The incidence of rugby football
injuries
in
LYLE J. MICHELI, M.D. EDWARD M. RISEBOROUGH, M.D.
The runner
game of rugby football, direct foreof Amencan gridiron football, is
undergoing
a
widespread revival in the specifically, in the Bos-
United States, and, ton area.
Dr. of
Lyle J.
Michael>
is
Assistant Clinical Professor
Orthopaedic Surgery, George Washington University School of Medicine; Orthopaedic Sur-
geon, Malcolm Grow U S.A.F Medical Center, Washington, D C
Dr Edward M Riseborough is Attendmg Orthopaedic Surgeon, Childrens Hospital Medical
Center, Boston, Mass , Associate Professor of Orthopaedic Surgery, Harvard Medical School, Boston, Mass Photo Credit Courtesy of Matthew Godek, Alex-
andria, Vad
football and American football are frequently compared and contrasted by their respective proponents as to playing skills required, and the relative dangers involved in playing each sport. It is the purpose of the present study to report the incidence, nature, and severity of injuries sustained in rugby football by players of seven Boston area rugby clubs in the Spring 1971 season. A brief review of the historical relationship between rugby and American football
Rugby
93
and a summary of the present mode of play of rugby union football should help to put the results of this study and the conclusions drawn from it in better perspective. Soccer football, the most widely played football game in the world today, is also the oldest, and the direct forerunner of both rugby and American football. In 1823 a schoolboy at the Rugby school in England disrupted a soccer game by picking up the ball and running with it across the goal line. Within thirty years, this new approach to football had developed into a completely separate game, rugby football. A soccer style of football was first played in the United States. The first intercollegiate football game, between Princeton and Rutgers in 1869, was actually played by soccer rules. Five years later, the first rugby style of game was played between Harvard and McGill in Boston. The rugby style of game, with its running, passing, and tackling, quickly supplanted soccer. It was through progressive modifications of the rugby style of play that our modern American football has evolved. Modern rugby union football still remains quite close to the early rugby style of play and differs from American football in a number of important ways. There are fifteen men on a team. The game is divided into two forty-minute halves, with no time-outs or substitutions allowed. Protective equipment, developed to a sophisticated and sometimes dangerous degree in American football, is specifically prohibited in rugby. The game begins with a kick-off, as in football. Play is continuous, except for stoppages following infractions of rules, and running is the prime method of advancing the ball, though it can be kicked directly TABLE I
94
forward
at any
time
by
the ball carrier. An
opponent carrying the ball may be tackled, but
blocking is allowed. The ball may be only passed laterally or backwards. Any no
member of the team is eligible to receive a pass or field a kick if he is on-sides. Scoring is done by running the ball across the goal line and touching it down, by kicking it through the uprights as a conversion after a touchdown, or by a penalty kick. MATERIALS AND METHODS
Spring 1971 season, 389 participants the four college and three club sides were studied (Table I). Any injury for which medical attention was required or sought was recorded, whether the injury had occurred during a game or practice session. These injuries were graded according to the time elapsed before full participation could be resumed With a minor injury, no game time was lost and the participant could play the following week. An injury of moderate severity resulted in missing at least one but not more than two games; and a major injury resulted in a player’s missing three games or the remainder of the season. Moderate and major injuries were confirmed by the authors either by direct examination or discussion with the attending physician. In the
on
RESULTS
A total of 38 injuries were recorded for an overall injury rate of 9.8%. Thirty-one of these were received in actual games, and seven in practice sessions: 1 1 were major, 211 moderate, and 6 minor injuries. An analysis of these injuries by area injured (Table II) showed that the shoulder girdle received the highest incidence of in-
total of 12; more significantly, I 1 of of moderate or major severity. Head/neck and knee were next, with five each. There were four injuries of the chest/ abdomen, three each to the back/spine, lower limbs, and ankle; and one to the foot An analysis of these injuries by type (Table III) showed fractures to be the leading diagnosis, a total of eight There were six contusions and six sprains, five strains, five acromioclavicular separations, three abrasions/lacerations, two dislocations, and one each of cerebral concussion, hermated nucleus pulposus, and tear of the meniscus of the knee. An overall summary of these rugby injuries is possible by comparing the type of injury with the area injured (Table IV). There were five injuries to the head/neck area, three facial lacerations, one broken nose, and one concussion. There were two chest contusions and two cases of fractured nbs, but no abdominal injuries were reported. The three injuries to the back were a contusion of the lumbar region, a low back strain, and a herniated nucleus pulposus, confirmed operatively. Shoulder girdle injuries will be reviewed separately. The two other upper extremity injuries were a Colles fracture and a fractured phalanx, both requiring closed reduction. In the lower limb, there was one quadriceps contusion, and one each of hamstnng and gastrocnemius strain. There were five
jury,
a
the 12
TABLE III
TABLE II
Characteristics of Total Area
Injuries by
Characteristics of Total
Injuries
by Type
were
knee
injuries:
one
contusion from
a
direct
kick, three strains of the medial collateral and one tear of the lateral menisThree sprains of the ankle and one case of multiple metatarsal fractures completed the list of lower extremity injuries. The prevalence of shoulder injuries was striking, comprising as they did almost one-third of the total injuries observed (Table V). These included two fractured
ligament, cus.
clavicles;
two
glenohumeral dislocations;
five acromioclavicular separations, one of which was operated on; two strains; and one contusion. These injuries were the foremost cause of lost playing time, with eleven of the twelve moderate or major injuries. DISCUSSION
Injured review of rugby is that of Mr. T. C. O’Connell, FRCS, of Dublin, who reported his experiences with twenty years of rugby injuries in 19546 (Table VI). He found head injunes, primarily lacerations and concussions, to be the leading area of injury (21.5%) while shoulder injuries (18%), were second in frequency of occurrence. The incidence of knee injuries in his study (12.5%), was similar to that found in our
The
most comprehensive injuries presently available
study. at two sites, shoulders and knees, further discussion, and can be compared with our experiences with American football injuries. As previously noted, the preponderance of shoulder injuries in this
Injuries
merit
95
TABLE IV
TABLE V
Distribution of Total
Shoulder Girdle
Injuries by Type
Injuries
Total of
12
study was a striking finding. The majority of these injuries were sustained by a tackling player, or by a player striking his shoulder against the ground after being tackled or missing a tackle. The possibility of decreasing these injuries or their severity by the use of specific shoulder strengthening exercises, or by the use of some form of soft foam shoulder padding which might be allowed in rugby, would seem to merit further study. The lower number of knee injuries in this sport than in American football, where knees are the prime site of injury, is relatively easily explained, and is consistent with a number of the studies of American football injuries. Blocking, specifically, blocking of the cross-body variety, is totally absent in rugby. A recent review of knee injuries at the University of Michigan by Dr. Thomas Peterson has shown that more than half of all such football injuries which he observed were caused by cross-body blocks,’ while only a third were due to no-contact or tackling injuries, the mechanisms which would be working in rugby. In addition,
96
and Area
several recent studies of footwear in football to be in basic agreement that the use of a soccer-style shoe, which is also worn in rugby, appears to result in a lower incidence of knee injury. Finally, the use in American football of rigid protective equipment about the head, shoulders, and forearms may be counterproductive, allowing the tackler or blocker to hit at a significantly higher velocity and level of kinetic energy than if he were not so protected, with a resultant increase in the severity of injury to his target, whether knee, ankle, or abdomen A comparison of relative rates of injury in various sports is hazardous, at best. Many studies of sports injuries are concerned with the variety of types of injury rather than a specific incidence of injury, and reports vary considerably as to the standard of seem
comparison-per game, ticipant.~ The following
or parstudies of footwhile not always to put the present
season,
ball and rugby injuries, directly comparable serve study in perspective (Table VII). Allen reported the incidence of injury in an eight-team club league with 465 particiat Clark Air Force Base.’ There were 290 injuries, a 62% rate of injury, resulting in 38 hospitalizations and 22 operations. He attributed the high rate of injury to poor conditioning and training. Garrahan reported a 20% rate of injury per season in high school football in Rhode Island over a five year penod.3 A similar study in Ohio found essentially the same rate of injury.
pants
TABLE VI
General
Analysis
of All
Injuries
during one season in an English rugby league and found a 4.4% rate of injury Our study, as previously noted, found a 9 8% rate of injury
TABLE VII
Relative Occurrence of
Injury
Determining an acceptable rate of injury for a given sport is a difficult proposition and perhaps depends as much upon philosophic judgment as medical fact Without doubt, the contact sports have a significantly higher rate of injury than most others being played, yet we proceed on the assumption that the individuals involved are prepared to accept the implied risks of these sports. Within these limits, however, it appears that the risks of injury in contact sports could be lowered two ways first, by improving conditioning, coaching, and officiating; and second, by evaluating changes in protective equipment and changes in the rules that would increase safety but still maintain the essential qualities of these games. Rugby in the Boston area is presently being played with borderline coaching and officiating on poor fields, and by players who are sometimes only half-conditioned and possess a rudimentary knowledge of the rules and strategy of the game. This is fairly characteristic of much of the rugby presently being played in the United States We might expect a progressive decrease in the rate of injury of this game as these conditions improve.
Because of sustained efforts
by interested
physicians, trainers, and schools, the data on injuries in collegiate football have been more accurately collected and studied
in
recent
years The most recent and most accurate
compilation of this data is reported m the National Collegiate Football Injury Report 1970, compiled by the Joint Commission on Competitive Safeguards & Medical Aspects of Sports, using records completed at 40 schools engaged in NCAA college play. Of 2,894 players studied, 1,468 (52%) sustained a total of 2,782 injuries. More than ten per cent (10.7%) of these required surgical correction.s Studies of injuries in rugby football are Mr. O’Connell estimates a 10-12% of injury per season, with a rugby season approximately three times the length of ours.s Archibald reported all injuries
scarce.
rate
References 1 2
3
4
Allen ML Air Force Football Injuries JAMA 206 1053 1058, 1968 Archibald RM An analysis of rugby football injuries in the 1961 62 season Practitioner 189 333 334, 1962 Garrahan WF Incidence of high school football injuries Rhode Island Med J 50 833 835, 1967 Haddon W Jr Principles in research on the effects of sports on health JAMA 197
885-888, 1966 5 Joint Commission on Competitive Safeguards and Medical Aspects of Sports National Football Injury Report 1970 Lincoln University of Nebraska, 1972 6 O’Connell TCJ Rugby football injuries and their prevention J Irish Med Assoc (Jan) 1958 7 Peterson TR The cross body block, the major cause of knee injuries. JAMA 211 449 452, 1970
97
DISCUSSION
MERVYJBo J. CROSS, M.D., Tulane University : The authors are to be complimented on
adding to the scarce literature on rugby injuries. The scarcity of literature on the subject does not mean that injuries are uncommon.
Rugby football, in Australia particularly, is divided into professional and amateur codes. Major differences occur. The professional game or Rugby League has thirteen players. When the player is tackled his team retains possession and a &dquo;play the ball&dquo; ensues similar to a &dquo;down&dquo; in American football. If the ball goes into a touch a &dquo;scrum&dquo; results. The game of Rugby League is also played in England, France and New Zealand. These countries participate in a World Cup every four years. An incidence of 9.8% appears low to me as an ex-professional player and team physician.
In
one
year
as
team
physician, I readily
recall such bizarre injuries as a dislocated lens of an eye, duodenal contusion with malaena, compression fracture of the first lumbar vertebra and open dislocation of the metacarpo-phalangeal joint of the thumb. This was in addition to the usual &dquo;Charlie horse,&dquo; memscal tears, acromioclavicular dislocations and ankle injuries. These injuries occurred among only twenty-six players. It is unfortunate that the rugby playing nations do not report on their injury rates, but I’m sure the excellent example of the authors will stimulate their overseas colleagues to reveal the presently hidden dangers of rugby. JAMES P. AHSTROM, JR., M.D., Oak Park, Illinois: The information presented here, contrary to popular impression, indicates that there are fewer injuries in rugby than in American football. The suggestions of the
J Cross, M B B S, F R A C S, is a Fellow in Sports Medicme, Tulane University School of Medicine, New Orleans, La
Mervyn
98
authors that this is due to the practice of blocking, especially the cross-body block, and to the false security offered by protective devices in American football would seem to be logical It is possible that a larger sample of injuries might yield a higher incidence of significant knee injuries. The understandable likelihood of direct trauma to the shoulder explains the high incidence of injury in this area. The use of soft padding should be a helpful preventive measure and should be investigated. DR. LYLE J MICHELI: The authors apprecithe comments of Dr. Ahstrom and Dr. Cross on this paper. Our continued clinical experience with injuries from this game remains consistent with the pattern of injuries found in this study. Dr. Cross’s comments on the apparently higher rate of injury in Rugby League play are interesting and consistent with the impressions of a number of our colleagues who are familiar with both Rugby Union, the amateur game, and Rugby League. As Dr. Cross has noted, there are significant differences in the rules of these two games. Rugby Union is the only style of rugby presently being played in this country, and, judging from Dr. Cross’s catalogue of injuries of a Rugby League team, this is probably a fortunate circumstance. It appears to us that Rugby League, as a game, is much closer to American gridiron football, in so far as one of the direct objectives of the game is for a player to dnve ahead at maximal velocity to obtain as much territory as possible, while his opponent, in turn, strikes him with maximal impact in order to stop his forward progress. Rugby Union, on the other hand, is much more akin to soccer football, in so far as the objective is to play the ball, not the man, and to capture the ball from the opponent and then to proceed on with play. We would therefore expect Rugby Union to have a significantly lower rate of injury than Rugby League, as well as American gridiron ate
football.
injuries
in
LYLE J. MICHELI, M.D. EDWARD M. RISEBOROUGH, M.D.
The runner
game of rugby football, direct foreof Amencan gridiron football, is
undergoing
a
widespread revival in the specifically, in the Bos-
United States, and, ton area.
Dr. of
Lyle J.
Michael>
is
Assistant Clinical Professor
Orthopaedic Surgery, George Washington University School of Medicine; Orthopaedic Sur-
geon, Malcolm Grow U S.A.F Medical Center, Washington, D C
Dr Edward M Riseborough is Attendmg Orthopaedic Surgeon, Childrens Hospital Medical
Center, Boston, Mass , Associate Professor of Orthopaedic Surgery, Harvard Medical School, Boston, Mass Photo Credit Courtesy of Matthew Godek, Alex-
andria, Vad
football and American football are frequently compared and contrasted by their respective proponents as to playing skills required, and the relative dangers involved in playing each sport. It is the purpose of the present study to report the incidence, nature, and severity of injuries sustained in rugby football by players of seven Boston area rugby clubs in the Spring 1971 season. A brief review of the historical relationship between rugby and American football
Rugby
93
and a summary of the present mode of play of rugby union football should help to put the results of this study and the conclusions drawn from it in better perspective. Soccer football, the most widely played football game in the world today, is also the oldest, and the direct forerunner of both rugby and American football. In 1823 a schoolboy at the Rugby school in England disrupted a soccer game by picking up the ball and running with it across the goal line. Within thirty years, this new approach to football had developed into a completely separate game, rugby football. A soccer style of football was first played in the United States. The first intercollegiate football game, between Princeton and Rutgers in 1869, was actually played by soccer rules. Five years later, the first rugby style of game was played between Harvard and McGill in Boston. The rugby style of game, with its running, passing, and tackling, quickly supplanted soccer. It was through progressive modifications of the rugby style of play that our modern American football has evolved. Modern rugby union football still remains quite close to the early rugby style of play and differs from American football in a number of important ways. There are fifteen men on a team. The game is divided into two forty-minute halves, with no time-outs or substitutions allowed. Protective equipment, developed to a sophisticated and sometimes dangerous degree in American football, is specifically prohibited in rugby. The game begins with a kick-off, as in football. Play is continuous, except for stoppages following infractions of rules, and running is the prime method of advancing the ball, though it can be kicked directly TABLE I
94
forward
at any
time
by
the ball carrier. An
opponent carrying the ball may be tackled, but
blocking is allowed. The ball may be only passed laterally or backwards. Any no
member of the team is eligible to receive a pass or field a kick if he is on-sides. Scoring is done by running the ball across the goal line and touching it down, by kicking it through the uprights as a conversion after a touchdown, or by a penalty kick. MATERIALS AND METHODS
Spring 1971 season, 389 participants the four college and three club sides were studied (Table I). Any injury for which medical attention was required or sought was recorded, whether the injury had occurred during a game or practice session. These injuries were graded according to the time elapsed before full participation could be resumed With a minor injury, no game time was lost and the participant could play the following week. An injury of moderate severity resulted in missing at least one but not more than two games; and a major injury resulted in a player’s missing three games or the remainder of the season. Moderate and major injuries were confirmed by the authors either by direct examination or discussion with the attending physician. In the
on
RESULTS
A total of 38 injuries were recorded for an overall injury rate of 9.8%. Thirty-one of these were received in actual games, and seven in practice sessions: 1 1 were major, 211 moderate, and 6 minor injuries. An analysis of these injuries by area injured (Table II) showed that the shoulder girdle received the highest incidence of in-
total of 12; more significantly, I 1 of of moderate or major severity. Head/neck and knee were next, with five each. There were four injuries of the chest/ abdomen, three each to the back/spine, lower limbs, and ankle; and one to the foot An analysis of these injuries by type (Table III) showed fractures to be the leading diagnosis, a total of eight There were six contusions and six sprains, five strains, five acromioclavicular separations, three abrasions/lacerations, two dislocations, and one each of cerebral concussion, hermated nucleus pulposus, and tear of the meniscus of the knee. An overall summary of these rugby injuries is possible by comparing the type of injury with the area injured (Table IV). There were five injuries to the head/neck area, three facial lacerations, one broken nose, and one concussion. There were two chest contusions and two cases of fractured nbs, but no abdominal injuries were reported. The three injuries to the back were a contusion of the lumbar region, a low back strain, and a herniated nucleus pulposus, confirmed operatively. Shoulder girdle injuries will be reviewed separately. The two other upper extremity injuries were a Colles fracture and a fractured phalanx, both requiring closed reduction. In the lower limb, there was one quadriceps contusion, and one each of hamstnng and gastrocnemius strain. There were five
jury,
a
the 12
TABLE III
TABLE II
Characteristics of Total Area
Injuries by
Characteristics of Total
Injuries
by Type
were
knee
injuries:
one
contusion from
a
direct
kick, three strains of the medial collateral and one tear of the lateral menisThree sprains of the ankle and one case of multiple metatarsal fractures completed the list of lower extremity injuries. The prevalence of shoulder injuries was striking, comprising as they did almost one-third of the total injuries observed (Table V). These included two fractured
ligament, cus.
clavicles;
two
glenohumeral dislocations;
five acromioclavicular separations, one of which was operated on; two strains; and one contusion. These injuries were the foremost cause of lost playing time, with eleven of the twelve moderate or major injuries. DISCUSSION
Injured review of rugby is that of Mr. T. C. O’Connell, FRCS, of Dublin, who reported his experiences with twenty years of rugby injuries in 19546 (Table VI). He found head injunes, primarily lacerations and concussions, to be the leading area of injury (21.5%) while shoulder injuries (18%), were second in frequency of occurrence. The incidence of knee injuries in his study (12.5%), was similar to that found in our
The
most comprehensive injuries presently available
study. at two sites, shoulders and knees, further discussion, and can be compared with our experiences with American football injuries. As previously noted, the preponderance of shoulder injuries in this
Injuries
merit
95
TABLE IV
TABLE V
Distribution of Total
Shoulder Girdle
Injuries by Type
Injuries
Total of
12
study was a striking finding. The majority of these injuries were sustained by a tackling player, or by a player striking his shoulder against the ground after being tackled or missing a tackle. The possibility of decreasing these injuries or their severity by the use of specific shoulder strengthening exercises, or by the use of some form of soft foam shoulder padding which might be allowed in rugby, would seem to merit further study. The lower number of knee injuries in this sport than in American football, where knees are the prime site of injury, is relatively easily explained, and is consistent with a number of the studies of American football injuries. Blocking, specifically, blocking of the cross-body variety, is totally absent in rugby. A recent review of knee injuries at the University of Michigan by Dr. Thomas Peterson has shown that more than half of all such football injuries which he observed were caused by cross-body blocks,’ while only a third were due to no-contact or tackling injuries, the mechanisms which would be working in rugby. In addition,
96
and Area
several recent studies of footwear in football to be in basic agreement that the use of a soccer-style shoe, which is also worn in rugby, appears to result in a lower incidence of knee injury. Finally, the use in American football of rigid protective equipment about the head, shoulders, and forearms may be counterproductive, allowing the tackler or blocker to hit at a significantly higher velocity and level of kinetic energy than if he were not so protected, with a resultant increase in the severity of injury to his target, whether knee, ankle, or abdomen A comparison of relative rates of injury in various sports is hazardous, at best. Many studies of sports injuries are concerned with the variety of types of injury rather than a specific incidence of injury, and reports vary considerably as to the standard of seem
comparison-per game, ticipant.~ The following
or parstudies of footwhile not always to put the present
season,
ball and rugby injuries, directly comparable serve study in perspective (Table VII). Allen reported the incidence of injury in an eight-team club league with 465 particiat Clark Air Force Base.’ There were 290 injuries, a 62% rate of injury, resulting in 38 hospitalizations and 22 operations. He attributed the high rate of injury to poor conditioning and training. Garrahan reported a 20% rate of injury per season in high school football in Rhode Island over a five year penod.3 A similar study in Ohio found essentially the same rate of injury.
pants
TABLE VI
General
Analysis
of All
Injuries
during one season in an English rugby league and found a 4.4% rate of injury Our study, as previously noted, found a 9 8% rate of injury
TABLE VII
Relative Occurrence of
Injury
Determining an acceptable rate of injury for a given sport is a difficult proposition and perhaps depends as much upon philosophic judgment as medical fact Without doubt, the contact sports have a significantly higher rate of injury than most others being played, yet we proceed on the assumption that the individuals involved are prepared to accept the implied risks of these sports. Within these limits, however, it appears that the risks of injury in contact sports could be lowered two ways first, by improving conditioning, coaching, and officiating; and second, by evaluating changes in protective equipment and changes in the rules that would increase safety but still maintain the essential qualities of these games. Rugby in the Boston area is presently being played with borderline coaching and officiating on poor fields, and by players who are sometimes only half-conditioned and possess a rudimentary knowledge of the rules and strategy of the game. This is fairly characteristic of much of the rugby presently being played in the United States We might expect a progressive decrease in the rate of injury of this game as these conditions improve.
Because of sustained efforts
by interested
physicians, trainers, and schools, the data on injuries in collegiate football have been more accurately collected and studied
in
recent
years The most recent and most accurate
compilation of this data is reported m the National Collegiate Football Injury Report 1970, compiled by the Joint Commission on Competitive Safeguards & Medical Aspects of Sports, using records completed at 40 schools engaged in NCAA college play. Of 2,894 players studied, 1,468 (52%) sustained a total of 2,782 injuries. More than ten per cent (10.7%) of these required surgical correction.s Studies of injuries in rugby football are Mr. O’Connell estimates a 10-12% of injury per season, with a rugby season approximately three times the length of ours.s Archibald reported all injuries
scarce.
rate
References 1 2
3
4
Allen ML Air Force Football Injuries JAMA 206 1053 1058, 1968 Archibald RM An analysis of rugby football injuries in the 1961 62 season Practitioner 189 333 334, 1962 Garrahan WF Incidence of high school football injuries Rhode Island Med J 50 833 835, 1967 Haddon W Jr Principles in research on the effects of sports on health JAMA 197
885-888, 1966 5 Joint Commission on Competitive Safeguards and Medical Aspects of Sports National Football Injury Report 1970 Lincoln University of Nebraska, 1972 6 O’Connell TCJ Rugby football injuries and their prevention J Irish Med Assoc (Jan) 1958 7 Peterson TR The cross body block, the major cause of knee injuries. JAMA 211 449 452, 1970
97
DISCUSSION
MERVYJBo J. CROSS, M.D., Tulane University : The authors are to be complimented on
adding to the scarce literature on rugby injuries. The scarcity of literature on the subject does not mean that injuries are uncommon.
Rugby football, in Australia particularly, is divided into professional and amateur codes. Major differences occur. The professional game or Rugby League has thirteen players. When the player is tackled his team retains possession and a &dquo;play the ball&dquo; ensues similar to a &dquo;down&dquo; in American football. If the ball goes into a touch a &dquo;scrum&dquo; results. The game of Rugby League is also played in England, France and New Zealand. These countries participate in a World Cup every four years. An incidence of 9.8% appears low to me as an ex-professional player and team physician.
In
one
year
as
team
physician, I readily
recall such bizarre injuries as a dislocated lens of an eye, duodenal contusion with malaena, compression fracture of the first lumbar vertebra and open dislocation of the metacarpo-phalangeal joint of the thumb. This was in addition to the usual &dquo;Charlie horse,&dquo; memscal tears, acromioclavicular dislocations and ankle injuries. These injuries occurred among only twenty-six players. It is unfortunate that the rugby playing nations do not report on their injury rates, but I’m sure the excellent example of the authors will stimulate their overseas colleagues to reveal the presently hidden dangers of rugby. JAMES P. AHSTROM, JR., M.D., Oak Park, Illinois: The information presented here, contrary to popular impression, indicates that there are fewer injuries in rugby than in American football. The suggestions of the
J Cross, M B B S, F R A C S, is a Fellow in Sports Medicme, Tulane University School of Medicine, New Orleans, La
Mervyn
98
authors that this is due to the practice of blocking, especially the cross-body block, and to the false security offered by protective devices in American football would seem to be logical It is possible that a larger sample of injuries might yield a higher incidence of significant knee injuries. The understandable likelihood of direct trauma to the shoulder explains the high incidence of injury in this area. The use of soft padding should be a helpful preventive measure and should be investigated. DR. LYLE J MICHELI: The authors apprecithe comments of Dr. Ahstrom and Dr. Cross on this paper. Our continued clinical experience with injuries from this game remains consistent with the pattern of injuries found in this study. Dr. Cross’s comments on the apparently higher rate of injury in Rugby League play are interesting and consistent with the impressions of a number of our colleagues who are familiar with both Rugby Union, the amateur game, and Rugby League. As Dr. Cross has noted, there are significant differences in the rules of these two games. Rugby Union is the only style of rugby presently being played in this country, and, judging from Dr. Cross’s catalogue of injuries of a Rugby League team, this is probably a fortunate circumstance. It appears to us that Rugby League, as a game, is much closer to American gridiron football, in so far as one of the direct objectives of the game is for a player to dnve ahead at maximal velocity to obtain as much territory as possible, while his opponent, in turn, strikes him with maximal impact in order to stop his forward progress. Rugby Union, on the other hand, is much more akin to soccer football, in so far as the objective is to play the ball, not the man, and to capture the ball from the opponent and then to proceed on with play. We would therefore expect Rugby Union to have a significantly lower rate of injury than Rugby League, as well as American gridiron ate
football.
