Rugby Injury Imaging

Abstract

In 1823, when William Webb Ellis picked up the football and ran with it when playing in a school match for Rugby School in England, the game of rugby was born. In 1845, that same school wrote the first rules of the game, and in 1871 the English Rugby Football Union was created. Since that time, the game has flourished and spread across the world, from England to the four corners of the globe. The game of rugby thrives on athleticism, skill, and bravery. Due to the nature of the game, collision-based injuries are common. However, as the sport has grown in the professional modern era, the players are also susceptible to many noncontact injury patterns. The array of injuries encountered in rugby places radiology central to player welfare and injury management. This article illustrates the range of injuries commonly encountered in one of the fastest growing full-contact sports in the world.

Fig. 1

The Sharks versus the Lions in the Currie Cup, illustrating the vulnerability of the forward to collision and axial load related injuries during the scrum. (File licensed under the Creative Commons Attribution-Share Alike 4.0 International license. Cropped. Original available at ttps://commons.wikimedia.org/wiki/File:Rugby_playing_Scrum.jpg#Licensing.)

Fig. 2

Harlequins versus London Welsh in the English Premiership, capturing a high-impact collision involving rapid deceleration and rotational force, key mechanisms behind common tackle-related injuries. (File licensed under the Creative Commons Attribution 2.0 Generic license. Cropped. Original available at https://www.flickr.com/photos/fearless_fred/8420113408/in/album-72157632623889304 .)

Fig. 3

A 30-year-old amateur rugby player presented with occipitocervical neck pain after a head-on-head collision in a tackle. ( A ) Coronal and ( B ) left parasagittal computed tomography images show an impacted intra-articular fracture of the left occipital condyle (Anderson and Montesano type 1) (arrows). ( C ) Coronal short tau inversion recovery magnetic resonance imaging shows marrow edema associated with the acute fracture (arrow). Because there was no instability, owing to maintained ligament integrity, the injury was treated nonoperatively with external stabilization. The player had no neurologic impairment.

Fig. 4

A 27-year-old amateur female rugby player with a thoracolumbar junction chance fracture sustained during a frontal tackle to the abdomen. ( A ) Sagittal computed tomography on day 1 shows a transverse fracture through the T12 spinous process (short arrow), an impacted L1 superior end-plate fracture with anterior wedging, a retropulsed superoposterior fragment (long arrow), and a small displaced anterosuperior corner fragment. ( B ) Sagittal short tau inversion recovery magnetic resonance imaging (MRI) on day 2 demonstrates associated marrow edema (arrows), mildly raised signal within the conus medullaris, and soft tissue edema posterior to the interspinous ligament. This is an unstable three-column chance-type fracture. ( C ) Sagittal and ( D ) T2-weighted MRI at 3 years postinjury show a cyst/syrinx within the conus medullaris (arrows). The T11–L3 posterior fusion metalwork and mild kyphosis at the level of the chronic L1 superior end-plate fracture are noted. The player had T10 American Spinal Injury Association B impairment.

Fig. 5

A 27-year-old male amateur rugby player with bilateral facet dislocation sustained during a tackle involving buckling combined with forced flexion. This is an unstable injury, due to the associated complete ligamentous disruption. ( A ) Left and ( B ) right parasagittal computed tomography (CT) images show anteriorly locked or “jumped” C5 upon C6 articular processes (arrows). ( C ) Sagittal CT in midline demonstrates grade 2 anterolisthesis of C3 on C4 (arrow). ( B ) and ( C ) Right and left parasagittal computed tomography (CT) images show anteriorly locked or ‘jumped’ right sided and distracted left sided C3 on C4 articular processes (arrows). ( D ) Sagittal T2 midline magnetic resonance imaging at 5 days post surgical internal fixation demonstrates post-traumatic cord oedema from C2 to C5 and a small focus of intramedullary cord haemorrhage at the C3/4 injury level (arrow). ( E ) Sagittal T2 midline magnetic resonance imaging at 1 year post surgical internal fixation shows maturing post-traumatic cystic myelomalacia within the cord at C3-C4 (arrow). The patient had American Spinal Injury Association grade A neurologic impairment at 1 year post injury.

Fig. 6

A 25-year-old professional male rugby player presented with neck pain after a tackle. ( A ) Sagittal computed tomography (CT) shows grade 1 anterolisthesis of C3 on C4 (arrow). ( B ) Right parasagittal and ( C ) left parasagittal CT images show right-sided facet joint subluxation with fracture of the right C4 articular process and widening of the left C3–C4 facet joint, respectively (arrows). ( D ) Sagittal T2-weighted magnetic resonance imaging at 1 month shows anterior fusion of C3–C4, with cord swelling and residual hematoma (arrow). ( E ) Sagittal T2 MRI at 1 year shows cystic myelomalacia at the level of the cord injury (arrow). The patient had ongoing American Spinal Injury Association A impairment.

Fig. 7

A 34-year-old male amateur front-row player became acutely quadriplegic in a collapsed scrum. ( A ) Computed tomography at the time of injury shows chronic upper cervical vertebral body sclerosis, particularly involving C5 (arrow), with no acute fracture. ( B ) Sagittal short tau inversion recovery, ( C ) axial T2-weighted, and ( D ) sagittal T2-weighted magnetic resonance imaging (MRI) images through the midline, and ( E ) sagittal T1-weighted left para-midline MRI on the day of injury show edema and swelling of the cervical cord (thick arrow). There is interspinous ligament and ligamentum flavum injury (short arrow), with epidural hematoma (long arrows). The player was treated with traction. ( F ) Sagittal T2-weighted MRI at 2 months postinjury demonstrates a small residual intramedullary cyst at the level of C5 (arrow). The player was left with C4 American Spinal Injury Association D impairment on follow-up at 2 months.

Fig. 8

A 26-year-old male rugby player injured after being tackled from the front. ( A ) Coronal short tau inversion recovery magnetic resonance image and ( B ) computed tomography of the chest show a minimally displaced fracture (arrows) of the manubrium extending onto the left sternoclavicular joint.

Fig. 9

A 22-year-old male rugby player who received a direct impact to the front of the chest from a tackling opponent. There was immediate pain and he was removed from play. ( A ) Coronal fat-saturated (FS) proton-density (PD)-weighted magnetic resonance image (MRI) demonstrates multiple left costal cartilage fractures (arrows). ( B ) Axial FS PD MRI through the fourth costal cartilage shows posterior “dislocation” of the costal cartilage, not an atypical appearance (arrows).

Fig. 10

A 24-year-old male rugby player who experienced a lateral compression injury after falling to the ground onto his right side. Coronal fat-saturated proton-density magnetic resonance images showing ( A ) a fracture through the inferior medial aspect of the first costal cartilage (arrow) and ( B ) a tear of the right sternoclavicular joint capsule, with an edematous but intact intra-articular disk (arrow).

Fig. 11

A 20-year-old female rugby player who experienced a first anterior glenohumeral instability episode when engaging with an opponent. ( A ) Sagittal fat-saturated (FS) T2-weighted magnetic resonance imaging (MRI) through the right shoulder joint demonstrates a Hill-Sachs lesion with associated bone contusion commensurate with the recency of the injury (arrow). ( B ) Axial FS proton-density MRI shows anterior capsulolabral tear and joint effusion (arrow).

Fig. 12

A 30-year-old female rugby player injured her left acromioclavicular joint when falling to the ground. There was immediate pain and the player was removed from the field. ( A ) Coronal fat-saturated (FS) proton-density magnetic resonance imaging (MRI) demonstrates acromioclavicular joint dislocation, with rupture of the acromioclavicular ligaments and capsule (arrow). ( B ) Sagittal FS T2-weighted MRI shows disruption of the coracoclavicular ligaments (arrow).

Fig. 13

A 19-year-old male rugby player, imaged after reduction of a right elbow joint dislocation. ( A ) Sagittal fat-saturated proton-density magnetic resonance imaging (MRI) demonstrates full-thickness tears of the radial (long arrow) and ulnar (short arrow) collateral ligaments from the respective humeral attachments. ( B ) Coronal short tau inversion recovery MRI shows tear of the anterior joint capsule (arrow).

Fig. 14

A 28-year-old male amateur rugby player presented with finger pain after pulling the ball away from an opponent. ( A ) Longitudinal and ( C ) transverse still images from dynamic ultrasound (US) assessment of the left ring finger at the time of injury in extension show a gap between the flexor tendon and underlying metacarpal at the level of the A2 and A3 pulleys (arrows). ( B ) Finger flexion during dynamic imaging shows this gap increasing (arrow) due to tendon “bowstringing” that indicates torn pulleys. The A1 pulley was thickened; the A4 pulley was intact. After a month of conservative management, the patient presented again with increased pain after returning to play. ( D ) Longitudinal still US images in extension and ( E ) in flexion show lifting of the flexor tendon as previously (arrows) that had now progressed to involve the region of the proximal aspect of the A4 pulley. ( F ) Transverse US shows disorganization of the A2 pulley (arrows).

Fig. 15

Oyonnax Rugby versus Union Bordeaux Bègles, illustrating a ruck after a tackle. Note the two opponents standing over the ball in the “jackal” position that biomechanically involves a low stable stance with trunk flexion, active knee extension, a strong core, and hands trying to grip the ball close to the ground to contest possession. (File licensed under the Creative Attribution-ShareAlike 3.0. Unreported license. Cropped. Original available from https://commons.wikimedia.org/wiki/File:USO_-_UBB_-_20150829_-_Ruck_3.jpg .)

Fig. 16

A 25-year-old male rugby player sustained a hamstring injury while in the “jackal position” (trunk flexion and lower limb extension) during a ruck. ( A ) Axial fat-saturated (FS) proton-density (PD) magnetic resonance imaging (MRI) demonstrating acute full-thickness transverse tear of the conjoint semitendinosus long head of biceps femoris tendon (arrow). ( B ) Coronal FS PD MRI showing discontinuity of the tendon (arrow), with loss of tendon tension and marked muscle edema (British Athletic Muscle Injury Classification grade 4c).

Fig. 17

A 23-year-old male rugby player injured during a ruck. ( A ) Sagittal and ( B ) coronal fat-saturated proton-density magnetic resonance imaging show multi-ligament injury of the knee secondary to dislocation. Both the anterior (long arrow) and posterior (short arrow) cruciate ligaments are ruptured. The lateral collateral ligament and distal biceps tendon have avulsed and retracted from their combined attachment onto the head of the fibular (thick arrow). The deep and superficial bands of the medial collateral ligament are torn at their femoral attachments (thin arrow). ( C ) Immediate on-field postinjury photograph with player's permission. Note the knee malalignment.

Fig. 18

A 28-year-old professional rugby player, presented in-game with an acute tearing sensation at the right posterior leg. 𠀨A𠀩 Sagittal, 𠀨B𠀩 coronal, and 𠀨C𠀩 axial proton-density fat-saturated magnetic resonance images show partial tearing of the fibular intramuscular aponeurosis of soleus 𠀨arrows𠀩. The aponeurosis demonstrates loss of tension and marked surrounding muscle edema 𠀨Olympic Park grade 3𠀩.

Fig. 19

A 21-year-old male rugby player experienced an acute ankle dorsiflexion with external rotation injury. ( A ) Low axial fat-saturated (FS) proton-density (PD) magnetic resonance imaging (MRI) through the distal tibiofibular syndesmosis shows a ruptured and coiled anterior inferior tibiofibular ligament (arrow). ( B ) Higher axial FS PD MRI through the distal tibiofibular interosseous membrane demonstrates a positive “broken ring of fire” sign, with fluid at the anterior, lateral, and posterior margins of the tibia above the syndesmotic ligaments (arrows). This sign was shown to be associated with functional syndesmosis instability at the time of surgery.