Injur y in e li te coun t y- leve l h ur ling: a pr ospec t i ve study

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1 BJSM Online First, published on October 19, 2010 as /bjsm Original article Injur y in e li te coun t y- leve l h ur ling: a pr ospec t i ve study John C M ur phy, 1,2 C onor G iss ane, 3 C a t her ine B lake 2 1 Medical Scientifi c Committee Gaelic Athletic Association, Dublin, Ireland; 2 University College Dublin, Dublin, Ireland; 3 St Mary s University College, Twickenham, UK Correspondence to Dr Catherine Blake, UCD School of Public Health, Physiotherapy and Population Science, Room A1.03, Health Sciences Centre, University College Dublin, Belfi eld, Dublin 4, Ireland; c.blake@ucd.ie Accepted 19 May 2010 A B S T R A C T O b j e c t i v e To determine the incidence, prevalence and nature of sports injuries in elite male hurling players. D e s i g n Prospective study of county-grade hurling teams. Incidence, prevalence and descriptions of injuries were collated. S e t t i n g Four county teams during the 2007 season; January to September inclusive. P a r t i c i p a n t s A total of 127 male players were followed over 34 weeks. Data were collected on a median (IQR) of 31 (30 32) players per team per week. The mean age was 23.3±2.5 years. R e s u l t s There were 204 injuries to 104 players (82%, 95% CI (74 to 88)). Injury incidence rate during matchplay (102.5 (84.4 to 123.2)) was 19 times higher than for training (5.3 (4.2 to 6.5)) (RR=19.5 (14.8 to 25.6)). The mean weekly prevalence of injury was 13.9% (12.5 to 14.8). Most injuries were new (n=170, 83.3%, (77.6 to 87.8)) and acute (n=165, 80.9% (74.9 to 85.7)). Muscle strain (n=86) accounted for 42.2% (35.6 to 49) of the total. 71% of injuries were to the lower limb (n=143, (63.5 to 76.0)) with hamstring strain (n=33, 16.5% (11.8 to 21.8)) predominating. Fractures constituted 7.4% injuries (n=15, 95% CI (4.5 to 11.8)), 12 of which were to the upper limb. There were three (1.5% (0.5 to 4.2)) eye injuries and one concussion injury (0.5% (0.1 to 2.7)). C o n c l u s i o n s These results provide data on hurling injuries using defi nitions that refl ect international consensus statements. Injury incidence from match-play in particular is high compared with other sports. These fi ndings have relevance for clinicians and coaches. I N T R O D U C T I O N Hurling is one of Ireland s Gaelic games, contested by two teams of 15 players over min on a pitch with dimensions of up to 145 m long and 90 m wide. 1 2 Each hurler carries an ash stick (camán) used to propel a hard leather ball (sliotar), of diameter mm and weight g on the ground or though the air. 3 The objective is to beat the defence and goalkeeper sending the ball between the opposition s goalposts, either below the cross bar for three points (goal) or above for one point. Hurling has been compared with other stick sports, such as hockey and shinty. 4 One of the unique characteristics of the game is the speed (up to 160 km/h) with which the sliotar is propelled though the air, having been struck at full force. Blocking of the ball and contesting possession in the air using the stick is similarly forceful. Other key skills include the ability to run while balancing or bouncing the ball on the stick and the ability to both catch and strike the ball while moving. 3 It is suggested that contact between the stick and the body of the player in possession is common. 1 The potential for injury is considered high enough for the Gaelic Athletic Association to extend the mandatory wearing of helmets with face guards to all player grades from January Several investigators have documented injury in hurling, with retrospective research carried out in a hospital setting. 5 9 These focused on specific injuries such as the head and face, 5 occular, 9 hand 7 and ankle. 10 To date, there has been only one prospective study of injury incidence in hurling dating back to Since then there have been changes relating to training, rules and protective equipment; thus further epidemiological research in hurling is justified. Such a study would define the nature and magnitude of the injury problem 12 and would guide further research into aetiological factors of injury and prevention strategies. 13 The purpose of this study was, therefore, to describe injury incidence and prevalence in elite male county-level hurlers. Incidence will be further described in terms of injury mechanism, whether received during playing or training, injured body region and type of tissue injured. M E T H O D S A prospective cohort study was carried out over one competitive season including the National Hurling League (NHL) and All-Ireland Hurling Championship competitions. Weekly data collection ran from 1 January 2007 until the team was eliminated from the All-Ireland Hurling Championship. The earliest elimination was in July, and the last was in September Four intercounty hurling teams took part, having satisfied the criterion of having a chartered physiotherapist, or a medical doctor present at every training session or match to classify and record injury data. P a r t i c i p a n t s Participants were male senior county-level hurlers. A player was deemed a member of the panel (squad) if selected by the relevant county manager. The size of the playing panel could change throughout the playing season. Each team had a median IQR of 31 (30 32) players per week. Ethical approval and consent Players were advised of the purposes of the study and were given the opportunity to decline participation. Only coded data were recorded, and player anonymity was preserved. The study Murphy Copyright JC, Gissane Article C, Blake C. author Br J Sports (or Med their (2010). employer) doi: /bjsm Produced by BMJ Publishing Group Ltd under licence. 1 of 5

2 received ethical approval by UCD Human Research Ethics Committee. D e fi nitions Injury was defined as Any injury that prevents a player from taking a full part in all training and match play activities typically planned for that day, where the injury has been there for a period greater than 24 h from midnight at the end of the day that the injury was sustained. 14 A player was deemed to have returned to sport when able to take a full part in training activities and be available for match selection (adapted from Brooks et al ). 14 Injuries were classified into acute injuries, overuse injuries or chronic injuries in line with the description of Van Mechelen et al. 15 Severity of injuries was classified as mild (lasting up to 1 week), moderate (up to 4 weeks) or severe (>4 weeks). 15 A recurrent injury was defined as a reinjury to a previously injured region as determined by the team physiotherapist or doctor. P r o c e d u r e s Prior to commencing the study, participating players were allocated a unique identification number and provided baseline data regarding demographics and history of previous injuries. Age was defined in years as of 1 January Each week, the team physiotherapist or doctor recorded data regarding new injuries to players and also updated information about previous injuries. Information was entered using an electronic interface via the SurveyMonkey platform. 16 Data included any additions to or removals from the playing panel, along with information regarding the amount of time spent both playing and training. The recorders also specified the status of players reported as injured the previous week (still injured, partial fitness, full fitness). For each new injury, the designated contact was required to provide the following data: when the injury took place; mechanism of injury; time in the game by quarter; weather conditions; injured body region; main tissue injured; side of injury; clinical diagnosis; severity of the injury. A n a l y s i s Results were analysed by calculating percentages and injury rates per 1000 h, with respective 95% CI. RR (risk ratio) and 95% CI were used to compare injury rates. Where complete data were not recorded, percentages were calculated from available totals. Computations were calculated using SPSSv15 (SPSS, Chicago, Illinois), 17 the Confidence Interval analysis package v and VRP injury statistics software. 19 R E S U LT S During the study, 127 players were followed from four teams. This sample represents approximately 12% of the teams engaged in all divisions of the NHL competition and approximately one-third of teams participating in the All-Ireland Hurling Championship, the premier competition. Over the 34 weeks, data were collected on a median (IQR) of 31 (30 32) players per team per week. The mean age of the players was 23.3 (SD 2.5) years. During the study, there were 204 injuries to 104 players (82%, 95% CI (74 to 88)). Forty-eight players (38%, (30 to 47)) received one injury, and 56 (44%, (30 to 47)) received more than one injury. The injury rate during match play (102.5/1000 h (84.4 to 123.2)) was over 19 times higher than for training (5.3 (4.2 to 6.5)) (RR=19.5 (14.8 to 25.6)) ( table 1 ). Weekly prevalence was expressed as percentage registered injured during each 7-day period. The mean was 13.9% (12.5 to 14.8), range %. There were multiple peaks and troughs in the prevalence distribution, but the period when the greatest percentage of players were injured was just prior to mid-season during April. Given a mean prevalence of 13.9%, one could expect four players from a squad of to be injured in any week. When expressed as percentages, more injuries occurred during match play (55.4%) than during training activities (41.7%) ( table 2 ). Where injury was incurred during match play, 60.8% occurred in the second half of the game, and most injuries occurred in dry conditions ( table 2 ). The majority of injuries were classified as new (83.3%) and acute (80.9%), defined as occurring through a single event of macrotrauma. Most were mild or moderate, with less than 10% being severe ( table 3 ). Table 4 illustrates the regional location of injury and the main tissue injured. Soft-tissue injuries were most common, with muscle strains accounting for 42.2% of all injuries. Lower-limb injury predominated with 70.1% of injuries in this region. The most frequent lower-limb injuries were hamstring strain (n=33, 16.5% (11.8 to 21.8)), quadriceps strain or haematoma (n=18 (5.7 to 13.5)), ankle soft tissue injury (n=18, 9% (5.7 to 13.5)), groin soft tissue injury (n=18, 9% (5.7 to 13.5)) and calf muscle strain (n=12, 6% (3.4 to 10)). Thirty-one injuries were to the upper limb (15.2% (10.9 to 20.8)), and 12 of these were fractures, sustained to the finger (n=5), thumb (n=2), carpal/metacarpal (n=4) and forearm (n=1) regions. There were three further fractures, to the ribs, fibula and fifth metatarsal, giving a total (n=15) fracture incidence of 7.4% (4.5 to 11.8). Of the 11 head and neck injuries, three (1.5% (0.5 to 4.2)) were ocular injuries. The remainder included lacerations and contusions (n=3, 1.5% (0.5 to 4.2%)) and one concussion injury (0.5% (0.1 to 2.7)). D I S C U S S I O N I n j u r y r a t e The major finding of this study was that the injury rate of 102.5/1000 h (95% CI 84.4 to 132.2) carried an injury risk that was 19 times higher than training (5.3/1000 h (4.2 to 6.5). As this study used a similar injury defi nition to that used by Brooks et al, 14 direct comparison can be made with other sports, and it is striking to see that the injury rate for match play in hurling in particular is higher than that reported for most other field sports to date. Injury rate in hurling is high by comparison with some football codes An injury rate for training of 2 per 1000 h, 20 and 91 per 1000 h for match play was reported for professional rugby union. 21 For Table 1 Injury incidence per 1000 h Location Exposure time (h) No of injuries Injuries per 1000 h Match play Training Unspecifi ed 6 2 of 5 Murphy JC, Gissane C, Blake C. Br J Sports Med (2010). doi: /bjsm

3 soccer, the Union of European Football Associations (UEFA) injury study found an injury incidence of 27.5 per 1000 h for match play and 4.1 per 1000 h for training. 22 Injury incidence was 25.7 injuries per 1000 h in Australian Football League, 23 but in rugby league, the injury rate was 405 per 1000 playing hours. 24 For Gaelic football, match play injury at per 1000 h was far lower than that found in hurling, but it is interesting to note that similar training incidence rates ( vs 5.3/1000 h) were recorded for Gaelic football and hurling, respectively. Injury in hurling is clearly more common than in other games which involve the use of sticks Dick et al 27 found only 12.6 match and 3.2 training injuries per 1000 h in men s lacrosse. Shinty, another Gaelic game originating in Scotland, had an overall injury rate of 2.7 injuries per 1000 h, but this only included injuries requiring hospital attendance. 4 For elite ice hockey, the injury rate was 11.7 per 1000 game hours and 1.1 per 1000 training hours. 28 In the Swedish elite bandy league, 7.3 injuries per 1000 game hours were recorded, 29 while in youth bandy only two injuries per 1000 game hours were reported. 30 All of these sports show lower injury rates than the hurlers studied here, but some caution in making comparisons is warranted due to differences in injury definition and playing level of the cohorts studied. This current study represents the largest scale research into the epidemiology of hurling injury. Prior to this, the 1996 study by Watson was the most significant in the sport. 11 When classified into match and training injury, differences between the cohorts are apparent. The match injury rate here was three times greater than in 1996 (34.2/1000 h), while training injury was also slightly higher (5.3 vs 4.4/1000 h). 11 Notwithstanding these differences, data from these two hurling studies indicate that male hurling players are more susceptible to injury during match play than most other field sports, with the exception of rugby league. Most injuries were acute traumatic events, and although most injuries were mild or moderate, 9.3% were deemed severe with an absence from play of greater than 4 weeks. The physical nature of hurling is clear with the potential for injury through contact with other players, the stick and the ball, but it is not obvious why match play injury in this game should exceed that of most other sports. One could speculate that the hurlers could be less fit, and indeed examination of the physiological profile of elite hurling players has shown a higher percentage body fat, lower speed endurance, lower estimated Vo 2 max and lower abdominal endurance when compared with elite soccer players. 2 By comparison with Gaelic footballers, hurlers also showed lower speed endurance and upper body strength. 2 These characteristics, however, reflect the demands of the game of hurling, and further examination of the relationship between fitness and susceptibility to injury is required to explore this hypothesis. Other factors which might influence injury are enforcement of playing rules, adherence to protective equipment as well as protocols for training, rehabilitation and return to play after injury. It was notable that 19% of injuries were classified as chronic or overuse injuries and further evaluation is needed to determine both the nature of these injuries and injury risk factors. R e g i o n a l i n j u r y d i s t r i b u t i o n Lower-limb injuries predominated, accounting for 70.1% of all injuries. This is comparable with 71% reported for Gaelic football 25 and 73% for soccer. 22 For lacrosse, lower-limb injuries represented 48.1% of game injuries and 58.7% of training Table 2 Injury details Location of injury (n=204) Competitive match play to 62.1 Training match play to 22.4 Training to 31.4 Unspecifi ed to 6.3 Time in match (n=102) First quarter to 17.1 Second quarter to 38.9 Third quarter to 37.8 Fourth quarter to 41.9 Environmental conditions (n=171) Dry to 77.3 Wet to 27.1 Dry and windy to 12.6 Wet and windy to 7.4 Snowing to 4.2 Windy to 3.2 Table 3 I n j u r y c l a s s i fi c a t i o n New/recurrent (n=199) New to 89.7 Recurrent to 20.1 Acute/chronic (n=201) Acute single event of macrotrauma to 86.8 Chronic requiring ongoing treatment to 2.8 Overuse repeated microtrauma to 23.3 Severity (n=200) Mild to 51.9 Moderate to 52.4 Severe to 14.4 Table 4 I n j u r y d i s t r i b u t i o n Regional distribution of injury (n=204) Head/neck to 9.4 Shoulder/arm/elbow to 6.3 Forearm/wrist/hand to 17.5 Trunk/spine to 14.1 Hip/groin/thigh to 45.6 Knee to 11.8 Shin/ankle foot to 30.3 Main tissue injured (n=204) Muscle to 55.8 Ligament to 20.8 Bone to 22.9 Tendon to 11.2 Joint (general) to 7.5 Skin to 7.5 Meniscus to 2.7 Unspecifi ed to 6.9 Subclassifi cation of muscle and bone injuries (n=135) Muscle strain to 49.0 Muscle haematoma to 11.2 Bone contusion* to 14.7 Bone fracture to 11.8 *Fracture outruled, periosteal trauma. 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4 injuries 27 and only 22% of injuries in shinty. 4 In bandy, lowerlimb injury was similarly lower at 37%. 29 The high prevalence of lower-limb injuries in hurling is accompanied by a corresponding lower proportion of upper-limb injuries, than reported for other field games involving sticks. Only 15.2% of injuries were to the upper limb in this hurling cohort, compared with 26.2% of game injuries and 16.9% of training injuries in lacrosse 30 and 34.3% of injuries in shinty. 4 In elite ice hockey, upper-limb injuries were similarly more prevalent (27.6%; 88/319), 28 while the proportion in bandy was 25%. 29 The regional distribution of injury also contrasts with earlier hurling data where 53% lower limb, 33% upper limb and 22% injuries to the head, face and eye region were recorded. 11 These results show that this hurling cohort had an injury distribution more in keeping with football than other stick games and that there is a different regional pattern of injury to earlier hurling research. The variation from prior hurling data might be due to an overall reduction in upper-limb and head/face injury due to the introduction of protective gloves, mouth guards and helmets in recent years, giving rise to a corresponding proportional increase in injury to the lower limb. The discrepancy from other sports might be explained by the biomechanical demands of hurling on the lower limbs. Hurling is played on a field that is larger than other outdoor sports such as field hockey and lacrosse; thus players cover larger distances, both in sprinting forward and in running backwards. The ball can be struck with the stick on the ground or in the air, and both catching and kicking the ball are permitted. Running with the ball balanced on the stick is a particular skill, and striking the ball from running in possession requires rapid deceleration and planting of the feet. Furthermore, the ball can be caught or struck while in the air, often necessitating jumping and landing. It is also permitted to side-to-side charge an opposing player who is in possession of the ball or when competing for the ball. 3 Head, neck and ocular injuries can occur in stick games with potentially serious consequences, and 5.4% injuries (3% to 9.4%) were to this region in hurling. One point five per cent (n=3 (0.5 to 4.2)) were ocular injuries, and there was one concussion injury (0.5% (0.1 to 2.7)). These results are lower than the 1996 hurling data (4% eye injury, 3% concussion). 11 In an elite ice hockey team, 16.9% (54/319) injuries were to the head, face and neck, 27 while 25% injuries were to the head and face in an elite bandy league. 29 Longitudinal research into collegiate lacrosse 27 and men s ice hockey 31 also show higher percentages for concussion (8.6% lacrosse, 9% ice hockey for games; 3.1% lacrosse, 5.3% ice hockey for training), but rule changes and developments in protective equipment have been associated with declining injury rates over time for these sports. Direct comparisons should be made with caution, given potential differences in definition and reporting mechanisms, but the findings of this study suggest that the incidence of head and face injury may be less than in other stick sports. T i s s u e i n j u r e d Soft-tissue injury was most common in hurling, with muscle strain, tendon and ligament trauma accounting for 42.2%, 6.9% and 15.2% of injuries, respectively. Despite considerable variation in injury definitions, limited comparisons can be made. The hurling results reflect the UEFA soccer study where muscle strains, tendon injuries and ligament injuries were 35%, 7% and 18%, 22 while in rugby union, 44.7% of match injuries and 51.7% of training injuries were to muscle 4 of 5 or tendon. 21 In Gaelic football, however, muscle strains were lower, explaining only 27.8% injuries with combined muscle tendon injuries at 31.1%, 25 while ligamentous ankle injury figures were more similar to hurling accounting for 12.7% 10 and 13.3% 26 of injuries. For elite ice hockey, muscle strains were also lower at 26% while ligament sprains were only 9.4%. 28 Ankle ligament injuries were the most common injuries in lacrosse game play (11.3%) and practice (16.4%), proportions that are comparable with hurling. 27 For bandy, ligament rupture (19%) and ligament sprain (14%) were common, while strains were only 6%. 29 Previous research in hurling showed that the most common injuries were muscle strains, as was found here, albeit constituting a far lower percentage of all injuries (24.4% vs 42.2%). 11 Previously, the hamstrings accounted for 41% of strains in hurling, similar to this study, while the 18% ligament injuries found earlier is also consistent with the current results. 11 The incidence of fracture in this hurling cohort was 7.4%, which is comparable with previous hurling research where 9% of all injuries were fractures, 11 but is lower than reported in bandy (22%) 29 and shinty (26%). 4 The differences in injury description between studies highlights the need for a standard taxonomy such as the Orchard classification system to be applied However, the challenge for any classification tool is to balance simplicity and ease of use with comprehensive data collection. There were specific challenges in conducting injury surveillance research in hurling. The first relates to the amateur status of the game where the entire data-collection process was only possible through the goodwill and commitment of the participants. Another unique factor in determining accurate data stems from the fact that the players not only play at elite county level but also represent home clubs in local competition. This is possible, since, unlike other sporting codes, there is not always a weekly game at intercounty level. Provision was made for the recording of exposure and injury in club matches and training, but it is possible that omissions might have occurred. This also related to the practice of using challenge games against an opposing external team as preparation What is already known on this topic Hurling is a high-speed, physical sport which is played with a stick and ball. The potential for injury is well recognised, but prospective data on injury epidemiology have become outdated. What this study adds When injury defi nitions consistent with consensus statements for other sports were applied, the incidence of injury during match play in elite hurling was higher than for most fi eld sports. The risk of injury was 19 times greater for match play than training. Data regarding distribution, severity and mechanism of injuries provide information on the nature of injury in the contemporary game of hurling. Murphy JC, Gissane C, Blake C. Br J Sports Med (2010). doi: /bjsm

5 for competition. Data regarding these were also collected, and injuries incurred were classified as match play injury. The positive features of this study include the prospective methodology, the use of standardised injury defi nitions which are in agreement with international consensus statements, the exclusive focus on elite players and the recruitment of experienced sport s injury practitioners for diagnosis and classification of injury. The sample represented 12% of teams in the NHL and 33% of teams in the All-Ireland Championship, so these fi ndings can be considered to provide a reasonable representation of injury in elite countylevel hurling. Data collection is ongoing with refi nement of injury classification, which will allow more precise estimates of injury to be reported. Furthermore, risk factors associated with recurrent injury will be explored, with a view to guiding prevention strategies. 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