The Extreme Athlete


  • The definition of extreme sports (ES) extends to any sport featuring high speed, height, a real or perceived danger, a high level of physical exertion, highly specialized gear, or spectacular stunts and involves elements of increased risk. ES activities tend to be individual and can be pursued both competitively and noncompetitively.

  • ES activities often take place in remote locations and in variable environmental conditions (weather, terrain). Little or no access to medical care may be present, and even if medical care is available, it usually faces challenges related to longer response and transport times, access to limited resources, limited care provider experience due to low patient volume, and more extreme geographic and environmental challenges.

  • Popular ES include BMX and mountaineering; hang gliding and paragliding; free diving; surfing (including wave, wind, and kite surfing), personal watercraft; whitewater canoeing, kayaking, and rafting; bungee jumping, BASE jumping, and skydiving; extreme hiking and skateboarding; mountain biking; inline skating; ultraendurance races; alpine skiing and snowboarding; and ATV and motocross sports.

  • In the last 2 decades, there has been a major increase in both the popularity of and participation in ES, with dedicated TV channels, internet sites, high-rating competitions, and high-profile sponsors drawing more participants.

  • The popularity of ES has been highlighted in recent years by the success of the X Games, an Olympic-like multiday multisport competition showcasing the talents in ES.

  • The risk and severity of injury in some ES is high, and participation in ES is associated with risk of injury or even death. Therefore, the extreme athlete, both amateur and professional, as well as the medical personnel treating these athletes, must consider the risk of injury and measures for injury prevention.

  • Medical personnel treating the ES athlete need to be aware that there are numerous differences between the common tra­ditional sports and this newly developing area. These relate to the temperament of the athletes themselves, the particular epidemiology of injury, the initial management following injury, treatment decisions, and rehabilitation.


  • Injury mechanisms in ES are not well understood, particularly the injury pattern in many sports.

  • The highest injury rates in ES are justifiably found in two groups: new and inexperienced athletes who have just started engaging in ES and experienced extremists.

  • Reported injury rates in ES may be expected to increase during competition rather than training, a trend well recognized in common team sports as athletes are trying to push their limits even further for prizes, audience, or fame.

  • In some ES disciplines, the injury and fatality rates are hard to establish due to a lack of formal recorded events.

  • In many situations, the extreme athlete competes against oneself or the forces of nature, and the sport is practiced in relative isolation.

  • Unlike expected terrain and environmental conditions that are similar in most traditional sports (i.e., soccer is played on a real or synthetic grass field), comparison of injury rates across ES is difficult given the large variance in terrain and environmental conditions, which often change variably during a single competition or event.

Specific Extreme Sports and Their Associated Injuries


  • Skydiving is a major air sport of parachuting from an aircraft.

  • It can practiced both competitively and recreationally, with over 5.5 million jumps performed annually by over a million jumpers worldwide, including tandem jumps.

  • Injury rates are relatively high in sport skydiving.

  • Majority of the collective total number of jumps is performed by a significantly smaller number of sports skydivers, whereas a larger number of participants perform fewer jumps each.

  • Recent fatality estimations are about 1 per 16,300 jumpers and approximately 1 fatality per 88,000 jumps, which increases to 1 per 4,000 skydivers, excluding tandem jumps data.

  • About 60% of fatalities are categorized as expert jumpers, while students account for about 20% of fatalities.

  • Most fatalities (~70%) occur with the skydiver having at least one functional parachute on, and the majority have been caused by human error.

  • Fatalities are mostly related to low or no pull of the parachute (~30%), malfunctions of the parachute system (~15%), reserve canopy problems (~15%), midair collisions (~20%), and landing errors (~20%).

  • Fatalities are more common in experienced jumpers in their 4 th to 5 th decade of life and with on average 11 years of experience in the sport.

  • More than half of fatalities occur in jumpers holding the highest parachute license (USPA D-License).

  • Injury rates in skydiving are around 170 per 100,000 jumps, with only about 30% of these requiring a visit to an emergency department, and as few as 10% necessitating hospital admission.

  • About two thirds of injuries in skydiving are minor, with around a third of these commonly being abrasions and contusions. Lacerations constitute an additional 20%–25% of all minor injuries.

  • About 50% of injuries requiring emergency department follow-up treatment involve extremity trauma, with lower extremity injuries dominant (featured in as many as 80% of cases).

  • Fracture rates in skydiving are estimated at 0.5 fractures per 100,000 jumps (mostly limbs but also spinal).

  • The incidence of nonfatal events is estimated to be around 1 incident in every 2,000 jumps, decreasing to 1 per 3,200 jumps in licensed jumpers.

  • About 90% of the nonfatal injuries occur around the landing, with about 50% of injuries involving the lower extremities ( Fig. 101.1 ), about 20% involving the upper extremities ( Fig. 101.2 ), about 20% involving the back and spine, and <10% involving the head.

    Figure 101.1

    A hard stop landing in skydiving (or in paragliding), which can lead to a knee ligament injury.

    (Courtesy of Ori Kuper.)

    Figure 101.2

    An off-balanced landing in skydiving (or in paragliding) can result if a forearm fracture or even a pelvic injury.

    (Courtesy of Dr. Omer Mei-Dan.)

  • Injury severity is normally equally distributed between minor and moderate, with around 40% of each, with severe injuries accounting for a little over 10%.

  • Most serious injuries are experienced by licensed skydivers, while students in training have a 6-fold higher injury rate.

  • Women seem to be overreprepresented, with a higher proportion of landing injuries than men.

  • Although many parameters and participants have changed over the last 20 years, injury rates remain similar. Modern equipment has decreased overall morbidity and mortality, but it has also led to faster landings with increased limb injuries.

BASE Jumping

  • BASE jumping [ B uilding, A ntenna, S pan (a bridge, arch, or dome), and E arth (a cliff or other natural formation)] is a sport that developed from skydiving and uses specially adapted parachutes to jump from fixed objects (see Fig. 101.1 ).

  • The sport is estimated to involve only about 2,500–3,000 active members worldwide but is considered among the most dangerous adventure sports in the world, and significantly more dangerous than skydiving, as BASE jumps are performed from much lower altitudes (often less than 500 feet above ground level).

  • The sport appears to predominantly attract male participants.

  • It has been banned from many popular launch sites, such as the Eiffel Tower in Paris and in many national parks in the US.

  • Lower falling speeds with far less aerodynamic control and a high risk of losing flying stability leave little room for error. If the parachute is deployed while the jumper is unstable, there is a high risk of entanglement or malfunction. In such cases, the single canopy used may also be facing the wrong direction, which may not be problematic in skydiving.

  • Off-heading opening of the parachute resulting in an object strike is the leading cause of serious injury and fatality in BASE jumping.

  • As the sport takes place in close proximity to a cliff, a tower, or a building which is used as a jumping platform, the risk of collision with an object in BASE jumping is increased ( Fig. 101.3 ).

Jul 19, 2019 | Posted by in SPORT MEDICINE | Comments Off on The Extreme Athlete

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