Watch this video of Dr Stuart O’Flanagan, Consultant Sports & Exercise Medicine Physician at UPMC Sports Surgery Clinic and Leinster Rugby, presenting on ‘Common Injuries in Rugby7’s.’
This video was recorded as part of UPMC Sports Surgery Clinic’s online Public Information Meeting, focusing on Common Rugby Injuries, Causes and Prevention.
Good evening my name is Dr Stuart O’Flanagan and I’m delighted to speak to you this evening on this rugby themed webinar series. I’m going to be talking about Rugby 7s’ and some common injuries. It is a very exciting time for the men’s 15s’ as they start their world cup journey. For the first time were going to have two Irish rugby teams in the 7s’ competition competing in the Olympic games in Paris in 2024. I thought it would be good to share some insights into the programme there.
I will be going through an overview of Rugby 7s’, The IRFU National Sevens Programme, Common Injuries, Injury Prevention and also the approach we take here at UPMC SSC Sports Medicine.
Although played on the same size pitch and has the same size ball Rugby 7s’ is much more amenable and has many more similarities to other field sports like Gaelic Games and Soccer.
My background, I am a Consultant Sports and Exercise Medicine Physician here at UPMC Sports Surgery Clinic Sports Medicine. I also look after the medical side of the Irish National 7s’ team and I am also a Team Doctor with Leinster Rugby.
Rugby 7s’ is exactly how it seems. It has 7 players on a full-size field. The games consist of two 7-minute halves and typically a tournament will have 2-3 games in one day in a tournament which is usually over the course of a weekend. Typically, there are 3 forwards and 4 backs so a scrum will have 3 people in it as opposed to 8 in a 15 aside game and what that does is it provides a lot of space around the pitch for people to gain ground. It certainly rewards the people who are fast and athletic. Not only are they good at running in straight lines but they are also very good at changing direction, side-stepping, weaving through players. Speed, pace power and quick footwork are all highly rewarded in the game of 7s’.
The IRFU 7s’ programme was established a number of years ago and has rapidly evolved. They are now made up of 2 squads, Men’s and Women’s and they have about 20 players per squad. The majority of which are professionally contracted. They are based in the IRFU performance centre which is in the National Sports Campus in Abbottstown. The facilities are state of the art. There are 3 outdoor pitches. There is a half-sized indoor pitch to be used when the weather is less pleasant, they have a fully equipped gym, medical and recovery rooms, hydrotherapy pools, rooms for video analysis and a canteen with some full-time chefs who provide the players meals throughout the week. The players are here Monday – Friday and then travel all around the world to take part in 7s’ tournaments. Our two squads competed in the world series which has recently been rebranded and there is 8 venues across 5 continents. Men’s and Women’s competitions mirror each other. The competitions are played in exotic destinations like Dubai, Cape Town, Perth. North American venues such as Vancouver, LA. Asian venues such as Hong Kong and Singapore. Finishing in Madrid where the Men and Women will be competing in.
This year will be a very big year for our teams as mentioned as mentioned they have qualified for the Olympic Games in Paris in 2024. Our Women’s team qualified earlier in the year in Toulouse by finishing in the top 5 in the world series for the first time ever. Shortly followed by our Men’s team who qualified in Krakow in Poland through the European games earlier on in the Summer. It will be our Men’s second visit to an Olympics having qualified for the last Olympics in Tokyo which was played in July of 2021. I was very fortunate to have travelled over to that to a very different games during Covid-19 times where essentially all of the games were played behind closed doors. We have approximately 80% of our men’s team who have been to an Olympics along with our staff who have a lot of experience going into Paris it will be a huge experience for everyone.
I’m going to touch on the types of injuries that we see in 7s’ Rugby. While there are lots of similarities with the 15s’ game, this game is much faster, quicker and as I said rewards quick, powerful, evasive players and it’s all about finding space and avoiding contact.
The types of injuries that we see can be categorised into a few different areas. Contact Injuries vs Non-contact Injuries. Contact injuries occur in tackles and rooks. Whereas, Non-contact injuries are related to running and sprinting in particular which we will touch on shortly. Now let’s look at Injuries in relation to training and games. What is the type of injuries that happen in a training session and what are the types of injuries that happen in a game? Games are obviously a lot higher intensity due to the amount of running at high speed, much harder collisions and often the injuries in games can be related to contact situations. Then we often look at injuries in terms of incidence and severity so how many injuries of a certain type are we experiencing every year and how severe are they? We might have lots of muscle injuries that are keeping players out for a week or two but we might have more severe injuries such as a broken bone or a sprained joint which may even take longer. These are the kind of things we look at when we talk about injuries in 7s’ Rugby.
In the IRFU we perform and annual injury & illness surveillance and what that does is it helps us look back at the year just gone but also allows us to compare the years prior in terms of what kind of injuries we are receiving in our squads so is there trends that we can look at to try and reduce or prevent future injuries and are there things that we have addressed that have been issues in the past that we are now better at? In the last 12 months we have had a good overview of the Men and Women’s squads with some similar type injuries. The most common injury in training for Women is Ankle Sprains and the average time from injury to return to play is around 24 days. In games, calf injuries are the most common type of injury that we see and statistically players recover within 15 days. When we look at the Men’s side Hamstrings seem to be the most common injury that we have seen in training. The average time to return is about 27 days and in games which are more contact related injuries the most common injury we see is Ankle Sprains which statistically take about 25 days to recover. You can see that on average a player may be out for 3-4 weeks when sustaining an injury in a game and it tends to be the lower limbs so the joints and the muscles of the legs that have been impacted the most.
What are the most common causes of injury? I eluded to it previously, sprinting and high-speed running are really the big things and with less players on the pitch and with more space means more time is spent sprinting and running away from people and often those sprint efforts will be anywhere between 20 and 80 metres. They could be running the length of the pitch and they could be doing it repeatedly in the 14 minutes of the game that they are playing and Hamstrings are common across all sports especially field sports, Gaelic Games, Football and 7s’ is no different a lot of our players have previously been involved in Athletics and have done running so we are very well exposed to sprinting and running at the intensity at the World Series but Hamstrings still always tend to be one of the main issues. The Calf is another muscle injury which is more commonly found in the Women players this season but again for the same purpose and as well as the videos that I showed earlier, Jordan Conroy weaving in and out of players and changing direction is a big thing in 7s’. There is a lot of demand on the ankle as players sharply decelerate, change direction, side step and go again. That is certainly one of the reasons that we have seen a number of injuries to the ankle this year as well as the contact situations where players get caught up in tackles and their feet get planted in the ground, they are twisting and turning trying to get out of tackles where the ankle can roll or turn and be injured.
|Treating Hamstring injuries is something that we are very familiar with and it is really important to have a good understanding of the anatomy and how the muscles work and in turn what the demands of the players are so we can treat the injury.|
As you can see on the MRI scan this is what we use to diagnose injuries. It allows us to grade it between a 1,2&3 which allows us to determine when it is a player will be able to return. This gives us an indication of how hard or how quickly we can push an injury and also when they are going to be next available
Similarly, with the Calf a very important group of muscles the two Gastrocnemius muscles on the outside and the Deeper Soleus muscles all 3 equally as important as they combine and run into the Achilles Tendon and again we use modalities such as MRI to assess for injury to help us understand what the type of injury is but also what the timelines will be for the return to play for these athletes.
A big area of focus for us is on ankle stability and as you can see on the side of your screen there is a lot ligaments stabilising the ankle both on the inside and the outside as well as the top of the ankle and one type of injury we see more commonly in the last few years is a high ankle sprain also known as a Syndesmosis. Which is a ligamentous structure keeping the joint stable at the top of the ankle both at the front and the back and this is something we have seen probably more related to the surfaces that our players are playing on around the world in terms of harder pitches in warmer climates as well as some of the stadiums, particularly in North America they can be Baseball or NFL stadiums where the ground is artificial grass and the ground is harder and there is more impact going through the ankles.
In the 7s’ programme we put a lot of focus on prevention. My area of interest is more on preventing injuries rather than dealing with them initially. If we can prevent them coming, knowing what we know from the last 12 months or perhaps, maybe the last 36 months we can try and address that in the weekly schedule. Here is an example of a week for a player and this is all the work that they do outside of rugby. We often do quite a lot of work in the gym to prepare for pitch sessions. The focus would be on movement health so getting the spine and hamstrings warm and loose as well as getting the muscles around them active. We put a lot of focus on the shoulder as you could imagine because rugby tackling requires good shoulder health as well as putting some work into ankle balance, control and strengthening the muscles surrounding it. We put big emphasis on what we call posterior chain or hamstring and gluteal strength as well as neck strength which is something we use to help prevent concussions and this might be done on a couple of days during the week as you can see on the schedule. There is always preparation for training and playing but also preventing injuries based on what we have seen before and of course we also have the team approach but we also have the individual approach so some exercises will be very specific to a player and their injury history in particular. You can see an awful lot of work and thought goes into preparing a player during the week and this is an average week outside of tournament times.
The kind of things we look at are for the hamstring strength and the high-speed running. High speed running is the equivalent of a vaccine for our players in terms of hamstring injuries so we look to ensure they get a number of exposures where they are running at very high speeds. We constantly work on the strength of the hamstring and the muscles surrounding that and similarly in the calf the 3 muscles I mentioned we look at training them regularly with heel raises with a bent knee and a straight leg as well as sprinting and endurance running. Running volume is important for the calf and our players cover long distances repeatedly so it’s ensuring they have enough in the tank particularly when the intensity is very high and the temperature and humidity levels can be different also. As I mentioned, strength so you can see some jump testing in the bottom picture there where we are getting real stiffness into the ankle to allow players to withstand falls as they run jump and evade the opposition.
Our approach here at UPMC Sports Surgery Clinic is very similar. We look at any athlete that comes in and as I said a lot of the injuries that we see in 7s’ I see now on a daily basis particularly now at the moment as it is championship time in Gaelic and Hurling. Also, Soccer and Hockey we also get many from Athletics in at the moment as well and many of them have transitioned to 7s’ over the years. We look at the History thinking what has the injury been? Also, focus examination. We often utilise imaging such as MRI’s to make the diagnosis to allow us to understand what structures have been injured and also to give us an idea of the timeline. There is very big structures in the hamstring including muscle, fascia overlying the muscle and tendon which runs through and each of those has a different way managing and helping a player return to play often with strength and then running and indeed high-speed running in time before re-integrating into playing and training. We look at other measures such as strength, we do a lot of isokinetic dynamometry testing as you can see some strength testing of the thighs in that picture and we also look at jump testing as well as a measure of reactive strength. Ultimately, that culminates in a rehab plan for the athlete to allow them to return to sport. The aim here really is prevention trying to get them back once and for all and to reduce any risk of future injury as a result.
Ankle sprains are really common and this injury is probably the most common presentation of a joint injury that appears in an A&E clinic or a Physiotherapy clinic around the country.
|The biggest predictor of a future ankle sprain is a previous ankle sprain so prevention is really key.|
Once you manage the early stage of the sprain like the swelling and the pain, making sure that there is nothing more serious than physiotherapy is really important making sure we restore the balance of what we call proprioception and improving the strength of the muscles in the ankle which can drop off really quickly, particularly in the calf and the muscles around the gastrocnemius and gastrocsoleus which I mentioned in the talk are really critical for that and once you have got a good level of strength you can start turning to hopping and jumping and once that is all good you may return to running and move back into sports and specific drills.
In my perspective, prevention is the most important part because it is the most common injury and it is really about managing that well so you are robust enough to return to play sport or do any direction change in certain activities.
The big thing with that high-grade injury is that you have damaged all the ligaments. I’m guessing it is on the outside of the ankle, the lateral ligaments. It is the clinical assessment that is really important.
When you have that level of injuries you have the potential to have ankle instability and as I mentioned the thing that we want to prevent is recurrent sprains because you can get damage to the joint, the alignment and the cartilage. It’s really about trying to improve the balance, proprioception and making sure that the athlete feels stable and not vulnerable.
If all else fails then you should be looking at getting some help from foot and ankle orthopaedic colleagues and on occasion rehab doesn’t work out or the joint is not stable then we look at procedures to stabilise the joint using surgery. We try the best we can to see how well we can manage it and you would be surprised I have had capped rugby players and All-Ireland hurlers with really high-grade injuries who do very well but when you involve all 3 ligaments or even the ligament higher up the syndesmosis that’s more of a challenge and it all depends on the clinical picture and the assessment, function and reassessing it in short intervals.
There is quite a bit, even though the ball is the same shape and the same pitch the sports are quite different. As there is more space on the pitch in a 7s game that requires more running and also high-speed running.
Players tend to be lighter and quicker. There are heavier players but generally, they are like sprinters or track and field athletes. They have similar profiles to GAA athletes.
I remember a couple of years ago we had some players who came across from one of the 15 aside provincial teams and they did more high-speed running in a warmup for a training session than they had done in the whole season and that was measured on the GPS units that they wear on their back.
There is lots more running and lots more adaptations required to protect people from the likes of hamstring and calf injuries.
Hamstring strains and injuries are another big thing that we see a lot of in the clinic here and by the time they end up in my clinic. Often, they would maybe have 5 or 6 and often try to make their own return by trying some physio and rehab or sometimes they try to just take some rest, and the big thing is getting the diagnosis from the start.
We use MRI here quite often because it tells us what type of injury it is whether it is a muscle injury or if it is the tendon which runs through the muscle, and that gives you an idea of the timeline sometimes people injure because they come back too soon and sometimes there is no way of knowing without a clinical assessment or an MRI.
In general, the stronger the hamstring, and the muscles that support it around the hip and pelvis the more robust people are, but sprinting is also like a vaccination. In addition, if you are playing a sport where there is lots of high-speed running then you have to be strong but you also have to be used to running fast. They are all the things that we love to do to try and prevent injuries.
We worry a little bit less about flexibility its not really as important but if your muscles are ready for running and changing direction we can then work around hip mobility and movement around the back, and that’s the principle we take with things like strength, sprinting and then making sure you have the right diagnosis from the start.