Cruz-Ferreira António Miguel1, 2, 3, Rodrigues José Carlos1, Vital Paulo1, Cruz-Ferreira Eduardo Miguel4, Moreira Francisco5
1 Federação Portuguesa de Rugby, Lisboa, Portugal;
2 Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal;
3 Centro de Estudos Investigação em Saúde da Universidade de Coimbra, Coimbra, Portugal;
4 Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal;
5 Aspire Academy Sports Medicine Centre, Aspetar, Doha, Qatar
Introduction: Rugby union has one of the highest injury incidence rates among all collective sports. Data on incidence and type of injuries at non-professional level in rugby are sparse. Our objective was to assess the severity, incidence, type and location of injuries sustained during the top-tier of the Portuguese rugby union senior male fifteens championship.
Methods: A cohort prospective study recording time-loss injuries occurring during the 2017/18 season in Portugal was conducted. All senior male top-tier clubs were invited to participate. Main outcome measures included: incidence rate, anatomical location, type, injury incident and severity. Data were collected using an online platform. Methodology used was similar to previously published studies, and Ethical approval was obtained.
Results: A total of 91 injuries were recorded corresponding to an overall incidence rate of 37.92 injuries per 1000 player match-hours. Average severity was 28.16 days. Contact preceded 84.6% of injuries, and tackle was responsible for 48.1%. Most injuries occurred in the lower limb (50.5%) and were joint/ligament or muscle/tendon injuries (31.9 and 20.9%, respectively). Incidence rate was lower at club level in fifteens, when compared to Portuguese rugby sevens or international fifteens. However, injury severity did not differ from previous studies.
Conclusions: Injury incidence was lower in the Portuguese club competition, compared to other studies in elite international and Portuguese sevens studies, being similar to other community level and non-elite studies in rugby. During a match in the top Portuguese rugby championship, an average of 1.52 injuries may occur, leading to an average absence of 4 weeks. This represents a significant burden to players and teams and strategies aiming at its mitigation should continue to be considered and designed.
Introduction: Le rugby à XV présente l’un des taux d’incidence de blessure les plus élevés de tous les sports collectifs. Les données sur l’incidence et le type de blessures au niveau non professionnel dans le rugby sont rares. Notre objectif était d’évaluer la gravité, l’incidence, le type et la localisation des blessures subies au cours du championnat portugais de rugby à XV masculin senior.
Méthodes: Une étude prospective de cohorte enregistrant les blessures avec temps d’absence du sport survenues au cours de la saison 2017/18 au Portugal a été menée. Tous les clubs de première division masculine ont été invités à participer. Les principaux indicateurs de résultats comprenaient: le taux d’incidence, la localisation anatomique, le type, l’incident de blessure et la gravité. Les données ont été collectées à l’aide d’une plateforme en ligne. La méthodologie utilisée était similaire à celle des études publiées précédemment et l’approbation éthique a été obtenue.
Résultats: Au total, 91 blessures ont été enregistrées, ce qui correspond à un taux d’incidence global de 37,92 blessures pour 1000 heures de jeu. La gravité moyenne était de 28,16 jours. Le contact a précédé 84,6% des blessures, et le plaquage a été responsable de 48,1% d’entre elles. La plupart des blessures se sont produites dans les membres inférieurs (50,5%) et étaient des blessures articulaires/ligamentaires ou musculaires/tendineuses (31,9 et 20,9%, respectivement). Le taux d’incidence était plus faible dans les clubs de rugby à XV que dans les clubs portugais de rugby à VII ou de rugby international. Cependant, la gravité des blessures ne différait pas des études précédentes.
Conclusions: L’incidence des blessures était plus faible dans les compétitions de clubs portugais que dans d’autres études portant sur l’élite internationale et le rugby à 7 portugais, et similaire à d’autres études portant sur le rugby au niveau communautaire et non élite. Au cours d’un match du championnat portugais de rugby de haut niveau, 1,52 blessure en moyenne peut survenir, entraînant une absence moyenne de 4 semaines. Cela représente un fardeau important pour les joueurs et les équipes, et des stratégies visant à les atténuer devraient continuer à être envisagées et conçues.
Mots-clés: rugby à XV, épidémiologie, blessures athlétiques
Rugby union has one of the highest injury incidence rates of all sports, both at amateur and elite levels. In 2013, Williams et al.  found that the injury incidence rate at the professional level was 81 injuries per 1000 player-match-hours, while other authors presented even higher rates, in some cases higher than 100 injuries per 1000 player-match-hours [2,3].
At the top-level, most injuries occur after a tackle, with the tackled player being at higher risk of injury than the tackler1 [4–7]. Muscle/tendon and joint/ligament injuries of the lower limb are the most common types and location reported, also at this level [1,4,5].
Regarding amateur rugby, a recent meta-analysis found a lower incidence rate of 46.8 per 1000 player-match-hours . Type and location of the most frequent injuries overlapped the reports for the professional level, and contact events, especially tackle, were also responsible for the majority of injuries among amateur players [8–10]. On average, both at elite and amateur level, injury severity averaged 20 days of absence from training and/or practice [1,8].
As a systematic review recently showed, data for rugby sevens found that injury incidence rates in rugby sevens were higher than those reported for the 15-a-side variant, at the same level of competition. Injuries were also more severe, resulting in longer absence periods. The authors also suggested that it might result from the fact that rugby sevens is played with greater speed, leading to an increase in energy transfers during tackles, more running and turning manoeuvers [5,11–14].
Although sparse, data extracted from a small study conducted in a senior male team competing in the top-division of Portuguese rugby, reported an incidence rate of 66.66 injuries per 1000 player match-hours, and an average severity of 20.79 days . In rugby sevens, a club competition-based cohort study found that injury incidence in Portugal at this level (133.9 injuries per 1000 player match-hours)  was similar to the reports of studies at the international level , while injury severity was lower.
As data regarding injury incidence and severity at rugby union fifteens club level in Portugal is sparse, we aimed at determining the incidence and nature of injuries in the Portuguese rugby union senior male top-tier Championship.
We conducted a cohort prospective study, during the 2017/18 season, where the epidemiology of injuries in the Portuguese senior male rugby union players was assessed at club level. All the 12 clubs competing at the Portuguese senior male top-tier championship in 2017/18 were invited to participate in the study. Teams’ medical staffs that agreed to participate recorded all injuries occurring during their matches. Informed consent was obtained from the players.
Injuries were then reported to the researchers using an online form, that collected data regarding date of injury, anatomical location, type of injury and the activity/phase of the game in which it occurred. Definitions and procedures used in this study were compliant with the international consensus statement on injury surveillance studies for rugby, and the methodology was similar to previously published studies [3,16]. Injury was defined as ’any physical complaint sustained by a player during a Portuguese Senior Male Top-tier Rugby Championship match that prevented the player from taking a full part in training and/or match play for more than one day following the day of injury’. Severity was defined by the number of days an injured player was unavailable for practice and matches, and all injured players were followed up until their return to competition. Exposures were calculated based on fifteen players being exposed for 80 minutes per match. No allowances were made for players removed (yellow or red cards). Injury incidence rate is presented in number of injuries per 1000 player-match-hours. Injury data are reported as proportion (%). Severity is reported as mean days. Ninety-five percent confidence intervals (95% CIs) were calculated for severity, proportions, and injury rate. Significant differences in values for incidence and severity were assumed if the 95% CIs did not overlap.
Ethical approval was obtained from the Ethical Committee of the local Regional Health Administration and institutional collaboration was granted by the clubs and the Portuguese Rugby Union. Statistical analysis was performed using SPSS software (Version 22.0. Armonk, NY).
The Portuguese club top-tier fifteens competition in 2017/18 included two phases. During the first phase of the study, only ten of the twelve teams agreed to participate. For the second phase of the season (Final Groups), another four dropped-out. Data regarding the teams that did not collaborate or that dropped-out during this period were excluded from the analysis of the respective phase. Once competition formats changed from the 2017/18 to the 2018/19 season (number of teams reduced), it was decided to stop collecting data for the club competition at the end of the first season. Data are summarized in tables 1 and 2.
A total of 91 injuries were reported, corresponding to an overall injury incidence rate of 37.92 injuries per 1000 player-match-hours (95%CI: 30.71-46.33). Total exposure amounted to 2400 player match-hours. There was a difference, however, between the number of injuries and injury rates reported for the first and the second phase of the competition. During the first phase (total exposure of 1200 player-match-hours), 55 injuries were reported, while during the second phase (same exposure) only 36 injuries were recorded, thus leading to a rate of 45.83 (95%CI: 34.86-59.22) and 30.00 (95%CI: 21.33-41.08) injuries per 1000 player-match-hours, respectively.
With 50.5% (95%CI: 39.6-60.4) of all injuries, the lower limb was the most frequently affected site. Regarding the type of injury (see table 1), joint/ligament and muscle/tendon accounted for most of injuries (52,8%). Contact preceded 84.6% (95%CI: 76.9-91.2) of all injuries, and tackle was the game phase where 48.1% of them occurred, with being tackled the single most frequent event preceding an injury
(table 2). There was no difference between the position of injured players, as 50.5% (95%CI: 40.7-61.5) were forwards and 49.5% (95%CI: 38.5-69.3) backs. Average severity of all injuries reported was 28.16 days (95%CI: 17.52-41.54).
Ten teams actively participated in the study, while two did not submit any forms. A total of 91 injuries were identified during the season. In the first phase of the competition, 10 teams provided data, while on the second, only six participated. The incidence rate, location, and type of injuries found on the Portuguese National championship are similar to other amateur competitions. Regarding the location and type of injuries, as well as the event preceding them, both at elite and amateur level, on the international scene or national rugby, the data appear to be very consistent. The lower limb, muscle / tendon or ligament injuries occupy prominently the first place. In a Portuguese top-tier club fifteens match, 1.52 injuries (0.76 per team) are expected. However, one important point that should be of concern is the average injury severity recorded in this competition. In the case of Portuguese competition, it was higher than that reported in previous studies for both elite and amateur rugby.
When comparing injury incidence rates between the different phases of the competition assessed in our study, no significant statistical differences were found, as all confidence intervals overlapped. However, injury severity was lower during the last phase, which it is difficult to explain and is probably biased by the lower participation rate from teams. One very interesting point is that injury rates in the top Portuguese club competition in fifteens was lower than the reported the previous season for the same competition in sevens.16 These finding are in line with previous reports of injury data from both variants, with sevens being associated to higher injury incidence rates [5,17,18].
One very outstanding finding is the low incidence of concussions in this group. If we look into the rates reported (5.5 per 1000 player match-hours) it clearly falls below the current average reported incidence of these type of injuries, both at sevens and fifteens [3,19]. On the other hand, it is important to understand that in Portugal at club level, Recognize and Remove approach is in place, thus for a suspected or confirmed concussion the player will be absent from training and competition for a period of three weeks or more. This might be the reason for an underreporting of concussions in this group, as well as the need for more education of all agents about the risks of concussion for our players.
Also, on a practical approach to use of this data, it becomes clear that Portuguese rugby clubs should consider the need to implement effective injury prevention strategies that proved to reduce the burden of injuries in rugby. Notably, ACTIVATE a program developed in England and adopted by World Rugby have recently showed a significant impact in the incidence of injuries (MSK and concussion, mainly) among those implementing it . In addition to injury prevention, which is paramount to assure the safety in our sports, we urge the clubs to implement effective strategies to report and record their injuries. In a semi-professional or amateur setting, we understand the struggle of some teams to collect and report data on their player’s injuries, however, it is accepted by the scientific and sport community that only by holding the correct information regarding a topic, effective change can be suggested. Injury burden in rugby is significant – for both clubs and the players – so attempting its mitigation is key for the success of the sport. To complete an effective quality improvement cycle in the field of rugby injuries, collecting, reporting and analyzing data is the first and critical step. A suggestion is to regularly collect data (after each match) and issue weekly injury reports. Clubs can use the same template/form of this study and this will allow clubs to begin a quality process and assure the storage and management of this relevant data. We hope that clubs and their agents become aware of that relevance by the publishing of this paper.
When analyzing the data obtained, several limitations should be discussed. Firstly, the data refer to only one season. Second, to obtain the data, the authors relied on the collaboration of the medical teams from each club, which may lead to a smaller than actual sample due to the possibility of unreported injuries or lack of willingness to participate. Another methodological problem identified is related to the determination of injury severity. From the 91 reported injuries, teams did not submit the recovery dates for 21 of them. Reasons included: not responding to inquiries; loss of clinical data; athlete moved from club/country; changes within medical teams. Also, because they are non-professional teams, the level of medical support available for proper recovery might not have been optimal, thus impacting in the recovery of players.
Nevertheless, this was the first study ever conducted in the Portuguese rugby fifteens top-tier competition that included all the teams participating the event. Also, it provided robust data that allows us to benchmark injuries in the non-elite Portuguese club rugby and understand the unique challenges of the sport at this level. It is, crucial that future studies in Portuguese rugby aiming at determining the burden of injuries in their competitions understand the specificities of the clubs. Creating a methodology that relies more in the researcher and less in the clubs might help to boost the quality of data, as previous studies achieved .
Our findings are unique and represent the first data ever reported for a senior male rugby fifteens competition in Portugal. Incidence rates, event, type, and location of injuries in the Portuguese championship were similar to other amateur competitions. During the tournament, on average, 1.52 injuries can occur in each match, and, on average, an injured player will be absent from training and/or competition for 28.16 days. The design and implementation of effective strategies to mitigate the burden of sports injuries in Portuguese rugby are needed and this study provides the benchmark for future investigations.
Miguel Cruz-Ferreira, MD, PhD
- Williams S, Trewartha G, Kemp S, Stokes K. A Meta-Analysis of Injuries in Senior Men ’ s Professional Rugby Union. 2013:1043-1055. doi:10.1007/s40279-013-0078-1.
- Kemp SPT, Brooks JHM, Fuller CW, et al. England Rugby Premiership Training & Injury Audit Season Report.; 2012.
- Fuller CW, Taylor A, Kemp SPT, Raftery M. Rugby World Cup 2015: World Rugby injury surveillance study. Br J Sports Med. 2017;51(1):51-57. doi:10.1136/bjsports-2016-096275.
- Fuller CW, Sheerin K, Targett S. Rugby World Cup 2011: International Rugby Board Injury Surveillance Study. Br J Sport Med. 2013;47(18):1184-1191. doi:10.1136/bjsports-2012-091155
- Cruz-Ferreira A, Cruz-Ferreira E, Santiago L, Taborda L, Taborda Barata L. Epidemiology of injuries in senior male rugby union sevens: a systematic review. Phys Sportsmed. 2017;45(1):41-48. doi:10.1080/00913847.2017.1248224.
- Best JP, McIntosh AS, Savage TN. Rugby World Cup 2003 injury surveillance project. Br J Sport Med. 2005;39(11):812-817. doi:10.1136/bjsm.2004.016402.
- Fuller C, Taylor A, Molloy M. Epidemiological study of injuries in international rugby sevens. Clin J Sport Med. 2010;20(3):179-184. doi:10.1097/JSM.0b013e3181df1eea.
- Yeomans C, Kenny IC, Cahalan R, et al. The Incidence of Injury in Amateur Male Rugby Union: A Systematic Review and Meta-Analysis. Sport Med. 2018;48(4):837-848. doi:10.1007/s40279-017-0838-4.
- Gardner AJ, Iverson GL, Williams WH, Baker S, Stanwell P. A systematic review and meta-analysis of concussion in rugby union. Sport Med. 2014;44(12):1717-1731. doi:10.1007/s40279-014-0233-3.
- Roberts SP, Trewartha G, England M, Goodison W, Stokes KA. Concussions and Head Injuries in English Community Rugby Union Match Play. Am J Sports Med. 2017;45(2):480-487. doi:10.1177/ 0363546516668296.
- Ross A, Gill NN, Cronin J. The match demands of international rugby sevens. J Sports Sci. 2015;33(10):1035-1041. doi:10.1080/02640414.2014.979858
- Ross A, Gill N, Cronin J. Match analysis and player characteristics in rugby sevens. Sport Med. 2014;44(3):357-367. doi:10.1007/s40279-013-0123-0.
- Higham DG, Pyne DB, Anson JM, Eddy A. Movement patterns in rugby sevens: Effects of tournament level, fatigue and substitute players. J Sci Med Sport. 2012;15(3):277-282. doi:10.1016/j.jsams. 2011.11.256.
- Higham DG, Pyne DB, Anson JM, Hopkins WG, Eddy A. Comparison of activity profiles and physiological demands between international rugby sevens matches and training. J Strengh Cond Res. 2013:1-22. doi:10.1097/JSC.0000000000000215.
- Cruz-Ferreira AM, Cruz-Ferreira EM, Ribeiro P, Santiago L, Taborda-Barata L. Epidemiology of time-loss injuries in senior and under-18 Portuguese male rugby players. J Hum Kinet. 2018;June(62):73-80. doi:10.1515/hukin-2017-0159.
- Cruz-Ferreira AM, Cruz-Ferreira EM, Silva JD, Ferreira RM, Santiago LM, Taborda-Barata L. Epidemiology of injuries in Portuguese senior male rugby union sevens: a cohort prospective study. Phys Sportsmed. 2018;46(2):255-261. doi:10.1080/00913847.2018.1441581.
- Fuller CW, Taylor A, Raftery M. 2016 Rio Olympics: an epidemiological study of the men’s and women’s Rugby-7s tournaments. Br J Sports Med. 2017;Jan 30. p:1-8. doi:10.1136/bjsports-2016-097301.
- Fuller CW, Taylor A, Kemp SPT, Raftery M. Rugby World Cup 2015: World Rugby injury surveillance study. Br J Sports Med. 2017;51(1):51-57. doi:10.1136/bjsports-2016-096275.
- Lopez VJ, Ma R, Weinstein MG, et al. Concussive Injuries in Rugby 7s: An American Experience and Current Review. Med Sci Sports Exerc. 2016;48(7):1320-1330. doi:10.1249/MSS.0000000000000892.
- Jacques JP, Rodrigues JC, Cruz-Ferreira AM. ACTIVATE – Programa de prevenção de lesões da World Rugby. Revi Fisio Desportiva. 2022;12(12): 14-15