International rugby is more brutal than ever with players fitter, faster and stronger. And despite the increasing physical demands, more and more is being asked of the game’s top talent.
England, for example, are playing on three successive weekends in three different continents this month in the Nations Championship.
If that isn’t mad enough, throw in a meaningless match against a French XV in Vannes at the end of June in which Alex Dombrandt suffered a serious knee injury that will keep him out of next season. These sorts of games need to be eradicated. I’m sure Dombrandt’s club Harlequins were not impressed to lose their captain that way.
It is all too much at a time when rugby is battling a workload issue and a head injury crisis. Solutions must be found if the sport is going to continue to thrive.
Injury data shows a player’s exposure to ‘head acceleration events’ – a technical term experts use for how brain injuries and concussions are caused, describing how a player’s brain moves inside the skull during a collision – are between three to 12 times higher in matches compared to training. So why are games like the England versus a French XV happening?
The bottom line is money. But that should not come at the expense of the players because if the sport is not careful, its top stars will either burn out – look at England captain Maro Itoje sitting out this month’s Tests – or decide the risks are now not worth it. Last season, both Itoje and Tommy Freeman exceeded the RFU’s 30-game-a-season limit. What’s the point of it if it can be exceeded?
Ellis Genge goes into battle for England in Johannesburg last weekend. This weekend he will be playing in Liverpool and next, in Argentina
Ollie Chessum and his England team-mates look knackered after a gruelling Test match in South Africa which came on the back of a tough season
England will travel 25,000 miles this summer. Johannesburg, Liverpool to face Fiji on Saturday, then Argentina the following weekend. I experienced it as England coach – the 1998 ‘tour from hell’ to Australia, New Zealand and South Africa – so it’s not unprecedented. But I thought I’d never see the likes again.
It’s dangerous. In fact, it’s madness. World Rugby preaches that player welfare is No 1 priority. But what we’re seeing doesn’t back that up. Rugby must do more to look after its players. Without them, there’s no game.
Hundreds of former stars are in a legal battle with World Rugby, the RFU and the WRU over neurodegenerative diseases they are now suffering with. The players claim they are a result of head injuries suffered in their careers. There is no sign of a resolution and rugby’s reputation is suffering, which has an impact on grassroots participation. The sooner a verdict is found, the better.
I am passionate about these issues and for the past six months, I’ve been examining them. I’ve found there’s a lot of good things being done to make the game safer. But a lot more can be done.
What is a person’s vulnerability to a brain injury?
Improving player welfare is a costly business. Yes, the international game makes money, but at club level the sport is not awash with cash. But that cannot be an excuse.
‘When I watch a game of rugby, it just makes me want to scream,’ Dr Sabine Donnai, founder and chief executive of health management company Viavi, tells me. ‘The game can 100 per cent carry on. But certain things need to be done.’
When I watch a game of rugby, it just makes me want to scream
Dr Donnai has worked with Chelsea’s footballers to maximise their brain health and is one of the world’s leading experts in the field. ‘Nobody is helping the players to protect themselves and I find that really tragic,’ she says. ‘Rugby is brutal. The demands on the brain are a lot more than in the past. Players are going to have to start thinking ahead. They need to realise they’re going to put themselves in a position where they’re opening themselves up to danger in terms of a potential brain injury.
‘Repetitive head injuries impact brain health but medicine in the UK is driven by a mindset of cure rather than prevention. That’s a huge problem. There’s a need for young sportspeople to start taking these things seriously.’
If I was coaching today, I’d want to be leading on this with the help of experts like Dr Donnai. And I believe that players need to place welfare at the top of their agenda. Players often go outside of their clubs to spend their own money on injury treatment or specialist coaching. So why not for brain health?
England captain Maro Itoje has had to sit out the Nations Championship as he is in danger of burn-out
England’s Tommy Freeman (above) exceeded the RFU’s 30-game-a-season limit last season, as did Itoje
‘It’s not just rugby – skiers and boxers are also exposed to repetitive head injuries,’ Dr Donnai says. ‘The vast majority aren’t going to have a problem. But 12 to 15 per cent will – not because their head injuries are necessarily worse, but because their brains are more susceptible. The key is to ascertain what is a person’s vulnerability to a brain injury.
‘There is lots of investigation that can be done to find out if someone is more at risk. It is never too late to start looking after your brain.’
Proactive not reactive
Rugby must now be more proactive than reactive on player welfare. Former players are suffering with issues such as early-onset dementia and motor neurone disease, including two members of the England team I coached: Steve Thompson and Lewis Moody.
While there is no definitive medical proof that head injuries in rugby lead to MND, there are some studies that have suggested a link. A 2025 medical paper which studied more than 85,000 adults who had suffered a traumatic brain injury found approximately a 2.6-fold higher risk of a subsequent MND diagnosis.
The renowned Professor Willie Stewart from Glasgow’s School of Psychology & Neuroscience produced research which found former international rugby players had a two-and-a-half-times higher risk of neurodegenerative disease than expected.
‘I don’t think anyone’s stupid enough to think that getting hit in the head multiple times isn’t going to have some sort of impact,’ Moody told me, when we spoke earlier this year.
Moody’s MND news and the struggles of players such as Thompson hit everyone in the rugby world hard. We must do everything we can to ensure what has happened to them does not get repeated with the game’s current players.
I am confident that can happen, but rugby chiefs have to wake up. Now is the time for meaningful, joined-up decision-making which can make a real difference.
‘I don’t think anyone’s stupid enough to think that getting hit in the head multiple times isn’t going to have some sort of impact,’ Lewis Moody told me earlier this year
The struggles of players such as Steve Thompson, who was in my World Cup-winning team, has hit everyone in the rugby world hard
Gloucester’s game-changing truck
Towards the end of the PREM season, I visited Kingsholm for Gloucester’s clash with Sale. I was more interested in what was in the car park than on the field – a huge truck that followed the team home and away.
Inside was Europe’s most powerful MRI scanner and other cutting-edge medical equipment that Gloucester have been working on with Oxford University and the Podium Institute.
‘This is one piece of what will hopefully be a bigger rugby puzzle across the world,’ Gloucester’s head of medical services, Rhys Hughes, told me. ‘We’re looking at how we can make our players bigger, faster and stronger. But we’re also looking at how we can make them safer.’
This is exactly what I wanted to hear. Gloucester’s impressive brain health truck costs £2,000 each time it has to move around the country and the total investment for the season was in the region of £2-3million. That is money well spent.
Around half of the squad took part in the study which saw their brain health assessed at the start of the season. If one of those players suffered a head injury during a game, they were then analysed further.
The MRI scanner provides detailed brain imaging, while blood profiling and saliva samples are also analysed to ascertain changes in a player’s brain. My only disappointment was that more players did not choose to be involved.
‘What we’ll find, I don’t know,’ Hughes said. ‘Something. Or maybe nothing. Both those results are very good. If we find something, we can put things in place to better improve our management of players. If we find nothing, it tells us what we’re doing is working – though that wouldn’t mean we’d rest on our laurels.
Sir Clive Woodward with Gloucester’s head of medical services, Rhys Hughes, outside their impressive brain health truck
‘I believe rugby is safe,’ says Gloucester captain Lewis Ludlow, who took part in his team’s brain health testing. ‘Let’s not fear head injuries. Let’s try to understand them better’
‘The MRI scanner won’t diagnose concussion and never will because head injuries are multifaceted. Getting to that stage is the silver bullet. We’re a long way from that. The thing that might take us closer to that is not the brain scan, but the blood or saliva markers.’
Gloucester’s brain health truck project wouldn’t have happened without external funding. Some might question whether that makes studies truly independent, but they wouldn’t take place without it and rugby is better for them happening. In an ideal world, all clubs would be doing it.
‘This is a game we love and we want to inspire the next generation to play it,’ Hughes added. ‘We’ve identified a potential problem and now we want to improve it to make sure the health of the current players and those who come through the door in 20 or 30 years’ time is improved.’ Amen.
Lower tackle height
In the last decade, technological advancements have helped improve rugby safety. Changes to the head injury assessment process, extended mandatory standdown periods following concussion and the use of instrumented mouthguards are all examples.
Lowering the tackle height is another possibility. It was trialled by the RFU in England’s community game after World Rugby and the RFU analysed more than 150,000 tackles. At the current Under-20 Junior World Cup in Georgia, they are experimenting with a lower tackle height, with the sternum now the upper marker.
The results will be fascinating as if it’s deemed a success, it could be brought in at international level. That would change the game but could also have a big impact on player safety.
Let’s get a better understanding
‘I believe rugby is safe,’ said Gloucester captain Lewis Ludlow, who took part in his team’s brain health testing. ‘There is lots of talk about early-onset dementia and MND. I know people who have those who have never played a game of rugby. There are so many discussion points among players on safety. Let’s not fear head injuries.
Leading players such as England’s Immanuel Feyi-Waboso (above) have missed high-profile matches after self-reporting concussion symptoms
‘The game has made big strides,’ former England captain Courtney Lawes says. ‘Things can always be tweaked, but it’s a massive improvement from when I started playing’
‘Let’s try to understand them better. Medical advances have allowed us to understand knee injuries better. It’s the same with head injuries. Everyone wants the game to be safe, but we don’t want to lose the essence of what makes rugby what it is – things like big collisions.’
I believe there’s been a significant mindset shift among today’s players on head injuries. In a different generation, it was, unfortunately, seen as a badge of honour to be concussed and keep playing. It was something I did in my own playing career.
Now we know that’s beyond foolish. Leading players such as Immanuel Feyi-Waboso and Garry Ringrose have missed high-profile matches after self-reporting concussion symptoms. That would not have happened in the past.
Moody suffered multiple concussions in his time. He played on against Tonga at the 2007 World Cup after being knocked unconscious. ‘The game, professionally, is in a better place now in terms of safety and concussion,’ he said. ‘It’s more the amateur game. But if you’re role-modelling at the highest level, then it drips down.’
Ludlow added: ‘It takes a strong-minded individual to withdraw from a game. And it’s down to awareness.
‘I played in a game with Exeter this season where we saw a member of the opposition’s mouthguard flashing and we flagged it to the referee. That’s a clear sign someone has taken a nasty bang. As players, we want to ensure we’re as safe as possible on the field.’
Gloucester’s brain health trial is the sort of thing I’d like to see extended. There is money in the game to fund such projects and this is where World Rugby has to come in. But they are too busy being preventative to avoid paying out millions in damages over brain injuries rather than being proactive. That has to change.
A groggy Thompson is helped from the pitch but it was, unfortunately, seen as a badge of honour to be concussed and keep playing back in the day
‘The game, professionally, is in a better place now in terms of safety and concussion,’ Moody insisted
World Rugby must step forward
World Rugby should dominate this space, ensuring concussion guidelines are mandatory and the same across all nations. Crucially, they are the ones who can afford to hand out grants which club teams and national unions can spend in this area to ensure their most valuable employees are better protected.
It’s heartening to see good work being done on concussion, but it’s not joined up.
Interestingly, Hughes disagreed with my notion. ‘That’s unfair,’ he said. We’ve had tremendous support from PREM Rugby and the RFU. There are lots of people and organisations who are trying to do the right thing. You could join it all up, but that’s the same for any research.
‘I actually think it’s a strength having so many research projects going on because it means we can look at each of them and see what’s best to take out of them. If everyone were singing from the same hymn sheet, you’re not going to have different ideas. The way we manage concussion is vastly different and improved compared to even five years ago. Lots of work has gone into that.’
That work has to continue and not just with professionals, but also at the community level. It is this area of the game that I will explore next.
Part Two of Sir Clive Woodward’s examination of the game’s issues at grassroots level will be published on Thursday
