* Sports Medicine Fellow, Thomas Jefferson University Medical Center ** Sports Medicine Fellow, Duke University + Contributor Editor to Rugby Magazine # Associate Professor, Rothman Institute, Pennsylvania Hospital & Thomas Jefferson University Medical Center ^ Associate Professor, Department of Orthopaedic Surgery, Boston University Medical CenterThe following is a summary of an article prepared for publication in a professional journal. Please (contact the authors for permission to reproduce.
The American Orthopaedic Rugby Football Association,(AORFA), with the invaluable help of Toks Akpata, has analyzed the incidence and factors contributing to cervical spine injuries. The incidence of cervical spine injuries is well documented in the literature from commonwealth nations and S. Africa. Although Toks Akpata and Bruce Smith have published articles in Rugby Magazine no study has appeared in the US. medical literature discussing the incidence or etiology of cervical spine injury in rugby.
All the cervical spinal injuries in rugby in the United States from 1970 to 1994 that were reported documented were critically analyzed. There were 59 such cases collected, an average of 2.46 per year. There were 30 (50.8%) junior level (collegiate or high school players), 28 (47.5%) men's club players and one (1.7%) women injured. In regards to position, 34 (57.6%) were front row players (28 (82.4%) hookers and 6 (17.6%) were props); 10 (16.9%) were second row or loose forwards, 13 (22%) were backs, with 2 (3.4%) players position were unknown. Ninety-seven percent of injuries (57) occurred during a game. Fifty-eight percent (34 players) of injuries occurred during the scrum. Twenty-one of these (35.6%) injuries occurred when the scrum engaged while 13 (22%) happen when the scrum collapsed. Eighteen (30.5%) players were injured during a tackle. The remainder of these injures (7 (11.9%)) occurred during rucks and mauls. Eight (23.5%) of the cervical spine injuries that involve the front row had documented mismatches of experience in the front row and size with collegiate versus men's clubs. While seven (28%) of 25 injuries that occurred during loose play involved some type of "foul" play.
Many authors have all discussed what elements of rugby are responsible for catastrophic cervical spine injuries. Prior to 1983, the scrum was responsible for 40 to 60% of the documented cervical spine injuries that occurred. Milburn8 states that the scrum epitomizes the physical nature of rugby. It has been reported that forces equivalent to 1.5 tons are exerted on the cervical spine during a scrum. During scrum engagement the front rows impact their heads and intertwine them with their opposition. At this time the cervical spine is slightly flexed. This slightly flexed position eliminates the normal lordosis of the cervical spine allowing the force of engagement to be transmitted to the cervical vertebrae and soft tissue, thus predisposing the neck to injury. If the player's head, on engagement, slips under his opponent's, the forces can cause a combination of hyperflexion and rotation on the neck resulting in unilateral or bilateral facet fracture/dislocation. If the front rows' heads directly contact the opposition's shoulder or the scrum collapses and the vertex of the head strikes the ground a burst fracture may result depending and the vertebral level depends on the position of the neck at contact.
Over the past ten years there have been numerous law changes. Many of these involve the activities of the scrum. These changes are aimed at preventing barging on engagement and at tactics that may collapse the scrum such as rotating the scrum "wheeling" (rotating the scrum). Many authors have demonstrated the positive influence that the medical community can have on rugby play. Silver (1983) reported on 63 catastrophic cervical spine injuries that occurred from 1956 to 1983 to the Rugby Union in the United Kingdom. Silver's work subsequently resulted in positive law changes (1984) by the International governing body. Since then, there has been an ensuing decrease in the incidence of cervical spine injuries. Taylor theorized that injuries that occur when the scrums engage (when the prop's or hooker's head strikes his opponents) or collapse maybe be reduced by depowering. He suggests that the front rows engage separately without the rest of the pack. This would significantly decrease the force exerted on the front row's cervical spine thus preventing many of these injuries. Burry in a study from New Zealand showed a 3 fold decrease in the incidence of cervical spine injuries when rules were adopted to slow the pace of scrum engagement. At present time, these concepts are not used in rugby in the U.S..
As injuries in the United Kingdom and other rugby playing nations declined, (from law changes relating to the scrum) a heightened awareness of catastrophic events during other phases of play occurred. Past literature indicates that almost 40% of catastrophic cervical spine injuries were the result of a tackle. More recently Scher in 1991 in South Africa demonstrated a change in the pattern of mechanism in which these injuries occur, with the tackle now responsible for the majority of these injuries. In an extensive literature review, Smith confirmed an almost equality between the incidence of cervical spine injuries during the scrum and tackles. A high tackle was responsible for almost 50% of these injuries, thus a recognizable and avoidable cause.
In the United States in contrast to the rest of the world there is a significantly higher percentage (57.6% in US, 41.5% in the world literature) (See Fig. 6) of cervical spine injuries taking place during the scrum. Milburn in his research on the biomechanics of the scrum concluded that not only are older and more experienced players able to generate and transmit the force of the scrum these players can also better dissipate the forces generated. While most Americans begin to play rugby while in college, rugby players in other countries begin playing as schoolboys. The occurrence of injuries is magnified by the fact these players, of larger mass and strength, are playing the game and positions with much less experience than in other nations. Eight (23.5%) of the cervical spine injuries that involve the front row had documented mismatches of experience in the front row, either different caliber or level of players or inexperience players in the front row match up against each other. It is difficult to assess how many other injuries occurred because of experience players in skill positions. Another disturbing and significant difference in US rugby versus the world is the incidence of cervical spine injuries to hookers. In the US cervical spine injuries in hookers were responsible for 47.5% of injuries while the world literature reports only a 18.6% occurrence. (See figure 7)
Further, in the world the literature documents that only 30 to 40% of cervical spine injuries involved junior level players while in this study 50.8% (30) of the players injured were junior players. Alarmingly, 60% (18) of these injuries have happened since 1984, while only 46.4% (13) of men's injuries have occurred during the same time period. This supports the theory that in the US players of larger mass and little experience are playing skilled positions. A review of collegiate rugby programs reveals that many of them receive little coaching and there are not many facilities to practice scrummaging. Therefore inexperienced players in skilled positions (i.e., front row) are practicing against players with the same or only slightly more experience. In essence, the players are learning to scrummage in game situations.
Strategies to prevent cervical spine injuries occurring during the scrum include depowering the scrum as described in this article. This would be most efficacious in the collegiate level were coaching and facilities are extremely variable. Further, unskilled players must not be allowed to play in skilled position (i.e., Props & Hookers). During the most recent Women's World Cup in Scotland, the Scottish Rugby Union adopted a rule that if a skilled player (i.e., front row) is injured and there is not an appropriately skilled player to fill the slot, whenever a scrum is awarded it is changed to a line out. In higher level play this most likely will have little effect. In lower and junior levels this could prevent many injuries.
As we reduce the incidence of cervical spine injuries during the scrum our focus needs to be drawn to the tackle as a cause of these injuries. The situation in the United States is complicated by the fact that many American ruggers are former football players and are taught to use their head as a "weapon" during a tackle or to deliver a blow to the ball carrier. Scher has describe the high tackle as the black spot in rugby. There is need to break the football mentality and teach both safer tackling techniques as well as proper techniques for the ball handler to ward off the tackler and keep the ball in play.
Strategies to prevent catastrophic injuries during loose play include instruction of players and referees on proper tackling technique while strictly enforcing rules against dangerous and high tackles, late hits, and "foul" play. The referee should be very involved in the ruck and mauls. Referees should locate the ball as best as possible and allow a reasonable amount of time for it to come out. If the ball cannot be located and will not emerge, play should be stopped and a scrum awarded. Recent rule changes make it advantageous for the team bringing the ball into the ruck or maul to keep it in play. It is too early to tell whether these new rules will make a difference but it should decrease the length of ruck or maul and the number that collapse. In addition, rules could possibly be changed preventing player from joining the ruck or maul with reckless abandon. Also, in the prevention of cervical spine injuries in all phases of the game, the importance of good coaching cannot be emphasized enough.
In contrast to men, cervical spine injuries in women are almost nil. With close to 250 teams in existence and an average of 30 collegiate sides added per year, women's rugby is the fastest growing form of rugby in the U.S.. Since 1970 there has been only one cervical spine injury. This occurred when one player fell on another's neck during loose play. The lower incidence of neck injuries in female rugby may be attributable to different styles of play. Women do not have the American football mentality; this results in less spearing and safer tackling than their male counterparts. Additionally, barging and high momentum impacts are extremely rare when the scrum engages. Consequently, women's rugby is safer in terms of risk for catastrophic injury than men's rugby.
The medical communities of the Commonwealth nations have documented numerous factors that have contributed to the understanding of catastrophic cervical spine injuries amongst rugby players. An understanding of the factors that contribute to catastrophic spine injuries is paramount to the eventual prevention of them. This study demonstrates an unacceptable incidence of cervical spine injuries in junior level players. In order for rugby to increase in popularity the sport must be made safer, especially for our junior level and inexperience players. Through this study we hope to influence change in rugby law and play, enhancing both safety and pleasure of the sport for players, coaches and spectator.