A Unique Insight Into the Incidence of Rugby Injuries Using Referee Replacement Reports

34 Br J Sports Med 2001;35:34–37 Br J Sports Med: first published as 10.1136/bjsm.35.1.34 on 1 February 2001. Downloaded from A unique insight into the incidence of rugby injuries using referee replacement reports

J C M Sharp, G D Murray, D A D Macleod

Abstract survey on injuries occurring during competi- Objectives—To obtain further infor- tive club rugby11 in Scotland, reviewing the mation on the incidence of injuries and accident and emergency department records of playing positions aVected in club rugby in all injured players in the Scottish Borders dur- Scotland. ing the season 1990–1991 (H J Vander Post, Methods—Routine reports of injury (per- personal communication), and encouraging manent) and blood (temporary) replace- clubs to report to the SRU all players admitted ments occurring in competitive club to hospital or dying as a result of playing or rugby matches by referees to the Scottish practising rugby. More recent epidemiological Rugby Union during seasons 1990–1991 to studies established jointly with Edinburgh 1996–1997 were analysed. University Department of Public Health Sci- Results—A total of 3513 injuries (87 per ences reviewed injuries occurring in adult and 100 scheduled matches) and 1000 blood school boy rugby in the Scottish Borders and replacements (34 per 100 scheduled Edinburgh schools.12 matches) were reported. Forwards ac- A further initiative was established in 1988– counted for 60% of the injury and 72% of 1989 when referees were asked to record all the blood replacements. Flankers and the replacements made for injured players during front row were the most commonly re- club matches in the competitive leagues. This placed forwards while wing and centre paper reports the findings from this study, three quarters were the most vulnerable which we believe to be unique, reviewing 3513 playing positions among backs. The inci- injury and 1000 blood replacement reports dence of injury replacements increased as over seven seasons of Scottish Rugby (1990– the match progressed up until the last 10 1991 to 1996–1997). minutes when the trend was reversed. Blood replacements showed a diVerent Materials and methods pattern with 60% occurring during the In the season 1988–1989, rugby referees in first half of the match. Scotland were required to notify the SRU of Conclusion—The most important finding any player who had to leave the field as the of the study was reliability of referees in result of injury or other “medical” reason—for documenting the vulnerability of certain example, hypothermia—for whom a replace- http://bjsm.bmj.com/ playing positions, and the timing when ment player was permitted. The quality of injuries took place, thus assisting coaches and team selectors when choosing re- SRU CHAMPIONSHIP Division ...... placement players for competitive club RESULT CARD and representative rugby matches. This study re-emphasises the need for continu- K.O...... Date ...... /...... /...... ing epidemiological research. HOME TEAM AWAY TEAM (Br J Sports Med 2001;35:34–37) on September 25, 2021 by guest. Protected copyright...... Keywords: rugby injuries; referee replacement reports; Scottish Rugby Union Pen. Drop Try Con Pen. Drop Try Con

No. No. During the 1970s, rugby union was criticised by the media alleging an increase in aggressive Pts. Pts. and deliberately dangerous play. Numerous FINAL ...... Honorary Medical clinical and epidemiological studies of rugby SCORE Advisors, Scottish injury were subsequently reported from the REPLACEMENTS Rugby Union 1–5 6–10 British Isles and overseas, identifying an ...... Position ...... J C M Sharp apparently greater incidence and severity of D A D Macleod ...... Time ...... injury and the vulnerability of certain playing PLAYERS RETIRING NOT REPLACED Department of positions, in particular front row forwards. Medical Statistics, The Scottish Rugby Union (SRU) led the ...... Position ...... University of way in the British Isles, following the introduc- ...... Time ...... Edinburgh tion of competitive club rugby based on BLEEDING PLAYERS RETIRING TEMPORARILY G D Murray national leagues in Scotland in 1973, with a ...... Position ...... Correspondence to: series of research projects which collected ...... MrDADMacleod, St information about the nature, incidence, and Time John’s Hospital, Livingston, causes of injury in an eVort to enhance preven- Referee's Signature ...... West Lothian EH54 6PP, Name ...... Club ...... Scotland, UK tion and treatment. These studies included Accepted 24 August 2000 establishing the ﬁrst national coordinated Figure 1 Scottish Rugby Union result card.

www.bjsportmed.com Rugby injuries and referee replacement reports 35 Br J Sports Med: first published as 10.1136/bjsm.35.1.34 on 1 February 2001. Downloaded from 25 bleeding, or illness. As a result, the value of referee replacement reports in monitoring the Injury replacements occurrence of rugby injuries was diminished. Blood replacements Referees continued to report temporary blood 20 replacements for a further season until the end of 1996–1997 but this has subsequently been discontinued. The data presented are purely descriptive, 15 without any formal statistical analysis. To make replacement rates comparable, they are sum- marised as replacements per 100 scheduled 10 matches, or, when reporting on speciﬁc playing positions, as replacements per player per 100 scheduled matches. This allows for the fact that the reporting of injury and blood replacements 5 does not span exactly the same seasons, that

No. of injury/blood replacements (%) the number of matches per season varies, and that the diVerent positions have one or two players per team (and hence two or four players 0 1 2 3 4 5 6 7 8 9 10 11 12 13 per match). Match week Figure 3 Injury (1990–1995) and blood (1993–1995) replacements by match week Results number. Reports on 3513 injury replacements (87 per recording replacements was improved in the 100 scheduled matches) and 1000 temporary season 1990–1991 by the introduction of a blood replacements (34 per 100 matches) redesigned prepaid postal match result card on were received by the SRU from referees of which the referee could also record the playing competitive club matches during the seven position of the injured player and the time dur- seasons 1990–1991 to 1996–1997. The ing the match that the replacement took place number of reports of injury replacements (ﬁg 1). The number of players per team who increased from 410 in 1990–1991 (64 per 100 could be replaced because of injury increased matches) to 554 in 1994–1995 (87 per 100 from three in 1990–1991 to four in 1995– matches), when up to three replacements were 1996. In addition, during 1993–1994, the laws permitted per match for each team. The total of rugby also permitted temporary replace- number of injury replacements increased to ment for the treatment of players who were 989 in 1995–1996 (116 per 100 matches) bleeding. Their position and time of injury when the number of replacements permitted were similarly recorded. had been increased to four per team and the With eVect from November 1996, substi- playing season extended. Reports of tempo- tutes were permitted in rugby union for tactical rary replacement of players because of bleed- http://bjsm.bmj.com/ reasons as well as replacements for injury, ing varied from season to season, peaking at

Table 1 Type of replacement by playing position (backs/forwards) and season 1990–1997

1990–1991 1991–1992 1992–1993 1993–1994 1994–1995 1995–1996 1996–1997 Totals “Injury” replacements (permanent) Backs 164 185 225 203 228 385 — 1390 (40%) Forwards 245 263 299 380 325 600 — 2112 (60%) Unspeciﬁed 1 —321 4—11 on September 25, 2021 by guest. Protected copyright. Totals 410 448 527 585 554 989 — 3513 “Blood” replacements (temporary) Backs — — — 56 62 91 72 281 (28%) Forwards — — — 175 139 230 175 719 (72%) Totals 231 201 321 247 1000 Totals 410 448 527 816 755 1310 247 4513

Table 2 “Injury” and “blood” replacement reports by individual playing positions, 1990–1997

Injury replacements 1990–1996 Blood replacements 1993–1997

Rate per player Rate per player Playing position Number per 100 matches Rank order Number per 100 matches Rank order

Backs Full back 182 2.3 10 37 0.6 8 Wing 3/4 419 2.6 6 54 0.5 10 Centre 401 2.5 7 88 0.7 7 Stand-oV 191 2.4 9 33 0.6 9 Scrum half 197 2.4 8 69 1.2 6 Forwards Prop 554 3.4 2 183 1.5 3 Hooker 244 3.0 3 78 1.3 4 2nd row 446 2.9 5 144 1.2 5 Flanker 633 3.9 1 212 1.8 1 No 8 235 2.9 4 102 1.7 2 Unspeciﬁed 11 3513 1000

www.bjsportmed.com 36 Sharp, Murray, Macleod Br J Sports Med: first published as 10.1136/bjsm.35.1.34 on 1 February 2001. Downloaded from Table 3 Injury replacement by division (I–VII), 1990–1991 to 1994–1995

Match week number

Division 12345678910111213Totals (%)

I 43271523214127232629182225340(13.4) II 29 46 30 35 33 34 30 37 24 38 17 24 27 404 (16.0) III 26 40 40 29 31 32 26 32 27 35 22 30 22 392 (15.5) IV 25 40 24 34 30 34 39 20 33 29 26 35 33 402 (15.9) V 33384140363335273638272426434(17.2) VI 27 29 25 22 25 18 20 25 25 30 20 9 10 285 (11.3) VII24192029202622122418141425267(10.6) Totals 207 239 195 212 196 218 199 176 195 217 144 158 168 2524

321 in 1995–1996 (38 per 100 matches) but ted per team (from three to four) and in the decreasing to 247 (29 per 100 matches) in the format of competitive club rugby in Scotland following season (table 1). during season 1995–1996. Of the 3513 injury replacements, 2112 Comparison of blood replacement reports (60%) involved forwards and 1390 (40%) by divisions during seasons 1993–1994 and backs; in 11 reports no playing position was 1994–1995 and later seasons 1995–1996 and identiﬁed. In every season, forwards were con- 1996–1997 similarly indicated a smaller sistently injured more often than backs (inter- number being used in lower divisions. seasonal range 57–65%) even allowing for the 8:7 excess of forwards over backs. This pattern was even more apparent for the 1000 blood Discussion replacements, of whom 72% were forwards Every epidemiological surveillance system has (interseasonal range 69–76%) (table 1). individual advantages and disadvantages, with Flankers (3.9 per individual player per 100 under-reporting a consistent feature. In this matches) followed by prop forwards (3.4) were unique study using routine referee reporting, the playing positions most often replaced as a compliance was almost 100% because of their result of injury. Among backs, wing (2.6) and requirement to complete result cards and centre three quarters (2.5) predominated. Full forward them to the SRU after every champi- back (2.3), stand oV (2.4), and scrum half (2.4) onship match. Any shortfall was attributed to were the least commonly replaced players, reports being telephoned in lieu of written although the replacement rates were very simi- completion of a card. In addition, the data lar for all back positions. Flankers (1.8 per obtained from routine reports was inexpensive player per 100 matches) and the Number 8 and straightforward to administer. The dis- (1.7), all in the back row of the scrum, were the advantage was its failure to obtain information players most often requiring attention to with regard to the phase of play and the nature bleeding wounds, followed by each of the other and cause of the injury sustained as well as

forward positions. Scrum half (1.2) and centre being limited to first XV teams playing in the http://bjsm.bmj.com/ three quarters (0.7) were the backs most com- senior leagues of club rugby in Scotland. monly aVected (table 2). In the season 1995–1996, the format of Injury incidence increased as the match pro- competitive rugby in Scotland was changed gressed up to the last 10 minutes, when the from the previous structure of seven divisions trend was reversed (fig 2). In the 3509 each including 14 clubs (a total of 98 clubs) to instances when the time of an injury was speci- four premiership divisions each of eight clubs fied, 1068 (30%) occurred during the first half and seven national leagues each of 10 clubs, of the match and 2441 (70%) in the second thus increasing the total number of clubs half. involved in competitive rugby to 102. As a on September 25, 2021 by guest. Protected copyright. Blood replacements showed a diVerent result the comparison of the frequency of pattern, with 598 (60%) of bleeding injuries replacements at diVerent levels of competitive occurring during the first half of the match rugby was thereafter more diYcult to under- decreasing to 402 (40%) in the second half take. (fig 2). This study identified that 50% of injury While the incidence of injury and bleeding replacements occurred in the six matches replacements did not vary substantially played in September and October, the first two throughout the season, there was a notable months of the season. The remaining matches decrease in the number of injury replacements, in the league competitions were spread out in particular during the later weeks of the sea- during the rest of the season. Garraway and son (fig 3, table 3). Macleod12 showed that injuries were most In the first five seasons (1990–1991 to common during the first two months of the 1994–1995) a total of 2524 injury replace- season, quoting a period prevalence of 15.2 per ments were reported by referees, with the 1000 playing hours, amounting to 60% of all greatest number recorded in division V (434) injuries which occurred in the season, com- followed by division II (404), division IV (402), pared with 12.3% in March and April. Similar division III (392), and division I (340). The early season injury patterns have been reported lowest incidence of reports was in divisions VI including a South African analysis of injuries in and VII (table 3) where the availability of school boy rugby.8 replacement players was less likely. This distri- The number of temporary and permanent bution was less clear in the seasons after the injury replacements reported at diVerent levels changes in the number of replacements permit- of rugby nevertheless suggest that, although

www.bjsportmed.com Rugby injuries and referee replacement reports 37 Br J Sports Med: first published as 10.1136/bjsm.35.1.34 on 1 February 2001. Downloaded from there is a greater incidence of injuries in the the game. It is becoming increasingly diYcult upper echelons of Scottish rugby, this is not a for the referee to maintain an accurate record major feature. Although a full complement of of replacements of players for injury or tactical replacement players is less likely to be a feature reasons as a result of recent law changes. It is at lower levels of competitive rugby, a degree of suggested therefore that a touch judge, or under-reporting by referees in the lower fourth oYcial in those matches where one was leagues must also be borne in mind. available, could record the timing and position The observed decrease in the number of of injured or bleeding players, adding this injury replacements during the last 10 minutes information to the referee’s report card at the of matches can reasonably be attributed to no end of a match. This invaluable source of epi- further replacements being available and/or demiological information would therefore not injured players playing on with only a few min- be lost as a research tool and perhaps could be utes of a match remaining. Similarly a reduced developed further at representative and inter- availability of replacements for bleeding inju- national level. ries during the later stages of a match would not be entirely unexpected. We thank the SRU and their referees for their support and assistance throughout the period of the study. Our thanks are In addition to confirming the feasibility of also due to Mrs Derena Ritchie for typing the manuscript. this approach to analysing rugby injuries, perhaps the second most important finding 1 Durkin TE. A survey of injuries in a first class rugby union from the study was to show once again the football club from 1972–76. Br J Sports Med 1977;11:7–11. 2 Davies JE, Gibson T. Injuries in rugby union football. BMJ incidence of injury among certain playing posi- 1978;2:1759–61. tions, in particular the flankers and front row 3 Hoskins T. Rugby injuries to the cervical spine in English schoolboys. Practitioner 1979;223:365–6. forwards, thus assisting team coaches and 4 Addley K, Farren J. Irish rugby injury survey: Dungannon Football Club, 1986–87. Br J Sports Med 1988;22:22–4. selectors when choosing the replacements most 5 Sparks JP. Half a million hours of rugby football. The inju- likely to be required for injured players. It is not ries. Br J Sports Med 1981;15:30–2. surprising that bleeding injuries more or less 6 Dalley DR, Laing DR, Rowberry JM, et al. Rugby injuries: an epidemiological survey, Christchurch, 1980. New followed a similar pattern. In eVect, the use of Zealand Journal of Sports Medicine 1980;10:5–7. 7 Burry HC, Calcinai CJ. The need to make rugby safer. BMJ up to 87 permanent replacements for injuries 1988;296:149–50. per 100 scheduled matches and 38 temporary 8 Roux CE, Noakes TD. The epidemiology of schoolboy injuries. In: Intermittent high intensity exercise. London: E&FN replacements for bleeding injuries was remark- Spon, 1993;1:419–26. ably low, before the law changes in the game of 9 Clark DR, Roux C, Noakes TD. A prospective study of the rugby entitling the use of replacements for tac- incident and nature of injuries to adult rugby players. SAfr Med J 1990;77:559–62. tical reasons. 10 Dalley DR, Laing DR, McCartin PJ. Injuries in rugby foot- There remains a continuing need for further ball Christchurch 1989. New Zealand Journal of Sports Medicine 1992;20:2–5. epidemiological studies into the incidence, dis- 11 Sharp JCM, Macleod DAD. Injuries in competitive rugby football in Scotland. Update 1981;2.2:1355–61. tribution, and nature of injuries in rugby 12 Garraway WM, Macleod DAD. Epidemiology of rugby 12 13 union, along with the establishment of football injuries. Lancet 1995;345:1485–7. 13 Upton PAH, Roux CE, Noakes TD. Inadequate pre-season properly funded case registers reporting key preparation of school boy rugby players: a survey of players 14

injuries. The referee in rugby union has an at 25 Cape Province high schools. SAfrMedJ http://bjsm.bmj.com/ 1996;86:531–3. increasingly wide range of responsibilities 14 Garraway WM, Macleod DAD, Sharp JCM. Rugby injuries: because of the complex nature of the laws of the need for case registers. BMJ 1991;303:1082–3.

Take home message

Sports medicine must endeavour to make a positive contribution to player safety, irrespective on September 25, 2021 by guest. Protected copyright. of the sport involved. Recommendations to players, coaches, oYcials, and governing bodies designed to minimise illness or injury in sport should be based on reliable data. Inviting match oYcials to record basic details about players unable to complete a match because of injury has proved to be an accurate source of information.

www.bjsportmed.com 138 Br J Sports Med 2001;35:138–140

enigma, it would seem wise counselling to accord with my earlier findings. It has been ensure that those antioxidants are packed suggested that rugby league is a much safer LETTERS TO before visiting one of nature’s wonders! game as the ruck and maul have been DAMIAN MILES BAILEY abolished. However, the incidence of injury is THE EDITOR Senior Lecturer in Physiology, four players out of 26 000 with broken necks 1998 Mt Kanchenjunga Medical Expedition, for rugby league versus five players out of c/o Hypoxia Research Unit, Health and Exercise 500 000 for rugby union, which does not Sciences Research Laboratory, support this claim. University of Glamorgan, Pontypridd CF37 1DL, UK J R SILVER The ups and downs of high altitude Fellow of the Institute of Sports Medicine mountaineering 1 Sharp C. Exercise at altitude. Br J Sports Med Consultant in Spinal Injuries, 2000;34:404. National Spinal Injuries Centre, 2 Bailey DM, Davies B, Davison G, et al. Free Stoke Mandeville Hospital, Bucks, UK EDITOR,—Professor Craig Sharp delighted us radical damage at high-altitude; isolating the with a recent account of his world record source and implications for the pathophysiol- 1 Garraway WM, Lee AJ, Hutton SJ, et al. Impact ascent of Mt Kilimanjaro in the 1960s and ogy of acute mountain sickness. Newsletter of the of professionalism on injuries in rugby union. voiced his concerns about the physiological International Society for Mountain Medicine Br J Sports Med 2000;34:348–51. 2000;10:3–13. dangers inherent in such a feat;1 the madness 2 Garraway M, Macleod D. Epidemiology of rugby 3 Montgomery HE, Marshall RM, Hemingway football injuries. Lancet 1995;345:1485–7. and exuberance of youth! It is interesting to H, et al. Human gene for physical performance. 3 Silver JR. Injuries of the spine sustained in note that this record was established during Nature 1998;393:221–2. rugby. Br J Sports Med 1984;228:37–43. the height of one of the most unforgettable 4 Silver JR. Injuries of the spine sustained during rugby. Br J Sports Med 1992;26:253–8. debates in mountaineering history provoked Professionalism and injuries in rugby 5 Silver JR. The prevention of spinal injuries in by the initial uncertainties of Barcroft, union rugby football. Paraplegia 1994;32:442–53. Margaria, and Henderson, the possibility of 6 Schneider RC. Head and neck injuries in football: an “oxygenless” ascent of Mt Everest. The 1 mechanisms, treatment, and prevention. EDITOR,—Garraway et al are to be congratu- Baltimore: Williams and Wilkins, 1973. epochal ascent without supplemental oxygen lated on their meticulous investigation of the by Messner in 1978 subsequently put paid to incidence of rugby injuries. any speculation and reinforced what T H Rugby has a very high incidence of injuries. EVectiveness of stretching to reduce Huxley (1825–1895) once remarked “The Garraway et al state: “An injury episode injury great tragedy of science; the slaying of a occurred in a professional team for every 59 beautiful hypothesis by an ugly fact!” minutes of competitive play”—that is, one There appears to be a conflict of ideas in two The “get up and get down” philosophy of serious injury among 30 professional players of the leaders in the October issue of the 1 mountaineering has become an increasingly every 59 minutes. Of greater concern is the journal. Reid and McNair state on page 322 popular practice among enthusiasts who are fact that Garraway et al reported two neck that “it is important for rowers to include either pitting their physical attributes against dislocations, one of which resulted in perma- hamstring stretches in their training pro- the stopwatch or, as Messner would main- nent neurological damage, in this recent grammes”, their argument being that stiVness tain, merely limiting their time spent in the paper compared with nil in the earlier one.2 of the hamstrings would prevent pelvic “death zone”. Perhaps the most astonishing The question of rugby injuries is an rotation and increase the likelihood of back 2 feat of all was achieved during an Italian emotive one and I have been concerned, over pain. Shrier, however, demonstrates that expedition to Mt Everest in May 1996 when the years, with the incidence of severe injuries there is no evidence that stretching before Hans Kammerlander summited via the causing tetraplegia. The fact that professional exercise reduces injury. North Col in a record time of 17 hours and players are suVering a greater number of May I suggest that these views are not nec- then descended to basecamp on skiis! How- injuries was apparent from my own re- essarily incompatible. Firstly, it would seem ever, although extending the envelope of searches in 19843 on 67 patients with to me that there may be a diVerence between human endurance, the risks inherent in such tetraplegia whom I treated. I followed this up stretching abnormally tight tissues into a nor- an extreme sport simply cannot be ignored. in 19924 and 19945 and found that there was mal range of motion as opposed to stretching For example, research in our laboratory has a direct correlation between the standard of normal tissues into an excessive range. Is this recently indicated a pronounced increase in play, the fitness of the player, and the number diVerence specified in the studies of the metabolic biomarkers of free radical and of injuries. My findings suggested that greater eVects of stretching on injury prevention skeletal muscle damage at 5100 m due skill does not provide protection, as six of the referred to by Shrier? Perhaps it is a semantic primarily to the oxidative and reductive stress players injured were first class players and quibble, but what is stretching? Secondly, imposed by physical exercise and environ- there are only about 2000 such players in Reid and McNair illustrate the concept of the mental hypoxia respectively. We have also England compared with a total of 400 000 kinetic chain. Did the studies of the ineVec- incriminated free radicals in the pathophysi- players at all standards. The large number of tiveness of stretching look at stretching one ology of acute mountain sickness and en- injuries sustained on tours supports the view link in the kinetic chain to reduce injury else- dothelial dysfunction at high altitude.2 Thus, that the stronger and fitter the player, the where or were they concerned with merely when one considers the average hourly ascent greater the likelihood of an injury occurring. local eVects? rates by Sharp and Kammerlander of about The analogy with vehicle accidents is strik- P E SCHUR 611 m and about 215 m respectively ing, whereby the forces involved and the Wiggo Cottage, 135 Main Road compared with the more leisurely 12–30 m speed of deceleration are the major factors in Wybunbury, Nantwich typically encountered during a Himalayan determining the severity of the injury. This is Cheshire CW5 7LR, UK expedition, the potential for suVering at the confirmed in the first class game where the 1 Reid DA, McNair PJ. Factors contributing to hands (or more appropriately electrons!) of players run faster and are bigger and heavier low back pain in rowers. Br J Sports Med these ubiquitous biomolecules is all too and impact with greater force. 2000;34:321–2. apparent. Free radical generation may be fur- Schneider6 made a separate study of this 2 Shrier I. Stretching before exercise: an evidence ther compounded during a rapid as opposed among American players. He found that 141 based approach. Br J Sports Med 2000;34:324–5. to a steady controlled descent because of the serious injuries occurred among 780 000 mechanical trauma of eccentric muscle con- high school football players, 34 among tractions and greater increase in arterial pO2 70 000 university footballers, and 14 among implicit in reoxygenation injury. 4500 professional players, whereas, in Sand- But how do these mountaineers achieve lot football, an unskilled form of the game BOOK REVIEWS such remarkable feats and survive to tell the (where players do not wear protective cloth- tale when others falter even at the slightest ing!), 26 injuries occurred among 1 645 000 whiV of hypoxia? The fact that Professor players. He concluded that unskilled players Sharp was eVectively a native highlander at do not play as hard as highly skilled or the time of his record suggests that acclimati- professional athletes and that the greater Introduction to clinical neurology. 2nd sation may have conferred at least some pro- degree of force and skill exaggerates the like- ed. Douglas J Gelb. (Pp 386; £22.50.) tection. Or perhaps he is one of the lihood of injury. Oxford: Butterworth-Heinemann, 2000. genetically gifted with the I allele of the ACE Garraway et al1 say “where valid compari- ISBN 07506-7202-1. gene recently associated with improved per- sons can be made, it appears that professional formance at high altitude?3 While this re- rugby union produces higher injury rates General practitioners who have long lost the mains a riddle wrapped in a mystery inside an than professional rugby league.” This is not in art of performing and applying the findings of

www.bjsportmed.com Letters, Book reviews, Notes, Correction 139 a neurological examination will find this con- athlete. All in all, this is an excellent book cise American text a useful addition to the which will be of benefit to any sports or practice library, as an easily understood musculoskeletal practitioner. NOTES AND NEWS reference source. The book is primarily written for medical Analysis students, and achieves this aim as it is an Presentation 18/20 excellent introductory text. It contains nu- Comprehensiveness 17/20 merous practical tips for carrying out a thor- Readability 19/20 Institute of Sports Medicine masters ough neurological examination in one excel- Relevance 18/20 lent chapter. Fortunately, the text also Evidence basis 17/20 course contains many shortened or modified ver- Total 89/100 The Working Party of The Institute of Sports sions of aspects of the full examination, which Medicine and University College London will allow the physician or student to identify B THOMPSON (UCL) proposed that a new Course in Sport significant abnormalities, and then apply the Sports and Orthopaedic Medicine Clinic, and Exercise Medicine be set up. After eight- findings appropriately. Challenges are set Craigavon Area Hospital, N. Ireland een months of intensive preparation, the throughout the book, such as “Where’s the lesion?”, and discussion of case histories pro- course started in September 2000. It is based vides practical and applicable examples of on the Whittington campus of UCL but can application of the examination and accurate Chronic ankle pain in the athlete. Edited draw on the combined resources of the Whit- diagnosis. The format of these case histories by Glenn B PfeVer. (Pp 88; soft cover; tington, Middlesex, Royal Free, and Univer- sity College Hospitals. The course is designed is rather confusing initially, but a little $38.00) Illinois, USA: American Academy persistence enables the reader to learn a great as an MSc in the Department of Surgery and of Orthopaedic Surgeons, 2000. ISBN deal from their application. concentrates on high academic standards, Common neurological disorders are cov- 089203226X. including training in research techniques and ered broadly, but not in much depth, as the a solid foundation in basic science. title of the book suggests. There is good cov- In reviewing this book, I was first struck down by the American terminologies, then bogged Nevertheless, there will be a full clinical erage of new drugs and therapies for multiple exposure to all aspects and candidates will be sclerosis and Parkinson’s disease for those down by too much information in uninter- rupted essay format for two chapters expected to sit for the Diploma in Sports and doctors who may have fallen behind the rapid Exercise Medicine of the Academy of the advancement of neurological treatments. (“Sprains and soft tissue injuries” and “Sub- talar injuries”). There was a vast amount of Medical Royal Colleges. The Institute have provided an annual Analysis very relevant comprehensive information Presentation 15/20 contained in these sections—for example, bursary to defray the tuition fees of one can- Comprehensiveness 15/20 diVerent x ray views to request to visualise didate, and in this millennial year have also Readability 13/20 specific problems, but sadly it was diYcult to awarded a special Millennial Bursary. Relevance 18/20 access in essay format. This was let down the Evidence basis 17/20 book as a whole, as the last two chapters Total 78/100 (“Arthroscopic treatment of Osteochondral Annual awards ceremony MARK RIDGEWELL lesions and soft tissue impingements” and The Institute of Sport’s Annual Awards Cer- Kings Road Surgery, Mumbles, Swansea SA3 4AJ, “Nerve injuries to lateral leg and ankle”) were emony was this year held at The Royal Insti- Wales, UK excellently laid out with clear, helpful infor- tution, chaired by Sir David Money-Coutts mation for all sports physicians. They were KCVO. The Guest of Honour was Professor also very well illustrated, including a flow Christopher Llewellyn Smith FRS, the Prov- chart for chronic ankle pain management. ost of UCL, who commented in his address Tendinitis: its etiology and treatment. I know I am a simple ex GP in sports that the presence of The Institute physically William D Stanish, Sandra Curwin and medicine but, with limited time to read within the Department of Surgery was an books, I like clear headings, major points Scott Mandell. (Pp 140; £34.95) Oxford excellent example of the symbiosis between highlighted, and tables to compliment the University Press, 2000. the College and its many guest organisations, text. I also like pictures; the illustrations in the ISBN 0 19 263582 2. each contributing to the good of the others. first two chapters did little, if anything, to clarify the text (reduced size, unclear, black Three fellowships were awarded by the Insti- I must say that I liked this book. In a most tute to Dr Richard Budgett, Director of logical and readable fashion it set about what and white anatomy specimen photographs). Although this book, I think, is aimed at Medical Services, British Olympic Associ- can be a rather dour, but yet most clinically ation and Chairman, BOA Medical Com- important topic. Opening chapters on the orthopaedic surgeons, it has certainly in- mittee , Mr Graham Holloway, normal tendon and the etiology of tendinitis creased my knowledge and enthusiasm to see (in absentia) were followed by more clinically and exercise chronic ankle problems and I would recom- Consultant in Orthopaedic Surgery and related areas. Initial graphs and diagrams mend that anyone serious about sports medi- Sports Injuries, Ridgeway and BUPA Cam- were simple and clear but some of the later cine consider it as a reference book for those bridge Lea Hospitals, and to Dr Patrick Mil- clinical illustrations could have been im- diYcult ankle problems. If only the authors in roy, Regional Medical OYcer to the British proved by the use of photographs or colour. the latter part had edited the first two Athletics Federation, who gave an entertain- The renowned authors combine well to use chapters. ing and informative lecture on pitfalls and their obvious clinical experience to give a bal- dilemmas that he had encountered. The Sir anced viewpoint of both conservative and Analysis (chapters1&2) Robert Atkins Award was presented to Dr surgical treatments, with the emphasis being Presentation 6/20 Peter Wilmshurst for services to Diving on rehabilitation. All treatment options are Comprehensiveness 15/20 Medicine, and the recipient of the Millennial assessed and the evidence for their choice is Readability 6/20 Bursary Award, Dr Amir Ali Narvani, was given. Throughout, any statements are Relevance 12/20 congratulated by the Provost. backed up by suitable references and with Evidence basis 12/20 suggestions for further reading. Total 51/100 The clinical chapters cover common Annual symposium presentations—Achilles, jumper’s knee, hu- Analysis (chapters3&4) The Institute’s Annual Symposium on “Cur- meral epicondylitis—and take the reader Presentation 16/20 rent Dilemmas, a journey through Sports logically through pathology, etiology, diagno- Comprehensiveness 15/20 Medicine, Ethics and the Law” was held sis, and treatment. The book finishes with an Readability 16/20 jointly with the Section of Sports & Exercise outline of the eccentric exercise programme Relevance 15/20 Medicine of the Royal Society of Medicine on used in the authors’ Nova Scotia Sports Evidence basis 16/20 Medicine Clinic and analyses its application. Total 78/100 8 November 2000. A total of 10 speakers of At 140 pages, this book is concise and international repute presented papers to a therefore easily readable. Although the title J DUNBAR packed Barnes Hall at the Royal Society of does not mention exercise or sport, through- Sports Medicine Physician and GP locum, Medicine. Details of further such meetings out the book there are many references to the 63 Ochiltree, Dunblane FK15 ODF,UK can be obtained by contacting the RSM.

www.bjsportmed.com 140 Letters, Book reviews, Notes, Correction

BASEM Congress 2001 and those selected may be published in It will allow the holder to spend two weeks in The BASEM Congress 2001 is to be held at BJSM. Awards will be presented including a medical centre of excellence in the United the Vale of Glamorgan Hotel, Golf and the BASEM Young Researchers Award, States. Receipted expenses, including the air- Country Club, Wales, from 25–28 October presented to the best paper from an author fare, will be awarded to a maximum of 2001. Hosted by BASEM Wales, various top- less than 10 years qualiﬁed. Those not £2000. ics will be covered from the use of padding in selected for oral presentation will be invited The work should include a structured Rugby Union to exercise in extremes of tem- to present a poster, or poster only presenta- abstract of approximately 250 words and perature. There will be a free afternoon for tions may also be submitted. There will be a body text of a standard format (introduction, sporting pursuits and European Club Rugby poster award presented. Enquiries and sub- methods, results, discussion, conclusion, ref- Union matches are scheduled for that par- missions should be directed to: Dr Tim erences and an acknowledgement of support ticular weekend. Further details are available Jenkinson, Royal National Hospital for Rheu- received) of approximately 5000 words. The from Mrs Sue Roberts, BASEM Company matic Diseases, Upper Borough Walls, Bath closing date for submission is 1 August 2001, OYce, 12 Greenside Avenue, Frodsham, BA1 1RL. Tel: 01225 473428; fax: 01225 and the holder will be expected to give a 20 Cheshire WA6 7SA. Tel/fax: 01928 732 961; 473 437; email: Tim.Jenkinson@rnhrd- minute presentation of his or her work at the email: [email protected]. tr.swest.nhs.uk. BASEM Annual Congress. For further information, please contact the BASEM oYce. CALL FOR ABSTRACTS AIRCAST TRAVELLING FELLOWSHIP 2001 The BASEM 2001 congress committee invite This fellowship, funded by Aircast Limited If you have any notices of forthcoming events or submissions of abstracts for the presentation Partnership is open to medical practitioners items of news that would be of interest to readers of short papers and posters. All abstracts will under the age of 40 years, for unpublished of the journal,please forward them to the editor at be peer reviewed externally and anonymously work relevant to sport and exercise medicine. the address on the inside front cover.

25 CORRECTION Injury replacements Blood replacements

20 We regret that ﬁgure 2 was omitted from a recent article (BJSM 2001;35:34–7). The ﬁgure is reproduced here and we apologise to the authors and readers for this error.

10 % Distribution of replacements

0 0–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80

Half time Stage of match in minutes