A decade of concussion in rugby: a 2014–2024 systematic review and meta-analysis update

OBJECTIVE: To quantify the incidence of concussions identified through clinical assessments or diagnostic protocols in rugby union (RU) (sevens and XVs) and rugby league (RL) over the past decade and analyse differences by sex, playing level, match versus training exposure and concussion assessment protocols (Head Injury Assessment (HIA) vs non-HIA). DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Web of Science, Scopus, Embase, SPORTDiscus, PsycINFO and CINAHL were searched in February 2025 for studies published between 2014 and 2025. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were eligible if they reported concussions identified through clinical assessment or diagnostic protocols in rugby with extractable exposure data (match-player-hours and/or training-player-hours) and incidence rates per 1000 player-hours. RESULTS: 98 studies, comprising 10 591 concussions across 3 275 130 player-hours, met the inclusion criteria. Studies included data from 2003 to 2023. The pooled overall concussion incidence was 9.74 per 1000 player-hours (95% CI 8.54 to 10.95) in RU and 9.20 (95% CI 7.38 to 11.02) in RL, with no significant difference between codes (p=0.891). When analysed by subgroups, no statistically significant overall sex-based differences in concussion incidence were observed in either RU or RL; however, post hoc analyses identified higher concussion incidence among female youth players (<18 years) compared with males. Match play showed a markedly higher incidence than training (RU: 10.98 per 1000 match-player-hours vs 0.34 per 1000 training-player-hours; RL: 10.45 per 1000 match-player-hours vs 0.32 per 1000 training-player-hours; p<0.001). Studies using HIA protocols reported nearly double the incidence compared with non-HIA protocols (RU: 15.35 vs 7.72; rate ratio=1.83; p<0.001). Concussion trends reflected external factors, including COVID-19 disruptions and policy changes. CONCLUSION: Concussion incidence in rugby appears to be strongly influenced by match intensity and assessment protocol. Structured diagnostic approaches, such as the HIA protocol, are associated with higher reported concussion incidence, likely reflecting improved detection. PROSPERO REGISTRATION: CRD42023480774.