Dr Carly McKay – Injury prevention in rugby and football: are we making any progress? – Injury Rehab Network

The September Injury Rehab Network event with BASRaT featured a presentation from Dr Carly McKay. The online event took place on the evening of Monday 9th September with 160 sports rehabilitation practitioners in attendance.

Dr McKay discussed the current state of injury prevention research in rugby and football. The recording is available to watch here.

Dr Carly McKay

Dr Carly McKay completed her BKin (2006) and MSc in Sport Medicine (2008) at the University of Calgary (Canada) and her PhD in Kinesiology (2011) at Western University (Canada). She is currently a Reader in Injury Prevention, Director of Studies (MSc in Football Medicine in Association with FIFA), and Deputy Director of the Centre for Health, Injury and Illness Prevention in Sport (Chi2PS) at the University of Bath.

She sits on the executive of the UK Collaborating Centre on Injury and Illness Prevention in Sport (UKCCIIS), which is one of 11 International Research Centres for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. She serves as an Associate Editor for the Journal of Science and Medicine in Sport and is an academic advisor to the Royal Academy of Dance, London.

Her research focuses on the role of psychosocial and behavioural factors in sport injury risk and recovery, and using behaviour change approaches to support injury prevention strategies.

Injury prevention in rugby and football: are we making any progress?

Significant effort has been made in the past two decades to reduce the risk of injury in sports like rugby and football. Several prevention strategies have led to significant injury reductions in large-scale studies and international sport governing bodies have introduced law changes and programmes specifically developed to promote player welfare. Yet, injury rates are at an all-time high. How can we claim to be making progress if things seem to be getting worse?

This talk considered the current state of injury prevention research in rugby and football, with emphasis on understanding why interventions that have shown such promise in trials ultimately haven’t had meaningful population-level effects. The talk covered key concepts related to intervention development, injury surveillance, and player monitoring, and the challenges encountered when scaling up evidence to widespread practice.

Introduction and Disclosures

Dr McKay provided a summary of her background and involvement in injury prevention research in rugby and football. Carly works at the University of Bath as part of the UK Collaborating Centre on Injury and Illness Prevention in Sport (together with University of Edinburgh). Dr McKay acknowledged that the research she was presenting was conducted in association with England Rugby, World Rugby and FIFA.

The State of Play in Football

Dr McKay discussed current issues and research in relation to injuries in football.

In women’s football, the media have described an epidemic of ACL injuries. Research by Hallen et al. concluded that ACL injury has the highest injury burden in women’s football.

Carly considered hamstring injuries in men’s football, where a study by Ekstrand et al. concluded that hamstring injuries have doubled over a 21-year period, with injury rates increasing in both training and match play.

Dr McKay discussed injuries, including findings from studies by Robles-Palazon et al. and Chatha et al. Carly described the main findings as follows:

• Men tend to predominantly sustain muscle injuries to the thigh, and women often sustain joint and ligament injuries to the knee and ankle.
• The incidence of injuries increases with advances in age in males.
• Elite male players present higher match injury incidence than sub-elite.
• The quality of evidence for females is low; thus, more research is required.

The State of Play in Rugby Union

Dr McKay discussed injury prevalence in rugby union. The incidence of injuries is significantly higher in international and professional/ elite rugby for both women and men. Injury incidence rises to almost two injuries every team game in men’s international rugby compared to fewer than one injury every five team games in U13 schoolboys.

Injuries in elite women’s rugby union have increased from around 35 injuries per 1,000 hours in 2017 to around 45 injuries per 1,000 hours in 2023. Concussions in women’s rugby have also increased during the same period from six per 1,000 hours in 2017 to 15 per 1,000 hours in 2023.

Dr McKay discussed trends in match concussion incidence in men’s professional rugby union. Following a period of stability from 2003 – 2012, there was a growth in injuries from 2012 – 2017. Injury rates have stabilised in recent years and a range of interventions have been put in place to address and mange concussions including Graduated Return to Play protocols, Head Injury Assessment tools, education, video review, and independent match day doctors.

Carly considered injuries in youth rugby where research shows that injury incidence has fluctuated but remains consistent overall.

The effort’s gone in… what’s to show for it?

Dr McKay discussed how specific/ individual studies have shown a positive effect in reducing injuries but have led to limited change at scale. For example, the FIFA 11+ injury prevention programme has been consistently shown to reduce injuries in trials, and has been promoted in more than 80 countries but there has been limited uptake in practice.

The Activate programme

Activate from England Rugby is an injury prevention exercise programme. Carly shared insights from evaluation into the programme. Age level versions of the exercises are available with progressions through the season and resources for coaches and players.

Dr McKay described the initial efficacy evaluation of Activate in 14–18-year-old schoolboys which included sham control, and intervention groups. When comparing all teams the frequency of concussion reduced by 30% and days lost to upper limb injury reduced by 35%. For groups that used Activate three times per week the frequency of all injury reduced by 70% and frequency of concussion reduced by 60%.

In adult men non-professional groups, the research showed Activate led to a 40% reduction in lower limb injury and 60% reduction in frequency of concussion in all clubs involved. For clubs using Active twice per week the number of days lost to lower limb, shoulder, head a neck injuries reduced by 50%.

Athletes don’t exist in a vacuum – Dr McKay noted that programme implementation should take account of the individual factors of each club and player. For example, adaptations may be required to ensure exercises can be completed safely in different weather conditions.

Carly considered the youth context for research into the Activate programme. In the original efficacy trial, Activate was only used in 77% of match sessions and 80% of training sessions with 65% of components used in matches and 71% of components used in training sessions. In the adult context, barriers to programme implementation included team organisation, negative club culture and poor understanding of Activate. Facilitators in the adult context included positive club culture, delivery by researchers and good team organisation.

Health Action Process Approach (HAPA) model – Carly described the HAPA model for behaviour change which focuses on the motivational phase and volitional phase. In the motivational phase, intention may be impacted by self-efficacy associated with the task, outcome expectancies and risk perception. In the volitional phase self-efficacy is associated with maintenance and recovery. Action planning and coping planning are essential for turning intention into action. Barriers and resources may impact on planning and action control.

Dr McKay considered HAPA as a predictive model to assess likelihood of change/ impact from an intervention. Behavioural intention and action planning are key to adherence. Carly considered the gap that often exists between intentions vs behaviour.

The workshop components of the Activate programme were designed to include risk awareness, outcome expectancies, task self-efficacy, action planning and coping planning. Carly described how Activate was scaled up through the England Rugby regional structure, with specially trained Activate champions providing training and support to clubs. Programme adoption was significantly higher amongst coaches who attended workshops vs non-attendees. Attendees had greater self-efficacy and intention to use activate.

A complex environment

Dr McKay discussed the complex environment and different factors that may impact on programme implementation. Layers of complexity that can influence an individual’s ability to create change include:

• Interpersonal
• Organisational
• Community
• Governance

At an individual level, personal characteristics and environment may be limiting factors. Interpersonal considerations include perceived benefit, resource and leadership. Culture, processes and communication are factors that impact on change in organisations and norms, beliefs and expectations are associated with change in communities.

Scale up penalties – Dr McKay described how programme effectiveness from small scale research is challenging to scale up. Carly discussed how population impact can be limited by voltage drop with attenuation of effect when moving to practical context. Programme shift can also be an issue when users make adaptations to accommodate their circumstances.

Penalties in action – Dr McKay discussed some of the penalties observed in the scale up of Activate. Self-selected use led to voltage drop. The open access resources and on demand workshops were associated with programme drift. Carly described how the covid pandemic significantly impacted on research and implementation of Activate.

Structural barriers – Carly considered the barriers associated with the structure of organisations and gave an example of a school where they took parts of activate to work around other activities and priorities. The problem with this approach is that the programme isn’t implemented as designed, and outcomes may therefore be limited. Dr McKay described how prevention strategies typically target the governance level but need to reach the individual to create change. However, individuals don’t live in isolation and are subject to external influences and events.

Are we making any progress?

Dr McKay considered whether progress is being made in relation to injury reduction in football and rugby. Carly shared key learning points and research findings:

1. Risk messaging isn’t very effective. Just because people ‘know better’, doesn’t mean they will ‘do better’.
2. Theory-based approaches may lead to more lasting behaviour change. Programmes should focus on building self-efficacy and action planning.
3. Athlete behaviour doesn’t happen in isolation. It occurs in a specific context and is shaped by layers of influence that also need to change.

Carly acknowledged her colleagues at the Centre for Health and Injury & Illness Prevention in Sport (Chi2PS), England Rugby and World Rugby.

Follow Dr Carly McKay

University of Bath

Q&A

Dr McKay kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from Carly to the questions.

Presentation Recording

The recording of Carly’s presentation is available to watch here

2024 Injury Rehab Network events

Find out about and register your interest for all the Injury Rehab Network events with BASRaT planned for 2024

Please enter your details into the form below along with any questions or comments and a member of our team will be happy to provide you with more information: