The Incidence of Match and Training Injuries in Rugby League: A Pooled Data Analysis of Published...

The Incidence of Match and TrainingInjuries in Rugby League: A Pooled DataAnalysis of Published Studiesby

Doug King, Conor Gissane, Trevor Clark andStephen W. Marshall

Reprinted from

International Journal of

Sports Science & CoachingVolume 9 · Number 2 · 2014

International Journal of Sports Science & Coaching Volume 9 · Number 2 · 2014 417

The Incidence of Match and TrainingInjuries in Rugby League: A Pooled Data

Analysis of Published StudiesDoug King1, Conor Gissane2, Trevor Clark3 and

Stephen W. Marshall4,5

1Sports Performance Research Institute New ZealandSchool of Sport and Recreation

Faculty of Health and Environmental ScienceAuckland University of Technology, New Zealand

E-mail: [email protected] of Sport, Health and Applied Science,

St Mary’s University College,Twickenham, Middlesex, UK

3Australian College of Physical Education,Human Movement Discipline, Sydney Olympic Park,

NSW, Australia4Injury Prevention Research Center

University of North Carolina at Chapel HillChapel Hill, North Carolina, USA

5Department of EpidemiologyGillings School of Global Public Health

University of North Carolina at Chapel HillChapel Hill, North Carolina, USA

ABSTRACT

Studies reporting on injuries in rugby league have shown that the injury

incidence increases as the participation level increases. To provide pooled

estimates for the incidence of rugby league injuries in match and training

activities at all levels of performance and by gender. Searches of PubMed,

CINHAL, Ovid, MEDLINE, SCOPUS, ScienceDirect and SportDiscus®

databases were performed to identify studies published in English prior to

November 2012. Bibliographic searches were also carried out without

language restrictions. A pooled analysis of published studies which have

reported the incidences of rugby league match and/or training injuries. Two

reviewers extracted the study characteristics, numerical data and

assessed the quality, by adhering to the protocol for systematic review of

observational studies (MOOSE). A total of 34 studies (from 1,422 identified

in the initial search) were identified that reported data collection of rugby

league injuries that met the inclusion criteria. The data provided information

from a total of 5,785 match events totalling 87,185 match exposure hr. and

242,754 training exposure hr. The pooled analysis injury incidence for

match injuries was 148 (95% CI: 145 to 150) per 1,000 match hr. The lower

limb (69; 95% CI: 67 to 72 per 1,000 match hr.) was the most common

injury region recorded. Although contusions were the most common

pooled injury type (34.0; 95% CI: 32.3 to 35.8 per 1,000 match hr.) this

varied by participation level. The pooled analysis injury incidence for training

injuries was 12.6 per 1,000 training hr. The lower limb was again the most

common injury region recorded (5.7; 95% CI: 5.1 to 5.8 per 1,000 training

injuries) for all training studies and strains (3.1; 95% CI: 2.8 to 3.3 per 1,000

training hours) were the most common training injury type recorded. These

findings are indicative of the physical demands placed on players across

many levels of participation and in time further additions to this analysis are

warranted to provide a more detailed picture of the sport from an injury

prevention perspective.

Keywords: Epidemiology, Rugby League, Sports Injuries

INTRODUCTIONRugby league has a high incidence of injury, especially when compared with rugby union.1

Studies reporting on injuries in rugby league have shown that the injury incidence increasesas the participation level increases.2 In reviews of match and training injuries in rugbyleague,2-4 it was reported that match injuries varied from 15 to 8252, 6 per 1,000 match hourswhile training injuries ranged from 12.27 to 1068 per 1000 training hours. Limitations tothese individual studies are that they rely on small number of players, typically are only fromone club or competition, utilize different injury definitions and methodological approachesand usually are conducted over a short duration.9 As a result, the generalizability of theseindividual studies for the identification of the injury incidence in rugby league is limited.10

A strategy previously utilised10 is to combine the information provided by epidemiologicalstudies into a single estimate,11, 12 termed a pooled analysis.13 To achieve this technique it isrecommended that all the studies included in the analysis be on common grounds, havesimilar definitions, have a comparable population and have adequacy and specificity ofexposure data.14 By pooling the data, the information provided can then be statistically re-analysed providing more precise injury data.11 This has been previously undertaken onprofessional rugby league studies10 with the results identifying that the injury incidence forprofessional rugby league participation was 40 per 1,000 player hours. To date this is the onlypublished study reporting on combined data of rugby league injuries. This study10 onlyreported on the available studies at the professional level of participation. As such there havebeen no published studies reporting on the pooled analysis of semi-professional, amateur orjunior match or training injuries.

The purpose of this study was to review and update the pooled data estimates on rugbyleague injury epidemiology and add information for semi-professional, amateur and juniorlevels of participation in both match and training environments. Specifically, this includedestimates of injury incidence, injury severity, site and type and the comparison of injury ratesfor; player positions and groups for the different rugby league participation levels.

METHODThe methodology utilised in this study is similar to previous pooled analysis studiesreporting rugby league injuries10 and using the steps as described by Friedenreich.11, 15

418 The Incidence of Match and Training Injuries in Rugby League: A Pooled Data Analysis of Published Studies

SEARCH STRATEGY FOR IDENTIFICATION OF DATABASESSearches of PubMed, CINHAL, Ovid, MEDLINE, SCOPUS, ScienceDirect and SportDiscus®

databases were performed to identify studies published in English prior to November 2012. Thecomputer databases provided access to sports-oriented and biomedical journals, serialpublications, books, theses, conference papers, and related research published since 1948. Termsutilized for the search of relevant research studies included rugby AND league AND injur*.Bibliographies of all papers retrieved for evaluation were also examined for additional references.All articles that met the inclusion criteria were entered in an EndNote X4.0.2 database.

INCLUSION CRITERIAPublished studies that reported the incidence of injury in rugby league match and trainingactivities were collated. These studies were included in the analysis if they were:

1) Published later than 1990;2) Reported the match or training time exposure enabling calculation of player time

injury rates;3) Reported transient and/or missed match rates;4) More than one study reporting injuries at the identified participation level.

PROCEDURESAs all of the studies included in the pooled analysis were observational in design, tworeviewers extracted the study characteristics, numerical data and assessed the quality, byadhering to the protocol for systematic review of observational studies (MOOSE).16 Thisapproach was utilised as it enables a more precise estimate of effects of influential factors,takes into account confounding factors (participation level and age) and the heterogeneity ofthe studies.17 An additional advantage to utilising a pooled analysis approach is that the samestatistical model can be utilised with data from methodologically diverse studies.17

A total of 1,422 studies were initially identified through the database searches. Thisconsisted of 333 studies identified in PubMed, 43 in CINHAL, 679 in Ovid Medline, 186 inSCOPUS and 181 in Sports Discus (see Fig I). Some studies reviewed were initiallyidentified as being eligible for inclusion in the pooled analysis, but were excluded due to avariety of reasons. The exclusion of these studies were identified as being: a) Older than1990;18-20 b) Reporting of data as means;21, 22 c) Non reporting of all injuries or totalexposure times;21, 23-29 d) Use of a previously reported injury database;30 e) A review paper,2-

4, 31-35 and f) Self-reported injuries.36

A total of 34 studies were identified that reported data collection of rugby league injuries.This consisted of 26 studies1, 5-8, 37-57 reporting on rugby league match injuries and 11studies6, 8, 27, 45, 58-64 reporting rugby league training injuries (see Table I). Three studies6, 8, 45

reported both match and training injuries. One match injury study51 re-reported the samesource data, but also included additional data. The additional data was extracted ensuring thatthere were no replications. Injuries were separated into time-loss (TL) injuries (injuries thatresult in players missing the subsequent match or training session) and non-time-loss (NTL)injuries (injuries that do-not result in the player missing the subsequent match or trainingsession).4, 9, 65, 66 By including NTL injuries, it enabled a broader scope of data to analyse. Inaddition the injury site, type, playing position, playing group and match time were alsorecorded.49, 54, 64 Data pertaining to the participation level were reviewed and the studieswere grouped into professional, including reserve and elite;1, 7, 37, 44-48, 56, 57, 59, 60, 63 semi-professional, including sub-elite;6, 8, 38-40, 49, 61, 62, 67 amateur42, 43, 51-54, 58, 64 and junior.5, 41, 55


Many of the identified studies did not include all the areas of interest for the pooledanalysis. As a result it was necessary to extract specific information from individual studieson an ‘as-required’ basis throughout the analytical process and to exclude data if there wereless than two studies reporting at the same participation level. Not all studies reported theinjury sites, types and player positions by injury severity limiting the evaluation of theseareas to the total match and training injuries recorded. Injury severity was pooled for thenumber of injuries recorded in both match and training session studies in this analysis.

ASSESSMENT OF STUDY QUALITY All studies that met the selection criteria were assessed for quality based on modifiedpreviously published checklists.16 Quality was described as the confidence that the design,conduct and analysis of the study was such that it minimised bias in the estimation of thefactors associated with injury on the outcome measures.68 The quality assessment criteriautilised in this study have been previously identified.68

STATISTICAL ANALYSISThe data from the individual studies were combined as previously described.10 Incidencerates and 95% confidence intervals (CI) were calculated. To compare between injury rates,


Records after titles reviewed andduplicates removed (n=181)

Abstracts reviewed(n =60)

Records excluded(n=121)

Full-text articles assessed foreligibility(n=48)

Full-text articles excluded (n=12)Review articles (n=8)Older than 1990 (n=3)

Self-reported injuries (n=1)

Studies included in pooledanalysis(n=34)

Match (n=26)Training (n 11)

Records identified through databasesearching (n=1,422)

Full-text articles excluded (n=14)Not all injuries / exposure included

(n=9)Reporting data as means (n=2)

Previous database reported (n=3)

Scr

eeni

ngIn

clud

edE

ligib

ility

Iden

tific

atio

n

Figure I. Flow of Identification, Screening, Eligibility and Inclusion for thePooled Analysis of Match and Training Rugby League Injuries


risk ratios (RRs) were used. The RRs were assumed to be significant at p<0.05. To test forsignificant difference, chi-squared (χ2) goodness-of-fit tests were utilised.

RESULTSThe studies reported match injury data from a total of 5,785 match events totalling 87,185match exposure hr. (Professional: 2,226 matches; 41,736 match hr; Semi-professional: 713matches; 11,093 match hr; Amateur: 331 matches; 7,416 match hr; Junior: 2,515 matches;26,940 match hr). Studies reporting on training injury data were drawn from 242,754 trainingexposure hr. (Professional: 196,877 training hr; Semi-professional: 32,796 training hr;Amateur: 13,080 training hr). There were no published studies identified that reported onjunior training injuries.

Overall quality of the studies included in the pooled analysis was good (median 5/6; range4-5). Not all studies were prospective and no study had a blinded outcome.

POOLED ANALYSISThe pooled analysis injury incidence for match injuries was 148 (95% CI: 145 to 150) per1,000 match hr. (see Table 1). Semi-professional studies recorded more match injuries thanprofessional (RR: 2.5; 95% CI: 2.4 to 2.6; p<0.0001), amateur (RR: 1.2; 95% CI: 1.2 to 1.3;p<0.0001) and junior (RR: 2.6; 95% CI: 2.1 to 3.2; p<0.0001).There were more NTL thanTL (RR: 2.8; 2.7 to 2.9; p<0.0001) injuries recorded. This was similar for professional (RR:3.5; 95% CI: 3.3 to 3.7; p<0.0001) semi-professional (RR: 3.0; 95% CI: 2.8 to 3.2; p<0.0001)and amateur (RR: 1.5; 95% CI: 1.2 to 1.8; p=0.0003) studies.

Table 1. Rugby League Match and Training Injury Studies Utilised in thePooled Analysis by Number of Injuries Reported, Hours of Exposure andRate per 1,000 Hours with 95% Confidence Intervals

InjuriesNo. Hours Rate (95% CI)

Match injuriesa

Total 12,817 86,821 148 (145 to 150)Gender

Male1, 5-8, 37-52, 54-57 12,716 86,492 147 (145 to 150)Female53 101 329.2 307 (253 to 373)

Level of ParticipationProfessional1, 7, 37, 44-48, 56, 57 7,113 41,374 172 (168 to 176)Semi-Professional6, 8, 38-40, 49 3,977 11,093 359 (348 to 370)Amateur42, 43, 50-54 1,339 7,416 181 (171 to 191)Junior5, 41, 55 388 26,940 14 (13 to 16)

Training injuriesb

Total 3,070 242,754 12.6 (12.2 to 13.1)Gender

Male6, 8, 27, 45, 58-64 3,070 242,754 12.6 (12.2 to 13.1)Level of Participation

Professional45, 59, 60, 63 755 96,877 3.8 (3.6 to 4.1)Semi-Professional6, 8, 27, 61, 62 2,138 2,796 65.2 (62.5 to 68.0)Amateur58, 64 177 4,529 12.2 (10.5 to 14.1)

CI = Confidence Interval; (a) = rate reported per 1,000 match hours; (b) = rate reported per 1,000 training hours

The pooled analysis injury incidence for training injuries was 12.6 (95% CI: 12.2 to 13.1)per 1,000 training hr. (see Table 1). Semi-professional training session studies recorded moreinjuries than professional (RR: 18.7; 95% CI: 17.1 to 20.4; p<0.0001) and amateur (RR: 4.8;95% CI: 4.1 to 5.6; p<0.0001) studies. Semi-professional training studies recorded moreNTL (RR: 37.5; 95% CI: 33.8 to 41.7; p<0.0001) and TL (RR: 15.5; 95% CI: 12.6 to 19.2;p<0.0001) injuries than professional studies.

MATCH INJURIESThe tackler recorded more injuries than the ball carrier at the professional (RR: 2.2; 95% CI1.9 to 2.6; p<0.0001), semi-professional (RR: 1.3; 95% CI: 0.9 to 1.9; p=0.2393), amateur(RR: 1.4; 95% CI: 1.2 to 1.6; p=0.0003) and junior (RR: 4.3; 95% CI: 2.3 to 8.1; p<0.0001)levels of participation (see Table 2). The lower limb (69; 95% CI: 67 to 72 per 1,000 matchhours) was the most common total injury region recorded. Total lower limb injuries wererecorded more commonly in amateur than semi-professional (RR: 1.9; 95% CI: 1.7 to 2.0;p<0.0001), professional (RR: 3.2; 95% CI: 2.8 to 3.8; p<0.0001) and junior (RR: 4.7; 95%CI: 3.5 to 6.3; p<0.0001) rugby league. More injuries were recorded in the first than thesecond half (RR: 1.1; 95% CI: 1.0 to 1.2; p=0.0246) of pooled matches. Amateur studiesreported more injuries in the second half of matches (RR: 1.5; 95% CI: 1.4 to 1.7; p<0.0001)than semi-professional studies.

Table 2. Pooled Analysis Summary of Match Injuries by Participation Leveland Total Pooled Analysis for Total Injury Rate, Cause, site, Player Groupand Match Time per 1,000 Match Hours with 95% Confidence Intervals andNumber of Studies in Pooled Analysis

Total Professional Semi-Professional Amateur JuniorRate (95% CI)n Rate (95% CI)n Rate (95% CI)n Rate (95% CI)n Rate (95% CI)n

Total IR148 (145 to 150)26 172 (168 to 176)10 359 (348 to 370)6 181 (171 to 1915)7 14 (13 to 16)3

Injury CauseTackler 28e (25 to 30)14 17bcde (15 to 20)5 11ac (8 to 14)2 175abe (152 to 202)5 8ace (5 to 15)2

Ball Carrier 49 (46 to 53)14 37.7bc (34 to 42)5 13acd (10 to 17)2 230abd (203 to 261)5 36bc(28 to 48)2

Injury siteHead/Neck 34hi (33 to 36)20 29bcdghi (27 to 31)8 42adghi (38 to 46)4 46adghi (41 to 51)6 14abcgh (9 to 22)2

Upper Limb 35hi (33 to 37)20 26bcfhi (24 to 27)8 58acdfhi (53 to 63)4 122abdfhi (100 to 148)6 28cdfi (21 to 38)2

Lower Limb 69fgi (67 to 72)20 55bcdfgi (52 to 57)8 105acdfgi (98 to 112)4180abdfgi (153 to 211)6 38abcfi (30 to 50)2

Chest/Back 18fgh (17 to 20)20 17bfgh (15 to 18)8 23afgh (98 to 26)4 25ghi (16 to 38)6 15gh (10 to 23)2

Player GroupForwards 156 (148 to 164)10 75 (68 to 83)3 228 (208 to 249)2 547 (491 to 608)4 *1Backs 112k (106 to 119)10 54k (48 to 60)3 166k (150 to 183)2 385k (342 to 433)4 *1

Match TimeFirst Half 461 (438 to 486)8 NR 521cl (491 to 552)2 327bl (2897 to 371)5 *1Second Half 423 (401 to 447)8 NR 371c (346 to 397)2 586b (533 to 644)5 *1

CI: Confidence Interval; n= number of studies; IR = Injury rate; NR=Not reported; *= unable to complete pooledanalysis; Significant difference (p<0.05) than (a)=Professional; (b)=Semi-professional; (c)=Amateur; (d)=Junior;(e)=Ball carrier; (f)=Head/Neck; (g)=Upper Limb; (h)=Lower Limb; (i)=Chest/Back; (j)=Non-time loss;(k)=Forwards; (l)=Second Half



Although sprains were the most common match injury type (34; 95% CI: 32 to 36 per1,000 match hr.) this varied by participation level (see Table 3). Strains (35; 95% CI: 31 to40 per 1,000 match hr.) were more commonly reported at the semi-professional level whilecontusions (183; 95% CI: 162 to 206 per 1,000 match hr.) were more commonly reported atthe amateur level of participation. Amateur studies reported more fracture-dislocations (46;95% CI: 35 to 61 per 1,000 match hr.) than professional (RR: 1.2; 95% CI: 1.0 to 1.4;p<0.0001) and semi-professional (RR: 2.4; 95% CI: 1.8 to 3.3; p<0.0001) studies. Moreconcussions were recorded in amateur than professional (RR 2.4: 95% CI: 1.5 to 3.8;p=0.0002), semi-professional (RR: 3.0; 95% CI: 1.8 to 5.1; p<0.0001) and junior (RR: 2.5;95% CI: 1.2 to 5.5; p=0.0132) studies.

Table 3. Pooled Analysis Summary of Match injuries by Injury Type per1,000 Match Hours with 95% Confidence Intervals and Number of Studiesin Pooled Analysis

Injury type Total Professional Semi-Professional Amateur JuniorRate (95% CI)n Rate (95% CI)n Rate (95% CI)n Rate (95% CI)n Rate (95% CI)n

Contusions 28 (27 to 30)17 27 (25 to 29)7 19 (16 to 22)4 183 (162 to 206)5 *1Fracture/Dislocations 16 (15 to 18)17 24c (22 to 25)7 9c (8 to 12)4 47ab (37 to 59)5 *1Sprains 33 (32 to 35)17 50 (47 to 52)7 27 (24 to 31)4 84 (71 to 100)5 *1Strains 28 (26 to 29)17 42 (39 to 44)7 35 (32 to 40)4 70 (58 to 85)5 *1Wounds 13 (12 to 14)17 20 (19 to 22)7 9 (7 to 11)4 44 (34 to 56)5 *1Concussion 8 (7 to 9)18 7c (7 to 9)7 6c (5 to 8)4 18abd (12 to 26)5 7c (4 to 13)2

CI: Confidence Interval; n= number of studies; *= unable to complete pooled analysis; Significant difference(p<0.05) than (a)=Professional; (b)=Semi-professional; (c)=Amateur; (d)=Junior;

Although the hooker playing position recorded most injuries (Total: 380; 95% CI: 237 to442 per 1,000 match hr; Semi-professional: 372; 95% CI: 312 to 443 per 1,000 match hr.)the prop (595; 95% CI 487 to 727 per 1,000 match hr.) recorded the most injuries at theamateur level of participation (see Table 4).

Table 4. Pooled Analysis Summary of Match Injuries by Participation Leveland Player Position per 1,000 Match Hours with 95% Confidence Intervalsand Number of Studies in Pooled Analysis

Player Position Total Semi-Professional Amateur JuniorRate (95% CI)n Rate (95% CI)n Rate (95% CI)n Rate (95% CI)n

Prop 281 (248 to 318)6 210 (178 to 247)2 595 (487 to 727)3 *1Hooker 380 (327 to 442)6 372 (312 to 443)2 476 (346 to 654)3 *1Second Row Forward 242 (211 to 276)6 180 (151 to 215)2 482 (386 to 603)3 *1Loose Forward 245 (203 to 296)6 215 (171 to 271)2 388 (273 to 552)3 *1Half-back 187 (150 to 231)6 183 (1436 to 235)2 250 (162 to 388)3 *1Stand Off 263 (219 to 315)6 233 (187 to 291)2 188 (131 to 269)3 *1Centre 211 (183 to 244)6 164 (136 to 197)2 407 (319 to 519)3 *1Wing 163 (139 to 192)6 121 (97 to 150)2 338 (259 to 442)3 *1Full Back 225 (185 to 273)6 174 (135 to 225)2 451 (325 to 625)3 *1

CI: Confidence Interval; n= number of studies; *= unable to complete pooled analysis; Significant difference(p<0.05) than (a)=Semi-professional; (b)=Amateur;

TRAINING INJURIESThe tackler recorded more injuries than the ball carrier (RR: 1.6; 95% CI: 1.0 to 2.6;p=0.0754) in amateur training session studies (see Table 5). The lower limb was the mostcommon injury recorded (5.7; 95% CI: 5.1 to 5.8 per 1,000 training injuries) for all studiesreporting training sessions. Professional (RR: 37.5; 95% CI: 33.8 to 41.7; p<0.0001) andamateur (RR: 18.4; 95% CI: 14.5 to 23.4; p<0.0001) training session studies reported fewerlower limb training injuries than semi-professional training session studies. There were moreinjuries recorded in the second than the first half (RR: 1.4; 95% CI: 1.0 to 1.8; p=0.0413) ofamateur training sessions.

Table 5. Pooled Analysis Summary of Training Injuries by Participation Leveland Total Pooled Analysis for Total Injury Rate, Cause, Site, Player Groupand Match Time per 1,000 Training Hours with 95% Confidence Intervalsand Number of Studies in Pooled Analysis

Total Professional Semi-Professional AmateurRate (95% CI)n Rate (95% CI)n Rate (95% CI)n Rate (95% CI)n

Total IR12.6 (12.2 to 13.1)11 3.8 (3.6 to 4.1)4 65.2 (62.5 to 68.0)5 13.5 (11.7 to 15.7)2

Injury CauseTackler 10.2d (8.9 to 11.8)4 NR 20.6cd I17.7 to 24.1)2 2.9b (2.1 to 4.0)2

Ball Carrier 12.6 (11.1 to 14.3)4 NR 28.3c (24.8 to 32.3)2 1.8b (1.2 to 2.7)2

Injury siteHead/Neck 0.7gh (0.6 to 0.9)8 0.3bcgh (0.2 to 0.4)4 9.0acgh (7.1 to 11.4)2 1.2abfg (0.7 to 2.0)2

Upper Limb 0.9gh (0.8 to 1.0)8 0.3bcgh (0.2 to 0.4)4 10.2acgh (8.2 to 12.7)2 2.8abegh (2.0 to 3.9)2

Lower Limb 5.7efh (5.4 to 6.1)8 2.0bcefh (1.8 to 2.2)4 75.4acefh (69.5 to 81.7)2 8.6abefh (7.2 to 10.4)2

Chest/Back 1.4efg (1.3 to 1.6)8 0.8befg (0.7 to 1.0)4 13.8acefg (11.4 to 16.7)2 0.8bfg (0.4 to 1.4)2

Player GroupForwards 8.5 (6.9 to 10.3)2 NR NR 8.5 (6.9 to 10.3)2

Backs 6.7 (5.3 to 8.3)2 NR NR 6.7 (5.3 to 8.3)2

Match TimeFirst Half 11.3k (9.0 to 14.2)2 NR NR 11.3k (9.0 to 14.2)2

Second Half 15.4 (12.7 to 18.8)2 NR NR 15.4 (12.7 to 18.8)2

CI: Confidence Interval; n= number of studies; IR = Injury rate; NR=Not reported; Significant difference (p<0.05)than (a)=Professional; (b)=Semi-professional; (c)=Amateur; (d)= Ball carrier; (e)=Head/Neck; (f)=Upper Limb;(g)=Lower Limb; (h)=Chest/Back; (i)= Non-time loss; (j)=Forwards; (k)=Second Half

Strains (3.6; 95% CI: 3.4 to 3.9 per 1,000 training hr.) were the most common traininginjury recorded (see Table 6). This was similar for professional (0.8; 95% CI: 0.6 to 0.9 per1,000 training hr.) and amateur (5.0; 95% CI: 3.9 to 6.3 per 1,000 training hr.) studies.Contusions (30.4; 95% CI: 27.7 to 33.4 per 1,000 training hr.) were more commonly reportedfor semi-professional training studies. There were more fracture-dislocations recorded forsemi-professional studies than professional (RR: 37.8; 95% CI: 18.6 to 76.9; p<0.0001) andamateur (RR: 3.7; 95% CI: 1.7 to 8.0; p<0.001). There were more concussions were recordedin semi-professional than amateur (RR: 13.5; 4.2 to 43.9; p<0.0001) training session studies.


Table 6. Pooled Analysis Summary of Training Injuries by Injury Type per1,000 Training Hours with 95% Confidence Intervals and Number ofStudies in Pooled Analysis

Total Professional Semi-Professional AmateurRate (95% CI)n Rate (95% CI)n Rate (95% CI)n Rate (95% CI)n

Contusions 2.5 (2.3 to 2.7)7 0.4 (0.3 to 0.5)2 30.4 (27.7 to 33.4)3 1.5 (1.0 to 2.4)2

Fracture/Dislocations 0.5 (0.6 to 0.6)7 0.1bc (0.0 to 0.1)2 2.3ac (1.6 to 3.2)3 0.6ab (0.3 to 1.2)2

Sprains 2.7 (2.5 to 2.9)7 1.1 (1.0 to 1.3)2 22.1 (19.8 to 24.7)3 2.3 (1.6 to 3.3)2

Strains 3.6 (3.4 to 3.9)7 0.8 (0.6 to 0.9)2 29.4 (26.7 to 32.4)3 5.0 (3.9 to 6.3)2

Wounds 2.3 (2.1 to 2.5)7 0.1 (0.1 to 0.2)2 27.0 (24.5 to 29.9)3 0.8 (0.5 to 1.5)2

Concussions 0.3 (0.2 to 0.3)7 0.01 (0.00 to 0.04)2 3.1c (2.3 to 4.2)3 0.2b (0.1 to 0.7)2

CI: Confidence Interval; n= number of studies; Significant difference (p<0.05) than (a)=Professional; (b)=Semi-professional; (c)=Amateur

INJURY SEVERITYNon-Time Loss (NTL) injuries account for 80.9% of all match and 75.9% of all traininginjuries (see Table 7). Semi-professional match studies reported more NTL injuries thanprofessional (RR: 2.0; 95% CI: 1.9 to 2.2; p<0.0001) and amateur (RR: 1.9; 95% CI: 1.4 to2.7; p=0.0003) match studies. Amateur match studies reported more TL injuries thanprofessional (RR: 2.8; 95% CI: 2.4 to 3.3; p<0.0001) and semi-professional (RR: 1.2; 95%CI: 1.1 to 1.4; p=0.0116) studies.

There were more NTL than TL training injuries (RR: 3.0; 95% CI: 2.7 to 3.84; p<0.0001).Semi-professional training session studies reported more NTL injuries than professional(RR: 12.5; 95% CI: 10.3 to 15.3; p<0.0001) and amateur (RR: 1.6; 95% CI: 1.3 to 2.0;p<0.0001) studies. There were differences observed that professionals had a 66-folddifference (RR: 66.1; 95% CI: 60.8 to 71.8; p<0.0001), amateurs had a 45-fold difference(RR: 45.2; 95% CI: 37.4 to 54.6; p<0.0001) and semi-professionals had a 9-fold difference(RR: 9.5; 95% CI: 9.0 to 10.0; p<0.0001) between the incidence of training and matchinjuries. There were no differences observed for the number of semi-professional andamateur moderate match (_2=3.01, df=1, p=0.0827) and major training (_2=0.91, df=1,p=0.3410) injuries recorded.

DISCUSSIONThe aim of this study was to review and update the analysis of rugby league injuries. Aprevious rugby league pooled analysis10 utilised only professional matches and was limitedto the available published studies at the time. The current study encapsulates a broaderspectrum of published rugby league studies and incorporates both match and training injuriesat professional, semi-professional and amateur levels of participation. Studies reporting onjunior55 and women’s53 rugby league would have been included, but there were too fewpublished studies in these areas suitable for inclusion to enable a pooled analysis. Futurestudies are warranted to explore these groups of rugby league participants.

The use of a pooled analysis has been previously applied to rugby league injuryepidemiological studies.10, 45 This approach has been shown to produce an overall estimationof the injuries recorded by incorporating the data provided by the studies utilised.69 Thelimitations with the use of a pooled analysis methodology have been previously described11,

70 and issues such as the difference in study design (observation vs. self-reported injury);65,



Tab

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oo

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An

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66 injury type, site and severity definitions; data collection methods and times; data recordingmedium and the maintenance of the data medium were considered and addressed through toidentification of the data utilised. Despite these limitations, the strength of a pooled analysisis that it provides more accurate estimates of injury rates than individual studies thatprovided the data,10 can be utilised as comparisons against other pooled studies and to obtaina combined estimator of the quantitative effect of the relative risk of injuries in rugby leaguematch and training activities.11, 15

The major findings of this pooled analysis for studies reporting on match injuries were: i)semi-professional participants had a two-fold greater injury rate than professional andamateur participants; ii) there were significant differences between the rates of injury fordifferent body sites, with the lower limb being the most commonly recorded injury site forall levels of participation; iii) strains and sprains were the most commonly recorded injurytypes for professional and semi-professional participants; and iv) backs had a significantlylower risk of recording an injury when compared with forwards at all levels of participation.When reviewing training injuries the major findings were: i) semi-professional participantshad a 17-fold higher injury rate than professional participants, and a 4-fold higher injury ratethan amateur participants; ii) the lower limb was the most commonly recorded injury site forall levels of participation; iii) strains and sprains were the most commonly recorded injurytypes for professional and amateur participants; and iv) there were significantly more NTLthan TL training injuries recorded at all levels of participation.

It was not unexpected to find that professionals have a 66-fold and amateurs have a 45-fold decrease in the incidence of injuries occurring when comparing match and traininginjury incidence. What was unexpected was the finding that semi-professional participantsonly had a 9-fold decrease in the incidence of injuries comparing the match and traininginjury incidence. It has been reported that semi-professional participants have superiorphysiological capabilities than amateur participants6, 71 producing a higher playing intensitythat may result in a higher injury incidence.6, 30, 44, 57 But professional players also havegreater physiological attributes than amateur participants and a higher skill level than semi-professional participants6 and the decrease between match and training injuries is greaterthan amateur participants. These differences may be a result of the approach to trainingactivities at the different levels of participation. While professional players may undertakemore regular training sessions than amateurs, they likely moderate their training sessions sothat injury does not limit their ability to appear in competition. Amateur players partake inless regular training activities but rely on other employment as their source of income,64 soany injuries that occur may have a direct impact on their financial income. Semi-professionalplayers have a mix of payment for playing and may also utilise another source ofemployment for income.6 Over-exposure to a diverse range of physical activities may placethem at a higher risk of an injury occurring. Further studies are warranted to explore theissues that surround semi-professional players and the incidence of both match and traininginjuries such as employment type, training hours and coaching styles and how these may bereduced.

To assist in defining NTL and TL injuries the studies were reviewed to ascertain if: i) theinjury definition incorporated a TL definition; ii) they reported NTL and TL or only TL; iii)they described injuries resulting in TL from the activities being reported in the results; or iv)the tables contained identification of injuries that resulted in NTL and/or TL. The injurydefinition in two studies56, 57 were not identified, but they did report injuries by TL periods.Several studies did not report NTL and/or TL, and the definition utilised did not incorporateany TL definition. Consequently these studies were excluded from NTL and TL pooled


analysis. Future studies reporting on rugby league match and/or training injuries shouldconsider including an injury definition that includes a time loss definition.

The inclusion of NTL injuries in the pooled analysis was undertaken as previous studieshave reported between 70%57 and 92%42 of injuries do not meet the TL definition.Unfortunately a majority of the match and training studies reviewed in this pooled analysisreported the NTL and TL as a total number of the injuries recorded and did not specify theseby injury site, type, playing position, cause and match time. This is seen as a limitation tothis pooled analysis. Future studies reporting on match and training rugby league injuriesshould consider including this data. The inclusion of both TL and NTL injuries in rugbyleague studies has been previously suggested9 as it also acts as a guide to the health caremanagement and appointment of essential primary care personnel.66 Non-time loss injuriesstill require assessment, management and sometimes onward-referral to other health careservice providers.66 This has resource implications on the health-care practitioner whendealing with these injuries.65 As shown by this pooled analysis, NTL injuries accounted for80.9% of pooled match injuries and 75.9% of pooled training injuries.

As shown in this pooled analysis it can be seen that in match activities semi-professionalrugby league participants have a higher reported injury rate than professional and amateurparticipants, the ball carrier records more injuries than the tackler to the lower limbs inforward playing groups during the first half of matches and sprains were the most commoninjury type. In training activities it can be seen that strains are the most common traininginjury, the ball carrier is more commonly injured than the tackler and more training injuriesoccur in the second than the first half of matches. Awareness of this can assist in injuryreduction programmes and further studies reporting on interventions to assist in the reductionof these injuries are warranted.

CONCLUSIONA combined estimate of injuries within a specific sport through pooled analysis providesmore precise evidence and meaningful information about the sport, while controlling forbetween-study variation due to individual sub-cohort characteristics. This synthesis hasilluminated differences in injury rates at several levels in the game, along with informationabout the differences in injury between playing and training for rugby league. These findingsare indicative of the varying physical demands placed on players across many levels ofparticipation.

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