The occurrence of cycling injuries in the western province: A descriptive study

0n 21 October 1989, a total of 902 randomly selected cyclists were questioned at the finish of the Burger-Sanlam 100km/50km race to determine the prevalence of cycling injuries in the preceding year. Of the total sample 551 cyclists (61 %) reported they had been injury-free during the 12 month period prior to the investigation. The remaining 351 cyclists had sustained a total of 681 injuries during the same period ie approximately 2 injuries per cyclist per year. The most commonly reported injuries were over-use injuries resulting in pain and discomfort in the back and neck regions (41%), with pain in the knee joint being the second most frequently reported injury (29%). This descriptive study has provided valuable base-line information on the types and frequency of injuries sustained by South African cyclists. In particular, the high number of overuse injuries associated with faulty ergonomics has generated hypotheses for further study. An intimate knowledge of the ergonomics related to the sport, as well as attention to educational programmes is also strongly indicated.


INTRODUCTION AND MOTIVATION
Descriptive studies are the natural pre cursor to other studies, and are essential in providing researchers with base-line infor m ation before m ore involved types of studies are embarked upon. Descriptive studies generally examine the occurrence and distribution of diseases or injuries ac cording to group characteristics such as sex, race, age, socio-economic status or geographical distribution. An attempt is then made to explain the observed find ings. This can aid in the identification of possible causal (aetiogical) factors, and fre quently generates hypotheses for further study1. The lack of inform ation regarding the occurrence of cycling injuries in South Africa, together with the increasing popu larity of th l sport, prompted this descrip tive study.
The pa^t two decades has seen a sharp increase in the popularity of both com peti tive and "fu n " cycling2.
Cycling appears to be a relatively "safe" sport as there are no repetitive, high-impact, full-w eightbearing movements in volved, as is the case in running. The ap parent safety of the sport prompts both medical and supplementary health profes sionals to encourage the use of cycling for the promotion and maintenance of health, as well as for rehabilitation purposes3'4. Sportsmen too, frequently use cycling for rehabili ta tion purposes following injury or operative procedures to the knee. Cycling injuries can be grouped into two main ca tegories: • Injuries rela ted to falls, crashes, or colli sions • Injuries related to over-use5.
Falls and accidents are regarded by some authors as the main cause of all cv- 6 7 cling injuries ' . H ow ever, over-use in juries, and in particular over-use injuries of the knee-joint, are of particular interest to m an y m e d ic a l p r a c titio n e r s and physiotherapists. During steady cycling, forces eq u iv alen t to body w eight are exerted on the pedals. During intermittent accelerations (eg. inclines, race start), these forces can exceed three times the body mass. More com petent cyclists maintain a high tempo ("sp in") of 80-100 revolutions per minute resulting in exceptionally fast alternating flexion and extension of the knee6,8. Incorrect positioning of the cyclist can result in stressful forces being re peatedly exerted on the knee-joint. This may result in the incidence of new injuries, or the aggravation of underlying pathology.

Study design:
In th is d e s c rip tiv e stu d y , the re searchers examined the occurrence of cy cling injuries over the 1 year period Oc tober 1988 to October 1989. The distribu tion of injuries according to cycling status (am ateur/fun/serious) and registration with clubs and Pedal Power Associations was examined.

Sampling:
The population consisted of 3 264 cy clists who completed the Burger-Sanlam 100km/50km race on 21 October 1989. The sample consisted of 923 cyclists (28%) ran domly selected as they crossed the finish ing line. Data on 21 cyclists was incomplete leaving a final study sample of 902 cyclists.

Measurement:
Each subject was interviewed and infor ma tion regarding the following was ob tained: • Personal data • C y c lin g s ta tu s (A m a te u r/ p ro fe ssional/serious-fun/fun-rider) • Membership with clubs/Pedal Power Associations • Occurrence o f injuries and falls (used sy n o n y m o u sly w ith co llisio n s and crashes) in the preceding 12 month period.

RESULTS AND DISCUSSION:
Cycling status: The distribution according to cycling status can be seen in Figure 1 (page 63) which illustrates that the majority of cy clists (852/923) were either fun-or serious fun-riders, with only a very small propor tion (50/923) being classed as amateurs. These findings confirm the popularity of "fu n " cycling . W hile this distribution may not necessarily reflect the proportions of cyclists (according to cycling status) of the total population who took part in the Burger/Sanlam race, it has been the authors' experience that the large number of funriders (52%) is characteristic of the Burger-Sanlam race. The total lack of participation by professional riders may be due to the Rapport cycle tour running concurrently.
In South Africa there are only a small handful o f highly-com petitive cyclists (amateurs) who are registered with the SA Cycling Federation. It was therefore ex pected that they would be out-numbered by the serious fun-riders (5% vs 40%). The status of 21 cyclists could not be deter mined and these cyclists were excluded from further study. ABSTRACT *0 n 21 October 1989, a total of 902 randomly selected cyclists were questioned at the finish of the Burger-Sanlam 100km/50km race to determine the prevalence of cycling injuries in the preceding year. Of the total sample 551 cyclists (61 %) reported they had been injuryfree during the 12 month period prior to the investigation. The remaining 351 cyclists had sustained a total of 681 injuries during the same period ie approximately 2 injuries per cyclist per year. The most commonly reported injuries were over-use injuries resulting in pain and discom fort in the back and neck regions (41%), with pain in the knee joint being the second most frequently reported injury (29%). This descriptive study has provided valuable base-line information on the types and fre quency of injuries sustained by South African cyclists. In particular, the high number of over use injuries associated with faulty ergonomics has generated hypotheses for further study. An intimate knowledge of the ergonomics re lated to the sport, as well as attention to educa tional programmes is also strongly indicated.
The percentage of fun-riders w ho are members of an organised body (like a PPA) is low (36%). PPA 's are regionally or ganised and ensure a good standard of organisation, safe routes and the strategic placement of water tables. PPA 's also pub lish a newsletter which could inform the cyclist about scientific training methods and the causes and treatment of injuries. Membership of a PFA would therefore presuppose a relatively high level of edu cation of the cyclist and a correspondingly low prevalence of injuries. However, a study of the Western Province magazine Life Cycle shows that the content is largely comprised of readers opinions, race criti cisms and articles on the wearing of hel mets. There are few articles on the causes and treatment of injuries, and no articles on the importance of correct ergonomics with a view to the prevention of injuries.
...continued from page 61 each of the different cycling status groups is given in Figure 2.  As only 36% of the fun-riders group were members of cycling clubs or PPA's, the authors expected the occurrence of in juries amongst the fun-rider group to ex ceed that of the other two groups.

Occurrence of injuries: General
The types and frequency of injuries as reported by the 902 sample subjects for the 12-month period October 1988 October 1989 can be seen in Table 1.  Table 1 indicates that more than half the total group (61%) were injury-free during the preceding 1 year period. Pain and dis comfort, excluding pain in the knee-joint, was most frequently reported (41% of all injuries). Pain in the knee-joint was the second most frequently reported injury (29% of all injuries), with "falls" (which included crashes, collisions or accidents) being the third m ost frequently reported injury (20% of all injuries).
It was postulated that the more serious the level of competition, the higher the proportional increase in injuries. An exam ination of the percentage of injuries for The proportions of cyclists who re ported being injury free during the preced ing 12-m onth period varied from 34% (17/50) for the amateur cyclists, to 41% for the serious fun-rider group (152/371) and 53% for the fun-rider group (255/481). If one examines the distribution of cyclists sustaining injuries in each of the different groups, the percentage of amateur cyclists sustaining injuries exceeds that of the serious-fun and fun-rider groups for all types of injuries.
The large proportion of amateur cyclists who sustain injuries may be attributed to factors such as high speeds, increased ag gression, and increased time and intensity of training. Serious fun-riders are less com petitive than amateurs and cycle for indi vidual performance, while fun-riders cycle merely for pleasure.
W hile 523 cyclists reported being in jury-free during the preceding 12-month period, the rem aining 379 subjects re ported a total of 681 injuries during the same period.
W hile 34% of amateurs in this study, who made up the smallest group, experi enced some degree of pain or discomfort this comprises only 3% of the total number of injuries. This is in marked contrast with the other two groups (serious-fun and funriders), where pain and discomfort com prised 18% and 21% of all injuries respec tively. W hile physiotherapists may, there fore, treat injuries sustained by highly competitive amateur cyclists, they can ex pect to see large numbers of injuries from the other two categories of cyclists as well.

Occurrence of injuries: Specific
In this study, falls were the third most frequently reported injury, and comprised 20% of all injuries (See Table 1). This is in contrast with Town (1985) who regards falls as "the most important source of in juries amongst cyclist"7. The percentages of falls in this study is higher than the prevalence of 13% as reported by Kruze et al10, whose study sample consisted of 528 students who cycled for sport, recreation or competitive reasons. (The samples in these two stu d ies are th erefo re com parable.) The percentage of reported falls per cy cling status group was: • amateurs (26%) • serious fun-riders (20%) • fun-riders (9%) The low number of falls reported in the fun-rider group may be attributed to sev eral possible factors such as lower speeds, less com petitiveness and aggression, and fewer hours and kilom eters on the cycle.
The percentage of falls reported by the amateur cyclists in this study (26%) is mar kedly higher than the 3.2% as reported by McLennan et al (1988) whose study sample consisted only of amateurs9. This finding may be a reflection of the inexperience of our amateur cyclists due to lack of interna tional com petition, or the fact that prior to this study, little or no seeding was done in most cycle races.
McLennan et al (1988) report that the prevalence of falls in the USA was reduced from 3.2:% to 1.5% after a four-year period during which an injury-prevention pro gramme was implem ented9. In com pari son with this reduced percentage, South African cyclists appear to have a much higher frequency of falls when compared to their Am erican counterparts ie., a seventeen-times higher occurrence of falls. Of even greater concern is the fact that all of the falls reported in M cLennan's study oc curred during races held at 1,500 metres above sea-level, where acute mountainsickness (which impairs concentration and reflexes) plays a m ajor causative role in the incidence of falls9. It is evident from the results in this study that there is a need to increase the standard and safety of all as pects of cycling in South Africa. Clubs and PPA 's could play an im portant and active role in this respect.
The injuries sustained from falling can be divided into m inor and major injuries.

Minor injuries:
Bruises and abrasions: The three ca tegories of riders showed no marked dif ferences with regard to minor injuries sus tained, w ith the frequency o f bruising ranging from 92% in the amateur group to 95% in the fun-rider group. Abrasions oc curred less frequently, varying from 31%-35% in the three groups. Ballham et al (1988) on the other hand, reported a much higher occurrence of abrasions (46.7%) oc curring am ongst a group of cyclists of mixed cycling status12. T his is slightly higher than the percentage found in this study. It is possible that the percentage in this study is an under-estimation, as it be came apparent, while interview ing sample subjects, that many did not regard bruises and abrasions as "inju ries".

Major injuries:
Fractures: The amateur riders in this study had a 23% occurrence of fractures as a result of falls. This is slightly lower than the 49.3% amongst American amateurs as reported by McLennan et al (1988)9. The apparently higher proportion of fractures in the American study should, however, be compared with caution, as the sample size was very large (n = 5482) and all falls had occurred in races exceeding 1500 metres above sea-level.
In this study 16.5% of the serious funrider and fun-rider groups sustained frac tures, which is com parable with the find ings o f Tucci and Barone (1988) and Biburz et al (1986) of 20% and 14.1% respec tively11,2.
Dislocations and sprains: Only 6% of cyclists sustained a dislocation or sprain as a result of a fall.
Head injuries: In South Africa the wear ing of helm ets is optional, although it may be a pre-requisite for participation in cer tain competitions. In this study 8.2% of cyclists reported suffering a head injury after falling. M cLennan et a l(1988) re ports a prevalence of 15% decreasing to 0% after the successful implementation o f an accident-prevention programme and the introduction of legislation enforcing the wearing of helmets of a specified safety standard9. In view of the possible severity of this type of injury, it would appear that South Africa has a definite need for the implementation of sim ilar precautionary measures. In addition, educational pro grammes regarding road safety, ensuring the good mechanical functioning of cycles and other safety measures (such as the wearing of protective clothing; teaching cyclists how to slip, fall, slide etc) are im perative.

Areas of pain and discomfort (knee joint excluded):
It can be seen from Figure 2 that there was an almost equal distribution of reports of pain and discom fort among the three groups of cyclists (30%-34%). Most cyclists are likely to experience some degree of pain or discomfort, particularly when unfit or cycling long distances. The degree of pain and discom fort may be further in creased if positioning on the cycle is faulty or the wrong equipm ent is used.
More than half of the cyclists in each of the three groups experienced pain or dis comfort in the back and neck regions. This is frequently due to the sustained position of flexion on the cycle, faulty ergonomics, poor training techniques and/or weak ab dominal and/or back musculature. By cor recting the positioning on the cycle, streng thening the trunk musculature, and regu larly stretching the neck and lower back, these symptoms can be prevented6 '13,5,14. It is therefore important for the physiother apist to give attention to the latter prob lems (including an examination of the cy clist on his cycle) rather than just treat the presenting com plaints symptomatically.
Pain and discomfort in the buttocks was most evident in the fun-rider group and was probably due to their being unaccus tomed to the long distance of between 50km-100km they had just completed. Re lief can be found by correct positioning, regular training and the correct saddle size.
According to Noakes et al (1990), van Velden et al (1990) and Bohlman JT (1981), pain and discomfort in the hands is a com mon problem of cyclists15,3'6. In contrast with their findings, however, only 3.2% of the cyclists in this study reported this com plaint. Pain and discomfort in the upper limb region can be further minimised by correct positioning w ith resultant im p roved w e ig h t-d istrib u tio n , freq u en t changes of hand position and an improved level of fitness.
M u scle in ju ries did not featu re as prominently as was expected. Only 2.5% of all injuries fell into this group. Seven of the amateur riders experienced serious muscle injuries in comparison with only 15 cyclists in the serious-and 10 cyclists in the funrider groups.
Although not as com petitively inclined as the amateurs, the serious-and fun-rider cyclists still form a sizeable group who m ay r e q u ir e th e in te r v e n tio n o f a physiotherapist in order to prevent a re currence of the inj ury. In this study, muscle tears and tendinitis occurred equally fre quently.
The occurrence of dehydration, hypo thermia and hyperthermia ranged from 14% in the amateurs to 2% in the fun-rider group. The high summer temperatures in South Africa, during which most of the competitions take place, again highlights the urgent need for adequate education of cyclists to increase their awareness of these potential problems.

Pain and discomfort in the knee joint:
O f all the cyclists in this study 21.6% reported having experienced pain or dis comfort in the knee-joint in the preceding 12-month period (See Table 1). Thirty per cent of the amateurs, 26% of the serious fun-riders and 18% of the fun-riders had been afflicted by knee pain (See Figure 2). A subsequent investigation of this group showed that in 80% of the cases this pain resulted from incorrect ergonomic adjust ments leading to an incorrect critical knee angle. The critical knee-angle is defined as follows: With the cranks in the horizontal posi tion, a perpendicular line, which falls just posterior to the patella of the knee joint, should fall through the ball of the foot and the axle of the pedal, or as close as possible to it.
It has been the author's observation that fun-riders often train irregularly. They possibly also run the highest risk of having ergonomic faults with regard to frame size, saddle-height and positioning on the cycle. H ow ever, contrary to expectations, the percentage of knee-pain experienced in this group was the lowest. However, as fun-riders generally follow a training pro gram m e of low intensity, the effect of ergonomic faults w hich m ay have con tributed to the developm ent of knee-pain, could well have been obscured.
The occurrence of knee-pain amongst the amateurs was high (30%), and could be due to over-use and/or faulty ergonomics. M ore than half the cyclists experiencing knee-pain were members of PPA's. There fore, although these cyclists have access to clubs, trainers, and possibly the newest information regarding training methods, it would appear that little information from PPA newsletters regarding correct ergon om ics is conveyed, or if so, successfully reaches its target group.
In the light of these findings, it is imper ative for physiotherapists treating cyclists with sym ptom s of knee-pain to refrain from treating purely sym ptom atically. An examination o f the cyclist on his bike, to ensure that the critical knee-angle is cor rect, must be included in the rehabilitation programme. This is further emphasised when it is considered that sixty cyclists in this group had suffered previous injury or surgery to the knee-joint. They had started cycling on the recom m endation that it was a relatively "safe sp ort" and ideal for reha bilitation purposes. In the case of these cy clists a very carefu l exam in ation is needed to distinguish betw een the prior knee injury and incorrect ergonomics as the cause of their knee pain.

CONCLUSION
The above descriptive study has exam ined the occurrence of injuries in a select sample of cyclists who participated in the Burger-Sanlam race in October 1989. Al though 61% of the subjects reported that no injuries had been sustained in the preced ing 12-month period, a total of 681 injuries were reported. Pain and discom fort in the back and neck regions were m ost common, with pain in the knee-joint being the sec ond m ost frequently reported injury.
The percentage of cyclists reporting in juries over the preceding 12-month period was lowest in the fun-rider group. The percentage o f falls experien ced by all groups of riders was high, and indicates the need for the im plem entation of acci d en t-p rev en tio n and ed u cational pro grammes. Pedal Power Associations and clubs should play a more dynamic and educational role with regard to the causes and prevention of injuries. Legislation to enforce the com pulsory wearing of hel mets is also strongly indicated.
Cyclists should be made aware of the importance of correct positioning in order to prevent over-use injuries particularly of

INTRODUCTION
Cricket in South Africa plays a major socio-economic role and, through innova tions such as the one day limited overs and day-night games, is increasingly drawing the attention of large crowds throughout the country.
Cricket is becoming far more aggressive and faster1 and is placing greater strains on the cricketer's body. The lumbar area of the cricketer is one of the areas that is being placed under increased strain, especially in the fast bowling action2. This is taking place at a time when, with increased pro fessionalism, cricketers can least afford to be affected by disabling injuries, such as Low Back Pain (LBP).
LBP in itself has far reaching affects on the general com munity with as much as 5% of all time absent from work being attributed to LBP3. W ith theadded stresses and strains of modern cricket, epidemic levels of LBP are expected amongst cric keters. The problem of LBP is further ag gravated by the difficulty of making an accurate diagnosis. LBP is often charac terised by the stooped appearance associ ated w ith old age which could be harmful to the self esteem of a cricketer with LBP. Therefore, LBP is not frequently discussed by the cricketing fraternity, making it ex tremely difficult to ascertain the trueextent of LBP in cricketers.
The dearth o f research on cricket in South Africa and the changing nature of the game challenges science and medicine to explore the various aspects of the game.

METHOD
A questionnaire was given directly to 110 cricketers, 55 from the first teams of five cricket clubs and from five schools in the Western Cape during the 1991/92 sea son. The questionnaire consisted of an in itial set of close-ended questions as well as a further set of open-ended questions which allowed the respondents to voice their opinions.
A grading scale of pain severity was used to m easure LBP. The pain being graded as follows: Grade 1, an ache but could continue playing, G rade 2, pain which forced the player to leave the field and Grade 3, pain which prevented the playing of a match. Each respondent was classified as either a fast bowler (FB), slow bowler (SB), batsmen (BAT) and a wicket keeper (WK).
Numerous cricket practices and mat ches were visited in order to gain general information on warm-up methods, differ ent techniques shown and to obtain a feel for the cricketers' personalties and idio syncrasies.
The data obtained from the question naire was presented by means of descrip tive statistics with null hypotheses being formulated and tested by appropriate stat istical tests.

RESULTS
The return response was 90%. The mean age was 20.2 years with a range of between 15 and 35 years, with 55.6% of respondents being above 18 years old and 44.4% were younger than 18 years. The mean number of years playing cricket was 12.3 years with a range between 3 and 27. The respondents consisted of 37.4% FB, 58,6% BAT, 27.3% SB and 11.1% WK.