“Living in the bubble of professional sport is a privilege and one day it is going to burst. I bump into retired team-mates all the time and their message is unanimous. The real world is not nearly as much fun.” – Dylan Hartley

The fact that rugby is a brutal and attritional sport is uncontroversial, but as Dylan Hartley’s book The Hurt demonstrates, rugby is only just beginning to understand that the pain does not stop the moment a player retires.

A new study by Durham University scientists has become the first investigation to analyse the cumulative injury-load of an elite player – and then measure the sustained impact on the athlete’s life after they retire. Commencing in 2016 as an independently-funded development of the New Zealand Rugby Health project, 189 former elite rugby players (145 from union, 44 from league) took part alongside control groups.

The researchers were testing for trauma, taking a detailed account of each participant’s injury history, prodding every inch as they took blood, ran bone density scans, studied brain response, put them through ECGs and even balance tests. Ex-Premiership stalwart Tom May referred to the test as an ‘MOT’ on his Twitter account.

Dr Karen Hind leads the project and has specifically worked on musculoskeletal health and rugby for more than a decade, including groundbreaking research into the hidden toll on players’ spines. Speaking to Rugby World, Dr Hind explained how some of her most recent findings surprised her.

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“When the numbers came in it was eye-opening how many injuries players were sustaining. If they’re suffering multiple traumatic injuries during their playing career, what does that mean once they retire? It’s only natural that repetitive trauma is going to cause problems in later life, it doesn’t just go away. We’ve known this, it just needed to be quantified with evidence. That’s what our study is looking to provide – the numbers.”

High profile: Former England’s captain Dylan Hartley (Getty Images)

These numbers themselves are startling. A player averages 1.6 injuries per season over a playing career of 24.3 years. Add those numbers up and that’s nearly 40 injuries before retirement. The stark statistics lead to an important question – how vulnerable are players once their rugby stops?

“The players were really responsive to the project,” Dr Hind explains. “A frequent comment from former rugby players was that while they are signed to a contract, the medical care and support is there, but when they retire they don’t have any specific medical support and are left to sort it out. This can be daunting and expensive, or mean long waiting times on the NHS.”

The UK Rugby Health Project aims to supply the objective figures to the testimony of players like James Haskell, who spoke candidly about the issue on his podcast The Good, the Bad and the Rugby.

“I hadn’t got medical insurance because all the way through our careers we were looked after. I had no aid to get an MRI scan on three parts of my body. I need treatment on three bulging discs, I need an injection in my ankle, I need shoulder surgery. And no one’s going to pay for that apart from me. And obviously you don’t get insurance pay-outs because it’s all classed as wear and tear. And we are not unique.”

Judging by the findings of Dr Hind’s team, Haskell is certainly correct when he claims not to be alone. Retired players are up to nine times more likely to suffer the continued effect of injuries than control subjects who have never played a contact sport. Osteoarthritis is more than twice as likely in ex-professional players than the general population (51% v 22%). 68% of players have suffered a knee ligament injury, and 27% are still affected by that knee – compared to corresponding figures of 20% and 7% amongst non-contact sport athletes.

Reading the report is to be reminded that the injuries of a career are chronic, and the battle with chronic pain never stops.

Work in the women’s game is also taking place. “We’re also studying female rugby players but haven’t got enough numbers there yet,” says Dr Hind. “From what we’ve seen in the data coming back from retired females, we’re looking at exactly the same situation.”

Crossover: Initial data suggests women’s game will see similar (Getty Images)

So what’s being done about this?

For those involved in the UK Rugby Health Project, these figures demand action, and the report makes several recommendations focused around player welfare.

Dr Hind adds: “Players are not commodities but human beings who’ve got families and lives ahead of them. They need to be looked after post-career and I don’t think that’s happening at the moment. The governing bodies have a duty of care to these professional players, who, at the end of the day, are their employees.”

One group trying to look after players post-retirement is the Rugby Players’ Association (RPA), whose Rugby Director is the ex-Bath, Bridgend and Leeds player Richard Bryan. He welcomes this new study and insists that changes are being made.

“As with all this research, it helps inform us about the questions that we need to ask our retired members, to formulate where we need to focus our attention. There’s a quite significant amount of work taking place by all stakeholders around the game,” he says. “At the forefront of that is the work that’s going on around English rugby, around the Professional Rugby Injury Surveillance Project (PRISP), alongside the RFU and Premiership Rugby.”

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So what about for players who have already retired?

“In terms of physical health specifically, there’s our charity Restart,” Bryan explains. “Traditionally Restart has helped players where they’re unable to potentially pay themselves to help fund treatment for rugby-related injuries.”

“Another service we put in place is a formal treatment pathway for retired RPA members who report suffering from the long-term effects of concussion. Via this pathway players have accessed a neurophysical assessment, which can lead to a referral to a neurologist at the Institute of Sport, Exercise and Health. They can also access support from our confidential counselling service, run by Cognacity, where a third of callers are retired players.”

Rep the logo: Players in Restart Rugby T-shirts (Getty Images)

The Durham University study revealed that 81% of players have sustained a concussion at some point in their career. But for Dr Hind, post-retirement care must go further.

“Medical cover needs to see them through their ageing. It needs to be seen as lifelong cover,” she insists. As matters stand, rugby union players are only medically covered for the nine months after the end of their contract. After that, save for any RPA assistance, they’re on their own.

The RPA are reviewing their services in the wake of Covid-19, and Bryan says that this is slated to be part of discussions. “Part of our review is how should the wider game, not just Restart, put a more systematic plan in place for how players can cope with the effects of their playing career.”

The UK Rugby Health Project does suggest one innovative idea which may help with this systematicity – monitoring injuries at player level rather than club level.

Dr Hind says: “When a player signs a new contract, a medical record of their injuries will not usually follow them into another club. An individual player’s injury history could instead be followed as they move across professional contracts, and specific strength, conditioning and therapy prescribed to prevent recurrence of injury.” But, as she acknowledges, there may be a problem.

“This information could help look after that player, but they might not want to disclose that for fear of not getting a contract. There needs to be more transparency, more care, more understanding of the situation from a player’s point of view.”

It’s not the only place where players, clubs and governing bodies come into conflict. One of the interesting aspects of the UK Rugby Health Project is that it is independently funded, something relatively rare amongst rugby studies. After all, who’s going to fund research into rugby if not rugby?

Watching over: World Rugby govern the sport (Getty Images)

This means studies are often reliant on the investment of governing bodies, whose funds allow a far greater amount of research to take place than would otherwise be possible. But how much control do these organisations have over any research findings?

Buried in a publicly accessible World Rugby contract are two short clauses which grant the organisation full power to selectively publish potentially seismic results. Clause 5.5 – ‘All Results and Results IPR shall be owned by the Company from the date of their creation’, and 5.7 – ‘The Applicant shall only be entitled to publish and/or disclose to a third party the whole and/or any part of the Results with the prior written approval of the Company’.

According to a 2016 investigation by the NZ Herald, these clauses have already been at the centre of a research dispute between World Rugby, New Zealand Rugby and scientists from the Auckland University of Technology (AUT).

The Herald investigation claims that “World Rugby and the NZRU did not give approval for the full report and all the results to be released”, meaning potentially important conclusions may have been omitted from the final presentation.

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For example, one of the key passages, whose release World Rugby and NZRU reportedly would not sanction, was obtained by the Weekend Herald under the Official Information Act. It reads: “To better address the implications for player neurocognitive health, we believe players should be aware of the potential increased long-term risk of cognitive impairment from concussion, so they can make informed choices about engagement in sport and return to play following injury.”

The NZRU and World Rugby deny the New Zealand Herald report, but the former’s most senior scientist, Dr Ken Quarrie, has spoken publicly about the conflict of interest between scientific research and governing bodies.

Guided by science: Dr Ken Quarrie (Getty Images)

“I have grappled with the inherent conflict that is associated with such research, but not doing it is not an option,” says Dr Quarrie. “I personally do not believe that a national sporting organisation (NSO) can claim to be a truly independent arbiter of such research, and in my time with the NZRU we never sought to do so.”

The future? Rugby seems to have hit a stumbling block. Scientific research is desperately needed in a sport played by 2.5 million in the UK and Ireland alone. The startling results of the UK Rugby Health Project suggest that research into the repercussions of a professional career has barely scratched the surface.

These Durham University researchers still have a lot more data and information to publish – their paper on cumulative injuries is the first of at least eight, with future work due on the relationship between injuries and mental health, cognitivity and brain markers respectively.

These could begin to provide biological explanations for the symptoms of post-concussion syndrome or give us more clues into a possible link between head trauma and motor neurone disease. Dr Hind is also co-leading the Global Rugby Health Research network alongside colleagues from AUT. It all shows that we’re only just seeing the effects of a professional career on retired athletes.

Study ahead: More to learn from studying injuries (Getty Images)

The dilemma is this. Does rugby pursue truly independent research but accept that a lack of funding may lead to slower progress? Or do governing bodies plough money into their own studies yet be unable to be a ‘truly independent arbiter’ of this research? Neither option is especially appealing.

One answer could be for governing bodies to consider removing the clauses in their academic contracts which give them sole control over the release of research. Governing bodies are worried about the potential impact such research could have on participation numbers – but is the cat already out of the bag? A 2017 study has shown that only 45% of former elite rugby players would recommend a career in the professional game to family and friends – a depressingly high number.

It’s a number which shows players are bearing chronic pain in their hips, their knees, their backs and their heads. It’s been a problem since the birth of professionalism. And if the risks aren’t known, the game won’t change.

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