score. They are taken from the centre of the field.

Drop-outs usually occur when the ball is touched down over the try line or progresses over the dead ball line to the advantage of the defending side. Drop-outs are taken from the twenty-two metre line.

In both cases the ball is usually kicked in the air towards the opposing forwards while forwards from the kicking side endeavour to reach the ball first or dispossess the catcher. The scrum is used to restart the game after certain infringements. The forwards from each side combine in the prescribed manner, and push against each other with heads interlocked and backs. The ball is thrown into the front row of the scrum where the hooker from each side attempts to scoop it back with his foot.

A wheel occurs when a prop forward ceases to push in a scrum and acts as a pivot around which the forward momentum revolves, turning the scrummage through an angle of 90° to the original line of direction.

The scrum is collapsed by a player in the front row falling to the ground, either deliberately or by accident, when both sides are exerting maximum effort. The effect is to change the direction of the force being applied by both sets of forwards. The force is redirected towards the ground instead of being maintained in a horizontal plane resulting in a pile-up of bodies.

The maul occurs when a player from one team is stopped with the ball while still on his feet . He then attempts to screen the ball from the opposition and release it to his own supporting players. Opposing forwards combine in an attempt to dispossess him and drive him backwards.

The ruck occurs when a player is grounded with the ball and individuals from both teams attempt to drive over this player and the ball so that it is made available to supporting team members .

Risks

Few observers dispute that there are risks inherent in playing rugby. However, the element of risk can be reduced or intensified by: 1. the application of techniques, for example, collapsing the scrum, head-on tackles or ‘rucking’ players off the ball; 2. the manipulation of the laws, for example, Law 19 dictates that a player who is lying on the ground and (a) is holding the ball, or (b) is preventing an opponent from gaining possession of it, or (c) has fallen on or over the ball emerging from a scrummage or ruck, must immediately play the ball or get up or roll away from it. Failure to observe this law results in the award of a penalty kick at the place of the infringement.

It may be contended that if this law was applied correctly the frequent pile-ups and resultant injuries would not be seen. 3. the inculcation of attitudes in the participants, for example, a hard uncompromising attitude appears to be increasingly encouraged. Administrators are, of course, implicated: they can, after serious incidents, take positive measures by banning offenders from further participation for discretionary periods, or alternatively impose severe financial penalties.

A study of player behaviour demonstrates that more players are at risk for longer periods of time in rugby than in most field invasive games. In addition, exposure to risk is immediate due to the prescribed method of starting the game which invariably involves congregation of both sets of forwards as the ball drops from the kick-off.

Minor injuries occur regularly and neglect of these can sometimes have serious long-term repercussions. Neglect in this instance has been ascribed by Tooth (1974) to such factors as the quality of first aid available, the attitude of the coach or captain and the attitude of the player.

Serious injury has been the exception rather than the rule in rugby. Between 1968 and 1974, no cases of paralysis as a result of rugby injury in South Wales were reported. Since 1974, however, the annual average rate has been one case per season with two cases during the early part of the 1978/1979 season (WiUiams and McKibbin, 1978). As physical conditioning of players has become more rigorous over the years, it is probable that the increased injury incidence is due to a greater recklessness in play.

CHARACTERISTICS OF RUGBY INJURIES

There is a fair degree of discrepancy between personnel involved in playing or coaching and medical researchers as to what should validly constitute a recorded injury. It appears that the most viable operational definition incorporates the criteria of the injured player being unable to continue the game, requiring medical attention and needing a minimum recovery period of ten days (Walkden, 1975).

A systematic appraisal of the characteristics of rugby injuries requires that their type, anatomical site and relative frequency be identified prior to assessing the determinative nature of such factors as the class of rugby in which the injury was sustained, fatigue, the pitch and weather conditions, the tactics employed by the teams and the playing position. Table 1 shows the results of various studies of the site and frequency of rugby injuries.

The most frequently injured part of the body is the head and neck where lacerations and contusions tend to prevail, while the shoulder, arm, knee and ankle joints each account for approximately half that suffered by the head and neck. The trunk, which includes the back and abdomen, sustains the least number of injuries. If the body is considered in terms of larger regions a distinct pattern more clearly emerges. The lower limb, consisting of the hip, knee and ankle joints, the upper limb, consisting of the hands, arms, shoulders and collar bones, and the head and neck each account for slightly less than one-third of all injuries, the trunk being a residual region accounting for less than one-tenth and thus of relatively less significance. Injuries, therefore, are fairly evenly distributed over three main regions, although the types of injury experienced in all four regions differ appreciably.

An examination of injury types becomes more meaningful when the injured player’s playing position is taken into consideration. The head and neck region experiences mainly lacerations, concussion and, to a lesser extent, haematomata and fractures. Such injury types are most frequently inflicted by means of a boot or hand. This suggests that a significant proportion are deliberately inflicted; this is a widely upheld proposition which is difficult to substantiate. Nevertheless it is the forwards who receive most injuries in this region especially to the ears and face. These tend to be ofa less serious nature than those suffered by the backs in the upper and lower limb regions but are far more frequent.

The game phases which predispose forwards to head and neck injuries are the binding of locks, the collapsing of scrums, the ruck and maul in pursuit of second-phase ball (a situation exacerbated by the 1977-1978 tackle law innovation permitting a player to retain possession of the ball until it touches the ground), and finally the line-out. Forwards, according to Davies and

Gibson (1978), and especially prop forwards, sustain significantly more injuries not only in the head and neck region but in all regions. There are, nevertheless, certain specific exceptions to this generalisation. Walkden (1975), for instance, ascertained that concussion predominated among the backs with the full-back alone accounting for 30 per cent of all cases. The fullback position is most at risk to injury in all regions, according to Walkden, a proposition reinforced by Durkin’s (1977) investigations (Table 2). Recent kicking law innovations and tactical developments in the contemporary game can undoubtedly account for this trend with the evolution of the running, attacking, abrasive and more committed full-back as exemplified by J. P. R. Williams and Andy Irvine. The same trend would also account for the high risk factor associated with the number 8 and back row play in general identified by Roy (1974). The foraging, driving and high degree of commitment now demanded of back-row players undoubtedly explains their high rank order in injury frequency. The inter-relationship between injury site and type and forward positions is more readily identifiable in the context of first-class rugby. Durkin (1977) showed that over one-third of all injuries at this level were lacerations of which approximately two-thirds were to the scalps and faces of forwards.

Tactics employed at international and first-class competition, and which have permeated down throughout all levels of club rugby, have concentrated upon retaining possession and so called ‘good ball’ from first- and second-phase play. This necessitates very tight and aggressive forward play, a dearth of back play, rolling mauls, crash balls, back-row moves, and first, second and even third phase play, all of which engender situations conducive to the occurrence of head and neck injuries, especially to forwards.

In the same way that head and neck injuries are associated with forward play so also are injuries to the lower leg and shoulder girdle shown to be related to playing positions in the back division. Backs on the whole, including the scrum-half and full-back, experience less frequent but more serious injuries located mainly in the shoulder, knee and ankle joints. Injuries of a less severe but still incapacitating nature, such as muscle tears, seem also to be the prerogative of backs.

By far the most prevalent types of injury in the upper and lower limb regions are ligamentous and cartilaginous; they account for nearly one-third of the injuries in these regions and double that of fractures, sprains, tears and strains. Damaged ligaments are the most common soft tissue injury and they are experienced mainly in the knee and ankle and, to a lesser extent, the shoulder joints. Torn cartilages, on the other hand, occur half as frequently and tend to be located almost exclusively in the knee joint, with the exception of rib cartilages which are damaged relatively infrequently. The leg is also the main location of such less severe injuries as tears, haematomata, sprains and strains which occur with such frequency that precise diagnostic information is lacking. Nevertheless, they cause considerable disruption to the continuity of players’ performances.

Backs are the major recipients of soft tissue injuries sited in the leg. This can undoubtedly be accounted for by the velocity at which the player is running when tackled, the sudden changes in direction executed in swerving and side-stepping and recent innovations in boot and stud design. The crash tackle has also largely replaced the more traditional techniques, particularly in the centres. The impact force absorbed by the lower leg is considerable and contributes to the incidence of ligamentous and cartilaginous injuries to the knee and ankle. This situation has been compounded by the popularity of both low cut boots, which afford little stability to the ankle joint, and more effective traction-inducing studs. Modern studs effectively anchor the knee and ankle joints while permitting the upper leg to rotate either in a tackle or during sudden changes in direction, thereby inducing cartilaginous and ligamentous damage. Centres are especially susceptible to these circumstances as they are the recipient of lateral tackles from the opposition back-row, head-on crash tackles from opposing centres, sudden forceful changes of direction executed in making a break, and violent twisting at the base of mauls in which they have been caught.

Fractures and dislocations dominate the types of injuries found in the upper limb. Fractures of the hand, arm and clavicle and dislocations of the fingers and shoulder, especially acromio-clavicular separation, are commonly experienced by backs. The scrum-half is particularly vulnerable to fractures and dislocations of the metacarpals, phalanges, radius and ulna, a result of harassment by the boots of opposing forwards around the scrum and line-out. It is the shoulder joint, however, which experiences most damage in this region. It accounts for one-quarter of all joint injuries, similar to that of the ankle and second only to the knee in which one-third of joint injuries are sited. Dislocation, particularly acromio-clavicular and, to a lesser extent, sterno-clavicular separation and fracture of the clavicle each account for nearly 40 per cent of shoulder injuries, the backs being again the main recipients.

The crash tackle contributes significandy to the high incidence of shoulder injuries among backs. Both the execution of the tackle, where a direct blow is imparted by the shoulder, and the aftermath, where the tackled player is liable to fall heavily on the point of the shoulder joint, are circumstances where either fracture or dislocation occur. The centres and full-back are most at risk followed by the wings and fly-half. The latter under contemporary strategy is rarely called upon to tackle, relying upon his back-row to execute this task while lying deep in order to effect tactical kicks. Nor is he liable to be subject to incessant crash tackles as the off-side law constrains his opposing back-row. The techniques involved in executing and receiving a tackle are thus instrumental in determining the prevalence of shoulder joint injuries. When tactics place emphasis on retaining possession, backs tend to lie up flat and hit their opposite numbers hard and high in an attempt at dislodging the ball, thereby making it available for their own back row to initiate counterattacks or second-phase. These tactics unquestionably enhance the likelihood of shoulder injuries and it is the backs who are in the forefront of the aggressive high velocity crash tackling in the modern game.

Another relevant factor, in addition to tactics, is the playing surface. Hard surfaces heighten the number of shoulder injuries as the unyielding surface affords little protection at the point of impact. Conversely, a wet and muddy ground inhibits the likelihood of ankle and knee joint injuries as it provides little purchase for studs, thereby allowing the lower leg to rotate freely. Upper limb region fractures and dislocations are similarly reduced on yielding surfaces. Van Heerden (1976) found that over 70 per cent of injuries occurred on dry surfaces while Roy (1974) reported over 80 per cent of knee injuries occurred on dry, firm pitches.

The fast, hard and competitive nature of the modern game together with bigger and fitter players has resulted in a constantly increasing number of injuries. It has been suggested in the context of soccer that the more committed a player is to tackling the less likely he is to sustain injury (Thomas and Reilly, 1975). Experience in rugby is that increased competitiveness and its attendant commitment appears to have led to increased aggression, a win-at-all-costs attitude and dirty play. Training is more frequent and intense, and injuries occurring during practice sessions now account for one-third of the total. Fatigue is a factor in this context, and as it increases during a game, concentration, technique and physical resilience decline. The last quarter has consequently been found by Davies and Gibson (1978) to attract nearly half of the injuries sustained during first-class games.

The constantly evolving laws of rugby will in future determine to a significant extent the site, frequency and type of injuries experienced. Attempts at keeping the game open by restricting kicking outside the 22 metre line have resulted in the full-back being brought into play more often and thus receiving more injuries. The tackle law has diminished the importance of the ruck, enhanced that of the maul and created the collapsed maul, thereby increasing the likelihood of hand, face and head injuries arising from trampling and scraping. The gradual retreat of the mark and its eventual possible disappearance could conceivably encourage the increase in high tactical kicks, thereby endangering the full-back even more. Rugby appears to be in a perpetual state of flux in terms of its tactics, laws and code of ethics. These factors in turn regulate the characteristics, site, frequency and type of rugby injury.

INJURIES IN SELECTED GAME PHASES

It should already be apparent that certain features of play precipitate injury. Some examples of game phases likely to produce trauma include the kick-off, line-out, scrummage, ruck and maul.

Kick-off

The side receiving the kick-off is exposed to a full frontal charge by opponents. Back injury is quite common when the player fielding the ball is isolated and turns his back to the advancing forwards in an attempt to shield the ball.

Line-out

In the line-out the contestants for the ball engage in elbowing their opponents resulting in facial and upper-torso injuries . In addition, dumping or up-ending of a player who is airborne results in shoulder damage when making contact with the ground. Scrum-halves can be rendered particularly vulnerable in this phase when presented with a badly delivered ball and exposed to forwards advancing through the line.

Scrummage

Injuries in the scrummage result from various causes: 1. The scrum may collapse. The front rows are then particularly exposed to serious neck and spinal damage. Although illegal, this has developed into an effective strategy to counter the wheel and the eight man drive. 2. The opposing front rows charge into one another at the commencement of a scrum; head and facial damage often ensues. 3. Wheeling of the scrum can produce tension of the neck and trunk. Here, injuries associated with the collapsed scrummage may also be experienced.

Due to the necessity of binding, the ears of the back five players often develop haematomata or ‘cauliflower ear’. In addition the aggression associated with front row play often prompts exchanges of punches. Hookers who are pillared between their props sometimes fall the victims of punches, kicks, and even eye gouging from unscrupulous opposing second row forwards.

Ruck and maul

Second-phase play as constituted by the ruck and maul is a component of the game in which the incidence of maliciously induced injuries is high.

In an endeavour to get possession of the ball in the ruck, players on the ground are walked on. In addition, if they interfere with efficient retrieval of the ball they are often scraped or raked out of the ruck away from the ball as well as being stamped upon.

In the process of wresting the ball from opposing players, fingers may be damaged in the maul. Sometimes eyes are gouged and mouths maliciously ripped. The equally illegal practices of charging into mauls and pulling opponents from them also occurs.

Tackling

Injuries are sustained by both the tackier, due to incorrect techniques, and the tackled person, due to severity of the tackle or subsequent landing. Tackling from the front, side and rear can produce facial injuries if the tackler’s head is incorrectly positioned. The tackled player often suffers injuries to the menisci of the knee and the ligaments of the ankle and knee. Osteoarthrosis may be a long-term effect. In addition, incorrect landing techniques frequently produce fractures and dislocations in the acromio-clavicular and sterno-clavicular articulations.

Crash tackles in which two opponents meet head-on can result in a multiplicity of facial and upper torso injuries. The dangerous and illegal stiff-arm tackle produces similar results although confined to neck and facial areas.

Running, side-stepping and swerving

Although no inter-personal contact is involved, these skills, practised mainly by backs, can damage the knee and ankle joint. The likelihood of injury is increased by the traction afforded by a firm pitch and by the length (and thus traction) of studs and the low (and thus supportive) sides of boots. Such injuries which result from rapid tension, flexion and extension of the hip, knee and ankle joints may be obviated by modifications to equipment and the playing surface.

Fielding the high-ball

The full-back is exposed more than any other position in catching a high kick from the opposition in the face of advancing opponents. This partially explains the high risk nature of the position. Upon being hit by several of his opponents while attempting to simultaneously watch the opposition and catch the ball, the full-back is liable to suffer any one of numerous injuries.

PROTECTIVE CLOTHING

Traditionally, the use of protective clothing to prevent injury in rugby has not been widely accepted. The use of shoulder pads is illegal except in special circumstances at the discretion of the referee. Shin pads are used by hookers and prop forwards while bandages and strapping are used liberally to fortify joints, particularly those of the hand and ankle. Injuries to the ankle are further intensified by the universal adoption of the lightweight, low cut boot.

The piece of preventive equipment which has made the biggest impact in recent years is the gum shield. Individually moulded types are preferable . Mouth protectors can reduce the incidence and severity of facial fracture and protect teeth. It is also claimed that they reduce the incidence of concussion because they modify the transmission of the blow through the temporo-mandibular joints (Williams, 1975).

In certain areas, mini-rugby participants are forced to wear mouthguards, while in some countries insurance coverage requires that these protectors must be worn.

Only a selection of situations which can generate risk within the game of rugby union has been covered. No attempt has been made to describe the numerous situations which may arise outside of these set game phases and which may intensify risk. To some extent these are common to other field invasive games and contact sports.

The total milieu of the game decrees that all players are vulnerable. The qualities required in a rugby player were perhaps best summed up by Craven, the South African coach (Crawford, 1978): ‘A player must be hard because he is expected to play against hard men and he must make contact with hardness. A player will experience bumps and jolts and he will fall or be flung to the ground like a rag. Players will fall on him and even tread on him. Elbows, knees or even hard heads will strike him without pity, and if the player has a faint heart these things will hurt him and even frighten him.’

One crucial problem which faces the administrators of rugby football is how to stop or even reverse the trend towards violent play. If a suitable answer is found to that problem then, hopefully, injuries within the game will be reduced both in numbers and severity.

REFERENCES

Adams, I. D. (1977). Rugby football injuries. British Journal of Sports Medicine, 11, 4-6. Archibald, R. M. (1962). An analysis of rugby football injuries in the 1961/1962 season. Practitioner, 189, 333-334. Crawford, S. A. G. M. (1978). New Zealand rugby: vigorous, violent and vicious. Review of Sport and Leisure, 1, 64-84. Davies, J. E. and Gibson, T. (1978). Injuries in Rugby Union football. British Medical Journal, 2, 1759-1761. Davies, R. M., Bradley, D., Hale, R. W., Laird, W. R. E. and Thomas, P. D. (1977). The prevalence of dental injuries in rugby players and their attitude to mouthguards. British Journal of Sports Medicine, 11, 72-74. Durkin, T. E. (1977). A survey of injuries in a first-class Rugby Union football club from 1972-1976.

British Journal of Sports Medicine, 11, 7-11. Hawke, J. E. and Nicholas, N. K. (1969). Dental injuries in rugby football. New Zealand Dental

Journal, 65, 173-175. Micheli, L. J. and Riseborough, E. M. (1974). The incidence of injuries in rugby football. Journal of

Sports Medicine, 2, 93-98. O’Connell, T. C. (1954). Rugby football injuries and their prevention: a review of 600 cases. Journal of the Irish Medical Association, 34, 20-26. Roy, S. P. (1974). The nature and frequency of rugby injuries: a pilot study of 300 injuries at Stellenbosch.

South African Medical Journal, 48, 2321-2327. Thomas, V. and Reilly, T. (1975). The relationship between anxiety variables and injuries in top-class soccer. Proceedings European Sports Psychology Congress (Edinburgh). Tooth, R. M. (1974). Prevention of injury in rugby.

Australian Journal of Sports Medicine, 5, 29-32.

Van Heerden, J. J. (1976). An analysis of rugby injuries. South African Medical Journal, 50, 1374-1379.

Walkden, L. (1975). The medical hazards of rugby football. Practitioner, 215, 201-207.

Williams, J. P. R. (1975). Prevention of rugby injuries.

In T. C. J. O’Connell (ed). Injuries in rugby football and other team sports. Irish Rugby Football Union, Dublin. WiUiams, J. P. R. and McKibbin, B. (1978). Cervical spine injuries in Rugby Union football. British Medical Journal, 2, 1749.

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