Injury, Int. J.

Care Injured 34 (2003) 207214

Sports injury or trauma? Injuries of the competition off-road motorcyclist

Nona T. Colburn , Richard D. Meyer
Division of Orthopaedics, University of Alabama Medical Center, and the Baptist Health Systems, 3317 Teakwood Road, Birmingham, AL 35226, USA

Accepted 7 February 2002

Abstract
A prospective analysis of the injuries of off-road competition motorcyclist at four International Six Day Enduro (ISDE) events was
performed utilizing the injury severity score (ISS) and the abbreviated injury scale (AIS). Of the 1787 participants, approximately 10%
received injuries that required attention from a medical response unit. The majority (85%) sustained a mild injury (mean ISS 3.9). Loss of
control while jumping and striking immovable objects were important risk determinants for serious injury. Although seasoned in off-road
experiences, mean 15.3 years, 54% of those injured were first year rookies to the ISDE event. Speeds were below 50 km/h in the majority
of accidents (80%), and were not statistically correlated with severity. The most frequently injured anatomical regions were the extremities
(57%). The most common types of injury were ligamentous (50%). Seventy-seven percent of all fractures were AIS grades 1 and 2. The
most common fractures were those of the foot and ankle (36%). Multiple fractures involving different anatomical regions, or a combination
of serious injuries was seen with only one rider. When compared to the injuries of the street motorcyclist, competition riders had lower AIS
grades of head and limb trauma. Off-road motorcycle competition is a relatively safe sport with injury rates comparably less than those of
contact sports such as American football and hockey.
2003 Elsevier Science Ltd. All rights reserved.

1. Introduction moderately severe. Only a few studies have been designed to

Motorcycle riding, in general, has a reputation for be-
ing dangerous [1,5,9,24]. Through variable methods of data
collection, injury patterns of the recreational road motorcy-
clist have been well established. Overall, these injuries are
likely to be severe (injury severity score (ISS) > 8), involve
multiple anatomical areas including head, abdomen, and tho-
rax, and show a preponderance of musculoskeletal injuries
in the form of fractures and dislocations [1,46,9,10,15,27,
32,33,35,38,41]. Fractures are usually open, contaminated,
and markedly comminuted [9,15,19,27,35,38,41]. A mortal-
ity rate of 34% has been reported [4,9,10,15,33,35,38,41]
and up to 20% required treatment in an intensive care unit
[15,26]. Collision of the motorcycle with another motor ve-
hicle is a common scenario [21,37,38,40,41]. Alcohol use
has been implicated in up to 70% of all fatal and non-fatal
motorcycle road crashes [4,5,7,9,28,37,38,40].
Investigations on the injury patterns of the competition
motorcyclist, both on [18,36] and off-road, are few. Injury
patterns in scrambling [39], motocross [11], enduro [22], and
desert racing [13] were predominately musculoskeletal, in-
volved only one anatomical region, and were deemed mild to
Corresponding author.
E-mail address: colburncycle1@aol.com (N.T. Colburn).
quantify motorcycle injuries by an objective measurement of
severity, the abbreviated injury scale (AIS) and the calculated
ISS [6,17,33,40]. To date there are no formal prospective
studies on the relative risk and injury patterns sustained by
an exclusive population of off-road motorcycle competitors.
The study was designed to prospectively ascertain the
type, severity, and mechanism of injury in an exclusive pop-
ulation of competition off-road motorcyclist.
2. Materials and methods
2.1. Sports fundamentals
The International Six Day Enduro (ISDE) is the largest
world championship off-road motorcycle sports event. Com-
monly referred to as the Olympics of Motorcycling, the
ISDE originated in England in 1913. Each year teams from
different countries compete against each other and the terrain
in a 6 days test of endurance. Points are awarded based on the
ability to complete sections of trail within a time schedule
posted by the event organizer. Hazards are primarily from
varying terrain. The averaged maximum speed allowed is
40 km/h (25 miles/h). The standard protective attire worn by
the competitor provides better protection from injury than

0020-1383/03/$ see front matter 2003 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 3 9 - 6
208 N.T. Colburn, R.D. Meyer / Injury, Int. J. Care Injured 34 (2003) 207214
that seen in any other population of motorcycle rider [24],
and includes helmet, shoulder pads, chest protector, gloves,
hip and knee pads, kidney belt, and knee-high padded boots.
The presence of trained medical personnel is mandatory at
the ISDE. This includes ambulances, physicians, emergency
medical technicians, an evacuation helicopter, an on-site
medical center, and a systematic radio communications op-
eration. In addition many countries have Team Physicians
who are primarily involved in the treatment of minor in-
juries and stabilization of old injuries. Coordination of the
response service is the responsibility of the Chief Medical
Officer (CMO), an emergency or sports medicine trained
physician.
2.2. Population studied
From 1992 to 1995 for four consecutive ISDE events
in Australia, Holland, USA and Poland, respectively a
prospective record was obtained on all injured competitors
attended by the medical response unit. Prior to each event
riders underwent a mandatory history and physical exami-
nation. Those with current or prior medical problems that
could prove hazardous in competition were excluded from
participation. Minimum age requirement for the ISDE is
16 years.
2.3. Data collection
In the context of this investigation, a rider was injured as
the result of mechanical energy sustained in a crash. Many
competitors fell from their motorcycles, but since they did
not require medical attention form the medical response unit,
they were not included in the analyzed results. Minor injuries
attended by the Team Physicians were also not included.
During the events in Australia (1992) and USA (1994),
injured riders were brought from the course by emergency
medical technicians to fully equipped centralized medical
facilities headed by a CMO. Emergency diagnostic and
therapeutic capabilities, including radiography, were avail-
able. At these facilities the first author was able to carefully
examine and record all details of the riders injuries in-
cluding subsequent diagnostic and therapeutic modalities
utilized. Individual riders were also interviewed and per-
sonal data and information concerning the nature of the
accident were obtained. Personal data included age, years of
riding experience, years of ISDE participation, and amount
of physical training prior to the event. Information concern-
ing the nature of the accident included the mechanism of
injury or how the rider lost control; how they were ejected
from the motorcycle; and the estimated speed at the time
of the accident. Those riders, as deemed by the CMO, who
required inpatient hospital care were then transported to
outlying Australian and American hospitals, respectively.
Information was obtained from the hospitals regarding in-
patient care received including the course and management,
operative procedures, and initial outcome.
During the events of 1993 and 1995, injured riders were
triaged in the field and dispersed by emergency medical
technicians to outlying Dutch and Polish medical facilities,
respectively. Therefore, data obtained by direct interview
concerning the mechanism of the accident, and personal
demographics were not available. Details of the injuries, di-
agnostic and therapeutic management, and initial outcome
were obtained by review of medical documentation from
emergency departments and inpatient hospital care.
Injury diagnosis were coded by the first author and vali-
dated by the CMO of each event according to the AIS, 1985
revision [14], and from which the ISS was calculated [2,3].
The 1985 revision was preferred because of its separate clas-
sification for external injuries, under which minor or moder-
ate injuries to the skin could be coded independent of their
location on the body surface, rather than dispersed across
body regions. External injuries as a distinct AIS class were
felt to be important in pattern recognition for this population
of motorcyclist.
With data obtained from interviewed riders at the Aus-
tralian and American medical centers, ranked ISS were
analyzed with respect to independent variables regarding
personal data and the nature of the accident, measured
both by univariate Pearson correlations and by selecting a
joint multiple regression equation by the stepwise selection
method. Differences were declared statistically significant at
P < 0.05. The kappa coefficient of interobserver variation
was 0.258.
3. Results
3.1. Demographics
A total of 1787 riders were entered in the four ISDE
events. Riders completing the events had successfully tra-
versed an average of 1535 km of combined trail and mo-
tocross laps in an allotted average of 2421 min (40 h and
21 min). There were 172 (9.6%) riders that required atten-
tion from the medical response unit. Of those 172 injuries,
completed questionnaires were obtained only at American
and Australian events for 121 riders, giving an overall
response rate of 70%. The incidence varied from 4.5%
(Holland) to 15.5% (USA) (Table 1). Approximately 93%
of the total injuries were evenly distributed during the first
4 days of each event. There were no fatalities.
Table 1
Distribution of injuries per event
Event Participants Injuries %
Australia 395 38 9.6
Holland 488 22 4.5
USA 540 83 15.4
Poland 364 29 8
Total 1787 172 9.6
 N.T. Colburn, R.D. Meyer / Injury, Int. J. Care Injured 34 (2003) 207214 209

Table 2 as based on random screenings, could not be implicated as

Demographics a major cause of accidents.
Sex Number of % Estimated speed at the time of accident, was below
riders 50 km/h in 80% of those injured riders who had been in-
Male 119 98.3 terviewed. Overall speeds were much slower in Tulsa, 88%
Female 2 1.7 below 30 km/h, as compared with 12% below 30 km/h in
Age (years) Australia. Twenty-two riders were unable to give an esti-
1622 17 14 mate (Fig. 1).
2329 44 36.4
3036 40 33.1
3744 12 9.9
3.2. Mechanism of injury
>45 3 2.5
NA 5 4.1 The most common mechanism reported for loss of control
Average: age range 1652 years 29.3 of the motorcycle in a crash situation was collision with an
immovable object (70%), such as a tree or rock. This was fol-
Riding experience (years)
05 10 8.3 lowed by loss of traction (15%), and collision with a movable
610 23 19 object (6%), such as a boundary marker or another motor-
1115 26 21.5 cyclist. Loss of control from high speed wobble, a condition
1620 34 28.1 where the motorcycle starts to oscillate and becomes diffi-
2125 14 11.6
cult to steer, accounted for approximately 2% of the total.
2630 9 7.4
>31 1 0.8 The most common direction in which the rider was thrown
NA 4 3.3 from the motorcycle was over the handlebars (45%). Forty
Average: riding experience range 232 years 15.3
percent of those injured riders ejected from the motorcy-
cle reported the hands or arms as being the initial point of
ISDE experience (years)
contact as they landed (Table 3). Forty riders were injured
1 65 53.7
2 20 16.5 without porting from the motorcycle.
3 13 10.7
4 6 5 3.3. Abbreviated injury scale and patterns injury
5 2 1.7
6 5 4.1
7 1 0.8
Utilizing the AIS, 72% of the injured riders had only
8 2 1.7 one of the six major anatomical regions involved ranging in
9 2 1.7 severity from one to five. Ninety-one percent of all injuries
>10 1 0.8
NA 4 3.3 Table 3
Average: ISDE experience range 113 years 2.2 Mechanism of injury

Physical training (h per week) Loss of control Mean ISS Number %

05 20 16.5 of riders
610 43 35.5 Jumping 10 5 4.7
1120 32 26.4 Immovable objects 9.5 74 70
2130 6 5 High speed wobble 4.5 2 1.8
3140 2 1.7 Loss of traction 2.8 16 15
>41 3 2.5 Movable objects 2 6 5.7
NA 15 12.4 Amnestic 3 2.8
Average: physical training range 063 h per week 12.1 Ejected from bike 76 62.8
Over the handlebar 34 44.7
To left side 17 22.4
Demographics of the injured riders who completed ques- To right side 23 30.3
tionnaires are shown in Table 2. There were 119 males and Backwards 2 2.6
2 females. Ages, when available, ranged from 16 to 52 with Not ejected 40 33.1
a median of 29.3. The mean years of riding experience was Amnestic 5 4.1
15.3, with a S.D. of 6.6. The mean ISDE experience was Initial landing
2.2 years with a S.D. of 1.9. The amount of physical train- Hands/arms 30 36.6
ing in hours per week averaged 12.1. Seventy-one percent of Shoulders 24 29.3
the riders reported training at least 620 h per week in vari- Head 5 6.1
Hip/buttock 10 12.2
ous training activities such as running, bicycling, swimming,
Back 2 2.4
lifting weights, and practice riding. Injured riders were well Feet 4 4.9
protected in crash situations, as 92% reported wearing all
Amnestic 7 8.5
articles of standard protective equipment. Alcohol or drugs,
210 N.T. Colburn, R.D. Meyer / Injury, Int. J. Care Injured 34 (2003) 207214

Fig. 1. Estimated travel speed at injury.

were minor or moderate, AIS grades 1 and 2. The most fre- Ligamentous injuries, fractures and dislocations were
quently involved regions were the extremities (57%), exter- fairly evenly distributed between the upper (57%) and
nal injuries to the skin (23%), and head (9%). Spine (5%), lower (43%) extremities. Ligamentous injuries were pri-
thorax (4%), and abdomen (2%), were almost evenly dis- marily grade 1 (75%), involving the shoulder girdle and
tributed and did not constitute a major portion of the injuries knee, as acromioclavicular separations and collateral liga-
(Table 4). ment strains, respectively. Fractures and dislocations were
Injuries to the extremities were composed of ligamen- predominantly grades 1 and 2 (77%). Bones of the foot
tous (47%), fractures and dislocations (46%), and muscular and ankle were the most frequently involved (36%), 50%
strains (7%). Severity was predominately AIS grades 1 and of which were grades 1 and 2 phalangeal and metatarsal
2 (98%). Fig. 2 illustrates the injuries by body part and type. fractures. Other fractures included the hand/wrist (23%),
and upper arm/shoulder girdle (18%), with fractures to the
clavicle, metacarpal, phalynx, scaphoid, and humerus.
Table 4
Out of the 49 total fractures, 9 were comminuted and 5
Patterns of injury by the AIS were open. Forty-three percent of the open and commin-
uted fractures were to the toes and metatarsals. There were
AIS region Injuries (%) Grade
four AIS grade 3 dislocations involving the shoulder, hip,
1 2 3 4 5 and wrist, respectively. Multiple fractures involving differ-
Extremity 57 70 44 12 0 1 ent anatomical regions, or a combination of serious injuries
Ligamentous (60) 46 13 1 0 0 was seen with only one rider.
Fractures (49) 10 31 7 0 1 In Holland an automobile struck a rider at high speed trav-
Dislocations (10) 6 0 4 0 0 eling on a forbidden public highway. He sustained bilateral
Muscular strains (8) 8 0 0 0 0
open femur fractures, fractures of the left hand and elbow
External 23 38 13 0 0 0 (extremity, AIS grade 5), and a closed head injury (head,
Head 9 10 5 6 0 0
AIS grade 3).
Spine 5 10 0 0 0 0
Thorax 4 6 2 0 0 0 Nine percent of the injured riders sustained head injuries.
Abdomen 2 3 2 0 0 0 Concussion was the most common diagnostic finding (85%).
Grade total 137 66 18 0 1
Severity, based upon the degree of consciousness and the
presence or absence of neurological deficits, ranged from
Grade (%) 61.7 29.7 8.1 0 0.5
grades 13, with 47% grade 1. Two head injuries involved
N.T. Colburn, R.D. Meyer / Injury, Int. J. Care Injured 34 (2003) 207214 211

Fig. 2. ISDE injuries: body part and type.

Fig. 3. ISS of the injured riders.

212 N.T. Colburn, R.D. Meyer / Injury, Int. J. Care Injured 34 (2003) 207214
facial fractures. One rider sustained a serious AIS grade 3
mid-face LaFort with fracture-dislocation of the mandible,
broken teeth, and extensive facial lacerations (Australia).
Injuries to the thorax and abdomen were mainly blunt
trauma, resulting in bruised and broken ribs, and abdominal
contusions, grades 1 and 2. There were no spinal fractures
or dislocations. All the spine injuries were acute strains to
the cervical or lumbar spine, grade 1.
3.4. Injury severity score and analysis of variables
ISS ranged from 1 to 34, or minor to critical. Eighty-five
percent of the injuries were classified as mild with ISS scores
of 15. Forty-eight percent of the injuries were ISS 1 and 2.
The mean ISS was 3.9 (Fig. 3).
With data obtained from interviewed riders, analyzed re-
sults showed that ranked ISS did not correlate with either
experience in off-road riding or experience in international
competition. Though the majority of injured riders were
highly experienced in off-road riding, overall they had little
experience in international competition. This suggested that
although rookie participants may have been injured more
frequently, their injuries were not necessarily more severe.
Leaving the motorcycle during a jump was associated
with increased injury severity in Australia (P = 0.0016),
but staying with the motorcycle resulted in higher ISS in
America (P = 0.020). Those riders who stayed with the
bike were more likely to be injured striking an immovable
object (P = 0.0012), and sustain an injury to the lower ex-
tremity (P = 0.008). This was a reflection of the American
rocky terrain, as a rider would sustain a fractured metatarsal
after striking an immovable rock or stump. Riders who were
ejected over the handlebars were more likely to have struck
an immovable object (P = 0.014), initially land on their
head or shoulders (P = 0.004), sustain fractures to the up-
per extremity (P = 0.016), and sustain greater damage to
the motorcycle (P = 0.027). There was a highly significant
association between severity of injury and those riders who
sustained fractures (P = 0.0001).
Injury severity was not significantly correlated with speed
at the time of accident (P = 0.430). However, speed was
significantly correlated with the amount of training (P =
0.0001) and the years of ISDE experience (P = 0.05).
Therefore, riders who were injured at higher speeds were
usually highly trained seasoned ISDE participants.
4. Discussion
The injuries in off-road competition motorcyclist from
four International events were objectively measured using
the AIS and ISS. Additional information from Australia and
America allowed the ISS to be analyzed with respect to
personal data and nature of the accident. Overall, approx-
imately 10% received injuries that would require attention
from a medical response unit. The majority (85%) sustained
a mild injury, mean ISS 3.9. Loss of control while jumping
and striking immovable objects were important risk determi-
nants for serious injury. Although seasoned in off-road ex-
periences, mean 15.3 years, 54% of those injured were first
year rookies to the ISDE event. Speeds were below 50 km/h
in the majority of accidents (80%). Surprisingly, both speed
at the time of the accident and riding experience were not
statistically correlated with injury severity.
The extremity was the most frequently injured anatomical
region (57%). The most common type of injury was liga-
mentous (47%). Seventy-seven percent of all fractures was
grades 1 and 2. The most common fractures were those of
the foot and ankle (36%).
In Holland adverse weather conditions and impassable
trails forced riders to leave off-road sections for paved high-
way. One rider was hit by an automobile and sustained the
highest ISS (34) of the four events. Since this injury pat-
tern and mechanism of injury is no different from that seen
with the street motorcyclist [1], it is difficult to classify as
an off-road injury. To avoid such confrontations competi-
tors should stay on the planned course and promoters should
mark any hazardous points well in advance.
Two prospective casualty based studies of street motorcy-
cle injuries [33,40] were compared to the ISDE population
by the chi square test with regards to ISS frequency distribu-
tion. Street riders had significantly higher ISS than off-road
competition riders, primarily due to higher AIS grades of
head and limb trauma.
Since the definition of injury severity and the method
of data acquisition on sports injuries differ considerably
[20,34], rates of sports injury are more meaningful when
expressed as incidence per unit exposure time, or by calcu-
lating the number of injuries/1000 h of sports participation.
When utilizing an incidence-density denominator [34],
the relative risk of injury for the ISDE competitors was
2.7/1000 h ridden. Comparison with other sports show the
incidence of injury/1000 exposure hours can be as high as
18, 32, 59, and 66 in rugby [12], soccer [20], American
football [16] and hockey [23], respectively (Table 5).
The injury profile of ISDE competitors suggests that
off-road motorcycle competition is a relatively safe sport.
Though different riding conditions and terrain cause differ-
ent types of injuries, the pattern is predictable. Most injuries
occur in the form of fractures as a rider strikes an immovable
object or sustains a twisting ligamentous injury to the lower
extremity, or external injuries to the skin, not unlike those
Table 5
Comparison of injury exposure rates
Sport Source Number of injuries/1000
exposure hours
Off-road motorcyclist ISDE 2.7
Rugby [12] 18.3
Soccer [20] 32
Football [16] 59.3
Hockey [23] 66
 N.T. Colburn, R.D. Meyer / Injury, Int. J. Care Injured 34 (2003) 207214
seen in a contact sport such as football [8,25,30,31,42] or a
limited contact sport such as bicycling [29]. For the competi-
tor, special attention should be paid to conditioning of the
knee and upper extremity. Instruction on proper falling and
rolling techniques could help to reduce the relative increased
frequency of fractures seen in the off-road motorcyclist.
Since its inception in 1913, important advancements
have evolved to make the ISDE safer, most notably with
helmet, protective equipment and motorcycle technological
design. Stricter selection criteria for competitors, training
experience, conditioning, and the skills of the riders have all
vastly improved. Though complete prevention of injury in
the off-road motorcycle competitor cannot be expected, the
medical profession should be able to triage, diagnose and
treat injuries more effectively by being attuned to the nature
of the competition, its performance demands, patterns of
injury and injury rates.
Acknowledgements
The Baptist Health Systems, Birmingham, Alabama USA
sponsored this investigation, under the supervision of past
residency directors, Dr. William S. Blakemore and Dr. Joe
Bancroft. We gratefully acknowledge the cooperation of
the CMOs of each event who made every effort to assist us
in collection of information, Dr. Joe Girr (Australia), Dr.
Rick Hill (USA), and Dr. Marian Poludnikiewicz (Poland).
Appreciation is also due to Hugh Fleming, American Mo-
torcyclist Association, who helped to coordinate travel and
arrange contacts. We also acknowledge Edwin Bradley,
Ph.D. and Al Bartolucci, Ph.D. for statistical support, and
finally the ISDE competitors and ancillary personnel at
each event for their outstanding cooperation.
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