South Africa’s (SA’s) unique history in rugby has been long and complex but memorable.
For the months of September and October this year, all rugby fans will turn their attention to watch the Rugby World Cup (RWC) hosted by France, and enjoy several dramatic weeks of international rugby.
The defending champions – SA’s Springboks – will be chasing the success of their 2019 RWC trophy.
The Boks hammered home an emphatic win over England to hoist the winner's trophy in the 2019 RWC final.
PC: SABC Sport
Rugby, founded 200 years ago, is a sport where players - who traditionally wear minimal protective gear - progress an oval ball across the field, to score points by planting it over the opponents’ try line. Players may gain further points from the try by 'converting' it when the ball is kicked through the uprights.
Regular physical contact is an essential part of play and this results in significant forces being transmitted from one individual to another. This predictably leads to frequent, severe and, sometimes, fatal injuries.
In fact, it has been estimated that one in four players sustains an injury every season.
Almost 60% of injuries are sustained during matches, with the rest occurring during practice.
The pattern of rugby injuries varies widely and may be affected by the player’s size, age, player position, phase of play and duration into the competitive season.
A lineout can present danger to both jumpers and supporters
When Do Rugby Injuries Occur?
Most injuries occur early in the game season when players have not been fully conditioned and are still gaining play experience. During a match, the second half usually sees more injuries than the first half.
Rugby has four main phases of play:
- The tackle
- The ruck and maul
- Set pieces (i.e. scrum and lineout)
- Open play
An illegal tackle. Coaches should emphasize good sportsmanship and fair play to prevent injuries.
The Tackle
Tackling during open play is considered one of the riskiest phases of play for injuries, due to the forces generated when a player at speed makes contact with the ground or an opponent.
In general, the player being tackled is twice more likely to be injured than the tackler.
Players with slower momentum during a tackle are more likely to be injured than the faster moving player. This scenario contributes to a third of injuries during this phase of play.
Blind tackles (the tackler outside the field of vision on the player being tackled) contribute to half of the volume of injuries sustained during tackles, with the tackler generally sustaining the injury.
A ruck engaged over a fallen player during a women's rugby match
The Ruck and Maul
When the ball is in possession of a player tackled to the ground, a ruck is engaged by several supporting and opposing players in a bid to retain or gain possession of the ball once the player on the ground releases it. Neck injuries may occur in this phase as the defending players are rucked off the ball.
South Africa delivering a devastating maul masterclass against the then RWC hosts, Japan, in 2019.
Screenshot courtesy of Rugby World Cup
A maul is when several players, on their feet, bind around the ball carrier to oppose a move by the defence to take possession of the ball by holding the ball carrier .
The Scrum
Following a penalty, to restart the game, opposing teams form a tunnel known as a scrum. The teams lock shoulders with their heads low and interlocked, then push back against each other to gain possession of the ball that gets thrown into the scrum.
Springbok Women, engaged in a scrum, breezed past England in an decisive 38-5 victory in London.
PC: SA Rugby
Neck injuries in rugby are generally related to the scrum or ruck.
The referee is responsible for monitoring the safe engagement of both, to diminish the frequency of this type of debilitating injury.
A reduction in the incidence of severe injuries in rugby over the years has been attributed to the increased diligence of match officials, who enforce appropriate engagement of the scrum and correct positioning of players in line outs.
'Bok lock Franco Mostert launched into the air in a hotly contested lineout against England, Cape Town 2021.
PC: Reddit
A lineout, like a scrum, is a means of restarting the game when a ball has gone off the field of play. The ball is returned to play when the thrower tosses the ball between two parallel lines of opposing players.
The lineout consists of supporters who hoist their designated jumpers into the air. The thrower is permitted to call out a code which alerts their teammates of the destination of the throw.
After the ball has been caught, the jumper(s) are safely brought to ground by their supporting teammates.
What Types of Injuries Do Rugby Players Commonly Sustain?
The injuries sustained vary and may depend on player position and the phase of play they are most engaged in.
Overall, soft tissue injuries are the commonest type of rugby injury and include muscle and ligament trauma (tears, hematomas, contusions, etc). Soft tissue injuries also include overuse injuries, like bursitis and tendinits.
Forwards are more involved in set pieces, rucks, and mauls and suffer more head and neck injuries than other players.
Backs dominate open play and sustain more shoulder and arm injuries.
Springbok captain Siya Kolisi recovering after Anterior Cruciate Ligament (ACL) reconstruction surgery in April this year.
PC: SA Rugby Mag
Lower limb injuries
The lower limb has the highest rate of injury, irrespective of player experience. Thigh and knee injuries account for nearly 40% of lower limb injuries.
Knee injuries
Hamstrings and ACL injuries result in the most missed days of play among forwards and backs respectively. Meniscal tears (the stabilizing cartilage within the knee) are usually severe and also result in a significant number of missed days of play.
Upon returning to sport Posterior Cruciate Ligament (PCL) injuries tend to affect high speed running the most.
Ankle injuries
Ankle sprains and leg injuries were the next most frequently sustained injuries.
Research presently supports the use of an external support to reduce the frequency of ankle injuries. A well fitted and sport-appropriate brace is capable of providing support without hindering performance. This can be obtained through an experienced orthotist.
Certain hand injuries in rugby (such as a 'jersey tendon injury' pictured above) may require surgery. Depicted the typical mechanism of injury where the tendon/bony attachment near the tip of the finger is forcefully disrupted.
Upper limb injuries
These account for nearly 20% of all injuries, with a severity comparable to lower limb injuries, in respect of the months needed to recover.
Injuries to the upper limb include both soft tissue trauma (cuts, bruises, sprains, rotator cuff tears) as well as fractures and dislocations (which may result in chronic instability).
Hands, thumbs, fingers and shoulders are commonly injured, with more severe injuries requiring surgery.
Acromioclavicular joint (ACJ) dislocations and shoulder dislocations in rugby are not uncommon.
PC: 7News
ACJ disruptions have not been shown to be career limiting injuries despite their high incidence in professional players. Studies show that players who underwent surgery for higher grade ACJ injuries were able to return to play sooner and were happier with their shoulder function than those who did not.
Protective gear, such as shoulder pads, have unfortunately not been seen to decrease the frequency of severe shoulder injuries.
Head injuries
Ranging from cuts to concussions, this region of the body accounts for nearly 30% of all injuries, likely as a result of contact with other players or with the ground during tackling, rucking and scrumming.
While backs and forwards suffer a similar frequency of head injury, forwards, however, have been shown to sustain more severe injuries through foul play during rucks and mauls.
Soft shell rugby headgear hasn’t been proven to provide benefit. Gum guards, however, have been shown to help prevent jaw, mouth and dental injuries.
Unsightly 'cauliflower ears' are a result of neglected auricular hematomas - i.e. internal bleeding from broken earlobe cartilage.
PC: Mirror
Blunt injuries to the ear may result in cartilage fractures and localised bleeding which, if poorly treated, result in an unsightly deformity known as a ‘cauliflower ear’.
Neck injuries
These are usually the result of extreme cervical spine (c-spine) flexion or hyperextension at the level of the middle to lower neck bones.
Neck injuries usually occur early in the season, due to players lacking physical conditioning, and mostly occur during the scrum and also during tackles.
During play, front row players often experience significant forces in the neck (up to seven times the minimum required to cause fractures and ligament injuries to the neck). Hookers are usually at risk of sustaining about one third of these injuries.
The repetitive trauma experienced during these phases of rugby has been shown to result in a higher rate of c-spine wear and tear in older players.
Pictured left is French lock Walid Maamry - one of the heaviest players currently in the sport - who stands at 6ft. 6 in. and weighs a whopping170kg!
PC: ledauphiné
Who gets affected most by rugby injuries?
Larger players (i.e. those with a higher Body Mass Index [BMI]) have a higher injury rate, due to the larger forces dissipated upon contact with opposing players/the ground.
The high speed tackles that often occur midfield, result in midfield backs sustaining more injuries than forwards. Forwards, on the other hand, sustain a higher frequency and more significant severity of upper limb injuries than backs. Front line players also experience the greatest amount of cervical spine trauma.
A study of injury patterns during the 2003 RWC demonstrated the top three positions associated with the highest frequency of injury were:
- Flanks (who clear up loose balls and begin new phases of play)
- Centres (break through the opposition defence line)
- Number 8s (act as a ‘battering ram’ during rucks)
Other notable positions also at high risk of injury include:
- Hookers (whose role includes keeping the ball moving forward)
- Wings (usually complete tries and are often tackled in those attempts)
- Fullbacks (key defenders)
- Locks (are usually the tallest members of the team and are responsible for jumping during lineouts)
Gum guards are some of the widely used, but limited, protective gear in rugby.
How do we prevent rugby injuries?
Coaches should develop a conditioning program that emphasizes player strength, power, speed, endurance, agility and flexibility.
Strength is the ability to overcome resistance, whereas power is the ability to overcome resistance but in the shortest period of time. Both are important components of fitness in rugby.
Strong players are more likely to recover from injury, so the back, neck, hip and core muscles should be targeted in these training programmes.
Position-specific conditioning is key to helping players withstand the physical demands of their unique playing position in the field.
Endurance is the sustained ability to repeat a physical activity. Building player endurance helps players return to a high level of performance after injury.
Flexibility is the ability of muscles and joints to move through an unrestricted and painless range of movement. Flexibility allows for easier and deeper movements, helps address muscle imbalances and increases strength and stability. Greater flexibility therefore reduces the risk of injury during sport, while improving performance.
Flexibility workouts that address lower limb muscles (such as the hamstrings and hip flexors) and lower limb joints reduce the likelihood of injury.
Additionally, taking time off during the week and between seasons allows players to regain strength and flexibility.
Appropriate use of a foam roller can help improve hamstrings flexibility while addressing sore muscles.
For professional athletes, the practice of 'periodization' reduces the risk of overtraining by varying the intensity and volume of training over a long period in order to reach peak performance around the time of major tournaments during the year. Off-season training may focus on general preparation and building muscle. The preseason focus may build on strength and power development, while in-season training ensures maintenance of levels of conditioning achieved during the off- and pre-season periods.
In particular, resistance training has been shown to be a safe and valuable training tool in the prevention of injury in youth and adolescent athletes. This is particularly when the training programme is properly supervised and designed with safe techniques and in a non-competitive environment.
Sonny Bill Williams of the All Blacks carded for an illegal shoulder tackle to the head and neck of Lions' wing Anthony Watson .
PC: ESPN
Coaches should also address technical aspects of the game - specifically when players tackle, ruck and scrum. Good sportsmanship and fair play should be encouraging by promoting strict adherence to the rules of the game during training and matches. This reduces the risk of injuries and penalties.
Coaches should encourage the use of permitted fitted equipment, such as gum guards, ear guards and ankle guards.
Coaches and players should be unafraid to stop play if an athlete is injured. Playing through pain affects player performance, prolongs the recovery period and increases the risk of further injury.
‘Rest is best’ to manage overuse injuries. Seeking appropriate medical attention, using medication as recommended to manage pain and reconditioning reduces the risk of further injury when players are ready to return to play.
The reason rugby players are referred to as heroes!
PC: SNL
Conclusion
The pace of play in rugby has, over past decades, become faster, with even bigger and better players populating the field.
Granted the limited protective gear and complexity of rugby, position-specific physical conditioning for rugby is important as a tool to avoid injury and improve play.
Insight into these physical demands, and adequate preparation offers the rugby player a competitive advantage and promotes their longevity throughout their athletic career.
Should you sustain an injury, it is best to seek appropriate medical care early in the course of your recovery.
Contact Dr Maina should you need an assessment of your sports injury.
Development rugby in Gauteng, South Africa: building a love to play.
PC: SA Rugby
Dr Anne Maina
Specialist Orthopaedic surgeon
MBBCh (Wits), FC Orth (SA), MMed Ortho (Wits) CIME
References:
1. Micheli L. Injury Prevention Series: Rugby. Boston Children's Hospital Orthopaedic & Sports Medicine. 2013. Accessed: https://www.childrenshospital.org/sites/default/files/2022-03/injury-prevention-rugby.pdf
2. Kaplan KM, Goodwilli A, et al. Rugby injuries. Bulletin of the NYU Hospital. 2008:86-93.
3. Posthumus M, Durandt J. Physical Conditionig For Rugby. Sport Science Institute of South Africa. Boksmart. 2009. Accessed: https://www.springboks.rugby/media/ewvborcf/physical-conditioning-for-rugby-players.pdf
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