Br. J. Sp. Med., Vol 24, No. 1

Role of the team physiotherapist in rugby unionfootball

D.A. McLean, BA, MCSP, CertEdSenior Lecturer, The Queen's College, Glasgow G3 6LP, UK

The team physiotherapist plays an important role in rugbyunion football. Traditionally, this is seen as injury careand rehabilitation, but increasingly the role focuses oninjury prevention. The author discusses these aspects withreference to statistics from recent Scottish internationaltours.

Keywords: Rugby union football, physiotherapy, injuryprevention

IntroductionIn soccer and rugby the popular image of the teamphysiotherapist is the man on match day with a blackbag and the magic sponge. Certainly it is a rolecommonly undertaken, yet it is the least important.Central to the job is injury care and rehabilitation.The most important role of the team physiotherapistis injury prevention. This can only be achieved if thephysiotherapist is part of a support team consisting ofmanager/coach, doctor and administrator. To ensurethat all members of the support team not only believein injury prevention but will act accordingly is amajor challenge.Over the last 10 years I have been associated as a

team physiotherapist with the sport of rugby union.

Field of playA change in the rules allows players to receiveattention for an injury while play continues. This wasinitiated to reduce the number of stoppages. It wasfelt that players feigned injury to gain a tacticaladvantage. The fact that this occurred is supported bythe reduction in stoppages since the new law wasimplemented in 1988.The feigning of injury and the sudden complete

recovery makes the spectator question in every casehow it is possible for players to be completelyincapacitated one minute yet able to play normallythe next. Many injuries in contact sport are totallydisabling for approximately two minutes; beingwinded, being kicked on the inside of the knee, or thehand being numbed when stood on. The effect can bemore long lasting and the fact that the player is soon

able to function normally is testimony to the stoicalnature of the determined competitor.The decision which has to be taken when a player

is injured during the game is whether or not fullfunction can be achieved. If not, then the playershould leave the field of play. The steps in theprocess of examination are exactly the same as thosein a clinic. The only difference is that it has to be donein about one minute.From the bench at the side of the pitch, observation

of the mechanism of injury is often impossible. Thusthe first questions are 'What happened?' and 'Wheredoes it hurt?'. The next question asks the player tomove the injured part. Depending on the responseselicited, tests of joint stability are performed. If theseare normal, the player must then demonstrate fullactive range and full isometric muscle strength. Thetime which this process takes allows the player toovercome the shock of trauma along with the fear ofsevere injury and its consequences. At this stage, theplayer may request cold or an embrocation to beapplied to the skin as a counter-irritant. The next twominutes of activity in the game is the final test offunctional ability. All of the above assumes the injuryto be to the limbs, which it is in the majority of cases.Head 'knocks' require a slightly different approach.

When the player is lying motionless, the patency ofthe airway and normal function of the cardiorespira-tory systems are paramount. More often, if the playerhas lost consciousness, he is recovering by the timethe physiotherapist reaches him. The first questionstest understanding of commands and memory.Coordination of eye movements may be checked. Theplayer may complain of altered vision. The easiestgross test of the nervous system, and the test which ismost often positive, is inability to balance. The playermay either stagger when getting to his feet, or will beunable to balance unaided while standing on one leg.

Irrespective of the injury, where there is anyuncertainty about a player's ability to continue, heshould be removed from the field of play until he isable to demonstrate his fitness. The role of themedical adviser is very important at this stage. Thisregime is obviously of benefit to the player and it isbetter for the team since a player whose fitness is inquestion will produce misunderstanding and errors.The introduction of replacements in rugby union hashelped to avoid players continuing to play when unfitto do so.

Br. J. Sports Med., Vol 24, No. 1 19

Address for correspondence: D.A. McLean, Queen's College, 1Park Drive, Glasgow G3 6LP, UK.C 1990 Butterworth & Co (Publishers) Ltd0306-3674/90/010019-06

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Preparation for the game in the changing room

The structure of the hour before kick-off is very muchin the hands of the coach and the team captain. Thereare a great variety of activities carried out by groupsand individuals during that hour. If there are aspectsof the preparation which appear to be misdirectedthen through informal conversation the activity canbe analysed. If it is judged to be inappropriate,changes can be introduced. An example is theavoidance of over vigorous warm-ups started tooearly in hot humid changing rooms. This reducesenergy stores and causes unnecessary fluid loss.Moderate fluid intake is encouraged in the changingroom. Wherever possible, appropriate indoor oroutdoor warm-up facilities should be provided andused. It is sensible for teams to use the field of play.Warm-ups should include skills and activities whichare part of the game'The same applies to individual players. While it is

accepted that much of the activity is for psychologicaleffect, if activities are noted to be dangerous ornegative in effect then, through discussion, theplayer's activities may be modified. The unexpectedcan be avoided wherever possible by getting to knowplayers. However, the levels of stress just before kick-off can lead to the most unusual requests. Experienceis the best guide to response. Players may requestjoints to be manipulated. Even if the player is wellknown to the physiotherapist, this is a difficultrequest to respond to and would demand carefulreview to identify if in fact manipulation was actuallyneeded.Many players apply strapping and do so to an

appropriate standard. However, there are exampleswhen strapping could be applied more efficiently.Player education is required. The same applies toactive and passive warm-ups. The massage prior to

the game does not replace an active warm-up.However, players often seek the sanctuary of thecouch where they can lie quietly and, with the help ofslow deep massage, try to manage their high levels ofstress. Some players use the firm physical contact ofmassage as the first step in preparation for physicalcontact.

Order, organization and forward planning avoidscomplications and worrying distractions. Every mem-ber of the support team must play his part to achievethis.

Preparation before the gameAs much as possible is done before arriving at thestadium. Adhesive strapping is used for those withprevious history of inversion injury2 or talar instabil-ity3. Strapping can also be used to control hyper-extension of knee or elbow4. Protection may beneeded for an acromioclavicular joint which is stilllocally tender following subluxation. Padding of feetor boots is frequently required for bruising of thedorsum of the foot which inhibits kicking, or blisterswhich inhibit running. When grounds are hard, bonypoints may suffer direct trauma. This causes long-lasting pain on direct contact and so benefits fromprotection. Figure 1 shows one example of the use ofchiropody felt positioned to protect a recent cut justabove the eyebrow. Secured in the substance of thefelt is a piece of thermoplastic. Make-up was used tomake the pad skin coloured to avoid attractingattention. It is important that examples such as theseare skilfully applied and the player has time to testthem before the game so that adjustments can bemade. Better still, the effect of padding and strappingcan be tried out on the final practice session beforethe match.

Figure 1. Chiropody felt used to protect an injury above the eyebrow. (Courtesy of the Glasgow Herald).

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It is widely recognized that in soccer and rugbyunion some players are not 100 per cent fit when theytake the field. Seasons are long and punishing andplayers accumulate problems. In training, contactoccurs up to two days before the match and injuriesoccur or past injuries can be aggravated. Immediatetreatment to reduce the amount of tissue reaction isessentials. Muscle soreness and tightness is commonand, because this appears to predispose to muscledisruption, everything possible must be done toreduce these. Gentle activity, heat and massage areused6.

Fitness to play following injuryDecisions about fitness to play can be very difficult tomake. In rugby union the laws of the game state thatit is the player who declares himself fit to play. Theplayer's view is important. However, it is hoped thathe will listen to advice. The longer the back-up teamand the players have been working together then themore likely it is that there will be mutual trust.Decisions have to be made about injuries which occurin the two weeks prior to a match. This amount oftime away from full training causes a small physio-logical decrement. In fact, in the middle of a seasonthis length of break may have psychological benefits.In these cases the problem remains to predict the rateof recovery since to rule the player out unnecessarilywould be wrong, yet to leave the decision too latemay disrupt team preparation. One reason for thedifficulty in predicting rate of recovery is that thedegree of disruption of soft tissue injuries cannot bemeasured directly. Five general guidelines are in-cluded to help judge prognosis.

* OnsetWhen sudden pain is felt during running, theseverity of disruption is likely to be greater thanwhen the onset of pain is delayed until the nextday. Both cases allow a clearer judgement to bemade about severity than when the onset is spreadover several days or weeks.

* Degree of function at the time of injuryBecause of pain, fear and anxiety the picture is notclear unless of course there is complete rupture,dislocation or fracture.

* Joint range and muscle strength at 24-28 h post injuryA better judgement of severity can be made at thisstage. However, inhibition due to pain may stillcloud the issue.

* Rate of improvement within the first four daysForce production, rate of force production, andpercentage of top running pace achieved, will helpjudgement of the rate of recovery over the nextweek or two. This is illustrated by comparison oftwo examples in Table 1.

* Previous history of a similar injuryIf comparison can be made with a previous injurysuffered by the player, then the time to recovery ofthat injury is a useful guide.

The person in overall charge of team selection will seta deadline by which time the player has todemonstrate his fitness.

Table 1. Partial tear of hamstrings. Two subject comparisonof maximum voluntary contraction (MVC) and return toplay

Days post injury Day3 Day 10 Day2l Day35

Subject 1 60% MVC - - PlaySubject 2 90% MVC Play Play Play

To demonstrate fitness, all positive tests originallycarried out on the examination couch should now benegative. All elements of function can be tested in thefinal squad session before the game, but it is possiblefor players to hide any remaining dysfunction if thisis the only method of testing. Full speed, accelera-tion, and ability to change direction should be carriedout in competition with other players and compari-sons made. Comparisons can also be made ifprevious measurements for the same tests have beenrecorded.

In the real world, many more aspects than physicalfitness are considered before a final decision isreached. Relevant factors include the quality of playerresource, the relative importance of the game andthose which follow, the time in the season or thetour, the experience of the player and the stage of theplayer's career.

RehabilitationIn rehabilitation of musculoskeletal injuries the timeto full recovery may be split into three phases. Thefirst phase coincides with the acute stage which mayspan approximately two to five days. The secondphase is one of restricted physical activity which mayspan three days to six weeks or even longer. The finalphase is participation in the game at a level below theplayer's recognized level of ability.

In phase one, the objective is to prevent or reducesecondary cell death7 and thus the accompanyingdelay of resolution. This is achieved by applying theprinciples of acute injury care5.

In phase two, restricted activity is carried outwithin the limits of pain. Initially, the aim is tostimulate resolution of the inflammatory process8 aswell as good quality of repair. Re-education of use isincluded. The major components are balance, equal-ity of function between right and left, and eccentricmuscle control. Within this phase, the objective ofrestricted activity gradually moves towards retrainingto achieve physiological fitness and tissue fitness;that is tensile strength and elasticity of connectivetissue. The latter part of this phase may involvecertain units of training done with the squad.Phase three allows the player to test his fitness and

skill levels where the added pressure of winning isless and the quality of opposition less severe. Itprovides time for the player to regain confidence.Each phase is important, but the phase of greatest

effect is the second phase because it is here that thefoundations are laid for prevention of recurrence ofinjury.

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The content, structure and progression of phasetwo are difficult to judge because there is nobiomechanical model on which to base a retrainingprogramme other than the principle that activitystimulates repair9. Studies of tendon healing, liga-ment healing and wound healing offer guidelines,but the large majority of sports injuries are not totalruptures so these time scales do not necessarilyapply. If one adds to this conditions such as tendinitisand focal degeneration in tendons, then exactpredictions of the timing and vigour of reloading ofligament and tendon are impossible.Muscular injuries pose similar problems. Since the

majority of muscle injuries in sport are partial tears, amost relevant study by Nikolaou10 investigated theeffect on rabbit muscle when strained to 80 per cent offailure. The result was tearing of muscle fibres nearthe distal musculotendinous junction. The ability ofthe muscle to generate force was maximally reducedat 24 h recovering to 92 per cent in seven days whenscarring and fibrosis was evident. The experimentalmethod made it clear that the cause of the forcereduction was intrinsic to the muscle. It must beremembered that healing in rabbits may be quickerthan in humans. Clinical evidence would suggest thatthe average recovery to full function for hamstringstrains is 14 days11, yet in 14 days fibrous repair hasregained only 25 per cent of its tensile strength12.This apparently conflicting evidence illustrates thedilemma when dealing with the musculotendinousunit. Resolution of arthropathies is just as difficult to

13gauge

In view of these limitations, the foundations onwhich to base phase two of rehabilitation are veryinsecure. Guidelines, therefore, are general but arenecessary to enable a way forward to be identified. Inaddition to the five guidelines included in the sectionabove, a further four are listed to help identify theappropriate type of activity and work-load.

* Total time of inactivity or unstructured activity since theinjuryA judgement on how much fitness has been lost14and whether or not the activity will have allowedhealine or prevented healing can be made.

* Intensity and volume of work (load degree) prior toinjuryThis aids in the identification of the initial loaddegree, taking into account the time of anyinactivity. This may have a bearing on the cause ofthe injury.

* Dependency of recurrence on intensity or volumeThis determines which of the two should beavoided in the early stages of recovery.

* Components of performance to be maintained orimprovedThere may be objectives of conditioning, skilldevelopment or tactical awareness which can beincluded which have no detrimental effect on theinjury. Indeed, they may have a positive effect onthe quality of repair.

Wherever possible the activity chosen to aid recoveryshould be structured in such a way to produce a

training effect for components of fitness required bythe sport15.The following is an example of one unit of work

included in phase two to illustrate the use of the lastfour guidelines. A player suffered a partial tear of theadductor longus muscle when sprinting from astanding start. Ten days later, hip abduction was fulland painless as was manually resisted hip adduction,flexion and medial rotation. He was able to reach 50per cent of his top running pace before pain wasexperienced. Previous to the injury his best time for100 metres was 12.3 seconds, so even at 50 per cent ofhis top pace there was the capability to run at 6.6minute miling. This was just slower than his beststeady state running pace. Because the injuryoccurred mid-season and time away from runningwas ten days, it would be safe to test the effect ofshort interval steady state runs at approximately halfvolume. The unit of work was four repetitions of twominute runs with two minutes recovery. This causedno reaction to the muscle injury and so could beprogressed to a point where aerobic fitness could beimproved at a time when full speed and change ofdirection could not be achieved.When the other components of phase two and

three of rehabilitation are complemented by theplayer's clear understanding of the time scalerequired to regain tensile strength of tissue, physiolo-gical fitness, skill and coordination, then recurrenceof the injury or the production of a related injury areless likely.

Player compliance with a rehabilitation programmewill be improved if the time scale can be directed to aparticular part of the season which has specialsignificance for that player. Unless the player isaiming for the zenith of his career or is approachingits end, the long term view should be taken. In everycase achievable intermediate functional goals must beset to maintain the player's compliance and motiva-tion. These are even more important if prediction ofthe rate of recovery does not fit with the timescale of amajor sporting event in the player's life. It is alsoimportant that external pressures from manager,coach, peer group, and family are not contradictoryto the management of the injury.

Injury preventionThe very nature of contact sport makes it impossibleto prevent all injury. Nevertheless, every effortshould be made to avoid injury. During the game,technique is all important and the astute coach veryquickly recognizes dangerous practices. Their skilledeye in game analysis and knowledge of the rules areessential for injury prevention during the game.Senior players can play the same role and theirexpertise should be used.What the physiotherapist has to offer is more

related to prevention of injury during training.Assessment of tissue reaction to particular work loadsis particularly important. An example is included toillustrate the point.A middle distance runner during the winter

preparatory period has done the first strength

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endurance hill session on a Saturday. The next dayone calf felt sore and tender. A slow recovery run wasdone on Sunday, and on Monday the session was afast four mile road run. This produced a reaction atthe musculotendinous region of the calf which tooksix weeks to recover with the accompanying loss ofform. This could have been avoided by one or twodays rest with modification of the next two day'straining load. The mistake here was not necessarilyone of training load, but of failing to identify thesignificance of the tissue response to a new trainingload. The identification of tissue responses whichrequire work loads to be changed is an important roleof the physiotherapist, who may thereby facilitate areturn to full function.Another aspect of injury prevention in training

relates to the specific structure of training sessions. Inrugby union this is particularly apparent duringtours.On tour, amateur players are in a position to train

every day. For the coach this is an ideal opportunityto improve fitness and skill levels. The success of atour is based on results, so the coaches' objectives canbe understood. Unfortunately, a very dynamicapproach can be counter-productive, as analysis ofinjuries from three Scottish rugby tours suggest (Table2). (Definition of an injury: signs and symptoms ofmusculoskeletal origin which cause the player to misstraining or playing the next day.)

Table 3 shows that the frequency of intrinsic injury,which includes overuse injuries, is greater thanextrinsic injury and that intrinsic injury tends to occurmore frequently in training. Table 4 indicates thatinjuries incurred in training take longer to resolve.This is probably due to the higher incidence ofintrinsic injuries in training.The frequency, density, volume, intensity and

uneven progression of physical activity are allcontributory factors to intrinsic injury. The messageis clear if the number of injuries and time lost due toinjury are to be reduced16.When planning the structure of training and game

preparation, the individual player must be consi-dered. During the 1987 Rugby World Cup theincidence of injury in training was one every 2.9 h

Table 2. Origin and frequency of musculoskeletal injurieson three Scottish tours

1981 1982 1987(New Zealand) (Australia) (New Zealand)

Injuries sustainedduring training 4 (25%) 8 (38%) 9 (45%)

Injuries sustainedduring game 10 (62%) 10 (47.6%) 6 (30%)

Both 2 (13%) 2 (9.5%) 4 (20%)Other 0 (0%) 1 (4.9%) 1 (5%)

Incidence of injuries relatedto time during:Training 1 per 11 h 1 per 6.75 h 1 per 2.9 hGame 1 per 1.06 h 1 per 1.20 h 1 per 0.86 h

compared with one every 6.75 and 11 h in 1982 and1981 respectively. A possible explanation for thehigher incidence was the relative experience of theplayers. The average age of the three touring partieswas very similar but the average number of caps wonwas much higher in 1987. The relationship betweenexperience at the top level and musculoskeletal injuryis even clearer in Table 5 and illustrates just one aspectwhich should be considered when conditioning ateam of individuals.Coaches are under extreme pressure because their

reputation is at stake. Ironically, their approach toconditioning can increase that pressure. This can onlybe changed if there is prospective and regulardialogue which includes player, coach, physio-therapist and doctor to ensure that the structure ofconditioning programmes acknowledges the cor-relation between frequency, intensity, volume, den-sity and injury17

Table 3. Frequency of intrinsic and extrinsicmusculoskeletal injuries on three Scottish tours

1981 1982 1987(New Zealand) (Australia) (New Zealand)

ExtrinsicTraining 0 0 4Game 5 8 3Total 5 (31%) 8 (38%) 7 (35%)

IntrinsicTraining 4 8 5Game 5 2 3Both 2 2 4Other 0 1 1Total 11 (69%) 13 (62%) 13 (65%)

Table 4. Average training time (days) lost due tomusculoskeletal injuries on three Scottish tours

1981 1982 1987(New Zealand) (Australia) (New Zealand)

Training 5.8 6.0 4.6Game 2.9 5.2 3.1

Table 5. Average age and number of caps of thosesuffering muscle tears and overuse injuries on threeScottish tours

1981 1982 1987(New Zealand) (Australia) (New Zealand)

Age 28.8 (27) 26.9 (26.6) 29.3 (27.9)Caps 13.4 (9.8) 12.7 (11) 28.3 (16.6)

Squad figures in brackets.

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Role of the team physiotherapist in rugby union football: D.A. McLean

ConclusionThe chartered physiotherapist can fulfil a variety ofroles in conjunction with medical back up. Injuryprevention is the most important. Prevention may beachieved if a support team is available to the players.The coach and physiotherapist are equally responsi-ble for injury prevention in training. The coach is theprime mover in prevention of injury on the fieldthrough teaching of safe techniques. The administra-tors have a responsibility to involve and consult asupport team and review the rules of the game toinclude the prevention of injury.

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