England Professional Rugby Injury Surveillance Project · England Professional Rugby Injury...

England Professional Rugby

Injury Surveillance Project

2012-2013 Season Report February 2014

England Professional Rugby Injury Surveillance Project 2012-2013 Season Report England Professional Rugby Injury Surveillance Project 2012-2013 Season Report

England Professional Rugby Injury Surveillance Project 2012-2013 Season Report

• Theoverallrisk(incidenceanddaysabsence)ofmatchandtraininginjuryinthePremiershipremainedstableduringthe2012-13seasonandwaswithinthe“normalrange”ofseasonbyseasonvariationseensincethestudybeganin2002.

• 335traininginjuriesthatledtotimelostfromtrainingand/ormatchplaywerereportedinthe2012-13season.Athirdofallreportedinjuriesoccurredintraining(rugbyskillsandstrengthandconditioningcombined),apotentiallycontrollableenvironment

- Theseverityoftraininginjurieswashigherthantheexpectednormalrangein2012-13.Thisislikelyduetotheincreaseinincidenceofmoreseveretraininginjuriesresultingingreaterthan28daysabsence.

- Theinjuriesthatcontributedmosttothisrisewereinferiortib/fibsyndesmosisinjuries(highanklesprains)andgrade2kneemedialcollateralligamentinjuries(MCL).

- Itishopedthatthepilotstudybeingundertakentocapturetheintensityandloadoftrainingin2013-14anditsrelationshipwithinjurywillallowbettercontextualisationofthischange.

• Aclearassociationbetweeninjuryburdenmeasuresandteamperformancefortheperiod2006-2012wasfoundwithalowerinjuryburdenassociatedwithahigherleaguepointstally.Therewasalsoasignificantinteractionbetweeninjuryburdenandsquadsize,suchthattherelationshipbetweeninjuryburdenandteamperformancedecreasedwitheachadditionalsquadmember.Thesefindingshighlighttheimportantrolethatmedicalandfitnessstaffhaveinreducingtheincidenceofandminimisingthetimelostinjuriesinordertoimproveteamperformancealongwiththeimportanceofanappropriatesquadsize.

• Concussionwas,forthesecondconsecutiveseason,themostcommonPremiershipmatchinjury.Theincidencefor2012-13wasabovetheexpectedvariationforthefirsttimeduringthestudyperiod.Itisthoughtthatthisincreaseiscausedbyanincreasedawarenessofconcussionandthusagreaterfocusandunderstandingofdiagnosis.Thishighlightstheimportanceofaco-ordinatedconcussionriskmanagementpolicy.The2013-14IRBPitchSideConcussionAssessment(PSCA)processisbeingtrialledinthePremiershipandLVCup.TheInjurySurveillanceGroupisalsospecificallyauditingConcussionmatchinjuriesandthereturntoplaypathway.Theresultsofwhichwillbeavailableinlate2014.

• Themedical/injuryelementsofthedatacollectionforthesurveillanceprojectwillbeintegratedintothenewRugbySquadelectronicmedicalrecorddatabaseforthe2013-14season.Thiswillprovidenewopportunitiestosurveyillnessandnontime-lossinjuries,deliverbespokediagnosisspecificquestionnairesandbettercorrelatetrainingloadandmatchinjuryrisk.

Executive summary

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Contents

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1819202124

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ExecutiveSummary

Background

Definitions

Keyfindings Matchinjuryincidenceandseverity

Traininginjuryincidenceandseverity

Injuryburdenandperformance

Reporting variability Injury recurrence

Matchinjuries Traininginjuries

Injuriesleadingtoretirement

MatchInjuryeventTimeinseason

Trainingvolume

Traininginjuryevent Concussion

Hamstringinjuries

Mostcommonmatchinjuries

Injury diagnosis

Highestrisktraininginjuries

Highestriskmatchinjuries

Englandmatchandtraininginjuryrisk

Mostcommontraininginjuries

Matchinjuries

Traininginjuries

RFUinjurysurveillanceprojectmethods

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AuthoredbytheEnglandProfessionalRugbyInjurySurveillanceProjectSteeringGroup

ChairedbyDrSimonKemp(ChiefMedicalOfficerRFU)andcomprising,MatthewCross(PhDStudentandInjurySurveillanceProjectResearchAssistant,UniversityofBath),DrJohnBrooks(ExInjuryRiskAnalystandExHarlequinsandEnglandSaxons),DrColinFuller(RiskManagementConsultantIRBandFIFA),NickJohnston(HighPerformanceDirectorWorcesterWarriors),DrTimAnstiss(RPAMedicalAdvisor),MrAndySmith(ConsultantinEmergencyMedicine,MidYorkshireNHSTrustandPremiershipRugbyClinicalGovernanceAdvisor),AileenTaylor(PhysiotherapistandExInjuryAuditResearchAssistant),DrGrantTrewartha(SeniorLecturer,UniversityofBath),SeanWilliams(PhDStudent,UniversityofBath)andDrKeithStokes(InjurySurveillanceProjectPrincipalInvestigator,UniversityofBath)

ThecontentofthereportisbasedondatacollectedandanalysedbyMatthewCross(UniversityofBath)

Theauthorswouldliketoacknowledgewithconsiderablegratitude,theworkofthedoctors,physiotherapistsandstrengthandconditioningstafffromPremiershipclubsandEnglandteamswhohaverecordedinjuryandtraininginformationthroughouttheproject

Timeofinjury

England Senior side

Currentpublications

Supplementarydata


IntroductionTheRugbyFootballUnion(RFU)andPremierRugbyLtd(PRL)firstcommissionedaninjurysurveillancestudyacrossthePremiershipandEnglandteamsin2002thatremainsdrivenanddirectedtowardstheimprovementofplayerwelfarethroughoutthegame.Thisreportpresentspremiership-widekeyfindingsfromthe2012-13season,butparticipatingclubsalsoreceiveindividualmid-andend-of-seasonreportscomparingtheirdatatoaPremiershipaverage.Theaimistoprovideinformationthatinformsbestpracticeguidelinesateachclub.The2012-13seasonresultsinthisreportarecomparedlongitudinallywiththeresultsfrom9previousseasons’research.TheRFUinjurysurveillanceprojectispivotalinbothprovidingthebaselinedataneededtoassesstrendsininjuryandinguidingfurtherinvestigationintoinjuriesthatarecommon,severeorincreasinginincidence.

ThemethodsfortheRFUInjurySurveillanceProjectcanbefoundattheendofthisreport.Supportingtablesareincludedinthesupplementarydatafilealongsidethisreport.

Developments2012-13Inlinewiththecontinuedgrowthininterestinconcussionandsubsequentplayermanagement,the2012-13seasonsawtheRFUintroduceaconcussionauditacrossall12premiershipclubs.Thiswasintroducedtoimproveunderstandingofthetimecourseresolutionofconcussionin professional rugby union and includes an audit of return toplaypractices.DatacollectionforthisstudyhasbeenrunningalongsidetheIRBglobaltrialofthePitchsideSuspectedConcussionAssessmentTool(PSCA).BoththeRFUconcussionstudyandtheIRBPSCAtrialcontinueintothe2013-14season,andthefindingswillbereportedin2014.

Inastudyrelatedtotheinjurysurveillanceproject,apilotstudysupportedbytheRFU,PRLandRugbyPlayers

Association(RPA)wasconductedin2012-13tocomparetheincidenceandnatureoftime-loss,non-time-lossandabrasioninjuriesduringmatchesplayedonartificialturfandnaturalgrass.Thisstudyhasbeenextendedtoafullstudythatwillcontinuethroughthe2013-14season.

Lookingforward2013-14Themedical/injuryelementsofthedatacollectionforthesurveillanceprojecthavebeenintegratedintothenewRugbySquadelectronicmedicalrecorddatabaseforthe2013-14season.Thiswillprovidenewopportunitiestosurveyillnessandtodrilldownonareasofspecificimportancethroughthedevelopmentofbespokedatacapturemethods.

Forthefirsttime,inapilotstudyalignedwiththeinjurysurveillanceproject,individualplayertrainingintensityandloadwillbecapturedfromanumberofPremiershipclubsin2013-14.Theaimofthisstudyistoinvestigatetherelationshipbetweentrainingintensityandloadandinjuryrisk,somethingnotyetexploredwithintheremitofthesurveillanceproject.

IncollaborationwiththeRFUlawsgroup,therewillalsobeanevaluationofthelawtrialamendmenttothescrumengagementsequence.ThischangeisbasedonresearchconductedbytheUniversityofBathonbehalfoftheIRB.Nextseason’sinjurysurveillancereportwillcommentupontheeffectofthislawamendmentonscruminjuryrisk.

Background

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Definitions InjuryAninjurywasdefinedas‘anyinjurythatpreventsaplayerfromtakingafullpartinalltrainingactivitiestypicallyplannedforthatdayand/ormatchplayformorethan24hoursfrommidnightattheendofthedaytheinjurywassustained’.Forexample,ifaplayerwasinjuredduringamatchonSaturdayandhewasabletotakeafullpartintrainingonMonday,theincidentwouldnotbeclassedasaninjury.Iftheplayer’strainingwasrestrictedonMondayduetotheinjuryreceivedonSaturday,theincidentwouldbeclassedasaninjuryandreported.

Injury severityInjuryseveritywasmeasuredastime(days)lostfromcompetitionandpracticeanddefinedasthenumberofdaysfromthedateoftheinjurytothedatethattheplayerwasdeemedtohaveregainedfullfitnessnotincludingthedayofinjuryorthedayofreturn.Aplayerwasdeemedtohaveregainedfullfitnesswhenhewas‘abletotakeapartintrainingactivities(typicallyplannedforthatday)andwasavailableformatchselection.’

Recurrent injuryAninjuryofthesametypeandatthesamesiteasanindexinjuryandwhichoccursafteraplayer’sreturntofullparticipationfromtheindexinjury.

Injury incidence and days absenceThelikelihoodofsustaininganinjuryduringmatchplayortrainingisreportedastheInjuryincidence.TheInjuryincidenceisthenumberofinjuriesexpressedper1,000player-hoursofmatchexposure(ortrainingexposure).Equallyimportanttotheplayerand/orhisteamishowlongplayersareabsent.Thisisknownasinjuryseverityandismeasuredindaysabsence.

StatisticalsignificanceAresultisconsideredtobestatisticallysignificantiftheprobabilitythatithasarisenbychanceislessthan5%or1in20.Inthisreportstatisticalanalysishasbeenperformedforthematchandtraininginjuryincidenceanddaysabsence.SPCchartinghasbeenusedtoshowtheexpectedlimitsofthesystemwithupperandlowerlimitssetat+/-2standarddeviationsfromthemean.

ThE ovERall RISk of InjuRy In ThE PREmIERShIP haS BEEn STaBlE SInCE 2002


Match injury incidence and severity SummaryofmatchinjuryriskMatchinjuryriskremainswithintheexpectedlimitsofnaturalseason-to-seasonvariationbasedonthedatasince2002(Forabreakdownofincidenceandseveritybyseasonsee table S1).

Likelihoodorincidenceofinjury588matchinjuriesthatledtotimelostfromtrainingand/ormatchplaywerereportedinthe2012-13seasoncomparedwithameanof678injuriesfortheperiod2002-12.Thematchincidencefor2012-13was73/1000playerhours.Thisincidenceislowerthaninpreviousseasonsandlikelyreflectsthedropoffin2-3dayinjuriesseenintable S2.405teammatcheswereincludedintheanalysisduring2012-13equatingtoanaverageof49matchinjuriesperclubfortheseasonand1.5injuriesperclubpermatch.Thisisaround6injuriesperclublowerfortheseasonthanin2011-12.

Severityofinjuriesanddaysabsencefromplayingandtrainingasaresultofmatchinjuries Theaverageseverityof25daysforaninjurybeforereturntoavailabilityformatchselectionalsofallswithinexpectednaturalvariationbasedondatasince2002,howeverfigure1bshowsatrendingpatternhighlightinganincreaseintheseverityofmatchinjuriesfortheperiodsince2002.

Thetotalnumberofdaysabsenceasaresultofmatchinjuriesfor2012-13wasverysimilartothemeanacrossthestudyperiod.Theaveragedaysabsenceperclubpermatchin2012-13was35(Foramoredetailedbreakdownofinjuryincidenceby severity type see table S2).

key findings

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Training injury incidence and severity SummaryoftheTraininginjuryrisk335traininginjuries(rugbyskillsandstrengthandconditioningcombined)thatledtotimelostfromtrainingand/ormatchplaywerereportedinthe2012-13season. Thisequatedtoanincidencerateof2.6/1000playerhoursoraround28injuriesperclubperseason(Aseasonbyseasonbreakdowncanbeseenintable S3).

Theincidenceofinjuryintrainingfellwithintheexpectedlimitsofnaturalseason-to-seasonvariationbasedonthedatasince2002,andwasverysimilartothemeanincidenceforthestudyperiod(2.6vs.2.4/1000playerhours).Theseverityoftraininginjuries(29days)washigherthantheboundsofexpectednaturalvariation.Thisislikelyduetotheincreaseinincidenceofmoreseveretraininginjuries(>28days) (table S4).Theinjuriesthatcontributedmosttothisrise wereinferiortib/fibsyndesmosis(totaldaysabsence953days,meanseverity56days)andkneeMCLgrade2injury(totaldaysabsence611days,meanseverity61days).

Furtherresearchintothemanagementoftheseinjuriesmaybeofparticularinteresttoclinicians.Thisincreaseininjuryseveritycombinedwithnosignificantchangeintrainingvolumemaymeanthatthemostlikelyexplanationisanincreaseintrainingintensity.Theprocessofcapturing training load and intensity in selected clubs will startin2013-14andshouldproveinvaluableinordertocontextualisetheseresults.

2002-03

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Incidence Mean Lower limit-2SD Upper limit-2SD

Mean: 82

2012-13: 73

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Mean: 21.52012-13: 25

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Mean: 18342012-13: 1784

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Mean: 21

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Mean: 50

2012-13: 78

70

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90

Figure 1a: Incidenceratesofmatchinjuriesoverthestudyperiodwithmean±2xstandarddeviationshown.Note-foranormaldistribution,95%ofalldatashouldfallbetween(Mean-2xstandarddeviation)and(Mean+2xstandarddeviation).

Figure 1b: Severityofmatchinjuriesoverthestudyperiodwithmean±2xstandarddeviationshown

Figure 1c: Daysabsence/1000hrsfrommatchinjuriesoverthestudyperiodwithmean±2xstandarddeviationshown

Figure 2a: Incidenceratesoftraininginjuriesoverthestudyperiodwithmean±2xstandarddeviationshown

Figure 2b: Severityoftraininginjuriesoverthestudyperiodwithmean±2xstandarddeviationshown

Figure 2c: Daysabsence/1000hrsfortraininginjuriesoverthestudyperiodwithmean±2xstandarddeviationshown


Injury burden and performance SummaryofmatchinjuryriskWehaveexploredtheassociationbetweeninjuryburden andleagueperformanceinthePremiershipfrom2006-2012.Ithasbeensuggestedthattherearetwomajorcomponentsofsportsteamperformance;playerskillandplayerdurability,andthatplayerdurabilitymaybeanunder-recognisedfacetofteamsuccess.ThisisthefirstinvestigationoftheassociationbetweeninjuriesandteamperformanceineliteRugbyUnion.

Therelationshipbetweenteamseasonperformance(Premiershipleaguepointstally)andinjuryburden(‘overallinjuryincidence×meanabsenceperinjury’)formatchandtraininginjuriescombinedwasdetermined.Teamsquadsizewasalsoincludedintheanalysistodeterminewhethertheeffectofinjuryburdenonteamperformancedependedonsquadsize.Thethresholdforsmallestworthwhilechangewassetatthreeleaguepoints.

Aclearassociationbetweeninjuryburdenmeasuresandteamperformancewasfoundwithalowerinjuryburdenassociatedwithahigherleaguepointstally.Achangeof42injurydaysper1000playerhours(95%CI;26to111)wasassociatedwithachangeinleaguepointstallyof3points.Therewasalsoasignificantinteractionbetweeninjuryburdenandsquadsize,suchthattherelationshipbetweeninjuryburdenandteamperformancedecreasedwitheachadditionalsquadmember.Thesefindingshighlighttheimportantrolethatmedical,physiotherapistsandfitnessstaffhaveinreducingtheincidenceand/orseverityofinjuriesinordertoimproveteamperformance.Moredetailedresultsofthisanalysiswillbepublishedseparatelytothisreport.

Workedexample1Theaverageclubin2012-13sustained77injuries(49matchand28training)withanaverageseverityof27days. Thecombinedincidenceforeachclubwas6.7/1000playerhours,meaningtheinjuryburdenfortheaverageclubis 182days/1000hours.Thismeansthatareductionofasingleinjuryleadstoareductionin2.4days/1000hoursofinjuryburden.For2012-13ifaclubreducedtheirtotalnumberofinjuriesby18thiswouldgiverisetoareductioninburdenof42days/1000hours,andtherefore,basedonthemodelwouldbeattributedtoanadditional3leaguepoints.

Workedexample2Reducingtheaverageseverityofinjury(duetoa‘real’changecausedbyimprovementsinthetreatmentandmanagementofaplayer,ratherthanrushingaplayerbacktocompetitionbeforefullrecoveryhasoccurred)canalsoinfluenceperformance(asinjuryburdenistheproductofincidenceandseverity).In2012-13,a1dayreductioninaverageseveritycauseda6.7days/1000hourreductionininjuryburden.Toachieveaworthwhilechangeinperformance(3leaguepoints)theaverageseveritywouldneedtobereducedby6days.

Thetwoexamplesabovedealexclusivelywiththereductionofincidenceorseveritytohighlighttheireffect,butthemostlikelyoutcomewouldbeasimultaneouschangeinbothvariablesleadingtoaworthwhilechangeinperformance.

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Reporting variability Followingcommentsmadeaspartofthescientificpeer-reviewprocessforpapersrecentlypublishedbythegroup,andforinternalqualityassuranceweinvestigatedthevariabilityinreportingoftimeloss(i.e.,onedayormore)andmatchtimeloss(i.e.eightdaysormore)withinandbetweenclubsfortheperiod2002-13.Ithaspreviouslybeenstatedthatthereliabilityinthereportingofinjurieswithaseverityoflessthan7daysisnotasgoodasthoseinjuriesthataremoresevere(≥8days).

Therewasnocleardifferenceinthevariabilityofreportingwhenusingaone-dayversusaneight-daydefinitionofinjury.Thisindicatesthatthereliabilityofreportingofinjuriesthataremild(accordingtotheIRBconsensusstatement)isasgoodasmoderateinjuries.Clinically,injuriesthatcarryaseverityoflessthaneightdaysrepresentalargeproportionoftreatmenttimeandburdenuponclubmedicalstaffandthus,wewillcontinuetocollectdataonthisbasis.Moredetailedresultswillbepublishedinashortpaperseparatelytothisreport.

Injury recurrence SummaryofrecurrentinjuryriskRecurrentinjuryriskformatchandtrainingin2012-13remainswithintheexpectedlimitsofnaturalseason-to-seasonvariationbasedonthedatasince2002(althoughseason2002-03fallsoutsideofwhatisexpected). Therehashowever,beenadecreaseeveryyearsince 2008-09.The2012-13incidencerateforrecurrentmatchinjuries(4.2/1000playerhours)wasbelowthemeanincidenceof9.1/1000playerhoursfortheperiod2002-12.

Fornewinjuriestheseveritywas20daysforboth2002-12and2012-13andforrecurrentinjuries28daysand26daysrespectively.Theseverityofmatchnewvs.recurrentinjuriesby season can be seen in table S5.

Themostcommonlyreportedrecurrentmatchinjuryforseason2012-13wasHamstringmuscleinjury(4injuries).Moredetailofthemostcommonrecurrentmatchinjuries can be seen in table S6.

NB.Concussionwasnotincludedintheanalysisofrecurrentinjury as subsequent concussions are considered as a repeat injuryratherthanarecurrenceofthesameindexinjury.

Ofrecurrentmatchinjuriesin2012-13,52%occurredwithinonemonthofreturntoplay,32%within1-6months,3%greaterthanayearand12%werenotspecified.Thisisasimilarproportionofreportedrecurrentinjuriesoccurringwithinonemonthofreturntoplaywhencomparedtopreviousseasons(61%intheperiod2008-2012).

Between2007-08and2010-11therewasadecreaseintheincidenceofrecurrenttraininginjuriesandthisincidence hasremainedthesameforthelast3seasons.Theincidenceofrecurrenttraininginjuriesin2012-13(0.1/1000playerhours)wasbelowtheincidenceobservedin2002-12(0.28). Inadditiontheseverityofnewvs.recurrenttraininginjuriescan be seen in table S7.

Workdefiningpracticaltoolstohelpmedicalteamsandcoachesevaluatewhenaplayerisappropriatelyrehabilitatedfromcommonandhighriskinjuriesshouldcontinue.ThesurveillanceprojectusestheIRBconsensusdefinitionofwhatconstitutesarecurrentinjury(aninjuryofthesametypeandatthesamesiteasanindexinjuryandwhichoccursafteraplayer’sreturntofullparticipationfromtheindexinjury).

ConCuSSIon waS ThE moST Common PREmIERShIP maTCh InjuRy


Match injuries

Training injuries

Injuries leading to retirementThenumbersofplayersretiringwithareportableinjuryfromwhichaplayerdidnotreturntofullfitnesshavebeencollectedeachseason.Fiveplayersretiredinthe2012-13seasonwithanunresolvedinjury.Thelocationsoftheseinjurieswere2–Cervicalspine,2–Shoulder&1-Concussion.

Thenumberofretirementsasaresultofinjuryfromwhichtheplayerhadbeendeemedtohavereturnedtofullfitnessbeforeretirementarenotreportedinthesurveillanceprojectandthereforearenotincludedinthisreport.Thefiguresinthisreportthereforedonotreflectthetotalnumberofplayerswhoretireasaresultofinjury.

Time of injuryTheprofileforthetimingofinjurieswithinamatchremainedsimilartotheperiod2002-12.Thepercentageofinjuriesforwhichnoprecisetimeofinjurywasidentifiedwasidenticaltothatreportedin2011-12at10%ofallmatchinjuries.Thisremainssimilartotheproportionofinjuriesforwhichnoknownassociatedeventisidentified.

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Time in season Therehasbeennosignificantchangeoverthestudyperiodinthetimeduringtheseasonwheninjuriesoccur.ThisseasonsawasignificantdifferenceintheincidenceofinjuriesreportedinNovemberandFebruary,andwillbeexaminedfurthernextseason.InjuriesweresustainedthroughouttheseasonwithapeakininjuryincidenceseeninApril,thelastfullmonthoftheseasonin2012-2013.

Match injury eventTheprofileofinjurycausationleadingtomatchtime-lossinjuryremainsverysimilarwhencomparedtotheperiod2002-12.Thetackleremainsthemostcommonmatcheventresultingininjury.Themostcommoninjuriesasaresultofthetacklein2012-13were:

Ball carrier:anklelateralsprain,MCLinjury,concussion,inferiortibiofibularsyndesmosisinjury,andcostochondral/sternal injury

Tackler:concussion,Acromioclavicularjointinjury, inferiortibiofibularsyndesmosisinjuryandcervicalstinger/burner injury

Thesefindingsremainsimilartothepastthreeseasons.

Runningremainsthesecondmostcommonmatcheventassociatedwithinjury,(15%ofallmatchinjuryevents). Themostcommonmatchinjuriesasaresultofrunningarecalfmuscleinjuryandhamstringmuscleinjury,thesetwogroupingsalonecombinedtomakeup60%ofallinjuriesrelatedtorunning.

Theincidenceofinjuryassociatedwithcollisioneventswassimilarfor2012-13whencomparedwith2002-12,ofthetotalnumberofinjuriesresultingfromcollisions;theproportion ofthoseresultingfromperceivedaccidentalcollisionwas70%in2012-13,lessthanthe82%reportedinseasons2011-12and2010-11.

Theincidenceofinjuriesforwhichtheassociatedeventwasnotidentifiedwasthesamein2012-13as2011-12(10%)andverysimilarto2010-11(11%).

Mean: 10

2012-13: 5

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Figure 4a: Incidenceratesofrecurrentmatchinjuriesoverthestudyperiodwithmean±2xstandarddeviationshown

Figure 4b: Incidenceratesofrecurrenttraininginjuriesoverthestudyperiodwithmean±2xstandarddeviationshown

Figure5:Percentagedistributionbymatchquarter

Figure6:Incidenceratesofmatchinjuriesbymonth oftheseason

Figure 7: Incidenceratesofmatchinjuriesbyinjuryevent


Training injury eventWhencomparedtotheperiod2002-12therewasnosignificantchangeintheincidenceratesforany trainingmodality.

Sincethestudybeganin2002,thelikelihoodofsustainingatraininginjuryduringstrengthandconditioningsessions(weightsandnon-weights)hasvariedfromalowerlimitof 1.3injuriesper1000hoursandanupperlimitof2.7injuriesper1000playerhours,withanaverageseverityofinjurybetween13and24daysandthetotaldaysabsence/1000hoursbetween23and49days(abreakdownofincidence by severity grouping can be seen in table S4).

Duringconditioningnonweightstrainingsessions,mostinjurieswereasaresultofrunningrelatedactivities(75%).Duringrugbyskillcontactsessions,mostinjuries(30%)resultedfromrunningrelatedactivities,withthetacklebeingthesecondmostcommoncauseofinjury(16%).

ConcussionDuring2012-13therewere54reportedmatchconcussions(35Premiership,10EuropeanCompetition&9Nationalcupcompetition)and5trainingconcussions.Duringthe2012-13season91%ofreportedconcussionsoccurredinmatchplayand9%intraining.90%ofplayerswentthroughtheseasonwithoutsustainingaconcussion.10%ofplayerssustained 1ormoreconcussionswithnoplayersustainingmorethan 2separateconcussiveeventswithintheseason.

Themeanincidenceformatchconcussionsduringthestudyperiodwas4.6/1000hours.Theincidencefor2012-13felloutsidetheexpectedvariationforthefirsttimeduringthestudyperiod.Itisthoughtthatthisincreaseiscausedbyanincreasedawarenessofconcussionandthusagreaterfocusandunderstandingofdiagnosis.TheIRBpreliminarydatafromthePSCAtrialshowsa25%increaseinthenumberofconcussedplayersbeingremovedfromplaywhencomparedwithpreviousseasons.Asmentionedearlierinthisreport,moredetailedresultsfocusingonconcussionandsubsequentplayermanagementandrecoverywillbepublishedseparately.

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Hamstring injuries Hamstringinjuriesremainthemostcommonandhighestrisktraininginjuryacrossthestudyperiod,themajorityofwhicharethoughttobepreventable.Therewasnochangeintheincidenceofhamstringtraininginjuriesin2012-13whencomparedto2002-12(0.39/1000hours).Thedifferenceindaysabsence/1000hourswasalsonotsignificant(9.5vs.6.1).Acommonviewpointisthattrainingoffersacontrollableenvironmentwhereinjuriescanbereduced.Itisclearfromthedatathatthishasnotyetbeenachieved.Aseasonbyseasonbreakdowncanbeseenintable S9.

Training volume ThetotaltrainingvolumeperplayeratPremiership clubsin2012-13waslowerthanthatfortheperiod 2002-12(5.9hours/weekvs.6.6hours/week).Trainingvolumeforstrengthandconditioningandrugbyskillswerebothlessthanseenintheperiod2002-12(3.1vs.3.7hours/weekand2.7vs.2.9hours/weekrespectively)althoughnoneofthesedifferenceswerestatisticallysignificant. Asimilarproportionoftimespentincontactandnon-contactsessionsmeansthatchangeinincidencedoesnotappeartoberelatedtochangeintypeoftraining.Aseasonbyseasonbreakdowncanbeseenintable S8.

Theriskofinjuryduringtrainingisafunctionofthecontent/activity,thevolumeandtheintensity.Itishopedthatthetrainingloadpilotstudymentionedabovewillgivevaluableinsightintotheroleoftheintensityofthetrainingsessiononinjuryriskwhichcurrentlyremainsunclear.

Injury diagnosis Summaryofthemostcommonandhighestrisk matchinjuriesConcussionwas,forthesecondconsecutiveseason,themostcommonmatchinjurywiththehighestincidenceseensince2002.ThisriseinincidenceislikelyduetoacombinationofincreasedawarenessthroughtheRFUconcussionaudit&PSCAtrial,increasingeducationandawarenessactivitiesfromtheIRBandRFUandgreatermediaattention. ThePSCAtrialison-goingandthus,thedirectimpactof thetoolonplayerremovalcannotbecommentedupon.

The2012-13seasonalsosawalargeriseinincidenceofinferiortibiofibularsyndesmosisinjuries,possiblyduetoanincreasedawarenessofthesignsandsymptomsamongstmedicalpractitionersnationally.MCLinjuriesareseeninthetop5mostcommonmatchinjuriesagainin2012-13.Thighhaematomadroppedoutofthe3mostcommoninjuriesforthefirsttimesince2002.

Inferiortibiofibularsyndesmosisinjurieswasthehighestriskmatchinjuryforthefirsttimein2012-13,afterdroppingoutofthetop5matchhighestriskinjuriesin2011-12(theyweresecondhighestrankedin2010-11).

Overalltherehasbeenverylittlechangeinthehighestriskmatchinjuriesoverthestudyperiod.

Rugby skills

- contact

Rugby skills

- non-contact

Conditioning

weights

Conditioning

non-weights

0

1

2

3

4

5

6

Inci

denc

e/10

00hr

s

2002-12 2012-13

7

8

9

2002-03

2003-04

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

0

1

2

3

4

5

6

Inci

denc

e/10

00hr

s


Mean: 4.63

2012-13: 6.77

8

Figure8:Incidence rates of training injuries by session type

Figure9:Incidenceper1000playerhoursofmatch concussions by season

1/3 of all REPoRTEd InjuRIES oCCuR In TRaInIng (RugBy SkIllS and CondITIonIng)


Most common match injuries

18


19

Highest risk match injuries

Figure10.Incidencerates(incidence/1000hours)andmovementofthetop5mostcommonmatch injurieseachseasonfor2009-13

Thigh haematoma

Hamstring muscle

Ankle lateral ligament

Concussion

Calf muscle

200

9-10

Thigh haematoma

Hamstring muscle

AC joint

Concussion

Calf muscle

2010-11

Concussion

Hamstring muscle

Thigh haematoma

Calf muscle

MCL

2011-12

Concussion

Hamstring muscle

Syndesmosis

MCL

Thigh haematoma

2012-13

Knee cartilage

Shoulder dislocation

Foot fracture

Hamstring muscle

MCL

200

9-10

ACL

Syndesmosis

MCL

Tib/fib fracture

AC joint

2010-11

ACL

MCL

Hamstring muscle

Shoulder dislocation

PCL/LCL2011-12

Syndesmosis

MCL

Hamstring muscle

ACL

Clavicle fracture

2012-13

Figure11.Daysabsence/1000hoursandmovementofthetop5highestriskmatchinjuriesacrossthestudyperiod

4.9

4.9

4.0

3.9

3.7

5.4

4.6

4.8

3.9

3.7

5.1

5.0

4.9

4.8

4.0

6.7

4.9

3.8

3.6

3.3

124

114

104

102

97

184

131

108

97

92

186

148

119

108

92

145

141

130

108

95

Summaryofthemostcommonandhighestrisk training injuriesTheprofileofthemostcommontraininginjuriesisverysimilartothatseenacrossthisstudyperiod.Theonlychangein2012-13isthedecreasedincidence/rankofHipflexor/Quadricepsinjuryandafirstappearanceintothetop5mostcommontraininginjuriesforlumbarsofttissueinjury.

Hamstringmuscleinjuriesremainedthemostcommontraininginjurythroughoutthestudy.Hamstringmuscle,ACLinjuriesandLumbardisc/nerverootinjuriesremainthehighestrisktraininginjuriesthroughoutthestudyperiod.


20


21

Most common training injuries Highest risk training injuries

Figure12.Incidenceratesandmovementofthetop5mostcommontraininginjuriesacrossthestudyperiod

Hamstring muscle

Calf muscle


Abductor muscle

Hip flexor/quad muscle

200

9-10

Hamstring muscle

Calf muscle


Abductor muscle


2010-11

Hamstring muscle

Calf muscle


Abductor muscle


2011-12

Hamstring muscle

Calf muscle

Abductor muscle



2012-13

Hamstring muscle

Knee cartilage

Archilles tendon

Lumber disc/nerve root

Syndesmosis

200

9-10

Hamstring muscle

ACL

Calf muscle


Knee cartilage 2010

-11Hamstring muscle


Calf muscle


Tib/fib fracture

2011-12

Hamstring muscle

ACL


Calf muscle

Lumber soft tissue

2012-13

Figure13.Daysabsence/1000hoursandmovementofthetop5highestriskmatchinjuriesacrossthestudyperiod

0.38

0.20

0.12

0.11

0.09

0.45

0.30

0.15

0.14

0.11

0.42

0.24

0.11

0.10

0.09

0.39

0.29

0.18

0.10

0.09

6.1

3.8

3.3

2.8

2.6

6.9

6.8

3.8

3.7

3.1

7.3

6.5

3.4

2.1

2.1

9.5

6.3

5.3

4.9

4.5


EnglandmatchandtraininginjuryriskNostatisticallysignificantchangeinriskwasseenin2012-13.

ThelikelihoodofsustaininganinjurywhilstplayingfortheEnglandseniorsideincreasedforthefirsttimesince2007-08,howevertheaverageseverityofinjuriesinmatchandtrainingdecreased.Thesechangeswerenotstatisticallysignificant.

Note:therelativelysmallnumberofseniorEnglandtrainingsessionsinthestudymakesthedifferencesseeninthisgroupmuchmorelikelytohavearisen“bychance”ratherthantobetheresultofa“true”difference,reflectedinthewide95%Confidenceintervalsandthelackofstatisticalsignificanceintheresults.

MatchInjuries

England Senior side

24


25

Traininginjuries

Total number of injuries

Injuries / 1000 hrs (95% CI)

Injuries per match

Average sever-ity, days

Days absence / 1000 hrs (95% CI)

Days absence per match

2002-03 53 221(169-289) 4.4 19 4264(4010-4533) 85

2003-04 83 207(167-256) 4.1 11 2371(2225-2527) 47

2005-06 30 136(95-195) 2.7 10 1391(1243-1556) 28

2006-07 30 136(95-195) 2.7 28 3836(3586-4104) 77

2007-08 55 162(119-205) 3.2 24 3876(2852-4901) 78

2008-09 23 96(57-135) 1.9 8 813(480-1145) 16

2009-10 23 88(52-125) 1.8 19 1712(1012-2411) 34

2010-11 14 78(37-119) 1.5 23 1789(852-2726) 36

2011-12 16 62(31-92) 1.2 29 1754(894-2613) 35

2012-13 31 111(78-158) 2.2 24 2618(1841-3722) 52

Rugby skills Strength and conditioning


Average severity, days





2002-03 4.5(2.6-8.0) 15 69(60-80) 4.0(1.0-15.9) 4 16(8-32)

2003-04 7.6(5.3-11.0) 12 89(80-99) 6.3(3.8-10.3) 13 79(68-90)

2005-06 0.6(0.1-4.0) 4 2(1-6) - - -

2006-07 9.8(5.9-16.3) 15 149(131-169) - - -

2007-08 7.3(4.5-10.1) 9 74(46-103) 2.5(0.5-4.6) 12 34(7-61)

2008-09 6.5(3.0-10.0) 20 135(62-209) 12.1(4.2-20.0) 18 233(81-385)

2009-10 5.3(3.4-8.3) 8 46(30-73) 4.0(2.0-8.6) 6 26(12-55)

2010-11 1.7(0.8-3.5) 7 12(5.7-26) 4.4(1.8-10.5) 5 22(9.1-52.5)

2011-12 3.2(1.4-5.1) 22 70(31-110) 2.8(0.4-5.3) 18 51(6-95)

2012-13 3.7(1.6-9.0) 20 58(24-139) 1.1(0.2-7.8) 9 10(1-71)

Table4:Englandtraininginjuryincidence,averageseverity&daysabsencesince2002-03

Table3:Englandmatchinjuryincidence,averageseverity&daysabsencesince2002-03


Writteninformedconsentwasobtainedfrom591registeredPremiershipsquadplayersforthe2012-13season.Threeplayersdidnotgiveconsentandassuchtheirdatawerenotrecorded.Atotalof405gameswereincludedintheanalysesforthe2012-2013season.

InjuriessustainedintrainingandinallmatchesintheAvivaPremiership,LVAnglo-WelshcupandEuropeanCompetitions(HeinekenandEuropeanChallengeCup) wereincluded.

InjuriessustainedwhileplayersrepresentedEnglandwerereportedseparatelyandareanalysedseparatelyinthisreport.

Matchandtraininginjurydata,andtrainingexposuredata,wereprovidedbyall12Premiershipclubsin2012-2013.Acompletesetofdatawerecollected.

MedicalpersonnelateachPremiershipclubandtheEnglandseniorteamreportedthedetailsofeveryinjurysustainedbyaplayerattheirclub/teamthatwereincludedinthe

studygrouptogetherwiththedetailsoftheassociatedinjuryeventusingastandardinjuryreportform.Strengthandconditioningstaffrecordedthesquad’sweeklytrainingschedulesandexposureonastandardtrainingreportform.Teammatchdayswerealsorecordedbystrengthandconditioningstaff.

InjurydiagnoseswererecordedusingOrchardcodes(OSICS).Thissportsspecificinjuryclassificationsystemallows detailed diagnoses to be reported and injuries to be groupedbybodypartandinjurypathology.

TheinjurydefinitionsanddatacollectionmethodsutilisedinthisstudyarealignedwiththeIRBConsensusstatementoninjurydefinitionsanddatacollectionproceduresforstudiesof injuries in rugby union

Rfu injury surveillance project methods

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Furtherdetailedinformationoninjuryriskinthiscohortofplayerscanbeobtainedfromthefollowingpeerreviewedpublicationsthatanalysedatacollectedaspartofthesurveillanceproject

Abstracts/presentations

JHMBrooks,CWFuller,SPTKemp&DBReddin.TheIncidence,SeverityandNatureofInjuriesCausedbyTacklinginProfessionalRugbyUnionCompetition.Presented(poster)atTheAmericanCollegeofSportsMedicineAnnualMeeting,1stJune2006.Publishedin:MedicineandScienceinSportsandExercise2006:38(5)S351-352.

JHMBrooks,CWFuller,SPTKemp.TheIncidence,SeverityandNatureofGroinInjuriesinProfessionalRugbyUnion.PresentedatTheAmericanCollegeofSportsMedicineAnnualMeeting,1stJune2006.Publishedin:MedicineandScienceinSportsandExercise2006:38(5)S351.

JHMBrooks,CWFuller,SPTKemp&DBReddin.Theincidence,severityandnatureofinjuriescausedbybeingtackledinprofessionalrugbyunion.Presented(oral)atTheFacultyofSportsandExerciseMedicine,RoyalCollegeofPhysiciansIreland(RCPI)andRoyalCollegeofSurgeons,Ireland(RCSI)AnnualScientificMeeting,Dublin,5thSeptember2005

JHMBrooks,CWFuller,SPTKemp.Theincidence,severity,andnatureofscrummaginginjuriesinprofessionalrugbyunion.Presented(poster)at1stWorldCongressofSportsInjuryPrevention,Oslo,Norway23rd-25thJune2005.Publishedin:BrJSportsMed39:377.

Publications

SWilliams,GTrewartha,SPTKemp&KAStokesAmeta-analysisofinjuriesinseniormen’sprofessionalrugbyunion.SportsMedicine2013;43(10)1043-1055.

CWFuller,AETaylorJHMBrooks&SPTKempChangesinthestature,bodymassandageofEnglishprofessionalrugbyplayers:A10-yearreview,JournalofSportsSciences2012DOI:10.1080/02640414.2012.753156

SCCheng,ZKSivardeen,WAWallace,DBuchanan,DHulse,KJFairbairn,SPKemp&JHBrooks.Shoulderinstabilityinprofessionalrugbyplayers-thesignificanceofshoulderlaxity.ClinicalJournalofSportsMedicine2012Sep;22(5):397-402

CJPearce,JHMBrooks,SPKemp&JDCalder.TheepidemiologyoffootinjuriesinprofessionalrugbyunionplayersFoot&AnkleSurgery.2011Sep;17(3):113-8.Epub2010Mar5.

JHMBrooks&SPTKempInjurypreventionprioritiesaccordingtoplayingpositioninprofessionalrugbyunionplayers.BritishJournalofSportsMedicine2011Aug;45(10):765-75.Epub2010May19

RASankey,JHMBrooks,SPTKemp&FSHaddadTheepidemiologyofankleinjuriesinprofessionalrugbyunionplayers.AmericanJournalofSportsMedicineDec2008;36:2415-2424

CWFuller,TAshton,JHMBrooks,RJCancea,JHall,&SPTKempInjuryrisksassociatedwithtacklinginrugbyunion.BritishJournalofSportsMedicine2010;44(3):159-167

JHMBrooks,CWFuller,SPTKemp&DBReddinAnassessmentoftrainingvolumeinprofessionalrugbyunionanditsimpactontheincidence,severityandnatureofmatchandtraininginjuries.JournalofSportsSciences200826:8,863-873

SPTKemp,ZHudson,JHMBrooks&CWFuller.TheepidemiologyofheadinjuriesinEnglishprofessionalrugbyunion.ClinicalJournalofSportsMedicine2008;18:227-234

CWFuller,JHMBrooks,RJCancea,JHall,&SPTKempContacteventsinrugbyunionandtheirpropensitytocauseinjury.BritishJournalofSportsMedicine,Dec2007;41:862-867

JHeadey,JHMBrooks&SPTKemp.TheepidemiologyofshoulderinjuriesinEnglishprofessionalrugbyunion.AmericanJournalofSportsMedicine,Sep2007;35:1537-1543

RJDallana,JHMBrooks,SPTKemp&AWWilliams.TheepidemiologyofkneeinjuriesinEnglishprofessionalrugbyunion.AmericanJournalofSportsMedicine,May2007;35:818–830

CWFuller,JHMBrooks&SPTKemp.Spinalinjuriesinprofessionalrugbyunion:aprospectivecohortstudy.ClinicalJournalofSportMedicine,2007;17(1):10-16

JHMBrooks,CWFuller,SPTKemp&DBReddin.Incidence,riskandpreventionofhamstringmuscleinjuriesinprofessionalrugbyunion.AmericanJournalofSportsMedicine,2006;34:1297-1307

JHMBrooks,CWFuller,SPTKemp&DBReddin.EpidemiologyofinjuriesinEnglishprofessionalrugbyunion:part1matchinjuries.BritishJournalofSportsMedicine,Oct2005;39:757-766

JHMBrooks,CWFuller,SPTKemp&DBReddin.EpidemiologyofinjuriesinEnglishprofessionalrugbyunion:part2traininginjuries.BritishJournalofSportsMedicine,Oct2005;39:767–775.

JHMBrooks,CWFuller,SPTKemp&DBReddinAprospectivestudyofinjuriesandtrainingamongsttheEngland2003RugbyWorldCupsquadBritishJournalofSportsMedicine,May2005;39:288–293

Current publications


Supplementary data

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TableS1:Matchinjuryincidence,averageseverityanddaysabsencesince2002-3

Season Total number of match injuries


Injuries per club per match

Average severity, days (95%CI)


Days absence per club per match

2002-03 748 100(92-107) 2.0 16(15-17) 1556(1444-1667) 31

2003-04 653 88(82-95) 1.8 20(19-22) 1773(1637-1909) 35

2005-06 482 75(68-82) 1.5 21(19-23) 1591(1449-1733) 32

2006-07 755 90(84-97) 1.8 21(20-23) 1879(1745-2013) 38

2007-08 660 83(77-89) 1.7 19(18-21) 1613(1490-1736) 32

2008-09 769 100(93-107) 2.0 23(21-25) 2285(2123-2446) 46

2009-10 636 80(73-86) 1.6 22(20-24) 1722(1588-1856) 34

2010-11 746 93(86-99) 1.9 21(20-23) 1917(1779-2054) 38

2011 -12 655 82(76-88) 1.6 27(25-29) 2222(2052-2392) 44

2012-13 588 73(67-79) 1.5 25(23-27) 1784(1645-1936) 35

TableS2:Matchinjuryseveritysince2002-03

TableS3:Traininginjuryincidence,averageseverityanddaysabsencesince2002-3

Season Incidence /1000 hrs

2 - 3 days

4 – 7days

8 - 21 days

22 - 28 days

29- 84 days

> 84 days

All

2002-03 24 33 26 4 9 3 100

2003-04 19 26 23 3 14 4 88

2005-06 10 19 24 5 13 3 75

2006-07 17 30 22 6 11 5 90

2007-08 15 24 26 4 10 4 83

2008-09 18 30 26 5 14 6 100

2009-10 15 21 25 4 10 4 80

2010-11 17 27 27 5 11 5 93

2011-12 13 21 22 6 13 7 82

2012-13 6 20 24 6 13 4 73

Total number of training injuries

Rugby skills Strength and conditioning

Season Injuries / 1000 hrs (95% CI



Injuries / 1000 hrs (95% CI



2002-03 159 3.3(2.7-4.0) 28 93(90-97) 2.3(1.7-3.0) 13 29(27-31)

2003-04 217 1.7(1.4-2.0) 26 44(42-45) 1.3(1.1-1.6) 17 23(22-24)

2005-06 203 2.2(1.9-2.6) 22 49(47-51) 1.5(1.2-1.9) 16 24(22-25)

2006-07 209 2.1(1.7-2.5) 18 37(35-38) 1.6(1.3-2.0) 16 25(24-27)

2007-08 318 3.2(2.7-3.7) 19 60(51-68) 2.7(2.2-3.1) 15 44(36-52)

2008-09 258 2.5(2.1-2.9) 26 63(53-73) 2.4(2.0-2.9) 17 41(34-49)

2009-10 298 2.8(2.4-3.2) 21 59(50-67) 2.1(1.7-2.4) 18 37(30-43)

2010-11 340 3.1(2.7-3.5) 25 76(66-87) 2.6(2.1-3.0) 17 41(34-48)

2011-12 323 2.7(2.4-3.1) 26 68(59-78) 2.2(1.8-2.6) 18 39(32-46)

2012-13 335 3.2(2.9-3.6) 33 106(93-121) 2.0(1.7-2.4) 24 49(41-60)

Incidence / 1000 hrs

2 - 3 days

4 – 7days

8 - 21 days

22 - 28 days

29- 84 days

> 84 days

All

2002-03 0.64 0.49 1.11 0.18 0.42 0.18 3.0

2003-04 0.21 0.40 0.52 0.11 0.30 0.08 1.6

2005-06 0.46 0.58 0.60 0.10 0.35 0.10 2.2

2006-07 0.57 0.42 0.51 0.10 0.20 0.07 1.9

2007-08 0.50 0.76 0.94 0.14 0.38 0.07 2.8

2008-09 0.43 0.57 0.77 0.17 0.31 0.10 2.4

2009-10 0.33 0.76 0.70 0.19 0.34 0.07 2.4

2010-11 0.48 0.76 0.91 0.21 0.32 0.13 2.8

2011-12 0.25 0.62 0.82 0.15 0.30 0.14 2.3

2012-13 0.35 0.55 0.79 0.19 0.49 0.21 2.6

TableS4:Traininginjuryincidenceinseverityclassificationssince2002-03


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New injuries Recurrent injuries

Injuries / 1000 hrs

Average severity, day

Days absence / 1000 hrs

Injuries / 1000 hrs



2002-03 /1000hrs 14 1084 17 24 436

2003-04 72 18 1333 12 34 433

2005-06 67 20 1372 9 31 277

2006-07 76 21 1574 7 33 260

2007-08 74 19 1444 8 21 167

2008-09 85 21 1800 13 34 483

2009-10 72 21 1515 7 29 206

2010-11 87 21 1776 5 26 140

2011-12 77 27 2106 4 23 114

2012-13 68 25 1659 4 26 122

TableS5:Newandrecurrentmatchinjuryincidence,averageseverityanddaysabsence

Diagnosis Number of injuries Average Severity

Hamstring muscle injury 4 33

Ankle syndesmosis injury 4

Calf muscle 3 37

Tibial Stress Injuries 3 6

2007-08 0.50 0.76

2008-09 0.43 0.57

2009-10 0.33 0.76

2010-11 0.48 0.76

2011-12 0.25 0.62

2012-13 0.35 0.55

TableS6:Thefivemostcommonmatchinjuryrecurrencesduring2012-13

New injuries Recurrent injuries

Injuries / 1000 hrs

Average severity, day


Injuries / 1000 hrs



2002-03 2.5 21 54 0.5 34 15

2003-04 1.3 21 27 0.3 36 11

2005-06 1.8 19 35 0.4 21 8

2006-07 1.7 17 30 0.2 16 3

2007-08 2.3 17 39 0.5 24 11

2008-09 2.0 21 41 0.4 27 10

2009-10 2.2 20 44 0.2 22 4

2010-11 2.7 20 53 0.1 58 7

2011-12 2.2 22 49 0.1 47 4

2012-13 2.6 29 69 0.1 34 4

TableS7:Newandrecurrenttraininginjuryincidence,averageseverityanddaysabsence

Training Hrs per week

Year Rugby Skills Strength & Conditioning

Total

2002-03 3.9 2.5 6.4

2003-04 5.0 3.7 8.7

2005-06 4.3 3.1 7.4

2006-07 4.1 3.1 7.2

2007-08 3.0 2.7 5.7

2008-09 3.2 2.6 5.8

2009-10 3.2 2.9 6.1

2010-11 3.1 2.8 5.9

2011-12 3.6 2.8 6.4

2012-13 3.1 2.7 5.9

TableS8:Averageplayertraininghoursperweek TableS9:Hamstringtraininginjuries,incidenceand daysabsenceper1000hrs2002-2011

Year Incidence/1000hrs Days Absence/1000hrs

2002-03 0.45 6.4

2003-04 0.21 4.2

2004-05 0.36 4.6

2006-07 0.32 5.1

2007-08 0.59 9.5

2008-09 0.36 5.0

2009-10 0.38 6.1

2010-11 0.45 6.9

2011-12 0.42 7.3

2012-13 0.39 9.5

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