ENGLAND PROFESSIONAL RUGBY INJURY SURVEILLANCE PROJECT SEASON REPORT 2018-19 ii Authored by the England Professional Rugby Injury Surveillance Project Steering Group Chaired by Dr Simon Kemp (Medical Services Director, RFU; Associate Professor Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine), Dr Stephen West (Injury Surveillance Project Research Assistant, University of Bath), Dr Tim Anstiss (Medical Advisor, RPA), Dr John Brooks (Injury Risk Analyst and Ex Harlequins and England Saxons), Richard Bryan (Rugby Director, RPA), Dr Matthew Cross (Research and Rugby Development Manager, Premiership Rugby; Honorary Research Fellow, University of Bath), Lewis Henderson (Rugby Systems and Data Controller, RFU), Duncan Locke (Head of RFU Performance Analysis Service, Insight Analysis), Brian O’Leary (High Performance Co-ordinator, London Irish Rugby Football Club), Dr Andy Smith (Consultant in Emergency Medicine, Mid Yorkshire NHS Trust and Premiership Rugby Clinical Governance Advisor), Dr Sean Williams (Lecturer, University of Bath), Professor Keith Stokes (Injury Surveillance Project Principal Investigator, University of Bath; Medical Research Lead, RFU) The content of the report is based on data collected and analysed by Dr Stephen West (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 England Professional Rugby Injury Surveillance Project 2018-19 iii AT-A-GLANCE SUMMARY Premiership Rugby Match Injuries Injury Incidence: 103 / 1000 hrs Injury Severity: 34 days Injury Burden: 3479 days absence / 1000 hrs Injury Event: 28% tackling; 24% being tackled Most Common Injury: Concussion, 20% of all injuries (20.4/ 1000 hrs) Premiership Rugby Training Injuries Injury Incidence: 2.9 / 1000 hrs Injury Severity: 32 days Injury incidence and severity in the professional game Injury Burden: 93 days absence / 1000 hrs 2014-15 to 2018-19 Injury Event: 36% running; 12% tackling How common an injury is (incidence) increases from left Most Common Injury: Hamstring, 13% of all injuries to right and how many days are lost per injury (severity) increases from bottom to top. Each data point represents England Rugby Match Injuries a season. If the lines that extend from each point do Injury Incidence: 89 / 1000 hrs not overlap with those for other points then there is a Injury Severity: 19 days difference between seasons. For example, the incidence of Injury Burden: 1664 days absence / 1000 hrs injuries was greater in 2018-19 than in 2014-15 and 2015-16, Injury Event: 26% accidental collision; but not different from 2016-17 and 2017-18. Similarly, injury 13% being tackled/ ruck severity was greater in 2018-19 than in 2014-15 and 2015-16, Most Common Injury: Calf Strain, 13% of all injuries but not different from 2016-17 and 2017-18. 2017-18 2018-19 2015-16 2016-17 2014-15 DAYS ABSENCE PER INJURY ABSENCE DAYS INCIDENCE/1000 HRS England Professional Rugby Injury Surveillance Project 2018-19 iv EXECUTIVE SUMMARY The key findings from the 2018-19 season: • In 2018-19, the incidence of match injury was 103 • 39% of all injuries were sustained during training. per 1000 hours (1000 hours = 25 matches), or, on The incidence of training injuries was stable at average, 2 injuries per match. The average for 2002-18 2.9 per 1000 hours. On average each training injury is 86 per 1000 hours. Incidence in 2018-19 was within lasted 32 days. The burden of training injury was 93 the expected season-to-season variation. days absence per 1000 hours. • On average, each match injury lasted 34 days. This • During the 2018-19 season, neither the incidence, represents a deviation from the upward trend over severity nor burden of match injuries was recent seasons, but it is higher than any other season different between artificial turf and grass. apart from 2017-18. • When data from six seasons is combined, the • The burden of match injury was 3479 days absence incidence of match injuries on natural grass per 1000 hours, which is the highest seen since 2002 and artificial turf are not different. However, the and is above the expected season-to-season variation. severity of match injuries on artificial turf is, on This was due to an increase in incidence and the average, 7 days greater than that on natural grass relative stability of injury severity during the 2018-19 (natural grass, 31 days; artificial turf, 38 days). season. • When combining four seasons of training injury data, • Concussion incidence in 2018-19 was 20.4 per injury incidence is similar on artificial turf and 1000 hours. For the eighth consecutive season, natural grass. Although not significantly different, concussion was the most commonly reported injuries on artificial turf last, on average, 5 days match injury, contributing 20% of all match injuries. longer than those on natural grass. Concussion incidence is within the limits of expected season-to-season variation, but is the second highest • The incidence of match injuries for the England it has ever been. The highest recorded concussion Senior side for 2018-19 was 89 per 1000 hours with an incidence was 20.9 per 1000 hours in 2016-17. average severity of 19 days. • On average, each match concussion resulted in 22 • For training injuries in England rugby skills sessions days missed, which is above the expected season-to- (contact, semi-contact and non-contact combined), season variation. There has been an increase in the the incidence was 9.9 per 1000 hours, which is higher relatively small number of concussions for which the than that of the surveillance period average (6.5 per time to return was more than 84 days. Compliance 1000 hours) and the burden of 371 days absence per with the mandatory return to play protocols for 1000 hours was above the average since 2002 but concussion was excellent, with no players returning lower than 2017-18 (579 days absence). to play in less than 6 days. • In 2018-19, 9 players retired because of injury. • The burden of match concussion was higher than at any point since 2002 at 455 days absence per 1000 hours. • 52% of all match injuries were associated with the tackle, with 25% of all injuries associated with tackling and 27% associated with being tackled. The tackle is key game event to consider when developing concussion and all injury reduction strategies. England Professional Rugby Injury Surveillance Project 2018-19 v Professional Game Action Plan on Player Injuries The results of the England Professional Rugby Injury Surveillance Project (PRISP) 2018-19 season report inform a Professional Game Action Plan on Player Injuries, which is endorsed by the Professional Game Board. Updates on the 18-19 season action plan are made available at the same time as the 18-19 season PRISP report with details provided separately to this document. England Professional Rugby Injury Surveillance Project 2018-19 vi CONTENTS 2 AT A GLANCE SUMMARY 3 EXECUTIVE SUMMARY 6 KEY FINDINGS 7 Match injury incidence, severity & burden 10 Training injury incidence, severity & burden 12 Concussion 15 The tackle 17 Time in the season 18 Injuries leading to retirement 19 Artificial turf 23 Training injury event 24 Injury diagnosis 24 The most common match injuries 25 The highest burden match injuries 26 The most common training injuries 27 Highest burden training injuries 28 ENGLAND SENIOR SIDE 29 RFU INJURY SURVEILLANCE PROJECTS METHODS 30 Project definitions 31 CURRENT PUBLICATIONS 34 SUPPLEMENTARY DATA England Professional Rugby Injury Surveillance Project 2018-19 vii KEY FINDINGS MATCH INJURY INCIDENCE, SEVERITY & BURDEN Likelihood or incidence of match injury In 2018-19, match injury incidence was 103/1000 hours, which is about 69 injuries per club. This is the highest incidence recorded since 2002 but remains within the expected limits of season-to-season variation (Figure 1). On average, each club experienced 2.0 injuries per match during the 2018-19 season. Note - For a normal distribution, 95% of all data should fall between (Mean - 2 x standard deviation) and (Mean + 2 x standard deviation). FIG Figure 1 Upper limit-2SD Lower limit-2SD Mean Incidence INCIDENCE/ HRS 2002-032003-042005-062006-072007-082008-092009-102010-112011-122012-132013-142014-152015-162016-172017-182018-19 Figure 1: Incidence rates of match injuries over Note: For a normal distribution, 95% the surveillance period with mean ± 2 x standard of all data should fall between (Mean deviation shown. - 2 x standard deviation) and (Mean + 2 x standard deviation). Severity of match injuries The average severity of match injury for the 2018-19 season was 34 days lost per injury (Figure 2) which is 9 days greater per injury than the average since 2002 (25 days). This represents a deviation from the upward trend over recent seasons, but it is the second highest severity recorded. The sustained higher levels of injury severity over recent seasons suggests that there has been a genuine increase in the severity and complexity of injuries. Average (mean) days absence provides a useful measure to assess changes in severity of injuries over time, but it can be skewed by a small number of significant long-term injuries; therefore, the median value is also useful. Median severity of injury for 2018-19 was 14 days, compared with 9 days for the 2002-18 period (Table S1). A summary of injury incidence by severity category can be found in the supplementary data (Table S2) England Professional Rugby Injury Surveillance Project 2018-19 FIG B viii Figure 2 Upper limit-2SD Lower limit-2SD Mean Severity DAYS ABSENCE PER INJURY ABSENCE DAYS 2002-032003-042005-062006-072007-082008-092009-102010-112011-122012-132013-142014-152015-162016-172017-182018-19 Figure 2: Mean severity of match injuries over the surveillance period with mean ± 2 x standard deviation shown.