The unknown risks of youth rugbyBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h26 (Published 08 January 2015) Cite this as: BMJ 2015;350:h26
All rapid responses
Eighteen months after this excellent editorial the school rugby season is once more approaching. In response to safety concerns raised by Michael Carter in this editorial and by other eminent health professionals such as Professor Pollock, we conducted a questionnaire survey targeted at rugby playing schools in the UK. Our aim was to look at compulsion to play, informed consent, safety precautions, and schools’ approach to recording and auditing of rugby injuries.
A structured questionnaire was distributed to 447 rugby-playing schools in Autumn 2015, with the help of the Good Schools Guide. Only a quarter of schools (116) returned the questionnaire (perhaps itself an indicator of attitudes to safety). Many expressed concerns about anonymity and publicity.
Rugby was compulsory in 77% of responding schools, with nearly all playing contact rugby. Half introduced contact rugby after an introductory period playing tag rugby. Introduction of contact rugby varied in age from 8 until 13. In 12 schools, students were allowed to choose between tag and contact rugby.
Only 9% of schools required express parental consent for children’s participation in contact rugby, while 6% required this only if a boy played against children from an older age band. Many schools felt that consent was implied when children were registered with the school or by the signing of a general sports consent form.
87 schools (75%) had clear protocols for recognition and management of concussion, either their own or RFU/SRU models, while the remainder had none, or non-specific instructions - for example, to ‘ask parents to take the child to their GP’. While 90% of responding schools playing contact rugby recorded rugby injuries, only 44% had a clear process for reviewing injuries. This translates to 10% not maintaining any records of rugby-related injuries at all. Poor recording of rugby injuries by schools and medical institutions was raised in this editorial as a key blocker to understanding the true incidence of rugby-related injuries amongst school children. This was reflected in our study, illustrated by the lack of systematic auditing of rugby injuries in 56% of the responding schools.
All but one school had basic measures in place to reduce risk and optimise safety in lessons and matches, with an emphasis on teaching good technique, checking the state of the pitch, and first aid training for staff. To their credit, a minority had advanced measures, such as coaches obtaining a 1st4Sport Level 3 certificate in coaching Rugby Union and mandatory annual RugbyReady courses. Some had medically-trained personnel attending matches.
Most provided staff with concussion recognition training, ranging from online e-learning to regular updates on rugby-specific head and spinal injuries. A minority were working with the University of Bath in a collaboration to increase fitness training and reduce injuries in youth rugby.
The introduction of weight / physique matching is moving up the agenda, especially where coaches have seen it working well in New Zealand’s schools. However, while 19 (16%) followed the common New Zealand practice of matching children by weight rather than age during training, only 2 schools did so formally for matches, with a quarter of schools volunteering that an RFU directive prevented weight-matching.
The government’s plan was to increase financial provision for rugby in state schools, and the RFU’s All Schools project aims to increase the number of secondary state schools playing rugby union. This would be an opportune time to expand the discussion to ensure robust safety systems are in place and that injuries are carefully audited before implementation.
The Department of Education places the duty of care firmly on schools. We feel that compulsion to play, lack of informed consent and poor auditing of injuries by many schools should be urgently addressed before placing a larger number of children at increased risk of long-term injury. Until we have strict auditing of school rugby injuries and choice to play in a sport that carries a significant risk of injury, with strict safety precautions in place, parents and schools must not be complacent as children continue to be injured, sometimes seriously.
Pollock AM. Tackling rugby; what every parent should know about injuries. Verso Press, 2014.
Pfister T et al. The incidence of concussion in youth sports: a systematic review and meta-analysis.. Br J Sports Med 2016;50 292-297.
Competing interests: No competing interests
I am a junior doctor that has worked in anaesthetics, intensive care and in the emergency department. I am also a lifelong rugby player and supporter.
This debate has recently been reignited by Professor Allyson Pollock's open letter calling for a move to make rugby a non-contact sport for children and adolescents.
Life is a game of risks versus benefits and even at a young age the enjoyment of rugby as a contact sport can foster significant benefits that can be developed into adult life including increased strength and fitness, development of a competitive edge and significant camaraderie of being part of a successful team. Putting your body on the line is probably the ultimate form of leadership. Taking contact out of the game takes away an edge which would be sorely missed by its participants and could take away from them in their future lives. Often rugby is the preferred sport of the larger child, (it was for me!). I have certainly gained weight since stopping playing, will this add further to the burden of childhood obesity, (and therefore adult associated chronic diseases and cost to the NHS?).
There are obvious risks associated with playing rugby and I think most children that have reached "tackling age" have an appreciation of this, as do their parents. However I agree these risks are not yet presented in a contextualized and easy to understand format for children and parents
I think that if we are to have a serious debate about forcing children to play non-contact rugby, we should properly think about and present the risks. You mention two deaths as a direct result of rugby. How many deaths have you seen from children being hit by cars, either cycling or as pedestrians. Have you seen deaths from football? Diving or swimming? We need to look at everything, not just single out rugby!
I agree we need a proper database of injuries and then a rational look at the results, taking into account the significant benefits competitive rugby can provide.
In addition many injuries may be avoided by other means: correct positioning and better coaching. Perhaps we should not play on an age basis but on a weight category basis, children obviously develop differently and at different times over adolescence.
Competing interests: No competing interests
The response to my editorial has been extensive and very illuminating. A large portion of it from parents of rugby injured children. Trewartha and Stokes' communication deserves special attention as much of it relates to work sponsored by the sports regulatory body in England. I absolutely agree that there has been a noticeable boom in injury prevention initiatives and injury surveys over the past couple of years.
Appropriately too in my view as observations by myself, other parents and increasingly some authors, suggest that injury is more of a problem than is generally accepted. I make no apology for supporting this assertion. The stakes are after all, very high. The reasons for this are becoming clear. A great deal of research in the UK involves restricted study groups both in terms of size and composition. This is true even for contemporary initiatives such as the RFUs CRISP project. We thus remain far from consensus informed by a comprehensive national data set. The value of such has clearly been demonstrated by the smart rugby initiative in New Zealand, where meticulous injury data are collected by the national accident injury compensation scheme. These have contributed to initiatives that have demonstrably reduced injury incidence in that nation. The other issue is that so many contemporary surveys depend on self reporting of injury by players, clubs and schools. The potential for under reporting in these situations is obvious.
Another point I'd like to make is that the machinery for prospectively acquiring a national data set already exists. All clinical activity by emergency departments and GPs is coded and there are several redundant ICD codes that could potentially be deployed to allow large scale surveillance of all rugby ( and other sporting) injuries. This would require a national public health initiative of sorts as ICD codes are generally not deployed unless associated with a tariff. This is something my department is already working on with NHS England.
Trewartha and Stokes also imply that the children's game is comprehensively supported by a wrap around interest from RFU sponsored bodies, particularly when it comes to injury. Having observed school and club rugby over a decade in this region, I think the reality is that such involvement is actually very patchy. Despite the fact that Bristol Paediatric Neurosurgery is an internationally recognised, research intense department and the RFUs injury surveillance service is based only twelve miles from here in Bath, we have not in ten years had any approach regarding injured players we've seen, return to play schedules or development of research collaborations. Given the number of paediatric rugby injuries we treat, this seems to be a bit of a missed opportunity. And indicative of the relative inertia, that until very recently, has bedevilled progress in this field.
Competing interests: No competing interests
Mr Carter's article was interesting and while it contains some inaccuracies and assumptions, one cannot disagree that we must strive to minimise serious injury. In a society, where the dangers of inactivity in children are increasingly causing concern, and opportunities to develop the core values rugby promotes are more limited, the minor bruises and soft tissue injuries that are an inevitable part of a contact sport may be more acceptable but we need to continue to modify the risks of more serious injuries. Many daily activities carry risks of serious physical injury (e.g. driving or cycling) - and we have to take appropriate steps to reduce risk and then balance residual risk against benefits.
We would contest that risks are not assessed in the same way as other activities. Schools, clubs and RFU evaluate rugby risks and put controls in place to minimise them. This includes developing regulations (covering aspects like age groupings, length of play) and the rules of play. A number of changes have been made recently to alter the introduction of various components of the game, for player welfare as well as enjoyment and engagement. The most significant controls remain in the training and management of players. There is no substitute for good technique and good discipline, through coaches who instil the right values, and referees who are well trained and proactive at controlling situations that could become dangerous. The Rugby Ready course, designed by World Rugby (formerly the IRB), ensures all coaches know how to teach players safe techniques in all aspects of contact.
Previously the RFU asked all clubs to report injuries requiring hospital treatment or keeping a player off work/school for a specified period. A few years ago, it only became necessary for all to report the most serious of injuries. Since then a sample of clubs were included in a programme called CRISP (Community Rugby Surveillance Project) which looks in detail at relatively minor and major injuries. This produced more useful information; by restricting it to a sample the amount of data was manageable while still allowing statistically significant results. CRISP only surveys injuries at 1st XV level and important findings are made widely available.
CRISP appears to confirm that the tackle is the worst area for injuries. The best way to control this is through good training in correct technique and strong refereeing. Interestingly the number of injuries to the tackled player exceeds those to the tackler. Some of these may be due to poor technique by the tackler but it does highlight whether we should give more attention on falling safely, which features more in Rugby League coach education and is being enhanced in local coaching for under10s. CRISP does not support the scrum being a hotspot for injuries although it is the source for a limited number of very serious injuries. Following trials in a number of countries, including France, various changes have been made a) the introduction of full scrums and contested scrums has been delayed in the New Rules of Play, b) youth scrums are not fully contested (neither side can push >1.5m) which significantly reduces risk of collapse, and c) the engagement sequence has been changed to make it a pushing contest between those already in safe body positions.
The impact of an over-heated tribal atmosphere has not been quantified but does seem to have the potential to adversely affect player discipline and hence increase the risk of injury. I think the scenario Mr Carter describes is outdated and would no longer be the norm. Support materials (figure 1) and advice have been given to all local clubs through the ‘Play Nice’ initiative and they are also being offered grants to promote the core values of the game.
We would also highlight a recent RFU campaign on concussion: http://www.englandrugby.com/my-rugby/players/player-health/concussion-he...
The use of weight-bands instead of age-groups is interesting. Contrary to what is often thought, this is not quite what happens in New Zealand. Their system is a composite. In each age-group up to under 13 (Mini) there are two strands - a standard group for those within a weight-bracket for that age and a 'restricted' group for those below this weightbracket. Those above the given weight bracket for age play with the age group above. This is a system which bigger clubs could operate in the UK but it is more difficult for smaller clubs who would struggle to have both standard and restricted groups and for schools which may timetable games based on school years. Banding according to physical maturation would be even more difficult to implement.
There is no information in the CRISP reports on the spread of injuries across the season or indeed whether, if they cluster early in the season, this is caused by poor conditioning and/or harder ground conditions. CRISP does show that more injuries happen late in the game which could relate to conditioning. This is ameliorated at mini and youth level by playing shorter games. Notably the injury scenario seems to be worse in the professional game and in higher divisions within the amateur game, where one would expect better conditioning. We suspect this may be due to all the power-based gymwork, leading to bigger impacts and less fat to absorb them. Conditioning work in children should be largely cardiovascular, to build up endurance to maintain skilful performance. With most Minis this is achieved through our normal training programme with ball in hand but youth players, may need conditioning programmes outside their normal rugby training.
In summary , at grass roots level, hard work reduces the risk of significant injuries so our game remains worth playing but we should never be complacent and remain transparent. As a profession so closely linked with rugby, medical professionals play an important role in primary injury prevention. Rugby however remains a game focused on building personal qualities, and promotes exercise, in a generation of declining activity levels, and many players have positive experiences, friends and memories that last a lifetime.
Competing interests: Nick has been coaching for many years, Mark is a coach and a parent.
Carter’s paper on the schoolboy rugby injury crisis is both timely and helpful.
Concerns regarding rugby injury are not new. In 1954 O’Connell reported an injury incidence of 1 per 31 playing appearances. This increased to 1 per 17 playing appearances in 1992.(1) Currently it is suggested that the injury rate has increased to a level where 1 in 4 rugby players can expect a significant injury during the course of a season.
The changes in the injury rate and profile are underscored by Mr Carter`s paper. The answer to the changing profile may lie in the laws of the game. In 1995 rugby union became an “open game” and professionalism was embraced by the rugby fraternity. From that moment on the commerciality of rugby union became a primary concern. The injury rate also increased at the onset of professional standing for rugby union. Bathgate demonstrated a nearly 2 fold increase in injury incidence after the onset of professionalism with a rate change of 47 to 74 injuries p er 1000 player hours.(2)
In 2009 the Laws were changed to speeded up rugby union to make it easier to play, easier to referee and easier for the public to understand. The upshot was an exciting professional game and an explosion in injuries in both amateur and schoolboy rugby, all in an effort to promote a professional game that very few school boys would ever play.
As a result of the Law changes continuity was increased and the ball is now in play for longer periods of time during a rugby match. This was of the order of 22 minutes in 1991 in the pre professional era, and now is of the order of 36 minutes. At the 2011 Rugby World Cup the ball was in play for an average of 35 minutes 25 seconds or 44.3% of the allotted 80 minutes of the rugby game.
With a greater playing time and more continuity, professional teams placed greater emphasis on the breakdown where possession can be contested and possession maintained. Rugby players have become bigger and heavier with a great emphasis placed on size by modern coaches. This too undoubtedly affects the injury profile, particularly during high speed contact in the tackle which is the single event that accounts for the largest proportion of injury (46.6%) across all levels of play.(3)
The changes in the Laws of rugby are considered to have created a better and more exciting visual spectacle but excellence in this sport does not specifically equated to professionalism.
The overt crowd aggression that Carter`s paper highlights at school rugby matches is a relatively new phenomenon in rugby union football and often borders on tribalism. This has come from professional sport where winning is the only end point and enjoying a good match or your child’s participation for its own sake may not be enough.
This raises a question. Is school boy rugby a sport--“a competitive pursuit with an objective way to score and hinder your opponent's ability to score”--or a game "which is both entertaining to play and watch”? Schoolboy rugby football can be both with the added advantage of being an educational tool for life skills.
As Carter has clearly outlined, there is a significant need for audit to quantify the extent of the problem and grasp the nettle of underage rugby injury. However should the medical profession also recommend a change in the Laws of rugby union pertaining to schoolboy rugby?
Rugby football from its inception was a game which had room on the pitch every one: “the piano movers and piano players”. The changes in the Laws over the past number of years have created a game that suits the former only, with a significant increase in injury rate and severity. Has the time come to change the Laws for schoolboys and cadet players, and make this level of rugby a safer game? This may then address the fundamental problem that the pattern of injuries have changed since the “Laws” changed to make the professional game more attractive to a viewing audience. Perhaps the time has come for schoolboys to return to the rugby game of the 1980s and 1990s, when the rugby injury rate was less significant. This could be simply achieved by reworking the Laws for school boys.
Some simple changes in school boy rugby might have a significant impact on the danger areas of the tackle, the breakdown and scrum, as well as reducing the ”ball in play time” to the low 20 minutes by reducing the length of school boy matches.
The time has come for the medical profession to influence this important debate, and act as an advocate to ensure the safety and survival of this wonderful old game, and protect the vulnerable school boy rugby player.
1 O’ Brien C; Retrospective survey of rugby injuries in the Leinster province of Ireland 1987-1989. , Br J Sports Med. Dec 1992; 26(4): 243–244.
2. Bathgate A, Best JP, Craig G, Jamieson M. A prospective study of injuries to elite Australian rugby union players. Br J Sports Med. 2002;36(4):265-9; discussion, 9
3 McIntosh AS, Dutfield R;. Rugby Union Injury Surveillance Study. 2007 Summary Report. Sydney, Australia: School of Safety Science, University of New South Wales; 2007.
Competing interests: No competing interests
This editorial raises important issues and the subsequent responses indicate an increasing evidence base. Rugby Union has a responsibility to young people. It is not possible to consider youth rugby without considering the game as a whole The game now exists under significant competitive, financial and physical pressures.
I write with some reflections based on playing top level schools rugby, stopping playing in medical school due to injury, and being a voluntary medical officer for an English National League side.
I would make the following observations and points:
1. Young players will dream of wealth and fame based on what they see in the elite game;
2. Professional players , directors of rugby and their staff will take physical risks to win;
3. Elite games are often dominated by defence, with a rugby league approach coming from that game in which there are 13 players on the pitch and the game stops after each successful tackle;
4. Rugby union attacks often begin further back, accelerating into the defence line at higher speed;
5. Head to head collisions in the tackle are more common causing more lacerations and concussion;
6. High tackles fill me with dread. One suggestion I would like to make to the law makers would be to draw a line on all shirts at nipple level and rule that all tackles in open play are made below it. A yellow card should go to all who tackle above this. . This might also favour the attackers on both sides and result in a more open game for the benefit of players and spectators.
Competing interests: No competing interests
We welcome the BMJ’s recognition of the issues of injury risk in schoolboy rugby players as an area very much in need of further study[1, 2]. However, it is unfortunate the editorials do not discuss the current efforts in this area.
In response to Mr Carter comments ‘it is vital that schools, clubs, medical facilities, and, most importantly, regulatory bodies cooperate now to quantify the risks of junior rugby’, we wish to highlight there is an active programme of research into this very issue in different parts of the UK, which is in the peer reviewed literature[3-9] and the national press.
In Scotland, a collaboration of medical professionals and research academics was formed 4 years ago to address schoolboy rugby injuries. This independent group has worked with the rugby authorities, clubs and schools in order to effect change. As such we have been able to influence schoolboy rugby playing policy in Scotland through the provision of evidence based recommendations.
We have already pursued a path that is suggested in the current editorial: We initially focussed on collating the serious injury risk then addressed the troublesome issue of differing physical statures of youth players and progressed to looking at particular areas of high risk, such as the transition to senior rugby and the scrum . As a direct result, the playing age for schoolboy rugby competitions in Scotland has been changed, and specific policy adopted to prevent ‘under aged and undersized’ boys playing in a potentially dangerous environment with older boys. An evidence based system of maturity testing has been in place in Scotland for the last 3 years.
We do not wish to sound complacent; much more work needs done, as has been identified in the editorials. We wholeheartedly agree with the need for robust epidemiological data collection and have repeatedly called for this[4, 10] but we disagree with the statement that there is a lack of will or ambition to set up a national data set of injuries. We are currently working with the rugby authorities, schools and clubs to achieve comprehensive reporting of injuries. However, the work we have done has been unfunded relying on support from the University of Edinburgh. If schoolboy rugby injuries were a higher priority for funding bodies, and resources were available, considerable progress could be made; we would like to highlight this as the major barrier rather than denial, concealment or conspiracy.
David Hamilton , Jamie Maclean  & Hamish Simpson 
 University of Edinburgh
[2 ]Perth Royal Infirmary
1. Godlee F, The NHS is not (yet) in crisis, but what about school rugby? BMJ 2015;350:h78
2. Carter M. The unknown risks of youth rugby: And the urgent need to quantify them. BMJ 2015;350:h26
3. MacLean JGB, Hutchison JD. Serious neck injuries in U19 rugby union players: an audit of admissions to spinal injury units in Great Britain and Ireland. Br J Sports Med 2012;46:591–4.
4. Nutton RW, Hamilton DF, Hutchison JD, Mitchell MJ, Simpson AHRW, Maclean JGB. Variation in physical development in schoolboy rugby players: can maturity testing reduce mismatch? BMJ Open. 2012;2:e001149
5. Hamilton DF, Gatherer D, Jenkins PJ, Maclean JGB, Hutchison JD, Nutton RW, Simpson AHRW. Age-related differences in the neck strength of adolescent rugby players: A cross-sectional cohort study of Scottish schoolchildren. Bone Joint Res 2012;1:152–7.
6. Hamilton DF, Gatherer D, Robson J, Rennie N, Graham N, Maclean JGB, Simpson AHRW. Comparative cervical profiles of adult and under-18 front row rugby players: implications for playing policy. BMJ open 2014;4:e004975.
7. Palmer-Green DS, Stokes KA, Fuller CW, England M, Kemp SP, Trewartha G. Match injuries in English youth academy and schools rugby union: an epidemiological study. Am J Sports Med. 2013;41:749-55
8. Palmer-Green DS, Stokes KA, Fuller CW, England M, Kemp SP, Trewartha G.Training Activities and Injuries in English Youth Academy and Schools Rugby Union. Am J Sports Med. 2014 [epub] Dec 15
9. Nicol A, Pollock A, Kirkwood G, Parekh N, Robson J Rugby union injuries in Scottish schools. J Public Health (Oxf). 2011;33:256-61
10. Hamilton DF. Addressing cervical injuries in schoolboy rugby players. International Rugby Board Medical Conference. 2013. Dublin
Competing interests: We have no financial competing interests
The problem is perhaps laid out at the start.
"Schools, coaches, and parents all contribute to a tribal, gladiatorial culture that encourages excessive aggression, suppresses injury reporting, and encourages players to carry on when injured. "
I'm reminded of a recent post by Donald Clark "Character education – an assassination"
"In the UK we have an entirely different, and hugely influential, stream of thought that comes originally from Thomas Arnold and the public school system. Let’s call it the ‘playing fields of Eton’ complex, but anyone who has experience in the UK system knows exactly what this is. "
"Character and conformity are easily confused. Far from shaping ‘character’ in schools, we should be doing the opposite and encouraging students to question these norms and become autonomous learners, able to distinguish between moral inculcation, based on assumed social norms, from more open tolerant approaches to education."
Clark suggests that most sports are better done outside school altogether. Too many kids are deterred from taking part because they naturally suspect that it's meant to be "character education", not fun. And compulsion is not the best way to encourage people.
Some kids (and some adults) are attracted to sports that carry a risk, and that's up to them. One solution might be to give kids a chance to try rugby (and sailing, and boxing, and MMA) at an early stage, with plenty of safety precautions, perhaps with local clubs. Those who don't like them shouldn't be compelled to carry on. Those who do will be all the keener because they would be doing something they really want, free of school-masterish preaching. And some of those who drop it at school will come back later. A few will make the Olympics: most will just have fun.
Competing interests: No competing interests
Sir, We read your Editorial ‘The unknown risks of youth rugby- And the urgent need to quantify them’ with much interest.
In the past couple of years, few subjects at the intersection of medicine and sport have generated as much public interest as sports injuries and concussions – especially in youth rugby. This is of particular note in Northern Ireland where two catastrophic injuries have recently occurred in the schoolboy game, resulting in one fatality and one quadriplegia.
Although a number of studies within the United Kingdom have already highlighted a high incidence of injury in schoolboy rugby, these have analysed a small sample of the playing population over limited time periods and have been of suboptimal study design.
The current lack of comprehensive, clear, and coherent data from a surveillance study is striking and makes its development a priority. It is only after collection of such data that a framework to minimise the risk of injury in youth rugby can be truly developed.
To help close this data gap, a group of like-minded and allied healthcare professionals, all of whom have a rugby-playing background, established a regional research group, Rugby Injury Surveillance in Ulster Schools (RISUS). This has been funded by the MITRE charity and supported by the Ulster University. The aim of the group was to establish and oversee a local surveillance system to accurately determine the incidence of all rugby related injuries and concussion in senior schools rugby in Ulster.
This online Injury Surveillance System, (www.risus.info) went live at the start of the current season. All of the School first XV squads in Northern Ireland are participating in the project with over 800 schoolboys recruited over the 2014-15 season. In addition, pre-season data on all participants was collected on a range of factors relating to their demographic information, concussion history, use of protective equipment, nutritional supplement use as well as the volume/nature of strength and conditioning.
We agree with Michael Carter that the key to such a project is engagement with the sports regulating body. For without them it will be impossible to implement strategies to reduce risk. We have found such support from the Irish Rugby Football Union and Ulster Branch who fully endorse our project.
Our ultimate aim is that the data will allow our national rugby bodies to develop regional policy, if necessary enforce rule changes, and increase recognition of injuries in order to mimimise the risk to youth rugby players. We hope to publish our study findings at the end of this playing season.
We fully endorse Mr Carter’s comments.
Competing interests: The RISUS group receive research grant funding from the Irish Rugby Football Union (IRFU) and Ulster Rugby
The message about adequate pre-season training should be relayed to universities and their students as well as schools.
My son (2nd row) suffered a mid cervical fracture dislocation in his first term at university after coming back from a gap-year in which he hadn't played or trained. With hindsight, I wondered whether some proper pre-season training to build up his neck muscles might have prevented the injury.
Fortunately, the story had a happy ending for which we will be forever grateful to a fantastic NHS neurosurgeon , anaesthetist and team.
Competing interests: No competing interests