To describe the incidence and characteristics of injuries among US high school rugby players and to identify possible injury risk factors.
Descriptive epidemiological study.
The 2005 and 2006 US high school rugby seasons.
A convenience sample of 121 boys' and girls' US high school rugby clubs.
Exposure to playing rugby.
Main Outcome Measures
Incidence, characteristics, and risk factors of rugby injuries.
Enrolled clubs reported 594 injuries during 113 641 total high school rugby athletic exposures (81 627 practice exposures and 32 014 match exposures). Rugby injury rates were 5.2 injuries per 1000 total athletic exposures, 1.3 injuries per 1000 practice exposures, and 15.2 injuries per 1000 match exposures. The mean age of the injured athletes was 16.5 years (SD, 1.2 years; range, 13-19 years) and 87.0% were male. The most commonly injured body sites were the head (21.7%), ankle (13.3%), and shoulder (12.8%). Fractures (16.0%), concussions (15.8%), and ligament sprains (incomplete tears) (15.7%) were the most common diagnoses. Practice and competition injuries were similar with respect to the proportion of concussions and head, shoulder, ankle, and knee injuries. More than half of all injuries resulted from being tackled (30.8%) and tackling (28.8%).
As the popularity of youth rugby continues to grow in the United States, increasing numbers of physicians and certified athletic trainers will find themselves treating rugby-related injuries and answering questions from parents about the comparative safety of rugby. To our knowledge, this is the first large-scale study to describe injury rates and identify possible injury risk factors among US high school rugby players.
From 2003 to 2004, the number of boys' youth rugby clubs in the United States increased by 15% from an estimated 429 to 492 clubs, while the number of girls' youth rugby clubs increased by 31% from an estimated 96 to 126 clubs.1 This rapid increase in the number of US high school rugby participants has resulted in concerns about the risk of injury associated with playing rugby at this level. Although rugby does pose a relatively high risk of injury to participants, as do all contact sports, the few studies that have directly compared rates of injury in rugby with rates of injury in other contact sports such as football or ice hockey have indicated that rugby is as safe as or safer than other contact sports.2- 5 Previously reported pediatric rugby injury rates have ranged from 7 to 47 injuries per 1000 player hours.6- 9 However, to our knowledge, no studies have investigated rates of injury among US youth rugby players.
Well-designed surveillance systems that collect accurate exposure and injury data are needed to determine injury rates among sports and recreational activities. Data collected by such surveillance systems can also enable researchers to identify patterns of injury and risk factors associated with injury, which is the first step toward decreasing injury rates. While injury surveillance systems are effective tools for collecting reliable data on which injury prevention research can be based,10- 18 to date, paper- and telephone-based surveillance systems have largely proved labor and cost intensive. The advent of Internet-based surveillance tools that address these concerns provides researchers with possible means of more efficiently studying sports- and recreation-related injuries.12,13,19
The objectives of this study were to describe the incidence and patterns of injuries among US high school rugby players and to identify risk factors associated with injury using an Internet-based surveillance system.
The RIO (Reporting Information Online) system, an Internet-based surveillance system, was used to perform surveillance of injuries sustained by US high school rugby players during the 2005 and 2006 seasons. The RIO system is closely modeled after the National Collegiate Athletic Association Injury Surveillance System, which has successfully collected reliable data on injuries, athletic exposures, and risk factors since 1982 and has been used to develop preventive interventions that have had proven success in reducing injuries among collegiate athletes.13 The RIO Internet-based injury surveillance system has been successfully used in several other projects, including studies of high school sports-related injuries and illnesses as well as injuries among campers and staff at US summer camps.19- 23
Potential participants were identified from rugby club contact lists obtained from USA Rugby, the sport's national governing body; Rugby Magazine, the most popular US rugby magazine; and rugby Web sites. Each of the 553 identified US high school rugby clubs with a valid e-mail address was sent an e-mail that informed them of the surveillance project, invited them to participate, and provided a link to the RIO Web site that allowed them to enroll in the study. Of the convenience sample of 157 clubs who expressed interest in participating, 121 clubs (21.9% of all of the identified US high school rugby clubs) representing 98 boys' and 23 girls' clubs enrolled in the study and reported at least 1 week of data. Each enrolled high school rugby club designated a club reporter. Preferred club reporters were the following (listed in order of preference): a club physician (2.5%), a club-certified athletic trainer (2.5%), another club medical personnel member (ie, nurse, emergency medical technician, etc) (1.7%), a club coach (77.7%), an adult club manager (8.3%), or another adult associated with the club (6.6%) (reporter status was unknown for 0.7% of clubs). Each reporter received a training packet and a set of self-guided PowerPoint slides (Microsoft Corp, Redmond, Washington) detailing the data entry process. Additionally, a personal training session conducted via telephone by a member of the research staff on the use of the Internet-based surveillance system was available on request.
During the 2005 and 2006 US rugby seasons, which included 21 weeks in 2005 and 23 weeks in 2006, each participating club was asked to complete weekly exposure reports for each week its team was in session. These weekly exposure reports collected athletic exposure information and the number of reportable injuries sustained by club members that week. An athletic exposure was defined as 1 player participating in 1 rugby practice or match where he or she was exposed to the possibility of athletic injury. Athletic exposure was expressed in 2 parts: (1) the number of player practices was the sum of the number of players at each practice during the past week, and (2) the number of player matches was the sum of the number of players who played in each match during the past week. A reportable injury was defined as an injury that occurred as a result of participation in an organized high school rugby match or practice; required medical attention by a club physician, certified athletic trainer, personal physician, emergency department, or urgent care facility; and resulted in restriction of the high school rugby player's participation in regular school or rugby activities for 1 or more days beyond the day of injury. This injury definition has been used in several other sports injury surveillance studies.19- 23
In addition to the weekly exposure report, for each reportable injury, reporters completed an injury report that collected detailed information about the injured player (age, sex, and self-reported height and weight), injury (site, type, severity, assessment, and disposition), and injury event (mechanism, phase of play, related to illegal activity or foul play, etc) based on witnessing injuries, athletes' self-reports, documentation from medical assessments, and so on. The Internet-based surveillance tool also provided reporters with the ability to view all of the data they had reported throughout the study as well as the option to update injury reports with information that was not available at the time the initial report was submitted (eg, the need for surgery, final injury disposition).
Each week, reporters received an e-mail reminding them to log into the Internet-based surveillance system. Reporters who failed to log in to complete the weekly exposure and injury report received an e-mail reminding them to do so, and reporters who repeatedly failed to log in to complete the weekly exposure and injury reports received a telephone call to assess their willingness to continue participation. Because clubs across the United States begin and end their seasons at different times during the calendar year, each reporter provided data only while his or her club was in season.
Injury rates were calculated as injuries per 1000 athletic exposures, practice injuries per 1000 player practices, and match injuries per 1000 player matches. Data were analyzed using SPSS version 13.0 statistical software (SPSS, Inc, Chicago, Illinois) and Epi Info version 6 statistical software (Centers for Disease Control and Prevention, Atlanta, Georgia). Statistical analyses included the χ2 test with Yates correction and t test. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated to assess the magnitude of associations. P < .05 was considered statistically significant. This study was approved by the Nationwide Children's Hospital's Institutional Review Board.
The US high school rugby clubs participating in the study completed injury reports for 594 injuries (103 in practice, 488 in competition, and 3 unspecified) during 113 641 total high school rugby athletic exposures, which included 81 627 practice exposures and 32 014 match exposures. The overall injury rate was 5.2 injuries per 1000 total rugby athletic exposures. The injury rate was significantly higher among boys (5.5 injuries per 1000 total rugby athletic exposures) than girls (4.1 injuries per 1000 total rugby athletic exposures) (RR = 1.3; 95% CI, 1.1-1.7; P = .02).
Injury rates differed by type of rugby exposure, with reported injury rates of 1.3 injuries per 1000 rugby practice exposures compared with 15.2 injuries/1000 rugby match exposures (RR = 12.1; 95% CI, 9.8-14.9; P < .001). Whereas the injury rate per 1000 practice exposures was similar for boys and girls (1.3 and 1.0, respectively), girls sustained a higher injury rate per 1000 match exposures (19.5) than boys (14.8) (RR = 1.3; 95% CI, 1.0-1.7; P = .048).
The mean age of the injured athletes was 16.5 years (SD, 1.2 years; range, 13-19 years) (Table 1). Injuries were most commonly a new injury (86.4%) rather than a recurrence or complication of a previous injury. The most commonly injured body sites were the head (21.7%), ankle (13.3%), shoulder (12.8%), and knee (11.1%) (Table 1). Fractures (16.0%), concussions (15.8%), and ligament sprains (incomplete tears) (15.7%) were the most common diagnoses. Impact with another player (50.8%) and impact with the playing surface or ground (24.9%) were the most common mechanisms of injury. More specifically, in regard to activity at the time of injury, 30.8% of injuries occurred while the player was being tackled, 28.8% occurred while the player was tackling, 14.0% occurred in rucks, and 9.9% occurred while running in play. Three activities, being tackled (33.0%), tackling (31.9%), and rucks (22.3%), contributed to 87.2% of concussions. Of all injuries, 46.5% kept the athlete out of play for less than 10 days, 23.1% kept the athlete out of play for 10 to 21 days, and 26.9% kept the athlete out of play for more than 21 days (time loss was not reported in 3.5% of injuries) (Table 1).
There were no significant differences in injury diagnosis, time loss, or final injury disposition (ie, outcome) based on the injured athletes' age or height. The average weight of injured forwards (mean [SD], 83.25 [15.03] kg) was significantly greater than that of backs (mean [SD], 70.29 [9.54] kg) (P < .001). Injuries sustained by forwards and backs were similar in terms of body part injured, diagnosis, and final injury disposition. However, forwards experienced a greater proportion of muscle-tendon strains (incomplete tears) (11.8%) than backs (5.7%) (RR = 2.1; 95% CI, 1.2-3.7; P = .02). Forwards also experienced a greater proportion of injuries that kept the athlete out of play for only 1 to 2 days (18.3%) compared with backs (9.5%) (RR = 1.9; 95% CI, 1.2-3.0; P = .006).
With regard to protective equipment, 93.6% of players were wearing a mouthguard when injured, 12.6% were wearing a scrumcap (soft, padded headgear that covers the ears), and 10.4% were wearing shoulder pads. More specifically, of the players who sustained a head injury, 97.7% were wearing a mouthguard and 9.3% were wearing a scrumcap. Three of the 5 players who sustained a mouth or tooth injury were wearing a mouthguard at the time of injury, and 11.8% of players who sustained a shoulder injury were wearing shoulder pads. Of injuries that occurred during a competition (n = 488), 24 (4.9%) were directly related to action that was ruled illegal activity or foul play by a referee or disciplinary committee. Of those injuries related to illegal activity or foul play, 41.7% were concussions, 12.5% were fractures, and 12.5% were dislocations.
Of the 594 reported injuries, 517 (87.0%) of the injured athletes were male and 77 (13.0%) were female (Table 1). Overall, patterns of injury tended not to differ for boys and girls (Table 1). Boys and girls sustained a similar proportion of concussions (16.1% and 14.3%, respectively). Boys experienced a greater proportion of injuries that kept them out of play longer (≥ 10 days) (52.3%) than did girls (35.1%) (RR = 1.5; 95% CI, 1.1-2.0; P = .005). All of the injuries that forced an end to the player's rugby career (n = 11) occurred among boys and included 4 fractures, 2 complete dislocations, 2 nerve injuries, 1 concussion, 1 torn cartilage, and 1 unknown shoulder injury.
For both boys (82.4%) and girls (80.5%), most injuries occurred during a competition. Of those injuries that occurred during practice (n = 103), 49.5% were sustained during full-contact drills or scrimmages, 19.4% during tackling practice, 29.1% during noncontact practice, and 2.0% in other or unknown types of practice. Practice and competition injuries were similar in respect to the proportion of head, shoulder, ankle, and knee injuries as well as in the proportion of concussions, fractures, and ligament sprains. A greater proportion of practice injuries resulted from running while in play (19.4%) (RR = 2.4; 95% CI, 1.5-4.0; P < .001) and no apparent contact (12.6%) (RR = 2.8; 95% CI, 1.5-5.4; P = .003) compared with competition injuries (8.0% and 4.5%, respectively). While a significantly greater proportion of injuries related to being tackled were sustained in competition (34.0%) than in practice (16.5%) (RR = 2.1; 95% CI, 1.3-3.2; P < .001), there was no significant difference in the proportion of injuries related to tackling in competition (29.9%) compared with practice (24.3%) (RR = 1.2; 95% CI, 0.9-1.8; P = .30).
Injuries with a time loss longer than 21 days (n = 160) were most commonly to the knee (16.9%), shoulder (15.0%), and clavicle (14.4%) (Table 2). The most common diagnoses were fractures (41.9%), ligament sprains (incomplete tear) (13.1%), ligament sprains (complete tear) (6.3%), and acromioclavicular joint separations (5.0%). Of the injuries that resulted in a time loss longer than 21 days, the most common mechanisms of injury were impact with another player (44.0%) and impact with the playing surface or ground (32.7%). More specifically, in regard to activity, 37.1% of injuries resulting in a time loss longer than 21 days resulted from being tackled and 32.7% resulted from tackling.
Of all injuries, 26.1% forced the athlete to end his or her 2005 rugby season and 1.9% forced the athlete to end his rugby career. Injuries that forced an end to the player's season (n = 155) or career (n = 11) were most commonly to the shoulder (16.3%), knee (16.3%), and head (13.9%) and were most commonly fractures (36.1%), ligament sprains (incomplete tears) (13.9%), and concussions (10.2%).
As the popularity of rugby continues to grow among US youth, increasing numbers of physicians and certified athletic trainers will find themselves treating rugby-related injuries and answering questions from parents about the comparative safety of rugby. There is a growing body of literature on the rate of youth rugby-related injuries in other countries; however, to our knowledge, this is the first large-scale study of US high school rugby injuries. A recent study using the same surveillance system, exposure measurement, and injury definition found the overall US high school boys' football injury rate to be 4.4 injuries/1000 athletic exposures19 compared with the overall injury rate in US high school rugby found to be 5.2 injuries/1000 athletic exposures. While caution should be used when comparing injury rates across studies, in the United States, high school rugby appears to have a lower injury rate than ice hockey, higher injury rates than basketball and soccer, and similar injury rates to football and wrestling.19,21,24- 31
As in other fields of injury, epidemiological findings can help shape the development and implementation of recommendations for sports-related injury prevention. For example, we found that the largest proportion of high school rugby injuries occurred while tackling or being tackled, which is similar to previous findings.8,9 Preventive interventions to decrease injuries associated with the tackle could include providing coaches with materials designed to help them run proper tackling drills, showing players videos demonstrating proper tackling techniques, educating referees on the injury risks associated with unsafe tackling techniques, and encouraging referees to penalize unsafe tackling when warranted (laws related to tackling can be reviewed in full in the rugby union law book32). Coaches should ensure that all players are adequately prepared for the physical nature of matches by simulating match conditions at practice, thus allowing for the proper mechanics of tackling to be taught in a controlled yet realistic environment. Programs such as RugbySmart in New Zealand that implement preventive interventions like these have seen significant decreases in rugby-related injuries.18
Although we expected competition injuries to be more severe than practice injuries, they were not. While most of the injuries were sustained in competition, the proportions of fractures, concussions, and injuries that resulted in a time loss longer than 21 days were similar in practices and competitions. Because the vast majority of practice injuries occurred during tackling practice, other contact drills, and full-contact scrimmages, preventive interventions could include providing high school coaches with materials designed to help them teach the development of tackling skills in practice through a progression of closely supervised drills (ie, from tackling stationary dummies to partial speed drills to tackling teammates at full speed) as well as guides on how to run controlled scrimmages. In addition, protective equipment should always be worn in practice as well as in competition.
One in 5 injuries sustained by US high school rugby players were injuries to the head, most of which were concussions. While similar to findings from previous research,4,8,9 this is an alarming finding. In an effort to decrease more serious head injuries, coaches as well as all medical personnel treating high school rugby players should receive education about concussion prevention, identification, and treatment as well as guidelines for athletes' return to play following concussion. A good source of this material is the educational packet, “Heads Up: Concussion in High School Sports,” which is a free and easy-to-use tool kit for mild traumatic brain injuries developed by the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm).
A disproportionate number of injuries related to illegal activity or foul play were more serious injuries. All coaches, athletes, and referees should be encouraged to commit to reducing the frequency of illegal activity or foul play, as two-thirds of all injuries related to illegal activity or foul play were concussions, fractures, or dislocations. Coaches, players, and referees should be educated about the dangers of illegal activity or foul play. Furthermore, referees should be made aware of and encouraged to follow guidelines developed by the USA Rugby Referees Association regarding recommended penalization of illegal activity or foul play.33
The overall injury rate for US high school rugby players was found to be generally lower than rugby injury rates reported in other countries (Table 3).6,7,9,10,34- 40 One possible explanation for this difference is that because US high school rugby is still early in its development, players with less experience may play at a lower level of intensity and competitiveness, thereby reducing the injury rate9,10; however, it could also be conversely argued that because US high school rugby players are younger and less experienced, the injury rate should be higher. The lower injury rate in the United States compared with those in other countries may also reflect a higher proportion of practice exposures compared with match exposures, as the practice injury rates in our study were substantially lower than match injury rates. Differences in exposure measurements (ie, match hours vs match exposures) and injury definitions should also be considered when comparing injury rates across studies. In addition, it should be noted that rugby union is the only code played at the high school level in the United States. Continued surveillance is needed to monitor injury rates as the popularity of youth rugby and the experience of US players increase.
Like all research projects, this surveillance study had limitations. For example, although to our knowledge this is the largest study of injuries among US high school rugby players to date and the only study to calculate exposure-based injury rates in this population, injuries reported here may not be fully representative of all US high school rugby injuries because we studied a convenience sample. Potential differences may exist between the US rugby clubs that volunteered to participate and those that did not, which could result in differences in injury rates and characteristics. While we understand the limitations of a convenience sample, it was the most feasible option given the constraints imposed by this population including the fluidity and lack of contact information for rugby clubs at the high school level, which is commonly a club sport in the United States. However, as our findings were similar to research on youth rugby from other countries, the concern of generalizability is minimized.
Additional limitations were related to the realities of conducting injury surveillance in this population. Because high school rugby clubs across the United States begin and end their seasons at different times during the calendar year and seasons have different lengths, not every club is in session to report for all of the weeks in the study period. However, the overall injury rate for clubs that reported at least 1 week (5.2 injuries/1000 rugby athletic exposures) and the injury rate for clubs that reported at least half of the weeks (4.9 injuries/1000 rugby athletic exposures) were very similar. Likewise, the injury rates per 1000 practice and match exposures were also similar. Another limitation is that high school rugby, predominantly a club sport in the United States, rarely has physicians or certified athletic trainers available at practices or competitions; thus, medically trained reporters are often not available. However, while most reporting was done by nonmedical personnel, most of the reported injuries were assessed by a doctor or other medical personnel such as an athletic trainer (93.0%). Despite limitations, these data in the absence of ongoing community-level surveillance systems for US high school rugby injuries are important for informing prevention initiatives.
Future studies using nationally representative samples of US high school rugby players are needed to further compare injury rates for high school rugby and other US high school sports. As the popularity of rugby among US high school athletes continues to grow, ongoing injury surveillance prompting the development of evidence-based preventive interventions to decrease injury rates will become increasingly important. Concerns among the general US public over the risk of injury associated with rugby will undoubtedly continue, and the burden on the health care system will continue to grow as the number of rugby-related injuries continues to increase. Ongoing surveillance of a nationally representative sample of US high school rugby clubs will allow researchers to monitor injury rates and patterns over time, to develop evidence-based preventive interventions, and to evaluate the effectiveness of implemented interventions.
Correspondence: Christy L. Collins, MA, Center for Injury Research and Policy, The Research Institute, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205 (firstname.lastname@example.org).
Accepted for Publication: June 28, 2007.
Author Contributions: All of the authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Collins and Comstock. Acquisition of data: Collins and Yard. Analysis and interpretation of data: Collins, Micheli, and Comstock. Drafting of the manuscript: Collins. Critical revision of the manuscript for important intellectual content: Collins, Micheli, Yard, and Comstock. Statistical analysis: Collins and Comstock. Obtained funding: Collins and Comstock. Administrative, technical, and material support: Yard. Study supervision: Micheli and Comstock.
Financial Disclosure: None reported.
Funding/Support: This work was supported by the United States Rugby Football Foundation.
Additional Contributions: The USA Rugby Medical and Risk Management Committee assisted in the development of the questionnaires and the Internet-based surveillance tool, and USA Rugby and Rugby Magazine provided contact information for high school rugby clubs.
Collins CL, Micheli LJ, Yard EE, Comstock RD. Injuries Sustained by High School Rugby Players in the United States, 2005-2006. Arch Pediatr Adolesc Med. 2008;162(1):49-54. doi:10.1001/archpediatrics.2007.1