History of Olympic Rugby — Rugby 15s

One of the greatest developments in modern Olympics was the creation of the International Olympic Committees’ (IOC’s) Olympic Agenda 2020, which sought to safeguard Olympic values and strengthen the role of sport in modern society. In essence, this agenda permitted host countries’ organizing committees to propose new sports for the Games they would be hosting. The primary purpose of this agenda was to prioritize innovation, youth engagement, and gender balance. In recent years, this has been successfully implemented, with sports like surfing, skateboarding, karate, baseball, softball and sport climbing debuting or reemerging at the 2020 Summer Olympics held in Tokyo, Japan, in 2021.

Alternatively, some sports may be removed from the Olympics due to disinterest or lack of appropriate global governing body; for example, sports like baseball and softball were previously removed from the Summer Games in 2005 due to the belief that those sports were only popular (e.g., competitive) in the Americas and parts of Australia and eastern Asia. Unfortunately, Olympic rugby shares a similar history.

Rugby debuted in the Olympics in the 15-a-side variation of the game in 1900 in Paris. This variation features 15 players on each team competing for possession of the ball through grappling, tracking, rucking, scrummaging, etc., in order to advance it across the pitch (which is 100 m long and up to 70 m wide) across the try line, similar to an end zone in American-style football. These matches last 80 minutes, broken down into two 40-minute halves.

Unlike American-style football, after each tackle, play keeps going, whereby tacklers have a moment to release the ball carrier and roll away, followed by the ball carrier releasing the ball, placing it towards their team and likewise rolling away. Amidst this chaos, arriving players on defense and offense will contest for the ball in a ruck, whereby they will bind to one another and attempt to drive the opposing player off of the ball. In rugby, the ball may only be passed backwards or laterally; however, you may advance the ball forward by running or kicking it.

If any of this sounds confusing to you as a new fan of the sport, you are not alone. For this, and many other reasons such as the lengthy matches, necessary time to recover between matches, and lack of global presence, rugby 15s fell out of the Olympics in 1924.

Modern Olympic Rugby — Rugby 7s

Rugby 7s, a variation of rugby 15s which is played on the same-sized pitch but with seven players per side and only seven-minute halves, was presented for inclusion in the 2012 Games, but was not formally accepted as an Olympic sport until the 2016 Olympics.

Rugby 7s has since been a staple of the modern Olympics, joining Paralympic Rugby (which has been included since the 2000 Games), as it is a sport played worldwide, with minimal equipment, and is the only collision sport where men and women play by the same rules. This version of rugby is more easily understood by laypeople, all the while presenting high-speed action and scoring. This upcoming Olympics will be the third consecutive Summer Games with Rugby 7s, giving the impression that rugby 7s is here to stay in modern-day Olympic competition.

American Rugby

Rugby is one of the most rapidly growing collision sports in the United States, and about one-third of registered players are women, which permits increasing opportunities for female athletes to participate at the collegiate level and receive financial support to do so. Currently, there are over four dozen men’s and women’s varsity rugby programs nationwide and countless club-level teams, with women’s rugby programs in particular seeking to grow to 40 varsity programs nationwide in order to achieve NCAA status.

Demands of the Game — Biomechanics of the Scrum

As mentioned above, rugby is a high-velocity and physically demanding sport. One of the hallmarks of physicality in rugby is the scrum. In the 15s variation of the game, the scrum consists of eight players from each team bound to one another (Figure 1) using only their legs and feet to drive over the mark of the scrum to move the ball to the back of the scrum to make it playable by their team.

The strength behind this movement has been featured in promotional content such as Oracle Red Bull Racing, whereby the Bath Rugby Club bound to one another in a scrummaging stance to compete against an F1 car — and the players didn’t give up any ground (Figure 2). In a scrum, the team producing the greatest force, in a controlled manner, will successfully win the scrum, providing tactical advantages in a game. Thus, force production is of great interest for rugby stakeholders.

Within the scrum, one can expect to see a sustained force output of 4-8,000 N for full packs (i.e., eight people) of male players. This force is typically maximized when players are binding at ~40% of their stature with feet parallel to one another and with the knees and hips at an angle of around 120°. Indeed, the maximum force measured during a sustained push of a full pack in laboratory conditions has been shown to be upwards of 16,000 N, which can be normalized to roughly twice their force-to-body-mass ratio. Importantly, these forces are less pronounced in the 7s variation of the game as there is only one row of three players from each team competing for the ball, with the focus in 7s being more on speed, longer runs and more frequent scoring.

Katie Hunzinger, Ph.D., ACSM-CEP, is a biomechanist, clinical exercise physiologist, and assistant professor of exercise science at Thomas Jefferson University. She is a former Division I rugby player and remains involved in rugby as either a consultant, World Rugby Educator, or regional-level rugby referee. Moreover, her research actively recruits rugby players as a means to better understand the mid- to late-life effects of repetitive neurotrauma through collision sports. Dr. Hunzinger’s goal is to make sport inclusive, safe, and sustainable.

Welcome to the highlights and the review of the AWESOME articles and case reports published over the last quarter in Current Sports Medicine Reports (CSMR). This past quarter for CSMR was amazing. I was going through the articles and cases that were published and on my first review I selected almost all of them. While this is a great problem to have, it would make this quarterly highlight too long, so I went back and selected what I thought were the best of the best.

Four highlighted section articles from the past quarter:

Oxygen Straight to the Brain: An Overview of Hyperbaric Oxygen Therapy for a Variety of Brain Morbidities written by Leighton, VanHorne and Parsons. This is a very interesting topic to me as we are frequently asked about hyperbaric oxygen therapy (HBOT) by veterans and first responders who are participating in the The THRIVE Program here at the University of North Carolina, Chapel Hill. The authors do a great job explaining what HBOT is, how it works and what the current FDA indications are for HBOT. They then examine the use of HBOT for mTBI, PTSD and headaches. They present and critique the evidence that is out there and rightly state “hyperbaric therapeutic impacts for these in the acute and chronic or prolonged symptoms are elusive.” Cost and lack of sustained relief are two areas emphasized by the authors and they conclude that better studies are needed to provide high fidelity treatment metrics.

Adaptive Athlete Considerations for Races and Other Mass Participation Sporting Events written by Sedgley, et al. There is always a lot of discussion on emergency action plans (EAPs) and one thing I liked about this topic when the authors approached me was the singular focus on adaptive athletes. Both the number of adaptive athletes participating in sports and the number of sports available to adaptive athletes continues to rise. This is a population that has unique medical complications and risks from athletic participation that must be considered. The authors did a great job of using current EAPs and highlighting the specific needs of adaptive athletes.

Vigorous Exercise in Patients with Hypertrophic Cardiomyopathy written by Fox, et al. It always felt to me that we talked about hypertrophic cardiomyopathy (HCM) from the standpoint of you can’t miss this on the PPE -- sudden cardiac death = no sports. However, we never talked about what can we do for these patients, other than not let them play sports.  The authors do a great job reviewing the evolving data on the topic and emphasizing shared decision making with HCM patients to allow participation in health promoting activities. 

A Scoping Review of the Epidemiology, Management, and Outcomes of Golf-Related Fractures written by Chen, et al. We just had the US Open down the road a bit in Pinehurst and I wanted to highlight golfers and note that Donald Ross can make some challenging greens. I love the game of golf but can’t really play due to some injuries. When I did golf, I just hoped my shots landed on earth. Watching the pros try to land their ball in a 3 x 5-inch area from 300 yards away is impressive. I wanted to highlight this article that thoroughly reviews golf-related fractures, not just the pisiform bone.

Case Reports

Case reports are a great way to learn, whether it is some rare, uncommon condition or just a different presentation of a common problem. I would like to highlight three not-to-be-missed cases from the past quarter:

Ice Sheet Cooling in the Field Reduces Morbidity in Exertional Heat Stroke written by Willcox, Rhodehouse and DeGroot. I had the privilege to work with Dr. Dave DeGroot while in the military and the work that continues to come out of The Army Heat Center under his direction is saving lives. They are working to find and show evidence-based ways to decrease the morbidity and mortality related to heat stroke during military training. Ice sheets work!

Gluteus Maximus Distal Myotendinous Junction Tear in a Pickleball Player: A Case Report written by King, Johnson and Jelsing. I have a couple older patients who are very active and competitive playing pickleball -- I never thought you could get hurt playing it. This is an interesting case report about a 72-year-old male who injured his gluteus maximus playing pickleball. This is an interesting case with an excellent review of anatomy.

Ankle Pain Due to Pigmented Villonodular Synovitis written by Chambers, Carey and Silvis. This is a super interesting case that reminds us to create broad differential diagnosis. I will admit I have only seen pigmented villonodular synovitis a couple times in the knee and it wouldn’t have been on my initial differential, but it will be now.

CSMR is ACSM’s official monthly clinical review e-journal. Written specifically for physician and clinician members, CSMR articles provide thorough overviews of the most current sports medicine literature. ACSM physician members receive an online subscription to this journal as a member benefit.

Shawn F. Kane, MD, FACSM, is a family physician, professor in the Department of Family Medicine, and adjunct assistant professor in the Department of Exercise and Sports Science at the University of North Carolina (UNC) Chapel Hill. He received his medical degree from the Uniformed Services University of the Health Sciences and served in the U.S. Army for 27 years. While in the Army he spent more than 18 years serving as a physician-leader in numerous units within the US Army Special Operations Command. He is interested in sports medicine, concussion care, veterans’ health, and primary care of patients with post-traumatic stress disorder. Dr. Kane joined ACSM in 2003 and became a fellow in 2011. He currently serves as the editor-in-chief for Current Sports Medicine Reports, on ACSM’s Clinical Sports Medicine Leadership Committee, ACSM’s Health & Fitness Summit Program Committee, and ACSM’s Program Committee. Outside of the office, Dr. Kane enjoys hanging out with his Leonbergers (big furry, cute German Mountain dogs), as well as working out and traveling.

We have all heard the following sports and exercise recommendations: “Load up on carbohydrates prior to an athletic event,” “Stretch prior to activity to avoid injury,” “Stand up straight and place your hands behind your head to recover from rigorous aerobic exercise,” “Buy running shoes based on foot arch and/or running form (and/or as assessed by an employee at the local shoe store)” and “Hydrate to prevent cramping, soreness and exertional heat illness.”

While some of these recommendations can be helpful in certain settings, they may not apply or may have less-than-positive effects in others; regardless, they are dogmatically repeated by well-meaning coaches, staff, parents and enthusiasts in the name of sports medicine and human performance without much additional consideration for their validity.

Such beliefs are ingrained in many sport and exercise circles and may only eventually be overcome with substantial evidence to the contrary. Even so, despite the 2019 study published in TJACSM by Michaelson et al. indicating that athletes recover better in the hands-on-knees position following high-intensity physical activity¹, I continue to hear participants confidently directed to stand up tall and place their hands behind their heads by coaches at my kids’ youth sports and at military physical fitness events.

The results of sports medicine and exercise science research are useful to a wide range of people, and our field is therefore readily accessible to the general public — that’s what makes it so great to be a part of. But because of this, there is also an abundance of forums where active people share ideas and dogma. We owe it to our field, and to those enthusiastic about active lifestyles, to critically test sport and exercise claims and practices and expand the sport science evidence base — particularly in service of safety. Such research represents valuable low-hanging fruit that may stand to help a lot of people.

Training programs, such as those in the military, may go many years between updates due to preference for the status quo and the cost required to modernize. It’s often difficult to get buy-in to change processes and approaches, even when addressed by respected subject matter experts sharing science-backed reasoning. To facilitate buy-in by decision makers when there is not direct evidence to apply to a specific situation or recommendation, sport science professionals should work to objectively confirm or refute the current approach by doing the relevant research. This valuable step of translational sport science is what my team set out to take in our recent study published in TJACSM.

Our study, “The Effect of Lightweight Shoes on Air Force Basic Training Injuries: A Randomized Controlled Trial” questioned whether the shoes the Department of Defense (DoD) issues its trainees —sturdy shoes with three customization options based on specific foot support needs — would be best at reducing injury. After all, they had been issued with that exact intent. Our sports medicine team, having noticed an association between the issued shoes and injuries treated in our clinics —and having heard trainees express dissatisfaction with said shoes — hypothesized that the practice of issuing such shoes in order to reduce injury ran contrary to what the ACSM describes as a good, safe running shoe, as well as to other evidence and recommendations. However, gaining traction toward changing the shoes issued to all enlisted DoD trainees without direct evidence of this suspected harm proved to be a tall task. So, we set out to put the standard-issue shoes to the test in this population by comparing them to a lightweight alternative.

Our results, gleaned from studying trainees at Air Fore basic military training, indeed suggest that issuing lightweight running shoes with a wide toe box and low heel-to-toe drop reduced injury risk.

Although we as sports medicine professionals might not need to be convinced of certain recommendations based on our experience and expertise, we often should pursue and share evidence like this with our patients, clients, and the lay public in order to overcome cognitive inertia and status quo bias. I encourage my colleagues to identify dogmatic practices and put the status quo to the test to promote evidence-based sport science for their specific populations.

Major Korey Kasper is an active duty and board-certified sports medicine and family medicine physician in the US Air Force. Dr. Kasper received his B.S. in Kinesiology from the University of Wisconsin-Madison and his MD from the Uniformed Services University of the Health Sciences in Bethesda, MD.  He subsequently completed a residency in family medicine in at the University of Nebraska Medical Center and a sports medicine fellowship at the National Capital Consortium in Washington, DC. Following training, he served as the Medical Director of Trainee Health Clinic and the VIPER Sports Medicine and Human Performance Program, where he worked to optimize the care, safety, wellness, and performance of military service members in training on JBSA-Lackland, TX. Currently, he is the Medical Director of Sports Medicine for the 6th Medical Group at MacDill AFB, FL.