Authored by the Women’s Rugby Injury Surveillance Project (WRISP) steering group

RFU:

  • Simon Kemp (Medical Services Director)
  • Katie Wojek (Player Welfare Manager)
  • Katy Hornby (England Women’s Lead Doctor)
  • Lewis Henderson (Rugby Systems and Data Controller)
  • Aisling Byrne (England Women’s Physiotherapist)

University of Bath:

  • Sean Williams (Lecturer)
  • Keith Stokes (Professor)
  • Lindsay Starling (Ph.D. candidate)

The authors would like to acknowledge with considerable gratitude, the work of the doctors, physiotherapists and strength and conditioning staff from the Premier 15s clubs and England teams who have recorded injury and training information throughout the project.


1 At-a-Glance Summary

Premier 15s Match Injuries

  • Injury incidence rate: 39 / 1000 h
  • Mean days missed: 46 days
  • Burden: 1794 days absence / 1000 h
  • Highest burden event: Tackled
  • Highest burden injury diagnosis: Knee other

Premier 15s Training Injuries

  • Injury incidence rate: 1 / 1000 h
  • Mean days missed: 51 days
  • Burden: 51 days absence / 1000 h
  • Highest burden event: Rugby skills, full contact
  • Highest burden injury diagnosis: Posterior thigh muscle strain/rupture/cramps

England Match Injuries

  • Injury incidence rate: 114 / 1000 h
  • Mean days missed: 28 days
  • Burden: 3192 days absence / 1000 h
  • Highest burden event: Tackling
  • Highest burden injury diagnosis: Hand/finger/thumb fracture

England Training Injuries

  • Injury incidence rate: 11 / 1000 h
  • Mean days missed: 67 days
  • Burden: 737 days absence / 1000 h
  • Highest burden event: Rugby skills, semi contact
  • Highest burden injury diagnosis: Knee sprain/ligament

2 Executive Summary

  • This is the third season of injury surveillance for the Women’s Premier 15s League competition. The Women’s Rugby Injury Surveillance Project (WRISP) will be pivotal in both providing the baseline data needed to assess trends in injury risk, and in guiding further investigation into injuries that are common, severe, or increasing in incidence.

  • The 2019-20 Premier 15s competition was halted in March 2020 due to the COVID-19 pandemic, and was subsequently declared null and void. Given that this is only the third season of data collection in the women’s professional setting, and that the current season was cut short due to the COVID-19 pandemic, there is currently insufficient data to comment on trends in injury risk or the significance of changes between seasons.

  • Overall, it is the view of the WRISP steering group that despite being one of the most comprehensive injury surveillance projects in the women’s game to date, the injury risk profile presented in the current report does not yet fully reflect the injury risk in this setting. A number of improvements to the data monitoring and quality-checking processes have already been made to ensure the WRISP data is of the highest quality for monitoring and reducing the risk of injury in the women’s professional game moving forwards.

  • The overall incidence of match injury in the Premier 15s was 39 / 1000 hs (10 injuries per team, or 1.6 injuries per match), which was similar to 2018-19 (35 per 1000 hours). This incidence rate is relatively low and might reflect under-reporting of minor (2-7 day) injuries. As such, it might be expected that the reported incidence will rise in future seasons as reporting continues to improve.

  • The average time missed per match injury was 46 days. This figure is higher than the men’s Premiership (38 days), and further reflects under-reporting of minor (2-7 day) injuries in this setting. The reported mean days missed per injury may be expected to fall in the future as reporting of minor injuries improves.

  • Concussion was again the most commonly reported match injury (5.3 per 1000 hours), making up 14% of all match injuries. Concussion prevention is a priority for the women’s game, alongside developing strategies to optimally detect and manage such injuries.

  • The incidence rate for training injuries was low (1 / 1000 h), whilst the average number of days missed per training injury was high (51 days). This equates to one time-loss training injury every 11 team-training sessions (assuming 2 h sessions involving 45 players). These data may reflect the challenges associated with detecting and reporting injuries in this setting. For instance, medics do not see players as regularly as in the men’s Premiership, and so minor injuries are more likely to be missed in the women’s game. Developing medical resources and practitioner reporting will impact upon this.

  • Despite their low incidence rate, training injuries still accounted for the majority (55%) all injuries reported in this setting. Given the more controllable nature of the training environment, these injuries should be a priority for future preventative efforts.

  • In contrast to the Premier 15s, the incidence rate in England international matches and training was high (114 and 11 per 1000 hours, respectively) and comparable to the men’s professional game. These data may reflect an improved ability to report minor injuries in the England international setting. For instance, England medical practitioners will have greater contact with players during international camps, compared to the practitioners in the Premier 15s, enhancing their ability to report minor injuries.

3 Introduction

This is the third injury surveillance report from the Women’s Premier 15s competition. The Women’s Rugby Injury Surveillance Project (WRISP) will be pivotal in both providing the baseline data needed to assess trends in injury risk, and in guiding further investigation into injuries that are common, severe, or increasing in incidence. It cannot be assumed that the injury risk profile from other rugby settings is applicable to the women’s professional game in England, and so appropriate injury prevention strategies can only be designed and evaluated through the collection of high-quality injury surveillance data.

The 2019-20 Premier 15s competition was halted in March 2020 due to the COVID-19 pandemic, and was subsequently declared null and void. Given that this is only the third season of data collection in the women’s professional setting, and that the current season was cut short due to the COVID-19 pandemic, there is currently insufficient data to comment on trends in injury risk or the significance of changes between seasons. Incomplete training exposure data was provided by four teams, and so the overall Premier 15s training exposure value was extrapolated from data provided by the six teams with 100% compliance. An effort will be made to ensure all Premier 15s teams provide adequate training exposure data in future seasons, in order to better inform our understanding of training injury risk. Finally, the context within which both the players and medical practitioners in the Premier 15s competition operate should be noted; the non-rugby work commitments of players will influence their injury risk and may prolong rehabilitation in some cases, whilst the reduced contact time for medical practitioners with players (compared to the men’s professional setting) will inhibit their ability to report minor injury/illness episodes and will thus influence these injury statistics.

Overall, it is the view of the WRISP steering group that despite being one of the most comprehensive injury surveillance projects in the women’s game to date, the injury risk profile presented in the current report does not yet fully reflect the injury risk in this setting. A number of improvements to the data monitoring and quality-checking processes have already been made to ensure the WRISP data is of the highest quality for monitoring and reducing the risk of injury in the women’s professional game moving forwards.

4 Definitions

Time-loss Injury

A time-loss injury was defined as ‘any injury that prevents a player from taking a full part in all training activities typically planned for that day and/or match play for more than 24 hours from midnight at the end of the day the injury was sustained’. For example, if a player was injured during a match on Saturday and she was able to take a full part in training on Monday, the incident would not be classed as an injury. If the player’s training was restricted on Monday due to the injury received on Saturday, the incident would be classed as a time-loss injury and reported.

Days missed

The time (days) lost from competition and practice was used as a marker of injury severity and was defined as the number of days from the date of the injury to the date that the player was deemed to have regained full fitness not including the day of injury or the day of return. A player was deemed to have regained full fitness when she was ‘able to take a part in training activities (typically planned for that day) and was available for match selection.’

Confidence interval (CI)

The confidence interval shows, with 95% certainty, the likely range of the true value for a given statistic.

Injury incidence rate

The likelihood of sustaining an injury during match play or training is reported as the injury incidence rate. The injury incidence rate is the number of injuries expressed per 1,000 player-hours of match exposure (or training exposure).

Burden

The burden of injury is a measure which takes into account both the frequency and the mean number of days missed of injuries. Burden is measured as the day’s absence per 1,000 player-hours of exposure.

Statistical significance

A result is considered to be statistically significant if the probability that it has arisen by chance is less than 5% or 1 in 20. In this report, statistical analysis has been performed for the match and training injury incidence and burden.

5 Premier 15s Match Injuries

5.1 Injury incidence rate

In the 2019-20 Premier 15s season there were 96 auditable match injuries that led to time-loss from training and/or match play. The analysis included 2460 total hours of match exposure, resulting in a match injury incidence rate of 39 injuries per 1000 match‐hours (95% CI: 31.9-47.7). This equates to 10 injuries per team per season, and 1.6 injuries per Premier 15s fixture. Last season (2018-19) the injury incidence rate was 35 injuries per 1000 match‐hours (95% CI: 30-42). For comparison, the incidence rate in the men’s Premiership was 88 per 1000 match-hours during the 2019-20 season. The incidence rate of injuries resulting in greater than seven days of absence was 26.8 per 1000 match-hours (95% CI: 21.1-34.1). For comparison, the incidence rate of injuries causing a player to miss seven days or more in men’s Premiership rugby during season 2019-20 was 60 per 1000 match-hours. In addition to the injuries recorded during Premier 15s fixtures, there were a further 18 injury events for registered players during University/Other fixtures (note, these injuries were not included in this Premier 15s analysis). This demonstrates the complex landscape faced by medical practitioners in this setting.

5.2 Days missed

The mean number of days missed per match injury during the 2019-20 season was 46 days, while the median was 17 days. Last season, the mean and median number of days missed per injury in the Premier 15s was 57 and 26 days, respectively. For comparison, the mean and median number of days missed for match injuries in the men’s Premiership was 38 and 11 days, respectively, during the 2019-20 season. These findings may be related to injury reporting issues whereby less-severe injuries are under-reported in the women’s game, rather than an inherently higher severity of injury diagnoses within the women’s game, as indicated by the relatively low incidence of minor (2-7 day) injuries (Table 1). The overall burden of match injury was 1794 days absence per 1000 hours. This value equates to approximately 29 days absence per team per match.


5.3 Injury event

Figure 2 shows the percentage of all injuries attributed to each specific match injury event for the 2019-20 Premier 15s season. Being tackled was the (known) match event most likely to result in a time-loss injury, and was the match event associated with the highest overall injury burden. This finding is in contrast to the men’s Professional game, where a greater proportion of injuries are incurred by the tackler rather than the ball carrier. The characteristics of tackle events in the women’s game will be explored in more detail in future seasons. ‘Unknown’ and ‘Other’ match injury mechanisms (with a ‘definite incident’ onset) accounted for 18% of all injuries (down from 30% last season). Continued efforts will be made to ensure more of these injuries are assigned to a specific mechanism in future seasons, in order to better form injury prevention strategies.

Figure 2. Incidence and mean days missed of Premier 15s match injuries by injury event. Size of bubble represents relative injury burden. ‘Unknown’ and ‘Other’ classifications are not displayed (n=17, 18% of all match injuries).

5.4 Injury location

Figure 3 provides the distribution of injuries across the four body regions. Overall, 44% of match injuries occurred to the lower limb, whilst 26% occurred to the head/neck. For specific injury locations, the head/face, shoulder/clavicle, and knee were the body locations with the highest incidence rate, whilst the knee and ankle were associated with the highest mean days missed (Table 2). The injury location with the highest overall burden was the knee.

Figure 3. The distribution of Premier 15s match injuries by body region. Hover over the region to see the percentage of injuries incurred in that region

Figure 4. Incidence and mean days missed of Premier 15s match injuries by injury location. Size of bubble represents relative injury burden. ‘Unknown’ and ‘Other’ classifications are not displayed (n=40, 30% of all match injuries).

5.5 Injury diagnosis

This section provides information about the injury diagnoses. The diagnoses comprise the body site and general injury type but do not provide the details of specific diagnoses. For example, knee ligament injuries are grouped rather than displaying specific injuries such as MCL or ACL. ‘Head/face other’ injuries were the most common single injury diagnosis. Concussion was the most common match injury. Knee sprain/ligament/other injuries carried the highest overall injury burden (Table 2).

5.6 Artificial turf

Four teams included in the current analysis played their home fixtures on 3G artificial turf pitches, resulting in a total exposure of 880 match hours on these surfaces, compared to 1580 hours played on natural grass surfaces. Overall, there was no statistically significant difference in the injury burden on artificial turf (1185 days per 1000 match-hours, 95% CI: 866-1622) compared with natural grass (2125 days per 1000 match-hours, 95% CI: 1639-2755). The injury incidence rate was higher on artificial turf versus natural grass (44.3 / 1000 h vs. 36.1 / 1000 h), whilst the mean number of days lost per injury was lower on artificial turf surfaces (27 days vs. 59 days, Figure 5). However, these findings should be interpreted cautiously, given the relatively low number of injuries recorded on artificial surfaces and the small amount of data available at this time. When combining data pertaining to surface type over the past three seasons, there was no significant difference in overall injury burden between the two surfaces.

\label{fig:fig5}Figure 5. Incidence and mean days missed per injury for Premier 15s match injuries played on artificial turf and natural grass surface during the 2019-20 season. Size of bubble represents relative injury burden.

Figure 5. Incidence and mean days missed per injury for Premier 15s match injuries played on artificial turf and natural grass surface during the 2019-20 season. Size of bubble represents relative injury burden.

Figure 6. Burden associated with Premier 15s match injuries incurred on artificial turf and natural grass surfaces for the 2017-18, 2018-19, and 2019-20 seasons, and for all seasons combined.

6 Premier 15s Training Injuries

6.1 Injury incidence rate

In the 2019-20 Premier 15s season there were 117 auditable training injuries that led to time-loss from training and/or match play. The analysis included 117047 total hours of training exposure, resulting in a training injury incidence rate of 1 injury per 1000 training‐hours (95% CI: 0.8-1.2). Note, incomplete training exposure data was provided by four teams, and so the overall Premier 15s training exposure value was extrapolated from data provided by the six teams with 100% compliance. An effort will be made to ensure all Premier 15s teams provide adequate training exposure data in future seasons, in order to better inform our understanding of training injury risk. The overall training injury incidence rate equated to approximately one time-loss training injury every 11 team-training sessions (assuming 2 h sessions involving 45 players), or 12 training injuries per team each season. The incidence rate for the 2018-19 season was 0.6 injuries per 1000 training-hours during. For comparison, the incidence rate in the men’s Premiership was 3.0 per 1000 training-hours during the 2019-20 season. The incidence of training injuries resulting in more than seven days of absence was 0.9 per 1000 training-hours (95% CI: 0.7 - 1). Despite their low incidence rate, training injuries still accounted for over half of all injuries reported in this setting. Given the more controllable nature of the training environment, these injuries should be a priority for future preventative efforts.

6.2 Days missed

As the current season was not completed, estimated return-to-play dates were provided for twelve training injuries, and these estimations were used to calculate the number of days missed for those injuries. The mean number of days missed for training injuries during the 2019-20 Premier 15s season was 51 days, while the median was 30 days. Last season, the mean and median injury days missed were 65 and 56 days, respectively. For comparison, the mean severity of training injuries in the men’s Premiership was 35 days during the 2019-20 season; these findings may again reflect a reduced ability to report minor (2-7 day) injuries in the Premier 15s, due to differences in medical/administrative resources in comparison to the men’s Premiership setting (Table 3). The overall burden of training injury was 51 days absence per 1000 hours.


6.3 Injury event

Table 4 shows the incidence, mean days missed and burden attributed to each specific training injury event for the 2019-20 season. Rugby skills training (full-contact) was the training format most likely to result in a time-loss injury and also represented the training format with the highest overall burden.

6.4 Injury location

In training, 56% of injuries were to the lower limbs (Figure 7), with a large majority of these (n=16) related to the posterior thigh (Table 5).

Figure 7. The distribution of Premier 15s training injuries by body region. Hover over the region to see the percentage of injuries incurred in that region

6.5 Injury diagnosis

This section provides information about the training injury diagnoses relating to the Premier 15s. Posterior thigh strains were the most common injury diagnosis in training and were also associated with the highest overall burden. The incidence of concussion injuries in training was low (0.1 per 1000 hours), but the absolute number of concussions was similar in training (n = 12) than it was for match-play (n = 13).

7 England Match Injuries

7.1 Injury incidence rate

In the 2019-20 season there were 16 auditable match injuries during England women’s matches that led to time-loss from training and/or match play. The analysis included 140 total hours of match exposure, resulting in a match injury incidence rate of 114 injuries per 1000 match‐hours (95% CI: 70-187). Last season (2018-19) the injury incidence rate for England match injuries was 146 injuries per 1000 match‐hours. In addition, the mean injury incidence rate during the 2010-2017 Women’s Rugby World Cup tournaments was 44 per 1000 match‐hours. The incidence rate of injuries resulting in greater than seven days of absence was 57.1 per 1000 match-hours (95% CI: 28.6-114.3).

7.2 Days missed

The mean number of days missed per match injury for the 2019-20 season 28 days, while the median was 7 days. Last season, the mean and median number of days missed per injury in England matches was 31 and 20 days, respectively. The mean days missed for injuries during the 2010-2017 Women’s Rugby World Cup tournaments was 46 days. The overall burden of match injury was 3192 days absence per 1000 hours. This value equates to approximately 456 total days absence per match. Compared to the Premier 15s, England injuries occurred at a higher rate but resulted in fewer days missed per injury (on average), resulting in an overall burden of injury that was significantly higher than that of the Premier 15s (3192 vs. 1794 days/1000 match-hours).


7.3 Injury event

Figure 8 shows the incidence and mean days missed for each specific match injury event for the 2019-20 season. Being tackled was the match event most likely to result in a time-loss injury, accounting for 22% of all match injuries. In contrast to Premier 15s matches, tackling was associated with a higher burden of injury compared to being tackled.

Figure 8. Incidence and mean days missed of England match injuries by injury event. Size of bubble represents relative injury burden.

7.4 Injury location

Figure 9 provides the distribution of injuries across the four body regions. Overall, 44% of match injuries occurred to the lower limb, whilst 39% occurred to the head/neck. For specific injury locations, the head/face was the body location with the highest incidence rate whilst neck/cervical spine injuries had the greatest overall burden, though this was accounted for by just two injuries. As such, the high burden of neck/cervical spine injuries is unlikely to be a consistent injury pattern in future seasons (Table 8).

Figure 9. The distribution of England match injuries by body region. Hover over the region to see the percentage of injuries incurred in that region

7.5 Injury diagnosis

This section provides information about the specific match injury diagnoses relating to the England women’s team. Concussion injuries were the most common injury diagnosis (Table 9), though all injuries had a low absolute number of occurrences.

8 England Training Injuries

8.1 Injury incidence rate

In the 2019-20 season there were 21 auditable training injuries that led to time-loss from training and/or match play. The analysis included 1954 total hours of training exposure, resulting in a training injury incidence rate of 11 injuries per 1000 match‐hours (95% CI: 7-16). Last season, the injury incidence rate during England training was 4.5 per 1000 training‐hours. The incidence of training injuries resulting in more than seven days of absence was 7 per 1000 training-hours (95% CI: 4-13).

8.2 Days missed

The mean number of days missed per training injury for the 2019-20 season was 67 days, while the median was 22 days. Last season, the mean and median number of days missed for England training injuries was 44 and 10 days, respectively. These data reflect the relatively high proportion of severe (>28 d) injuries (Table 10). The overall burden of injury was 737 days absence per 1000 hours.


8.3 Injury event

Table 11 shows the incidence, mean days missed and burden attributed to each specific training injury event for the 2019-20 season. Full-contact and semi-contact rugby skills sessions were the training formats associated with the highest injury incidence rate.

8.4 Injury location

In training, 62% of injuries were to the lower limbs (Figure 10), with knee and shoulder/clavicle injuries having the biggest burden (Table 12).

Figure 10. The distribution of England training injuries by body region. Hover over the region to see the percentage of injuries incurred in that region

8.5 Injury diagnosis

This section provides information about the injury diagnoses relating to the England training injuries. Anterior thigh muscle strain injuries had the highest incidence rate (n = 3). A single knee sprain/ligament injury was associated with the highest number of days missed (Table 13).