Summary

We have demonstrated that in spite of an increased awareness of head injury and evidence that rule changes made by World Rugby have had benefits to player welfare, head injury remains a common risk in professional elite Rugby Union and further work is required to further decrease the risk of head injury.

Abstract

Introduction

Head injury is of significant importance in many contact sports with ever growing interest in the subject as we gain awareness of the potential long-term sequelae of concussion. Rugby's governing body, World Rugby, has introduced rule changes in accordance with emerging evidence regarding head injury in an attempt to improve player welfare and decrease the rate of head injury.

We aimed to report the frequency of head injury and head injury assessment (HIA) and potentially identify any causative factors or trends associated with head injury within elite Rugby Union at the recent 2019 Rugby World Cup and compare these findings to those reported at previous Rugby World Cups to determine if such rule changes have been beneficial.

Methods

We reviewed all 45 games that were played in the tournament involving 20 teams during the 6-week long tournament. This comprised of 37 group matches and a further 8 in the knock-out stages. We recorded the number of head injuries sustained in the games, the position of the player, the mechanism of injury, whether the player had an HIA and whether they were cleared to return to play. We then compared these findings to those described within the literature relating to prior Rugby World Cups.

Results

A total of 68 head injuries were recorded (1.33 per game). Thirty-six players (52.9%) were removed from play in order to undertake an HIA. Of these 23 (63.9%) failed an HIA and therefore were considered to have suffered a concussion, 13 (36.1%) were permitted to return to play. The head injury rate in 2019 was 37.8 per 1000 player hours which demonstrated an increase from previous tournaments (22.0 in 2015; 14.6 in 2011; 4.7 in 2007). The rate of concussion was 23 per 1000 player hours in 2019 which was a decrease from the previous tournament (29 in 2015). In 2019, 63.9% of HIAs were failed and a player removed from play compared to 48.7% in 2015. We identified 17 cases (25%) in 2019 where a player was deemed to suffer a head injury and was not attended to on the pitch by medical staff. Four of these players were subsequently removed from play for HIA following review of the video footage by the independent match doctor. Foul play, where a player was penalised, accounted for 22 injuries (32.4%).

Conclusion

Head injuries remain common in Rugby Union with a rate consistent with at least one injury to be expected per game. We recorded a higher rate of head injury at the 2019 World Cup than at previous tournaments and observed that a player was more likely to fail their HIA in 2019 than in previous tournaments. These findings may represent a greater awareness from medical staff regarding head injuries and suggest that rule changes have had some benefit. The cases of player removal for HIA by the independent match doctor would support this. However, with the finding of up to 25% of head injuries not receiving an initial on-field HIA there remains room for improvement.