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THE INCIDENCE OF MOTOCROSS INJURIES: A 12 YEAR
INVESTIGATION.
Alberto Gobbi, MD, Benjamin Tuy, MD, and Ian Panuncialman MD
From Orthopaedic Arthroscopic Surgery International, Milano, Italy
Address correspondence to:
Alberto Gobbi, MD
O.A.S.I.
Via Amadeo G.A. 24
Milano 20133
ITALY
Tel. +39 02 7610310
Fax. +39 02 70124931
E-mail sportmd@tin.it or info@oasiortopedia.it
Paper n° 03 – 03 - 29
- 1 -
ABSTRACT
Introduction:
Off-road motorcycling is one of the most popular sport activities practiced by
millions of people in the world but little has been written on motocross
traumatology and prevention. This paper aims to evaluate motocross injuries
in terms of injury ratio, location, causes and possible prevention in a series of
competitions organized by Motorcyclistic Federations over a 12 year period.
Materials and Methods:
We retrospectively evaluated 1,500 accidents with 1870 rider injuries out of a
group of 15,870 athletes participating in European off-road competition from
1980 to 1991. Data were collected from race medical reports, insurance
declaration and follow-up forms filled up by riders involved in accidents. We
then classified the type and location of the injury, modality of the accident, the
protective gear used and the recovery of the riders. We compared our data to
lesions noted in motorcycle road races using the chi-square test and the z-
test.
Results:
The overall incidence of motocross injuries in our study was 94,5 ‰, while
stadium cross competitions had a 150 ‰ rate and outdoor motocross a rate
of 76 ‰ representing a risk of accident of 22,72 ‰ hours of riding.
Among the total 1870 injuries, 1076 were bruises, 27.9% of these were in the
upper extremities, 26.9% on the lower, 21.2% on the trunk, and 16% on the
face. There were 450 fractures recorded, 50.9% in the upper extremities, 38%
- 2 -
in the lower, and the rest were on the spine, chest, and skull. The 26 spine
fractures (5.8%) produced permanent neurologic sequelae in 8 patients.
Ligamentous lesions accounted for 344 cases with 206 (59.9%) occurring in
the lower extremities especially the knee (42.4%). Head trauma was noted in
86 cases (5.7% of accidents) producing coma in 3%, and loss of
consciousness in 14%. Limb involvement for all types of injuries were more
frequent on the left side (60%).
Conclusion:
Motocross is a high risk sport: our study revealed the most common
modalities and types of lesions sustained by the riders. Despite the reduction
of some injuries by better protective gears, the occurrence of knee sprain,
wrist, and clavicular fractures are still high. Furthermore, the high number of
spine lesions with subsequent neurologic deficit noted in indoor races puts into
question the safety of these events.
Key words: motocross injuries, off road motorcycling, sport specific injuries,
sport prevention, knee brace
- 3 -
INTRODUCTION
Off-road is one of the most popular motorcyclist activities practiced by millions
of people in the world; according to the latest International Motorcycle
Federation data, at least 50,000 people practice at different levels off road
competition in Europe. In addition, professional motocross’ spectacular side
endears it to the media, and hence to advertising sponsors, but exposes riders
to a high degree of risk. Competitive off-road motorcycling is inherently
dangerous due to the high speeds attained and the characteristics of the track.
Furthermore, high power ratings, ever more grueling circuits like stadium
indoor supercross, obsolete protective equipment, and in some cases
inadequate training increase the frequency and or the severity of accidents.
Despite the increasing popularity of this sport and the associated harm it
brings, little has been written on traumatology and prevention specific for
motocross. In fact, many articles including that by Costa (Esperienze di
traumatologia nello sport motoristico. Italian Motorcycle Federation. 1983
personal communication) dealing with motorcycle injuries focused on road and
track races.
[2,3,5,6,7,14,17]
This paper aims to evaluate motocross injuries in
terms of injury ratio, location, and causes in order to analyze the possibility of
preventing some of the frequent injuries.
The rider's means of protection
Protective devices worn by a motocross rider during a race are important in
order to avoid injuries. Clothing must meet four main requirements:
1) Protection of vital parts on hitting the ground;
- 4 -
2) Protection against stones and dirt thrown up by riders in front;
3) Good transpiration and ventilation;
4) Minimum weight and encumbrance.
HELMET: Two types of helmets are commonly used: Integral type (closed in
the front) is heavier than Jet type (1200 g vs. 1000 g) but provides more
protection to the face. During the race, debris can be thrown up by the rear
wheel of the rider ahead into the face. Furthermore, in case of a fall, the direct
impact on the ground can produce maxillo-facial injuries.
GOGGLES: Light rubber made, fitted with superimposed lenses easily
removable when covered with mud.
CHESTGUARD: Made of nylon and plastic mesh- work. Protects the chest,
shoulders, back and proximal part of the arm (not all the drivers like to use this
protection because it hinders some movements)
KIDNEY BELT: protects the abdomen and is reinforced with stiffeners at the
back to support the lumbar spine during landing from jumps.
TROUSERS: made of tough, fire-retardant synthetic fibers, nylon, and Kevlar
and containing padding for the sides, and jointed plastic knee and ankle pads.
- 5 -
BOOTS: leather (more recent models in combined leather and plastic), fitted
with shin pads and adjustable zips preventing plantar hyperflexion of the ankle
and malleolar plastic protections.
GAUNTLETS: leather or synthetic fibers like goretex and kevlar with dorsal
padding.
VEST: in very light nylon and Kevlar meshwork with light elbow padding for
protection against slight injuries.
KNEE PADS: Commonly used knee pads are made of plastic and are worn
under the trousers. They protect riders from bruises and contusions.
KNEE BRACE: made of rigid light weight carbon fiber construction with
durable strength, provides protection, and support in the full range of the knee
movement. Some models can be adjusted to provide customized fit.
Contoured tibial cuff adjusts medially and laterally for varus/valgus control and
precise tibial alignment and an anterior pad offers ACL support. A patellar
cup protects the knee in high impact situations.
MATERIALS AND METHODS
The senior author served as a physician of the Italian Motorcycle Federation,
the Italian National Team, as well as many other professional top level drivers
across Europe from 1980 to 1991.
All the riders participating to every competition authorized by National or
International Motorcyclist Federation at the moment of registration to the
- 6 -
competition must deliver the motocross driver licence where are reported: I.D.
of the driver, level of competition allowed, and injuries that requested
hospitalization occurred during the year.
This licence given to the director of the race will be returned to the driver at
the end of the competition; in case of injury the medical staff must note the
type of injury occurred on the “race medical report”. When there is a major
trauma requiring hospitalization the responsible of the medical staff must fill a
report indicating the I.D. and race number of the driver and the first diagnosis:
the licence with the medical form is saved from the National Federation
Committee until complete recovery and the type of injury is reported on the
licence, all these data are delivered to the Insurance Company and just in
case of die or “permanent sequelae” the company will pay a small
compensation to the athlete. We collected these “race medical reports” from
1980 to 1991 and furthermore we collected data of the drivers that reported
major injuries from the National Motorcyclist Insurance Company (Sportass)
files.
Riders involved in accidents were asked to fill up a questionnaire and the
senior author personally followed up all these injured riders over several years
conducting detailed interviews on the race tracks, during annual meetings, by
telephone and in some cases following athletes during rehabilitation or at
athlete’s home for those who reported spinal injuries.
Drivers were happy to collaborate to this project because the senior author
was personally involved to secure the riders safety during competitions being
a member of the Italian Federation Medical Committee. It was so possible to
analyze in details the type of injuries reported from a great number of
- 7 -
motocross drivers during several years of competitions at National or
International level.
Out of a group of 15,870 athletes participating in European off-road
competition (11,902 outdoor and 3968 indoor) at different levels and
authorized by the International Motorcyclist Federation (F.I.M.), we analyzed
1,500 (905 outdoor and 595 indoor) accidents involving rider injuries in
motocross races classified as 125, 250, and 500 cc.
All these data retrieved were used to classify and locate of the injuries, as
well as the modality of the accidents, protective gears used, and the recovery.
All the riders were males with an average age of 24 (range, 14-31) and the
analysis of 1500 accidents revealed 1870 secondary lesions that were divided
into:
a) Fractures;
b) Sprains and dislocations;
c) Contusion and Wounds;
Fractures were further divided into: upper extremity, lower extremity, chest,
skull and spine.
A distinction was made between trauma with ligament lesions of the upper and
lower extremities.
Contusion and wounds were also grouped by location: face, upper extremity,
lower extremity, trunk, and head or cranium (including concussions). The
presence of loss of consciousness and coma were noted for head injuries.
We also retrieved data from Italian Motorcycling Federation on motorcycling
injuries in road races for a period of 6 years and used it as our control group.
- 8 -
RESULTS
The 1500 accidents produced 1870 secondary lesions: most injuries
sustained by riders were contusions with or without wounds, these injuries
accounted for 1076 cases (57.5%) with 300 occurring on the upper (27.9%)
and 290 on the lower extremities (26.9%) Table 1.
The overall incidence of accidents in our study was 94,5 ‰ per year for
motocross races which is significantly lower than the 115 ‰ of road races
(z-test, p<0.0001). Furthermore, the incidence of accidents in the stadium
cross competitions was significantly higher at 150 ‰ per year than outdoor
motocross which was only around 76,0 ‰ (z-test, p<0.0001).
We considered in our 11 year observation, that each driver could spend about
5 hours riding the motorcycle between free and qualifying session and race;
the average number of races per year for each athlete is 30 and the qualified
number of drivers per race is 40 on an average number of 70 participants,
therefore the total hours of risk exposure is 66000. Hence the 1500 accidents
that we registered in our study represent a risk of accident of 22,72
‰ hours
of riding (avg. 4,5 accidents per race).
However our data show that compared to other sports, motocross has the
highest incidence of injuries (Fig 1) after motorcycle road races.
Insurance claims, according to the International Committee for Olympic
Games (C.O.N.I.) Report (Sportass. Infortunistica Sportiva 1983-1992,
personal communication) for sports injuries over the same time period show
that motocross has a 5.5 times higher rate than cycling which is the third
highest.
- 9 -
Analyzing the great number of contusions with or without wounds (1076) our
study revealed that the driver’s face was involved in 172 of these cases (16%)
and among these 69,77 %(120 drivers) were wearing a jet type helmets
(open on the face) while only 30,23% (52 cases) were using an integral type
(partially closed in the anterior part) z-test, p<0.0001. Twenty percent of these
cases required suturing and in most cases, this was done on the track. The
other wounds were abrasions caused by friction burns when the skin slides
on the ground rather than as a direct consequence of the fall. If the injury
was reported during free practice, qualifying sessions, or first heat, 75% of
these riders with bruises could continue the race.
In our study group fractures occurred in 450 cases (24% from all the injuries
reported): The upper extremities were involved in 229 cases. We recorded
50 Colles’, 48 scaphoid, and 10 other types of wrist fractures; phalanges were
involved in 40, metacarpal in 15, radial head in 17, and the clavicle in 49
cases.
Fractures of the lower extremities accounted for 171 cases involving the tibia
in 44, fibula in 48, both bones in 26, and the feet in 53 cases.
We also found a significant difference in the incidence of spinal fractures in
motocross riders compared to the control group. Spine fractures were reported
in 26 cases (5.8% from all fractures) while in the control group it was 3.5% (z-
test, p ∼ 0.0039) . The spinal injuries produced permanent neurologic
sequelae in 8 cases, five patients developed paraplegia after sustaining
fractures to T7, T11,and T12 vertebra, and the other three had tetraplegia
after C5 and C6 lesions. None of the 8 patients was able to regain normal
function in the affected limbs despite different types of treatment employed.
- 10 -
Since the advent of indoor races the spine fractures were noted to carry a
46% increase in producing permanent neurologic sequelae
We found 10 skull fractures (2.2% from all fractures) and in 5 cases the jaws
and face were involved: all these 5 riders were wearing jet helmets.
Our study revealed 344 ligamentous lesions. Lower extremities were affected
in 206 cases, especially the knee (146), and the ankle (50). There was a
significant difference in the number of knee injuries between riders using knee
pads 72,6% (106 cases) and those using special knee brace 27,4 % (40
cases, z-test, p<0.0001). In road races only 18% of all ligamentous injuries
were on the knee.
Among the 146 riders with knee sprains, 35% required surgery while only 15%
of the ankles were treated surgically with open ligament repair. We found 10
hip dislocations, one of which also required surgery for concomitant fracture of
the acetabulum.
On the upper extremities, we had 138 ligamentous injuries with 86 cases of
shoulder dislocations that were treated conservatively. The wrist was involved
in 25 cases with 10 requiring surgery while the elbow was dislocated in 15
cases and 12 were treated with closed reduction; the hand was involved only
in 12 cases. We noted that only 30% of the dislocations could be treated by
the personnel performing first aid at the track and the rest required
hospitalization.
- 11 -
The incidence of injuries to the extremities was significantly higher (60%) on
the left side (z-test, p<0.0001).
We found a significant difference in the incidence of cranial trauma between
motocross and road races (chi-square test, p<0.0001).
Head or cranial trauma was noted in 86 cases out of 1500 accidents (5.7% )
compared to 10.5% in road races. Loss of consciousness occurred in 16.3%
from motocross while in 43% from road races. There was no loss of
consciousness in 80.2% and 50% for motocross and road racing respectively.
Coma cases were significantly higher in road races (7%) as compared to
motocross (3.5%) (z-test, p<0.0001).
Distribution of injuries are significantly different between motocross and road
races (chi square p<0.0001). In particular, fractures are significantly higher in
motocross than road races (z-test, p<0.0001). Contusions and wounds are
significantly lower in motocross than in road races (z-test p<0.0001). We did
not find a significant difference between sprains and dislocations.
The comparison of injury type and location between road races and motocross
are shown in table 2.
DISCUSSION
Some interesting points concerning the mechanisms of injury emerge from our
data:
- 12 -
The protective role of helmets could not be underestimated. Several studies
have already proven that wearing of helmets significantly reduce the risk of
head injuries among motorcyclists.
[4,8,11,15,16,19]
Many maxillofacial injuries were the result of wearing a jet helmet which
exposes face to debris thrown up by the rear wheels of riders in front. Flying
debris are almost always responsible for these lesions rather than direct
impact with the ground. In motorcycle road races where riders always use an
integral helmet, we had a lower number of facial abrasions while we found a
higher number of cranial trauma with loss of consciousness (43% vs. 16%).
Similarly, Varley et. al.
[17]
observed a higher number of head injuries in road
races where the brain movement generated by the inertia of the higher speed
may result in damage even without direct impact.
Fractures arising from direct injury to unprotected sites like the clavicle
originate in the same way as those occurring on the common roads accidents.
Frequently, the mechanism of injury to the clavicle is a direct fall on the
shoulder .
[9]
The number of scaphoid, and Colles’ fracture (often bilateral) has increased
with indoor stadium supercross: this is due to the artificial obstacles that
permit high triple and double jumps and woops where the bumps are steep
and are at short distances to each other making it difficult for drivers to jump
over such bumps and subsequently increasing their susceptibility to crash.
Furthermore, 20% of these wrist fractures were not actually due to the fall but
were indirectly caused by the impact generated when their front wheels
incorrectly collide with the next bump. If the forward suspension of the
motorcycle is not well regulated cannot absorb the shock from such an impact,
- 13 -
hence the force is transmitted to the extended wrists of the drivers causing the
fracture, so the driver loses his control over his bike leading to a crash
because of the fracture.
Metacarpal fractures usually involve the base of the 1
st
and the neck of the 5
th
and are the result of indirect injury through stress on the thumb in forced
abduction in a fall, direct injury to the ulnar margin, or indirect injury to the
clenched fist in a fall or through collision with a marker pole.
We found 17 tibial plateau fractures caused by stress along the out stretched
leg when landing heavily after a badly executed jump, or when coming out of a
corner using the leg as a pivot; concomitant anterior cruciate ligament and
medial meniscal injuries were present in almost all these cases.
The main cause of fibular fractures, often with involvement of the malleolus, is
forced pronation and external rotation of the grounded foot when cornering or
direct impact by the bike on the leg; while metatarsal and phalangeal fractures
are by no means uncommon: they are due to direct impact of the tip of the
foot against the ground, or crashing under the wheel of one's own or another
racer’s bike. Local protection of the boot with a front stiffener and a plastic
ankle guard is of little help in these cases as opposed to direct injuries.
The vertebral fractures, which were noted to increase with the advent of
stadium indoor races, are of importance insofar as they carry the risk of
serious neurological complications. The dorsal and (to a lesser extent) the
cervical spine are primarily involved. Fracture of the dorsal spine is usually
caused by sudden forward flexion after a jump (jolt fracture), our series show a
higher rate of spine fractures compared to road races (5.8% vs. 3.5%).
- 14 -
Horner
[7]
showed that only 2 of 57 injured track or road circuit rider suffered
spine fracture. Cervical fractures are commonly produced after a rider
miscalculates his landing on bumps and his front wheel collides with the
ascent of the next bump and he is catapulted high into the air and he goes into
a half somersault landing on his head. Such a force can bring his neck into
hyperflexion thus producing the fracture and furthermore, in some instances,
the bike can fall on his back. The helmet itself may act as a lever in these
circumstances and increase the force applied to the spine but new helmets
present a different posterior profile in order to avoid this risk, and recent
studies show that these new helmets do not increase the incidence of cervical
spine fractures.
[11,19]
Our study revealed that majority of the ligamentous injuries were on the knee
(42.4%) which is similar to alpine skiing
[12]
while the road races group showed
less than 20% of ligamentous injuries to be on the knee. This injury is usually
the outcome of eversion and external rotation when the bike is leant over to
take a corner and the knee is employed as a pivot, and resulting in damage to
the medial collateral ligament or medial meniscus, or tearing of the anterior
cruciate ligament. This particular lesion may often follow landing after a high
speed jump with the knee in hyperextension or when the rider’s foot slides
down from the footbar and the driver tries to support the body weight by the
leg on the ground, in this circumstances the high speed cause a sudden
hyperextension and a subsequent ACL tear. We observed that as a rider
looses balance during a jump, he tries to maintain the bike in an upright
position usually using his leg as the object to break the impending fall: the
- 15 -
axial impact on the knee coupled with the momentum of the bike forcing the
knee into external rotation and extreme valgus can produce strain on the ACL,
MCL, and medial meniscus. The high incidence of these knee injuries can be
traced to a technical error in the approach of the jump or to the smallness of
the foot-rest. New bikes present larger foot bars with some spikes in order to
avoid sliding of the foot. It has been shown that currently available protective
knee braces can provide 20 to 30% greater resistance to a lateral blow, with
the possibility that the ACL is given even greater protection than the MCL.
[1,18]
The prevalence of left-knee injuries (60%) is presumably ascribable to
the greater number of left-hand bends on European circuits
[2]
and the gear
pedal being on the left side leaving less place for the foot to rest on.
In our group, there is a relatively minor incidence of ankle ligamentous injuries:
the joint itself is well-protected by the reinforced boot and damage is caused
when the tip of the foot hits the ground when landing after a jump, the
suspension reaches the end of its travel lowering the bike and the rider's feet
brush the ground. Striking the toes results in forced dorsal flexion of the ankle
together with eversion or (less commonly) inversion of the hindfoot. Here
again, there is a greater incidence of left-side injuries (65%).
A possible explanation may be the fact that the left foot is used for gear
changing: since a change is often made during a jump, the foot is placed in
plantar flexion and the toes are pointed towards the ground.
Motocross and our control group both showed a high shoulder dislocation rate:
in many cases, falling on an extended and externally rotated upper extremity
could have caused the dislocation.
- 16 -
Stadium indoor races were accompanied by a higher incidence of injuries due
to the presence of particularly exacting artificial obstacles, coupled with the
fact that the difficulty of overtaking often results in collisions between riders.
Furthermore: the higher incidence of injuries among amateurs during the last
part of the race as opposed to professional racers where injuries are more
common immediately after the start is obviously attributable to the latter
category's better training and equipment, coupled with greater skill and
experience.
CONCLUSIONS
Motocross is a high risk sport and is today's most widely practiced motorcycle
sport, both in Europe and USA. It is both physically and psychologically
demanding, and requires thorough training, a good sense of balance, specific
riding skills, and a good dose of pluck. Its diffusion, the constant increase in
the number of participants, and the high incidence of injuries make it
necessary to acquire an in-depth understanding of the mechanisms by which
such injuries are caused. Yet to our knowledge, there have been few if any
studies published on motocross injuries.
Our study revealed the most common modalities and types of injuries
sustained by the riders; we analyzed amateur and professional races to
obtain a truer picture of the traumatology specific to this sport. Despite
advances in the development of protective gears and training methods,
injuries brought about by accidents during competitions continue to hound the
drivers. Some injuries have been reduced by better protective gears like
maxillofacial and skull injuries, but the occurrence of knee sprain, wrist, and
- 17 -
clavicular fractures are still high. Furthermore, the associated high number of
spine fractures with subsequent neurologic deficit noted in indoor races puts
into question the safety of these events.
The occurrence of injuries is not exclusive to any particular sport, the
mechanisms by which they occur maybe different but what is important is to
acknowledge that most of these are not unavoidable. Prevention must be
sought through better equipment, riding techniques, and physical training.
Our data can help to fill the gap in the epidemiology and classification of
motocross injuries, we hope that they will be of service in the elaboration of
technical solutions designed to achieve a greater degree of safety. We
believe the modification of the physician involvement towards the competitive
riders and the evolution of training methods will lead to further changes in the
physiological characteristics of top level off road motorcyclists.
- 18 -
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- 21 -
INJURY
TYPE
LOCATION
Upper
extremity
Lower
extremity
Face Skull Cranium
(including
concussions)
Chest Spine Total
Fractures
(n =450)
229
(50.9%)
171
(38.0%)
0 10
(2.2%)
- 14
(3.1%)
26
(5.8%)
450
(24.1%)
Sprains and
Dislocations
(n=344)
138
(40.1%)
206
(59.9%)
- - - - - 344
(18.4%)
Contusion
and
Abrasions
(n=1076)
300
(27.9%)
290
(26.9%)
172
(16%)
- 86
(8%)
228
(21.2%)
0 1076
(57.5%)
Total 667 667 172 10 86 242 26 1870
Table 1 : Distribution of motocross injuries according to type and location
- 22 -
SEGMENTS
INVOLVED
Motocross Road Races
Fractures 24.1% 17.7%
Sprains and
Dislocations
18.4% 17.4%
Contusions and
Wounds
57.5% 64.9%
Table 2: Percent distribution of injuries according to type in motocross and
road races
- 1 -
0
2
4
6
8
10
12
14
motocross
bicycling
car racing
motorboat
downhill
Ski
equstrian
motorcycle
road races
sport
percentage
Figure 1: Average yearly percentage of accidents in different sports. From the
International Committee for Olympic Games (C.O.N.I.) Report
(Sportass. Infortunistica Sportiva 1983-1992).
- 2 -
