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Toolbox: Cycling Injuries Introduction
As with all competitive sports, there is also a risk for injury in competitive bicycling. The patterns of injury in bicycling are unique since exposures include high speed, obstacles like cyclists, pedestrians and motor vehicles, and unpredictable road, environmental and weather conditions.




There are many challenges to cycling on the open road. There is always a risk of both acute traumatic injuries and overuse injuries. Furthermore, bicyclists usually do not have any external protection beyond wearing a helmet. Injury patterns also differ between the type of bicycling, that is, road, cyclo-cross, off-road/mountain bike, and BMX, etc.. It is important to understand the pattern and epidemiology of injuries suffered by competitive bicyclists in order to implement appropriate injury prevention and treatment strategies.

The majority of studies examining the epidemiology of injuries in competitive bicycling are retrospective questionnaire and/or interview in design (Bohlmann 1981; Callaghan and Jarvis 1996; Clarsen, Krosshaug, and Bahr 2010; De Bernardo et al. 2012; Pfeiffer 1993; Pfeiffer 1994). That is, cyclists are surveyed or interviewed as to what injuries they suffered from a preceding period of time. These types of studies are easier and less expensive to conduct but are susceptible to confounding factors such as incomplete and/or inaccurate details and recall and selection bias. Also, the incidence of injury and rates of injury cannot always be determined since accurate exposure data is not usually known.

In professional and competitive bicycling, cyclists may not accurately report injuries for strategic reasons. Nonetheless, these studies are still valuable for providing an idea of the epidemiology of competitive bicycling injuries. A few prospective injury surveillance studies have examined injuries suffered by competitive road cyclists over a multi-year time period (Barrios et al. 1997; Barrios et al. 2011) or during a single or a series of BMX and off-road bicycle race(s) (Brøgger-Jensen, Hvass, and Bugge 1990; Chow and Kronisch 2002; Kronisch et al. 1996).

The usual outcome measures that injury studies try to quantify include the incidence, rate, location, severity and type of traumatic and overuse injuries. The findings of bicycling injury studies to date can be difficult to compare because definitions of injury, calculations of injury incidence and rates, and descriptors of location, severity and type of injury are not consistent.

In this first article of a three article series on injuries in competitive cycling, the incidence, rate and severity of bicycle injuries will be reviewed.



Incidence of Injury
The overall incidence of injuries in competitive road cyclists ranges between 58 and 86%. When examined separately, the incidence of traumatic and overuse injuries ranges between 38.4 to 48.5% and 51.1 to 61.6%, respectively. In comparison, recreational cyclists have an incidence of traumatic injuries of 24.5% and overuse injuries ranging from 84.9 to 88% (van der Walt et al. 2014; Wilber et al. 1995).

The incidence of acute traumatic injuries at competitive off-road and BMX bicycling races have been reported to be 0.4% and 6.3% (Brøgger-Jensen, Hvass, and Bugge 1990; Kronisch et al. 1996), respectively. Kronisch et al. (1996) remarked that their study findings probably underestimates the true risk injury in competitive off-road/mountain biking since their study only examined traumatic injuries that were suffered in one race event and that pro/elite cyclists usually compete in 14 to 17 events per year and train 10 to 12 hours per week.

Bohlmann (1981) evaluated the incidence of injuries suffered by 3700 competitive bicyclists who rode different road bicycling disciplines. Of the 77 injuries that were reported, criterium, track and road bicyclists suffered 49.3, 29.9 and 20.8% of the total injuries.

Rates of Injury
Rates of injury in competitive bicycling have been reported as number of injuries/racer, number of injuries/year and number of injuries/km by Barrios (1997 and 2011) and de Bernardo (2012). In two separate prospective injury surveillance studies, competitive road bicyclists were followed between 1983 and 1995 and between 2003 and 2009 (Barrios et al. 2011). An increase in rate of both traumatic and overuse injuries was observed in 2003 to 2009 when compared to 1983 and 1995. All three studies reported higher rates of over-use injury compared to rates of traumatic injury.

Severity of Injury
Barrios et al. (1997 and 2011) and de Bernardo et al. (2012) used the Abbreviated Injury Scale (AIS) to rate the severity of injuries in competitive road bicyclists. The AIS is a 6-point injury severity ranking system with a score of 1 meaning minor injury and a score of 6 meaning unsurvivable injury (Joint Committee on Injury Scaling 1980). 77.9 to 94.1% of traumatic and over-use competitive road bicycling injuries were found to be AIS 1 and 2 (mild and moderate) in severity. Not unexpectedly, the studies found that over-use injuries tended to be AIS 1 in severity while traumatic injuries usually ranged between AIS 2 to 5 in severity.

Interestingly, even though road bicycling injuries for the most part not very severe, they can result in significant time loss with 17.6 to 35.9% and 43 to 67% of all injuries leading to 1 to 7 and 7 to 28 days of lost time in training and competition, respectively. Fifteen to 17% of injuries lead to greater than 28 days of time loss in training and competition and were usually caused by traumatic injuries.

Chow et al. (2002) and Kronisch et al. (1996) use the Injury Severity Score (ISS) to rate the severity of injuries suffered by participants of off-road cycling races. The ISS is an anatomical injury severity scoring system which determines an overall score for patients with multiple injuries with scores range from 1 (minor) to 75 (most severe/unsurvivable) (Baker et al. 1974). ISS scores range, on average, between 2.9 and 3.0. The more serious injuries usually resulted from being thrown over the handlebars.

Summary
In summary, there is a high incidence of injury in competitive bicycling. Although the injuries that are sustained are typically minor in severity, many result in prolonged periods of reduced or stopped training and competition. The second article of this 3 article series will review the location, type, diagnosis and mechanism of injury in competitive cycling.

Xorret de Cati - Spain - wielrennen - cycling - cyclisme - radsport - crash Merhawi KUDUS GHEBREMEDHIN (Eritrea / Team Dimension Data) pictured during La Vuelta ciclista a Espana 2017 (2.UWT) stage 8 from Hellín - Xorret de Cati (199,5 km) - photo Luis Gomez/Cor Vos © 2017

References
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Barrios, C, Nieves De Bernardo, Pablo Vera, C Laiz, and Michal Hadala. 2011. “Clinical Patterns and Injury Exposure Rates in Elite Road Cycling Are Changing over the Last Decade.” Br J Sports Med 45: 310–84. doi:10.1136/bjsm.2011.084038.

Barrios, C, D Sala, N Terrados, and JR Valenti. 1997. “Traumatic and Overuse Injuries in Elite Professional Cyclists.” Sports Exercise and Injury.

Bohlmann, Thomas. 1981. “Injuries in Competitive Cycling.” Physician Sports Med 9: 117–24.

Brøgger-Jensen, T, I Hvass, and S Bugge. 1990. “Injuries at the BMX Cycling European Championship, 1989.” British Journal of Sports Medicine 24 (4): 269–70. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1478891&tool=pmcentrez&rendertype=abstract.

Callaghan, Micheal J, and Christopher Jarvis. 1996. “Evaluation of Elite British Cyclists: The Role of the Squad Medical.” Br J Sports Med 30: 349–53.

Chow, Tony K, and Robert L Kronisch. 2002. “Mechanisms of Injury in Competitive Off-Road Bicycling.” Wilderness and Environmental Medicine 13 (1). Elsevier: 27–30. doi:10.1580/1080-6032(2002)013.

Clarsen, B, R Bahr, M W Heymans, M Engedahl, G Midtsundstad, L Rosenlund, G Thorsen, and G Myklebust. 2014. “The Prevalence and Impact of Overuse Injuries in Five Norwegian Sports: Application of a New Surveillance Method.” Scandinavian Journal of Medicine & Science in Sports, no. Mi (March): 1–8. doi:10.1111/sms.12223.

Clarsen, B, T Krosshaug, and R Bahr. 2010. “Overuse Injuries in Professional Road Cyclists.” The American Journal of Sports Medicine 38 (12): 2494–2501. doi:10.1177/0363546510376816.

De Bernardo, Nieves, Carlos Barrios, Pablo Vera, César Laíz, and Michal Hadala. 2012. “Incidence and Risk for Traumatic and Overuse Injuries in Top-Level Road Cyclists.” Journal of Sports Sciences 30 (10): 1047–53. doi:10.1080/02640414.2012.687112.

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Joint Committee on Injury Scaling. 1980. The Abbreviated Injury Scale (AIS). Arlington Heights, IL.

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McCrory, Paul, Willem H Meeuwisse, Mark Aubry, Bob Cantu, Jirí Dvorák, Ruben J Echemendia, Lars Engebretsen, et al. 2013. “Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport Held in Zurich, November 2012.” British Journal of Sports Medicine 47 (5): 250–58. doi:10.1136/bjsports-2013-092313.

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Pfeiffer, R. 1993. “Injuries in NORBA Pro/elite Category off-Road Bicycle Competitors.” Cycling Science 5 (1): 21–24.

Pfeiffer, R. 1994. “Off-Road Bicycle Racing Injuries--the NORBA Pro/Elite Category. Care and Prevention.” Clinics in Sports Medicine 13 (1): 207–18. http://www.ncbi.nlm.nih.gov/pubmed/8111853.

Thompson, Diane C, Fred Rivara, and Robert Thompson. 2009. “Helmets for Preventing Head and Facial Injuries in Bicyclists.” Cochrane Database Syst Rev.of Systematic Reviews, no. 4. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001855/pdf/standard.

Van der Walt, Alta, Dina van Rensburg, Lizelle Fletcher, Catharina Cornelia Grant, and Andrew John van der Walt. 2014. “Non-Traumatic Injury Profile of Amateur Cyclists Entering a One-Day Cycle Challenge.” Submitted for Publication.

Wilber, C A, G J Holland, R E Madison, and S F Loy. 1995. “An Epidemiological Analysis of Overuse Injuries among Recreational Cyclists.” International Journal of Sports Medicine 16 (3): 201–6. doi:10.1055/s-2007-972992.






Written By: Dr. Victor Lun, MSc., MD, CCFP, Dip. Sport Med is a Sport Medicine physician who practices at the University of Calgary Sport Medicine Centre. He is the team physician for several winter and summer sport Canadian national sport teams.

Medical Advice Disclaimer
The information included in this article is for educational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult their healthcare provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a medical condition or treatment plan. Reading the information on this article does not create a physician-patient relationship.

 

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