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Objectives: To determine the rates, severity and burden of knee injuries in professional male rugby union from the English Premiership., Methods: Injury and exposure data were captured over 20 seasons using a prospective cohort design. Knee injury incidence, days' absence and burden were recorded for each injury type and by pitch surface type for match and training., Results: The rate of knee injury in matches was 9.8/1000 hours (95% CIs 9.3-10.3). Mean days lost were 50 (95% CI 46 to 53) in matches and 51 (95% CI 44 to 57) in training. In matches, medial collateral ligament injuries were the most common, while anterior cruciate ligament (ACL) injuries had the highest mean severity and burden. There was no significant change in the count of knee injuries over time; however, average severity increased significantly (annual change: 2.18 days (95% CI 1.60 to 2.77); p<0.001). The incidence of match knee injury was 44% higher on artificial pitches than grass pitches (incidence rate ratio: 1.44 (95% CI 1.21 to 1.69); p<0.01), with no significant difference in severity between surfaces. In matches, the tackle was the event most commonly associated with knee injuries for all diagnoses, except ACL injuries (running). In training, running was a more common injury event than the tackle., Conclusion: Knee injuries in matches are common and severe in English professional men's rugby union. Despite an increased focus on player conditioning and injury prevention throughout the study period, rates of knee injury remained stable, and resulting days' absence increased. New strategies for the prevention of knee injuries should be considered a priority., Competing Interests: Competing interests: SWW holds grant funding from the World Rugby; SH PhD funding from the Rugby Football Union (RFU). MC is employed by the Premier Rugby Limited. SPTK is employed by the RFU. KAS is employed by the RFU. AMW is a shareholder in the Innovate Orthopaedics and DocComs start-ups. AMW receives lecturing fees, research support and part funding of a clinical fellow from Smith and Nephew. AMW is an editorial board member of the AJSM and is a member of the board of directors of ISAKOS. SW has received funding from the World Rugby and the RFU/Premiership Rugby., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This review and meta-analysis aimed to describe the current rugby-7s injury epidemiological literature by examining injury data from both sexes, all levels of play, and their associated risk factors. Studies published up until March 2024 were included. These studies were retrieved from six databases using search terms related to rugby-7s or sevens, tackle, collision, collision sport, injury, athlete, incidence rate, mechanism, and risk factor. Only peer-reviewed original studies using prospective or retrospective cohort designs with a clearly defined rugby-7s sample were considered. Included studies needed to report one injury outcome variable. Non-English and qualitative studies; reviews, conference papers, and abstracts were excluded. Twenty studies were included. The meta-analysis used the DerSimonian-Laird continuous random-effects method to calculate the pooled estimated means and 95% confidence interval. The estimated mean injury incidence rate for men was 108.5/1000 player-hours (95% CI: 85.9-131.0) and 76.1/1000 player-hours (95% CI: 48.7-103.5) for women. The estimated mean severity for men was 33.9 days (95% CI: 20.7-47.0) and 44.2 days (95% CI: 32.1-56.3) for women. Significantly more match injuries occurred in the second half of matches, were acute, located at the lower limb, diagnosed as joint/ligament, and resulted from being tackled. Fatigue, player fitness, and previous injuries were associated with an increased risk of injury. There were no statistically significant differences between women's and men's injury profiles. However, the inherent cultural and gendered factors which divide the two sports should not be ignored. The findings from this review will help pave the way forward beyond the foundational stages of injury prevention research in rugby-7s., (© 2024 The Author(s). European Journal of Sport Science published by Wiley‐VCH GmbH on behalf of European College of Sport Science.)

Objectives: The aim of this study was to compare the incidence, severity, and burden of injury in starting and replacement players from professional men's teams of five rugby unions., Methods: Match injuries of greater than 24 h time-loss (including data on the severity, match quarter, event, body region) and player minutes of match exposure data were collated for all starting and replacement players in the men's English Premiership, Welsh Pro14 (both 2016/17-2018/19 seasons), and Australian, New Zealand, and South African Super Rugby (all 2016-2018 seasons) teams. Injury incidences and mean injury burden (incidence × days missed) were calculated, and rate ratios (RRs) (95% confidence intervals [CIs]) were used to compare injury incidence and burden between starting (reference group) and replacement players., Results: Overall injury incidence was not different between starters and replacements for all injuries (RR = 0.98, 95% CI 0.88-1.10), nor for concussions (RR = 0.85; 95% CI 0.66-1.11). Mean injury burden was higher for replacement players (RR = 1.31, 95% CI 1.17-1.46). Replacement injury incidence was lower than the starters in the third (RR = 0.68, 95% CI 0.51-0.92) and fourth (RR = 0.78, 95% CI 0.67-0.92) match quarters. Injury incidence was not different between starters and replacements for any match event or body region, but compared with starters, replacements' injury burden was higher in lower limbs (RR = 1.24, 95% CI 1.05-1.46) and in the tackled player (RR = 1.30, 95% CI 1.01-1.66)., Conclusion: This study demonstrated a lower injury incidence in replacement players compared with starters in the second half of matches, with a higher injury burden for replacement players due to higher mean injury severity., (© 2024. The Author(s).)

The tackle contest is the most common and most injurious match contact event in rugby and is an indicator of performance. Tackle Ready is World Rugby's tackle technique education program. Limited research has characterized the tackle contest in women's rugby. The purpose of this study is to: (1) identify the match situational characteristics, ball-carrier and tackler technical actions demonstrated in elite women's Rugby Union and (2) to determine the extent to which Tackle Ready recommended tackle techniques were exhibited. Technical characteristics for 1500 tackle events in the 2022-2023 Women's Six Nations Championship were visually assessed according to a predefined coding framework and the Tackle Ready program. Tackles lacked full completion (0.2%) of the 22 coded Tackle Ready techniques with 47% of the recommended techniques demonstrated in each tackle on average (range 15%-98%). A high proportion of tackles involved two defenders (48%), approaching ball-carriers from the side (38%) or oblique angles (39%), in an upright position (30%), and with initial contact made with the arm (51%). Incorrect pre-contact head positioning and head placement upon contact accounted for 50% and 15% of tackles, respectively, and there was a mean of 14 (95% CI 11-18) head and neck contacts to a tackler and 18 (95% CI 14-22) head and neck contacts to a ball-carrier per game. Targeted interventions to encourage adoption of recommended techniques are needed to reduce tackle-related injury risk in women's rugby. This study provides valuable context for future discussion across law enforcement, coach education and gender-specific tackle coaching in the women's game., (© 2024 The Authors. European Journal of Sport Science published by Wiley‐VCH GmbH on behalf of European College of Sport Science.)

Background: Rugby Union is a collision team sport played globally. Despite this, significant concerns have been raised regarding the sport's safety, particularly in youth players. Given this, a review of injury rates, risk factors and prevention strategies is required across different youth age groups as well as in males and females., Objective: The objective of this systematic review (SR) and meta-analysis was to investigate injury and concussion rates, risk factors and primary prevention strategies in youth rugby., Methods: To be included, studies were required to report either rates, risk factors or prevention strategies in youth rugby and to have a randomised controlled trial, quasi-experimental, cohort, case control, or ecological study design. Exclusion criteria included non-peer-reviewed grey literature, conference abstracts, case studies, previous systematic reviews and studies not written in English. Nine databases were searched. The full search strategy and list of sources are available and pre-registered on PROSPERO (Ref: CRD42020208343). Each study was assessed for risk of bias using the Downs and Black quality assessment tool. Meta-analyses were conducted using a DerSimonian Laird random effect model for each age group and sex., Results: Sixty-nine studies were included in this SR. The match injury rates (using a 24-h time-loss definition) were 40.2/1000 match hours (95% CI 13.9-66.5) in males and 69.0/1000 match hours (95% CI 46.8-91.2) in females. Concussion rates were 6.2/1000 player-hours (95% CI 5.0-7.4) for males and 33.9/1000 player-hours (95% CI: 24.1-43.7) for females. The most common injury site was lower extremity (males) and the head/neck (females). The most common injury type was ligament sprain (males) and concussion (females). The tackle was the most common event associated with injury in matches (55% male, 71% females). Median time loss was 21 days for males and 17 days for females. Twenty-three risk factors were reported. The risk factors with the strongest evidence were higher levels of play and increasing age. Primary injury prevention strategies were the focus of only eight studies and included law changes (n = 2), equipment (n = 4), education (n = 1) and training (n = 1). The prevention strategy with the most promising evidence was neuromuscular training. The primary limitations included a broad range of injury definitions (n = 9) and rate denominators (n = 11) used, as well as a limited number of studies which could be included in the meta-analysis for females (n = 2)., Conclusion: A focus on high-quality risk factor and primary prevention evaluation should be considered in future studies. Targeting primary prevention and stakeholder education remain key strategies in the prevention, recognition and management of injuries and concussions in youth rugby., (© 2023. The Author(s).)

Objectives: To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and/or head impact risk., Design: This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Data Sources: Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review., Eligibility Criteria: Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English., Results: In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies., Conclusions: Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC., Prospero Registration Number: CRD42019152982., Competing Interests: Competing interests: PE: Data consultant to the National Hockey League. Received an honorarium for the administrative aspects of the concussion consensus review. JMG: No conflicts of interest. ATK: Research funding for PhD received from Canadian Institutes of Health Research and University of Calgary Eyes High Doctoral Recruitment Scholarship. Youth Council Member for the Canadian Institutes of Health Research Institute of Human Development, Child, and Youth Health’s. MPP: No conflicts of interest. SWW: Research funding received from World Rugby. SBailey: PhD Research was funded by Scottish Rugby, the national governing body for rugby union in Scotland. LM: No conflicts of interest. AMB: Peer-reviewed research funding from the Social Sciences and Humanities Research Council, Sport Information Resource Center board member, Canadian Athletic Therapists Association committee member. Received an honorarium for the administrative aspects of the concussion consensus reviews. SBroglio: Research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense-USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex and EA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medicolegal litigation, and received speaker honorarium and travel reimbursements for talks given. He is coauthor of 'Biomechanics of Injury (3rd edition)' and has a patent pending on 'Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source' (US Application No. 17/164490). He is on the and is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present), British Journal of Sports Medicine (2008 to 2019). GAD: Member of the Scientific Committee of the 6th International Consensus Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF and FIFA; however, has not received any payment, research funding, or other monies from these groups other than for travel costs. BEH: No conflicts of interest. JDS: No conflicts of interest. KAS: Employed (part-time) by the Rugby Football Union, the national governing body for rugby union in England. Research funding received from World Rugby, Rugby Football Union, Premiership Rugby, Football Association Premier League, England and Wales Cricket Board, and British Racing Foundation. MT: No conflicts of interest. RT: Employed as a consultant by World Rugby, the body that regulates the sport of Rugby Union globally. The role includes research into prevention of concussion through various interventions. NW: International Paralympic Committee Medical Committee. RZ: Current or past competitively funded research grants from Canadian Institutes of Health Research (CIHR), National Institutes of Health (NIH), Health Canada, Ontario Neurotrauma Foundation (ONF), Ontario Ministry of Health, Physician Services Incorporated (PSI) Foundation, CHEO Foundation, University of Ottawa Brain and Mind Research Institute, Ontario Brain Institute (OBI), and Ontario SPOR Support Unit (OSSU), and the National Football League (NFL) Scientific Advisory Board. I hold Clinical Research Chair in Pediatric Concussion from University of Ottawa, and I am on the concussion advisory board for Parachute Canada (a non-profit injury prevention charity). I am the cofounder, Scientific Director, and a minority shareholder in 360 Concussion Care (an interdisciplinary concussion clinic). AH: No conflicts of interest. KAS: Kathryn Schneider has received grant funding from the Canadian Institutes of Health Research, National Football League Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary) with funds paid to her institution and not to her personally. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is coordinating the writing of the systematic reviews that will inform the 6th International Consensus on Concussion in Sport, for which she has received an educational grant to assist with the administrative costs associated with the writing of the reviews. She is a member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid positions). CE: Carolyn Emery has received external peer-reviewed research funding from Canadian Institutes of Health Research, Canada Foundation for Innovation, International Olympic Committee Medical and Scientific Committee, National Football League Play Smart Play Safe Program, and World Rugby. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is an external advisory board member for HitIQ., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To investigate the influence of previous season match exposure on injury incidence and burden in elite men's rugby union., Design: A three-season (2016-17 to 2018-19) retrospective cohort design was used to collect and analyse injury and exposure data across English Premiership rugby union teams., Methods: Generalised linear mixed-effects models were used to model the influence of match exposure (all match involvements, match involvements of ≥20 mins, and full-game equivalents) upon match and training injury incidence and burden in the following season., Results: Involvement in ≥31 matches within a season was associated with substantially increased match and training injury burden in the following season. Match exposure was not clearly associated with injury incidence in the following season. The increased match injury burden associated with higher match involvements appeared to be driven by an increased risk for older (>26 y) Forwards, whilst the increased training injury burden associated with higher match involvements appeared to be driven by an increased risk for older (>26 y) Backs., Conclusions: The present study demonstrates that all match involvements, regardless of duration, should be considered when exploring associations between match exposure and injury risk. High match involvements (≥ 31 matches) are associated with elevated injury burden, in both matches and training, in the following season. The physical and psychological load of players with high previous-season match exposure should be carefully managed., Competing Interests: Declaration of Interest Statement Richard Bryan and Mark Lambert are employed by the Rugby Players Association. Matthew Cross is employed by Premier Rugby Limited. Simon Kemp and Keith A. Stokes are employed by the Rugby Football Union, the governing body for rugby union in England. Sean Williams has received research funding from the Rugby Football Union and Rugby Players Association., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The use of artificial playing surfaces in professional rugby union is growing, but their effect on the injury risk profile remains unclear. The aim of this study was to examine the effect of playing surface on match injury risk in men's professional rugby in England. Six seasons of injury data (2013/14-2018/19) were collected from 15 professional English, men's rugby teams participating in domestic and European competition. The incidence, severity, and burden of match injuries were compared across playing surfaces. The dataset included 3351 injuries from a combined European and domestic data set (separated in to 2 categories; artificial and natural/hybrid surfaces) and 2675 injuries from a domestic only dataset (separated into 3 categories; artificial, hybrid, and natural surfaces). There were no differences in incidence rates between surface types on combined European and domestic match data, but injury burden was significantly greater on artificial (3082 days/1000 h, 95% CI 2847-3337) in comparison with natural/hybrid surfaces (2364 days/1000 h, 95% CI 2277-2454, p < 0.001). These differences were primarily driven by a significantly greater mean severity of hip/groin, and foot/toe injuries on artificial surfaces. This is the largest study to date to examine the relationship between surface type and injury risk in rugby union. The average severity and burden of injuries sustained on artificial surfaces was significantly greater compared with those sustained on hybrid/natural grass surfaces. This study can inform those involved in selection of surface for elite sport, weighing up the positive and negative elements of the varying surface types., (© 2022 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.)

Objectives: The objective of this study was to identify and report the incidence and mechanisms of suspected injury and concussion in women's rugby union., Design: A cross-sectional video analysis study., Methods: Using video analysis of non-professional, single-angle footage, cases of suspected injury and concussion were identified and reported, based on content validation and consensus by eight rugby-specific researchers, therapists, and sport medicine physicians., Results: There were 225 suspected injuries recorded in 48 games [Suspected injury rate (IR) = 117.5/1000 h (95 % CI;102.6-133.9) or 4.7 suspected injuries per match]. The on-field medical attention IR was 95.0/1000 h (95 % CI;81.7-109.9: 3.8 per game). Suspected concussions accounted for 26 % of injuries (30.8/1000 h: 95 % CI;23.5-39.7: 1.2 per game). The attacking team sustained 64 % of suspected injuries. Permanent removal from play was observed for 29 % of suspected injuries. The most common suspected injury locations were head/neck (28.4 %) and lower extremity (27.6 %). The tackle accounted for 67.1 % of all suspected injuries, with a propensity of 11.2/1000 tackle events (95 % CI;9.5-13.2) or 3.1 tackle-related injuries/game. Of tackle-related injuries, 63.6 % were to the ball carrier while 52.2 % of tackle-related concussions were to the ball carrier., Conclusion: This study adds to the growing body of literature examining women's rugby. The rate of suspected injury is high compared with other studies. It is acknowledged that these are suspected injuries not supported by prospective injury surveillance. The high proportion of suspected injuries that are tackle-related warrants specific attention to identify tackle characteristics associated with injury and concussion., (Copyright © 2022 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Objectives: To describe injury and concussion rates and mechanisms in female high school rugby players., Design: Two-year prospective cohort study., Setting: High school rugby., Participants: Participants included 214 female High school rugby players (year 1) and 207 female High school players (year 2) from the Calgary Senior High School Athletics Association 2018 and 2019 rugby competition., Intervention: None., Main Outcome Measures: Match and training injury and concussion. Injury definition included any injury resulting in time loss, inability to complete a session, and/or requiring medical attention. Details of reported injuries were collected on injury report forms and validated by a certified athletic therapist on a validated online injury surveillance platform. Exposure hours for players were tracked using paper or virtual weekly exposure forms by team designates., Results: A match incidence rate (IR) = 93.7 injuries/1000 match hours (95% confidence intervals (CI): 78.6-11.7) and training IR = 5.3 injuries/1000 training hours (95% CI: 4.0-6.9) were estimated. The tackle accounted for 109 (70%) match and 37 (44%) training injuries. Tackling was the most frequent mechanism of injury (IR = 37.5 injuries/1000 match hours, 95% CI: 27.5-51.8 and 1.2 injuries/1000 training hours, 95% CI: 0.7-2.4). Sixty-two match concussions (IR = 37.5 concussions/1000 match hours, 95% CI: 26.8-52.3) and 16 training concussions (IR = 1.0 concussions/1000 training hours, 95% CI: 0.7-1.4) occurred. Of 78 reported concussions, 78% for match and 56% for training were physician diagnosed. Tackling was the most frequent mechanism of concussion in matches (IR = 18.1 concussions/1000 match hours, 95% CI:11.4-28.6)., Conclusions: Injury and concussion rates in female high school rugby are high. The tackle accounted for the highest proportion of injuries. Prevention strategies (eg, tackle policy change, tackle-training programs, and neuromuscular training) should be explored to increase sport safety., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Concussion is the most common match injury in rugby union. Some players wear padded headgear, but whether this protects against concussion is unclear. In professional male rugby union players, we examined: (i) the association between the use of headgear and match concussion injury incidence, and (ii) whether wearing headgear influenced time to return to play following concussion. Using a nested case-control within a cohort study, four seasons (2013-2017) of injury data from 1117 players at the highest level of rugby union in England were included. Cases were physician-diagnosed concussion injuries. Controls were other contact injuries (excluding all head injuries). We determined headgear use by viewing video footage. Sixteen percent of cases and controls wore headgear. Headgear use had no significant effect on concussion injury incidence (adjusted odds ratio=1.05, 95% CI: 0.71-1.56). Median number of days absent for concussion whilst wearing headgear was 8 days, compared with 7 days without headgear. Having sustained a concussion in the current or previous season increased the odds of concussion more than four-fold (odds ratio=4.55, 95% CI: 3.77-5.49). Wearing headgear was not associated with lower odds of concussions or a reduced number of days' absence following a concussion., Competing Interests: KAS and STPK are employees of the Rugby Football Union, which is the governing body for rugby union in England. MJC is employed by Premiership Rugby, the body responsible for the highest-level rugby union competition in England., (Thieme. All rights reserved.)

Aim: To describe trends in the incidence of match concussions and time to return-to-play in professional rugby union., Methods: Match concussion incidence (injuries per 1000 player-match-hours) and time to return-to-play (mean and median days absence) were recorded in 3006 male professional rugby union players over 16 seasons (2002/03 - 2018/19)., Results: From 2002/03 to 2009/10, incidence of concussions was stable at 4.3/1000 player-match-hours. From 2009/10 to 2018/19, there was an increase in concussion incidence, with the highest incidence in 2016/17 at 20.9/1000 player-match-hours (95% CI: 17.9-24.3). Annual prevalence of concussion also increased, suggesting more players were concussed rather than the same players sustaining more concussions. Before the introduction of standardized graduated return-to-play (GRTP) guidelines in 2011, 27% of players returned to play in <6 days. After the introduction of the GRTP, this decreased to 7%, with no players returning in <6 days after 2014/15. Between 2002/03 and 2018/19, incidence of all other injuries remained stable., Conclusions: From 2009/10 onwards, the incidence of diagnosed concussions increased. Since the introduction of the GRTP, there has been a dramatic reduction in the number of players returning in <6 days.

Objectives: The Professional Rugby Injury Surveillance Project is the largest and longest running rugby union injury surveillance project globally and focuses on the highest level of rugby in England., Methods: We examined match injuries in professional men's rugby over the period 2002/2003 to 2018/2019 and described trends in injuries over this time., Results: Over the period 2002/2003-2018/2019, 10 851 injuries occurred in 1 24 952 hours of match play, equating to a mean of 57 injuries per club per season and one injury per team per match. The mean incidence, severity (days absence) and burden (days absence/1000 hours) of injury were 87/1000 hours (95% CI 82 to 92), 25 days (95% CI 22 to 28) and 2178 days/1000 hours (95% CI 1872 to 2484), respectively. The tackle accounted for 43% injuries with running the second most common activity during injury (12%). The most common injury location was the head/face with an incidence of 11.3/1000 hours, while the location with the highest overall burden was the knee (11.1 days/1000 hours). Long-term trends demonstrated stable injury incidence and proportion of injured players, but an increase in the mean and median severity of injuries. Concussion incidence, severity and burden increased from the 2009/2010 season onwards and from 2011 to 2019 concussion was the most common injury., Conclusion: The rise in overall injury severity and concussion incidence are the most significant findings from this work and demonstrate the need for continued efforts to reduce concussion risk as well as a greater understanding of changes in injury severity over time., Competing Interests: Competing interests: SK and KAS are employed by the Rugby Football Union. MC is employed by Premier Rugby., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Training load monitoring has grown in recent years with the acute:chronic workload ratio (ACWR) widely used to aggregate data to inform decision-making on injury risk. Several methods have been described to calculate the ACWR and numerous methodological issues have been raised. Therefore, this study examined the relationship between the ACWR and injury in a sample of 696 players from 13 professional rugby clubs over two seasons for 1718 injuries of all types and a further analysis of 383 soft tissue injuries specifically. Of the 192 comparisons undertaken for both injury groups, 40% (all injury) and 31% (soft tissue injury) were significant. Furthermore, there appeared to be no calculation method that consistently demonstrated a relationship with injury. Some calculation methods supported previous work for a "sweet spot" in injury risk, while a substantial number of methods displayed no such relationship. This study is the largest to date to have investigated the relationship between the ACWR and injury risk and demonstrates that there appears to be no consistent association between the two. This suggests that alternative methods of training load aggregation may provide more useful information, but these should be considered in the wider context of other established risk factors., Competing Interests: SK and KS are employed by the Rugby Football Union, the national governing body for rugby union in England. MC is employed by Premiership Rugby, the body responsible for the highest league of rugby union in England. The research was funded by the Rugby Football Union and Premiership Rugby., (Thieme. All rights reserved.)

Context: Individual and team injury burden and performance are 2 key considerations facing practitioners in the daily prescription of an athlete's training load. Whereas a considerable number of researchers have examined univariate relationships between training load and performance, training load and injury, or injury and performance, few investigators have examined all 3 concurrently., Objective: To assess the association among training load, injury burden, and performance in professional rugby union., Design: Descriptive epidemiology study., Setting: The English Premiership competition., Patients or Other Participants: Individual injury and training load data, as well as team performance data, were captured during the 2015-2016 (n = 433 players) and 2016-2017 (n = 569 players) seasons., Main Outcome Measure(s): Data were aggregated into team average scores for each week, including weekly (acute) load, smoothed chronic load, changes in load, injury burden, and weekly performance. Linear mixed modelling techniques were used to assess the association among measures., Results: Injury burden was negatively associated with performance, with a high weekly burden associated with a likely harmful (P = .01) decrease in performance. Training load measures displayed only trivial associations with performance. Only the acute:chronic workload ratio measure was clearly associated with injury burden, with a possibly harmful effect (P = .02). Both squad size and player availability were associated with only trivial changes in performance., Conclusions: Whereas no association between average training load and performance existed, associations between training load and injury burden and between injury burden and performance were clear. Further investigation using more sensitive and individualized measures of load, performance, and injury may elicit a clearer relationship and should be considered for future work., (© by the National Athletic Trainers' Association, Inc.)

Rugby union is a popular team sport that demands high levels of physical fitness and skill. The study aim was to examine trends in training volume and its impact on injury incidence, severity and burden over an 11-season period in English professional rugby. Data were recorded from 2007/08 through 2017/18, capturing 1,501,606 h of training exposure and 3,782 training injuries. Players completed, on average, 6 h 48 minutes of weekly training (95% CI: 6 h 30 mins to 7 h 6 mins): this value remained stable over the 11 seasons. The mean incidence of training-related injuries was 2.6/1000 player-hours (95% CI: 2.4 to 2.8) with a mean severity rising from 17 days in 2007/08 to 37 days in 2017/18 (Change/season = 1.773, P < 0.01). Rate of change in severity was dependent on training type, with conditioning (non-gym-based) responsible for the greatest increase (2.4 days/injury/season). As a result of increasing severity, injury burden rose from 51 days absence/1000 player-hours in 2007/08 to 106 days' absence/1000 player-hours in 2017/18. Despite the low incidence of injury in training compared to match-play, training accounted for 34% of all injuries. Future assessments of training intensity may lead to a greater understanding of the rise in injury severity.