Medical problems encountered in long distance running are usually minor, but
with increasing numbers in mass-participation events the risk of incidents
occurring has multiplied.
Trained, elite runners are better able to tolerate adverse conditions without
risk of injury, but their performance will still be impaired. Even slight
departures from ideal conditions will rapidly increase the incidence of injury
among the masses of recreational runners. These may be due to heat or to cold,
but rare incidents of cardiovascular collapse and sudden death can occur in any
climate. More recently, deaths have resulted from exertional hyponatremia. This
condition is due to excessive amounts of water drunk before, during or after the
Although it is impossible to guarantee that such incidents will not occur the
advice on this page aims to help race organisers to:
- make informed decisions on reducing general medical risks
- provide timely advice to their participants
- organise their race-day medical provision
- deliver prompt medical assistance to race participants in need
- deal with any serious medical incidents that do arise
The advisory notes following are an abridged version of IAAF Competition
Medical Handbook, Part II: Medical Management and Administration for Long
Distance Road Racing (third edition). For more complete guidance than that
offered below, please consult this publication, or seek advice from the
International Institute for Race Medicine (IIRM)
Injuries sustained though heat or cold are directly related to environmental
conditions. Temperature, humidity, exposure to direct sun, wind and altitude are
mediated by individual factors like the runner's level of conditioning, heat
acclimatisation, pace, fluid intake and clothing.
When the date for a race is chosen a main determinant should be that it is held
at a climatically benign time of year. In all other than very cold climates
races are normally started as early as possible in the morning to allow elite
runners optimal conditions and the mass participants a chance to finish before
mid-afternoon peak temperatures.
Organisers should review historic meteorological data to determine the best time
of the year to hold the race. Risk of heat injury rises above 21C and 50%
humidity. Temperatures of above 28C with near-100% humidity represent severe
conditions which should be avoided. Holding the race under acceptable
environmental conditions should be a condition upon which the race is sanctioned
by the national federation.
Medical ethics require that the medical director makes recommendations to the
race director based on the best interests of runners and race volunteers and
staff. Even so, it is difficult to imagine cancellation of a major
mass-participation event with heavy involvement of sponsors and TV. If the race
director does not follow the medical recommendations, the medical director
should make these known to runners prior to the start of the race so that they
can reach an informed individual decision on whether to participate.
Lightning storms would almost certainly require the start to be postponed, and
hurricanes or typhoons would require the race to be cancelled. Beyond such
obvious cases, intelligent analysis of the risks involved in any given
circumstances demands a strong working relationship between the race director
and the medical director.
If race day is significantly hotter than the preceding days, or if the few days
leading up to and including race day are extremely hot, then the risk of
exertional heat stroke is much increased. Runners will either not be
acclimatised or else they may start the race already dehydrated from previous
heat exposure. If this is the case an announcement to this effect should be made
at the race start.
A graded flagging system based on the Heat Stress Index (HSI) has been devised
[where HSI = 0.7 wet bulb temperature + 0.2 black globe temperature + 0.1 dry
bulb temperature]. According to this system:
Black flag (extreme risk, HSI > 28C):
If cancellation is not possible participants should be advised of the risks and
not to compete.
Red flag (high risk, 28C > HSI > 23C):
All runners should be aware that heat injury is possible. Those susceptible to
heat should be advised not to compete and all runners urged to slow their pace
and hydrate adequately.
Yellow flag (moderate risk, 23C > HSI > 18C):
Those participants with high risk for heat stroke should withdraw.
Green flag (low risk, 18C > HSI)
White flag (low risk of hyperthermia but increased risk of hypothermia, 10C >
When this information is not available conditions can be roughly assessed by the
dew point temperature. If it lies between 15-21C conditions are stressful,
between 22-27C they will be oppressive and above 27C dangerous for runners
competing at high levels of exertion.
Elite competition may be subject to less restrictive conditions, but equivalent
guidelines developed for military personnel still advise:
HSI > 26C: Caution for risk of heat stroke
HSI > 28C: Discretion for unseasoned competitors
HSI > 30C: Suspend competition if less than three weeks acclimatisation
HSI > 32C: Suspend competition
Note that under this advice many championship races - such as the Women's
Olympic Marathon in Athens - would have been postponed.
There are relatively few races staged in conditions of extreme cold other than
those adventure races purpose-designed for this (Antarctica, North Pole) which
will feature safety procedures built in to their planning. Specialist
precautionary clothing will be required below 0C, and races should be cancelled
if temperatures drop to below -30C. Greater problems may be faced by unprepared
runners in normally temperate locations when unexpectedly cold conditions arise
- especially when exacerbated by rain and/or strong wind chill.
Information for runners
One of the best ways to avoid injury problems arising during a race is to give
runners advance warning of the risks they may face and the precautions they can
take to minimise these. There are several opportunities a race organiser can use
to do this:
Race instructions for registered runners
This is the best chance the race organiser will get to deliver detailed medical
advice to runners, alongside more general instructions.
It should include information on adequate training and race preparation, likely
race conditions, any specific risks, hot or cold weather self-care, the heat
stress warning system (if employed), fluid replacement, potential medical
problems that may arise during the race and an outline of what medical coverage
is available. Runners should be informed in advance that they should not
participate on race day if they feel ill or have just been ill. Recent
feverishness, vomiting, diarrhea, chest pains or other discomfort should be
taken as a signal for the runner to withdraw.
Runners should be warned to dress for the expected weather conditions. Hat and
gloves will allow much better body heat retention in cold weather. Polypropylene
tops will wick moisture away from the skin surface. In hot weather loose mesh
clothing is suitable and runners should be advised to start slowly, make use of
what shade is available and hydrate fully before and during the race. Runners
must be careful not to hydrate in excess of their loss of sweat as this can
cause hyponatremia, but is only likely to arise where runners are moving slowly
and stopping to take on significant amounts of water at every opportunity.
Runners can safely attempt to drink 300-600ml/hour during the race, preferably
in portions of 100-200ml every 20 minutes. By weighing themselves before and
after training sessions runners can estimate their individual fluid losses under
different conditions. After the race runners should drink a litre of fluid for
every kilogramme of weight lost.
Runners should be advised to change into dry clothing as soon as possible after
finishing. Plastic or foil sheets distributed at some race finishes are only
good as windbreakers and have no insulation value.
Runners should be instructed to print their name, address, phone number and
details of any ongoing medical problems, allergies and current medications and
supplements on the back of their runner number.
The start announcer should declare the following information:
- the current and predicted weather conditions (temperature, humidity, dew point, wind speed, cloud cover)
- the heat stress index colour coding
- the location of aid stations with medical personnel and types of fluid
- the need for appropriate race fluid intake, and the risks of taking too
much. Post-race re-hydration should be started immediately, until urine returns
to a pale straw colour.
- an explanation of warm or cold weather self-care
- the availability of medical coverage during the race
Runners at particular risk (the young, old, unfit or overweight, or those who
have suffered heat distress in the past, etc) should be made aware of this.
Pre-race seminars and runners' clinics and notices in local print and electronic
media can be used to further disseminate medical information relevant to them.
Each race should appoint a medical director, preferably a medical doctor, with
control of medical operations. The medical director and team should be included
in the race insurance.
Apart from the medical director, the following staff categories may be needed:
- Doctors with experience in sports medicine and emergency care
- Nurses with critical care or emergency room experience
- Paramedics and Emergency Medical Technicians
- Certified athletic trainers
- First response personnel
- Non-professional personnel with first aid training can serve as spotters,
assistants and record keepers.
- Non-medical support staff can act as recorders, transporters and supply
- Massage therapists are a useful but not essential part of the medical team.
Numbers of these personnel required will depend on the number of participants
and the injury rate of each particular race, which can usually be calculated
after two or three years of experience. Adverse conditions, either hot and humid
or very cold conditions, will need higher staffing levels. Staff can be most
efficiently deployed if the race follows an out-and-back route, rather than
using a loop or point-to-point course
Staff may be deployed:
- at fixed locations (aid stations) along the route
- in medical vehicles
- as first-response teams
- at the finish line
[for further details, particularly staffing requirements at these locations, see
the section on Medical provision at the race,
A pre-race day briefing should be conducted to familiarise all volunteers with
how medical coverage will be organised and delivered. When a meeting is not
possible written instruction sheets should be given out. A brief meeting in each
medical area just prior to the race should be used to reinforce earlier
instructions and relay any update in plans.
Medical staff should be easily identifiable, both by runners and by others in
the medical team, by using caps, armbands, t-shirts or vests labeled with the
person's specific function. Clothing for the medical team should be distinctive
from that of general volunteers, and races often use a red colour-coding.
Advanced life support emergency ambulance coverage should be available both at
the finish line and along the course. there should be one ambulance for races
less than 25km and two for races over 25km. Emergency response should aim to
have first aid available within 4 minutes of the incident, and emergency vehicle
response within 8 minutes. Course configuration and access restrictions may
dictate greater numbers of vehicles or the use of first response teams on
bicycles or motorbikes with minimal supplies, but also carrying automatic
defibrillators, whenever these are available..
Transportation for dropouts in good health should be arranged promptly, so that
this does not interfere with arrangements for those who cannot complete the
course due to fatigue, minor injury or illness. Medical support vehicles should
not be used to transport healthy runners otherwise unable to complete the
Local hospitals and emergency services should be notified of the race date,
start time and duration, course route, road closures and anticipated casualties.
Race volunteers should use the telephone accessed emergency notification system
Medical provision at the race
At the Start:
- Traffic control - Crowd and traffic control must ensure the unimpeded
flow of runners to the start and over the start line.
- Fluids - 500ml of water should be available for each runner, for
races lasting more than one hour. Carbohydrate/electrolyte drink should also be
- Toilets - Provision should be adequate and take into account
male/female race participation rates and duration of use of the facility. Mobile
toilet providers will have experience of general requirements.
- Starting order - Runners should be seeded into categories of expected
finish time. Runners expecting to run faster times should be placed closer to
the start line. Each category should be grouped within a well-marked area. This
should ease passage over the start line and assist runners to pace themselves
better during the race.
- Baggage check - A baggage check system is required for races where the
temperature is below 21C, and clothing storage should be available at all races.
- Announcements - Pre-race announcements should describe the actual and
anticipated weather conditions, the race medical provision including the
location of aid stations, the identification of medical volunteers and types of
fluid available. Runners should be reminded of the advice for self-care and
hydration in hot (or cold) weather which they should have previously received in
their race information packs.
- Heat stress indicators - Colour-coded flags indicating the heat
stress level should be prominently displayed (and announced) in the start area,
and in longer races also at aid stations along the course.
- Assessment - Weather conditions should be recorded for future
reference. Wherever possible, runners should be weighed before and after the
race to assess hydration loss. In ultra-marathons with low numbers of runners
each runner should have their starting weight recorded on their race number so
it can be checked against any subsequent weighing to detect excessive weight
loss (or gain, in cases of over-hydration).
On the course:
- Traffic control - Course marshals should be stationed at every
intersection and change in course direction. Vehicles should be diverted with
the co-operation of the highway authorities and police, or in smaller races
directed across intersections during breaks in the flow of runners.
- Crowd control - The starting pens, the finish area and the medical
area should all be cordoned off to provide for efficient through movement of
runners. Security will be needed to enforce this separation so that after
finishing runners have easy access to medical services, fluid replacement, dry
clothing, goodie bag and/or medal pickup, and into the reunion area.
- Communications - Radio-equipped spotter vehicles located at the
start and finish line, at aid stations and at fixed points on the course, or in
medical vans and sweep vehicles will speed the delivery of medical care. All
problems should be reported to a medical communications director to implement
the response. Spotters in radio contact patrolling between aid stations will
improve response times. Every volunteer should know the location of the nearest
pay phone so that they can also report problems when they arise, or use their
own mobile phone to do so. To assist in this a card printed with race day
contact numbers of key race personnel should be distributed to all staff.
This structure of communications will allow for information to be relayed from
many different sources, including other runners reporting incidents.
Communications volunteers should be easily identifiable to assist with this.
- Medical vans equipped with radio, medical personnel and supplies adequate to
deliver advanced life support should be supported by local emergency vehicles
accessible through the communications network. Medical vehicles should have
access lanes to the course.
- Sweep vehicles to pick up runners unable to complete the course should be
equipped with radio communications, fluids and blankets. One vehicle should
remain at the back of the field to close the course.
- A supply van should be available with additional medical supplies to
replenish depleted stock
- Evaluation - Impaired runners should be evaluated at the discretion of
the medical staff, and should not necessarily be retired from the race. Any
medical official has the authority to remove an impaired runner from further
competition if it is judged in the runner's best interest. Lack of orientation,
staggering or weaving or inability to focus vision are some obvious symptoms of
serious impairment. Runners and medical staff should be informed in pre-race
material of the basic evaluation criteria. Aggression is an early sign of heat or
cold injury and should be dealt with as such by the medical staff. Stopping the
runner and checking body temperature, blood pressure, pulse, respiration and
mental state will give better grounds for decision, and whether to further
transport the runner to the finish line medical station or to a local hospital
- Time limits - A reasonable time limit should be established for both runners
and volunteers and transportation should be made available to those unable to
finish within this time (for example, a six-hour time limit for a marathon would
equate to a pace of approx. 9 minutes/km).
Location - Major aid stations should be placed at high-risk areas
where risks of casualties are higher or access for evacuation is difficult.
Minor aid stations should be located every 5km and be located approximately 100m
after the water station. Very large fields may require more water stations but
runners and staff should be cautioned against excessive fluid intake.
- Major aid stations - equipped and staffed to provide the same level
of care as the finish line medical station.
- Minor aid stations - usually located in conjunction with water
stations to provide first aid and relief from minor discomfort (such as blisters
and chafing) and to transport any more serious cases on to specially equipped
Staffing - Aid stations should have a doctor, paramedic, emergency
medical technician, nurse or trained first-aid volunteers, a communications
operator and a recorder. The most qualified person should be in charge of the
Supplies - Aid stations should have available: ice and small plastic
bags, towels, petroleum jelly, blankets for races held under 21C, athletic
therapist kit and supplies for minor musculoskeletal injuries, chairs, cots and
a covered shelter.
Fluids - Approx. 250 - 330ml of water (common bottle sizes) should be
provided per runner, along with a glucose-electrolyte replacement drink. If it
is an out-back course supplies should be doubled and separated into two equal
parts, ready to serve to one side for the outward journey and to the other side
for the return. If two races pass by the water stations (eg marathon and
half-marathon) at different times then the supplies planned for each race should
be stored and served separately. Sponges are of no practical value in
dissipating body heat and are an unnecessary expense. Drinking is of far more
value than sponging.
Signs - Availability of drinks and their type, and the position of
aid stations, should be indicated to runners 100m before their location. Heat
stress indicators may also be posted at the aid stations.
Toilets - Portable toilets should be located at aid stations along
the course according to the volume of runners.
At the finish line:
- Medical area - The medical area should be located 100m or less past
the finish line. Any runners suffering collapse after crossing the finish line
must be swiftly evacuated to the medical area, which will also preserve
unimpeded flow across the finish line.
- Security - The medical area must be cordoned off with solid barriers
to secure it from spectator or media access. Credentials should be required for
access, except for runners in distress. A waiting area should be placed near to
the medical area.
- Staffing - For races with more than a thousand runners a triage
officer (preferably an emergency room doctor with sports medicine interest)
should direct distressed runners to appropriate delivery of care. Other
specialisms usefully employed may be family practice, emergency room, internal
medicine, and intensive care doctors from cardiology, pulmonology and
anesthesiology. A podiatrist and orthopedic surgeon can take care of bone and
joint problems. Nurses, physician assistants, emergency medical technicians,
paramedics and athletic trainers will make up the remainder of the team.
Non-medical personnel including stretcher bearers, walkers, clothing fetchers
and recorders should support the medical team in equal numbers.
- Supplies - Finish line field hospital supplies should include
adequate shelter from weather, toilets, lighting, and electrical source or
generator, heaters in cool conditions or fans and ice immersion tubs if it is
hot. Other facilities may include: defibrillator, cardiac resuscitation drug kit,
intubation kit, oxygen tank and administration sets, hand washing stand, cots,
chairs, blankets, towels, water in large containers and ice in plastic bags or
an ice chest, tables, stethoscopes, blood pressure cuffs, clinical thermometers
(and hyperthermia/hypothermia versions), elasticized bandages, inflatable arm
and leg splints, intravenous fluids and administration equipment (supervised by
a doctor), dressings and adhesive dressings.
- Records - Care records will serve both medical and legal purposes and
allow better planning for future races (for example, in the calculation of
staffing and supplies required). Meteorological conditions should also be
- Fluids - Water and/or carbohydrate/electrolyte replacement drink
should be readily available a short distance past the finish line. 500ml per
runner is recommended. Fruit juices and soft drinks are also acceptable for
post-race replenishment, and some salt content is recommended.
- Baggage check - Clothing should be easily accessible to runners
after finishing, especially in cold conditions.
- Medical area layout
- there should be easy access to the medical
area from the finish line and unimpeded movement within the medical area. The
area itself can be divided into sectors dealing with medical and skin, bone and
joint functions. All cases requiring intravenous lines should be grouped in the
same part of the tent. Emergency vehicles should have unimpeded entrance and
exit to the medical area.
- Spotters - Personnel should be stationed throughout the finish chutes
and reunion area to look out for possible cases of post-race collapse.
- Information - An injured runner list should be posted in a location
easily accessed by the public (within the reunion area) and updated regularly to
allay fears of relatives and friends of those runners who have not been located
in the reunion area. Computerised check-in and check-out in the medical area
will speed up this process. Runner numbers could be used instead of names, but
these may not be known to the family.
Protocol in serious cases
A pre-arranged protocol should be followed in any case of a serious incident,
such as a death. This should address the need for confidentiality and
notification of the family, as well as cover public comment through the press.
The medical director and the race director should act as spokespersons and all
public comment should be made through them. Members of the medical staff should
not discuss the case outside the immediate medical team, and should be made
aware of this obligation before race day.
For detailed information on likely medical situations arising during road races,
suggested medical protocols and interventions, please consult Part II, section 5
of the IAAF Competition Medical Handbook.
For further advice on medical aspects of the organisation of distance
races, the International Institute for Race Medicine (IIRM) maybe
able to assist.