Blowing the whistle on competitive scrums

The issue of risk in both rugby union and rugby league has been a widely debated topic over recent years and much has been done already to improve safety. Yet with 63 collapses for every 100 scrums in last year’s Six Nations tournament and evidence to suggest that the statistics on cervical spine injuries do not take into account whether the player is involved in the scrum or not (Brown et al, 2014) – should we consider the end of competitive scrums in rugby union?

As another major rugby tournament draws near, recent discussion has focused on the risk of head trauma and concussion, both short and long term, which has become a highly debated issue in sports across the world. Much of the impetus for this has arisen from American sports such as American Football and ice hockey.

Some parallels can be drawn between these American sports and rugby. The high impact nature of the sport is, in part, what makes it appealing to players and spectators but with this high impact comes a significant risk of injury. It is accurate to suggest that many, if not all participation sports come with a risk of injury, but in rugby the risk of both head and cervical spine injuries are increased and it is these injuries that have both life threatening and life altering consequences for the players involved and for their families.

The risk of both head and cervical spine injury is heightened by the seemingly increasing size and strength of professional rugby players at the highest level of both codes but at that level, the players are of similar size and the medical support teams are instantly available. Lower down the pyramid and particularly in junior games where young people of different heights and build are often put against each other despite being in the same age bracket, the potential for injury is arguably greater. This is particularly true if one scrum is more dominant than another.

Whilst much of the recent focus has been on head injuries and concussion, in my opinion greater awareness is needed about another potential threat from rugby, the damage that can be done to the cervical spine which has the potential to cause tetraplegia. Reviewing the literature, it is the tackle and the scrum that represent the occasions when a cervical spine injury are more likely to occur. The probability of cervical spine injury occurring as a result of a tackle can be reduced by good tackle technique are proper enforcement of the laws of the game, but it is the scrum that remains an area of concern with some evidence suggesting that the number of cervical spine injuries resulting from scrum collapses has been underestimated as the research is not focussed on those players who form the scrum.

One of the key differences between rugby union and rugby league is that the scrum in rugby league is treated merely as a method of restarting the game where the ball enters a six man pack and exits quickly to allow the game to continue. The rugby union scrum is much more of an integral part of the game with considerable forces applied by each pack of eight players which makes collapsing of the scrum more likely. Less research has been produced about rugby league as a sport but what does exist suggests that having these non-competitive scrums can reduce the incidences of cervical spine injury. Rugby union purists may suggest that the scrum represents an integral part of their sport which has been played for many decades and that cervical spine injuries are rare. Improvements have been made in the conduct of competitive scrums in rugby union but the risk of injury cannot be completely eradicated and one would argue from a medical perspective that, acknowledging that cervical spine injuries are uncommon, the consequences of a cervical spine injury are too severe to be ignored. This is particularly true at a time of increased awareness of safety in sport.

The main focus of my article was to evaluate the medical imaging strategy of cervical spine injuries in rugby players which had traditionally been challenging due to patient size and new NICE Guidelines on cervical spine injuries are expected soon. The imaging can only come after an injury. If we are serious about protecting particularly our young players from cervical spine injury then the continued practice of competitive scrummaging should be questioned. The risk of injury cannot ever be totally excluded but greater focus is needed on those head and neck injuries that have significant long term consequences.

paper is available online at Radiography an international, English language, peer-reviewed journal of radiographic imaging and radiation therapy.

Ref: Brown J, Lambert M, Hendricks S, Readhead C, Verhagen E, Burger N and Viljoen W (2014) Are we currently underestimating the risk of scrum-related neck injuries in rugby union front-row players? Abstract from the IOC World Conference on Prevention of Injury and Illness in Sport, Monaco 2014