Injury and illness among athletes during a multi-day elite cycling road race

'Downhill race for a rainbow jersey': the epidemiology of injuries in downhill mountain biking at the 2023 UCI cycling world championships-a prospective cohort study of 230 elite cyclists

Objectives

This study aims to understand the prevalence, incidence rate, anatomical sites, injury severity and main medical actions carried out during official training and racing by elite downhill mountain biking (DHMTB) riders during the 2023 Union Cycliste Internationale (UCI) Cycling World Championships.

Methods

The participants of this prospective, observational study were elite male and female cyclists competing at the UCI DHMTB World Championships located in the Nevis range in Fort William, Scotland, in 2023. This study followed the injury reporting guidelines established by the International Olympic Committee, which include the Strengthening the Reporting of Observational Studies in Epidemiology-Sports Injury and Illness Surveillance (SIIS) and the cycling-specific extension. Injuries were defined as 'tissue damage or other derangement of normal physical function due to participation in sports, resulting from rapid or repetitive transfer of kinetic energy requiring medical attention'. All epidemiological data were collected by the local organising committee medical professionals working at the event through an online survey. All data inputted were screened daily by the lead event physician and UCI medical delegate.

Results

Throughout 5 days of the championships, 10.4% of the 230 cyclists sustained at least one injury. The overall injury incidence rate was 3.3 (95% CI 3.1 to 3.5) per 100 rides. The incidence rates were higher in the training 4.3 (95% CI 4.0 to 4.6)/100 rides than in the racing 2.2 (95% CI 2.1 to 2.3)/100 rides. There was a greater incidence of injury in female cyclists in the training 5.8 (95% CI 5.0 to 6.6)/100 rides and racing 4.5 (95% CI 3.9 to 4.9)/100 rides compared with male cyclists. Female cyclists experienced more severe injuries, with an average of 12.6 (±14, 95% CI 5.66 to 19.54) days lost to injury compared with 5.5 (±1.6 95% CI 1.89 to 9.11) seen in male cyclists. The main event medical actions were lifting, immobilisation and helmet removal.

Conclusion

This study provides insights into the risk of injury to athletes within DHMTB. Our findings suggest more focus should be placed on the female DHMTB athlete. Additionally, this study provides unique information about common medical actions required of medical professionals working at DHMTB events and the importance of pre-event scenario training.

Hyperthermia and Exertional Heatstroke During Running, Cycling, Open Water Swimming, and Triathlon Events

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.

Injuries in elite road cyclists during competition in one UCI WorldTour season: a prospective epidemiological study of incidence and injury burden

METHODS

Fifty-four male athletes from two different teams were involved. Accidents and injuries were recorded immediately after the incident by a team physician present at every race. Exposure, location, type and cause of injury have been recorded. Incidence was calculated. Severity was measured as a cumulative severity score and burden depicted in a risk matrix.

RESULTS

Total time of exposure was 12537 hours over 3524 athlete days and 544002 kilometers of racing. 98 accidents were recorded, with 83 leading to injury. The total number of recorded injuries was 193. Injury incidence for all injuries was 54,8 (±SD 47,7-62,8) /1000 athlete days, 15,4 (±SD 13,4-17,7) /1000 athlete hours and 35,5 (±SD 30,8-40,8) /100.000 km raced. By far the most frequent types of injury were hematomas, contusions and bruising (n = 141, 73%) followed by lacerations (n = 22; 11,4%). Most injuries affected the arm and elbow (n = 34, 17,6%) followed by the shoulder and clavicle (n = 28, 14,5%) and occurred with contact (79%). Fractures pose a high injury burden due to long time loss, whereas hematomas, contusions and bruising showed the highest incidence numbers but comparably less time loss.

CONCLUSION

Road cyclists' injuries have been underestimated in previous studies. Hematomas, contusions and bruising pose the highest number of injuries with a broad degree of severity and range of injury burden. Fractures are less common but show the highest injury burden. The upper extremities are involved the most.

Return to competition following clavicle fractures in professional road cyclists

Objectives

Clavicle fractures are common injuries sustained by cyclists, but there is little evidence about return to competition times (RTCT) in elite cyclists. Our aim was to investigate this, and risk factors for delayed return.

Method

We identified elite cyclists who sustained clavicle fractures between 2015 and 2020. Freely available records were reviewed to validate data for RTCT. Secondary outcomes included return to outdoor cycling, management, time to surgery, cause of injury, other injuries, and ability to complete the event returned to.

Results

Records were reviewed of 1449 cyclists, identifying 188 clavicle fractures. 44 were recurrent fractures and were excluded. Those with isolated clavicle fractures (111; 92 male, 19 female) had a mean RTCT of 56.7 days, compared with 74.9 for those with multiple injuries (33) (p = 0.048). Those with multiple injuries were excluded from secondary outcome measures. All those with isolated injuries returned to elite competition. 83% were managed surgically with an RTCT of 53.8d, with no significant difference to those managed non-operatively, 59.3d (p = 0.61). RTCT was significantly lower for injuries sustained January-July (46.5d) than August-December (95.8d, p = 0.00). The incidence during Grand Tours was 0.06/1000 h for males (95% C.I 0.03-0.09), and 0.11/1000h (95% C.I 0.00-0.26) for females.

Conclusion

This is the largest study evaluating return to sport in elite cyclists with clavicle fractures. Athletes with isolated clavicle fractures, able to return the same season, took an average 46.5 days to return to competition. Elite cyclists are at high risk of clavicle fractures and the majority are managed surgically. RTCT is longer than often expected by the media, and this data can help plan rehabilitation, and manage expectations in both professional and amateur cyclists.

Level of Evidence

Level V.

'It's All Downhill from Here': A Scoping Review of Sports-Related Concussion (SRC) Protocols in Downhill Mountain Biking (DHI), with Recommendations for SRC Policy in Professional DMB

INTRODUCTION

Downhill mountain biking (DHI) is a form of cycling and does not currently have a specific sports-related concussion (SRC) assessment.

OBJECTIVE

To review the extent, range and nature of research investigating SRC in DMB, provide a summary of key literature findings relating to its identification and management, and then develop a SRC protocol specific to DMB.

DESIGN

Scoping review as per recognised methods.

SETTING

Literature-based. The following databases were searched: MEDLINE, EMBASE, Scopus and Web of Science, with no restrictions on date. Results were limited to the English language.

PARTICIPANTS

Six articles were included in the review from 64 identified articles. The article had to specifically include an analysis of adult downhill riders for inclusion.

OUTCOME MEASURES

Study type, study group (amateur/professional), concussion incidence, concussion assessment and recommendations.

MAIN RESULTS

Concussion incidence was identified as between 5-23%. No study outlined a trackside assessment of cyclists or a protocol for return to play where SRC was identified. Several authors identified that riders often continued to participate despite the presence of a concussion. No sport-specific SRC assessment was determined for DHI, and a SRC assessment was therefore developed.

CONCLUSIONS

This review illustrates the lack of studies and formal protocol in SRC assessment for DHI. In light of this, we propose a three-stage framework specific to the sport to best identify a concussion and act where appropriate while minimising disruption to competition. This framework involves assessing the cyclist on the 'sideline', a second assessment post-event in the medical room and a third assessment the following day. A SRC consensus meeting specific for DHI is suggested with an identified need for updated guidance from UCI, requiring possible rule changes for the sport.

Incidence of Injuries, Illness and Related Risk Factors in Cross-Country Marathon Mountain Biking Events: A Systematic Search and Review

Background

Cycling is a popular global sport and method of transportation and a significant contributor to admissions to hospital emergency units following an injury. Mountain biking events present additional challenges with remote venues and isolated courses, for which on-site medical care is often provided, for both injury and illness occurring during races. National health data may not represent these unique events, and specific data on incidence of injury and illness in mountain biking events are essential. Therefore, the aim of this study was to review the available injury and illness literature, reporting methods and risk factors in cross-country mountain biking.

Methods

Search engines PubMed, Scopus, CINAHL (EBSCOhost), Scopus, PEDro and the Cochrane Library were systematically searched, and a grey literature search was performed. Narrative analyses of the types, severity and area of injuries and illness type and severity were performed as pooling of data was impossible due to insufficient high-quality studies with the same injury and illness definitions.

Results

Seven studies comprising 28,021 participants were included for analysis. Four to 71% of participants sustained an injury in a cross-country mountain bike event. Injuries to the skin were the most common, followed by bony injuries and concussion. Five to 47% of cyclists reported the onset of gastrointestinal symptoms post-event. The prevalence of illness during events ranged from 0.5 to 23.0%.

Conclusion

The injury and illness definitions were varied and prevented clear comparisons between studies. Injury and illness present a concern in cross-country marathon mountain biking and should be investigated further to provide the true burden of these during race events.

Registration: This protocol has been registered with PROSPERO International prospective register of systematic reviews (No: CRD42019134586).

[Emergency service care of mountain bike elite races : Rescue concept and analysis of 5 years of world cup elite cross-country/downhill and marathon stage races]

BACKGROUND

Despite the ever-gaining popularity of mountain bike sports, the number of studies in regards to injury patterns and organizational aspects of rescue services is rather sparse. To efficiently support mass events such as the Union Cycliste Internationale (UCI) World Cup and UCI Championship, the World Championships and Swiss Epic Marathon, efficient rescue concepts are crucial. Challenges include high risk of injury in disciplines such as Downhill as well as the need to cover events in remote and often rough terrain in the Swiss Alps during the Swiss Epic Marathon, providing medical services not only for participants but also for spectators. We analysed the number of injuries sustained by participants as well as the different challenges for rescue services at these events.

METHODS

Retrospective analysis of emergencies at the Swiss Epic from 2016-2020, the UCI World Cup Races from 2015-2017 and 2019, as well as the UCI Championship 2018. Summary of the organizational aspects of the attending rescue services and special requirements and track concepts used at the events analysed.

RESULTS

Significantly higher probability of injury in Downhill disciplines vs. Cross-Country. In particular traumatic brain injury and extremity fractures. More severe injuries (NACA III to IV) were more common in Downhill compared to other disciplines (p < 0,01).

CONCLUSION

Mass events require rescue concepts tailored to the competition's sport as well as it's terrain. The number of injuries was low but their severity necessitates highly qualified personnel and efficient rescue logistics to be planned beforehand. GPS-tracking and central disposition of mobile rescue resources is essential for marathon races while track competitions benefit from a mix of stationary posts and mobile units.

Risk factors for not finishing an ultramarathon: 4-year study in 23996 race starters, SAFER XXI

BACKGROUND

Limited data support pre-race medical screening to identify risk factors for not finishing an endurance running race. The aim of the study was to determine risk factors associated with not finishing an ultramarathon.

METHODS

A prospective, cross-sectional study of Two Oceans ultramarathon (56km) race starters who completed a pre-race medical screening questionnaire. Race day environmental conditions were recorded on race day. Univariate analyses of risk factors associated with the did-not-finish (DNF) included race day factors and pre-race medical screening history.

RESULTS

Risk factors for DNF amongst 23996 starters during the 56km race included older age and being female (p<0.0001). After adjusting for age and sex, the following were significant univariate risk factors: fewer years of running (p<0.0001), less previous race experience (p<0.0001), less training / racing per week (p=0.0002), lower average weekly training distance (p=0.0016), slower race vs. training speed (p<0.0001), lack of allergies (p=0.0100) and average wet-bulb globe temperature (p<0.0001).

CONCLUSIONS

Females, older age, training-related factors (less training / racing, average weekly training distance, race vs. training speed) and average wet-bulb temperature, were risk factors for not finishing an ultramarathon. The results may not only assist runners and coaches in race preparation, but also have clinical implications for the medical planning prior to races.

Injury rates per mile of travel for electric scooters versus motor vehicles

OBJECTIVE

This study determined the vehicle-miles-traveled (VMT)-based injury rate for stand-up, dockless electric rental scooters (e-scooters), and compare it with the VMT-based injury rate for motor vehicle travel.

METHODS

In this secondary analysis of existing data, the e-scooter injury rate was calculated based on e-scooter injuries presenting to an emergency department or the emergency medical services system in Austin, TX between September and November 2018. Injuries were identified by Austin Public Health through a targeted e-scooter epidemiological injury investigation; e-scooter VMT data were reported by e-scooter vendors as a condition of their city licensing. Comparative injury rates for motor vehicle travel in Texas, and specifically in Travis County were calculated using annual motor vehicle crash (MVC) injury and VMT data reported by the Texas Department of Transportation.

RESULTS

There were 160 confirmed e-scooter injuries identified by the e-scooter injury investigation, with 891,121 reported miles of e-scooter travel during the study period. This produces an injury rate estimate of 180 injuries/million VMT (MVMT). The injury rates for motor vehicle travel for Texas and for Travis County were 0.9 injuries/MVMT and 1.0 injuries/MVMT, respectively.

CONCLUSION

The observed VMT-based e-scooter injury rate was approximately 175 to 200 times higher than statewide or county specific injury rates for motor vehicle travel. These findings raise concerns about the potential higher injury rate associated with e-scooters, and highlight the need for further injury surveillance, research and prevention activities addressing this emerging transportation technology.

Thermoregulatory and metabolic responses to a half-marathon run in hot, humid conditions

This study describes the thermoregulatory and metabolic responses during a simulated half-marathon (21 km) run performed outdoors in a hot, humid environment. Ten male runners were recruited for the study, The run was carried out individually under solar radiation on a predetermined path in the following environmental conditions (ambient temperature: 27.96 ± 1.70 °C, globe temperature: 28.52 ± 2.51 °C, relative humidity: 76.88 ± 7.49%, wet bulb globe temperature: 25.80 ± 1.18 °C). Core temperature, skin temperature, head temperature, heat storage, heart rate, expired gases, rating of perceived exertion, and speed were measured or calculated before the start, every 3 km, and immediately following the run. Comparisons were made for each dependent variable using one-way repeated measures analysis of variance tests, and a Bonferroni test. Average run time and pace were 101:00 ± 9:52 min and 4:48 ± 00:16 min km^-1, respectively. Participants significantly reduced their running speed, oxygen consumption, and heat storage at 9 km (p < 0.05). While core temperature was significantly increased at 6 km (p < 0.05) before plateauing for the remainder of the run. The key finding was that most of the runners reduced their pace when a T_core of 39 °C was reached which occurred between 6 and 9 km of the run, yet runners were able to increase their speed demonstrating an "end-spurt" near the end of the run.

Management of mental health emergencies in elite athletes: a narrative review

Mental health emergencies require a rapid, effective response. We searched the literature on mental health emergencies in athletes and found five papers. None of these addressed elite athletes. Nonetheless, common mental health emergencies may present in the sports environment and may place the athlete and others at risk. Sports teams and organisations should anticipate which emergencies are likely and how medical and support staff can best respond. Responses should be based on general non-sporting guidelines. We stress the importance of clinicians following standard procedures.

Sports-related concussion (SRC) assessment in road cycling: a systematic review and call to action

Background

Sports-related concussion (SRC) is a recognised risk in road cycling and can have serious health consequences. Recent high-profile cases of professional road cyclists continuing to participate in races despite suffering obvious SRC have highlighted the difficulties in assessing SRC within road cycling.

Purpose

To undertake a systematic review of the literature on SRC assessment in road cycling.

Study design

Systematic review.

Methods

Literature describing SRC assessment in road cycling was identified by searching MEDLINE, EMBASE, PsycINFO and Web of Science. Two reviewers independently screened titles and abstracts for eligibility and a qualitative analysis was undertaken of included studies.

Results

From 94 studies identified, two were included for review. Gordon et al describe the presentation of a single case of paediatric concussion following a cycling crash. They highlight the utility of SRC evaluation using the Sport Concussion Assessment Tool (SCAT) as well as the importance of a stepwise return-to-play protocol. Greve and Modabber discuss a number of traumatic brain injuries that occurred during the 2011 road cycling season and, as a minimum, call for riders to be withdrawn from competition following loss of consciousness or amnesia. Both studies are at high risk of bias and of low quality.

Conclusion

Road cycling poses unique challenges for the assessment of SRC. This review illustrates the lack of published evidence to advise effective means of SRC assessment within road cycling. The Union Cycliste Internationale (UCI) regulations advise the use of SCAT-5 for concussion assessment but this tool is impractical, requiring modification for use in road cycling. We would like to call on the UCI to hold a consensus meeting to establish an evidence-based SRC assessment protocol and return-to-riding protocol for road cycling.

Declines in exercise performance are prevented 24 hours after post-exercise ischemic conditioning in amateur cyclists

Brief moments of blood flow occlusion followed by reperfusion may promote enhancements in exercise performance. Thus, this study assessed the 24-h effect of post-exercise ischemic conditioning (PEIC) on exercise performance and physiological variables in trained cyclists. In a randomized, single-blind study, 28 trained cyclists (27.1 ± 1.4 years) performed a maximal incremental cycling test (MICT). The outcome measures were creatine kinase (CK), muscle soreness and perceived recovery status, heart rate, perceived exertion and power output. Immediately after the MICT, the cyclists performed 1 of the following 4 interventions: 2 sessions of 5-min occlusion/5-min reperfusion (PEIC or SHAM, 2 x 5) or 5 sessions of 2-min occlusion/2-min reperfusion (PEIC or SHAM, 5 x 2). The PEIC (50 mm Hg above the systolic blood pressure) or SHAM (20 mm Hg) treatment was applied unilaterally on alternating thighs. At 24 h after the interventions, a second MICT was performed. In all the groups, the CK levels were increased compared with the baseline (p < 0.05) after the 24-h MICT. The PEIC groups (2 x 5 and 5 x 2) felt more tired at 24 h post intervention (p < 0.05). However, both PEIC groups maintained their performance (2 x 5: p = 0.819; 5 x 2: p = 0.790), while the SHAM groups exhibited decreased performance at 24 h post intervention compared to baseline (2 x 5: p = 0.015; 5 x 2: p = 0.045). A decrease in the maximal heart rate (HR) was found only in the SHAM 2 x 5 group (p = 0.015). There were no other significant differences in the heart rate, power output or perceived exertion after 24 h compared with the baseline values for any of the interventions (p > 0.05). In conclusion, PEIC led to maintained exercise performance 24 h post intervention in trained cyclists.

Analgesic Management of Pain in Elite Athletes: A Systematic Review

OBJECTIVE

To identify the prevalence, frequency of use, and effects of analgesic pain management strategies used in elite athletes.

DESIGN

Systematic literature review.

DATA SOURCES

Six databases: Ovid/Medline, SPORTDiscus, CINAHL, Embase, Cochrane Library, and Scopus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Empirical studies involving elite athletes and focused on the use or effects of medications used for pain or painful injury. Studies involving recreational sportspeople or those that undertake general exercise were excluded.

MAIN RESULTS

Of 70 articles found, the majority examined the frequency with which elite athletes use pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anesthetics, and opioids. A smaller set of studies assessed the effect of medications on outcomes such as pain, function, and adverse effects. Oral NSAIDs are reported to be the most common medication, being used in some international sporting events by over 50% of athletes. Studies examining the effects of pain medications on elite athletes typically involved small samples and lacked control groups against which treated athletes were compared.

CONCLUSIONS

Existing empirical research does not provide a sufficient body of evidence to guide athletes and healthcare professionals in making analgesic medication treatment decisions. Based on the relatively robust evidence regarding the widespread use of NSAIDs, clinicians and policymakers should carefully assess their current recommendations for NSAID use and adhere to a more unified consensus-based strategy for multidisciplinary pain management in elite athletes. In the future, we hope to see more rigorous, prospective studies of various pain management strategies in elite athletes, thus enabling a shift from consensus-based recommendations to evidence-based recommendations.