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Safety in youth rugby: education is not the answer to the concussion crisis

19 Sep, 16 | by BJSM

By Adam White @AdJWhite, Dr. Tim Gamble, and John Batten @JBatz85 

Injury worries

Despite the potential health benefits from participating in the sport, rugby is under increasing scrutiny as a result of the high number of injuries experienced by youth participants. We know, for example, that injury rates in rugby union for participants under 21 years of age can be as high as 128.9 injuries per 1000 playing hours, with a mean injury incidence rate of 26.7 per 1000 playing hours. The tackle is often to blame, causing sixty-three per cent of all injuries in one study on school rugby.


Concussion has received particular attention due to the potential long-term impacts (e.g., chronic traumatic encephalopathy) it may have upon brain functioning. Indeed, a systematic review of concussion in youth sport, stated that rugby had the highest risk of concussion compared to sports such as Field Hockey and American Football. In fact, one recently published study in Sweden shows many of the damaging social outcomes of concussion. Concerned about the potential damage the tackle may be having on children, we and the Sport Collision Injury Collective recently wrote to the British government urging them to ban tackling in rugby in school sport.

The HEADCASE programme

The Rugby Football Union’s response to safety concerns in their sport is through the delivery of educational initiatives. Specifically, the online HEADCASE programme provides key stakeholders with information about recognising concussion and managing injured players (i.e., secondary prevention). Delivered through an online, interactive web platform, it is freely available for players, coaches, officials, parents, teachers, first-aiders and spectators to complete. This potentially represents an improvement to player-safety, with the rugby authorities (the Rugby Football Union, World Rugby etc.) leaders in the management of brain trauma in sport. However, the following sections highlight some concerns about the effectiveness and delivery of this health-focused educational programme.

Voluntary participation

Globally, some rugby authorities require their coaches and teachers take either annual or biannual training to coach the sport. The Rugby Football Union, however, has no mandate for coaches to have undertaken HEADCASE training – although any individuals seeking to undertake a new coaching or refereeing qualification (which is also not mandatory to coach or officiate) are required to complete the programme before attending a course. Yet, this neglects the vast population of coaches who have completed their qualifications before the introduction of the HEADCASE programme, or those coaches and officials who do not seek qualifications at all. Furthermore, coaches and officials in England who have completed the training will only have to do so once, with no immediate plans to make it a yearly requirement like rugby governing bodies in the southern hemisphere.

Lack of evaluation

There is poor evaluation of educational initiatives aimed at reducing injury in sport. Only two rugby programmes (BokSmart and RugbySmart) complete all four elements of Van Mechelen’s Model of Injury Prevention (i.e., establishing the extent of the injury problem, establishing the aetiology and mechanisms of sports injury, introducing a preventative measure, assessing its effectiveness by repeating the process) to establish intervention effectiveness. Subsequently, researchers have asserted: ‘There is a dearth of evidence to support the effectiveness of such programmes’. Additionally, a recent BJSM systematic review found the concussion prevention benefits of technique training and practice time restrictions may be limited to a specific sub-set (i.e., 11-15 year olds) of the at-risk athletic population.

Education and injury prevention

Unless sporting bodies evaluate the effectiveness of their training, the impact upon injury prevention is unknown. However, evidence from the health and safety literature suggests that when implementing controls to manage risk, educational interventions are somewhat limited in effectiveness. Specifically, the Hierarchy of Control asserts that elimination of a risk is the most effective way of management, with personal protective equipment being the least effective, and administrative controls (i.e. education) the second least effective. Thus, altering the structure of an activity (substitution) or eliminating the mechanism – in this case tackling –  are likely to be much more effective interventions for the prevention of injuries than educational initiatives. Exemplifying this, law amendments in youth Ice Hockey (i.e., removing the body check) resulted in a reduction of injuries and concussions.

The way forward

Injury prevention must be the priority when considering the current concussion crisis in sport.  However, if the Rugby Football Union is committed to education about tertiary care of brain trauma at this stage, programmes should specify mandatory annual participation for the rugby workforce, with comprehensive evaluations of their effectiveness simultaneously undertaken. Although unlikely to be as effective as altering the structure of the sport (e.g., moving from contact rugby to touch rugby in schools), such changes may help to reduce the risk of concussion in youth rugby, while maintaining the cardiovascular and psychosocial health benefits offered by participation.

Conflicts of interest: None to be declared.


Adam White [] @AdJWhite, is a doctoral researcher at the University of Winchester and founding member of the Sport Collision Injury Collective. He also sits on the committee of the England Rugby Football Schools Union.

Dr. Tim Gamble [] is a Senior Lecturer in Psychology at the University of Winchester. His main research interest is investigating risk and protective equipment, specifically the unintended consequences of safety equipment provision.

John Batten [] @JBatz85 is a senior lecturer in the Department of Sport and Exercise at The University of Winchester where he is currently programme leader for the BSc/MSci (Hons) Sport and Exercise Science.

Working in gymnastics – it’s a balancing act

7 Sep, 16 | by BJSM

By Emily Ross (@EmilyRossPhysio)

Whoa…working in gymnastics, where do we start?

Gymnastics is a mesmerising sport which requires a level of power, flexibility, and not to mention a dedication and focus I have never previously witnessed in a childhood and adolescent age group. We are going to do a roundoff full twist through my top 5 tips from working in the world of gymnastics.

acro gymWe will cover:

  1. What is needed in Acrobatic Gymnastics?
  2. .. Gymnastics and Rugby Union are basically the same?
  3. How a physio’s role in gymnastics can include risk assessment on acrobatic moves
  4. Why we must remember that gymnasts and rugby players are similar characters
  5. The role of a physiotherapist in a childhood and adolescent sport

Professionally I have had the opportunity to work with two very different sports; on one hand, Men’s Rugby Union, an open-skilled, dominated by male adults, contact sport with an 80 minute weekly peak in performance and on the other hand Acrobatic Gymnastics, a closed-skilled, female dominant population, aged pre and post maturation, who perform 2-3 minute routines just a handful of times across the competitive season. Now first things first, I have to admit I am not an ex-gymnast, although I am flattered when people ask; so the world of gymnastics was a brand new experience when I joined an Acrobatics Gymnastics Club 4 years ago.

I highly recommend working in gymnastics. This sport presents exciting challenges as a medical professional, and the opportunity to work closely with gymnasts from their initial development stages, up to, career highlights of international competition. We have all recently enjoyed the Artistic and Rhythmic gymnastics disciplines at Rio 2016. If you’re wondering what Acrobatic Gymnastics is, then I would liken Acrobatic gymnastics to the floor element in Artistic gymnastics.

Here are my top five tips for working with gymnasts…

acro gym 2No.1: Spend time watching training, understanding the movement and strength requirements for gymnastics.

In acrobatics gymnastics, for the majority, gymnasts work in Pairs (Base and Top) or Trios (2 Bases and a Top), although you can also see a Men’s 4. If we take a Trio as an example; a Base will need to support the body weight of up to 2 gymnasts in both static and dynamic positions. The variety of partnerships and multidirectional nature means gymnastics is difficult to explain succinctly. You could describe Acrobatic Gymnastics as a sport of flexibility, strength and power throughout a multiple planes of movement [1].

The interesting medical challenge of gymnastics presents itself in the population of athletes you are working with. You are working with young female (predominantly in our club) athletes in a sport which combines non-modifiable intrinsic risk factors for injury; age, anatomical, hormonal, as well as the post-menarche neuromuscular control deficits, although the latter can be addressed [1-7]. Consider that these young athletes are required to hold load and complete movements in such outer ranges, which most fully developed adults would struggle to complete without issue, injury or long term effects. When I started at the club, it was eye-opening to find out that regular medical provision was relatively rare in club gymnastics.

No.2: Spend time with the coaches to appreciate the way movement is judged in competition.

The sports medicine discipline is a common skill-set needed to work in sport. However my experience in rugby, regarding power and movement efficiency in conditioning, needed to be built upon when I also started working in gymnastics. In rugby, as like many other sports, conditioning focuses on the action, be it sprinting efficiency to make that break away try, the power behind a tackle, a time efficient tumble turn in the pool, or serving an ace in tennis, the list goes on. There are many ways you could complete all of these, however usually coaches and the medical team would support an athlete to complete it in the most physically efficient and powerful manner, to produce the result successfully and safely without injury. Whereas in gymnastics, it is not just about the efficiency of an action, but the aesthetics of how gymnasts complete it, which was a new clinical consideration for me.

Gymnastics has a unique focus on specific limb alignments in scoring and deductions, where a limb may not be scored as ‘straight’ unless there is a degree of hyperextension at the knee or sufficient plantarflexion at the ankle. In rugby, I would aim to target excessive knee hyperextension on grounds of minimising joint translation, stress on the passive system and improving neuromuscular control of end range extension in basic tasks and progressing this into sport-specific loading drills. In gymnastics hyperextension is sought after; entering the world of gymnastics challenged my previous experience and understanding on sport-specific targets. For these reasons I believe No.2 is a relevant point for those transitioning from other sports as well as any new graduates joining the sports world.

No.3 : Consult with the coaches on safety screening acrobatic moves they selected in a routine.

I am proud to work in a club where the coaches’ main focus is long term health beyond gymnastics. Acrobatic gymnastics is not directly focused on efficiency of movement; it challenges the parameters of balance, joint range and motor control in each routine. I questioned what I could add to the club, as I have had no previous experience in gymnastics. Learning idiosyncrasies of the sport was accelerated from listening to coaches’ feedback on training; this can highlight where to aim any screening and prevention ideas. My role in gymnastics became clear when coaches asked about making gymnasts more flexible, more ‘fast-twitch’, or more powerful to throw higher. This is where my in experience rugby and sports medicine was truly complementary. I found building an inter-professional relationship with the coaches adds so much to a team and buy in is tenfold when they know you’re working towards joint goals, points mean prizes…literally.

acro gym 3The safety screening term developed from the coaches asking for my clinical opinion on gymnasts’ biomechanical risk/suitability for a move of higher acrobatic tariff (difficulty) or new routines when partnerships change. The coaches say this is one of the most valuable roles; particularly when they are pushing the boundaries of a gymnast’s capability with new elements. If you are venturing into gymnastics, clinically this is reassuring to be able to avoid putting a gymnast’s musculoskeletal system at more risk by adapting elements of a gymnast’s routine. Adaptations will occur either because anatomically they do not have the range or strength deficit in a certain range for an acrobatic element.

Now this assessment is not fool proof, and I do not have hard-and-fast criteria. I understand the current discussion on movement analysis and other screening efficacy [8-11], maybe screening is the wrong term, but I would advocate the value of our clinical opinion to assist coaches in risk assessment. This allows the gymnasts to develop routines which they will be able to safely maintain, and I will implement a supplementary programme for that gymnast to aim at a higher tariff moves through the season. In fact this is where I came across my research idea to examine the neuromuscular control in young female gymnasts for my MSc, which I’m preparing for submission, but that is for another blog.

No.4: Pay attention to the potential to underreport symptoms.

I have identified many differences in rugby and gymnastics; after time, if you squint and tilt your head to the side, you realise as athletes, they’re hugely similar, yep, I did say similar! Both of these multidirectional-team sports demand incredibly strong athletes, who can regularly withstand an extraordinary load!

One of the fundamental reasons I work in rugby and gymnastics is that both athletes have this overt resilience, drive and committed mind-set. It is these characteristics, which will lead them to national and international levels but can also mask injuries. By comparison, weekly competitions in rugby, the drive for the players to make the next match is clear – I’ve found gymnastics is no different, and even harder at times in run up to competitions, as a gymnast cannot be as substituted out of a Trio, as easily as a rugby player in a 45-man rugby union side. Be careful that their enthusiasm to compete doesn’t overshadow the gymnasts’ communicating symptoms to you.

gym 4No.5: Build a rapport and communication with gymnasts’ of all ages is vital.

Working in a childhood and adolescent sport, you will meet gymnasts who may act with the professionalism of an adult, but they will only be 8 years old. Often gymnasts will never have been taught how to do basic S&C movement patterns, much as we don’t understand the Acrobatic specific terminology. We need to remember they are used to a different sporting-language, they may have not experienced an injury before, or know what an appropriate stretching sensation should be, or the difference between DOMs and a muscle tear. Certainly you will get some puzzled faces with Visual Analogue Scoring.

With symptom reporting in mind, I focused my first season at the club on communication rapport and educating the squad on what we called ‘good and bad pains’. This included teaching the gymnasts what physio can do to help them, why that will help in competitions, and what they can tell me regarding what they are feeling or concerned about.

I enjoy gymnastics because you are working with athletes who are developing in socially, physically, and mentally. Never underestimate gymnasts’ ability for information retention, but you must also not forget their ages. I feel we have a responsibility in their development, and I’m talking more than just physical performance. On reflection, so many times in the rugby world, I have run through players’ past medical history and hear stories of previous injuries as juniors that weren’t flagged, or investigated as you might have hoped, which leads to a frustrating unknown in baseline and query over initial prognosis of an injury.

Working in gymnastics we have an exciting opportunity to be the first medical professional to teach efficient loading strategies and movement patterns, to athletes new to non-sport specific conditioning. We have the responsibility to make sure they complete conditioning safely and efficiently for their developmental stage and anatomy, and the opportunity to further diminish the old school negativity around extreme gymnastic conditioning. We can help to start their athletic career with a professionalism (sports medicine hat on); from explaining strength and conditioning, the importance of communication, to highlighting the benefit of continuing other sports at school. I have found, this results in gymnast buy in, support from their parents and satisfied coaches’ by excelling in performance and long term resilience, which is pretty damn satisfying in the SEM WORLD.

Summary of advice!

  • Spend time watching training, understanding the movement and strength requirements for gymnastics Rugby and gymnastics are more similar than you think…. Understand the resilience 
  • Spend time with the coaches to appreciate the way movement is judged in competition
  • Consult on safety screening with the coaches on acrobatic moves selected in a routine and assess the risk/suitability
  • Be careful that gymnasts’ enthusiasm to compete doesn’t overshadow their symptoms reporting.
  • Building a rapport and communication with gymnasts’ of all ages, educating them to address sport with a sports medicine hat on.
  • Never let rugby players in sparkly gymnastic leotards, there isn’t therapy for that.

Emily Ross is a Specialist MSK and Sports Physiotherapist with a special interest in Rugby Union and Acrobatic Gymnastics. She has been the Head of Medical Services at the Oxford School of Acrobatic Gymnastics for 4 years, she has worked at Harlequins RFC Academy and at Championship level rugby. She also works at the Centre of Health and Human Performance. You can follow her on Twitter (@EmilyRossPhysio)


[1] Deley, G, Cometti, C, Fatnassi, A, et al. Effects of combined electromyostimulation and gymnastics training in prepubertal girls. J Strength Cond Res 2011;25:520–526

[2] Hewett, T, Myer, G, Ford, K. et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the  Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study. American Journal of Sports Medicine 2005;33:492-501. DOI: 10.1177/0363546504269591

[3] Lim, B-O, Lee, Y, Kim, J, et al. Effects of Sports Injury Prevention Training on the Biomechanical Risk Factors of Anterior Cruciate Ligament Injury in High School Female Basketball Players. American Journal of Sports Medicine 2009;37:1728-34. DOI: 10.1177/0363546509334220

[4] Myer, G, Ford, K, Palumbo, J, et al. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. Journal of Strength and Conditioning Research 2005;19:51-60.

[5] Myer, G, Ford, K, Brent, J, et al. Differential neuromuscular training effects on ACL injury risk factors in “high-risk” versus “low-risk” athletes. BMC Musculoskeletal Disorders 2007;8:39 DOI:10.1186/1471-2474-8-39

[6] Myer, G, Brent, J., Ford, K, et al. A pilot study to determine the effect of trunk and hip focused neuromuscular training on hip and knee isokinetic strength. British Journal of Sports Medicine 2008; 42:614-619. DOI: 10.116/bjsm.2007.046086

[7] Myer, G, Sugimoto, D, Thomas, S, et al. The influence of age on the effectiveness of neuromuscular traiing to reduce anterior cruciate ligament injury in female athletes: a meta-analysis. American Journal of Sports Medicine 2013;41:203 – 215.

[8] Clarsen, B, Berge, H. Screening is Dead! Long live Screening. Br J Sports Med 2016;50:769. DOI:10.1136/bjsports-2016-096475

[9] Hewett, TE. Response to ‘Why screening tests to predict injury do not work- and probably never will…a critical review’ Br J Sports Med Published online first: [07/07/16] 2016. DOI:10.1136/bjsports-2016-096388

[10] Moran, R, Schneiders, A, Major, K, et al.  How reliable are functional movement screening scores? A systematic review of rater reliability. Br J Sports Med 2015. DOI:10.1136/bjsports-2015-094913

[11] Wright, A, Stern, B, Hegedus, E, et al. Potential limitations of the Functional movement screen: a clinical commentary. Br J Sports Med 2016 50:13 770-771 DOI:10.1136/bjsports-2015-095796

#RSNlive16: Rugby Science Network 2016 Conference (September 13th and 14th, 2016)

19 Aug, 16 | by BJSM

Tackling. Concussion. Doping. Rugby is a sport which has had to confront some big topics in the public domain over the past few years, and has persistently shown significant commitment to ensuring the welfare of its participants, be it through research, education, or otherwise.

RSN live picture

As a collision sport, injuries are unavoidable – and so there has been much in the form of injury research in the game, with the RFU in England, the NZRU in New Zealand and the SARU in South Africa in particular, providing examples of high quality surveillance research over the past few years. World Rugby, the governing body, deserve much credit for clear and effective leadership – and have been at the forefront of ensuring player welfare through taking account of this research and enforcing rule changes, most notable when it comes to dangerous tackles and the scrum.

With its inclusion in the Olympics however, and with more lucrative prizes, nations and teams have been searching for the marginal gains of sporting performance, which as a result has provided a great bulk of research, some of which has been published in the BJSM.

As such, rugby medicine has a high quality and diverse range of research topics – the vast majority of which are applicable to both team, and individual sports – and may be of interest to the majority of the BJSM readership. Interested in knowing more?

The University of Bath, who have been at the forefront of rugby medicine through their work with the RFU, have organised a two-day conference, on September 13th & 14th, at which much of this research will be presented. Topics include: injury prevention; dietary supplementation; skill development; long-term player welfare; and concussion – which will be brought to life by a fantastic array of speakers including Prof Ross Tucker, Prof Graeme Close, and Dr Martin Hagglund amongst others.

Whilst tickets are available online, if you can’t make it in person, they will be live-streaming the talks for free via their website, with even an opportunity to join in the conversation through the usual social media channels via #RSNlive16. BJSM+ will be tweeting from the event and helping to widen the conversation – we look forward to engaging with the SEM community on a wide range of issues.

Can’t wait? Here are some seminal #RugbyMedicine papers to whet your appetite:

We look forward to your contribution to #RSNlive2016

International Rugby Sevens Returns to Singapore: The Medical Team’s Perspective!

9 Jun, 16 | by BJSM

By Dr Dinesh Sirisena (@sports_med_doc) and Dr Joanne Probert (@probertjo)

Dinesh was both Field of Play Lead and Match Day Doctor, and Joanne was Medical Director at the 2016 Rugby Sevens.  They share their experience of being part of the medical team, when preparing for and delivering care and end with 5 take home points for anyone planning to do at a major sporting event in the future.

It was April 2016 and with the year well underway, one of the most highly anticipated events on the Singapore calendar rolled into town; the long awaited HSBC Rugby Sevens was back after a 10-year hiatus and there was an air of expectation.  Having just completed the Hong Kong stage, the 16 international teams arrived with plenty of support and Fiji were hot favourites having won the earlier event.  At the heart of the tournament is the anticipation that one team will be crowned victorious after two-days of high intensity, fast paced and zinging rugby, and thus began the Singapore stage.

rugby winners

Preparation is Key When Delivering Medical Care

Compared to its fifteens counterpart, the rapid turnover of matches (over 50 in total), high impact and non-stop activity for just under 15 minutes, presents unique challenges for medical teams supporting such events.  Even with past experience from tournaments such as Singapore Cricket Club and Schools Sevens, the local and international media interest created from the return to Singapore meant the medical room, pitch-side team (doctor, physiotherapist and ambulance crew) and head injury spotters needed to be on our toes.

A key element in developing the medical team was the regular cohort of clinicians chosen from Singapore Rugby. Also, limiting numbers meant that we better understood each other’s patterns of working and were very familiar with various protocols.  Our continual increase in pitch-side efficiency reflected this approach.

Equally, with World Rugby leading the way in concussion management internationally, the medical team was well versed in Head Injury Assessment (HIA) protocols: what to look out for during games and when to request assessments.  The CSx Headguard app (, with its electronic record of the HIA and previous data for comparison, made the assessments more efficient.

Match Day Arrives

The weekend finally arrived coupled with plenty of Twitter and Facebook updates.  The number and frequency of matches kept us busy and made for two long days. Fatigue particularly set in on the second day when there were higher-stake matches. Teamwork and daily essentials such as readying equipment, performing run-throughs and ensuring there was a regular supply of coffee, were key components to a successful weekend for the medical team.

One of the significant differences compared to domestic matches was the constant media presence.  For the tournament organisers, entry of teams onto the field of play and half-time footage were important times for filming and it was essential that players were the focus.  Equally, with free-flowing social media in the stands, it was essential that we maintained our professionalism and integrity.  Often, there would be calls from the spectators to take photographs or retrieve something from the field of play, but fortunately this did not faze the team.

Removals from play due to concussion risked excluding a player from the remainder of the tournament, so ensuring we made a correct diagnosis was essential.  To ease the decision-making responsibility extra steps were taken; in addition to the pitch-side HIA/Match Day Doctor, a HIA spotter was made available to provide feedback and replay footage from the stands.  It meant that HIA assessments become a shared decision after careful analysis.

The heightened awareness of on-field events brought with it another challenge to maintain focus!  With the high turn-around of matches, there was little time to “switch off” and enjoy the event.  Often, even when away from pitch-side or the spotter location, we found ourselves analysing games from the medical room, assessing movements and looking out for potential injuries. This relentless monitoring of events was draining, even if we witnessed no injuries.  To ease this pressure and keep refreshed, we constantly cycled roles.

Despite the challenges of working in this environment, the event was a fantastic experience. It was humbling to work amongst a close-knit group of colleagues, who maintained team spirit and supported each another fully.  In situations where we were called upon to help athletes on field, the team worked seamlessly and feedback on social media and organisers was overwhelmingly positive.

As a side benefit, being part of the medical team also meant that you had the best seats in the stadium when your favourite team came on!

What Next?

The HSBC Rugby Sevens will be returning to Singapore next year and will hopefully become a permanent fixture on the sporting calendar.  While the medical team reflects on the event and plans for 2017, the significant interest generated following Kenya’s surprise win will no doubt fuel the excitement further.  It seems Singapore may be the event where teams and organisers do not know what to expect, other than excellent medical care!

Take Home Messages

  1. Develop a strong rapport with organisers to identify their expectations.
  2. Identify key roles, select the medical team early and provide opportunities to work together prior to the main event.
  3. Ensure emergency protocols are in place and have been taken through rigorous practices.
  4. Maintain professional integrity when working under the spotlight of social and mainstream media.
  5. Make sure the team feels valued with treats, coffee and a celebratory drink at the end of the event.

Please do let us know what your experiences of Sevens Rugby or other event medical coverage have been – hopefully we can learn from each other!


Dr Dinesh Sirisena is an Associate Consultant in Sports Medicine at Khoo Teck Puat Hospital and was both Field of Lead and Match Day Doctor at the event.

Dr Joanne Probert is a Consultant in Emergency Medicine at Khoo Teck Puat Hospital and was the Medical Director for the event.

Tackle injury mechanisms in sport: How different is past, present and future research?

4 Jun, 16 | by BJSM

By Sharief Hendricks

My colleagues and I are currently working on a couple of reviews in rugby, and like most reviews, we went back as far as 1980. As we illustrated last year, the majority of rugby research has been published in the last ten years and a relatively small proportion has been produced before the year 2000.

rugby lions-1971

As I scroll titles of articles before the year 2000 to review, I notice how the purpose of studies hasn’t changed much over the last 15 years. For example, in 1999 Garraway et al. published an article titled Factors influencing tackle injuries in rugby union football. Recently, we published a paper titled Tackle technique and tackle-related injuries in high-level South African Rugby Union under-18 players: real-match video analysis. Although the aims of the studies seem similar, after a peruse of both articles, the difference between the two studies soon become evident. Let’s call this difference…progress?

I think Garraway et al.’s paper in combination with other around the same time were essential for the subsequent work on analysing tackle injuries in rugby union. The same can probably be said for the New Zealand’s RugbySmart outputs in the 90s, and the more recent South African BokSmart outputs.

The point of all of this is, what will the next 15 years bring? Knowing the progress we’ve made over the last 15 years, will we still be looking into tackle injury mechanisms 15 years from now? Probably yes. But I think with the advancement of technologies and more exposure to other fields, the way we approach the problem and frame the question will be different.

How has your research focus changed over the last 15 years? And how will it look 15 years from now?


Garraway, W. M., Lee, A. J., Macleod, D. A., Telfer, J. W., Deary, I. J., & Murray, G. D. (1999). Factors influencing tackle injuries in rugby union football. British Journal of Sports Medicine, 33(1), 37-41.

Burger, N., Lambert, M. I., Viljoen, W., Brown, J. C., Readhead, C., & Hendricks, S. (2016). Tackle technique and tackle-related injuries in high-level South African Rugby Union under-18 players: real-match video analysis. British journal of sports medicine, bjsports-2015.


Sharief Hendricks Twitter @Sharief_H is a Research Fellow, LeedsBeckett University and University of Cape Town,

The inaugural World Rugby Science Network Conference: 15-16th September 2015 (Universities of Bath and Cape Town)

13 Sep, 15 | by BJSM

Calling all Rugby science and sports medicine afficionados and all members of the rugby family — coaches, players and family members.

The inaugural World Rugby Science Network (formerly IRB) Conference, September 15-16th, 2015, promises to deliver practical insights on the latest research applicable to all Rugby codes.

The conference will bring together leading athletes, professionals, and enthusiasts with the overarching goal to transfer scientific knowledge into professional practice.

Session topics include concussion, genetics, performance, and injury mechanisms and prevention.

Keynote speakers include:

  • Dr Graeme Close, Liverpool John Moores University
  • Professor Mike McGuigan, Auckland University of Technology
  • Professor Carolyn Emery, University of Calgary

A limited number of physical seats are still available at conference co-host universities: Bath (United Kingdom) and Cape Town (South Africa).

On Tuesday (Day 1- Bath) you can view the presentations via live stream using the site.

On Wednesday (Day 2- Cape Town) the online subscriptions are fully booked.

We encourage you to participate in the conference’s Twitter discussion with speakers and fellow attendees at #RSNLive2015.

The conference is the main event of the Rugby year – and then it’s followed by the 2015 Rugby World Cup, that kicks-off on 18th September.

For more information visit:

Even players at the highest level get it wrong sometimes…the attempted tackle by Christian Lealiifano on Jonathan Davies

5 Jul, 13 | by Karim Khan

by Dr Sharief Hendricks (@Sharief_H)

On Saturday 22 June 2013, the British and Irish Lions recorded a historic win over the Wallabies in the First Test (of three) in Brisbane. As the score suggests, it was a fiercely contested match, and made for some entertaining rugby with debutant Israel Folau crossing the try-line twice, George North scoring one of the Lions most memorable tries, and Alex Cuthbert finishing off a well rehearsed Lions backline move. Even though the match was a display of Test Rugby at its best, the match also showed rugby’s unkind side – serious injuries. The Wallabies suffered 3 suspected serious injuries, one of them to another debutant, Christian Lealiifano, during the 1st minute of the game.


Christian Lealiifano, a physically conditioned 95 kg, started the match at inside centre (usually plays fly-half). From a lineout on the Wallabies 10 metre, the Lions aimed to set up play in the midfield with Jonathan Davies (103 kg) running an almost direct line at the defence. The defender lining up Jonathan Davies, was none other than debutant Christian Lealiifano. Christian Lealiifano was positioned almost directly opposite Jonathan Davies and attempted a front-on tackle. From the match footage, after the contact between the two inside centres, Christian Lealiifano failed to rise to his feet, and showed little or no movement. From the slow motion replay of the attempted tackle, it seemed Lealiifano might have had his head in an unfavorable position, where the vertex (top of his head) was the first point of direct contact with Jonathan Davies causing his neck to flex. From a defense perspective, play was moving from left to right, therefore, it is presumed a standard right shoulder front-on tackle was required.

A couple of points can be made from this unfortunate incident. Firstly, even players at the highest level get it wrong sometimes. Secondly, the importance of head placement and correct technique when executing a tackle. Note, this is not new information. A study conducted by the University of Nottingham, in collaboration with England Rugby Football Union, studied 6219 tackles over 2 English Premiership seasons (2003/2004, 2005/2006) to identify risk factors for tackle injuries 1. In view of this study’s in depth analysis of tackle injury, the attempted tackle by Lealiifano on Davies had all the components to place Lealiifano at high risk of injury. The tackle injury study, published in the British Journal of Sports Medicine (2010), identified the following risk factors for tacklers.

  • Playing position – tackler’s playing 10, 12, or 13 has a higher chance of injury than any other position.
  • Tackler vs Ball-carrier speed – tackler’s attempting to tackle a ball-carrier with a significantly higher speed before entering have a higher probability of injury.
  • Head position before tackle
  • Body region struck – tackler’s are at high risk of injury when contacting the ball-    carrier with the head or neck.

In addition to these risk factors, Lealiifano was technically playing out of position, which has been reported to also increase risk of injury in the tackle 2. Though, the positional demands of inside centre and fly-half are fairly similar. Also, it was Lealiifano’s debut match, and his first action of the game. Therefore, perhaps with the intention of making a big impact on his debut, he may have been a bit too eager to make the tackle, and as a result, got the timing wrong and found his head misplaced.

The physical and dynamic nature of the tackle contest places players at high risk of injury. While this risk of injury may always be present during these physical contests between the ball-carrier and tackler, techniques to significantly reduce this risk of injury, and at the same time effective from a performance perspective, have been highlighted previously 3. Lets hope Lealiifano is fit and well soon, and the remainder of matches in the British and Irish Lions Series are both injury free, and highly entertaining.


1   Fuller CWC, Ashton TT, Brooks JHMJ, et al. Injury risks associated with tackling in rugby union. Br J Sports Med 2010;44:159–67.

2   Garraway WM, Lee AJ, Macleod DA, et al. Factors influencing tackle injuries in rugby union football. Br J Sports Med 1999;33:37–41.

3   Hendricks S, Lambert M. Tackling in rugby: coaching strategies for effective technique and injury prevention. Int J Sports Sci Coach 2010;5:117–36.

This article also features in RugbyScience, a website dedicated to translating rugby research to all its relevant stakeholders i.e  coaches, players, medical staff, management, and parents.


Dr Sharief Hendricks currently holds a NRF Innovation Post Doctoral Research Fellowship at the University of Cape Town. His thesis was titled ‘The Tackle in Rugby Union: Understanding training and match behaviours to develop better coaching strategies for skill acquisition, performance, and injury prevention’. In his short academic career, he has already published over 10 peer-reviewed articles, presented at numerous international conferences, 3 of which he was one of the keynote speakers (including an International Rugby Board coaching conference). Sharief has also contributed significantly to national strategic documents for his country’s rugby union (SARU). Sharief has also played rugby at provincial level (Western Province Under 21, 2006), and represented the University of Cape Town Rugby Club at 1xv level (Club league and Varsity Cup). He still plays for the University of Cape Town to date. Sharief also co-edits a science communication blog called RugbyScience

The safest position on a rugby pitch?

17 Apr, 13 | by Karim Khan

By Dr Tim McEwen

rugby scrumAs an enthusiastic rugby player and a newly qualified Doctor, I am often asked by teammates what is the safest position on the rugby pitch. Is the assumption that playing on the wing is for wimps who don’t want to get hurt?

Rugby Union is growing in popularity, yet there is often a preconception that it can be dangerous and serious injuries are likely to occur, especially in certain positions. Interestingly, research indicates that the amateur game has a similar incidence and severity of injury to football and a much lower game injury ratio than other high intensity collision sports such as American football.

Within the game of rugby, analysis in the amateur game has found that flankers (men) and centres (women) were the most frequently injured during games, with the highest percentages of major injuries (causing more than 7 days training or matches to be missed) reported to be for the No 8 position (men and women). Fly halves and fullbacks were the least often injured in the men’s game whilst the scrum half got off lightest in the women’s game. In terms of injuries in training, it is bad news for any amateur men with presentations to do at work the following day as the head/face is the source of most complaints, whilst women suffer more knee injuries[i].

There has been far more research and analysis into the injury profiles of different positions within the professional game. Studies have shown that for every match 33 days of absence are incurred for forwards, and 28 days for backs. Forwards tend to suffer from shoulder, knee and ankle/heel problems whilst the lighter but fleeter of foot backs suffered most frequently from shoulder, hamstring and knee problems[ii].

Following concerns about injuries in the forwards and wasted game time due to the resetting of scrums, the International Rugby Board recently set up an expert Scrum Steering Group to give advice on law changes and referee instructions[iii]. Experimental law changes were brought in for the scrum at the start of the 2012/13 season. For this season, the instructions from the referee have been ‘crouch, touch, set’. Front rows crouch then touch and using their outside arm touch the point of the opposing prop’s outside shoulder. The props then withdraw their arms and the referee calls ‘set’ when the front rows are ready. The front rows will then set the scrum.

The RFU, in conjunction with the University of Bath, is currently undertaking a second study to see how the scrum can be further improved by looking at other engagement techniques, from this crouch, touch and set approach to a modified technique so that props maintain the touch before a deemphasised engagement technique.

Results are due this year with a focus on player welfare and trying to improve player, coach and referee education around scrummaging technique. At a time when there has been significant controversy regarding the understanding and refereeing of the scrum from within the professional game[iv][v], results are eagerly expected.

[i] Kerr HA, Curtis C, Micheli LJ et al. Collegiate rugby union injury patterns in New England: a prospective cohort study. Br J Sports Med;42:595-603.

[ii] Brooks JHM, Kemp SPT, Injury-prevention priorities according to playing position in professional rugby union players. Br J Sports Med 2011; 45:765-775.



Dr Tim McEwen is a Foundation Year 1 Doctor in the South Thames Deanery. He currently works at East Surrey Hospital. A former Harlequins U19 and U21 player, he now plays for Guildford RFC.

Wounds in Rugby – IT’S A DIRTY OLD GAME

23 Mar, 12 | by Karim Khan

The UK trainee perspective (The BJSM blog features the trainee perspective every two weeks)*

Guest blog by Dr Dee Clark

Over the time I have worked with Rugby Union teams, I have come across a number of methods for players dealing with their own skin “wounds”.  These have ranged from use of safety pins, sewing needles (“sterilised” in a flame or just “off the shelf”) through to complicated use of homemade vacuum devices to draw out pus.  Whilst this has been an educational experience (!), in my role as a team medic, and particularly as an ex nurse, it fills my heart with dread when presented with the aftermath of the self-treated or ignored wound.  What often starts off as a relatively innocuous complaint, can lead to loss of training time, game time and even hospital admission.

Rugby is played on dirty surfaces.  Training facilities can hide potential for infection disaster. The sharing of washing and drying areas and materials as well as the constant comings and goings of those being treated in physio and medical rooms have the potential to wipe out a team.  Despite this, basic hygiene and common sense are often not employed in a strategy aimed at keeping players fit and healthy to play.


In one season we carried out an audit after noticing recurrent skin infections.  It was shown that in the first half of the season 11 players from the squad needed formal treatment (antibiotics/ minor surgical procedures), with 6 losing training days and 3 losing game time.  Further investigation led us to link the rise with a change in training facility where cleanliness had been an issue. After changing this facility, our infection rate decreased dramatically.

What we did to change things!

We reviewed facility cleaning arrangements, talked to the players about general hygiene including towel sharing, reporting of wounds, covering abrasions etc, installed more hand gel dispensers and instigated more stringent cleaning processes for physio and medical rooms.

Staff and players were encouraged to use hand gel and to wash their hands with greater frequency. Players were encouraged to report skin breaks at an early stage and were discouraged from self-treatment.

Sometimes, being swept up in the search for that extra 1% to make us bigger, better, stronger and faster than the others, can cause us to forget the basics.  After all, an ounce of prevention is worth a pound of cure.


 Articles of interest

Hayton MJ, Stevenson HI and Jones CD et al.  (2004) The management of facial injuries in rugby unionBr J Sports Med;38:314-317 

Stacey A and Atkins B (2000) Infectious diseases in rugby players: incidence, treatment and prevention, Sports Med Mar; 29 (3) 211-220

Horgan M and Bergin C,  IRB Policy on Hygiene, Infection control and Prevention of infection

 Goodman R et al (1994), Infectious diseases in competitive sport, JAMA Mar; 271 (11) 862-867



Dr Dee Clark is a Sport and Exercise Medicine Registrar and GP in the North West.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK Trainee Perspective” which runs every two weeks.

Concussion in sport: The Consensus

3 Nov, 10 | by Karim Khan

Concussion is certainly hot this week! Lots of news stories of variable quality. Today we review the International Consensus statement itself.

This practical resource was established, using a consensus-based approach, at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. It updates the recommendations of the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport. Click here to read the full document.

Key areas include:

  • Management of acute simple concussion,
  • complex concussion and long-term issues,
  • Return to play,
  • Paediatric concussion.

BJSMs podcasts also include 3 interviews with concussion guru Professor Paul McCrory, one of the leads on the Consensus statement.  See also this systematic review on helmets.

What do You Think? How has the Consensus Statement on Concussion in Sport shaped how you view and treat concussion?

Keep an eye on our homepage as an opinion poll will be posted shortly.

BJSM blog homepage


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