Rugby Science Update 8

Professional male rugby union players’ perceived psychological recovery and physical regeneration during the off-season

The aim of this study was to explain the phenomenon of psychological recovery and physical regeneration of male professional rugby union players during the off-season. The study used a qualitative approach to gather the beliefs and experiences of players regarding their mental and physical health and well-being across the off-season period and identify the psychological and physical strategies adopted to recover and regenerate in preparation for the upcoming season. The study interviewed 34 male professional players, and found that the off-season is characterised by three phases that players undergo to preserve their mental and physical health and well-being to recover from the previous season and regenerate in preparation for the upcoming season. These include decompression from previous season, cognitive detachment from the rugby environment and preparation for preseason. Successful progression through all three phases appears to be influenced by variables including the work and life demands a player is encountering at the time, contextual factors such as their health status (ie, currently injured or ill), and their level of experience in the sport (eg, previous experiences of the off-season). The authors recommend players should receive sufficient time (5–6 weeks) in the off-season to progress through the phases of recovery and regeneration to prepare for the upcoming season, with consideration for the impact of work and life demands, contextual factors and experience levels. Also, education should be provided to all stakeholders regarding the importance of the off-season period for well-being (recovery and regeneration), together with strategies that can be used to enhance the quality of this process (ie, physically distancing from work environment to support cognitive detachment from rugby, engaging in development activities that nourish holistic identity and personal skill development). Clinicians should also support, where appropriate, player subgroups at risk of threats to well-being and welfare in the off-season period (long term or recently injured and younger professionals).

This is study is published in BMJ Open Sport & Exercise Medicine and is open access. 

Mellalieu, S. D., Sellars, P., Arnold, R., Williams, S., Campo, M., & Lyons, D. (2023). Professional male rugby union players’ perceived psychological recovery and physical regeneration during the off-season. BMJ Open Sport & Exercise Medicine, 9(1), e001361.

Tackling sport-related concussion: effectiveness of lowering the maximum legal height of the tackle in amateur male rugby – a cross-sectional analytical study

The aim of this study was to investigate the effect of a tackle law variation that reduces the maximum legal tackle height from the line of the shoulder of the ball barrier, to the line of the armpit, on injury, head injury and sport-related concussion (SRC) incidence in amateur community rugby union. The study used a cross-sectional analytical design over the period 2018 (control) and 2019 (intervention) in a South African collegiate student rugby competition – which included 42 teams. Reducing the legal tackle height from the line of the shoulder to the armpit of the ball carrier in community amateur rugby showed a trend towards reducing injuries, head injuries and SRC, however, these injury trends were not statistically different.

This study is published in Injury Prevention and is open access.

Van Tonder, R., Starling, L., Surmon, S., Viviers, P., Kraak, W., Boer, P. H., … & Brown, J. C. (2023). Tackling sport-related concussion: effectiveness of lowering the maximum legal height of the tackle in amateur male rugby–a cross-sectional analytical study. Injury prevention, 29(1), 56-61.

Performance indicators associated with match outcome within the United Rugby Championship

This study had 3 aims  i) identify performance indicators associated with match outcomes in the United Rugby Championship (URC), ii) compare efficacy of isolated data and data relative to opposition in predicting match outcome, and iii) investigate whether reduced performance indicator statistical models can reproduce predictive accuracy. The study analysed 27 performance indicators from 96 matches during the 2020-2021 URC season. Five key performances indicators differentiated between winning and losing in the URC –  kicks from hand, metres made, clean breaks, turnovers conceded and scrum penalties. Kicking was highlighted as a key driver for match success, with the probability of winning higher for a team kicking more than their opposition. Also, team performance data are much more efficient at predicting match outcomes when expressed relative to the opposition’s performance.

This study is published in the Journal of Science and Medicine in Sport and is open access. 

Scott, G. A., Bezodis, N., Waldron, M., Bennett, M., Church, S., Kilduff, L. P., & Brown, M. R. (2023). Performance indicators associated with match outcome within the United Rugby Championship. Journal of Science and Medicine in Sport, 26(1), 63-68.

Rugby Science Update 7

Longitudinal study of six seasons of match injuries in elite female rugby union

The aim of this longitudinal study was to describe the incidence, severity and burden of match injuries in elite adult women’s rugby union. Secondary aims were to describe injuries in different positional groupings (forwards and backs) and to describe the type and location of, and game event responsible for, injuries. The study found the incidence of injury was similar to those previously reported for women’s international match play, while lower than the elite men’s competition. Both the mean and median severity of injury were higher than those reported in elite men’s rugby. Concussion was the most common injury diagnosis, with the incidence of concussion increasing over the study period. The tackle event was associated with the greatest burden of injury, with ‘being tackled’ specifically causing the most injuries and concussions.

The study is published in the British Journal of Sports Medicine.

Starling, L. T., Gabb, N., Williams, S., Kemp, S., & Stokes, K. A. (2022). Longitudinal study of six seasons of match injuries in elite female rugby union. British Journal of Sports Medicine. Online first. 

The relationship between physical characteristics and match collision performance among elite international female rugby union players

The aim of this study was to investigate which combination of anthropometric and physical abilities explained variance in match collision performance, using both effort and performance variables, in international female rugby union matches. The study collected physical performance and anthropometric data from fifty-one international female rugby union players, and analysed collision actions (categorised as “effort” or “performance” variables) from 20 international matches. Among forwards, acceleration momentum, body mass and skinfolds were positively associated with winning collisions and carrying the ball into contact more frequently, whilst tackle frequency was positively associated with relative leg strength and power output. For the backs, the ability to win collisions was positively associated with relative leg power output, and negatively associated with body mass. Tackle frequency was also associated with maximum upper- and lower-body strength.

This study is published in the European Journal of Sport Science. Woodhouse, L. N., Bennett, M., Tallent, J., Patterson, S. D., & Waldron, M. (2022). The relationship between physical characteristics and match collision performance among elite international female rugby union players. European Journal of Sport Science, 1-10.

Lay of the land: narrative synthesis of tackle research in rugby union and rugby sevens

The purpose of this review was to synthesise both injury prevention and performance tackle-related research to provide rugby stakeholders with information on tackle injury epidemiology, including tackle injury risk factors and performance determinants, and to discuss measures that may improve tackle performance while reducing the risk of tackle injuries. Using a systematic review approach, a total of 177 rugby union studies and 13 rugby sevens studies were identified. The review found that the tackle consistently accounted for more than 50% of all injuries in rugby union and rugby sevens, both at the professional level and at the lower levels, with the rate of tackle injuries higher at the professional level (mean 32/1000 player-hours) compared with the lower levels (mean 17/1000 player- hours). Also, the frequencies of injury between the ball carrier and tackler were not largely dissimilar. A player’s tackle actions and technical ability was also highlighted as a major risk factor for injury and a key determinant of performance. While studies have used evidence-based education, or proposed progressive tackle technique training and law changes to modify player tackle actions and technical ability, it was noted that all three modifiers working in unison (as oppose to separately) will have a higher potential at reducing tackle injury risk while enhancing performance. With the guidance of tackle injury and performance studies, as well as stakeholder engagement, experiential and explorative tackle research also has potential to inspire innovative tackle injury prevention and performance strategies.

This is review is published in the BMJ Open Sport & Exercise Medicine and is open access. 

Burger, N., Lambert, M., & Hendricks, S. (2020). Lay of the land: narrative synthesis of tackle research in rugby union and rugby sevens. BMJ open sport & exercise medicine, 6(1), e000645.


Rugby Science Update 6

The role of player mass and contact speed on head kinematics and neck dynamics in rugby union tackling

This study aimed to use multi- body modeling simulations to examine how tackler and ball carrier mass and contact speed affect inertial head kinematics and neck dynamics. Simulations were run by independently varying the ball carrier and tackler mass (from 60 to 110kg) and speed (from 0 to 10 m/s). Peak resultant inertial neck dynamics (force and moment) and head kinematics (linear acceleration, angular acceleration, and angular velocity) were extracted from each simulation. The study found that the greatest inertial head kinematics and neck dynamics were sustained by a lighter player during a tackle with a heavier player, irrespective of their role as a tackler or ball carrier. For contact speed, the greatest inertial head kinematics and neck dynamics sustained by the ball carrier and tackler were when they were both traveling at the highest speed.

This study was published in the Scandinavian Journal of Medicine & Science in Sports

Tierney, G. J., & Tucker, R. (2022). The role of player mass and contact speed on head kinematics and neck dynamics in rugby union tackling. Scandinavian Journal of Medicine & Science in Sports, 32(2), 298-312.

Tackle technique and changes in Playerload™ during a simulated tackle: an exploratory study

The aim of this study was to explore how PlayerLoad™ changes between different levels of tackling technique during a simulated tackle. PlayerLoad™ did not significantly differ between technical score categories at the point of contact. However, during the tackle completion phase, tackles within the high technical scoring category recorded a higher PlayerLoadTM than low and medium technical scoring tackles. The PlayerLoad™ trace of tackles within the high technical scoring category were also more consistent throughout the tackle. The variability in the PlayerLoad™ trace may be the consequence of players not shortening their steps before contact, reducing their ability to control their movement during the contact and post-contact phase of the tackle. Using the PlayerLoad™ trace in conjunction with technique assessments offers coaches and practitioners insight into the physical-technical relationship of each tackle to optimise tackle skill training, monitoring and match preparation.

This study was published in the Journal of Sports Science and Medicine and free to download. 

Paul, L., Davidow, D., James, G., Ross, T., Lambert, M., Burger, N., … & Hendricks, S. (2022). Tackle Technique and Changes in Playerload™ During a Simulated Tackle: An Exploratory Study. Journal of Sports Science and Medicine, 21(3), 383-393.  

Three-dimensional mechanics of the rugby tackle, does the ball carrier alter their movement into contact in response to the tackler’s position?

The aim of this exploratory study was to identify if, when, and how, the ball carrier modified their motion when being tackled, in response to specific tackle instructions given to the tackler. The ball carrier was observed to modify their behaviour in response to anticipated changes in the tackler’s motion. Specifically, the ball carrier positioned their body at contact using one of two movement strategies: (1) increasing their stability via flexing their trunk, knee, and hips more when entering mid or high trunk tackles; or (2) offload the ball or perform an evasive movement strategy by positioning themselves in a more upright body position when being tackled at a low trunk tackle height. These findings, together with knowledge of tackle injury-risk factors, could inform future coaching interventions for the ball carrier to optimise their performance and mitigate injury risk during the tackle.

This study was published in the International Journal of Sports Science and Coaching and is free to access. 

Edwards, S., Tahu, T., Buchanan, M., Tucker, R., Fuller, G., & Gardner, A. J. (2022). Three-dimensional mechanics of the rugby tackle, does the ball carrier alter their movement into contact in response to the tackler’s position?. International Journal of Sports Science & Coaching, 17(2), 298-308.

Rugby Science Update 5

Activate is a 15–20min warm-up programme, designed to be completed prior to training and matches, with progressive, age-specific programmes. Neuromuscular training programmes such as Activate appear to have a dose–response relationship with injury rates, with three sessions per week providing the greatest preventative effect. The purpose of this study was to assess the effectiveness of Activate to lower match and training injury rates (incidence and burden) in schoolboy rugby union (under-12 to under-19). The secondary aim was to examine the dose–response relationship between weekly Activate adherence and injury incidence.

Individuals adopting Activate had a significantly lower training injury incidence than non-adopters, and lower match incidence and burden. Players completing Activate three times per week had significantly lower training and match incidence compared with those with low (<1 session) weekly adherence. Two-thirds of teams adopted Activate, with most completing Acti- vate three times per week. However, Activate was often not implemented as intended, with teams not using whole phases or failing to progress the programme.

The full text article is free to download in the British Journal of Sports Medicine.

Barden, C., Hancock, M. V., Stokes, K. A., Roberts, S. P., & McKay, C. D. (2022). Effectiveness of the Activate injury prevention exercise programme to prevent injury in schoolboy rugby union. British Journal of Sports Medicine. Online first. 

Physical and Technical Demands and Preparatory Strategies in Female Field Collision Sports: A Scoping Review

Women’s participation in field collision sports is growing worldwide. Scoping reviews provide an overview of scientific literature in a developing area to support practitioners, policy, and research priorities. The aim of this study was to explore the published research and synthesise information on the physical and technical demands and preparation strategies of female field collision sports. 43 studies met the inclusion criteria. Physical demands were the most highly investigated (n=24), followed by technical demands (n-18), tactical considerations (n=8) and preparatory strategies (n=1). The key themes embody a holistic model contributing to both performance and injury prevention outcomes in the context of female field collision sports. Findings suggest a gender data gap across all themes and a low evidence base to inform those preparing female athletes for match demands. Given the physical and technical differences in match-demands the review findings do not support the generalisation of male-derived training data to female athletes.

The full text article is published in the International Journal of Sports Medicine.

Dane, K., Simms, C., Hendricks, S., West, S. W., Griffin, S., Nugent, F. J., … & Wilson, F. (2022). Physical and Technical Demands and Preparatory Strategies in Female Field Collision Sports: A Scoping Review. International Journal of Sports Medicine. Online first. 

Players’, parents’ and staffs’ perceptions of injury prevention exercise programmes in youth rugby union

In youth rugby union, there is a belief that the risk of injury is high and that injuries can be prevented; however, successful implementation of injury prevention exercise programmes in ball sports is limited by barriers such as lack of time, resources and player or staff attitude and motivation. Stakeholders’ attitudes and beliefs regarding injury risk and prevention are important to understand, as they play a role in the adoption of injury prevention exercise programmes. This study aimed to describe staff members’, players’ and parents’ knowledge and perceptions of injury risk, injury severity and injury prevention in youth rugby union in Australia and explore facilitators and barriers to performing an injury prevention exercise programme. Staff, parents and players agree that the risk of injury is high, that injuries can be serious and that preventing injury is important. Allied health staff such as strength and conditioning coaches should be considered a viable alternative to coaches where available, although coaches remain key influencers and leaders in this setting. Barrier themes to performing an injury prevention exercise programme included poor attitude or motivation of the players, limitations related to the programme, poor attitude or motivation of staff, and lack of leadership in implementation of the programme. Facilitators to performing an injury prevention exercise programme included positive behaviour change through the use of structure and routine, strong leadership displayed by coaches and/or administration with the creation of rules or policy, leadership through positive role modelling, positive attitude of the players, and positive attitude of the staff.

This article is open-access in BMJ Open Sport and Exercise Medicine.

Sly, N., Soomro, M., Withall, A. L., Cullen, P., Turner, R. M., & Flahive, S. R. (2022). Players’, parents’ and staffs’ perceptions of injury prevention exercise programmes in youth rugby union. BMJ Open Sport & Exercise Medicine, 8(2), e001271.

    Rugby Science Update 4

    The Return to Sport Clearance Continuum

    The purpose of this article is to explore the concept of Return To Sport (RTS) being part of an evolving continuum rather than the traditional notion that RTS is a single decision made at a discrete point in time. The authors describe a 5 phase continuum – the Return to Sport Clearance Continuum (RTSCC).

    The first phase is the repair phase, where initial healing occurs post surgery. This is where swelling will be minimized, range of motion will be increased, and proper muscle activation will occur. Next will be the rehabilitation and recovery phase, where normal arthrokinematics are going to be restored. Then, the athlete will move to the reconditioning phase, where the focus will be on skill and force development, along with load volume tolerance. The athlete will then progress to the performance phase, where the athlete will transition to full team practice and competition. Finally, they will progress to the preseason/training camp phase, where they will properly be managed for the upcoming season after injury. Throughout the continuum training loads need. to be monitored on a near daily basis when possible, to avoid overloading the healing tissues.

    Full-text article:

    Draovitch, P., Patel, S., Marrone, W., Grundstein, M. J., Grant, R., Virgile, A., … & Jones, K. (2022). The Return-to-Sport Clearance Continuum Is a Novel Approach Toward Return to Sport and Performance for the Professional Athlete. Arthroscopy, sports medicine, and rehabilitation, 4(1), e93-e101.

    Skill Training Periodization in “Specialist” Sports Coaching

    In this paper, the authors propose a skill training periodization framework for “specialist coaches” based on skill training theory. Skill Training can be divided up into coordination training, skill adaptability training and performance training.

    This article is open access and free to download.

    Otte, F. W., Millar, S. K., & Klatt, S. (2019). Skill training periodization in “specialist” sports coaching—an introduction of the “PoST” framework for skill development. Frontiers in Sports and Active Living, 1, 61.

    Strength and conditioning in schools: a strategy to optimise health, fitness and physical activity in youths

    In this editorial, the authors argue that schools are an ideal environment for mass implementation of strength and conditioning interventions to support youth development. The author recommend that schools should aim to systematically incorporate strength and conditioning and wider physical activity into year-round timetables. This could be achieved by employing qualified youth strength and conditioning practitioners, and/or educating and upskilling current staff and stakeholders.

    Full-text article:

    Till, K., Bruce, A., Green, T., Morris, S. J., Boret, S., & Bishop, C. J. (2022). Strength and conditioning in schools: a strategy to optimise health, fitness and physical activity in youths. British Journal of Sports Medicine, 56(9), 479-480.

    Rugby Science Update 3

    A game for all shapes and sizes? Changes in anthropometric and performance measures of elite professional rugby union players 1999–2018

    This study aimed to assess the longitudinal changes in mass, velocity, momentum and peak kinetic energy using two decades of standardised elite and international rugby player data. The study showed that professional players are now leaner, heavier, faster and cover more distance than ever before. When professional rugby players collide, the forces involved have also risen. The implications of these findings however are yet to be fully understood.

    This article is open access and free to download on the journal’s website.

    Bevan, T., Chew, S., Godsland, I., Oliver, N. S., & Hill, N. E. (2022). A game for all shapes and sizes? Changes in anthropometric and performance measures of elite professional rugby union players 1999–2018. BMJ open sport & exercise medicine, 8(1), e001235. 

    Poor isometric neck extension strength as a risk factor for concussion in male professional Rugby Union players

    This study aimed to establish if reduced neck strength was a risk factor for concussion in professional male rugby players. The study identified a specific neck strength range associated with increased concussion rates and found that reduced neck extension strength is a risk factor for concussion in male professional rugby players.

    Farley, T., Barry, E., Sylvester, R., De Medici, A., & Wilson, M. G. (2022). Poor isometric neck extension strength as a risk factor for concussion in male professional Rugby Union players. British journal of sports medicine. Online first. 

    Effectiveness of the Activate injury prevention exercise programme to prevent injury in schoolboy rugby union

    The main aim of this study was to assess the effectiveness of Activate (a 15–20 min warm-up programme) to lower match and training injury rates (incidence and burden) in schoolboy rugby union (under-12 to under-19). A secondary aim was to examine the dose–response relationship between weekly Activate adherence and injury incidence. The study found individuals playing for teams adopting Activate had a lower match and training injury incidence when compared with those not using Activate. Individuals with high weekly Activate adherence (≥3 Activate sessions per week) had a lower match and training injury incidence than those with low adherence (<1 Activate session per week). Therefore, Activate appears effective at lowering injury risk in schoolboy rugby union, with maximum benefit when completing the programme three times per week.

    Barden, C., Hancock, M. V., Stokes, K. A., Roberts, S. P., & McKay, C. D. (2022). Effectiveness of the Activate injury prevention exercise programme to prevent injury in schoolboy rugby union. British Journal of Sports Medicine. Online first. 


    Rugby Science Update 2

    Comparison of Weightlifting, Traditional Resistance Training and Plyometrics on Strength, Power and Speed: A Systematic Review with Meta-Analysis

    This review aimed to explore whether weightlifting resulted in greater improvements in measures of strength, power, speed and change of direction speed compared with traditional resistance training, plyometric training or controls. Findings from 16 studies suggested there are moderate to large benefits of weightlifting for improvements in strength, counter movement jump, squat jump and speed performance when compared with no additional training beyond sports practice or typical physical activities. Whilst improvements in strength were found to be similar following both weightlifting and traditional resistance training, weightlifting may be superior for improvements in weightlifting performance (i.e. load lifted) and counter movement jump height. Factors such as population characteristics or programme design may also influence these outcomes.

    This article is open access and the full article is free to download.

    Morris, S. J., Oliver, J. L., Pedley, J. S., Haff, G. G., & Lloyd, R. S. (2022). Comparison of Weightlifting, Traditional Resistance Training and Plyometrics on Strength, Power and Speed: A Systematic Review with Meta-Analysis. Sports Medicine, 1-22.

    What Learning Environments Help Improve Decision-Making?

    This study attempted to provide a greater understanding of coaches’ perceptions and strategies for specifically developing on-ball decision-making abilities in players. In the paper, the authors were interested in what strategies coaches believe would improve player decision-making, how they would create a learning environment to specifically train decision-making, and how this may influence the on-ball decision-making opportunities for the players.

    The study found coaches are aware of the strategies which may promote decision-making opportunities for players such as the use of questioning, constraints-led pedagogy and using Playing Form rather than Training Form activities. While the data may suggest coaches are aware of potential strategies to promote player decision-making and are attempting to move away from traditional coaching approaches, the findings provide evidence to suggest that coaches still over-coach, with high amounts of instruction and a very stop-start nature to the activity. This coaching practice potentially limits the problem-solving and decision-making demands on players. The findings support researchers who indicate there is still a disconnect between intention and practice, with the application of more effective coaching methods proposed in the research still a challenge to implement for coaches.

    O’Connor, D., Larkin, P., & Williams, A. M. (2017). What learning environments help improve decision-making?. Physical Education and Sport Pedagogy, 22(6), 647-660.

    Characteristics of Complex Systems in Sports Injury Rehabilitation: Examples and Implications for Practice

    This review applies the complex systems approach to return to sport. The paper highlights the characteristics and terminologies of complex systems, using a case of anterior cruciate ligament injury rehabilitation. Alternative forms of scientific inquiry, such as the use of computational and simulation-based techniques, are also discussed—to move the complex systems approach from the theoretical to the practical level.

    This article is open access and the full article is free to download.

    Yung, K. K., Ardern, C. L., Serpiello, F. R., & Robertson, S. (2022). Characteristics of complex systems in sports injury rehabilitation: examples and implications for practice. Sports Medicine-Open, 8(1), 1-15.

    Rugby Science Update 1

    The impact of matches and travel on rugby players’ sleep, wellness and training

    The purpose of this study was to determine the influence of trans-meridian travel and matches on the sleep, wellness, and training of players from four Super Rugby teams during the 2017 Super Rugby season. Travel was associated with substantial sleep deprivation for three of the teams when overseas, which can be explained by travel fatigue, jet lag and a disruption of the normal sleep habit (sleeping in a non-familiar environment and sharing room with a team-mate). The findings of this research suggest that players in four Super Rugby players suffer reduced wellness and an overall sleep deficit when they travel overseas. As trans-meridian travel appears to affect players’ sleep, teams should implement strategies such as melatonin supplementation and light exposure to reduce the effect of jet lag. A correct sleep hygiene could also help players in catching up with the sleep loss they may experience throughout the season and following travel. As there was some evidence of substantial individual responses, teams should carefully monitor the sleep of their players with particular attention to those who sleep more than average, as they may suffer more sleep disruption.

    Lo, M., Aughey, R. J., Hopkins, W. G., Gill, N., & Stewart, A. M. (2022). The impact of matches and travel on rugby players’ sleep, wellness and training. PloS one, 17(2), e0261517.

    Training load, injury burden, and team success in professional rugby union: risk versus reward

    The purpose of this study was to establish whether associations among training load, injury burden, and performance exist within rugby. The study found injury burden was negatively associated with performance, whereas training load measures displayed only trivial associations with performance.

    West, S. W., Williams, S., Kemp, S., Eager, R., Cross, M. J., & Stokes, K. A. (2020). Training load, injury burden, and team success in professional rugby union: Risk versus reward. Journal of athletic training, 55(9), 960-966.

    Physical characteristics of different professional rugby union competition levels

    The purpose of this study was to evaluate whether differences in physical characteristics (running-related and collision-related) derived from microsensor technology exist between four different professional rugby union competition levels. The study found collisions per minute, Collision Load™ per minute and High Metabolic Load Efforts per minute were all higher during International Rugby and European Rugby Champions Cup match-play, when compared to PRO14 and British and Irish Cup match-play. Distance per minute and High-Speed Running distance per minute were lower during International Rugby and European Rugby Champions Cup match-play, when compared with PRO14 and British and Irish Cup match-play. Our data suggest that rugby union players require specific physical preparation for different levels of competition. In particular, players may need specific preparation for higher collision demands at higher levels of competition.

    Tierney, P., Blake, C., & Delahunt, E. (2021). Physical characteristics of different professional rugby union competition levels. Journal of Science and Medicine in Sport, 24(12), 1267-1271.

    Running and Patellofemoral Pain Syndrome: What makes you weak at the knees?

    Patellofemoral Pain Syndrome (PFPS) is a knee condition associated with anterior knee pain when loading the knee in movements like squatting, stair climbing, running and jumping (Ferber et al., 2015). Due to its high prevalence and running becoming an increasingly common form of exercise, it is important that high quality evidence regarding treatment and preventative strategies are made accessible to the public.

    Like most soft tissue injuries, PFPS is also a multifactorial condition involving structural, sensorimotor, somatosensory, psychological, and nociceptive processing changes (Powers et al., 2017). Consequently, a consensus paper was written which outlined the current evidence-based understanding of the complex aetiology of this condition. Figure 1 shows the varied levels of scientific knowledge on the proposed mechanisms of the pathophysiology in PFPS.

    To understand how best to deal with PFPS we are going to look at a question posed by Ferber et al.: what is the best form of exercise when treating PFPS? According to the most recent consensus statement on treatment regarding PFPS, there is an understanding that exercise and multimodal treatment involving knee, hip and core training is the most evidence-based approach when treating PFPS (Crossley et al., 2016). However, until 2015, there had not been research into whether, in isolation, a hip and core or knee protocol is more efficient (Feber et al., 2015).

    Feber et al. (2015) included 199 individuals suffering from PFPS in the USA in a randomised control trial comparing a 6-week knee protocol (Figure 3) to a 6-week hip and core protocol (Figure 2). These programs used functional exercises to progressively overload the participants throughout the 6-weeks. Both protocols produced similar statistically significant increases in maximum isometric knee extension strength (Hip/Core – 8.04% (p<0.05); Knee – 6.37% (p<0.05)) and functional capacity measured by the Anterior Knee Pain Score (Hip/Core – 12.58% (p<0.05); Knee – 12.90% (p<0.05)) post treatment . However, the hip and core protocol had a greater reduction in VAS pain scores after 3-weeks (p<0.05) even though pain scores were equal at 6 weeks. The hip and core also produced greater hip extension (Hip/Core – 11.34%; Knee – 7.13%; p<0.05) and abduction (Hip/Core – 11.46%; Knee – 8.21%; p<0.05) maximal isometric strength post treatment (Feber et al., 2015). Both of these variables are shown to be possible risk factors for PFPS (Figure 1). Therefore, the hip and core protocol may have a greater efficiency when treating PFPS as it targets more risk factors than the knee protocol.

    Six Week Hip and Core – Strengthening Protocol from Feber et al. (2015).

    Six Week Knee Focused Protocol from Feber et al. (2015)

    Therefore, this hip and core exercise protocol, which is time efficient and uses a shotgun approach against the risk factors relating to PFPS, may be a much sort after injury prevention program for runners wanting to avoid future anterior knee pain.


    Crossley, K. M. et al. (2016) ‘2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: Recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions)’, British Journal of Sports Medicine, 50(14), pp. 844–852. doi: 10.1136/bjsports-2016-096268.

    Ferber, R. et al. (2015) ‘Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: A multicenter randomized controlled trial’, Journal of Athletic Training, 50(4), pp. 366–377. doi: 10.4085/1062-6050-49.3.70.

    Powers, C. M. et al. (2017) ‘Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: Part 3’, British Journal of Sports Medicine, 51(24), pp. 1713–1723. doi: 10.1136/bjsports-2017-098717.

    Overuse injuries in basketball: A dribble of sprains and pains

    by Tumelo Lethule 

    Basketball has become one of the most popular sports in the world and has given us the pleasure of gushing over NBA stars such as O’neal, James, Curry and of course, the legendary Jordan. As a non-contact sport, basketball remained one of the safest sports ever played. However, as the sport seems to increase its popularity status; so did the injuries associated with the sport. Injuries most common to basketball are ankle sprains, knee injuries, lower back pains, facial and finger injuries as well as anterior cruciate ligament injuries.

    In comparison with contact and other non-contact sports, basketball has been classified as one of the sports with a higher injury risk of injury and injury incidence [2]. Because basketball is a sport that requires speed, strength and power to accomplish movements such as rebounds and jump-shots, one can presume that players are likely to suffer some injuries when performing these highly dynamic movements [2].

    Weiss, KJ et. al [1] used the Oslo Sports Trauma Research Questionnaire (OSTRQ) to record the onset of overuse injuries for the ankle, knee and lower back in professional male basketball players. The author assessed the prevalence and severity of overuse injuries and also determined the efficacy of the questionnaire over one season. The authors found that severe knee overuse injuries were reported more than ankle and lower back injuries [1], suggesting injury prevention strategies may need to focus on the knee.

    Another study showed the prevalence of injuries in female basketball players (19.5% ankle injuries, 20.6% knee injuries) and in male basketball players (28.4% ankle, 17.5 knee injury) [3] suggesting a higher injury risk in women than men. Zuckerman and his team [4] found that during practice, males had a higher rate of ankle injury compared to females while females have higher rate of overuse knee injuries curing practice. From these findings, one can assume that females are more at risk to knee injuries and male’s ankle injuries.

    While the underlying causes of injuries are yet to be fully understood, some research has emerged to understand how these injuries occur. Ankle sprains may occur as an athlete lands on an opponent’s foot. Overuse knee injuries seem to be caused by overloading and previous injury. Interestingly, knee injuries are seen mostly in centre players than any other positions, suggesting that playing positions may be a risk factor [2].

    The cause of overuse knee injuries and ankle sprains is still a puzzle that seems to have little pieces, at least for now. With that said, through injury surveillance and the identification of injury risk factors and further understanding how injuries occur, better injury prevention strategies can be formulated and implemented. Until then, sprains and pains remain a concern in basketball.


    [1] Weiss, K.J., McGuiren, MR, Besier, T.F., Whatman, CS, 2017. Application of Simple Surveillance Method for Detecting the Prevalence and Impact of Overuse Injuries in Professional Men’s Basketball. The Journal of Strength and Condition Research, 31(10), p2734-2739.

    [2] Cumps, E., Verhagen, E., and Meeusen, R. 2007. Prospective epidemiological study of basketball injuries during one competitive season: Ankle sprains and overuse knee injuries. Journal of Sports Science and Medicine, 6, p204-211.

    [3] Andreoli, C.V., Chiaramonti, B.C., Biruel, E., Pochini, Andre de Castro, Ejnisman, B., Cohen, M., 2018. Epidemiology of sports injuries in basketball: integrative systematic review. BMJ Open Sport Exerc Med

    [4] Zuckerman, SL, Wegner, AM, Roos, KG, et. al. 2018. Injuries sustained in National Collegiate Athletic Association men’s and women’s basketball, 2009/2010-2014/2015. British Journal Sports Medicine, 52: 261-268

    FIFA 11+: An effective way to reduce injuries in amateur soccer players?

    by Aminah Emeran

    Soccer is arguably the most popular sport globally, with an estimated 200 million players worldwide (1). There are many health benefits of playing soccer, including reducing the risk of type 2 diabetes and hypertension (2). Despite its health benefits, soccer also poses a significant risk of injury (3), particularly to areas such as the knee, ankle and thigh (4). These injuries are largely attributed to insufficient warm-ups, muscle fatigue and imbalance (5). A study conducted on the incidence of soccer injuries, showed that 15-20 injuries occurred per 1000 hours of match play, in players above 15 years old (6).

    Because of the high incidence of soccer injuries worldwide, an injury prevention strategy for amateur players was developed in 2006, called the FIFA 11+. The FIFA 11+ comprises of a simple warm-up routine consisting of 15 exercises, that soccer players are to perform for a minimum of 2 times per week. The warmup requires minimal equipment, is available online and can be performed within 10-15 minutes (7).

     The FIFA 11+ prevention programme

    Does the warmup reduce injury risk?

    This question was answered by conducting trials that implemented the FIFA 11+ intervention into real life practice. These trials were then analysed in systematic reviews. The studies selected for review were implemented in a range of locations including North America, Europe, Asia and Africa, and tested male and female amateur players, with ages ranging from 15-45 years (7–10).

    Overall results showed that implementing the FIFA 11+ warm-up for about 2 months, reduced the number of injuries in male and female amateur players between 13 and 25 years, by 30-39%. Studies also showed an improvement in motor and neuromuscular performance such as improved balance, increased quadriceps and muscle strength, speed and agility (7,8,10). The largest reduction in injury risk occurred when players adhered to performing the warm-up correctly. This was achieved with the help of supervision from coaches. Studies where little reduction in injury was seen, could be due to lack of compliance to the intervention and lack of guidance from coaches (7).

    These results sound very promising. However, there are some limitations in the studies analysed. These include a risk of outcome bias that could result from the participants knowing that they were receiving the 11+ intervention, and the researcher knowing what group did and did not perform the intervention (9). Some studies also used different injury definitions, with some not even defining the type of injury analysed (8).

    Despite these limitations, the warm-up has been successfully utilised in other sporting fields, such as basketball. It has also been endorsed by 20 FIFA Member Associations. Thus, given the high prevalence of soccer injuries sustained by amateur players, the FIFA 11+ intervention is recommended to reduce injury risk (7)(9).


    1. FIFA C. FIFA Big Count 2006: 270 million people active in football. FIFA Commun Div Inf Serv. 2007;31:1–12.
    2. Krustrup P, Bangsbo J. Recreational football is effective in the treatment of non-communicable diseases. Br J Sports Med. 2015;49(22):1426–7.
    3. Rahnama N, Reilly T. Injury risk associated with playing actions during competitive soccer. Br J Sport Med [Internet]. 2002;36:354–9. Available from:
    4. Price RJ, Hawkins RD, Hulse MA, Hodson A. The Football Association medical research programme: An audit of injuries in academy youth football. Br J Sports Med. 2004;38(4):466–71.
    5. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: The UEFA injury study. Br J Sports Med. 2011;45(7):553–8.
    6. Faude O, Rößler R, Junge A. Football injuries in children and adolescent players: Are there clues for prevention? Sport Med. 2013;43(9):819–37.
    7. Barengo NC, Meneses-Echávez F, Ramírez-Vélez R, Cohen DD, Tovar G, Correa Bautista JE, et al. The Impact of the FIFA 11+ Training Program on Injury Prevention in Football Players: A Systematic Review. Int J Environ Res Public Heal [Internet]. 2014;11:11. Available from:
    8. Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: A systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med. 2017;51(7):562–71.
    9. Sadigursky D, Braid JA, De Lira DNL, Machado BAB, Carneiro RJF, Colavolpe PO. The FIFA 11+ injury prevention program for soccer players: A systematic review. BMC Sports Sci Med Rehabil. 2017;9(1):1–8.
    10. Bizzini M, Dvorak J. FIFA 11+: An effective programme to prevent football injuries in various player groups worldwide – A narrative review. Br J Sports Med. 2015;49(9):577–9.

    Wimbledon – it’s not all just strawberries and cream

    by Jenna Bloom

    When you’re watching Wimbledon, have you ever wondered how busy the doctors and physiotherapists are behind the scenes?

    Well, McCirde et. al. (2016) wanted to determine the rate of injuries that occurred during Wimbledon, which could assist scientists to eventually develop measures to prevent injuries. (3)

    They study found that there were 700 injuries over the 10 years of Wimbledon (2003 to 2012), with a total of 12 212 sets played. The overall injury rate was 20.7 injuries per 1000 sets played. (3) McCirde et. al. (2016) observed that males had lower injury rates than females despite males playing more sets. (3) However, Sallis et. al. (2001) found that there was no significant difference in injury rate between females and males across seven different sports including tennis. (6) Differences in injury rates between sexes could be due to woman having higher oestrogen levels, more fat, more flexibility and less muscle mass. (5)

    Figure 1 indicates the percentage of each injury type sustained over the 10 years of Wimbledon. This figure shows that there was a large percentage of injuries sustained before Wimbledon, indicating the demanding nature of a professional tennis players’ season. (3)

    As seen in Figure 2 and 3, the most common injuries in both genders were in the shoulder, knee and lumbar spine. Groin, hip, heel and ankle injuries were more common in males than females, who suffered more wrist and foot injuries. From this we can see that in both genders, injuries in the lower extremities were most common. (3)

    Different tennis court surfaces have different properties. For example, on a grass court the ball bounces less and the rallies are shorter. (3) According to Nigg et. al. (1987) playing on various surfaces could be associated with injuries of the lower extremity. They further stated that overuse injuries have become more prevalent since the increased use of artificial surfaces. More research should be done to investigate the association between tennis court surfaces and injuries. (4)

    Research determining injury rates in tennis is extremely limited and often has variable outcomes. It is extremely important to determine injury rates in tennis players as it can improve knowledge regarding player care and can lead to the reduction of injuries. So next time you watch Wimbledon, remember – it’s not all just strawberries and cream!


    1. Dharsaun, A., Dharsaun, A., Patel, N. and Patel, N., 2021. These Are The 5 Best Serve Techniques In The History Of Tennis – Playo. [online] Playo. Available at: <; [Accessed 10 April 2021].
    2. Gordon, A., 2021. Science Explains Why Female Tennis Players Can Serve As Fast As Men. [online] Slate Magazine. Available at: <; [Accessed 10 April 2021].
    3. McCurdie, I., Smith, S., Bell, P. and Batt, M., 2016. Tennis injury data from The Championships, Wimbledon, from 2003 to 2012. British Journal of Sports Medicine, 51(7), pp.607-611.
    4. Nigg, B. and Yeadon, M., 1987. Biomechanical aspects of playing surfaces. Journal of Sports Sciences, 5(2), pp.117-145.
    5. Robert H. Shmerling, M., 2021. The gender gap in sports injuries – Harvard Health Blog. [online] Harvard Health Blog. Available at: <; [Accessed 13 April 2021].
    6. Sallis, R., Jones, K., Sunshine, S., Smith, G. and Simon, L., 2001. Comparing Sports Injuries in Men and Women. International Journal of Sports Medicine, 22(6), pp.420-423.

    The Knee-d to run

    by Shana-Lee Bownes

    Lockdowns that had us all cooped up in our homes for over a month seems to have sparked a greater appreciation for exercise in us all. Who can forget how ironically crowded the Cape Town beach front walkway was on the 1st May 2020 with walking folk and runners eagerly tottering about with mask-concealed smiles.

    Running is arguably one of the most accessible forms of exercise and a popular choice adopted by many trying to stay fit and get outside, especially during the hard lockdown. A survey conducted by De Jong and colleagues (2021) about running during the pandemic found a small but significant  increase in running mileage of 1,4km per week (great) but also a 1,4 times the injury risk compared to before the pandemic (not so great)(DeJong, Fish et al. 2021).

    Here’s the story: We dust off out running shoes and hop on the road. The first few training sessions are rough, but then they get easier and that’s when the bug bites. Suddenly you’re up at 5am on a Saturday for your long run and posting a snap of your coffee #postrunfeels. But that little niggle in your knee that gradually builds up as you run is still there and often when niggles are ignored they have the potential to turn into more serious injuries. When looking at the studies published in running injuries van der Worp and colleagues found that injury was reported between 19,8-25% in men and 79,1-79,5% in women who run (van der Worp, ten Haaf et al. 2015).

    Research on running injury prevention has unfortunately been somewhat inconclusive. Messier and colleagues have undertaken a very important step to improve research in this area by unpacking all of the different factors that contribute to developing running injuries. Over a two year period they followed 300 runners, testing running specific, physical and psychological characteristics. During the study 66% of participants sustained injuries in the two year period. Expressing more negative emotions, being a female and knee stiffness was associated with injury, this is unsurprising considering knee injuries were most commonly reported. Knee stiffness, especially in those weighing 80+ kilos, significantly increased the chances of developing one of those pesky overuse injuries (Messier, Martin et al. 2018).

    So, where to from here? Hopefully with this knowledge we can focus our efforts on discovering the mechanisms by which these risk factors contribute to injury. Hopefully by addressing these risks we can come up with strong preventative measures. Measures will translate well into the running community and when implemented – will protect us against injury.

    Until then in the wise words of Dean Karnazes: “Run when you can, walk if you have to, crawl if you must; just never give up.” (Meuller 2020)


    DeJong, A. F., P. N. Fish and J. Hertel (2021). “Running behaviors, motivations, and injury risk during the COVID-19 pandemic: A survey of 1147 runners.” PLOS ONE 16(2): e0246300.

    Messier, S. P., D. F. Martin, S. L. Mihalko, E. Ip, P. DeVita, D. W. Cannon, M. Love, D. Beringer, S. Saldana, R. E. Fellin and J. F. Seay (2018). “A 2-Year Prospective Cohort Study of Overuse Running Injuries: The Runners and Injury Longitudinal Study (TRAILS).” Am J Sports Med 46(9): 2211-2221.

    Mueller, S (2020). “60 Inspiring and Motivating Running Quotes” [online] Planet of Success. Available at: <; [Accessed 11 April 2021].

    van der Worp, M. P., D. S. ten Haaf, R. van Cingel, A. de Wijer, M. W. Nijhuis-van der Sanden and J. B. Staal (2015). “Injuries in runners; a systematic review on risk factors and sex differences.” PLoS One 10(2): e0114937.

    The Shot Heard Around the World: Achilles Tendon Injuries

    by Ashleigh Thomas

    If you’ve heard or experienced an achilles tendon rupture, you’ll know exactly what the title is alluding to. If you don’t know, an achilles tendon rupturing sounds like a gunshot, and it’s as painful as it sounds. Researcher Gregory Hess, in his 2010 review of “Achilles Tendon Rupture” in the Foot and Ankle Specialist Journal, writes that the number of sporting injuries is increasing with the increase in sport participation. The most common injury; achilles tendon injuries. This begs the questions: how can we avoid them (and the months of no sport participation and gruelling rehab) and who is most vulnerable?

    Schepsis, Jones and Haas (2002) comment that the increase in sport-related achilles tendon injuries as going from 2 to 12 cases per 100 000 in less than 10 years. Typically, this occurs in males during their 4th and 5th decade of life (Schepsis et al., 2002). The injury also appears to occur most commonly in racquet sports such as tennis, squash, and badminton (Schepsis et al., 2002:298). It appears that this injury is the achilles heel of middle-aged male squash players.

    It is important to understand the mechanisms of this injury. Hess (2010) explains that 53% of reported cases are due to the push-off mechanism (off the weight bearing leg with the knee extended). Other mechanisms include unexpected ankle dorsiflexion and violent dorsiflexion of a plantar flexed ankle during running/jumping/agility activities/activities involving eccentric loading/explosive plyometric contractions (Hess, 2010).

    Figure 1: The anatomy of the Achilles Tendon

    The achilles’ structure and function are also pieces of the puzzle. The achilles is an extension of two independently moving muscles, the gastrocnemius and soleus muscles, and it attaches to the posterior heel bone. The tendon is primarily composed of collagen which forms cross-links that allow it to resist high tensile forces (Hess, 2010). Forces stretching the tendon beyond 4% result in some of these cross-links failing and stretching beyond 8% is likely to result in a rupture (Hess, 2010).

    Additionally, defects in the tendon’s structure could result in a rupture as it has a poor nutrient and blood supply (Hess, 2010). A rupture is also likely if degeneration and overloading occur repeatedly over extended periods of time (Hess, 2010). Therefore, it makes sense that the proposed processes for achilles tendon degeneration and rupture are tendinosis and chronic tendinopathy because these conditions cause an imbalance between tendon degeneration and repair (Hess, 2010).

    How can we identify individuals who may be at risk of experiencing such excruciating pain? Through research, a number of intrinsic and extrinsic factors which predispose individuals to sustaining a rupture have been identified. The presence of these can increase the likelihood of a rupture. These factors, as described by Hess (2010), are seen in Figure 2.

    Figure 2: The extrinsic and intrinsic factors predisposing individuals to achilles tendon rupture adapted from Hess (2010).

    Individuals exhibiting these factors should take extra precaution as Hess (2010) writes that a combination of these factors reduce the tensile strength of the tendon and contribute to faulty biomechanics and compensatory mechanisms which can evolve into a tendon rupture. A key factor that Schepsis et al. (2002) emphasizes, and which Hess (2010) agrees with, is the degenerative effect of natural ageing on the tendon resulting from decreased blood flow, decreased collagen tensile strength and increased tissue stiffness (Schepsis et al., 2002). These aging effects reduce the tendon’s ability to handle stress, predisposing it to injury.

    All is not lost; there are things you can do to try to prevent this from happening. A rupture could be prevented by avoiding degenerative changes in the tendon by doing regular physical activity, and by allowing adequate rest following tendon injury (Hess, 2010). Eccentric strengthening of calf muscles has also been linked to prevention of rupture (Hess, 2010). However, we still have many questions to answer before we can say for certain what the best method of prevention is. This also speaks to the gap in this area and research going forward should focus on the implementation and the effectiveness of prevention programs.


    • Hess, G., 2010. Achilles Tendon Rupture. Foot & Ankle Specialist, 3(1), pp.29-32.
    • Schepsis, A., Jones, H. and Haas, A., 2002. Achilles Tendon Disorders in Athletes. The American Journal of Sports Medicine, 30(2), pp.287-305.
    • de. 2021. Achilles tendon – anatomy and importance. [online] Available at: <; [Accessed 9 May 2021].

    Rugby and CTE (Part 2)

    by Ken Quarrie
    I am at the point where I think chronic traumatic encephalopathy (CTE) is a term that isn’t very useful, because people are using it to mean very different things. I think “Sport-related neurodegenerative disease” and “Sport-related dementia” might be better. 

    Neurosurgeon Discuss Concussion Brain Injury CTE Kids Play Football Risk – Corn Nation

    In the above article, I think Dr Samadhani’s comments capture something that is really important – the conflation in the lay understanding of CTE pathology and brain function.In some of the media coverage there almost this “vulture-like” watching for the results of an autopsy, with any behavioural issues or life struggles then attributed to the “CTE” found.

    Is CTE a “progressive neurodegenerative disease?” that develops and spreads through the brain after trauma has finished? Or is it a pathology that, once the insult to the brain has “healed” (to the extent it does) pretty much remains inert? (See Iverson et al. 2019) There have been strong claims by some researchers that CTE is a primary, progressive neuropathology, as per Dr Ann McKee’s description here…

    Case-series studies do not provide a basis for making causal claims. There have been instances in the CTE literature where a discussion point in a paper describing a case-series has subsequently been cited as providing evidence for the assertion in later papers.

    Just like epidemiologists are not pathologists, neither are (most) pathologists experts in study design or epidemiology. I think some of the CTE papers might have stated things very differently had they had epidemiologists on board. Or maybe not? 🤷🏻‍♂‍Prof. Goldstein is here discussing the “profound discordance” the issues and difficulties (young people especially) were having prior to their deaths, and the degree of CTE pathology found at post-mortem.…
    The NIH video cast of the event is worth watching for those with an interest in what is, and is not, known about CTE. Discussions about the importance of Tau versus white matter changes, and much else besides.

    Brand & Finkel ⁦‪provide a useful framework for assessing decisions with respect to CTE. I respectfully disagree with *some* of their assertions and conclusions, but agree with much more than I disagree: See Brand & Finkel 2020

    People say “you don’t want to be on the wrong side of history with this”. Of course I don’t. No-one looks forward to being judged as having acted unwisely, or not having acted “soon enough” to prevent suspected harms.

    I don’t know what the future will hold. To minimise my chances of “being on the wrong side of history” I plan to continue to act according to my best understanding of the evidence, in light of the fact that society’s appetite for, and acceptance of, risk changes over time.

    At present I think the risks of developing CTE have:

    • Been exaggerated with respect to likelihood of outcome
    • Simplified (exclusion or disregard of other factors that may be contributing to poor health post-career)
    • There has also been premature linking of clinical conditions with pathology

    I have yet to see evidence of “lots” of former players presenting with early onset dementia. I sincerely hope I don’t, but if it occurs I would be driving hard for fundamental changes to the permitted activities in rugby. As I did a generation ago with respect to spinal injuries.

    That is not to say that changes in rugby since it became a professional sport might not have increased the risk. Part of a current project in which I am involved is to establish that risk – we are using a similar approach to that used by ⁦‪@WillStewNeuro⁩‬ and colleagues for football.

    There is good evidence that rugby, as a sport, has become more “physical” at the elite level of the sport since it became professional. This “old” paper from Will Hopkins and me shows some of the trends early after the introduction of professionalism. (Quarrie and Hopkins 2007). Players got (much) bigger (and faster) , and there were greater numbers of contact situations per match. More recent work by Schoeman et al. (2017) indicates those trends continued, although Tucker et al. (2021) and colleagues have produced a report that suggests that increases in body mass may now have plateaued.
    In any case, it is clear that since the sport became professional the average size, strength and speed of players has increased dramatically, as has their exposure to contact and high energy collisions. The effects of this have been well-documented in the extraordinary injury surveillance project run by the RFU. (West et al. 2020). Tackles have been identified as the element of play associated with the greatest injury burden in rugby. “Burden” is defined as incidence multiplied by severity. The research was conducted by people who are interested in rugby.

    Identifying that some aspect of an activity is the “most dangerous” does not necessarily imply that it must be removed. This is where comparative risks (across other activities/at different levels of the same activity) need to be considered.

    For what it is worth, I suspect that in cohorts of former high-level rugby players sequelae from musculoskeletal injuries (for example, osteoarthritis) will result in greater DALYs than will cognitive or psychological issues.

    As ⁦‪@WillStewNeuro⁩‬ has said elsewhere, we need to understand both absolute and relative risk to keep things in context. A large increase in relative risk on a very “vanishing small” base rate still yields a very low rate.

    Re-highlighting this important paper from the Lancet last year. It suggests that across the population, traumatic brain injury (across the entire spectrum of severity) accounts for about 3% of the modifiable life risks for the development of dementia. (Livingston et al. 2020)

    Heavy alcohol use, which has been (at least historically) a feature of involvement with participating in New Zealand rugby from the teenage years on, features as a risk. The lack of solid science to date around causal relationships between head injury and CTE is highlighted. (Livingston et al. 2020)

    The lack of solid science to date around causal relationships between head injury and CTE is highlighted.

    “The term chronic traumatic encephalopathy describes sports head injury, which is not yet fully characterised and covers a broad range of neuropathologies and outcomes, with current views largely conjecture.” (Livingston et al. 2020)

    This statement on the strength of the evidence stands in stark contrast to the claims made by various policy advocates and what seems to be widely believed in the media.

    There is an entire body of work underpinning public health interventions in sport – we aren’t just “making this up as we go along”. See, for…

    Many changes to rugby have been made as a result of that work. RugbySmart, BokSmart and other injury prevention programmes have been widely recognised within the sports science/ sports medicine communities as having had positive effects on the risks of injuries. Like many areas of science where the evidence is equivocal, debates often get heated. When the science is settled, there is little to argue about.
    I think people’s values and biases (and *everyone* has them, including me) play a part in how they interpret the evidence. I am happy to engage in good faith on the issues, but will ignore trolls who imply that I am a “shill” or “CTE denier”. I, having had multiple concussions during my rugby playing days, plus depression, would qualify as “possible CTE”. Have I got CTE pathology in my brain? Who knows? If I do, what relation does it bear to my current state? Again, who knows?!!
    The “Traumatic Encephalopathy Syndrome” first proposed by Montenigro et al. (2014) is remarkable in the breadth of conditions it encompasses, and the lack of specificity it entails. With respect to sports people going through tough times following their retirement – this is real, and well-recognised across a range of sports (contact and non-contact). But for former collision sports players these issues *do not necessarily mean* that they have “CTE” and have a one-way ticket to dementia. There are lots of very worried people who have conditions that are iatrogenic. Again, this doesn’t mean that for some the brain injuries they sustained during their sport didn’t contribute to what they are now experiencing, and for some their brain injuries were probably the major contributor.

    Ken Quarrie is the Chief Scientist for NZ Rugby. All views expressed are his own, and do not necessarily represent the position of his employer. The above article was compiled, with permission, from a thread of tweets by @KenQuarrie. For more on the topic, you can follow Ken at @KenQuarrie. You can also view Ken’s publications here – Ken’s Google Scholar Profile. 

    Rugby and CTE

    By Ken Quarrie 

    I have been seeing claims that some people are “sowing doubt” with respect to CTE (Chronic Traumatic Encephalopathy) and are thus acting like tobacco companies did with respect to heart diseases and lung cancer. I want to make a few comments about this. Before I get to the CTE issue, it is worthwhile that I put some background about me on the record, so that people are able to judge whether I am likely to have biases that might sway me to one position or another.

    I was brought up in New Zealand, in a family where rugby was *very* important. Dad played rep rugby for Wanganui and Waikato, and was an All Blacks triallist. As a kid I was a fan and obsessively read books about rugby and the All Blacks. I played the sport from childhood until my late 20’s. I had some really enjoyable times along the way. I also sustained (at least) five concussions. I was immersed in the Otago Uni/Dunedin rugby heavy drinking culture.

    I found that as I got older there were fewer aspects of the “rugby” culture with which I identified – @XTOTL captures some of that here: I also had a good friend injured at the age of 15 in a scrum. He has been in a wheelchair since 1984.

    As well as rugby, as a kid I loved science. I have managed to combine those two loves into a career. I wouldn’t call myself a rugby “fan” anymore. I am a rugby scientist, and it helps to have a little distance from your object of study. Nevertheless, I still work for NZ Rugby (conflict of interest klaxons!). Having worked on independent research studies examining risks for injury in the 1990’s, I took a role with NZ Rugby in 2000 as their first “Injury Prevention Manager”. I realised that, as a scientist, my employment represented a conflict of interest, but I believed I could have a greater impact on improving player safety and welfare from within rugby than from the outside.

    I have been adamant with NZ Rugby and World Rugby that I must be allowed to conduct research without interference about what I can study, how I can analyse it, and what I can say about it. A look at my research outputs will reveal an eclectic mix of rugby studies. So when people “poison the well” by implying that any research funded by or conducted by sports organisations must necessarily be “suspect” I feel personally attacked. Doing good science is what I care about.

    Doing good science is what I care about.

    From a personal level, the welfare of players has, and does, take precedence for me over considerations of “tradition” or “maintaining the essence of the game”. But managing risks does not imply “eliminating all risks”. Reasonable people can look at an issue and disagree about it.

    So – the “tobacco company line”. Tobacco companies systematically downplayed the risks of their products, and attempted to “sow doubt” in the public mind. How is the CTE/concussion debate different? A key difference is that, despite there having been strong claims made about what causes CTE, how it develops, and what clinical outcomes it leads to, the reality is that the science of CTE is very young. There really *is* a lot of doubt about a number of the issues!

    The issues include whether CTE is, as has been claimed by some, a primary, progressive neurodegenerative disease. Questions remain about the cause(s) of the pathology. Questions remain about the “pathognomonic lesion” – i.e. what distinguishes CTE from other pathologies. Questions remain about the prevalence of the pathology. MAJOR questions remain about the relationship between having CTE pathology in the brain and any given clinical outcome. Do I think brain injuries are bad for health? Yes, undoubtably. I also think that the public perception of the strength of the evidence, and the prevalence of CTE as a public health issue doesn’t match the scientific understanding of it *at this point*.

    So to accuse “rugby” as having acted like tobacco companies to sow doubt about CTE is simply a smear, and a lazy and demonstrably false one at that.

    If former rugby players are struggling – for whatever reason – my heart is with them. I pledge to do my best to understand more about the long term health outcomes of playing rugby, so that people can better understand the risks and make informed choices about play. People involved in rugby, like Colin Fuller, @Sharief_H, @drkeithstokes, @drsimonkemp, @mattjcrossie, @Scienceofsport and yours truly and many others have identified and documented risks in rugby via research studies and injury surveillance. Many changes to rugby have been made as a result of that work. RugbySmart, BokSmart and other injury prevention programmes have been widely recognised within the sports science/sports medicine communities as having had positive effects on the risks of injuries. Likewise, the @NZRugbyFound has done great work on tertiary prevention. So to accuse “rugby” as having acted like tobacco companies to sow doubt about CTE is simply a smear, and a lazy and demonstrably false one at that.

    Ken Quarrie is the Chief Scientist for NZ Rugby. All views expressed are his own, and do not necessarily represent the position of his employer. The above article was compiled, with permission, from a thread of tweets by @KenQuarrie. For more on the topic, you can follow Ken at @KenQuarrie. You can also view Ken’s publications here – Ken’s Google Scholar Profile.