Exploring the Efficacy of a Lumbo-Pelvic-Hip Injury Reduction Strategy in Professional Rugby Union Kate Louise Williams MSc, MSc, PGCHE, BSc(Hons), MSST Supervised by Ass Prof Andy Williams, Dr Christine Davies and Dr Morgan Williams Submitted in partial fulfilment for the award of the degree of Doctorate of Professional Practice University of Wales Trinity Saint David 2019 DECLARATION SHEET This work has not previously been accepted in substance for any degree and is not being concurrently submitted in candidature for any degree. Signed ................ ...................................................... (student) Date ........07.04.2019................................................................ STATEMENT 1 This thesis is the result of my own investigations, except where otherwise stated. Where correction services have been used the extent and nature of the correction is clearly marked in a footnote(s). Other sources are acknowledged by footnotes giving explicit references. A bibliography is appended. Signed ............... ...................................................... (student) Date .......... 07.04.2019.............................................................. STATEMENT 2 I hereby give consent for a redacted copy of my thesis, if accepted, to be available for photocopying and for inter-library loan, and for the title and a redacted summary to be made available to outside organisations. Signed ................. .................................................... (student) Date ................ 07.04.2019........................................................ STATEMENT 3 I hereby give consent for a redacted copy of my thesis, if accepted, to be available for deposit in the University’s digital repository. Signed ................... .................................................. (student) Date .............. 07.04.2019.......................................................... 2 Abstract Objectives: The aim of this study was to implement a complete sequence of prevention (Van Mechelen, et al 1987) to reduce lumbo-pelvic-hip (LPH) injuries in a professional men’s rugby union team and examine its effectiveness. A secondary aim was to examine, on completion of the tailored program, the players’ perceptions of injury reduction programmes. Design: Insider action research using an ecological mixed methods design. Methods: In season 1 baseline injury surveillance data was collected to establish the extent of the LPH injury problem. In season 2 and 3, a pre- season screening battery of hip and groin strength measures were administered pre and post the completion of a Yo-Yo IR1 test. Based on the change scores of the strength measures, the players were prescribed a tailored preventative exercise program that was followed during their lower limb strength sessions throughout the season. As part of the end of season 2 review, players were anonymously questioned on injury reduction programmes and their implementation. Injury surveillance data was prospectively recorded throughout. Results: The use of a tailored injury reduction programme aimed at reducing LPH injuries in professional rugby union successfully reduced total severity of injuries (936d v 417d in season 3). Average severity was significantly reduced across the three seasons (78d v 12.6d in season 3). Prevalence also reduced (21% v 13% in season 3) when compared to the baseline season 1. Players reported that they are confident in their ability to engage with injury reduction programmes providing it was individualised, written by the medical team/strength and conditioning staff in conjunction with the players themselves and performed under supervision by the medical team. Conclusions: A tailored LPH injury reduction programme can reduce total severity, average severity and prevalence of LPH injuries. Players’ reported that injury reduction programmes 3 are socially appropriate, important and expected in an elite environment. Insider action research should be considered when looking to implement injury prevention research in the real world setting. Key Words: Injury reduction, hip, groin, injury surveillance, players’ perceptions rugby union 4 While the individual man is an insoluble puzzle, in the aggregate he becomes a mathematical certainty. You can, for example, never for foretell what any one man will do, but you can say with precision what an average number will be up to. Individuals vary, but the percentages remain constant. So says the statistician. Arthur Conan Doyle/Sherlock Holmes, (1890) 5 Contents Abstract .................................................................................................................................................. 3 Table of Abbreviations ............................................................................................................................ 9 List of Tables ......................................................................................................................................... 11 List of Figures ........................................................................................................................................ 12 1.0 Introduction .................................................................................................................................... 14 1.1 Motivation for the Study ............................................................................................................. 15 1.2 Introduction to Sport Injury Risk ................................................................................................. 18 1.3 Factors Associated with Sports Injury Risk ................................................................................. 22 1.4 Theoretical Frameworks for Injury Prevention ........................................................................... 25 1.5 Injury Prevention Programmes in Sport ..................................................................................... 36 1.6 Anatomy of the Hip and Groin .................................................................................................... 42 1.7 Osteology .................................................................................................................................... 43 1.8 Muscle Morphology .................................................................................................................... 43 1.9 Hip and Groin Diagnostic Terminology ....................................................................................... 49 1.10 Incidence of Sports Related Groin Pain .................................................................................... 52 1.11 Aims and Objectives .................................................................................................................. 55 1.12 Summary ................................................................................................................................... 55 Chapter 2 Literature Review ................................................................................................................. 58 2.0 Introduction ................................................................................................................................ 58 2.1 Introduction to Rugby Union ...................................................................................................... 58 2.2 Injury Surveillance in Rugby Union ............................................................................................. 61 2.3 Systematic Literature Review Intrinsic: Risk Factors for Sports Related Groin Pain & Exercise Programmes for Groin Injury Reduction ........................................................................................... 67 2.3.1 Systematic Literature Review Method .................................................................................... 67 2.3.2 Literature Search ...................................................................................................................... 67 2.3.3 Study Selection ......................................................................................................................... 68 2.3.4 Data Extraction......................................................................................................................... 69 2.3.5 Best-Evidence Synthesis ........................................................................................................... 69 2.3.6 Exercise Reporting Standards .................................................................................................. 70 2.4 Results of Systematic Literature Review ..................................................................................... 70 2.4.1 Hip Range of Movement .......................................................................................................... 75 2.4.2 Adductor Muscle Strength ....................................................................................................... 78 2.4.3 Abductor Muscle Strength ....................................................................................................... 84 2.4.4 Adductor to Abductor Strength Ratios .................................................................................... 85 2.4.5 Hip Flexor Strength .................................................................................................................. 88 6 2.4.6 Hip Extensor Strength .............................................................................................................