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Original article
Incidence and aetiology of acute injuries during competitive road cycling
  1. Mathieu Decock1,
  2. Lieven De Wilde1,
  3. Luc Vanden Bossche2,
  4. Adelheid Steyaert2,
  5. Alexander Van Tongel1
  1. 1Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, Ghent, Belgium
  2. 2Physical and Rehabilitation Medicine, Sports Medicine Centre, Ghent University Hospital, Belgium
  1. Correspondence to Dr Alexander Van Tongel, Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000 Gent, Belgium; alexander.vantongel{at}uzgent.be

Abstract

Introduction Despite the ever-increasing popularity of bicycle racing, the high perceived risk of acute injuries and the recent media attention, studies of acute injuries in road cyclists are rather scarce. The goal of this study is to evaluate the incidence, aetiology and patterns of acute injuries in non-professional competitive road cyclists during cycling races in Flanders.

Material and methods All acute injuries that occurred during competition in Flanders in 2002 and 2012, collected in the injury registry, were analysed. The incidence, injury rate, diagnosis, circumstances and level of performance were evaluated.

Results A total of 777 documented reports of accidents (1230 injuries) were retrieved for the years 2002 and 2012. There was no significant difference between incidence and injury rate between 2002 and 2012. There was a strong significant difference in the incidence between the different levels of performance in both seasons. Severe injuries were seen in 29.5% in 2002 and in 30.1% in 2012. The most common location of a severe injury was the hand. Collision with another rider was the most common cause of injury.

Conclusions Almost 1 out of 6 non-professional competitive road cyclists had an accident during cycling races in 2002 and 2012 in Flanders and collision with other riders was the most important cause of a crash. The most common lesion was abrasion, but almost one out of three riders had a severe injury.

  • Cycling
  • Injury
  • Epidemiology
  • Trauma
  • Sporting injuries

https://doi.org/10.1136/bjsports-2015-095612

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    Introduction

    Competitive road bicycle racing has become a very popular sport and several races are followed by millions of spectators and TV viewers all over the world. However, road racing is one of the most dangerous endeavours in cycling.1 The average speed in bicycle races can be more than 40km/hour and the maximum speed can reach over 80 km/hour.2 The races are held on different types of roads, in all weather conditions, as dozen of riders frequently travel at high speed to compete for place (and space). Also, the use of protective equipment is limited to a minimum. All these things together allow one to assume that these athletes are exposed to a high risk of traumatic injuries.3

    Despite the ever-increasing popularity of bicycle racing, the high perceived risk of acute injuries and the recent media attention, studies of acute injuries in road cyclists are rather scarce.3–5 Most studies describe injury incidence in school groups, urban population or recreational cycling.6–9

    The goal of this study is to evaluate the incidence, aetiology and patterns of acute injuries in non-professional competitive road cyclists during cycling races in Flanders in 2002 and 2012.

    Material and methods

    The Flanders Cycling Federation features a region-wide insurance system that covers every member during competitive cycling. The Flemish riders of the evaluated levels of performance had to be registered in the Flanders Cycling Federation in order to be allowed to participate in official road cycling races. As a result, all acute injuries that occurred during competition are reported and collected in the injury registry. The injuries are always documented by a qualified physician in the outpatient clinic or in the emergency room on a standardised leaflet. The leaflet consists of several parameters such as name, date of birth and date of the incident. Next, the date of examination, diagnosis, intervention of a specialist, physiotherapist or radiologist, incapacitation and disability are also filled in by a qualified physician. A completed leaflet is required for the patient in order to get reimbursed by the Flanders Cycling Federation insurance system. Six different levels of performance were evaluated: riders from the U15, U17, U19 and U23 categories, elites without a contract and women. A total of 3331 road cyclists in 2002 and 4487 road cyclists in 2012 from these different categories were registered. The Flanders Cycling Federation organised 1728 road races for the evaluated levels of performance during cycling season 2002 and 1382 races during cycling season 2012.

    The diagnoses were subdivided using the system described by Vanlommel et al.10 We classified fractures, cartilage injuries, tendon ruptures, ligamentous injuries and dislocations as ‘severe’ injuries as used in previous literature.10 Circumstances were rider related or non-rider related. The data of both years were compared for type of injury, affected body part, severity, circumstances and level of performance.

    The approval to conduct this study was obtained from the Flanders Cycling Federation, insurance company Concordia NV and the Ethics Committee of the Ghent University Hospital.

    Statistical analysis was performed with SPSS (IBM SPSS Statistics for Windows, V.21.0, Armonk, New York, USA). For comparisons between the several groups, either χ2 or Fisher's exact tests were performed, depending on the expected frequencies for each question. The significance level for all comparisons was α=0.05.11

    The Flanders Cycling Federation contributed in this study. The authors declare that there are no competing interests.

    Results

    A total of 777 documented reports of accidents were retrieved for the years 2002 and 2012.

    In 2002, 307 different cyclists reported 329 accident files. This resulted in a total amount of 525 injuries, because often there were multiple injuries (table 1). The ratio of total injuries per total number of registered riders or the injury rate was 15.8% and there was an incidence (the ratio of the total number of incidents per total number of registered riders) of 9.9%. 7.2% (22) of the injured riders had more than one accident during that year. There was an average of 1.60 injuries per accident. In 20% of the organised races by the Flanders Cycling Federation, an accident was reported.

    View this table:
    Table 1

    Incidence and injury rate of the different levels of performance of road cyclists during 2002

    In 2012, 421 different cyclists reported 448 accident files with a total number of 705 injuries (table 2). The injury rate was 15.7% and there was an incidence of 10%; 5.9% (25) of the injured riders had more than one accident during that year. There was an average of 1.57 injuries per accident. In 32.4% of the organised races by the Flanders Cycling Federation, an accident was reported. This is significantly different from the number of crashes per race during 2002 (p<0.001).

    View this table:
    Table 2

    Incidence and injury rate of the different levels of performance of road cyclists during 2012

    There was a strong significant difference in the incidence between the different levels of performance in seasons 2002 (p<0.001) and 2012 (p=0.001; tables 1 and 2).

    The most common described lesion was abrasion/laceration (2002—66.6%, 2012—58.7%; table 3). Severe injuries were seen in 29.5% of the incidents in 2002 and in 30.1% of the incidents in 2012. In 3.3% of the incidents during 2002, multiple severe injuries were seen. During 2012, multiple severe injuries were seen in 3.8% of the incidents.

    View this table:
    Table 3

    Overview of the different categories of acute injury diagnosis in 2002 and 2012

    The most common location of a severe injury was the hand region (2002—26.2%, 2012—30.1%) closely followed by the shoulder region (2002—25.2%, 2012—29.4%; table 4). There was no significant difference between the type of injury and the level of performance in 2002 (p=0.14) and in 2012 (p=0.10). In 2012, there was an increase in severe injuries among riders of the youth categories, but the difference was not significant (p=0.39). In 2002 and in 2012, 30 (9.1%) and 35 (7.8%) concussions were described. A concussion was defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.12

    View this table:
    Table 4

    Overview of the different severe injuries and the affected anatomical regions

    No significant difference (p=0.52) was found.

    Concerning the circumstance of the injury, in 2002 and in 2012 82% were rider related. In both seasons, collision with other rider(s) was by far the most frequently (52.2% and 51.2%) reported cause of an accident (table 5).

    View this table:
    Table 5

    Overview of reported injury circumstances in 2002 and 2012

    There was no significant difference between the circumstance of the injury and the level of performance in 2002 (p=0.14) and in 2012 (p=0.10).

    Discussion

    In contrast to some other sports, studies on acute injuries in road cyclists are rather scarce. Only three studies described acute injuries in road cyclists with Barrios as a common author.3–5 The first study was published in 1997 and evaluated data of all injuries, both overuse and traumatic injuries, of road cyclists of 2 different professional cycling teams (65 riders) during a period of 13 years (1983–1995). Also, De Bernardo et al researched traumatic injuries in professional road cyclists. From the year 2002 until 2009, they registered these injuries in a retrospective way through clinical interviews in 51 riders. The third study was a descriptive epidemiological survey. They compared traumatic and overuse injuries of two groups of professional road cyclists. One group was called the historical group (1983–1995), and the other was called the contemporary group (2003–2009). The data of the historical group are the data of the first mentioned study. The contemporary group was exposed to two times as many traumatic injuries, but the injuries in the historical group were more severe.

    This is the first study that investigates the incidence, aetiology and injury patterns of acute injuries in a large cohort of road cyclists.

    The general injury rate of all categories of non-professional road cyclists was similar in both seasons: 16%. This is higher than the 10.4% found in professional road cyclists surveyed by Barrios et al from 1983 to 1995, but lower than the other group of professional road cyclists, surveyed by the same authors, from 2000 to 2009, in which the injury rate was 28.7%. However, these injury rates are not directly comparable because of different injury definitions. Furthermore, Barrios et al and De Bernardo et al3–5 investigated traumatic injuries during both training and racing activities. In the present study, an injury was defined as any injury of an athlete resulting from training or competition, irrespective of medical treatment requirement or time loss from sports activities. Becker et al and Moroder et al13 ,14 also used this definition in respectively a study of injuries in downhill mountain biking and snow kiting. This injury definition is recommended in three different consensus statements.15–17 In this study, only acute injuries that occurred during cycling races were described. Barrios et al and De Bernardo et al3–5 solely reported injuries that forced the riders to miss at least 1 day of training or competition. Minor traumatic injuries with no functional repercussions were not considered in their studies. According to Moroder et al,14 such an approach could lead to an underestimation of the injury extent in sports. Although the definition used by Becker et al and Moroder et al was followed in this study, there is probably still an underestimation of the total number of acute injuries during both seasons. This is because the injured road cyclists had to pay an exemption of €25 to the insurance company before they could receive a refund and thus were included in the company's database. This way, acute mild injuries could be missed. Multiple abrasions or lacerations and contusions or haematomas were considered as 1, leading to an underestimation of the total number of abrasions and contusions and therefore leading to an underestimation of the injury rate. The comparison of injury rates and incidences with other road cycling-related sports such as triathlon,18 ,19 off-road cycling 13 ,20–23 or off-road motorcycle racing24 is limited because of the difference in injury definition and methodology.

    In this study the incidences were similar in both seasons like the injury rates. During cycling season 2012 less races were organised and more riders were registered in the Flanders Cycling Federation, so there were probably more participants per race. Significantly more crashes per race were reported during 2012, but the general incidence was not significantly different from the incidence during 2002. This way we can suggest that an increase of participants during road cycling races in 2012 did not lead to an increase of total reported accidents.

    Of the male riders, U17-riders had the highest injury rate during both seasons. U15-riders, in contrast, had least injuries. A possible explanation is that road cyclists of the latter category were more limited in the participation in races than the U17-riders. U15-riders were allowed to participate in a maximum of 35 races per year. On the other hand, U17-riders could participate in a maximum of 50 races per year. An additional explanation is that road races in the U17-category are longer, which should also increase the risk of getting involved in accidents. When comparing youth with adult road cyclists, adults had a higher injury-rate. Adult riders were not limited in the participation in number of races and these races can be up to three times longer than the races in the youth categories. Acute injuries in female cyclists were more than twice as much reported in cycling season 2012 as in cycling season 2002. The reason therefore is unclear, but the relatively low registered females, as compared to the male riders, may play a role.

    Abrasions or lacerations and contusions or haematomas were the most frequent reported acute injuries during both seasons. Fractures were third most frequently reported. The number of sustained fractures increased in season 2012 as compared to season 2002. Most fractures occurred in the shoulder region, this number was similar in both seasons. In high-speed crashes the shoulder girdle is often the first point of contact with the ground in a crash. This causes the shoulder girdle to be very susceptible to fractures. Also the upper limbs are prone to this mechanism; they ensure that the body rolls over the shoulders in order to prevent the head hitting the asphalt.3 ,4 Youth riders were subject to an increase in severe injuries during 2012, but the difference was not significant. There were slightly less reported concussions in 2012 than in 2002. In both years, most reports came from the female riders. For clarification, wearing a hard shell helmet during bicycle races became compulsory in 2003. Several studies confirmed the protective effect of wearing a bicycle helmet for injuries of the head and face.25–29 Thompson et al found that helmets provide a reduction of 63 to 88% in the risk of head, brain and severe brain injuries. They also found that injuries of the upper and mid-facial areas are reduced by 65%.27 Benson et al26 noted an inconclusive effect of bicycle helmets on concussions Also in this study there was no significant difference, but this is probably because, although it was not mandatory, most riders already wore a hard helmet in 2002. A decrease in dental traumas was found in cycling season 2012. A possible explanation could be that bicycle helmets also offer prevention for dental traumas. However, this could not be confirmed by other studies. In this study, neck traumas were slightly more frequent during 2012. According to Attewell et al29 there were three studies that provided neck injury results to be more frequent in cyclists who wore a helmet at the moment of an accident, but they claim that this should not be applicable to the lighter helmets currently in use. Rivara et al30 found that helmet use did not affect neck injuries.

    In this study it was not possible to evaluate the long-term effects of the severe injuries on further sports participation and their economic consequences.

    This study is the first study that describes the aetiology of crashes in road cyclists. A distinction was made between rider-related factors and non-rider-related factors. In both seasons, rider-related factors accounted for 82% of the reported injury circumstances. According to our data, young riders crashed more because of rider-related factors as compared to adult riders, but there was no significant difference. This could be due to a lack of steering skills and a lack of experience in cycle racing. Collision with other riders is the most important cause of a crash. Slipping followed this. During season 2012, more riders got injured due to a crash in a sprint as compared to season 2002. This cause was notably more frequently reported by youth and female riders than by adult riders. A possible explanation is that a higher number of registered youth and female riders and a lower number of organised races led to bunch sprints with a bigger peloton, which might lead to more incidents. Slipping as the reported cause of a crash decreased in 2012. In non-rider-related factors, road surface damage or obstacles were in approximately one-tenth of the incidents reported as the main reason of injury during both seasons. In contrast, mechanical problems and collision with motor vehicles were only to a lesser extent responsible for accidents. The aetiology of the incidents was self-reported and subject to bias.

    What are the findings

    • One out of six registered non-professional competitive road cyclists in Flanders were injured during a race because of an accident.

    • Collision with other riders is the most important cause of an accident.

    • Abrasion is the most common injury type, but almost one out of three riders had a severe injury.

    How might it impact on clinical practice in the near future?

    • This study will inform the development of future targeted interventions to prevent sport injury in competitive road cyclists.

    Acknowledgments

    The authors want to thank the Flanders Cycling Federation for the providing information and insurance company Concordia NV for their role in collecting data.

    References

    1. ↵
      1. Greve MW,
      2. Modabber MR
      . An epidemic of traumatic brain injury in professional cycling: a call to action. Clin J Sport Med 2012;22:81–2. doi:10.1097/JSM.0b013e318243bf32
      OpenUrlCrossRefPubMed
    2. ↵
      1. Menaspà P,
      2. Abbiss CR,
      3. Martin DT
      . Performance analysis of a world-class sprinter during cycling grand tours. Int J Sports Physiol Perform 2013;8:336–40.
      OpenUrlPubMed
    3. ↵
      1. Barrios C,
      2. Bernardo ND,
      3. Vera P, et al
      . Changes in sports injuries incidence over time in world-class road cyclists. Int J Sports Med 2015;36:241–8. doi:10.1055/s-0034-1389983
      OpenUrlPubMed
    4. ↵
      1. De Bernardo N,
      2. Barrios C,
      3. Vera P, et al
      . Incidence and risk for traumatic and overuse injuries in top-level road cyclists. J Sports Sci 2012;30:1047–53. doi:10.1080/02640414.2012.687112
      OpenUrlCrossRefPubMed
    5. ↵
      1. Barrios C,
      2. Sala D,
      3. Terrados N, et al
      . Traumatic and overuse injuries in elite professional cyclists. Sports Exerc Inj 1997;3:176–9.
      OpenUrl
    6. ↵
      1. Wilber CA,
      2. Holland GJ,
      3. Madison RE, et al
      . An epidemiological analysis of overuse injuries among recreational cyclists. Int J Sports Med 1995;16:201–6. doi:10.1055/s-2007-972992
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      1. Emond SD,
      2. Tayoun P,
      3. Bedolla JP, et al
      . Injuries in a 1-day recreational cycling tour: Bike New York. Ann Emerg Med 1999;33:56–61. doi:10.1016/S0196-0644(99)70417-8
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      1. Yeung JH,
      2. Leung CS,
      3. Poon WS, et al
      . Bicycle related injuries presenting to a trauma centre in Hong Kong. Injury 2009;40:555–9. doi:10.1016/j.injury.2008.08.015
      OpenUrlCrossRefPubMed
    9. ↵
      1. Thompson DC,
      2. Thompson RS,
      3. Rivara FP
      . Incidence of bicycle-related injuries in a defined population. Am J Public Health 1990;80:1388–90. doi:10.2105/AJPH.80.11.1388
      OpenUrlCrossRefPubMedWeb of Science
    10. ↵
      1. Vanlommel L,
      2. Vanlommel J,
      3. Bollars P, et al
      . Incidence and risk factors of lower leg fractures in Belgian soccer players. Injury 2013;44:1847–50. doi:10.1016/j.injury.2013.07.002
      OpenUrlCrossRefPubMed
    11. ↵
      1. Gilbert EH,
      2. Lowenstein SR,
      3. Koziol-McLain J, et al
      . Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med 1996;27:305–8. doi:10.1016/S0196-0644(96)70264-0
      OpenUrlCrossRefPubMedWeb of Science
    12. ↵
      1. McCrory P,
      2. Johnston K,
      3. Meeuwisse W, et al.
      , International Symposium on Concussion in Sport. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med 2005;15:48–55. doi:10.1097/01.jsm.0000159931.77191.29
      OpenUrlCrossRefPubMed
    13. ↵
      1. Becker J,
      2. Runer A,
      3. Neunhäuserer D, et al
      . A prospective study of downhill mountain biking injuries. Br J Sports Med 2013;47:458–62. doi:10.1136/bjsports-2012-091755
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Moroder P,
      2. Runer A,
      3. Hoffelner T, et al
      . A prospective study of snowkiting injuries. Am J Sports Med 2011;39:1534–40. doi:10.1177/0363546511398214
      OpenUrlAbstract/FREE Full Text
    15. ↵
      1. Fuller CW,
      2. Ekstrand J,
      3. Junge A, et al
      . Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Clin J Sport Med 2006;16:97–106. doi:10.1097/00042752-200603000-00003
      OpenUrlCrossRefPubMedWeb of Science
    16. ↵
      1. Fuller CW,
      2. Molloy MG,
      3. Bagate C, et al
      . Consensus statement on injury definitions and data collection procedures for studies of injuries in rugby union. Br J Sports Med 2007;41:328–31. doi:10.1136/bjsm.2006.033282
      OpenUrlAbstract/FREE Full Text
    17. ↵
      1. Pluim BM,
      2. Fuller CW,
      3. Batt ME, et al
      . Consensus statement on epidemiological studies of medical conditions in tennis, April 2009. Clin J Sport Med 2009;19:445–50. doi:10.1097/JSM.0b013e3181be35e5
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Egermann M,
      2. Brocai D,
      3. Lill CA, et al
      . Analysis of injuries in long-distance triathletes. Int J Sports Med 2003;24:271–6. doi:10.1055/s-2003-39498
      OpenUrlCrossRefPubMedWeb of Science
    19. ↵
      1. Gosling CM,
      2. Forbes AB,
      3. McGivern J, et al
      . A profile of injuries in athletes seeking treatment during a triathlon race series. Am J Sports Med 2010;38:1007–14. doi:10.1177/0363546509356979
      OpenUrlAbstract/FREE Full Text
    20. ↵
      1. Chow TK,
      2. Bracker MD,
      3. Patrick K
      . Acute injuries from mountain biking. West J Med 1993;159:145–8.
      OpenUrlPubMedWeb of Science
    21. ↵
      1. Chow TK,
      2. Kronisch RL
      . Mechanisms of injury in competitive off-road bicycling. Wilderness Environ Med 2002;13:27–30.
      OpenUrlCrossRefPubMed
    22. ↵
      1. Kronisch RL,
      2. Chow TK,
      3. Simon LM, et al
      . Acute injuries in off-road bicycle racing. Am J Sports Med 1996;24:88–93. doi:10.1177/036354659602400116
      OpenUrlAbstract/FREE Full Text
    23. ↵
      1. Kronisch RL,
      2. Pfeiffer RP
      . Mountain biking injuries: an update. Sports Med 2002;32:523–37. doi:10.2165/00007256-200232080-00004
      OpenUrlCrossRefPubMedWeb of Science
    24. ↵
      1. Colburn NT,
      2. Meyer RD
      . Sports injury or trauma? Injuries of the competition off-road motorcyclist. Injury 2003;34:207–14. doi:10.1016/S0020-1383(02)00039-6
      OpenUrlCrossRefPubMed
    25. ↵
      1. Amoros E,
      2. Chiron M,
      3. Martin JL, et al
      . Bicycle helmet wearing and the risk of head, face, and neck injury: a French case—control study based on a road trauma registry. Inj Prev 2012;18:27–32. doi:10.1136/ip.2011.031815
      OpenUrlAbstract/FREE Full Text
    26. ↵
      1. Benson BW,
      2. Hamilton GM,
      3. Meeuwisse WH, et al
      . Is protective equipment useful in preventing concussion? A systematic review of the literature. Br J Sports Med 2009;43(Suppl 1):i56–67. doi:10.1136/bjsm.2009.058271
      OpenUrlAbstract/FREE Full Text
    27. ↵
      1. Thompson DC,
      2. Rivara FP,
      3. Thompson R
      . Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev 2000;(2):CD001855. doi:10.1002/14651858.CD001855
    28. ↵
      1. Thompson DC,
      2. Rivara FP,
      3. Thompson R
      . Helmets for preventing head and facial injuries in bicyclists. Nurs Times 2001;97:41.
      OpenUrlPubMed
    29. ↵
      1. Attewell RG,
      2. Glase K,
      3. McFadden M
      . Bicycle helmet efficacy: a meta-analysis. Accid Anal Prev 2001;33:345–52. doi:10.1016/S0001-4575(00)00048-8
      OpenUrlCrossRefPubMedWeb of Science
    30. ↵
      1. Rivara FP,
      2. Thompson DC,
      3. Patterson MQ, et al
      . Prevention of bicycle-related injuries: helmets, education, and legislation. Annu Rev Public Health 1998;19:293–318. doi:10.1146/annurev.publhealth.19.1.293
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • Contributors The Flanders Cycling Federation contributed in this study.

    • Competing interests None declared.

    • Ethics approval The approval to conduct this study was obtained from the Flanders Cycling Federation, insurance company Concordia NV and the Ethics Committee of the Ghent University Hospital.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement We have two anonymous data sets, one of the injuries in 2002 and one of the injuries in 2012. These databases may contain more detailed information and can be obtained by sending an email to one of the authors.