This thesis investigates the epidemiology and risk factors for injury in professional Rugby Union with a view to informing injury reduction strategies. Over the last decade, concussion has rapidly become the principal player welfare issue faced by collision sports. Chapter 3 highlights the high and rising incidence of concussion in the professional game and suggests some possible reasons for the changing landscape regarding the reporting of concussion in professional Rugby Union. Given this high incidence, the findings from this study reinforce the importance of further understanding concerning the safe return to play following concussion. Therefore, chapter 4 explores the short and medium term clinical outcomes and return to play of players following a concussion. Players who reported a concussion had a 60% increase in injury risk following return to play when compared with players who did not sustain a concussion. Additionally, 38% of players reported a recurrence of symptoms or failed to match their baseline neurocognitive test score during the return to play protocol. Together, these findings highlight the need to explore an alternative (either a more conservative or different rehabilitation model) return to play pathway. Another prominent player welfare issue in elite Rugby Union is the management of match and training load. Chapter 5 of this thesis was the first study to investigate the training load-injury relationship in professional Rugby Union. Players had an increased risk of injury if they had high one-week cumulative or large week-to-week changes in load. Furthermore, a `U-shaped` relationship was observed for four-week cumulative loads, with an apparent increase in risk associated with lower/higher loads and intermediate loads appeared beneficial in reducing injury risk in this setting. Finally, it has been suggested that the impact of illness on an athlete`s ability to participate can be as significant as that of injury. Chapter 6 provides the first study to investigate the epidemiology of time-loss illness in English professional Rugby Union. Although the burden of illness is significantly less than injury, the high severity and seasonal clustering of illness in this cohort clearly highlights the need for the continued surveillance of illness in this setting. Despite rugby being a collision sport with a primary focus on conditioning and performance, this research programme clearly highlights the potential for modifying existing practice in order to reduce injury risk. Conversely, injuries such as concussion are difficult to prevent without substantial law change, making the practical recommendations put forward in this thesis with reference to possible improvements in the management of players following concussion vital to consider. What was the most important clinical impact? Concussion: As a direct result of this work, there has been a significant reduction in the number of players returning sooner than recommended by the current guidelines. In addition, these findings have also been used to inform an open access community concussion education module for approximately 2 000 000 registered players, coaches and referees in England. Training load: Author made a number of league-wide recommendations for future training periodisation. Coaches should aim to reduce 4-week cumulative loads during the season in order to reduce the risk of injury. Players should reintegrate conservatively when returning from injury or who have been training within other squads when the player`s acute training load is unknown. Furthermore, consistent weekly loads (for non-injured players) should be applied to prevent any acute spikes in training load.
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