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Medical encounters, cardiac arrests and deaths during a 109 km community-based mass-participation cycling event: a 3-year study in 102 251 race starters—SAFER IX
Abstract
Background
There are few data on medical encounters, including deaths during mass-participation cycling events.
Objective
To determine the incidence and nature of medical encounters during a community-based mass-participation cycling event.
Design
Cross-sectional study across three annual events.
Setting
2012–2014 Cape Town Cycle Tour (109 km), South Africa.
Participants
102 251 race starters (male=80 354, female=21 897).
Methods
Medical encounters (moderate, serious life-threatening, sudden cardiac arrest/death), using the 2019 international consensus definitions, were recorded on race day for 3 years as incidence rates (IR per 1000 starters; 95% CI). Overall illness-related (by organ system) or injury-related (by anatomical region) encounters, and severity were recorded.
Results
We recorded 539 medical encounters (IR 5.3; 4.8 to 5.7). The IR was 3.2 for injuries (2.9 to 3.6), 2.1 for illnesses (1.0 to 2.4) and 0.5 for serious life-threatening medical encounters (0.4 to 0.7). In the 3-year study, we encountered three cardiac arrests and one death (2.9 and 1.0 per 100 000 starters, respectively). Injury IRs included upper limb (1.9; 1.6 to 2.1), lower limb (1.0; 0.8 to 1.0) and head/neck (0.8; 0.6 to 1.0). Illness IRs included fluid/electrolyte abnormalities (0.6; 0.5 to 0.8) and the cardiovascular system (0.5; 0.4 to 0.6).
Conclusion
In a 109 km community-based mass-participation cycling event, medical encounters (moderate to severe) occurred in about 1 in 200 cyclists. Injury-related (1/300 cyclists) encounters were higher than illness-related medical encounters (1 in about 500). Serious life-threatening medical encounters occurred in 1/2000 cyclists. These data allow race organisers to anticipate the medical services required and the approximate extent of demand.
... 50 As a result, meeting the clinical demands of various stressors and venues has become a priority in the realms of sports medicine and mass medical management. 44,51 Relevant to the present review, EHS is included among the possible serious and life-threatening problems that participants report to the event medical team 42,50,52,53 during foot races, 54-57 endurance cycling events, 52,58 triathlons, 43,59,60 and ultra-distance events. 40,52,58 It is especially relevant to triathletes that no previous review article has assessed hyperthermia and EHS across all of these endurance sports. ...
... 50 As a result, meeting the clinical demands of various stressors and venues has become a priority in the realms of sports medicine and mass medical management. 44,51 Relevant to the present review, EHS is included among the possible serious and life-threatening problems that participants report to the event medical team 42,50,52,53 during foot races, 54-57 endurance cycling events, 52,58 triathlons, 43,59,60 and ultra-distance events. 40,52,58 It is especially relevant to triathletes that no previous review article has assessed hyperthermia and EHS across all of these endurance sports. ...
... 44,51 Relevant to the present review, EHS is included among the possible serious and life-threatening problems that participants report to the event medical team 42,50,52,53 during foot races, 54-57 endurance cycling events, 52,58 triathlons, 43,59,60 and ultra-distance events. 40,52,58 It is especially relevant to triathletes that no previous review article has assessed hyperthermia and EHS across all of these endurance sports. Therefore, the dual purposes of the present review are to clarify the available evidence regarding the recognition of hyperthermia and EHS (a) by medical teams at outdoor running, cycling, open water swimming, and triathlon events; and (b) by professional organizations and writing groups in position statements and consensus documents regarding outdoor endurance activities. ...
Few previous epidemiological studies, sports medicine position statements, and expert panel consensus reports have evaluated the similarities and differences of hyperthermia and exertional heatstroke (EHS) during endurance running, cycling, open water swimming, and triathlon competitions. Accordingly, we conducted manual online searches of the PubMed and Google Scholar databases using pre-defined inclusion criteria. The initial manual screenings of 1192 article titles and abstracts, and subsequent reviews of full-length pdf versions identified 80 articles that were acceptable for inclusion. These articles indicated that event medical teams recognized hyperthermia and EHS in the majority of running and triathlon field studies (range, 58.8 to 85.7%), whereas few reports of hyperthermia and EHS appeared in cycling and open water swimming field studies (range, 0 to 20%). Sports medicine position statements and consensus reports also exhibited these event-specific differences. Thus, we proposed mechanisms that involved physiological effector responses (sweating, increased skin blood flow) and biophysical heat transfer to the environment (evaporation, convection, radiation, and conduction). We anticipate that the above information will help race directors to distribute pre-race safety advice to athletes and will assist medical directors to better allocate medical resources (eg, staff number and skill sets, medical equipment) and optimize the management of hyperthermia and EHS.
... In order to address this problem, a consensus statement was recently published to standardise definitions and methods of data recording and reporting of medical encounters at mass community-based endurance sports events. 14 We recently reported an IR of 3.2 injuries per 1000 race starters during a 109 km community-based mass participation cycling event, 15 using the definitions and methods described in the 2019 consensus document. 14 We also reported that the upper limb (IR=1.9) ...
... regions. 15 Determining the IR of injuries is the first important step in injury prevention, 16 and this must be followed by investigations to identify risk factors associated with these injuries. 16 Risk factors associated with acute injuries in mass communitybased endurance cycling events have not been thoroughly investigated. ...
... 18 This study is a component of the retrospective study at the Cape Town Cycle Tour that was conducted on all race starters from 2012 to 2014 and the details of the study methodology have been fully described. 15 The Cape Town Cycle Tour is held annually in Cape Town and is approximately 109 km. 19 During the 3-year study period, 128 350 cyclists registered for the races with 102 251 cyclists starting the races (race starters=79.7% of registrations). ...
Background
There are limited data on acute injury-related medical encounters (injuries) in endurance cycling events.
Objective
To determine the risk factors for injuries during a mass community-based endurance cycling event.
Design
Retrospective, cross-sectional study.
Setting
Cape Town Cycle Tour (109 km), South Africa.
Participants
102 251 race starters.
Methods
All injuries for 3 years were recorded by race medical doctors and nurses. Injuries were grouped into main anatomical area of injury, and a Poisson regression model was used to determine the risk factors associated with injuries.
Results
The four injury risk factors associated with all injuries during an endurance cycling event were sex (women vs men, p<0.0001), older age (p=0.0005), faster cycling speed (p<0.0001) and higher average individualised Wind Speed (aiWindSpeed, p<0.0001). The only risk factor for serious/life-threatening injuries was women (p=0.0413). For specific main anatomical areas: head/neck (women), upper limb (women, older age, faster cyclists), trunk (women, higher aiWindSpeed), and lower limb (higher aiWindSpeed).
Conclusion
Women, older age, faster cycling speed and higher aiWindSpeed were all risk factors for acute injuries during a mass community-based endurance cycling event. These risk factors should help inform race organisers and medical teams on race day to ensure the best medical care is given, and effective acute injury prevention programmes are disseminated.
... However, acute and vigorous exercise may cause sudden cardiac death (SCD) in competitive athletes [3]. Relatively higher rates of SCD have been reported in collegiate athletes, Olympic athletes, triathletes, and cyclists [4][5][6][7]. Although the risk of SCD among athletes has decreased with the implementation of pre-participation screening programs, it remains relatively high in specific subgroups, notably in male athletes, Black athletes, and basketball players [8,9]. ...
... The full text of identified articles was systematically assessed for eligibility after screening the title and abstract. The inclusion criteria for eligible studies in the meta-analysis were (1) written in English language, (2) published in peer-reviewed journals, (3) performed using prospective or retrospective cohort design, (4) observers included both sexes (a study was included when it reported events in both sexes but had 0 cases in one sex [usually in females]), (5) reported data including the incidence of SCA and/or SCD. Moreover, incidence rates that were not directly presented were generated based on existing data from the study; the rate was recalculated when the incidence was reported in a form other than per 100,000 athlete-years (AY); reported SCA/D that included causes unrelated to cardiac disease (such as trauma or heat stroke) were excluded, and the incidence was recalculated using the actual cases of SCA/D. ...
Background
Although many studies have demonstrated a lower incidence of sudden cardiac arrest or death (SCA/D) in female athletes than in male, there is limited understanding of the specific underlying causes.
Objective
This systematic review aimed to assess the disparities in SCA/D incidence between male and female competitive athletes and explore the associated etiologies.
Methods
A comprehensive search was conducted for retrospective and prospective studies examining SCA/D incidence in male and female athletes. Incidence and incidence rate ratios (IRRs) according to sex were evaluated.
Results
Among the 16 studies analyzed, 1797 cases of SCA/D were observed; 1578 occurred in males (87.81%). Ages ranged from adolescent to adult. The incidence was 1.42/100,000 athlete-years (AY) in males (95% CI 0.97–2.09), and 0.32/100,000 AY in females (95% CI 0.17–0.59), resulting in an IRR of 5.55. When considering athletes aged ≤ 35 years, the incidence was 1.46/100,000 AY in males (95% CI 0.91–2.34) and 0.30/100,000 AY in females (95% CI 0.14–0.66), with an IRR of 5.47. The IRR was 5.13 (95% CI 3.94–6.67) for the most recent studies with athletes enrolled only after the year 2000, versus 6.02 (95% CI 4.59–7.90) for the remaining studies covering all observed years. Hypertrophic cardiomyopathy (HCM) was the predominant cause among males (45.12%), while congenital coronary anomalies were more prevalent in females (33.04%).
Conclusion
The incidence of SCA/D in females was approximately 6 times lower than in males, with sex differences also in the leading causes of SCA/D. Understanding these discrepancies could lead to targeted strategies for the prevention of SCD in athletes.
Registration number
(PROSPERO 2023 CRD42023432022)/05.07.2023.
... This highly demanding sport discipline often leads to dehydration that can be further followed by hypotension; decreased coordination; fatigue; and, in some cases, fainting episodes [3]. More severe events attributed to cycling include arrhythmias, hypoxia, hypoglycemia, hyperventilation, and inappropriate dyspnea [4][5][6][7][8][9]. ...
... Additionally, demanding endurance events followed by electrolyte imbalance and increased sympathetic activation in some cases can lead to transit myocardial ischemia and repolarization changes which are the ground base of severe arrhythmias [29]. Recent research by Breedt [1] and Killops et al. [4] concluded that medical complaints in cycling predominantly refer to sustained injuries which are followed by cardiovascular symptoms with the incidence of life-threatening medical encounters of 0.5 per 1000 athletes. Our study data showed that symptoms of increased fatigue and tachycardia appeared more commonly at the beginning of the training season indicating that the telemetric monitoring of elite cyclists should be considered from the start of the macrocycle. ...
Background:
Cycling is a very demanding physical activity that may create various health disorders during an athlete's career. Recently, smart mobile and wearable technologies have been used to monitor physiological responses and possible disturbances during physical activity. Thus, the application of mHealth methods in sports poses a challenge today. This study used a novel mobile-Health method to monitor athletes' physiological responses and to detect health disorders early during cycling in elite athletes.
Methods:
Sixteen high-level cyclists participated in this study, which included a series of measurements in the laboratory; health and performance assessments; and then application in the field of mHealth monitoring in two training seasons, at the beginning of their training period and in the race season. A field monitoring test took place during 30 min of uphill cycling with the participant's heart rate at the ventilatory threshold. During monitoring periods, heart rate, oxygen saturation, respiratory rate, and electrocardiogram were monitored via the mHealth system. Moreover, the SpO2 was estimated continuously, and the symptoms during effort were reported.
Results:
A significant correlation was found between the symptoms reported by the athletes in the two field tests and the findings recorded with the application of the mHealth monitoring method. However, from the pre-participation screening in the laboratory and from the spiroergometric tests, no abnormal findings were detected that were to blame for the appearance of the symptoms.
Conclusions:
The application of mHealth monitoring during competitive cycling is a very useful method for the early recording of cardiac and other health disorders of athletes, whose untimely evaluation could lead to unforeseen events.
... • Medical encounter (ME): any injury or illness sustained by a race participant who presents to the medical team from the official start of the race up to 24 hours after the official cut-off time [24,31]. ...
Objectives:
Trail running is a popular off-road sport involving running in natural environments over various terrains, often in remote locations. This study aims to investigate the epidemiology and risk factors of injuries and illnesses, i.e. medical encounters, on race day among trail runners in a high-altitude ultra trail race.
Methods:
This descriptive cross-sectional study on an ultra trail race (38 km, 65 km and 100 km) in South Africa, included participants 18 years or older. Of the 331 race participants, 285(86.1%) consented to participate in the study. Data collection included demographic details, injuries (body region, specific body area, tissue type, pathology) and illnesses (organ system, symptom cluster, etiology). Risk factor analysis includes sex, age, weight, height, race distance, illness and injury history, training and running experience. Frequency (n, %), prevalence (%) and odds ratios (OR; 95%CI) are reported.
Results:
Eighty-nine (31.2%) individuals reported 131 medical encounters [49 injuries (37.4%); 82 illnesses (62.6%)]. Injuries were sustained by 14.7% of athletes, and 22.5% reported illnesses. For injuries, the lower limb was mainly involved (n = 41; 83.7%). Most injuries affected the foot (n = 18; 36.7%), ankle (n = 10; 20.4%) and knee (n = 7; 14.3%). Tissue types mainly involved skin (n = 21; 42.8%), ligament (n = 7; 14.3%) and muscle (n = 7; 14.3%). Multiple (n = 45; 54.9%) and gastrointestinal (n = 17; 20.7%) organ systems were mainly involved in illnesses. Only 100 km runners reported dehydration (n = 28; 31.5%), and one in every six of these runners (n = 5; 17.9%) did not finish. Runners reporting fatigue (n = 21; 23.6%) had a high (n = 8; 38.1%) did not finish rate. Two in every five participants (n = 36; 40.4%) with a medical encounter, did not finish. No medical encounter-associated risk factors were identified.
Conclusions:
Illnesses were more common than injuries during the mountainous ultra trail race. Sustaining a medical encounter increased the chance of not completing the race. Further research on the epidemiology of race day medical encounters in trail running is required.
... The online prerace medical questionnaire consisted of a series of questions that were based on recommendations by the European Association for Cardiovascular Prevention and Rehabilitation for pre-participation screening and cardiovascular disease evaluation (Borjesson et al., 2011;Maron et al., 2001). Full details of the development and implementation of this online prerace medical questionnaire has been described and used in previous studies (du Toit et al., 2020b;Killops et al., 2020;Rotunno et al., 2018;Schwabe et al., 2018;Schwellnus et al., 2019). In order to ensure that the screening tool was specific to the current population, additional questions were added, which were related to history of injuries in cyclists (current, or in the last 12 months). ...
Objective:
Patellofemoral pain (PFP) is a common cycling-related injury, and independent factors need to be identified to enable effective injury prevention strategies. We aim to determine factors associated with PFP in cyclists entering mass community-based events.
Design:
Cross-sectional study.
Setting:
2016-2020 Cape Town Cycle Tour.
Participants:
Consenting race entrants.
Main outcome measures:
62758 consenting race entrants completed a pre-race medical questionnaire, and 323 reported PFP. Selected factors associated with PFP (demographics, cycling experience and training, chronic disease history) were explored using multivariate analyses.
Results:
Prevalence ratio (PR) of PFP was similar for sex and age groups. Independent factors associated with PFP (adjusted for sex and age) were history of chronic disease [Composite Chronic Disease Score (0-10)(PR = 2.0, p < 0.0001) and any allergies (PR = 2.0, p < 0.0001)].
Conclusion:
A history of chronic diseases and allergies is associated with PFP in cyclists. Practical clinical recommendations are: 1) that prevention programs for PFP be considered when cycling is prescribed as a physical activity intervention for patients with chronic disease, and 2) that older cyclists presenting with PFP be assessed for the presence of risk factors or existing chronic disease.
... The development of this screening tool was based on the guidelines for cardiovascular evaluation of middle-aged/senior individuals that were engaging in leisure-time sport activities (Position stand from the European Association of Cardiovascular Prevention and Rehabilitation) [16], and adapted from previous studies done in distance runners [17,18]. Previous SAFER studies described this detailed methodology of the online medical screening tool development and implementation [14,[17][18][19]. In order to ensure that the screening tool was specific to the current population, additional questions were added, which were related to history of injuries in cyclists (current, or in the last 12 months). ...
Objective
Gradual onset injuries (GOIs) in recreational cyclists are common but not well described. The aim of this study is to describe the clinical characteristics of GOIs (main anatomical regions, specific anatomical sites, specific GOIs, tissue type, severity of GOIs, and treatment modalities) of GOIs among entrants participating in a community-based mass participation-cycling event over 5 years.
Methods
During the 2016–2020 Cape Town Cycle Tour, 62,758 consenting race entrants completed an online pre-race medical screening questionnaire. 1879 reported GOIs in the previous 12 months. In this descriptive epidemiological study, we report frequency (% entrants) of GOIs by anatomical region/sites, specific GOI, tissue type, GOI severity, and treatment modalities used.
Results
The main anatomical regions affected by GOIs were lower limb (47.4%), upper limb (20.1%), hip/groin/pelvis (10.0%), and lower back (7.8%). Specifically, GOI were common in the knee (32.1%), shoulder (10.6%), lower back (7.8%) and the hip/buttock muscles (5.2%). The most common specific GOI was anterior knee pain (17.2%). 57.0% of GOIs were in soft tissue. Almost half (43.9%) of cyclists with a GOI reported symptom duration >12 months, and 40.3% of GOIs were severe enough to reduce/prevent cycling. Main treatment modalities used for GOIs were rest (45.9%), physiotherapy (43.0%), stretches (33.2%), and strength exercises (33.1%).
Conclusion
In recreational cyclists, >50% of GOIs affect the knees, shoulders, hip/buttock muscles and lower back, and 40% are severe enough to reduce/prevent cycling. Almost 45% of cyclists with GOIs in the lower back; or hip/groin/pelvis; or lower limbs; or upper limb reported a symptom duration of >12 months. Risk factors associated with GOIs need to be determined and preventative programs for GOIs need to be designed, implemented, and evaluated.
... Acute serious cardiac events such as myocardial infarction, arrhythmia and sudden cardiac arrest are well described in both younger and older athletes during sports events [12][13][14]. Leading organizations recommend various pre-exercise screening regimes to identify those at risk, especially in masters (>50 years) athletes [6,15,16] using detailed and comprehensive pre-exercise screening questionnaires, in the form of a 'self-assessment of risk.' ...
Objectives
To determine the prevalence of self-reported pre-race chronic medical conditions and allergies in ultramarathon race entrants and to explore if these are associated with an increased risk of race-day medical encounters (MEs).
Methods
Data from two voluntary open-ended pre-race medical screening questions (Q1 – history of allergies; Q2 - history of chronic medical conditions/prescription medication use) were collected in 133 641 Comrades Marathon race entrants (2014-2019). Race-day ME data collected prospectively over 6 years are reported as incidence (per 1000 starters) and incidence ratios (IR: 95%CI’s).
Results
: Pre-race medical screening questions identified race entrants with a history of chronic medical conditions and/or prescription medication use (6.9%) and allergies (7.4%). The % entrants with risk factors for cardiovascular disease (CVD) was 30% and being older (>45years) and male (27.5%) were the most frequent CVD risk factors. 0.3% of entrants reported existing CVD. The overall incidence of MEs was 20/1000 race starters. MEs were significantly higher in race entrants reporting a “yes” to Q1 (allergies) (IR=1.3; 1.1-1.5) (p=0.014) or Q2 (chronic medical conditions and/or prescription medication use) (IR=1.3; 1.1-1.5) (p=0.0006).
Conclusions
Voluntary completion of two open-ended questions identified chronic medical conditions and/or prescription medication use in 6.9% and allergies in 7.4% of ultramarathon race entrants. This is lower than that reported for other races that implemented compulsory completion of a more comprehensive pre-screening questionnaire. Despite potential under-reporting, a pre-race self-reported history of chronic medical conditions and allergies was associated with a higher risk of race-day MEs.
... The prevalence of gradual onset cycling injuries is as high as 85% (Dettori & Norvell, 2006). Other SAFER studies have focused on the traumatic injuries in cyclists (Killops et al., 2020). Gradual onset injuries (GOIs) in cyclists are associated with long, repetitive training sessions (Clarsen et al., 2013;Decalzi et al., 2013), thus this paper will focus on the GOIs in cyclists. ...
Objectives
Prevalence, clinical characteristics and severity of gradual onset injuries (GOIs) in cyclists are poorly documented. We determine the prevalence, anatomical regions/sites affected and severity of GOIs among entrants in a community-based mass participation event.
Design
Cross-sectional study;
Setting
Cape Town Cycle Tour;
Participants
Race entrants
Main Outcome Measures
Of 35914 entrants, 27349 completed pre-race medical questionnaires. We studied 21824 consenting cyclists (60.8% of entrants). Crude lifetime prevalence, retrospective annual incidence, anatomical region/sites, specific GOI, tissue type and GOI severity is reported.
Results
The lifetime prevalence of GOIs was 2.8%, with an annual incidence of 2.5%. More common anatomical regions affected by GOIs were lower limb (43.4%), upper limb (19.8%), and lower back (11.5%). The knee (26.3%), shoulder (13%), and lower back (11.5%) regions were mostly affected. The most common GOI was anterior knee pain (14.2%). Of the GOIs, 55% were in soft tissue. 50% of cyclists reported symptom duration >12 months, and 37.3% of GOIs were severe enough to reduce/prevent cycling.
Conclusion
2.5% recreational cyclists report a GOI annually. >50% of GOIs affect the knee, lower back and shoulder. GOIs negatively affect cycling. Risk factors related to GOIs in cyclists need to be determined to develop and implement prevention programs.
Background:
Medical clearance is often recommended for athletes prior to endurance exercise. The primary aim was to determine the percentage (%) of race entrants that sought medical clearance prior to participation in endurance running events, describe the diagnostic modalities used by doctors to assess entrants seeking medical clearance, and the clearance advice given. Secondary aims were to investigate the factors associated with seeking and outcome of clearance.
Methods:
All consenting race entrants who completed an online screening questionnaire during registration to participate in the 21.1 km or 56 km Two Oceans marathon races from 2013-2015 (N.=60,609) were included. Runners were stratified into four risk categories: low risk (LR), intermediate risk (IR), high risk (HR) and very high risk (VHR). Runners were asked if they consulted with a medical doctor to obtain medical clearance. Follow-up questions enquired about what the doctor did when they sought medical clearance and what advice the doctor gave as an outcome of the medical clearance consultation. Prevalence (%, 95% CI) and Prevalence Ratios (PRs) are reported.
Results:
Over the 3-year period, 14.8% of entrants sought medical clearance. For clearance, doctors used history only (9.9%), history and physical examination (36.7%) and history, physical examination, and special investigations (53.0%). Most entrants seeking medical clearance were fully cleared to race (87.7% in 21.1 km and 85.9% in 56 km) (P=0.0156). Factors associated with seeking medical clearance include longer race distance, older age and a higher risk category (P<0.0001).
Conclusions:
The methods doctors use when conducting medical clearance consultations vary greatly. Further research is suggested to develop a protocol that doctors can use for medical consultations.
Objectives
Numerous reports have described injuries and illnesses in competitive athletes, but studies on leisure-time physical activity and associated adverse events in the general population have not been adequately reviewed. This study aimed to summarise the previous findings on this topic.
Design
Scoping review.
Data sources
PubMed and Ichushi-Web for articles in English and Japanese, respectively (13 April 2023).
Eligibility criteria for selecting studies
Articles on adverse events related to sports performed by ‘individuals and groups active in the community’ were included, whereas those on elite athletes, exercise therapy and rehabilitation, and school sports were excluded. Terms related to physical activity, exercise, sports and adverse events were used for the search strategies.
Results
The literature search yielded 67 eligible articles. Most articles were from the USA, Japan and Australia. Running, scuba diving, rugby and soccer were the most commonly reported sports. Adults were the most common age category in the samples. The most commonly reported adverse events were injuries; only 10 articles reported diseases. 13 longitudinal studies reported the frequency of adverse events based on the number of events/participants×exposure.
Conclusion
Adverse events such as sports trauma, disability and certain diseases occur sometimes during sporting activities by residents; however, the articles identified in this review showed biases related to the countries and regions where they were published and the sports disciplines and types of adverse events reported, and articles reporting the frequency of adverse events were also limited. This highlights the need for more high-quality observational studies on diverse populations in the future.
Objectives
To allow the implementation of effective injury and illness prevention programmes for road cyclists, we wanted to first identify the injury/illness burden to this group of athletes. We, therefore, undertook a systematic review of all reported injuries/illness in road cycling.
Design
Systematic review.
Data sources
Identification of articles was achieved through a comprehensive search of: MEDLINE, Embase, PsycINFO, Web of Science and Cochrane Library from inception until January 2020.
Eligibility criteria for selecting studies
Studies reporting injuries/illness in adults participating in road cycling. Cycling commuter studies were excluded from the analysis.
Method
Two review authors independently screened titles and abstracts for eligibility and trial quality. Initial search criteria returned 52 titles and abstracts to be reviewed, with 12 studies included after reviewing the full text articles.
Results
The most common injuries sustained were abrasions, lacerations and haematomas accounting for 40–60% of the total injuries recorded. Fractures (6–15%) were the second most frequent type of injury. Head injuries (including concussions) accounted for 5–15% of injuries with musculotendinous injuries accounting for 2–17.5%. The upper limb was more frequently affected by injuries than the lower limb, with amateurs appearing to be at higher risk of injury/illness than professionals. Clavicle was the prevalent fracture, with patellofemoral syndrome the number one overuse diagnosis. No meta-analysis of the results was undertaken due to the inconsistent methods of reporting.
Conclusion
This is the first systematic review of road cycling injuries. Injuries most often affected the upper limb, with clavicle being the most prevalent fracture and the most common overuse injury being patellofemoral syndrome.
Purpose:
There are limited data on risk factors associated with illness-related medical encounters (illMEs) in cycling events. The aim was to determine risk factors associated with illMEs in mass community-based endurance cycling events.
Methods:
A retrospective, cross-sectional study in the Cape Town Cycle Tour (109km), South Africa with 102251 race starters. All MEs for 3 years were recorded by race medical doctors and nurses. illMEs were grouped into common illnesses by final diagnosis. A Poisson regression model was used to determine if specific risk factors (age, sex, cycling speed, average individual cyclist WBGT - aiWBGT) are associated with illMEs, serious and life-threatening or death illMEs and specific common illMEs.
Results:
Independent risk factors associated with all illMEs during an endurance cycling event were slow cycling speed (p=0.009) and higher aiWBGT (p<0.001). Risk factors associated with serious and life-threatening or death illMEs were older age (p=0.007) and slower cycling speed (p=0.016). Risk factors associated with specific common illMEs were: fluid and electrolyte disorders (females, older age, higher aiWBGT) and cardiovascular illness (older age).
Conclusion:
Females, older age, slower cycling speed and higher aiWBGT were associated with illMEs in endurance cycling. These data could be used to design and implement future prevention programmes for illMEs in mass community-based endurance cycling events.
Research at a mass-based cycling event is challenging. Planning needs to start long before race-day, and consultation with all involved parties is required. Parties should agree on operations, that is, medical staff providing medical care and medical staff involved with data capturing need to know their specific duties and not overstep boundaries. Logistics need to be in place regarding the amount of staff required, in-time transport to work stations due to road closures, enough data capturing forms, and to be prepared for an exhaustive day in the outdoors. The team also has to stay until all cyclists have finished for the day.
It is important to identify risk factors associated with medical complications during ultra-marathons so that prevention programmes can be developed.
To determine risk factors for medical complications during ultra-marathons.
Prospective study.
Two Oceans ultra-marathon (56 km) races.
26 354 race starters.
Medical complications (defined as any runner requiring assessment by a doctor at the race medical facility or a local hospital on race day) were recorded over 4 years. Complications were subdivided according to the system that was affected and by final diagnosis. A Poisson regression model was used to determine risk factors for any medical complication and for more common specific complications.
Risk factors for medical complications during 56 km road races were less running experience (≤1 medal vs 2-4 medals, p=0.0097), and both fastest (<6 vs 6-7 min/km, p=0.0051) and slowest (>7 vs 6-7 min/km, p<0.0001) running pace category. Year of observation was also associated with risk of complications (2009 vs 2008, p=0.0176; 2009 vs 2010, p=0.0007; 2010 vs 2011, p=0.0112). Risk factors for specific common medical complications were: postural hypotension (slowest pace), serious exercise-associated muscle cramping (older age, fastest pace), gastrointestinal complications (slowest pace) and dermatological complications (fastest pace).
Less experience and running at either a slow or a fast pace were risk factors for complications during 56 km road running. Annual variation may also affect risk. Risk factors for specific medical complications were also identified. These data form the basis of further studies to assist medical staff to plan appropriate care at races.
The half-marathon (21 km) race is a very popular mass community-based distance running event. It is important to determine risk factors for medical complications during these events, so that prevention programmes can be developed.
To determine risk factors associated with medical complications during 21 km road running events.
Prospective study.
Two Oceans half-marathon (21 km) races.
39 511 starters in the 21 km race.
Medical complications (defined as any runner requiring assessment by a doctor at the race medical facility or a local hospital on race day) were recorded over a 4-year study period. Medical complications were subdivided according to the system affected and by final diagnosis. A Poisson regression model was used to determine risk factors for any medical complication and more common specific complications.
Independent risk factors for medical complication during 21 km running were older female runners (women >50 vs ≤50 years; p<0.0001) and year of observation (2008 vs 2011; p=0.0201: 2009 vs 2011: p=0.0019; 2010 vs 2011: p=0.0096). Independent risk factors for specific common medical complications were: postural hypotension (women, slow running pace), musculoskeletal complications (less running experience, slower running pace) and dermatological complications (women).
Older female runners are at higher risk of developing medical complications during 21 km road running races. Environmental conditions in a particularly cold climate may also play a role. Less running experience and slower running pace are associated with specific medical complications. Medical staff can now plan appropriate care on race days, and interventions can be developed to reduce the risk of medical complications in 21 km races.
Regular participation in physical activity is well established as an important component of a comprehensive lifestyle intervention programme for primary, secondary and tertiary prevention of chronic non-communicable disease.1-3 Recreational distance running, as one form of regular physical activity, is popular globally. Data published in the 2013 Running USA Annual report indicates that there are over 50 million runners in the USA, of which >29 million run for more than 50 days/annum, and >9 million runners run for more than 110 days/annum (2013 Running USA Annual report: http://www.runningusa.org). Furthermore, almost 75% of male and female runners indicated that the main motivation to continue to run is to stay healthy. The half marathon race is the most popular event and participation in this race has also experienced the greatest growth between 2000 and 2012. Apart from the general increase in the number of runners, there is also a concomitant increase in participation in mass community-based distance running events globally. In 2012 there were more than 30 half-marathon races and more than 10 marathon races that attracted >20 000 runners (2013 Running USA Annual report: http://www.runningusa.org). However, it is also well documented that vigorous (high intensity) physical activity, such as distance running, is associated with medical complications that can affect a variety of organ systems.4 Of particular interest is the fact that vigorous exercise may act as a trigger for cardiac arrest and sudden death as a result … [Full text of this article]
Cardiac arrest and sudden death during distance-running events have been reported but other medical complications, including serious life-threatening complications have not been well described.
To document the incidence and nature of medical complications during 21 and 56 km running races.
Prospective study.
Two Oceans Marathon races (21 and 56 km races).
65 865 race starters (39 511-21 km runners, 26 354-56 km runners).
Medical complications (defined as any runner requiring assessment by a doctor at the race medical facility or a local hospital on race day) were recorded in each of the 4 years of the study period. Complications were further subdivided into serious (potentially life-threatening) complications and deaths and were also analysed by system and final diagnosis.
In the 4 years, 545 medical complications were recorded, resulting in an overall incidence (per 1000 race starters) of 8.27. The incidence of serious (potentially life-threatening) medical complications was 0.56 (37 serious complications). Two deaths occurred in 21 km runners (incidence of 0.05). The most common specific medical complications were exercise-associated collapse (postural hypotension), dermatological conditions, musculoskeletal injuries and serious exercise-associated muscle cramping.
The incidence of medical complications was higher in 56 km runners but sudden cardiac deaths only occurred in 21 km runners. Serious medical complications were as common in 21 km as in 56 km runners. Risk factors for medical complications need to be determined in 21 and 56 km runners to plan strategies to reduce the risk of adverse medical events in endurance runners.
Objective To determine the incidence of sudden cardiac arrest (SCA) and sudden cardiac death (SCD) in men and women.
Design Retrospective cohort study.
Setting Two popular urban 42 km marathons.
Participants 1982 to 2009 finishers.
Assessment of risk factors Race records were assessed for finishers, age distribution and cardiac events by sex.
Main outcome measures The SCA/SCD incidence for all (total), male and female finishers.
Results There were 548 092 finishers with women finishers increasing from 10% to 40% over the first 18 years and remaining near 40% for the last decade. There were 14 SCA events (1 woman, 13 men) with seven successful resuscitations yielding an all finishers SCA rate of 2.6 per 100 000 finishers. The SCA rates (per 100 000) for men and women were 3.4 (95% CI: 1.8 to 5.9) and 0.6 (95% CI: 0.0 to 3.3), respectively (p=0.079). The male SCA rate for the 2000–2009 decade was 4.6 per 100 000 finishers (95% CI: 1.8 to 9.5). Eleven of 13 men were >39 years old. The OR of a man experiencing SCA compared with woman was 5.7.
Conclusions As the number of women participating in these two marathons has increased, the difference between the men's and total SCA and SCD incidence has increased for men, especially >39 years old, from coronary artery disease with men's incidence for SCA of 1 in 22 000 and SCD at 1 in 50 000 finishers over past decade.
Approximately 2 million people participate in long-distance running races in the United States annually. Reports of race-related cardiac arrests have generated concern about the safety of this activity.
We assessed the incidence and outcomes of cardiac arrest associated with marathon and half-marathon races in the United States from January 1, 2000, to May 31, 2010. We determined the clinical characteristics of the arrests by interviewing survivors and the next of kin of nonsurvivors, reviewing medical records, and analyzing postmortem data.
Of 10.9 million runners, 59 (mean [±SD] age, 42-13 years; 51 men) had cardiac arrest (incidence rate, 0.54 per 100,000 participants; 95% confidence interval [CI], 0.41 to 0.70). Cardiovascular disease accounted for the majority of cardiac arrests. The incidence rate was significantly higher during marathons (1.01 per 100,000; 95% CI, 0.72 to 1.38) than during half-marathons (0.27; 95% CI, 0.17 to 0.43) and among men (0.90 per 100,000; 95% CI, 0.67 to 1.18) than among women (0.16; 95% CI, 0.07 to 0.31). Male marathon runners, the highest-risk group, had an increased incidence of cardiac arrest during the latter half of the study decade (2000-2004, 0.71 per 100,000 [95% CI, 0.31 to 1.40]; 2005-2010, 2.03 per 100,000 [95% CI, 1.33 to 2.98]; P=0.01). Of the 59 cases of cardiac arrest, 42 (71%) were fatal (incidence, 0.39 per 100,000; 95% CI, 0.28 to 0.52). Among the 31 cases with complete clinical data, initiation of bystander-administered cardiopulmonary resuscitation and an underlying diagnosis other than hypertrophic cardiomyopathy were the strongest predictors of survival.
Marathons and half-marathons are associated with a low overall risk of cardiac arrest and sudden death. Cardiac arrest, most commonly attributable to hypertrophic cardiomyopathy or atherosclerotic coronary disease, occurs primarily among male marathon participants; the incidence rate in this group increased during the past decade.
Marathons pose many challenges to event planners. The medical services needed at such events have not received extensive coverage in the literature.
The objective of this study was to document injury patterns and medical usage at a category III mass gathering (a marathon), with the goal of helping event planners organize medical resources for large public gatherings.
Prospectively obtained medical care reports from the five first-aid stations set up along the marathon route were reviewed. Primary and secondary reasons for seeking medical care were categorized. Weather data were obtained, and ambient temperature was recorded.
The numbers of finishers were as follows: 4,837 in the marathon (3,099 males, 1,738 females), 814 in the 5K race (362 males, 452 females), and 393 teams in the four-person relay (1,572). Two hundred fifty-one runners sought medical care. The day's temperatures ranged from 39 to 73 degrees F (mean, 56 degrees F). The primary reasons for seeking medical were medication request (26%), musculoskeletal injuries (18%), dehydration (14%), and dermal injuries (11%). Secondary reasons were musculoskeletal injuries (34%), dizziness (19%), dermal injuries (11%), and headaches (9%). Treatment times ranged from 3 to 25.5 minutes and lengthened as the day progressed. Two-thirds of those who sought medical care did so at the end of the race. The majority of runners who sought medical attention had not run a marathon before.
Marathon planners should allocate medical resources in favor of the halfway point and the final first-aid station. Resources and medical staff should be moved from the earlier tents to further augment the later first-aid stations before the majority of racers reach the middle- and later-distance stations.
Mass participation endurance sports events are popular but a large number of participants are older and may be at risk of medical complications during events. Medical encounters (defined fully in the statement) include those traditionally considered ‘musculoskeletal’ (eg, strains) and those due to ‘illness’ (eg, cardiac, respiratory, endocrine). The rate of sudden death during mass endurance events (running, cycling and triathlon) is between 0.4 and 3.3 per 100 000 entrants. The rate of other serious medical encounters (eg, exertional heat stroke, hyponatraemia) is rarely reported; in runners it can be up to 100 times higher than that of sudden death, that is, between 16 and 155 per 100 000 race entrants. This consensus statement has two goals. It (1) defines terms for injury and illness-related medical encounters, severity and timing of medical encounters, and diagnostic categories of medical encounters, and (2) describes the methods for recording data at mass participation endurance sports events and reporting results to authorities and for publication. This unifying consensus statement will allow data from various events to be compared and aggregated. This will inform athlete/patient management, and thus make endurance events safer.
Objective:
To describe the incidence and patterns of injury and illness of male and female participants during a 94.7 km distance cycling event.
Design:
Descriptive study.
Setting:
Momentum 94.7 Cycle Challenge 2014.
Participants:
All 23 055 race starters (males = 17 520, females = 5236, not specified = 299).
Main outcome measures:
The incidence and type of all medical complaints and difference between sexes.
Results:
Incidence (per 1000 race starters) of all medical complaints was 38.69 (males = 36.52, females = 38.39), adverse medical events 11.88 (males = 10.73, females = 16.42) and serious adverse events 1.3 (males = 0.86, females = 2.67). The incidence of nontraumatic medical complaints was 32.49 (males = 33.39, females = 31.32) and of traumatic injuries was 3.99 (males = 3.14, females = 7.07). Females compared to males had a higher risk of sustaining traumatic injuries (P < 0.001), central nervous system, (P = 0.0062) and eye complaints (P = 0.0107). Most complaints (80.6%) were reported for the musculoskeletal system. Males 10-15 years (P = 0.0013) and females 23-39 years (P = 0.0336), and older than 50 years (P = 0.0002) had a higher than expected risk for traumatic injuries.
Conclusions:
Medical complaints ratio reported was 1:26 (males = 1:28, females = 1:26) in all starters during the cycling event. Cyclists that did not finish the race (adverse events) were 1:84 (males = 1:93, females = 1:61). Serious adverse events that required hospitalization were 1:769 (males = 1:1163, females = 1:374). The majority of admissions were for traumatic injuries, followed by cardiovascular complaints. Results from this study indicated that a wide spectrum of medical complaints can be expected during such an event with a higher risk for females to sustain traumatic injuries and to encounter central nervous system and eye complaints. Information regarding the pattern and type of medical encounters can prove useful during planning and management of similar future events.
Objective: To summarize the medical encounters (injury/illness) for runners and the meteorologic data collected in the medical area of a large marathon race. Design: Prospectively transcribed medical records were analyzed for encounter rate, injury/illness type, treatment rendered, and outcomes. The environmental conditions for each race day are compared with injury/illness rates and types. Setting: An urban 42-km marathon located at 44 " 53'N latitude and 93 " 13'W longitude, scheduled on the first Sunday of October with an early morning start time. Participants: 81,277 entrants in the Twin Cities Marathon from 1982 to 1994. Main Results: The start temperature range was -4 to 16 degrees C and the 4-h temperature range was 5-20 degrees C. The average dew point was 3 degrees C at the start and 4 degrees C at 4 h. The finish area medical encounter rates for marathon runners were 18.9 per 1000 entrants and 25.3 per 1000 finishers. Mild injury/illness accounted for 90% of finish line medical encounters. Runners presented with exercise-associated collapse (59%), skin problems (21%), musculoskeletal problems (17%), and other medical problems (3%). Only 112 runners received intravenous fluids and 30 runners were transferred to emergency medical facilities. One death occurred in 1989. Conclusions: Marathon racing in cool conditions is a safe activity and most of the medical encounters are of minor severity. An early morning start time contributes to a cool racing environment and a low injury rate. More than 99.9% of runners who finish this race leave the finish area without hospital or emergency room care. The injury/illness profile can be used to tailor medical care at the finish area of marathons.
The medical work load seems to increase both with heat and humidity, and with cold and rainy conditions. Heat tolerance during exercise is variable and heat intolerance may contribute to collapse and increase medical encounters. Exposure to cold, wet conditions results in increasing incidence of hypothermia in exhausted marathon runners. Finish-line encounters and course dropouts increase as conditions cool and warm away from the most advantageous conditions in the 4.4–15°C (40–59°F) wet bulb globe temperature (WBGT) range. The risk of requiring medical attention and not finishing rises considerably when the WBGT is >15.5°C (60°F). Comparing the correlation coefficients of the Boston Marathon and Twin Cities Marathon data suggests that the risks of medical problems and not finishing are associated with the warmest temperature of the race and not the start temperature. The community consequences of races conducted in hot and humid conditions can be significant, particularly when the WBGT is >15.5°C. The emergency medical systems can be overwhelmed with a surge of patients, some very ill, and the emergency call response times drop to unacceptable levels blocking access for the citizens of the community. With respect to marathon encounters, heat stress increases both the finish-line medical encounter rate and the on course drop-out rate, and seems to increase the incidence of hyponatraemia and heat stroke. Cold conditions increase the drop-out rate along the course and, if associated with wet conditions, also increase the encounter rate.
Hintergrund
Über Risiken und Verletzungen des Radsports ist in der Literatur wenig berichtet. Ziel vorliegender Studie war es, alle Verletzten der 182 Profi- und 18.788 Amateurradfahrer der Hamburger „Cyclassics“ 2006 zu erfassen.
Patienten und Methode
Die Verletzten wurden durch Daten des Rettungsdienstes, des Veranstalters und der Kliniken erfasst und in einem Fragebogen befragt.
Ergebnisse
70 Verletzte mit 193 Verletzungen wurden verzeichnet, die Verletzungsrate betrug 0,37%. Das mittlere Alter lag bei 44 (19–72) Jahren. Die Extremitäten waren in 94,4% der Fälle betroffen, häufigste Lokalisation war in 54,7% der Schultergürtel (32 Frakturen wurden registriert). Der „mittlere Abbreviated Injury Score“ (MAIS) betrug 1,34±0,73 (Spanne 1–4), der „Injury Severity Score“ (ISS) 2,86±3,61 (Spanne 1–20). 10% der Teilnehmer erlitten ernste Verletzungen (AIS≥3), statistisch signifikant häufiger bei Frauen als bei Männern (p
CARTER, R. Exertional heat illness and hyponatremia: an epidemiological prospective. Curr. Sports Med. Rep., Vol. 7, No. 4, pp. S20YS27, 2008. In active populations, heat illness remains a cause of exercise-related injury and death. There is evidence that hyponatremia also occurs, but less often than heat illness. Incidence rates of these conditions are determined by the population at risk and individual susceptibilities. Improved strategies are needed to identify high-risk individuals who are likely to develop either hyponatremia or heat illness.
A recent cluster of sudden cardiac deaths in marathon runners has attracted considerable media attention and evoked concern over the safety of long-distance running and competition. This review discusses the acute and potential long-term risks associated with marathon running and puts these into perspective with the many health benefits afforded by habitual vigorous exercise.
Data sources included peer-reviewed publications from 1979 to January 2010 as identified via PubMed and popular media.
Marathon running is associated with a transient and low risk of sudden cardiac death. This risk appears to be even lower in women and is independent of marathon experience or the presence of previously reported symptoms. Most deaths are due to underlying coronary artery disease. The value of preparticipation screening is limited by its insensitivity and impracticality of widespread implementation. Appropriate preparation and deployment of trained medical personnel and availability of automatic external defibrillators are expected to have a major impact on survival from cardiac arrests during marathons. Cardiac biochemical and functional abnormalities are commonly observed transiently following completion of a marathon, although their clinical significance is unknown.
Sudden cardiac deaths associated with marathon running are exceedingly rare events. Prevention should focus on recognition and investigation of prodromal symptoms, if present, and access to rapid defibrillation and trained medical personnel. The robust association of endurance running with improved quality of life and longevity underscores the importance of putting risks into perspective with other well-established health benefits of regular vigorous exercise.
As participation in marathon running has increased, there has also been concern regarding its safety.
To determine if the increase in marathon participation from 2000 to 2009 has affected mortality and overall performance.
Descriptive epidemiology study.
We used publicly available racing and news databases to analyze the number of marathon races, finishing race times, and deaths from 2000 to 2009 in marathons in the United States.
The total number of marathon finishers has increased over this decade from 299,018 in 2000 to 473,354 in 2009. The average overall marathon finishing time has remained unchanged from 2000 to 2009 (4:34:47 vs 4:35:28; P = .85). Of 3,718,336 total marathon participants over the 10-year study period, we identified 28 people (6 women and 22 men) who died during the marathon race and up to 24 hours after finishing. The overall, male, and female death rates for the 10-year period were 0.75 (95% confidence interval [CI], 0.38-1.13), 0.98 (95% CI, 0.48-1.36), and 0.41 (95% CI, 0.21-0.79) deaths per 100,000 finishers, respectively. There was no change in the death rate during this time period for overall, male, or female groups (P = .860, .533, and .238, respectively). The median age among deaths was 41.5 years (interquartile range, 25.5 years). Fifty percent (14/28) of deaths occurred in participants less than 45 years old. Myocardial infarction/atherosclerotic heart disease caused 93% (13/14) of deaths in those 45 years and older. A variety of conditions caused death in younger racers, the most common being cardiac arrest not otherwise specified (21%, n = 3).
Participation in marathons has increased without any change in mortality or average overall performance from 2000 to 2009.
There is no reporting system for marathon-associated sudden cardiac arrest (SCA) or sudden cardiac death in the United States. The purpose of this study was to estimate and characterize the risk of marathon-related SCA to assist with emergency planning.
A retrospective Web-based survey was sent out to all US marathon medical directors (n = 400) to gather details of SCA including demographics, resuscitation efforts, mortality, and autopsy results, if available.
A total of 88 surveys (22%) were returned from marathons run from 1976 to 2009 for a total of 1,710,052 participants. Risks of SCA and sudden cardiac death were 1 in 57,002 and 1 in 171,005, respectively. Men made up the vast majority of SCA victims (93%, mean age = 49.7 yr, range = 19-82 yr). Arrest site distributions were 0-5, 6-14, 15-22, and 23-26.2 miles. CAD was reported as the cause of death at autopsy in 7 of the 10 fatalities. An automated external defibrillator (AED) was used in 20/30 cases and associated with a higher survival (17/20 survivors vs 3/10 deaths, P = 0.0026).
SCA occurs in approximately 1 in 57,000 marathon runners, is more common in older males, and usually occurs in the last 4 miles of the racecourse. Prompt resuscitation including early use of an AED improves survival. Emergency planning to include trained medical staff and sufficient AEDs throughout the racecourse is recommended.
The Boston Marathon has been run for 115 years during which there were three sudden cardiac arrests. The most recent was a near death avoided by rapid cardiopulmonary resuscitation (CPR) and defibrillation. Awareness of the dangers of participating in a marathon, the risk factors associated with sudden death during competition, and the life‐saving importance of rapid CPR and defibrillation are essential for participants and event organizers. Available records and reports of the three known cases of cardiac arrest during the Boston Marathon were examined. These cases were identified by representatives of the Boston Athletic Association, which has organized each marathon since its inception. Pertinent literature was reviewed and new information was obtained during interviews of witnesses and rescuers. The data were analyzed in search of shared risk factors for cardiac arrest, death, and the optimal requirements for survival.
In 115 years, there were two cardiac deaths and one near death from cardiac arrest. A history of coronary artery disease, advanced age, and prolonged race time are risk factors for sudden cardiac arrest. Rapid application of CPR and defibrillation are essential for survival.
Prevention or reduction of life‐threatening cardiac incidents during marathon races might be achieved if participants of advanced age or with a history of coronary artery disease seek medical clearance prior to entering an event. Those with coronary risk factors should have a discussion with their physician. Availability of trained personnel and defibrillators are important considerations in marathon planning. (PACE 2012; 35:241–244)
This review of the current literature on myocardial infarction and sudden death in recreational master marathon runners aims to help raise awareness of the scope of the problem to primary care providers, and to provide guidelines for educating and screening in recreational master marathon runners.
Recent studies have shown that potentially fatal hyponatremia can develop during prolonged exercise. To determine the incidence of hyponatremia in athletes competing in ultradistance events, we measured serum sodium levels in 315 of 626 (50%) runners who were treated for collapse after two 90 km ultramarathon footraces (total starters 20,335; total finishers 18,031) and in 101 of 147 (69%) finishers in a 186 km ultratriathlon. In both races the athletes drank fluids with low sodium chloride content (less than 6.8 mmol.l-1). Hyponatremia (serum sodium level less than 130 mmol.l-1) was identified in 27 of 315 (9%) collapsed runners in the 90 km races and in none of the triathletes. In response to diuretic therapy, the runner with the most severe hyponatremia (serum sodium level = 112 mmol.l-1) excreted in excess of 7.5 l dilute urine during the first 17 h of hospitalization. These data suggest that, although symptomatic hyponatremia occurs in less than 0.3% of competitors during prolonged exercise even when they ingest little sodium chloride, it is found in a significant proportion (9%) of collapsed runners. A regulated contraction of the extracellular fluid volume would explain why the majority of athletes maintain normal serum sodium levels even though they develop a significant sodium chloride deficit during prolonged exercise. Alternatively, sodium chloride losses during prolonged exercise may be substantially less than are currently believed. Physicians treating collapsed ultradistance athletes need to be aware that as many as 10% or more of such patients may be hyponatremic.
Most of the 5423 entrants in the Melbourne 1980 Big M Marathon were non-elite athletes. A study of a stratified random sample of 459 entrants (which represented a 42% response rate) found that, while entrants reflected the community standards of disease, they pursued healthier lifestyles. Preparation for the marathon led to a number of positive changes in the health standard of runners. The principal negative consequence of marathon training was the high rate of musculoskeletal problems (30%). Before the race, only 4% of participants had an adequate fluid intake; 33% had pre-existing problems, mainly involving muscles and joints (63%) and viral or gastrointestinal illnesses (41%). These entrants had a 60% less chance of finishing the race. Symptoms during the race were reported by 92% of entrants, but most of these were not serious; only 6% of entrants were unable to finish the race. The pattern of symptoms after the race was similar to that during the race; 50% of these resolved within three hours. Ninety-seven entrants (2%) required medical attention during the race. Serious problems were rare (only in three entrants), and no runner required admission to hospital for longer than 24 hours. Entrants were at greater risk of requiring medical attention or experiencing problems during and after the race if they had a shorter preparation (less than two months), ran fewer kilometres per week (less than 60 km/week) in the last two or three months before the race, and had performed fewer long training runs (more than 24 km).
Providing medical care at special events is a growing area of concern of emergency physicians. Little information has been published on events in which participants outnumber spectators. We describe such an event at which the medical encounters far outnumbered any previously published report.
The California AIDS Ride 3 bicycle ride took place June 1-8, 1996, and covered 547 miles of highway between San Francisco and Los Angeles. One hundred five volunteer staff members provided medical care. Extensive patient encounters were recorded on a one-page form; all other encounters were recorded as hash marks by the provider. Two physicians reviewed the medical records and categorized each encounter.
Of the 25,379 patient encounters recorded over the 8 days of the event, 509 were triaged as greater severity (requiring an examination by a physician); 31% of these involved heat-related illnesses. Fifty-five patients required transport to local emergency departments by the local EMS systems; 7 of these patients required hospital admission.
The California AIDS Ride 3 required more medical personnel and resulted in more patient encounters than any similar event previously described. We describe the medical care team and patient encounters to facilitate planning for medical care at future class 3 events.
Study objective: To describe injuries during a 1-day urban cycling tour.
During the May 1996 "Bike New York" tour, we monitored EMS calls to identify injuries in a cohort of helmeted cyclists shielded from traffic. We collected demographic information from entry records, injury data from ambulance call reports, and follow-up on transported patients from telephone interviews with emergency physicians. Data were summarized using proportions, relative risks (RRs), 95% confidence intervals (CIs), and chi2
Approximately 28,000 cyclists participated, of which 23,502 (84%) were officially registered. Sixty-eight percent of registered bicyclists were male, and 92% were between 18 and 55 years old. Of the 140 EMS calls made during the tour, 136 (97%) involved participants; this yielded an injury incidence of 5 per 1,000 riders, or 12 to 13 per 100,000 person-miles. Injury was more common among younger cyclists (RR=1.4 for age </=35 years versus age >35 years; 95% CI, 1.0 to 2.0; P <.05), and possibly women (RR=1.3; 95% CI,.9 to 1.8; P =.11). Injuries were mostly minor, but there were 7 concussions and 6 clavicle fractures; none of the 140 injuries was fatal. Thirty-eight calls resulted in ED transport, and 5 of these patients were admitted. Although EMS units were evenly distributed along the route, most EMS calls occurred in only 3 of the 7 zones (P <.001).
Injuries during the largest 1-day US cycling tour were uncommon. More data are needed to determine the relative importance of injury risk factors. Data collection during mass events may help guide distribution of EMS personnel.
To summarize the medical encounters (injury/illness) for runners and the meteorologic data collected in the medical area of a large marathon race.
Prospectively transcribed medical records were analyzed for encounter rate, injury/illness type, treatment rendered, and outcomes. The environmental conditions for each race day are compared with injury/illness rates and types.
An urban 42-km marathon located at 44 degrees 53' N latitude and 93 degrees 13' W longitude, scheduled on the first Sunday of October with an early morning start time.
81,277 entrants in the Twin Cities Marathon from 1982 to 1994.
The start temperature range was -4 to 16 degrees C and the 4-h temperature range was 5-20 degrees C. The average dew point was 3 degrees C at the start and 4 degrees C at 4 h. The finish area medical encounter rates for marathon runners were 18.9 per 1000 entrants and 25.3 per 1000 finishers. Mild injury/illness accounted for 90% of finish line medical encounters. Runners presented with exercise-associated collapse (59%), skin problems (21%), musculoskeletal problems (17%), and other medical problems (3%). Only 112 runners received intravenous fluids and 30 runners were transferred to emergency medical facilities. One death occurred in 1989.
Marathon racing in cool conditions is a safe activity and most of the medical encounters are of minor severity. An early morning start time contributes to a cool racing environment and a low injury rate. More than 99.9% of runners who finish this race leave the finish area without hospital or emergency room care. The injury/illness profile can be used to tailor medical care at the finish area of marathons.
To report on the incidence, identify the risk factors, and clarify the clinical manifestations of acute hyponatremia in marathon runners.
An observational and retrospective case-controlled series.
The medical care area of the 2000 Houston Marathon.
Marathon finishers treated in medical area receiving intravenous fluids (N=55), including a more detailed analysis of 39 runners completing a retrospective questionnaire.
Vital signs, serum electrolytes, and finish time were analyzed via ANOVA studies between all non-hyponatremic (NH: N=34)) and hyponatremic (H: N=21)) runners. Fluid intake, training variables, NSAID use, and Symptomatology were further analyzed to delineate all significant differences between groups.
There were no significant differences in vital signs, training variables, or NSAID use between H and NH groups, although there was a trend towards the less experienced runners presenting with lower post-race sodium levels. H runners had lower potassium [K] (p=.04), chloride [Cl] (p<.001), and blood urea nitrogen [BUN] (p=.004) levels than NH runners. There was a significant inverse linear relationship between both finish time versus [Na] (r2 =.51) and total amount of fluid ingested versus [Na] (r2 =.39). The total cups of water (p=.004), electrolyte/carbohydrate solution (p=.005) and total amount of fluid ingested (p<.001) were significantly higher in H compared to NH runners and the degree of hyponatremia was related in a dose dependent manner. Vomiting was observed more frequently in H than NH runners (p=.03).
21 runners presented to the medical area of the Houston Marathon with hyponatremia (.31% of entrants). Excessive fluid consumption and longer finishing times were the primary risk factors for developing this condition. Vomiting was the only clinical sign differentiating hyponatremia from other conditions that induce exercise-associated collapse.
To describe the incidence and types of injury and illness treated during a multiday recreational bicycling tour.
In July 2001, 2100 bicyclists rode 520 miles from Minneapolis, MN, to Chicago, IL, during the 2001 Heartland AIDS Ride. A volunteer medical staff provided medical care along the route. All patient encounters were recorded in an injury and illness log. Information from the log was used to describe the incidence and types of injury and illness treated during the event.
A total of 2100 riders participated, with 244 patient encounters recorded. The 2 most common reasons for requiring medical care were dehydration (35%) and orthopedic injuries (27%). Forty patients were transferred to the hospital and 7 required admission.
Individuals charged with providing medical care for recreational bicycling events should be prepared to treat a wide variety of injuries and illnesses. In this and other studies, dehydration, heat illness, and overuse injuries were the most common reasons to require medical care. The results of this study suggest that implementation of prevention strategies before and during bicycling events may significantly reduce the requirement for on-site medical care.
Exertional heat stroke (EHS) during or following a marathon race can be fatal if not promptly recognised and treated. EHS is a true medical emergency and immediate cooling markedly improves the outcomes. It is critical to recognise EHS and stop the cell damage before the cascade of heat-induced tissue changes becomes irreversible. The goal is to keep the area that is >40.5 degrees C under the body temperature versus time curve at <60 degree-minutes. Measuring the rectal temperature is the only precise estimate of core temperature available for field use. The field treatment of EHS is immediate, total-body cooling with ice-water tub immersion or rapidly rotating ice-water towels to the trunk, extremities and head, combined with ice packing of the neck, axillae and groin. Any combination of delayed recognition or cooling increases the potential for morbidity and mortality. For optimal outcomes, it is best to treat immediately with on-site whole-body cooling if cardiorespiratory status is 'stable' and then to transfer the runner for additional evaluation and care.
The medical work load seems to increase both with heat and humidity, and with cold and rainy conditions. Heat tolerance during exercise is variable and heat intolerance may contribute to collapse and increase medical encounters. Exposure to cold, wet conditions results in increasing incidence of hypothermia in exhausted marathon runners. Finish-line encounters and course dropouts increase as conditions cool and warm away from the most advantageous conditions in the 4.4-15 degrees C (40-59 degrees F) wet bulb globe temperature (WBGT) range. The risk of requiring medical attention and not finishing rises considerably when the WBGT is >15.5 degrees C (60 degrees F). Comparing the correlation coefficients of the Boston Marathon and Twin Cities Marathon data suggests that the risks of medical problems and not finishing are associated with the warmest temperature of the race and not the start temperature. The community consequences of races conducted in hot and humid conditions can be significant, particularly when the WBGT is >15.5 degrees C. The emergency medical systems can be overwhelmed with a surge of patients, some very ill, and the emergency call response times drop to unacceptable levels blocking access for the citizens of the community. With respect to marathon encounters, heat stress increases both the finish-line medical encounter rate and the on course drop-out rate, and seems to increase the incidence of hyponatraemia and heat stroke. Cold conditions increase the drop-out rate along the course and, if associated with wet conditions, also increase the encounter rate.
Strenuous exercise, including marathon running, can result in damage to skeletal muscle cells, a process known as exertional rhabdomyolysis. In most cases, this damage is resolved without consequence. However, when the damage is profound, there is a release of muscle proteins into the blood; one of these proteins, myoglobin, in high concentrations and under certain conditions (such as dehydration and heat stress) can precipitate in the kidneys, thereby resulting in acute renal failure. Although the marathon is a gruelling physiological challenge, with races sometimes run in hot and humid weather, acute renal failure is relatively infrequent. From case reports, a high proportion of marathon runners who developed acute renal failure had taken analgesics, had a viral or bacterial infection, or a pre-existing condition. The rare cases of acute renal failure in marathon runners may be a situation of the 'perfect storm' where there are several factors (heat stress, dehydration, latent myopathy, non-steroidal anti-inflammatory or other drug/analgesic use, and viral/bacterial infection) that, in some combination, come together to result in acute renal failure.
Few data on risks and injury patterns of road cycling events are available. The aim of our study was to evaluate all injured participants in the 2006 Hamburg "Cyclassics".
Injuries of the 182 professional and 18,788 recreational participants were registered with the help of the emergency medical services, the promoter and the hospitals.
A total of 193 injuries were registered in 70 participants; the mean age was 44 years (range: 19-72). The injury rate amounted to 0.37%. Extremities were affected in 94.4%, and 32 fractures were registered. The MAIS amounted to 1.34+/-0.73 (range: 1-4), and the mean ISS was 2.86 +/- 3.61 (range: 1-20). The region affected most frequently was the shoulder girdle. Of the participants, 10% sustained serious injuries (AIS> or =3), which were significantly more frequent in women than in men (p<0.01). Based on 100,000 km most accidents occurred in the 55-km distance (p<0.01); 84.4% of the accidents occurred in groups. The mean speed at the time of the crash was 37.3 km/h (range: 0-57).
In conclusion, accidents were more likely to occur in inexperienced drivers, in the shortest distance, with straight conditions and in well-known dangerous areas.
- J Killops
Killops J, et al. Br J Sports Med 2019;0:1-8. doi:10.1136/bjsports-2018-100417
Original article
A view from the medical tent
- Crouse