Hughes R, Cross M, Stokes K, et al. Novel biomechanical injury risk score demonstrates correlation with lower limb posterior chain injury in 50 elite-level rugby union athletes. 


The full paper can be found here.


Tell us more about yourself and the author team.

Rhys Hughes: Sports physiotherapist currently working as senior team physiotherapist to Gloucester Rugby in the English Premiership. Alongside Rugby Union, Rhys’s previous experiences have included professional football and private practice. He’s combined his clinical interests of movement analysis and sports performance with his MSc in Sports Physiotherapy to lead the research team on this publication.

Dr Matt Cross: Research and Rugby Development Manager at Premiership Rugby.

Prof. Keith Stokes: Medical Research Lead at the Rugby Football Union (RFU).

Daniel Tobin: Head of Performance at Gloucester Rugby, Dan oversees the physical performance for all players within the programme, coordinating gym, training and coaching sessions to ensure the players maximise their physical capabilities, leading to an optimum performance the pitch. Dan has previously worked as Head of Fitness at Leinster Rugby. Early in his career and thinking he was wasted in his current role, Dan moonlighted as a stand-up comedian in his early 20s and once played mandolin for U2 on their elevation tour before quickly being ejected and returning to the sport performance field.

Eoin Power: Head of Medical Services at Gloucester Rugby, Eoin is responsible for managing the medical team whilst overseeing the player’s medical provisions at the club, ensuring player availability is maximised through the season. Eoin is also completing an MBA through the University of Gloucestershire, adding to his skill set in team management and sports performance. Away from the day job, Eoin enjoys fine wine, luxury items and an ice cream or two…

Steph McNally: Senior Sports Therapist at Gloucester Rugby. Steph has worked at the club for 6.5 years and has worked her way through the ranks since starting as an intern within the club’s senior team. Steph is responsible for recording and analysing injury statistics for the playing squad, alongside managing her player caseload. Steph’s interests include concussion management, vestibular rehabilitation and managing the large variety of injures that comes with working in top tier rugby.

Jonathan Pamment: Senior Strength and Conditioning Coach at Gloucester Rugby. Alongside managing his player caseload, Pam’s performance interests include movement analysis and running mechanics and how these relate to performance. He has worked at the club now for 6 years, having previously held a similar role with Hartpury University before being chaperoned out to Gloucester Rugby.


What is the story behind your study?

As many studies’ do, this research was born out of discussions surrounding injury prevalence, biomechanics and a lack of practically applicable recommendations. For years now, and still to this day, the two main risk factors of injury, according to the research, are considered as 1) an athlete’s age and 2) an athlete’s injury history. Proven Fact!

This next bit is very much anecdotal (I believe it will become more and more science-based), but what if these unmodifiable risk factors correlate with something else? The modifiable factor of an athlete’s biomechanics. It would make sense that the longer an athlete performs over time (age), they would arguably see further injury of a structure that is perhaps operating inefficiently, right? Leading to an increase in the second factor in that injury risk notion – a further injury or re-injury (injury history). We’ve all heard, seen or experienced that athlete who keeps tearing his/ her/ their Hamstring or Calf, for example. Out of all these cases, you can’t tell me the therapist, coach or rehabilitator hasn’t spent their time ensuring this structure is as solid and robust as possible only to see it re-injure weeks, months or even years later. So what if there’s an underlying factor that keeps leading to re-injury as an athlete progresses through their career? Biomechanics!?

There were many avenues we could go down with this study, and given the Injury Risk Score (IRS) is novel in its nature and completed in prone, I know there will be many readers who will immediately dismiss its relevance as clinically applicable but stay with us….. even if it’s just for the next bit.… You must consider certain aspects to complete a study for it to be published alongside trying to make it clinically relevant without losing practical focus. The prone position firstly allows for repeatability and careful analysis of movement. However, the findings that we were unable to publish because of their lack of objectivity are arguably the most interesting and are the ones that correlate with upright running mechanics.

Aside from this study, something that has become commonplace within our department when looking at performance is taking athlete Kinograms and implementing drills, coaching and treatment strategies to improve running performance. Once you’ve identified a problematic movement within the Kinogram the next part as a clinician or a coach is breaking down why that is happening and try to fix it. When breaking down the ‘Why’ of athlete’s Kinograms the interesting thing was the commonalities observed between the biomechanical compensations in the IRS and the movements seen in the running analysis. For example, many athletes’ struggle to achieve adequate amounts of true hip extension, utilising something else to achieve the range for running such as extending from the lumbar spine or abducting at the gleno-humeral joint. The compensations we were seeing during Kinogram analysis correlated with the findings we were seeing with the IRS on a treatment bed, highly relevant as we were able to start using the IRS as a form of quick analysis when breaking down and making sense of the Kinogram. We look forward to hopefully sharing some of these findings in the future, where the real interesting and juicy stuff starts.

Once you pair this with our Performance Departments vision of installing appropriate biomechanics into athletes to improve performance and reduce injuries, you have the first of many projects into practically relevant research.


In your own words, what did you find?

The IRS essentially looks at assessing if an individual can achieve true hip extension (from the acetabulum-femoral joint) and, if they can’t, where they may be getting this range from through compensation. Hip extension is non-negotiable for performance, and if an athlete isn’t achieving it through compromising a structure, then injury risk appears to be higher. The IRS directly correlated with the groups Posterior Chain Injuries (PCI) over the course of 1x playing season and provides preliminary support for its use as an assessment tool.

This is great, but what do you do with the findings? Easy…….. Change them – if an athlete’s risk is high and anecdotally, a score of 7/10 or higher seemed to be practically relevant for risk, but it’s important to note that a 1- point increase in IRS demonstrated a 35% increase in risk for a first or a further PCI. The IRS is the first strand in the rehab process for the PCI. If compensation exists here in prone, it’s more than likely to be present when upright. Use and coach the prone hip extension and knee flexion movement as an exercise. If an individual extends their hip using their lumbar spine – correct it – engage their core, reduce anterior tilt and ask them to perform it again. If they’re still struggling, ask why? Often the range isn’t present at the anterior hip, and stretch or tissue release of the rec fem or iliopsoas often promotes the use of the lower abdominals to correct anterior pelvic tilt. (This is, however, just one example, and there’s more than one way to skin a cat as they say… or more than one boring story Tommy Turner can tell you… sorry, he’s another member of our S&C team).


What was the main challenge you faced in your study?

The main challenge in data collection was predominantly COVID-19. The injury prevalence for the season was cut short with data at the end of the season missing, arguably the time you would pick up most of your injuries. Data collection itself was relatively easy and completed for a full squad in 2 hours, as it’s easily applicable. The relationship between the IRS’s findings and upright running proved difficult to include in publication due to its lack of objectivity. Still, the relationship seems to be present anecdotally and although it’s not something we were able to do at the time as it takes time and would be difficult to apply a full squad gait analysis. Using 3D kinematic software may be the way to go from a research perspective to prove this point though, even if it’s just a few individuals.


If there is one take-home message from your study, what would that be?

Prevent and rehabilitate, always considering an individual’s biomechanics!!! Age and previous injury are considered the 2 main risk factors to an athlete’s injury risk. The research base is significantly lacking, but biomechanics HAS to influence these risk factors. The IRS is an easily applicable assessment tool to begin understanding.

Thanks for reading, and always happy to take questions or discussion at RHphysio@gmail.com

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