Preventing head injury in rugby through law changes and effective tackle training
“The focus is on reducing concussion during tackles in rugby. Tackle injuries lead to the highest incidence and severity of head injuries and concussion. They can have huge immediate and long-term consequences,” said Sharief Hendricks of the Department of Human Biology at the University of Cape Town & Leeds Beckett University, United Kingdom. “We are concerned for the long-term consequence of repeated contact injury. Tackle injuries specifically drive policy decisions in world rugby.”
Hendricks, who grew up in Lentegeur, Mitchells Plain in Cape Town with parents who had grown up in District 6, said: “Rugby is a big part of that community and, of course, has played a huge part in South African politics. There is meaning and identification related to rugby in South Africa at all levels − especially as the team has become more transformed over the years.
He and his colleagues have done lots of research and published widely about rugby injuries and making the game safer. “We need to take the unsafe methods away and show which interventions are working,” he said. “Rugby has changed a lot and has shown willingness to change.”
And with an estimated 7.6 million players spanning 128 countries, it’s one of the most-played sports in the world affecting the lives of many people.
Tackling safety danger
Hendricks explained that the nature of the tackle in rugby exposes players to a high risk of head injury. “It’s a physical technical contest,”
The work involves analysing 1000s of tackles to understand how injuries occur and whether you need to fix the tackle event themselves or players’ techniques.
Hendricks explained that a prevention model comprises four steps: Step 1 is understanding the extent of the injury problem; Step 2 is understanding why and how these injuries occur; Step 3 is introducing preventive measures; and, Step 4 is assessing the effectiveness of those measures.
“But it’s more complex in reality,” he continued. “Changing one thing may have unintended consequences so you need a more complex systems-based approach.”
“We use a two-pronged, passive-active intervention continuum. The active part requires players, or any party directly responsible for the player’s safety and are deliberately involved in protecting the player. This is about self-efficacy and enhancing individual ability to perform the desired behaviour change. The passive part is about law modification. Integrating passive and active change is thought to be most effective in sustainable injury prevention.”
But all the video analysis and laboratory work does nothing without the involvement of the people concerned. “We take a socio-ecological approach including stakeholder engagement, behavioural science and public-health approaches. A collective approach is needed to ensure buy-in at every level.”
His current project, part of which will be done at STIAS, has two aims – i) to evaluate the effectiveness of a law change to reduce head injury and concussion in rugby across 11 rugby-playing nations; and, ii) to develop and evaluate the efficacy of a tackle-training programme in rugby.
World Rugby introduced the lower tackle height in May 2023. This reduced tackle height from shoulder to sternum with the aim of reducing head contact.
Hendricks explained that his group’s earlier work in a World Rugby-funded trial at Stellenbosch University in the Koshuis Rugby League had fed into this decision making. The local study found a reduction in concussion by 31% which was not statistically significant but had clinical relevance. Based on these and other findings, World Rugby made the new law change in community and youth rugby.
The study involves 11 nations − England, Wales, Italy, Japan, Scotland, South Africa, France, Argentina, Australia, New Zealand and Ireland, and nine rugby unions. It’s an evaluation to see if the law is working globally.
A pre-post study design is being used to understand the changes in tackle behaviour. Video analysis of over 3000 matches across the 11 nations is being conducted for 2022 and 2023 (pre-intervention) and another 3000 matches for 2024 and 2025 (post-intervention).
“So far 117 577 tackles have been analysed. It will be over 150 000 by the end,” said Hendricks.
“Thus far we are definitely seeing some behaviour change – the data are going in the right direction. Scotland has already published data showing it’s working.”
But he also noted that more work is needed on the issue of both players bending.
Law changes and performance
But rugby remains a highly competitive sport and behaviour changes won’t happen if they affect performance.
“To change policy the question of how the injury-prevention intervention affects performance also needs to be answered,” said Hendricks. “Players often still see performance as more important than injury prevention. This also relates to how interventions are communicated to players and coaches. There’s a need to emphasise the performance benefits not just injury prevention. National injury-prevention programmes such as RugbySmarts and BokSmart understand this and try to promote that ‘safe technique is also effective technique’.”
“Our work looking at performance as well has shown lowering the tackle height doesn’t impact performance.”
“We are also involved in tackle-skill training with coaches and players. There are some gaps between knowledge and practice. Coaches need the ability to coach proper technique for safety and performance. A tackle is a skilled contest between two individuals – it should be safe.”
“There’s a big drive among governing bodies for safety in sport. Coaches drive team culture and the newer coaches understand the importance of safety. You can’t coach in South Africa without doing the BokSmart programme.”
“It’s all about changing the image of rugby – and changing the messaging that says players should play on through their injuries,” he added.
They are also interested in understanding how interventions end up on the field using diffusion-innovation theory to try and understand why some are adopted and others not. Another factor is equipment and technology advances. Hendricks explained that the mouthguards players wear contain chips that measure head acceleration and, if this changes, players can be removed from the game.
Women’s Rugby
The recent Women’s World Cup has shown the growing popularity of the women’s game. But women’s rugby throws up unique challenges and part of Hendrick’s STIAS project is to understand these.
“South Africa is still a fairly paternalistic society – rugby is still seen as male sport,” he said. “But our team did well in the World Cup so this will change. There’s international research, but you need to understand the local context and challenges.
“Girls also start playing much later – maybe at 16 compared to 9- or 10-year-old boys. They therefore need to learn the techniques much later, so their training programme needs to be different.”
“Overall, information is not necessarily getting to the women even at the elite levels,” he continued. “Even the professional players are not always taught to tackle. A systematic review we completed has shown there are not a lot of interventions specifically for female players.”
Hendricks’ group is therefore introducing a six-week tackle-training programme for the provincial women’s team.
“But with all of this there’s a need to understand the context and culture behind it, and you need buy-in,” he concluded.
Michelle Galloway: Part-time media officer at STIAS
Photograph: SCPS Photograph