Rugby is a classic contact sport, and the rules of the game are designed to largely prevent serious injuries. Concussions remain a serious issue in elite rugby, but amateur and hobby players are less affected.
The Rugby World Cup being held in Japan at the moment is still the third-biggest sporting event in the world after the Summer Olympics and the Football World Cup.
Of course, football - or soccer depending on where you live - is still the world's most ubiquitous sport. A rugby match, by comparison, appears to many untrained eyes like a bunch of players running into each other a lot with an odd-shaped ball.
And unlike football players, most rugby players would rather burn in the fires of hell than show signs of pain or distress, despite the fact that certain types of injuries — like concussion— occur more frequently in rugby.
Awareness of concussion in soccer is, however, also rising. Research led by Glasgow University, funded among others by the Football Association (FA), found ex- footballers were three and a half times more likely to die of dementia as a result of suffering concussion, mainly from heading the ball, during their career.
The results apply to other sports, too, Dr. Willie Stewart, neuropathoplogist at Glasgow University and the lead author of the study, points out. Stewart is a leading expert on brain injuries in sport and also advises World Rugby, the global governing body.
But Martin Raftery from World Rugby says the two team sports nevertheless do not quite compare when it comes to collision injuries. Football is a "semi-contact"sport, rugby is a "full-contact sport," he told DW.
The comparison with, say, American football or ice hockey makes more sense, Raftery says, with all full-contact sports having similar rates of injuries.
Managing concussions has been a major issue for these types of sport, particularly at the elite level, but it is only been in the last few years that more players are acknowledging they've suffered from the effects of concussion.
In the 2017/18 season, the most commonly reported match injury in English professional rugby was concussion (17.9 per 1,000 player hours), according to data published by the Rugby Football Union (RFU), England's governing body.
It says concussions contributed 20% of all match injuries in the English premiership, European competitions and the Anglo-Welsh Cup. The injury remains a "top priority for the game," the RFU said on its website. Its data is widely seen as one of the most comprehensive on injuries in rugby.
Twenty or 30 years ago, "concussion was only diagnosed when someone was knocked out," Raftery says. Now, if someone has a headache following impact, it is classified as a concussion.
"The diagnostic threshold has been lowered over the years," Raftery explains. In 2001, a global consensus statement on concussion was published, setting off the ongoing process of managing concussion across a number of sports.
In 2012, World Rugby - or the International Rugby Board as it was called then - launched a pitch-side concussion assessment process, known as Head Injury Assessment (HIA) for professional rugby games that allows medics to take a player off the pitch for 10 minutes to conduct a standardized assessment.
The global governing body has also launched several trials aimed at making tackling safer, as it accounts for 76% of concussions in elite matches. World Rugby therefore promotes low-risk techniques, both by issuing warnings to players who are not bent at the waist when tackling and rewarding teams who take steps towards safe tackling.
The National Football League (NFL) in the US has also introduced concussion awareness initiatives. In 2011, it presented its first concussion protocol, which is reviewed annually to improve player safety. Incidents of concussion were reduced by 18% between 2012 and 2018.
Across all full-contact sports, the recognized level of brain injury is at a level, I think, where something must be done …We can't continue to see, every game or every second game, a player leaving the field with a brain injury," according to Stewart from Glasgow University.
A 'collision sport'
In the case of concussion, "What happens is that the skull ceases to move quite rapidly, but the brain - because it's a kind of semi-liquid - continues to move around in the skull. So the sudden acceleration of the brain in the skull causes the brain substance to be damaged," Stewart explains.
He emphasizes the level of damage is "minute," but it can cause the brain to function less efficiently, causing disorientation, dizziness, unsteadiness and possibly confusion. Only in 10% of cases do players lose consciousness.
It's hard to say, though, how many players have suffered long-term damage from a head injury, since in the past, players were reluctant to report these issues.
Stewart thinks that, apart from the fact that higher awareness of concussion has led to more cases being reported, the way elite players tackle these days is also playing a role.
"It now becomes a collision sport, where players quite purposely collide with each other to try and punch a hole through the opposition defense" - a technique less likely to be seen in community rugby, for example.
Although tackling above the shoulders is against the rules, tackles in the professional game are also higher today, Stewart says. They've moved away from the "textbook" tackle that aims for the legs with the tackler's head turned to one side to avoid injury.
There are also issues in the ruck, formed when the person tackled has gone to ground and a teammate binds him or herself to that player to secure the ball, all while the opposition tries to steal it.
"But you do see players now essentially launching themselves across that ruck trying to clear the opposition players out," Stewart says. Simply enforcing the rules of the game may help.
But rugby medical officer Raftery dismisses that argument, saying that, "If the tackling style had changed, then we would expect to see an increase in other traumatic injuries. But they haven't changed."
World Rugby chairman Bill Beaumont points out that the governing body "is committed to an evidence-based approach to reducing the risk of injury, and the latest data clearly shows that players are at greatest risk of concussion when making upright, but not necessarily illegal tackles."
"So it's not the game that's changed, it's the awareness and diagnosis," Raftery insists.
Elite v. grassroots rugby
Head injuries are far less common at amateur or community-level rugby. Raftery says the discrepancy is mainly down to speed.
"When the speed is higher, there is more chance of injury, a fact that applies to every sport, not just rugby."
At the elite level, injuries are also more likely to be reported.
But don't let that put you off joining your local rugby club.
"We tend to focus on the elite, male players and tend to forget that 99.9% of players are at amateur and grassroots level," Stewart says, adding that the benefits of participating in a sport outweigh the risks.
Raftery concurs. A study from rugby-mad New Zealand has shown that there are more injuries in school playgrounds than on the rugby pitch.
"You don't take any risk when you're not playing a sport at all, but also don't go the playground either," he says.