Facing up to the big hits: Rugby's search for solutions

In the third and final part of an investigation into rugby union's injury crisis, Chris Hewett talks to those responsible for shaping the future ­ and finds that while progress is being made in tackling the game's brutal toll, great challenges lie ahead

It does not fit easily with the wider doctrinal thrust of the Hippocratic Oath, this preparation of men for the slaughter, but while the sports medicine professionals currently working in English rugby generally have less time for philosophical musings than the players they treat, the big question must surely occur to them once in a while. Is rugby union sustainable at the top level, given the increasingly high risk of injury and seasonal casualty lists running into the thousands? Is it ethically sound for a doctor to associate himself with so perilous a game?

Dr Simon Kemp, the head of sports medicine at the Rugby Football Union and doctor to the England team, appears not to lose much sleep over the issue. "I've never felt my ethics have been compromised or endangered, or even challenged, by my work in rugby," he said towards the end of last week's gathering of the international squad at Loughborough University - a get-together notoriously undermined by the fact that more than 30 of the 50 invited players were injured and unable to train.

"As medical practitioners, we strive to offer care of the best quality to those who need it. That seems to me to be entirely consistent with the values of my profession. And anyway, we're not forcing people to play. Rugby is a pursuit - a gladiatorial pursuit - that people from all walks of life enjoy for all sorts of reasons. We don't want to lose that, do we? Or at least, not all of it."

If anyone is qualified to defend the role of doctors in rugby union, it is Kemp. When he is not dealing directly with his England charges, he is up to his eyeballs in research that he fervently believes will help ease the injury burden on the union game. Over and above his continuing work on the ground-breaking annual injury audit, and the development of a long-term risk management plan that will provide a foundation for preventative care as well as improvements in diagnostic and treatment disciplines, he has joined three colleagues - Dr John Brooks, Dr Colin Fuller and the video analyst Becky Cancea - in undertaking an exhaustive study into the dangers of the rugby tackle.

"This is being funded by the International Rugby Board, and we're four months into it," he said. "We are looking at almost 6,000 tackles across two seasons of Premiership matches - some 500 examples that caused injury to a player, plus more than 5,000 that were problem-free. We are breaking down each example into 25 elements and studying those elements in depth in an effort to define the tackle profile in professional rugby. It's the sort of thing they've worked on in American football with considerable success and if we get this right, there will be applications right across rugby union - not just to the medical side but to coaching, to the laws, to refereeing. There is so much we don't know about the tackle, about why some of them cause injury when others do not. To be honest, we're still not sure if most injuries are caused by the initial contact, or by the going to ground."

Kemp believes significant progress - "an advancement in joined-up thinking" - has already been made as a result of these many and varied investigations. "Our first task was to establish the scale of the problem and I think we've ticked the box there," he said. "The audit of injuries in Premiership and adult representative rugby now has mandatory status, which is a major step forward. Having finished the first one in 2004, we are now in the process of evaluating data from last season. I think this puts us ahead of many other governing bodies in the team sports field.

"The next stage is an aetiological one - a search for causes. The simplistic view says that collision causes injury, but that view is not of value in terms of what we are trying to achieve. We need to start with the injury and work backwards. What extrinsic factors were at work? What were the surface conditions? At what time of the season was the game being played? At what stage of the game did the incident occur?

"Then there are the questions concerning the athlete himself. What are his particular characteristics? Does he have a history of injury? If so, how recent? Was he at greater risk because he had just come out of rehabilitation? We can't put all rugby injuries in a big box and hope to draw sensible conclusions. We have to break them down. Only then will we get a management plan worthy of the name - one that allows us to make injury-specific recommendations.

"We already know certain injuries can be prevented with better science and better understanding. Hamstring problems, the most common complaint among rugby backs, are a case in point. With hamstrings, we have advanced into what we call 'prehabilitation' - certain exercises that help strengthen and protect the area and minimise the risk. The other side of the coin is concussion, which we can't prevent without making fundamental changes to the way rugby is played. What we can do here is identify the major risks - for the tackler, it is the front-on hit; for the ball-carrier, it is the high tackle - and provide guidance for those charged with reviewing the laws under which the sport is conducted."

Which is not to suggest that Kemp and his fellow researchers have all the answers to all the questions. Rugby union has had its share of false dawns on the player welfare front, from daft obsessions with body armour to the dangerous notion that a player can achieve indestructability if he spends long enough hammering himself into what he considers to be optimum condition. For every great leap forward taken by the scientists, there are 20 theories that fail to withstand scrutiny.

Over-training is now considered a very serious issue indeed. Down the years, some of the outstanding coaches in the game - some of its most advanced thinkers - have chosen to push their athletes to the limits of endurance in pursuit of a marginal improvement in performance that might win a tight game. It seems they were wrong. "The evidence here is quite clear," Kemp said. "Our work indicates that if players train for more than 7.5-10 hours per week, there is a significant increase in risk. If they train for more than 10 hours, there is almost a doubling of the severity of the injuries they sustain." Are we talking about all forms of training, or just the fully competitive rough stuff on a Tuesday morning? "All of it, barring the warm-up and the cool-down." So too much training is now a no-no.

Willie Duggan, that mischievous Irish forward from the 1970s, was better informed than he imagined when he condemned all preparatory work as "a surefire way to take the edge off your form". But what about the old chestnut of people playing injured? The history of the union game is littered with tales of heroic derring-do. Remember Robin Cowling, the Leicester prop, who kept scrummaging against a fearsome French front row despite a busted collarbone? Or Colin Meads, the All Black lock, who started a match with the Springboks with a broken arm? Or Alan Sharp, of Bristol, who played in a Scotland trial match with a broken leg and still got himself picked? Is it still part of the game, this insanity?

"My response to that question is: what do we mean by 'injured'?" Kemp replied. "Do we mean any physical complaint sustained as a consequence of playing rugby? If we use that definition, virtually everyone playing in a game will be playing injured. There is a difference between an athlete carrying some residual bruising from a "dead" leg that has no long-term consequence - something he is aware of, but which does not interfere with his performance - and someone playing with a headache from a concussion sustained the previous week. This is why we need specifics rather than generalisations. You can walk into any treatment room before any match and see people playing that day receiving medical attention and maintenance. Are these injuries, or minor physical malfunctions?

"There is still much to do in achieving an agreed set of standards in the professional game here. Some athletes operate both as club players and as elite England players, often in the same week, so there is urgent need for a symmetry of approach to their welfare. There has been an increase in medical staffing at Premiership level, but it is still the case that some clubs employ three physios while others have only two. Broadly speaking, there have been improvements. As recently as 2001, there was no systematic management of medical expenditure in the Premiership. Now, there is a centrally managed fund under very strict control that has resulted in greater, better-directed spending across the medical spectrum.

"What we need now is to keep pushing the agenda, to have an ongoing debate about what is acceptable in terms of risk and make rational, research-based judgments on the full range of welfare issues. Historically, there has been an acceptance of the consequences of injury in rugby union, but little or no strategy for treating or preventing it. Now, the interests of the players come first. Yes, there is an inherent risk of injury in this game, but if we put in the right kind of resources, I believe we can work ourselves into a position where we're equal to the challenge."

Body of evidence against wearing protective gear

The advanced research being undertaken by the likes of Dr Simon Kemp is crucial not only to the future course of sports medicine as it impacts on rugby union, but also to the current players' understanding of what is, and is not, good for them in terms of safety. A few years ago, large numbers of players bought into the idea that protective clothing - helmets, shoulder pads, chest guards - offered them immunity from a wide range of injuries. What happened? Everyone started tackling like Frank Bunce, the notoriously destructive midfield tackler from New Zealand, and paid the price in broken bones.

"It can be argued that if a player believes he is more protected than he really is, he puts himself at greater risk," Kemp said. "While no firm conclusions have been drawn from studies into the subject, there is a suggestion of this phenomenon occurring. Certainly, headgear is not sufficiently force-attenuated to prevent all head injuries, although it does minimise lacerations."

Protective gear is still commonly used. Stephen Larkham, the long-serving Wallaby outside-half, always wears a headpiece, as does his fellow Australian midfielder Matt Giteau. Chest and shoulder guards can still be seen every week in Premiership rugby. But the amount of padded clothing in regular use has dropped considerably in recent years and may fade from view altogether if major studies prove categorically that it lulls players into a false sense of security.

Dress code: What players can wear

Law 4.1

A player may wear... elasticated supports, shin guards, ankle supports, mitts, mouth guard, bandages, thin tape, and... (e) Shoulder pads... (to) cover the shoulder and collarbone only. No part of the pads may be thicker (g) Headgear... provided that no part of the headgear is thicker than 1cm when uncompressed