BackgroundAustralian Rules Football (ARF) is a contact sport with a disproportionately high number of associated injuries compared with other sports played in Australia (1-3). Players in the elite Australian Football League (AFL) competition are typically exposed to extreme mental, physical and tactical demands when striving for success at this level (4). The average playing career is approximately 6.2 years (5). For many AFL players, receiving a serious injury and losing the chance to compete is one of their biggest fears (6). While AFL players are aware their sport contains a risk of serious injury and the annual injury rates reported by the AFL since 1992 show serious injuries do occur, there remains a paucity of information on the longer term effects of these injuries following retirement from the game (7).

Current injury rates reported by the AFL reflect each playing season and provide important comparative data on the rates and types of injuries suffered by players across seasons. From an individual player’s perspective the data does not track multiple injuries per season, injuries received over several seasons, or the number of games played prior to, or following an injury. Current data on AFL injuries does not measure their impact

on a player’s short term playing career and any longer term health outcomes following retirement from the AFL. There is currently no available information on the accumulation of serious injuries by players over their AFL career, beyond a link to forced retirement.

In the AFL serious injuries are most common at joint sites; however, AFL players are also very exposed to potential hits to the head and consequently receiving a concussion (8). In recent years, the AFL have modified the rules of match day play such that any incidental or low grade contact with the head while attempting a tackle results in a free kick. More serious contact to the head can result in a playing suspension for the infringing player. These rule modifications designed to reduce head injuries, including concussions, may have reduced hits to the head, but the available data suggests no change in the average of less than one player per club receiving a concussion during any one AFL season (7). To be defined by the AFL’s injury classifications as receiving a concussion a player has to miss the following game. It remains unclear how many players receive a head injury and possibly a concussion, and recover well enough to be passed fit to play the following game. The current injury

monitoring system does not account for multiple concussions received by a player during a season, or over the course of their AFL career. There is currently no evidence of any short or longer term effects of hits to the head during a player’s career, or following their retirement from playing. AFL players retire from the game for a variety of reasons, including forced retirement through injury, and recent figures have indicated that approximately 135 players or 20% of current AFL players are joining the growing cohort of past AFL players each year (9). Retirement from competition is an inevitable part of every AFL player’s career and this report presents findings from a survey of past AFL players on their recall of receiving serious injuries and concussion while playing in the AFL.

MethodologyA survey, completed by past AFL players (n=592) with an average age of 55.1 y (±15.8) (median age 53 y) and playing career of 7.7 years (±4.1), sought recall on receiving serious injuries (requiring hospitalisation), the type and nature of the injury, any ongoing medical treatment and their impact on current daily living. Players who received a serious injury were also asked if they recalled receiving

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AFL careers and injuries: Perspectives of former players

At least one serious

injury

Number of serious injuries

Y 1-5 6-10 11-15 16+Classification %(n) %(n)

Age group (n=531) ___**___ _______________**________________

20-34 83.0 (83) 30.1 (25) 33.7 (28) 20.5 (17) 15.7 (13)

35-49 84.8 (117) 19.8 (23) 36.2 (42) 20.7 (24) 23.3 (27)

50-64 78.4 (127) 42.5 (54) 33.1 (42) 13.4 (17) 11.0 (14)

65+ 61.8 (81) 60.0 (48) 25.0 (20) 10.0 (8) 5.0 (4)

Games played (n=590) ___**___ ______________**_______________

1-50 70.4 (157) 52.2 (82) 29.9 (47) 5.7 (9) 12.1 (19)

51-100 77.4 (96) 28.3 (26) 35.9 (33) 26.1 (24) 9.8 (9)

101-150 81.4 (79) 36.4 (28) 31.2 (24) 16.9 (13) 15.6 (12)

151-200 87.3 (55) 28.3 (15) 30.2 (16) 26.4 (14) 15.1 (8)

201+ 84.8 (56) 26.8 (15) 32.1 (18) 17.9 (10) 23.2 (13)

Requires ongoing treatment (n=321) ___**___ ______________**_______________

Y 60.4 (194) 41.2 (40) 59.3 (64) 72.1 (44) 83.6 (46)

N 39.6 (127) 58.8 (57) 40.7 (44) 27.9 (17) 16.4 (9)

Impacts current daily activities (n=436) ______________**_______________

Y 64.2 (280) 45.1 (74) 75.5 (105) 77.1 (54) 77.0 (47)

N 35.8 (156) 54.9 (90) 24.5 (34) 22.9 (16) 23.0 (14)

Total (n=592) 77.2 (444) 38.1 (166) 31.9 (135) 16.1 (70) 14.0 (61)

Significant Chi Square value indicating an association between respectively, number of serious injuries and age group, games played, requires ongoing treatment and impacts current daily activities **Significant at p<0.01

Table 1: Prevalence of serious injuries amongst past players

ÌÌ A large proportion (64%) of past players remain affected in their current daily life from a previous AFL injury, with 60% (n=194) of these requiring on-going medical treatment.

ÌÌ Past players requiring ongoing medical treatment for their injuries were either covered by a private health insurance fund (53%) or were self-funding their treatment (39%).

ÌÌ Past players who received 1-5 serious injuries played (on average) significantly fewer games (70) than those who received 11-15 (108) or 16+ injuries (112).

ÌÌ Past players who experienced a greater number of serious injuries throughout their playing career were significantly

Key FindingsÌÌ The average number of

AFL games played ranged between 1 and 378 games, with an average career of 90 games.

ÌÌ The majority (77%) of past players recalled experiencing at least one serious injury (i.e. were admitted to hospital or received surgery on the injured site) during their playing career.

ÌÌ Over half of past players (62%) reported more than 5 serious injuries during their playing career.

more impacted in daily activities after retirement.

ÌÌ Past players sustaining serious lower limb injuries were significantly more likely to be impacted upon in daily activities than those who experienced head/neck or upper body injuries.

a concussion (self classified) during their AFL career. Past players were able to complete the survey online, by telephone, or hard copy, to maximise the response rate. All past AFL players who were members of the AFLPA alumni were invited to participate in the survey.

At least one concussion

Number of concussions

Y 1 2 3+Classification %(n) %(n)

Age group (n=408) _______________**_____________

20-34 71.1 (59) 25.4 (15) 22.0 (13) 52.5 (31)

35-49 82.1 (96) 10.4 (10) 35.4 (34) 54.2 (52)

50-64 70.1 (89) 22.5 (20) 30.3 (27) 47.2 (42)

65+ 70.4 (57) 20.4 (11) 35.2 (19) 44.4 (24)

Games played (n=437) ___**___ ___________ *____________

1-50 62.4 (98) 25.8 (25) 38.1 (37) 36.1 (35)

51-100 73.9 (68) 19.4 (13) 26.9 (18) 53.7 (36)

101-150 82.3 (69) 16.9 (11) 30.8 (20) 52.3 (34)

151-200 81.1 (43) 7.1 (3) 26.2 (11) 66.7 (28)

201+ 83.9 (47) 12.8 (6) 25.5 (12) 61.7 (29)

Total (n=444) 73.3(321) 18.2 (58) 30.8 (98) 50.9 (162)

Significant Chi Square value indicating an association between respectively, number of concussions and age group and games played. *Significant at p<0.05 **Significant at p<0.01

Table 2: Prevalence of concussion among seriously injured past players

Figure 1: Number of serious injuries per average games played

ÌÌ Of past players who sustained a serious injury, almost 75% reported sustaining at least one concussion during their playing career.

ÌÌ Four out of five past players, who recalled receiving a concussion, reported receiving multiple concussions, with one in two (51%) recalling three or more concussions during their playing career.

ÌÌ The prevalence of recalling a concussion was similar for each past player age group, with the lowest proportion amongst past players over 65 years of age.

ÌÌ There was a direct association between the average number of games played and the number of serious injuries sustained.

ÌÌ Past players, who sustained four or more serious injuries played on average 113 games or more.

ÌÌ Players who recalled sustaining one or more serious injuries played significantly more games (98) than those who did not sustain an injury during their professional career (68).

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ÌÌ There was a clear, direct association between the number of games played and the number of concussions sustained, amongst players also receiving a serious injury.

ÌÌ Past players recalling receiving at least one serious injury and one concussion played (on average) 84 games.

ÌÌ Past players who did not experience a concussion played (on average) significantly fewer games (72) than those who experienced

two (97) or three or more concussions (121).

ÌÌ Players who recalled sustaining a concussion at least once during their career played significantly more games (106) than those who did not recall receiving a concussion (72).

ÌÌ In addition to receiving a serious injury, suffering three or more concussions was associated with playing (on average) at least 100 AFL games.

Figure 2: Number of concussions per average games played

02 | www.uwa.edu.au

ConclusionsAlmost three quarters of the past players surveyed recalled receiving at least one serious injury (one that required hospitalisation or surgery) during their playing career. Of these players, 75% also recalled receiving at least one concussion during their AFL career. This level of serious injury and concussion amongst past players is markedly higher than any other reported level of injury and concussion amongst AFL players, past or present. The most comparative data source is the incidence of injuries and concussions reported in the annual AFL injury data, which reports a considerably lower incidence of serious injuries or concussions observed in this survey (7). Past player recall of serious injury and their own classification of a concussion (AFL injury data requires a head injury to result in the player missing the following game to be classified as a concussion) offer some explanation as to the difference with previous findings; although the levels found in this survey remain notably high. Past players in this survey also played more AFL games than the typical length of an AFL playing career and the high prevalence observed may reflect past players overcoming more serious injuries and concussions to have achieved a greater than average playing career.

This survey also found that multiple serious injuries were common amongst past players and these were directly associated with the number of games played. The recall of serious injury was similar across the age group of past players, suggesting receiving at least one serious injury has not changed greatly over the past several decades of AFL competition. Previous research has either focussed upon injuries that led to player retirement (10), or the incidence of injury during a season (3, 1). The results of this study offer new insight into the accumulation of serious injuries by individual players over their playing career. It is possible

that players may have over-estimated the number of serious injuries they received due to the nature of completing a “health and wellness” survey, although information on injuries and concussions were only a small part of the overall survey and not its main focus. Even accounting for some over estimation of receiving serious injuries the prevalence remains higher than expected.

Over 60% of players receiving serious injuries reported an impact upon their current daily life and required ongoing medical treatment. Not surprisingly, the greater number of serious injuries reported was directly associated with a higher impact on daily living and ongoing medical expenses. No comparable data in ARF or other professional sporting codes was found to compare with the longer term effects of injuries received during elite sporting careers. The current evidence on the impact of injuries is limited to descriptions of forced retirement coping mechanisms (10) and comparisons between past AFL players and community members with respect to knee joint injuries (12). Very little information exists around the impact of serious injuries several years and decades post career.

The high level of recall of concussion in this survey was unexpected, considering the current AFL injury data suggests that over the past 10 years, on average, less than 1 player per club per season sustained a concussion (7). This is in contrast to the data from this study, which suggests that 1 in 2 players sustain at least one serious injury and a concussion during their playing career. The statistics relating to concussion rates in current AFL footballers require that the player must miss a game to be registered as sustaining concussion, eliminating those players who recover in time for the next game from the data. In the present study concussion was not defined and therefore some

uncertainty would surround the ability of past players to recall an occurrence of a head injury that might medically be defined as a concussion. Nonetheless, receiving a concussion is a fairly traumatic injury and while not medically validated, almost three quarters of past players who had a serious injury also recalled at least one head injury they associated with a concussion and over half of these players reported multiple occurrences. The recent modification of AFL match day tackling rules in 2009 aimed to reduce head injuries would be supported by the findings of this survey, as a high proportion of past players report recalling a head injury which they considered a concussion.

There appears to be a large discrepancy between the AFL’s annual injury report data pertaining to injury and concussion and that of past players recalling their injury history. Direct comparisons are difficult given the different methodologies for collecting and reporting data, as well as the AFL reporting on current players and this survey on past players. The past players who responded to this survey represent a cohort who played almost twice as long as the current average playing career and were members of the AFLPA alumni (had to play at least one game at the elite level). They may not represent all past players and further research is required to validate the observations in this survey amongst the wider past player community.

This is the first survey of past players of Australian Rules football to explore serious injuries and concussion received during a player’s career. The results highlight that at least amongst past players who completed this survey, serious injuries and concussions are common over the course of a player’s career. Irrespective of whether a serious injury or concussion contributed towards a players retirement, past

players were also impacted upon in their current daily lives by their injuries, often requiring ongoing treatment years and sometimes decades later. These results, if supported by further research, have implications for preventing, treating and managing serious injuries and hits to the head during and after an AFL player’s career.

References1. Braham R, Finch C, McIntosh A, McCrory P. Community level Australian Football - a profile of injuries. Journal of Science and Medicine in Sport. 2004;7(1):96-105.2. Finch C, Valuri G, Ozanne-Smith J. Sport and active recreation injuries in Australia: evidence from emergency department presentations. British Journal of Sports Medicine. 1998;32:220 - 5.3. Gabbe B, Finch C. A profile of Australian Football injuries presenting to sports medicine clinics. Journal of Science and Medicine in Sport. 2001;4(4):386-95.4. Blumenstein B, Lidor R. The road to the olympic games: A four-year psychological preparation program. Athletic Insight. 2007;9(4):15-28.5. AFL Players’ Association. Player retirement data since 1997.6. Baillie PHF. Understanding retirement from sports - Therapeutic ideas for helping athletes in transition. Counseling Psychologist. 1993;21(3):399-410.7. Orchard J, Seward H, Orchard J. 20th Annual AFL Injury Report. Season 2011. Sydney, Australia: AFL Medical Officers Association, 2012.8. Braham R, Finch C, McCrory P. To participate or not to participate? Why football players contribute to research projects. British Journal of Sports Medicine. 2004;38(2):238-9.9. AFL Players Association. Player development retirement statistics 2008-2011.10. Fortunato V, Marchant D. Forced retirement from elite football in Australia. Journal of Personal and Interpersonal Loss. 1999;4(3):269-80.11. Orchard J, Seward H. Epidemiology of injuries in the Australian Football League, seasons 1997-2000. British Journal of Sports Medicine. 2002;36:39-45.12. Deacon A, Bennell K, Kiss Z, Crossley K, Brukner P. Osteoarthritis of the knee in retired, elite Australian Rules footballers. Medical Journal of Australia. 1997;166:187-90.

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