Traumatic injuries to runners.

Introduction

With improper training, runners can strain muscles, suffer heel spurs, and get sidelined by stress fractures. With proper training, many runners can avoid the worst of these troubles. Runners may also suffer traumatic injuries--broken bones, concussions and even death--as they run along roadways, or even jog down sidewalks. My research questions how often traumatic injuries occur to runners and whether statistics can suggest how runners can reduce their likelihood of traumatic injury.

We found that limited data is available regarding traumatic injuries to runners. Reports of runner injuries from falls and from being struck by motor vehicles are rare. When these runner injuries are documented, they correlate well with pedestrian event and injury characteristics. In fact, most runner data is buried in pedestrian information, rather than being considered separately. Certainly, one conclusion of this study is that we must push for the collection of traumatic injury data that is specific to runners.

Review of the trauma center data at my own hospital and a search for published findings on the subject did point to some practices/habits that appear to increase and some that decrease the likelihood of traumatic injury while running.

Review of trauma center data

A review of the trauma registry of a busy Level-1 Trauma Center (Spectrum Health Butterworth Campus, Grand Rapids, Michigan) for the calendar years 1994-2003, revealed that nine patients out of 19,989 injury admissions were listed as injured while "jogging." Six of the nine patients were injured by falls, while three were hit by automobiles.

The review showed a significantly higher level of injuries in the patients struck by cars as evidenced by their Injury Severity Score (ISS), a numerical system used to stratify injury severity in patients. (ISS scores of 1-9 are considered minor injuries. ISS scores of 10-15 are moderate injuries, while ISS scores of 16-24 are considered severe. Scores greater than 24 are listed as being very severe. Case fatality in patients with ISS scores of 1-9 are less than 1%; for those patients with ISS scores greater than 24, there is a 33% case fatality.)

Four of the runners injured by falls had an ISS of 4 and the two other runners who fell had scores of 9. Runners hit by cars had scores of 4, 13, and 29. Four of the seven runners who were injured by falls had lower extremity fractures. One had an upper extremity fracture and one had a ruptured spleen that was managed nonoperatively. All six runners with fractures caused by falls required open reduction and internal fixation (ORIF). This may indicate that the fractures were not simple, perhaps caused by a significant force.

One runner, who had been hit by a car, sustained an open tibial fracture along with a pelvic fracture. These fractures required ORIF with the open tibial fracture needing multiple procedures. This patient also had a mild traumatic brain injury. Another runner hit by a car required an emergent craniotomy for both epidural and subdural hematomas. The third runner hit by a car had a simple tibial fracture.

Discussion of literature

A review of the current literature shows scant information regarding traumatic injuries to runners. No trauma center data is available however small the series. Published reports tend to be old and are comprised of anecdotal case reports or government statistics. One clever and informative article gathered its data from newspaper stories accumulated by a national news clipping service.

An eight-year study from the state of Rhode Island from the early 1980s reviewed 17 "jogging" deaths. Sixteen of these deaths were felt to be due to cardiovascular disease. One traumatic death was recorded in the series. A 24-year-old male, who had lost one eye from a prior incident, was struck on his blind side by a vehicle while crossing the highway. He was running at 10:30 p.m. It was concluded that "less than 0.5% of all pedestrian deaths involved a jogger and only 6% of jogging deaths were traumatic" (1), (2).

The state of Kentucky reported only 46 "pedestrian jogging" injury cases out of 6044 total pedestrians injured by vehicles in the calendar years 1999-2004. This data covered 5994 accidents labeled "Collisions with Pedestrians." There were 326 deaths in 319 of these accidents. Only two deaths were reported as being "joggers." Ages of these jogger deaths were not reported. Most of the injuries occurred in joggers in the 15-44 year old age group. Eight joggers were injured while the vehicle that struck them was making a right hand turn, three by vehicles turning left, and one individual was injured while the vehicle was backing up. Twenty-eight were injured while the vehicle was driving in a straight line. One was struck in a parking lot and 10 vehicle actions that struck runners were listed as "other." The state of Kentucky did not delineate whether the injured joggers were running with or against traffic. Vehicle action totals are higher than number of injured runners because multiple vehicle actions were reported (3).

In 1992, an article published in the Journal of Sports Medicine and Physical Fitness reported a medicallegal case where a runner was struck by a car. The runner sought major damages in a civil court because of his injuries. The defendant's counsel during the case raised the possibility that the euphoria generated by prolonged exercise may have created in the runner a sense of "invincibility." They felt that this predisposed the runner to reckless action. Court documents show that the defendant's counsel used phrases such as "jogging addiction," "alteration of consciousness," and "endorphins." The jogger in question had a history of alcohol and drug use, as well as "video addiction." During the incident, the runner darted in front of a car that was determined to have been already 75% across the cross walk. The court determined that the runner's action was reckless and the case was dismissed (4).

As noted above, review of the available literature shows only a scant amount of information on traumatic injuries to runners. No trauma center data could be found on this subject. Runner mortality reports focus on the cardiovascular system only. The National Trauma Databank report from 2004, as published by the American College of Surgeons, has no information on traumatic injuries to runners.

In personal communication with the National Trauma Databank, a databank representative stated that there is "no current subset that exists" to capture these patients. Most runner injuries are best captured in pedestrian categories but they must be searched for diligently. In the Grand Rapids trauma center records cited above, the nine injured patients were identified in the "pedestrian" database. In addition, traumatic injuries to runners may be missed because trauma center data does not include scene deaths or patients treated and released from the Emergency Department. A review of statistics from the Kent County, Michigan Coroner's Office shows no reports of jogger or runner deaths caused by vehicles in the last five years of this study.

Review of pedestrian data does show some correlation with runner injuries as listed above.

A report on pedestrian injuries by the United States Department of Transportation and Federal Highway Administration (FHWA-RD-99-078) reviewed pedestrian injuries in the United States. Data was gathered from several trauma centers and emergency departments. Researchers found that 64% of injury events did not involve a motor vehicle accident, and most of the events occurred in parking lots, sidewalks, etc.

Of those that did involve a motor vehicle, 88% occurred on the roadway. Pedestrian collisions with motor vehicles were more likely to involve males (2 of 3) with Blacks and Hispanics making up 51% of those injured. Again, 35% of pedestrian and motor vehicle collisions occur on roadways between 2 p.m. and 6 p.m. and another 29% between 6 p.m. and 10 p.m. Those pedestrians who were hit by motor vehicles on roads had an average of 2.3 injuries compared to 1.8 injuries to those pedestrians who were struck on sidewalks and parking lots. Unfortunately, ISS scores were not used in that study. Fractures were the most common injury type with lower limb injuries and fractures being more common, particularly among those patients hit by motor vehicles. Pedestrians struck on roads have a higher rate of head, face, neck, and torso injuries.

The National Safety Council published pedestrian statistics in their Injury Facts 2003 edition. They reported 57,000 deaths and 65,000 injuries in motor vehicle-pedestrian accidents; 45% of the deaths reported occurred when pedestrians crossed or entered streets. This was the leading cause of death in all age groups. Some 10% of the deaths and injuries occurred while pedestrians walked in the roadway. More cases occurred while walking with traffic (5.8%) than when walking against traffic (3.8%). There was no mention in this report of any injuries that occurred while jogging or running.

The most specific article available on jogger injuries was written by Allan F. Williams, PhD, and appeared in Public Health Reports in 1981 (4). That article analyzed 60 cases of motor vehicle/jogger injuries from 28 different states where 30 runners were killed and 35 injured. He reviewed police reports for 54 of those incidents. Details were not complete for all the incidents but 19 of the 35 non-fatal injuries were considered "serious or critical." Males accounted for 66% of the runners evaluated--71% of the non-fatal injuries, and 60% of the fatalities. The peak age group was 15-24 years of age. Two or more runners were involved in almost 40% of the collisions. Half of the collisions took place between 3 p.m. and 9 p.m.

Slightly more than half (53%) of the collisions occurred when running with traffic in between intersections. The majority of these runners were hit from behind, while a small number (24%) were hit by an oncoming vehicle when running against traffic. Only 7% of the injuries occurred when running across the roads between intersections and 5% occurred when running across the roads at intersections.

Summary

Most injuries to runners do not involve a motor vehicle. Males are more likely to be injured while running than females and they are more likely to be hit by a motor vehicle. Those struck by motor vehicles are injured more severely as evidenced by higher ISS scores, more fractures, and more head and torso injuries. Motor vehicles cause more lower extremity fractures than upper extremity fractures. Most of the patients injured are between the ages of 15 and 50. Existing data suggests that runners are twice as likely to be hit by a motor vehicle when running in the direction of traffic than when running against traffic. Most runners and pedestrians injured by vehicles are struck in the afternoon or evening hours, presumably as the visibility diminishes.

A few recommendations can be made based on this information. Data shows that runners are safer if they run against traffic than with traffic. Runners should always watch all vehicles and expect that the vehicle does not see them. If runners choose to run in the dark, they should wear reflective items or flashing lights to improve visibility. When running with a group, runners are more likely to be injured when running abreast of one another, particularly runners closest to the road. Because traumatic injuries to runners are more likely to occur from falls than from being hit by a vehicle, runners should watch for uneven ground or poorly maintained roads or sidewalks.

Prior to beginning any running program, the would-be runner should make sure they are fit enough to undertake vigorous physical activity. Cardiovascular deaths from running appear to be more common than traumatic deaths.

TABLE 1 Traumatic injuries to runners (Spectrum Health Butterworth
Campus, Grand Rapids, MI)

CAUSE       CASE #  AGE    LOS    ISS         DIAGNOSES
                          (DAYS)

RUNNERS       1      42      2     9       FEMORAL NECK FX
FALLS

              2      36      3     4         SPLEEN LAC

              3      39      1     9   RT. DISPLACED OLECRANON
                                                 FX

              4      46      1     4           FIB FX

              5      22      1     4    LATERAL MALLEOLUS FX
                                          DISPLACED FIB FX

              6      35      5     4     LF. TIBIA PLATEAU FX

RUNNERS       7      54     14    29   SDH, EDH, LOC > 24 HRS.
HIT BY CAR                                   MULTIPLE FX

              8      49      3     4      TIBIA PLATEAU FX

              9      52      5    13   LOC, CHI RT TYPE 3 OPEN
                                        TIB SHAFT FX, PELVIC
                                                 FX

AVG                 41.6   3.8    8.8

REFERENCES

(1) Thompson, PD, et al. Incidence of Death during Jogging in Rhode Island from 1975 through 1980. JAMA. 1982; 247 (18): 2535-2538.

(2) Thompson, PD, et al. Fatal Collisions between Joggers and Automobiles in Rhode Island. Letter to Editor. JAMA. 1984; 251 (24): 3221.

(3) Kentucky State Police. Traffic Accident Facts, reports for 1999-2004. www.kentuckystatepolice.org//pdf/acfact99.pdf. Accessed March 10, 2005.

(4) Shephard, RJ. Vehicle Injuries to Joggers. Case Report and Review. J Sports Med Phys Fitness. 1992; 32 (3): 321-331.

(5) Williams, AF. When Motor Vehicles Hit Joggers: An Analysis of 60 Cases. Public Health Reports. 1981; 96(5): 448-551. NLM Unique Journal Identifier: 9716844.

Carlos H. Rodriguez, MD, FACS