enduro

mountain
bike
medical
funded and supported by conducted by
study
contents foreword
After almost three years of research, we’re pleased to present the results of
what is likely the largest medical study ever to be undertaken in mountain
biking.
Part 1 - Race Event Medical Study
Executive Summary page 3 Enduro racing is simply a competitive format that replicates mountain biking,
Rider demographics page 4 and therefore the aim of this study was not just to analyse elite sport, but also
Rider injury page 5 the mountain biking population as a whole.
When injuries happen page 5
Race position page 5 The report is split into two distinct parts; Part One focuses on the Enduro World Series (EWS)
Injury location and type page 6 and how, where and when riders get hurt in our own events, whilst Part Two surveyed riders
Injury diagnosis page 6 of all levels to find general trends in injury in all mountain bike riding regardless of racing or
events.

Part One includes over 2000 racers from 46 countries from 10 EWS events, giving us enough
data to provide what we believe to be accurate findings that we can all use to help us better
Part 2 - Rider Health Study
develop organised enduro competition in future years.

Executive Summary page 7

For Part Two we asked you, our riders and followers to complete an in-depth health survey
Rider demographics page 8
detailing all history of health issues and injury suffered from mountain bike riding (enduro for
Riding experience page 9
want of a better word) in and out of races or events. Overwhelmingly, over 3000 of you filled
Rider injury page 10
in the survey and 1940 of those riders from over 60 countries provided enough detailed and
When injuries happen page 10
complete responses for us to be able to be confident in the accuracy of the data. More than
Injury location and type page 11
half of riders who took part in the Rider Health Survey were riders racing below EWS level,
Injury diagnosis page 11
showing great engagement from amateur racers and riders too. Therefore, we feel confident
that this study provides a good reflection of injury and health for not just elite racers, but the
whole spectrum of rider ability and age.

A huge thanks to everyone who took part in our work and we hope you find the results as
Dissemination of education/information page 12 interesting and informative as we have.
Recommendations page 12
Conclusions page 13
Study Acknowledgements page 13
End Notes page 14
Chris Ball
Managing Director
Enduro World Series

2
part 1 two-season
enduro world series
race event
medical study
executive summary
During the two-season EWS race event medical study 8.9% of EWS riders were injured during the 10 EWS races.

Overall there were 9.35 injuries per 100 riders; this compares to 23.8% per 100 athletes in mountain biking during the Rio
2016 Olympic Summer Games[1], 34.4 for Snowboard Cross, and 20.7 per 100 athletes for Alpine Skiing, during the
Sochi 2014 Olympic Winter Games[2]

There were 0.08 race event injuries per rider per season with 12.3 days missed per injury in the EWS (all inclusive injury
definition); rugby has previously reported 1.8 match injuries per player per season with 33 days lost per injury (time loss
injury definition only)[3]

Almost a third of race event injuries occurred to inexperienced riders (those who only raced one EWS event)

Shoulder/clavicle injuries were the most common injury location, with shoulder/clavicle fractures and hand fractures the
injury diagnoses causing the greatest burden (total days needed to recovery from injury)

56% of shoulder/clavicle and 66% of hand fractures, occurred during falls, on rocky stages.

The rate of race event concussion injury was low, and severity mild. Overall 0.6% of riders competing in the 10 EWS
race events during 2017 and 2018 seasons suffered a concussion. This equated to 0.38 concussions per 100 EWS rider
races, or 1 concussion for every 263 EWS rider races.

A little over a third of all riders with a concussion did not take time off post injury, with just under a third continuing and
completing their race

The majority of laceration and contusion injuries were mild in severity, and occurred largely during steep technical stages.

3
rider demographics
Rider race and medical data was collected from 10 EWS races (Canada, France, New Zealand, Ireland, Italy,
Chile, Australia, Slovenia, Austria, and Madeira) during the 2017 and 2018 EWS Seasons.

Countries represented 46
Total number of riders 2,010
90% Male
10% Female

249 riders competed in both seasons (2017 and 2018), and 1411 riders only ever competed in one EWS race.

number of riders Table 1. Number (and percentage) of riders by race category

u21 senior masters total

(17 to 20) (w 21 to 34; m 21 to 39) (w 35+; m 40+)

296 1374 359 2029*

(14.6%) (67.7%) (17.7%)
women men women men women men women men
19 277 150 1224 29 330 198 1831
(*19 riders raced in more than one category i.e. an U21 rider then raced senior,
or senior rider then raced masters, from the 2017 to 2018 seasons)

women men

senior u21 masters

Figure 1. Percentage of riders by race category, by sex

4
 rider injury Rider injury data were collected by event medical staff during each EWS event, reporting any injuries where a rider sought medical treatment,
irrespective of whether there was any time loss or absence from racing. Injuries were reported for all stages, across both practice and racing
days.

During the two seasons 188 rider injuries were reported by event medical staff (Table 2). This equated to 8.9% of all riders in the study suffering
an injury, or equivalent to 9.35 injuries per 100 riders, with on average 12.3 days missed per injury.

Table 2. EWS medical reported rider injuries Figure 2 Percentage of riders injured and severity, by sex Table 3. Percentage of riders injured by race category

percentage 16
of riders
14

188 rider injuries 12

6.4 days
11.3% u21 men

179 total number of riders injured*

10 13.2 days
0% u21 women

8.3%
8

8.9% percentage of riders injured 6

senior men

9.35 injuries per 100 riders

4
14.7% senior women

7.6%
2

12.3 injury severity (days needed for recovery) 0

masters men

0%
*some riders had more than 1 injury during the study women men
masters women

injury rates were higher for female riders

but severity of injury was higher for male riders

when injuries happen race position

64%
in race
medical DNS

medical DNF
10.1%
45.7%
36% finished 39.4%
in official
training unknown 4.8%
Table 4. Percentage of rider injuries by race position
71% of injuries were caused by contact with the ground and
the remainder (29%) were for other reasons such as field of
20.1% of all Did Not Starts
play conditions, recurrence, overuse. 39.4% of riders (DNS) and Did Not Finishes
who sustained an injury (DNF) at EWS events were
due to injury
60% of all injuries occurred on rocky stages, and a third on
steep gradients (32%) completed the race

5
 injury location and type head
Shoulder/clavicle injuries caused the
greatest burden (total number of days
The shoulder/clavicle was the most commonly injured body location,
9.0% needed for recovery) with a total of
followed by the head, hand and lower leg (Table 5). The most
severely injured body locations (mean days needed for recovery, per
622.5 days lost due to all 25
injury) were the thoracic spine, thumb, shoulder and ankle. shoulder/clavicle injuries recorded.
body location no. of injuries % of injuries severity (days)

shoulder/clavicle 25 13.3% 24.9 shoulder/clavicle

17 9.0% 12.2
13.3%
hand

head 17 9.0% 5.4

lower leg 15 8.0% 11.8
elbow 14 7.4% 5.1
knee 13 6.9% 8.0
forearm 11 5.9% 5.7
11 5.9% 18.1
injury diagnosis
finger

ankle 8 4.3% 23.1

hip 7 3.7% 3.4
sternum/ribs 7 3.7% 11.6 hand Shoulder/clavicle fracture injuries caused the greatest burden
7 3.7% 15.0
9.0%
wrist
with a total of 442 days needed for recovery (Table 6).
lumbar spine/lower back 6 3.2% 4.5
face (inc. eye, ear, nose) 6 3.2% 1.2 injury diagnosis no. of injuries % of injuries severity burden
thigh 5 2.7% 8.0 (mean days
needed for
(total days
needed for

5 2.7% 34
recovery) recovery)
thumb

neck/cervical spine 4 2.1% 0.0 shoulder/clavicle fracture 9 4.7% 49.1 442

upper arm 3 1.6% 5.6 hand fracture 9 4.7% 17.9 161
thoracic spine/upper back 2 1.1% 45.0 wrist fracture 3 1.6% 35.0 105
pelvis/sacrum/buttocks/SIJ 2 1.1% 0.0
groin 1 0.5% 7.0 finger sprain 4 2.2% 26.3 105
abdomen 1 0.5% 10 Table 6. Injuries casuing the greatest burden by diagnosis

foot/toe 1 0.5% 0.0

Table 5. Number, percentage and severity of injuries, by body location.
lower leg Although not very severe the most frequently reported injury diagnoses were con-

most common injury types 8.0% cussion (7.3 % of all injuries), and lower leg (5.7%) and forearm (5.2%) lacerations.

recorded at EWS events Overall 0.6% of riders suffered a concussion, with on average 5.1 days lost per
injury. 42% of concussed riders had the SCAT 3/5 administered, the remainder did
not. 57% of riders diagnosed with concussion were reported to take time off riding
afterwards, the remainder had no time loss reported post race. 71% of riders with-
drew/abandoned, 29% continued racing.
lacerations contusions fractures

26% 19.2% 17.7%

4.8 days severity 4.7 days severity 34.3 days severity
Lower leg and forearm laceration injuries occurred largely during steep technical
stages.

6
part 2 rider health
study

In the second part of this report, the Enduro World Series carried out a rider health survey aimed at capturing broader information
about injury across all Enduro riders, both in and out of racing and throughout rider’s lives. The purpose was to provide wider insights
to help direct our education and sporting development for riders of all levels in both competitive racing, training and recreational
riding.

The EWS Rider Health Survey asked riders a series of detailed questions about their riding exposure and injury history. To minimise
recall bias riders were asked to only report significant injuries that lasted for 1 month or more. Minor injuries lasting less than 1
month were not recorded. The present report provides a summary of what riders themselves report occurring during their own riding.

executive summary
The majority of riders responding to the rider reported health survey were amateur/domestic enduro riders

Overall 40.7% of riders reported they had suffered a significant injury (an injury lasting a month or more) during Enduro mountain
bike riding

For the number of Enduro rider years reported, this equated to 0.15 significant injuries per rider per year, with 87.6 mean days
needed for recovery per injury.

The higher the level of Enduro riding and racing the greater the proportion of riders reporting a significant injury

Shoulder/clavicle injuries were the most common significant injury, representing a quarter of all injuries reported, with shoulder/-
clavicle fracture and shoulder dislocation injuries causing the greatest burden in terms of total number of days needed for recovery.

Concussion injury was the third most common diagnosis affecting 4% of all riders (equating 0.01 concussions per rider per year of
Enduro), and occurred more frequently in female riders. Overall a quarter of riders who reported suffering a concussion said they
continued their bike ride after the accident and almost two thirds of riders reported they did not follow a return-to-play (riding) pro-
tocol after suffering a concussion. Almost half of riders who reported a concussion also reported having had significant recurrenc-
es of concussion injury.

Race practice at an event shows the lowest proportion of injuries, with recreational riding or training away from events recording
the highest proportion of injury for all riders.

7
 rider demographics
Elite riders tended to be younger and with lower body mass compared with
Countries represented 61 other levels of riding (Table 8)
Total Survey Participants 1,940
91% Male
9% Female
female age
(yrs)
31.1 32.7 32.1
height 165.9 167.3 166.4
rider level: rider level: rider level: (cm)

ews ews tier 2 enduro body mass

(kg)
60.7 62.8 62.7
domestic
Riders competing Riders competing in Riders racing in Enduro
male age
(yrs)
32.0 32.2 34.0
internationally at
Enduro World Series
EWS affiliate events
(qualifiers, continental)
but not at any EWS or
EWS affiliate events
height
(cm)
179.1 179.6 179.3

20.7% 23.4% 55.9% 76.1 78.5 78.6

body mass
(kg)

combined age
(yrs)
31.9 32.3 33.6
Table 8: Mean age, height and body mass, by sex and level of riding

Of all Enduro riders responding to the survey 17.3% represented the United Kingdom,
The majority of responders were senior and masters level Enduro riders (Table 7). 14.0% the United States, 8.8% Canada and 8.4% Australia (Figure 4).

400
women men

205 (10.6%)
350
u21 (17 to 20)
300
1203 (62.2%) senior (w 21 to 34; m 21 to 39)
250

527 (27.2%) masters (w 35+; m 40+) 200

1935* total 150

100
Table 7. Number (and percentage) of riders by race category.
* Race category unknown for 5 riders
50

am m

ca ica
au da
lia

ire in

ne fra d
ze e

be ina

fin m
ge taly

lu e
po bia

sw gal

m en

a o
itz tria
nd

a l
ge a

ec nor d
pu y
po lic
sl nd
ec nia

er r
de nds

ilip rk

ro es

ra ia
gr ia
ce
i

th do
ut az
an

h wa
w nc

co il

ar fric
ic
n

an

au an

s
a
of do

iu

ph ma
ra

b
ch

ee
ed
na

la

la

la

la

la
er

sp

nt

e
rtu

ex
m

sw us

so br

ne ua
i
rm

pi
lg

la
al
st

ov

m
er
ng

n
re
h

st
ki
senior u21 masters
d
ite
es

cz
un

at
st
d
ite

Figure 3. Percentage of riders by race category, by sex

un

*28 countries with 3 riders or less not included in figure.

Figure 4. Number of riders by country of representation.

8
 rider experience
For all riders on average each rider reported 4.3 years Enduro mountain bike riding, equating to a total of 8,344 Enduro riding years. Enduro
World Series (EWS) riders reported participating in both Enduro riding and all types of mountain bike riding for more years compared to other
levels (Table 9). Male riders reported more years doing Enduro and all mountain bike riding compared with female riders.

Table 9: Years riding Enduro (and riding a mountain bike), by sex and present level.

ews 4.3 (11.2) 4.8 (13.8) 4.8 (13.4)

ews tier 2 3.3 (10.7) 4.4 (13.6) 4.3 (13.3)
enduro domestic 3.0 (8.4) 4.3 (13.3) 4.2 (12.7)
grand total 3.5 (9.9) 4.4 (13.3) 4.3 (13.0)

Of all Enduro riders completing the survey 29% reported having also competed previously in cross country mountain biking, 31% in Downhill
and 10% in other bike riding, while the remaining 30% had only ever ridden Enduro.

31%
29%
downhill
30%
enduro
cross country

9
 rider injury
Riders completing the survey were asked to report if they had had any significant injuries during their time doing Enduro training/general riding,
or competitive racing. A significant injury was defined as - any injury that caused pain and discomfort for most days for at least one month

In total, across all levels of riding, 789 riders reported sustaining 1234 significant injuries during Enduro riding (Table 10). Relative to the total
number of Enduro riding years this equated to a mean 0.12 significant injuries per rider per year.

Table 10. EWS rider health study injuries Figure 5. Percentage of riders injured and severity, by sex Figure 6. Percentage of riders reporting a significant injury
and severity, by level of riding

percentage 70 percentage 70
of riders of riders
60 107.8 days 60

1234 rider injuries

50 50
102.9 days

57.8 days
84.3 days
789 total number of riders injured* 40 40 83.5 days

30 30

40.7% percentage of riders reporting significant injury

20 20

0.15 injuries per rider per year 10 10

87.6 injury severity (days needed for recovery) 0

women men
0
ews ews tier 2 end dom

more female riders reported sustaining

a significant injury compared with male riders,
and with a greater severity

when injuries happen level and activity

at time of injury
ews ews tier 2 end dom total

racing 63 (32.8%) 27 (24.8%) 152 (16.3%) 242 (19.6%)

racing practice 31 (16.1%) 12 (11.0%) 109 (11.7%) 152 (12.3%)

Two thirds of all injuries were reported to occur during training/general
riding with the remainder either during racing or during formal race prac-
tice. training/riding 94 (49.0%) 70 (64.2%) 659 (70.6%) 823 (66.7%)
The higher the level of rider the greater the proportion of racing related
injuries, conversely the lower the level of rider the greater proportion of unknown 4 (2.1%) - 13 (1.4%) 17 (1.4%)
training related injuries (Table 11).

grand total 192 109 933 1234

Table 11. Number of significant injuries (and percentage) by level of riding, and activity at time of injury.

10
 injury location and type head
7.1%
The most commonly injured body location was the shoulder/clavicle, The most common type of significant injury (all levels, racing and
followed by the wrist, and then knee and head (Table 12), and most training combined) was a bone fracture (34.8% of all injuries) followed
severely injured the Pelvis/Sacrum/buttock, followed by the lower by dislocation/subluxation injuries (11.0%).
back/lumbar spine and upper back/thoracic spine.
Overall shoulder/clavicle injuries presented the greatest burden.

shoulder/clavicle

body location

shoulder/clavicle
no. of injuries

315
% of injuries

25.6%
severity (days)

93.7
25.6% injury diagnosis
wrist 119 9.6% 109.0
knee 88 7.1% 120.8 Shoulder/clavicle fracture was the specific diagnosis causing the

head 87 7.1% 90.0 greatest burden, followed by wrist fracture, concussion and then
shoulder dislocation (Table 13).
sternum/ribs 77 6.2% 44.9
hand 71 5.8% 70.5
ankle 49 4.0% 66.6
elbow 49 4.0% 71.5 wrist injury diagnosis no. of injuries % of injuries severity burden

47 3.8% 62.2 9.6%

(mean days (total days
needed for needed for
finger recovery) recovery)
lower back/lumbar spine 41 3.3% 133.1
thumb 36 2.9% 83.7 shoulder/clavicle fracture 111 9.0% 76.7 8519
lower leg 34 2.8% 50.4 wrist fracture 79 6.4% 101.2 7992
face 33 2.7% 25.3 concussion 81 6.6% 85.3 6913
26 2.1% 131.3
87 7.1% 72.7 6328
upper back/thoracic spine

thigh 25 2.0% 56.8 shoulder dislocation

forearm 23 1.9% 38.4 Table 13. Injuries casuing the greatest burden by diagnosis

pelvis/sacrum/buttock 22 1.8% 149.5

neck/cervical spine 20 1.6% 82.7
Nearly three quarters or all shoulder/clavicle and wrist fractures occurred
foot 19 1.5% 102.3 knee
during training, with half of shoulder dislocation and concussion injuries
hip 18 1.5% 114.8 7.1%
occurring during training and half during racing.
upper arm 11 0.9% 62.1
abdomen 8 0.6% 101.9 Female riders had a three times greater prevalence of concussion injury
toe 7 0.6% 83.7 than male riders. When experiencing a concussion 50% of riders said
achilles tendon 5 0.4% 106.6 they stopped riding immediately, 25% said they stopped a little while
groin 3 0.2% 70.3 later, and 25% said they continued riding. 74% of riders said they had
Table 12. Number, percentage and severity of significant injuries by body location. not heard of the SCAT concussion assessment, and 63% of riders said
they did not follow a return to play (riding) protocol post-concussion.

11
dissemination of education and information
Riders were asked where information, education and advice for the prevention and treatment of injury in Enduro riders should be targeted. Ranking in order of
importance, riders felt that the information should be aimed firstly at the riders themselves, followed by coaches and then team managers (table 14).

1st 2nd 3rd

team
4th
event 5th 6th
riders coaches managers medical family governing body 7th
sponsor

Table 14. Rank order

recommendations
Overall the rate of injury in the EWS race events was low, but targeting of specific interventions may help reduce the frequency and severity of injuries in some areas.

All riders report a substantial proportion of injuries occurring outside of Enduro race events (amateur riders in particular) and therefore education and best practice is
needed at all times, including when riders are out recreationally on the trails.

� Riders should wear more protective equipment against lacerations and abrasions during steep technical race stages, and also generally when training/doing recreational
riding, particularly on trails with steep rocky sections.
� Additional medical provision should be targeted by race event organisers around steep dirt and particularly rocky race stages
� Re-assessment of qualification criteria for new EWS riders/local riders who may only compete in one event.
� A rider head injury assessment protocol should be included at Enduro race events, for medical staff to use during and/or immediately after the race has been completed
for those suspected of having sustained a concussion.
� Introduction of ‘red flag’ concussion education for event Marshalls to enable them to radio down to race medical staff in the event of a suspected rider concussion
� If a rider is diagnosed with a concussion injury during racing they should be withdrawn immediately from competition.
� Concussion education information should be provided around ‘red flags’ and when to stop riding, reference guidance for treating concussion including how long a rider should
rest after injury, and return to play (riding) guidelines. This should be to targeted at recreational and domestic Enduro riders as well as EWS riders and their teams,
for use in training/general riding and racing.
� Provision for and rider use of shoulder pre-habilitation and rehabilitation training exercises to help reduce the number, and/or severity of significant shoulder injuries.
� Guidelines and educational information should be published in key other languages in addition to English
� First Aid skills/awareness/education is needed amongst riders as the majority of injuries occur during regular riding (training) away from organised events
� The mountain bike industry should consider future development of shoulder protection products

12
 conclusions
Injury patterns were similar across both medical reported injuries in EWS race events, and rider reported injuries across all levels. Female riders presented higher injury
rates than males riders, the majority of injuries were caused by contact with the ground, and shoulder injuries were most commonly reported and also caused the great-
est burden overall in terms of time lost and days needed to recover from injury.

While the rate of concussion injury was low there were some clear areas where positive changes can be made, and with concerns over longer-term health consequences
of repeated concussion injuries targeted injury prevention and education strategies focussed on this area will be of benefit.

Recreational riding or training away from events presented the highest proportion of injury for all riders. As riders tend to spend more time training/doing general riding
than racing it is perhaps unsurprising that more injuries occur in that environment, however it also highlights the importance of employing targeted prevention strategies
in both racing and training/general riding environments, across all levels of rider.

Targeted injury prevention strategies around laceration/abrasion injuries, shoulder injuries and concussion may help to reduce the rate, severity and recurrence rates in
these areas, and help to protect rider health.

study acknowledgements
A huge vote of thanks to all the EWS teams and riders for their assistance and cooperation and to the EWS race event medical staff who gave up their valuable time to
complete the data collection during the two-season medical study; and to all the individual riders who took the time to complete the enduro rider reported health survey.
Without whose help, time and input these projects would not have been possible.

Author
Dr Debbie Palmer, School of Applied Science, Edinburgh Napier University

13
 end notes
Ethical approval for the EWS Two-Season Medical Study and the Rider Health Study were granted through the
School of Applied Sciences, Edinburgh Napier University, UK. Rider Health Study consent was implicit
through a riders completion of the survey. EWS Medical Study rider consent was implicit through a riders par-
ticipation in an EWS sanctioned event. Injury definitions and data collection methods during the Two-Season
EWS Medical Study were aligned with the IOC injury and illness surveillance studies. Injury burden was defined
as the total number of days lost from riding (needed for recovery from injury). Injury severity was defined as the
average number of days lost from riding (needed for recovery), per injury. Injury severity categories were 1-3
days = minimal; 4-7 days = mild; 8-28 days = moderate; >28 days = severe.. [1] T Soligard, K Steffen, D Palmer
et al. Sports injuries and illnesses in the Rio de Janeiro 2016 Olympic Summer Games. British Journal of
Sports Medicine 2017; 51:1265-1271; [2] T Soligard, K Steffen, D Palmer-Green et al. Sports injuries and
illnesses in the Sochi 2014 Olympic Winter Games. British Journal of Sports Medicine 2015; 49:441-447; [3] J
Brooks, C Fuller, S Kemp et al. Epidemiology of injuries in English professional rugby union: part 1 match inju- funded and supported by conducted by
ries. British Journal of Sports Medicine 2005; 39:757-766.

13