Prerace medical screening and education reduce medical encounters in distance road races: SAFER VIII study in 153 208 race starters

Pre-race medical clearance in 60,609 distance running race entrants: which entrants sought clearance, what physicians did, and what was the outcome? SAFER XXXVII

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.

A high incidence of serious life-threatening cardiovascular medical encounters during a marathon (2014-2019) calls for prevention strategies: SAFER XL

OBJECTIVE

The aim of this study was to determine the incidence and nature (severity and type by organ system and specific diagnosis) of all medical encounters (MEs), including serious/life-threatening MEs (SLMEs) during a South African road marathon.

METHODS

This descriptive study was a retrospective analysis of data collected over 6 years at the Cape Town Marathon from 2014 to 2019, which included 40 446 starters. All MEs were collected and described as per the consensus statement for mass community-based sporting events. Incidences (I; per 1000 starters; 95% CI) are described for all MEs, SLMEs, and by organ system and specific diagnosis.

RESULTS

The incidence of all MEs was 8.7 (95% CI: 7.8-9.6) per 1000 starters. The largest contributor to all MEs, by organ system affected, was cardiovascular-related, with an incidence of 1.8 (95% CI: 1.4-2.2), where exercise-associated postural hypotension was the most common specific diagnosis (I = 1.3; 95% CI: 1.0-1.7). The incidence of all SLMEs was 1.0 (95% CI: 0.7-1.4) making up 11.7% (41/350) of all MEs. The incidence of SLMEs by organ system was highest in the cardiovascular system (I = 0.4; 95% CI: 0.3-0.7), with acute coronary syndrome (ACS) (I = 0.2; 95% CI: 0.1-0.4) the most common specific diagnosis. There were no sudden cardiac deaths (SCD) nor sudden cardiac arrests (SCA).

CONCLUSION

There was a high proportion of cardiovascular-related medical encounters, as well as SLMEs. We recommend that event organizers and race medical directors investigate prevention strategies to mitigate against risk of SLMEs, specifically acute cardiovascular SLMEs.

History of Multiple Allergies and Gradual Onset Running-Related Injuries in Distance Runners: SAFER XXXV

OBJECTIVE

To determine if any gradual onset running-related injury (GORRI) was associated with any allergies, multiple allergies (allergies to animals, plants, medication), and allergy medication use.

DESIGN

Cross-sectional descriptive study.

SETTING

Two Oceans Marathons (56 km, 21.1 km), South Africa.

PARTICIPANTS

A total of 76 654 race entrants (2012-2015).

INDEPENDENT VARIABLES

The prevalence (%) and prevalence ratios (PR; 95% confidence intervals) for history of (1) any allergies, (2) multiple allergies to broad categories of allergens (animal material, plant material, allergies to medication, and other allergies), and (3) allergy medication use.

MAIN OUTCOME MEASURES

Using a compulsory online screening questionnaire, the outcome was a history of any GORRIs, and subcategories of GORRIs (muscle, tendon) in the past 12 months and history of GORRIs (and subtypes of GORRIs) were reported.

RESULTS

In 68 258 records with injury and allergy data, the following were significantly associated with reporting any GORRIs: a history of any allergy (PR = 2.2; P < 0.0001), a history of allergies to broad categories of allergens (animal, plant, medication allergy, other) ( P < 0.0001), and the use of allergy medication ( P < 0.0001). A history of any allergies (PR = 2.4; P < 0.0001), all broad categories of allergies, and allergy medication use were significantly associated with muscle ( P < 0.0001) and tendon injuries ( P < 0.0001). The risk of reporting a GORRI increased as the number of reported categories of allergies increased ( P < 0.0001).

CONCLUSIONS

A novel finding was the cumulative risk effect with a history of multiple allergies. Further studies should aim to determine the underlying mechanism relating allergies and GORRIs.

Risk factors associated with a history of iliotibial band syndrome (hITBS) in distance runners: a cross-sectional study in 76 654 race entrants - a SAFER XXXIII study

BACKGROUND

Despite the numerous health benefits of distance running, it is also associated with the development of 'gradual onset running-related injuries' (GORRIs) one of which is Iliotibial Band Syndrome (ITBS). Novel risk factors associated with a history of ITBS (hITBS) have not been described in a large cohort of distance runners.

OBJECTIVE

To identify risk factors associated with hITBS in distance runners.

DESIGN

Descriptive cross-sectional study.

SETTING

21.1 km and 56 km Two Oceans Marathon races (2012-2015).

PARTICIPANTS

106 743 race entrants completed the online pre-race medical screening questionnaire. A total of 1 314 runners confirmed an accurate hITBS diagnosis.

METHODS

Selected risk factors associated with hITBS explored included: demographics (race distance, sex, age groups), training/running variables, history of existing chronic diseases (including a composite chronic disease score) and history of any allergy. Prevalence (%) and prevalence ratios (PR; 95% CI) are reported (uni- & multiple regression analyzes).

RESULTS

1.63% entrants reported hITBS in a 12-month period. There was a higher (p < 0.0001) prevalence of hITBS in the longer race distance entrants (56 km), females, younger entrants, fewer years of recreational running (PR = 1.07; p = 0.0009) and faster average running speed (PR = 1.02; p = 0.0066). When adjusted for race distance, sex, age groups, a higher chronic disease composite score (PR = 2.38 times increased risk for every two additional chronic diseases; p < 0.0001) and a history of allergies (PR = 1.9; p < 0.0001) were independent risk factors associated with hITBS.

CONCLUSION

Apart from female sex, younger age, fewer years of running and slower running speed, two novel independent risk factors associated with hITBS in distance runners are an increased number of chronic diseases and a history of allergies. Identifying athletes at higher risk for ITBS can guide healthcare professionals in their prevention and rehabilitation efforts.

Sudden cardiac arrest during marathons among young, middle-aged, and senior runners

AIM

There is limited evidence showing a relationship with age in the incidence of sudden cardiac arrest during exercise, which can be lethal at times.

METHODS

To examine the incidence by age group in sudden cardiac arrest, we prospectively observed cases of sudden cardiac arrest in full marathons certified by the Japan Association of Athletics Federations held between April 2011 and March 2019. Sudden cardiac arrest was defined as collapse during or 1 h after the race requiring chest compressions or the use of an automatic electrical defibrillation.

RESULTS

4.1 million persons ran in 516 marathons. Of the participants, 78.6 % were men. By age group, 37.4 %, 34.7 %, 19.6 %, and 8.3 % belonged to the < 40 s, 40 s, 50 s, and ≥ 60 s groups, respectively. During the study period, 69 sudden cardiac arrests (1.7 per 100,000 participants, 95 % confidence interval [CI]: 1.3-2.1) were observed, of which 66 were men. The incidence per 100,000 runners of sudden cardiac arrest was 0.9 (95 % CI: 0.4, 1.4), 0.9 (95 % CI: 0.4, 1.4), 2.6 (95 % CI: 1.5, 3.8), and 5.5 (95 % CI: 2.9, 8.2) for those in their under 40 s, 40 s, 50 s, and over 60 s, respectively, with higher rates for older age groups. Compared to men, the cases of SCA among women were less common (only three cases), and the incidence did not differ by age group.

CONCLUSIONS

Men, unlike women, had a higher incidence of sudden cardiac arrest during marathons according to age. Identification of this high-risk population could be important information in encouraging marathoners pre-participation self-screening.

Sex, training variables, history of chronic disease, and chronic injury are risk factors associated with a history of exercise-associated muscle cramping in 10,973 ultramarathon race entrants: a safer XXXVIII study

BACKGROUND

The prevalence of a history of exercise-associated muscle cramping (hEAMC) among ultramarathon runners is high. While the Comrades is one of the most popular mass community-based participation ultramarathons (90 km) globally, research on the epidemiology, clinical characteristics, and risk factors of entrants' lifetime hEAMC are scarce. This research aimed to describe the epidemiology, clinical characteristics, and risk factors of hEAMC among Comrades Marathon entrants.

METHODS

This was a retrospective, cross-sectional study in which 10973 race entrants of the 2022 Comrades Marathon participated. Entrants completed a prerace medical screening questionnaire that included questions related to the lifetime prevalence (%; 95% CI), severity, treatment and risk factors (demographics, training/racing variables, chronic disease/allergies, injury) for EAMC.

RESULTS

One thousand five hundred eighty-two entrants reported hEAMC in their lifetime (14.4%; 95% CI: 13.77-15.09). There was a significantly (P<0.01) higher prevalence of male (16.10%; 95% CI:15.34-16.90) than female (8.31%; 95% CI: 7.27-9.50) entrants with hEAMC (PR=1.94; 95% CI:1.68-2.23). The prevalence of hEAMC was highest in entrants with a: 1) 1 disease increase in composite disease score (PR=1.31; 95% CI:1.25-1.39); 2) history of collapse (PR=1.87; 95% CI 1.47-2.38); 3) past chronic musculoskeletal (MSK) injury (PR=1.71; 95% CI 1.50-1.94); and 4) MSK injury in the previous 12 months (PR=2.38;95% CI: 2.05-2.77). Training-related risk factors included an increase of 10 km weekly running distance (PR=0.97; 95% CI:0.95-0.99) and a training pace increase of 1min/ km (slower) (PR=1.07; 95% CI:1.03-1.12).

CONCLUSIONS

Future research should investigate the causal relationship between risk factors identified and hEAMC in ultramarathon runners. Findings from this study could assist in effective anticipation and adequate planning for treating EAMC encounters during community-based mass participation events.

Do five screening tools identify the same number of runners who require pre-exercise medical clearance? SAFER XXXIV

OBJECTIVES

Currently, there are five international screening tools that are recommended to identify individuals who require pre-exercise medical clearance to reduce the risk of medical encounters during exercise. Therefore, the aim was to determine the percentage of race entrants who are advised to obtain pre-exercise medical clearance and the observed agreement between these five different international pre-exercise medical screening tools.

METHODS

In all, 76,654 race entrants from the Two Oceans Marathon (2012-2015) that completed an online pre-race screening questionnaire. Five pre-exercise medical screening tools (American Heart Association (AHA), pre-2015 American College of Sport Medicine (ACSM), post-2015 ACSM, Physical Activity Readiness Questionnaire (PAR-Q), and the European Association of Cardiovascular Prevention and Rehabilitation (EACPR)) were retrospectively applied to all participants. The % (95%CI) race entrants requiring medical clearance identified by each tool and the observed agreement between tools (%) was determined.

RESULTS

The % entrants requiring medical clearance varied from 6.7% to 33.9% between the five tools: EACPR (33.9%; 33.5-34.3); pre-2015 ACSM (33.9%; 33.5-34.3); PAR-Q (23.2%; 22.9-23.6); AHA (10.0%; 9.7-10.2); post-2015 ACSM (6.7%; 6.5-6.9). The observed agreement was highest between the pre-2015 ACSM and EACPR (35.4%), for pre-2015 ACSM and PAR-Q (24.8%), PAR-Q and EACPR (24.8%), and lowest between the post-2015 ACSM and AHA (4.1%).

CONCLUSION

The percentage of race entrants identified to seek medical clearance (and observed agreement) varied considerably between pre-exercise medical screening tools. Further research should determine which tool has the best predictive ability in identifying those at higher risk of medical encounters during exercise.

Patellofemoral Pain Syndrome Is Associated With Chronic Disease and Allergies in 60 997 Distance Runner Race Entrants: SAFER XXX Study

OBJECTIVE

Patellofemoral pain syndrome (PFPS) is a common running-related injury. Independent risk factors associated with PFPS have not been described in a large cohort of distance runners.

DESIGN

Descriptive, cross-sectional study.

SETTING

21.1 and 56 km Two Oceans Marathon races (2012-2015).

PARTICIPANTS

60 997 race entrants.

ASSESSMENT OF RISK FACTORS

Participants completed a compulsory prerace medical screening questionnaire (history of PFPS in the past 12 months, n = 362; no injury history, n = 60 635). Selected risk factors associated with a history of PFPS were explored using univariate & multivariate analyses: demographics, training/running variables, history of chronic diseases (composite chronic disease score), and any allergy.

MAIN OUTCOME MEASURES

Prevalence ratios (PRs, 95% confidence intervals).

RESULTS

Risk factors associated with PFPS (univariate analysis) were increased years of recreational running (PR = 1.09; P = 0.0107), older age (>50 years), and chronic diseases (PR > 2): gastrointestinal disease (PR = 5.06; P < 0.0001), cardiovascular disease (CVD) (PR = 3.28; P < 0.0001), nervous system/psychiatric disease (PR = 3.04; P < 0.0001), cancer (PR = 2.83; P = 0.0005), risk factors for CVD (PR = 2.42; P < 0.0001), symptoms of CVD (PR = 2.38; P = 0.0397), and respiratory disease (PR = 2.00; P < 0.0001). Independent risk factors (multivariate analysis) associated with PFPS (adjusted for age, sex, and race distance) were a higher chronic disease composite score (PR = 2.68 increased risk for every 2 additional chronic diseases; P < 0.0001) and a history of allergies (PR = 2.33; P < 0.0001).

CONCLUSIONS

Novel independent risk factors associated with PFPS in distance runners are a history of multiple chronic diseases and a history of allergies. Identification of chronic diseases and allergies should be considered as part of the clinical assessment of a runner presenting with a history of PFPS.

A comparison of two pre-race medical screening tools in 5771 running race entrants-SAFER XXVIII

OBJECTIVE

To determine if two pre-race screening tools (abbreviated tool of two open-ended pre-race medical screening questions [ABBR] vs. a full pre-race medical screening tool [FULL]) identify running race entrants at higher risk for medical encounters (MEs) on race day.

METHODS

5771 consenting race entrants completed both an ABBR and a FULL pre-race screening questionnaire for the 2018 Comrades Marathon (90 km). ABBR tool questions were (1) allergies, and (2) known medical conditions and/or prescription medication use. The FULL tool included multiple domains of questions for chronic diseases including cardiovascular disease (CVD), symptoms, risk factors, allergies and medication use. ABBR responses were manually coded and compared to the FULL tool. The prevalence (%: 95%CI), and the test for equality of prevalence of entrants identified by the ABBR vs. FULL tool is reported.

RESULTS

The ABBR identified fewer entrants with allergies (ABBR = 7.9%; FULL = 10.4%: p = 0.0001) and medical conditions/medication use (ABBR = 8.9%; FULL = 27.4%: p = 0.0001). The ABBR tool significantly under-reported entrants with history of cardiovascular disease (CVD), CVD risk factors, other chronic diseases and prescription medication vs. the FULL tool (p = 0.0001). The ABBR tool identified fewer entrants in the "high" (ABBR = 3.4%; FULL = 12.4%) and "very high" risk (ABBR = 0.5%; FULL = 3.4%) categories for race day MEs (p = 0.0001).

CONCLUSIONS

An abbreviated pre-race screening tool significantly under-estimates chronic medical conditions, allergies, and race entrants at higher risk for MEs on race day, compared with a full comprehensive screening tool. We recommend that a full pre-race medical screening tool be used to identify race entrants at risk for MEs.

Males, Older Age, Increased Training, Chronic Diseases, Allergies, and History of Injury Are Independent Risk Factors Associated With a History of Exercise-Associated Muscle Cramping in Distance Runners in 76 654 Race Entrants - SAFER XXIX

OBJECTIVE

To determine independent risk factors associated with a history of exercise-associated muscle cramps (hEAMCs) in distance runner race entrants in a community-based mass participation event.

DESIGN

Cross-sectional study.

SETTING

2012 to 2015, Two Oceans marathon races (21.1 and 56 km), South Africa.

PARTICIPANTS

Seventy six thousand six hundred fifty-four consenting race entrants.

ASSESSMENT OF RISK FACTORS

Entrants completed an online prerace medical screening questionnaire as part of the entry process. In a multiple model, sex, age, training variables, history of chronic disease, allergies, and running injuries were included as potential factors associated with hEAMC in 21.1 and 56 km entrants.

MAIN OUTCOME MEASURES

Prevalence (%) and prevalence ratios (PRs, 95% confidence intervals) are reported.

RESULTS

Men ( P < 0.0001) and older age (>40 years, P < 0.0001) were significantly associated with hEAMC. Therefore, the model was adjusted for sex and age group and run separately for 21.1- and 56-km entrants. Specific independent risk factors associated with hEAMC in 21.1- and 56-km entrants were: a history of chronic diseases (21.1 km: PR = 1.9; 56 km: PR = 1.6; P < 0.0001), running injury in the last 12 months (21.1 km: PR = 1.7; 56 km: PR = 1.4; P < 0.0001), history of allergies (21.1 km: PR = 1.4; 56 km: PR = 1.2; P < 0.0001), and various training variables (PR = 1.0-1.1).

CONCLUSION

In 21.1- and 56-km race entrants, independent risk factors associated with hEAMC were men, older age, longer race distances, training variables, chronic diseases, history of allergies, and history of a running injury in the past 12 months.

Chronic diseases and allergies are risk factors predictive of a history of Medial Tibial Stress Syndrome (MTSS) in distance runners: SAFER study XXIV

BACKGROUND

Medial Tibial Stress Syndrome (MTSS) is one of the most common causes of exercise-associated lower leg pain in distance runners.

AIM

To identify risk factors predictive of a history of MTSS in distance runners entering the Two Oceans Marathon races (21.1 km and 56 km).

DESIGN

Cross-sectional study.

SETTING

2012 to 2015 Two Oceans Marathon races (21.1 km and 56 km).

PARTICIPANTS

Consenting race entrants.

METHODS

106,743 race entrants completed an online pre-race medical screening questionnaire. 76,654 consenting runners (71.8%) were studied. 558 verified MTSS injuries were reported in the previous 12 months. Risk factors predictive of a history of MTSS were explored using uni - & multivariate analyses: demographics (race distance, sex, and age groups), training/racing history, history of chronic diseases, allergies, and medication use.

RESULTS

Independent risk factors predictive of a history of MTSS (adjusted for sex, age group, and race distance) were a higher chronic disease composite score (PR = 3.1 times increase risk for every two additional chronic diseases; p < 0.0001) and a history of allergies (PR = 1.9; p < 0.0001). Chronic diseases (PR > 2) predictive of a history of MTSS were: symptoms of CVD (PR = 4.2; p < 0.0001); GIT disease (PR = 3.3; p < 0.0001); kidney/bladder disease (PR = 3.3; p < 0.0001); nervous system/psychiatric disease (PR = 3.2; p < 0.0001); respiratory disease (PR = 2.9; p < 0.0001) a history of CVD (PR = 2.9; p < 0.0001); and risk factors of CVD (PR = 2.4; p < 0.0001) (univariate analysis). Average running speed was associated with higher risk of MTSS.

CONCLUSION

Novel independent risk factors predictive of a history of MTSS in distance runners (56 km, 21.1 km) were multiple chronic diseases and a history of allergies. Identifying athletes at higher risk for MTSS can guide healthcare professionals in their prevention and rehabilitation efforts.

Pre-race self-reported medical conditions and allergies in 133 641 Comrades ultramarathon (90km) runners - SAFER XXIII

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 133641 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 (>45 years) or 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.

Factors associated with patellofemoral pain in recreational road cyclists: A cross-sectional study in 59953 cyclists - SAFER XXXIII

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.

Predictors of multiple injuries in individual distance runners: A retrospective study of 75,401 entrants in 4 annual races-SAFER XX

BACKGROUND

There are limited data on factors that predict an increased risk of multiple injuries among distance runners. The objective of this study was to determine risk factors that are predictive of individual runners with a high annual multiple injury risk (MIR).

METHODS

A retrospective, cross-sectional study at 4 annual (2012-2015) Two Oceans 21.1 km and 56.0 km races in South Africa with 75,401 consenting race entrants. Running-related injury data were collected retrospectively through an online pre-race medical screening questionnaire. The average number of injuries for each runner every year was calculated by taking a runner's race entry history and injury history into account and categorizing entrants into 4 MIR categories (high, intermediate, low, and very low (reference)). Multiple logistic regression modeling (odds ratios) was used to determine whether the following factors were predictive of a high MIR (average > 1 injury/year): demographics, training and racing, chronic-disease history (composite chronic disease score (CCDS)), and history of allergies.

RESULTS

Of all entrants, 9.2% reported at least 1 injury, and 0.4% of entrants were in the high MIR category; the incidence rate was 2.5 injuries per 10 runner-years (95% confidence interval (95%CI): 2.4-2.7). Significant factors predictive of runners in the high MIR category were: running for > 20 years: OR = 2.0 (95%CI: 1.3-3.1; p = 0.0010); a higher CCDS: OR = 2.2 (95%CI: 2.0-2.4; p < 0.0001); and a history of allergies: OR = 2.8 (95%CI: 2.0-3.8; p < 0.0001).

CONCLUSION

Runners who have been running recreationally for > 20 years and those with multiple chronic diseases or a history of allergies were at higher risk of multiple running-related injuries. This high-risk group can be targeted for further study and possible injury-prevention interventions.

Chronic prescription medication use in endurance runners: a cross-sectional study in 76,654 race entrants - SAFER XV

OBJECTIVE

To determine the prevalence of chronic prescription medication (CPM) use in distant runners (by age and sex) and to compare CPM use in 21.1 km vs. 56 km race entrants.

METHODS

A cross-sectional study of 76,654 race entrants who completed a pre-race medical screening questionnaire during race registration, which included questions on the use of CPM and CPM use in eight main categories of CPM. Prevalence (%, 95%CIs) and prevalence ratios (PR) are reported.

RESULTS

The prevalence of any CPM use was 12.5% (12.2-12.8). CPM use was higher in older age categories vs. the youngest age category (31-40 yrs vs. ≤30 yrs: PR = 1.4; 41-50 yrs vs. ≤30 yrs: PR = 2.1; >50 yrs vs. ≤30 yrs: PR = 3.4) (p < 0.0001) and females vs. males (PR = 1.1; p < 0.0001). The use of any CPM was significantly higher in 21.1 km vs. 56 km race entrants (PR = 1.2; p < 0.0001). Prevalence of CPM use in main categories was: blood pressure lowering medication (3.7%), cholesterol lowering medication (3.6%), asthma medication (3.1%), and medication to treat anxiety/depression (2.6%). The pattern of CPM in the main categories differed between 21.1 km and 56 km race entrants.

CONCLUSIONS

One in eight race entrants use CPM, with a higher prevalence of use among older race entrants, female vs. males, and 21.1 km vs. 56 km race entrants. Frequent CPMs used are blood pressure lowering medication, cholesterol lowering medication, asthma medication, and medication to treat anxiety/depression. The use of CPM medications may increase the risk of medical complications during exercise, and these data help identify subgroups of entrants that may be at higher risk for race medical encounters.

Burden of Injury and Illness in the Road Race Medical Tent: A Narrative Review

OBJECTIVE

To summarize the literature relating to prehospital care at 5 km through marathon distance road races and present the epidemiology of common medical encounters, significant medical complications, and medical outcomes.

DATA SOURCES

We searched PubMed and Google Scholar for the published literature pertaining to road race medical tent encounters at 5 km through marathon distance road races from 2000 to 2018. We included English-language, original articles reporting on injury and illness incidence.

MAIN RESULTS

Standard medical encounter definitions have recently been formulated in response to the previous lack of uniform definitions. The incidence of medical complications at road races may be influenced by environmental conditions and race distance. Minor and moderate medical encounters, such as dermatologic injuries, musculoskeletal injuries, and exercise-associated collapse, are common. Serious and life-threatening medical complications, including exertional heat stroke, exercise-associated hyponatremia, and cardiac arrest, are less frequent. Fatalities are also rare, with rates of 0.3 to 5 per 100 000 participants reported at marathons. The ratio of hospital transports to medical encounters is low.

CONCLUSIONS

On-site medical services play a key role in the safety of both runners and the community. Future research and care initiatives in this field should focus on optimizing treatment protocols, promoting injury prevention efforts and reducing host community costs.

Medical encounters at community-based physical activity events (parkrun) in the UK

OBJECTIVE

To determine the incidence, clinical correlates and exposure risk of medical encounters during community-based physical activity events in the UK.

METHODS

An analysis of medical data from weekly, community-based physical activity events (parkrun) at 702 UK locations over a 6-year period (29 476 294 participations between 2014 and 2019) was conducted in order to define the incidence and clinical correlates of serious life-threatening, non-life-threatening and fatal medical encounters.

RESULTS

84 serious life-threatening encounters (overall incidence rate=0.26/100 000 participations) occurred including 18 fatalities (0.056/100 000 participations). Statistical modelling revealed that the probabilities of serious life-threatening encounters were exceptionally low, however, male sex, increasing age, slower personal best parkrun time and less prior running engagement/experience (average number of runs per year and number of years as a parkrun participant) were associated with increased probability of serious life-threatening encounters. These were largely accounted for by cardiac arrest (48/84, 57%) and acute coronary syndromes (20/84, 24%). Non-life-threatening medical encounters were mainly attributed to tripping or falling, with a reported incidence of 39.2/100 000 participations.

CONCLUSIONS

Serious life-threatening and fatal medical encounters associated with parkrun participation are extremely rare. In the context of a global public health crisis due to inactivity, this finding underscores the safety and corollary public health value of community running/walking events as a strategy to promote physical activity.

Independent Risk Factors Predicting Gradual Onset Injury in 2824 Trail Running Race Entrants: SAFER XVIII Study

INTRODUCTION

Trail running is characterized by elevation changes, with uneven and varying running surfaces. Risk factors that may predict gradual-onset running-related injuries (GORRIs) in short-distance trail running have not been explored. The objective was to determine risk factors that predict GORRIs in trail running race entrants who entered mass community-based trail running events.

METHODS

In this descriptive cross-sectional study, data were collected prospectively from a prerace medical screening questionnaire over 4 trail run events held annually. Using a Poisson regression model, runner demographics, race distance, running training/racing variables, history of chronic diseases (number of chronic diseases reported as a cumulative "chronic disease composite score"), and allergies were investigated to determine factors predicting self-reported GORRI history in the previous 12 mo.

RESULTS

This study included 2824 race entrants (80% of entrants). The retrospective annual incidence for GORRIs was 13%. Independent risk factors predicting GORRIs were longer race distance (P<0.0001), increasing chronic disease composite score (P=0.0012), and a history of allergies (P=0.0056). The lower limb (94%) was the main anatomic region of GORRIs, and soft tissue injuries accounted for most (83%) GORRIs. Common specific GORRIs were iliotibial band syndrome (22%), Achilles tendon injury (10%), and hamstring injury (9%).

CONCLUSIONS

Independent risk factors predicting GORRIs among trail running entrants included longer race distance, a higher chronic disease composite score, and a history of allergies. This study has highlighted trail running race entrants at risk for sustaining GORRIs who could be targeted for future injury prevention interventions.

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.

Recommendations on the Appropriate Level of Medical Support at Ultramarathons

Participation in ultramarathons continues to grow, especially among older individuals and among younger runners who may have less running and wilderness experience than many past participants. While ultramarathons tend to have relatively few serious medical issues, adverse medical incidents do occur. These factors make it increasingly important that appropriate safety precautions and medical support are defined and implemented at these events to enhance the safety of participants, spectators, and volunteers. This document establishes the minimum recommended level of medical support that should be available at ultramarathons based on current knowledge and the experience of the authors. It offers a balance that is intended to avoid excessive stress on the local medical system while also precluding undue burden on events to provide medical support beyond that which is practical. We propose a three-level classification system to define the extent of medical services, personnel, systems, supplies, and equipment in place and recommend the level of medical support based on event size, distance/duration, remoteness, and environmental conditions that may be encountered during the event. This document also outlines the recommended education and training of medical providers and discusses other medical and logistical considerations related to the provision of medical support at ultramarathons. We suggest that ultramarathon organizers review and adopt these recommendations to enhance safety and reduce the risk of adverse events to participants.

Risk Factors for Illness-related Medical Encounters during Cycling: A Study in 102,251 Race Starters-SAFER XI

PURPOSE

There are limited data on risk factors associated with illness-related medical encounters (illME) in cycling events. The aim of this study was to determine risk factors associated with illME in mass community-based endurance cycling events.

METHODS

This is a retrospective cross-sectional study in the Cape Town Cycle Tour (109 km), South Africa, with 102,251 race starters. All medical encounters for 3 yr were recorded by race medical doctors and nurses. illME were grouped into common illnesses by final diagnosis. A Poisson regression model was used to determine whether specific risk factors (age, sex, cycling speed, and average individual cyclist wet-bulb globe temperature [aiWBGT]) are associated with illME, serious and life-threatening or death ME, and specific common illME.

RESULTS

Independent risk factors associated with all illME 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 ME were older age (P = 0.007) and slower cycling speed (P = 0.016). Risk factors associated with specific common illME were fluid and electrolyte disorders (females, older age, and higher aiWBGT) and cardiovascular illness (older age).

CONCLUSION

Females, older age, slower cycling speed, and higher aiWBGT were associated with illME in endurance cycling. These data could be used to design and implement future prevention programs for illME in mass community-based endurance cycling events.

Pre-race screening and stratification predicts adverse events-A 4-year study in 29585 ultra-marathon entrants, SAFER X

BACKGROUND

Pre-race screening and risk stratification in recreational endurance runners may predict adverse events (AEs) during a race.

AIM

To determine if pre-race screening and risk stratification predict AEs during a race.

METHODS

A total of 29 585 participants (Male 71.1%, average age = 42.1 years; Female 28.9%, average age = 40.2 years) at the Two Oceans ultra-marathon races (56 km) completed a pre-race medical screening questionnaire and were risk stratified into four pre-specified groups [very high risk (VHR; existing cardiovascular disease-CVD:3.2%), high risk (HR; risk factors for CVD:10.5%), intermediate risk (IR; existing other chronic disease, medication use or injury:53.3%), and low risk (LR:33.0%)]. Race starters, finishers, and medical encounters (ME) were recorded. Did-not-start (DNS) rate (per 1000 entrants that did-not-start), did-not-finish (DNF) rate (per 1000 starters that did-not-finish), AE rate [per 1000 starters that either DNF or had an ME], and ME rate (per 1000 starters with an ME) were compared across risk categories.

RESULTS

Adverse events were significantly higher (per 1000 starters; 95%CI) in the VHR (68.9; 52.4-89.9:P = .0407) compared with the LR (51.3; 46.5-56.7). The DNS rate was significantly different between the IR (190.3; 184.0-196.9) and LR (207.4; 199.2-216.0: P = .0011). DNF rates were not different in the VHR (56.4; 41.9-75.9) compared to LR (44.2; 39.7-49.1: P = .1295), and ME rate was also not different between risk categories, however, VHR (12.9; 7.0-23.9) was approaching significance compared to LR (6.9; 5.2-9.1: P = .0662).

CONCLUSION

Pre-race medical screening and risk stratification may identify athletes at higher risk of AEs. Further studies should be performed in larger cohorts to clarify the role of pre-race medical screening in reducing AEs in endurance runners.

Profiling Collapsing Half Marathon Runners-Emerging Risk Factors: Results from Gothenburg Half Marathon

Among several serious medical conditions, arrhythmia and heat stroke are two important causes of death during endurance races. Clinically, collapsing might be the first sign of these serious conditions and may mimic the more common and benign exercise-associated collapse. Several risk factors have been reported in the literature. We aimed to conduct a qualitative study to find a perceived risk profile among runners who collapsed and who were transported by ambulances to the nearest hospital during Gothenburg’s half marathon (2010–2017). Collapsing runners seem to lack the ability to make a decision to withdraw from the contest despite being exhausted. They feel the pain, but are unable to put meaning to their feeling, to adjust their pacing, and to handle other influences. Consequently, they do not overcome the problem or assess the situation. These individual mental characteristics may indicate a unique profile for collapsing runners. Pre-race health control and educational initiatives aiming at mental preparedness and information before endurance races might be a necessary step to avoid life-threatening complications.

Participant Opinions and Expectations about Medical Services at Ultramarathons: Findings from the Ultrarunners Longitudinal TRAcking (ULTRA) Study

Background

This work explores the opinions and expectations of ultramarathon runners about medical services and their perceived quality during ultramarathons.

Methods

Focused questions related to medical services at ultramarathons were included in the 2018 survey of Ultrarunners Longitudinal TRAcking (ULTRA) Study enrollees.

Results

Among the 1,156 respondents, 83.2% agreed that ultramarathons should provide at least a minimum level of medical support with basic first aid and emergency transport services rated as the most important medical services, and individuals with basic first aid training rated as the most important medical providers at ultramarathons. Participant safety was felt to largely be the responsibility of each runner as well as the race and/or medical director. Among 832 respondents having completed an ultramarathon in 2016-2018, their impression of medical services at 4,853 ultramarathons was generally favorable. Of the four percent of times in which medical support was needed, it met expectations 74% of the time. Of the total of 240 different medical issues for which medical support was needed, blister management was the most common, accounting for 26.7% of issues.

Conclusions

Even though medical services receive minimal utilization during ultramarathons, ultramarathon runners largely believe that these events should provide at least a minimum level of medical support. Ultramarathon runners place a high onus for safety during ultramarathons on themselves, but they also place a high level of responsibility on race and medical directors, so it is prudent for the race and medical directors to consider this information and avoid a mismatch between runner expectations and the medical services actually provided.

Medical encounters (including injury and illness) at mass community-based endurance sports events: an international consensus statement on definitions and methods of data recording and reporting

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.