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Introduction
Since the International Rugby Board (IRB) declared Rugby Union an ‘open’ game thus effectively ushering in professionalism, players have become faster and stronger.1 Force equals mass multiplied by acceleration: logically increased force at collision will lead to more injuries. Surveillance studies and injury databases have provided comprehensive datasets which confirm changing patterns of injury in rugby.2 We examine what is being done, and how safety can be improved in rugby.
Background
Rugby Union is experiencing unprecedented global growth. In total, 3.5 million men, women and children play worldwide, with 117 Unions in membership of the IRB.3 Modern rugby is ever more physically demanding due to increases in ball in play time, and speed of play. A fourfold increase in tackles and rucks per game has been noted.4–6 Teams with the tallest and heaviest players outperformed others in the Rugby World Cup.7 The IRB have appointed a Chief Medical Officer, a safety consultant and working groups to ensure that safety is maintained.
Injury trends
Epidemiological data provide insight into changes in the nature and frequency of injuries. Some injuries are unavoidable and ‘uncontrollable’, whereas others result from dangerous play. An international consensus statement on definitions and procedures used for injury surveillance has allowed meaningful comparisons of results across studies.8 The establishment of major event surveillance studies including the (2007) Rugby World Cup Injury Surveillance Study,2 and national injury databases such as the England Rugby Injury and Training Audit monitor the frequency and patterns of injury in Rugby.
These have demonstrated:
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high incidence of injury in Rugby Union relative to other team sports;
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an initial increase in injury risk since the advent of professionalism;
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since 2000, injury rates have reverted to levels close to the preprofessional game;
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reduction in injury incidence with decreasing age and competitive level;
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higher incidence of injuries during matches compared with training and
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the tackle is the most injurious event in the games, with collisions and scrums also more likely to result in an injury.
What can be done?
The IRB have demonstrated a readiness to introduce law changes, adapt sanctions, develop guidelines and educate players and officials in order to discourage dangerous play. Regular meetings between law makers, players and medical experts already exist looking at rules, sanctions and setting standards. IRB Medical Conferences have taken place since 2009, while a Player Welfare website was established in 2010.
Law changes
The Laws provide the framework for a game that is enjoyable to play, entertaining to watch and acceptably safe. In response to growing evidence of front row vulnerability to catastrophic neck injuries, the IRB amended the law of scrummage in 2007. Fuller et al9 conclude that since the introduction of the Law there has been a significant reduction in cervical spine injury associated with the scrummage. A further revised sequence of engagement: (‘crouch, touch, set’)10 limits acceleration, and consequently the collision force.
The introduction of the Law which made mouth guards compulsory for rugby union players in New Zealand led to a 43% drop in dental injuries in New Zealand club rugby players.11
Changes to sanctions
The IRB can recommend sanction change if wishing to change player behaviour. This is a quick way to effect a change in the game. The sanction for dangerous or ‘tip’ tackles was increased in 2009, and reinforced to team managers prior to the 2011 World Cup, with decreasing the risk of injury said to be the governing principle behind the IRB's ‘zero tolerance’ approach. Despite the furore surrounding Wales captain Sam Warburton's red card in the semifinal, the correct sanction was applied and the rate of tip tackles appears to have tumbled since. High profile incidents of eye-gouging have led to stricter sanctions and a reduction in incidence is anticipated.
Implementation
Citing commissioners were introduced in the 1999 world cup. These independent officials ensure that foul and potentially injurious play can be punished even if not detected by match officials. A White Card was introduced for the 2012 ‘Super 15’ season for incidents of suspected foul play where the referee is unsure what punishment is merited, or of the identity of the perpetrator. The incident is later reviewed by the citing commissioner.
Development and implementation of guidelines
The participation by the IRB in recent concussion consensus conferences and the adoption of international concussion guidelines12 highlights their commitment to enhancing player welfare practices. Recent trials by the IRB of the Pitch Side Concussion Assessment tool have now been widened, with all unions invited to implement the protocol within their elite domestic competitions. Under the trial players who have sustained a head injury with suspicious symptoms or signs will be able to leave the field of play for a standardised assessment undertaken over a 5 min period. In parallel, a longitudinal concussion study has been launched in partnership with New Zealand Rugby Union to evaluate the potential impact of head injuries and long-term health outcomes following exposure to professional Rugby.
Education
There is no convincing published evidence that player education makes rugby safer although this would appear intuitive. Evaluative studies of how best to educate all levels of rugby players would be informative and worthwhile. Education of staff can raise standards in player welfare, immediate care and subsequent management. In rugby playing countries the success of injury prevention programmes such as BokSmart13 and RugbySmart14 are now being evaluated. These initiatives aim to encourage evidence-based sports medicine and implement injury prevention strategies through education of coaches, players and referees. Similar resources have been developed by the IRB including a Player Welfare website, systematic reporting of catastrophic injury using online forms and secure databases (with direct feedback) has been rolled out. The Scottish Rugby Union is looking to track long-term player health, to evaluate the impact of a career in rugby.
Conclusions
The IRB promotes excitement, fair competition and player and spectator safety. Previous law changes have followed a review of where injuries occur, and have resulted in decreased catastrophic neck injuries, among others while preserving the integrity of the game. ‘Controllable’ injuries arise where injury prevention strategy can influence outcomes. Injury statistics resulting from foul play, set pieces and training in particular can be improved with player welfare and injury prevention strategies.
We must drive best practice in Player Welfare. Positive initiatives instituted must be supported, while it is the responsibility of all staff and players to be vigilant to the emergence of safety issues that place players at risk and develop plans accordingly.
While ‘safer’ as an adjective does not conjure up the same excitement as ‘faster’ ‘higher’ or ‘stronger’, application of rule and sanction change to decrease injury is an integral and welcome part of Rugby Union.
Acknowledgments
The authors are grateful to Mr Douglas Hunter for his input and expertise.
References
Footnotes
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Contributors AD, IM and JR were all involved in the conception, drafting, revising and final approval of this article
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.