In this article for On the Risk, RGA’s Lauren Garfield shares her husband’s harrowing cycling accidents and explores the balance between cycling injuries and fatalities and the health benefits of the activity.
During summer of 2023, our family hit a bit of a rough patch, literally. My husband, Eric, an avid amateur cyclist, had two serious accidents between the end of June and Labor Day weekend. Our experiences navigating his complex injuries highlight the frequency and severity of bicycling-related accidents globally.
From an underwriting perspective, I decided to explore the risks and injuries associated with cycling, examining relevant data and studies, to determine whether the perceived dangers are balanced by the physical benefits of the activity.
In my husband’s first accident, he was riding alone on the street in an urban park near our home when his bike locked up, and he shot up and over the handlebars. His hypothesis is that there was a catch in the chain, but we will never really know what happened. He hit his head, cracking his helmet. One thigh hit the top tube of the frame hard enough to bend it, and he scraped his torso along the ground, causing significant road rash on one side of his body. I got a call from him telling me he was okay but that he needed to be picked up… from the ambulance tending to him at the park. He and the paramedic decided that a trip to the hospital was not necessary. I disagreed but was overruled. Over the next few days, we struggled to figure out how to get him x-rayed while also getting his very raw body cleaned-up. He was bruised, sore, and scraped-up but did not have any broken bones. He was confused right after the accident, and having cracked his helmet, his initial confusion was followed by a headache and sore neck for the next week. I suspected he had a concussion, though this was not medically verified since he wouldn’t go to the hospital. I established a rule that after any future accidents, he was to go to the hospital. Little did I know that he would need to employ this rule just a few months later. He healed from the June accident over the following weeks, got right back on his bike, and started training for a series of Labor Day Weekend races.
During Labor Day Weekend, Eric was registered to compete in four different amateur races. On the second day, I got a call from him that there had been a large pile-up during the race, and he had been injured. I felt good about the fact that he was able to call me, but this call was more urgent and included a request to meet him at the hospital. He said he knew his clavicle was broken and that he was not going to wait for the ambulance – they were too busy working on riders who could not walk away from the accident.
I had no idea at this time how seriously injured he was. I imagined we would sit in the waiting room of the emergency room (ER) for many hours and then walk out with him in a sling. I was wrong, and we were about to begin an extremely scary week.
The most positive thing about the ER was that we walked right in and got a quick evaluation. It was not busy, and the sweating, bleeding cyclist with the sling was taken back quickly. An x-ray showed that in addition to his clavicle being broken in two places, Eric also had broken his fifth and sixth ribs and had a hemopneumothorax (blood and air in the chest cavity). The situation got very serious very quickly when they informed us he needed a chest tube and that we were not going anywhere for a few days. To summarize what felt like a very long week in the hospital, my physically fit and healthy husband got a chest tube and was admitted to the hospital. When they tried to remove the chest tube four days later, his lung almost immediately collapsed, and he received another chest tube. Then, he had to have surgery on his lung to keep it from collapsing using video-assisted thorascopic surgery (VATS) with talc pleurodesis, a procedure in which talc is used to induce inflammation of the lining of the lungs and chest cavity, leading to adhesion. This procedure was extremely painful, and Eric came out with two more chest tubes. At the end of a week in the hospital, he finally went home with instructions not to do anything more than walking for a month. He could not use his arm due to the broken clavicle, and he was still in considerable pain from the whole constellation of injuries and surgery.
Our family takeaway from this experience is that bike racing is over. Eric says that the broken bones alone probably would not have been enough to dissuade him from racing, but the experience with his lung was very convincing. He is going to find a safer way to satisfy his middle-age need for speed and competitive exercise.
This whole experience led me to wonder about the safety of cycling and any statistics available about accidents and injuries. Anecdotally, being part of the cycling community, we know several people who have had serious accidents, but my perspective is biased by the large number of cyclists I know. Therefore, I did some research, with underwriting in mind, to look for available data and studies about cycling and risk for serious accidents, injuries, and mortality. I wondered if my perception of cycling risk was accurate and if the positive benefits for physical fitness might balance any of these risks.
As it turns out, there are an estimated 130,000 injuries and 1,000 bicycle rider deaths each year in the United States,[1] with over 50 million people (ages 6 and older) participating in bicycling in 2020 and 2021.[2] The overall percent of the U.S. population (ages 16 and older) who rode at least once a week was relatively modest in 2022 at 25%, compared to the highest cycling countries: India (67%), China (66%), and the Netherlands (65%),[3] however, participation in cycling grew over the last decade by almost 10 million riders.[4]
The number of cycling-related fatalities has also risen over the last decade. National Highway Traffic Safety Administration (NHTSA) data shows there was a 5% increase in fatal bicycle crashes between 2012-2016 and 2017-2021, with 2.7 fatal crashes per million U.S. residents.[5] Urban areas saw a 62% increase in fatalities since 2012 while the rate decreased by 38% in rural areas. Cycling fatalities occurred in every state in 2021, with the top five being Florida, California, Texas, New York, and Arizona.[5] The League of American Bicyclists, using NHTSA data, found that the U.S. cities with the highest rates of fatal crashes 2017-2021 were New Orleans (9.9/M) and Tucson (8.9/M).[6]
Vehicle-cyclist crashes are a common source of cyclist fatalities, with 2% of motor vehicle crash deaths involving a bicyclist. Data from the U.S. Department of Transportation’s Fatality Analysis Reporting System shows that since 1975, the overall rate of vehicle-cyclist fatalities has decreased by 4%, but this has not occurred equally across demographic groups. The rate has declined by 90% in cyclists under 20 years old while it has increased four times in riders 20 years and older. In every year, male cyclists have been more likely to experience a vehicle-related fatality, with males 20 years and older seeing the largest increase in rate.[7] In 2021, the most recent year of available data, 61% of those killed were not wearing a helmet.
Compared to other sports and recreational activities in the U.S., bicycling leads to the highest number of recreation-related emergency department (ED) visits for traumatic brain injury (TBI).
In a CDC report using data from the National Electronic Injury Surveillance System-All Injury Program, between 2009-2018 more than 596,000 ED visits were reported for bicycle-related TBIs. Rates were highest in adult males and in children ages 10-14 years. The overall rates per 100,000 population decreased by 27% during the study period, with the rate decreasing 48% in children but only 5.5% in adults.[8] A study from The Netherlands[9] characterized bicycling accident outcomes by examining data from all patients admitted to a level-1 trauma center following a bicycling accident from 2007-2017. They reported 1,986 accidents, 83% associated with regular bicycles (not due to racing, off-roading, or e-bikes). Riders were 61% male, and 92.5% were not wearing helmets. They suffered multiple injuries in 41% of cases, and the mortality rate was 5.7%.
While there are risks associated with cycling, there are also health benefits. We reviewed a meta-analysis of 187,000 individuals (mostly European) and 2.1 million person years looking at exposure to cycling 11.25 MET.hours per week (intensity of 4.5 METs for 2.5 hours per week; METS = metabolic equivalents where one MET is the resting oxygen uptake when sitting and walking up a hill is equivalent to 4 METs). Investigators found a risk reduction of 0.90 (95%CI 0.87-0.94) in all-cause mortality, which is a 10% decrease in risk. This is comparable to the risk reduction achieved from 11.25 MET.hours per week of walking.[10] Similar risk reduction was found in a large English study[11] of 22,000 middle-age and older individuals followed for over a decade. They reported their physical activity and completed a health assessment. Cycling at least 60 minutes per week was associated with a 9% reduction in all-cause mortality. Finally, in a study from the U.K. biobank[12] looking at active commuting in 263,000 middle-aged adults, researchers found that commuting by cycling was associated with decreased risk of all-cause mortality (HR=0.59, 95%CI 0.42-0.83). It was also associated with decreased risk of cancer mortality (HR=0.60, 95%CI 0.40-0.90) and CVD mortality (HR-0.48, 95%CI 0.25-0.92).
Cycling can be a source of physical fitness and is associated with evidence of decreased all-cause mortality, however, it is not without risk. To put the rate of cycling fatalities due to motor vehicles into perspective, in 2022, there were 2.2 pedestrian deaths per 100,000 people in the U.S. (22 per million residents)[13] versus the rate of 2.7 per million U.S. residents for bicyclists.5 However, there were many more people walking and running than cycling, so it is hard to compare directly.
There are several actions cyclists can take to decrease their risk of morbidity and mortality. Using designated cycling tracks is associated with reduced risk of injury compared to cycling on streets shared with motor vehicles.[14] Helmet use can also decrease the risk of fatal and nonfatal head injuries, which is one of the major causes of mortality.[15][16] In underwriting, physical fitness is a positive attribute, and cycling is one way to achieve fitness and reduction of risk for mortality. However, underwriters need to look for evidence of risky cycling behavior when evaluating these applicants. Looking for history of previous accidents, especially multiple previous accidents, and for helmet use may be one way to determine if the applicant is taking more risks than average. Additionally, multiple ED visits for other injuries, history of TBI, and other avocations associated with risk (rock climbing, SCUBA diving, vehicle racing, etc.) may also indicate risk-taking behavior.
[1] Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Bicycle Safety. May 4,2022. Accessed 12/15/2023.
[2] Statista Research Department. Cycling – statistics & Facts. Statista. August 25, 2023. Accessed 12/15/2023.
[3] Statista Research Department. Weekly cycling frequency around the world 2022, by country. Statista. December 16, 2022. Accessed 12/15/2022.
[4] Statista Research Department. Bicycling participation in the U.S. 2010-2022. Statista. October 11, 2023. Accessed 12/15/2023.
[5] Allen Laman. Cycling fatalities reach 46-year high. Insurance Journal. June 7, 2023. Accessed 12/15/2023.
[6] Alex Fitzpatrick. These cities have the most bicycle deaths per capita. Axios. May 18, 2023. Accessed 12/15/2023.
[7] IIHS. Fatality Facts 2021: Bicyclists. IIHS. May, 2023. Accessed 12/15/2023.
[8] Sarmiento K, Haileyesus T, Waltzman D, Daugherty J. Emergency department visits for bicycle-related traumatic brain injuries among children and adults – United States, 2009-2018. Morbidity and Mortality Weekly Reports (MMWR). 2021:70(19);693-697. Accessed 12/15/2023.
[9] de Guerre L, Sadiqi S, Leenen L, Oner C, van Gaalen S. Injuries related to bicycle accidents: an epidemiological study in The Netherlands. European Journal of Trauma and Emergency Surgery. 2020:46;413-418. Accessed 12/15/2023.
[10] Kelly P, Kahlmeier S, Götschi T, Orsini N, Richards J, et al. Systematic review and meta-analysis of reduction in all-cause mortality from walking and cycling and shape of dose response relationship. International Journal of Behavioral Nutrition and Physical Activity. 2014:11;132. Accessed 12/15/2023.
[11] Sahlqvist S, Goodman A, Simmons R, Khaw K, Cavill N, et al. The association of cycling with all-cause, cardiovascular and cancer mortality: findings from the population-based EPIC-Norfolk cohort. BMJ Open. 2013:3(11);3003797. Accessed 12/25/2023.
[12] Celis-Morales C, Lyall D, Welsh P, Anderson J, Steell L, et al. Association between active commuting and incident cardiovascular disease, cancer, and mortality: prospective cohort study. BMJ. 2017:357;j1456. Accessed 12/15/2023.
[13] IIHS. Fatality Facts 2021: Pedestrians. IIHS. May, 2023. Accessed 12/15/2023.
[14] Lusk A, Furth P, Morency P, Miranda-Moreno L, Willett W, et al. Risk of injury for bicycling on cycle tracks versus in the street. Injury Prevention. 2011:17;131-135. Accessed 12/15/2023.
[15] Dodds N, Johnson R, Walton B, Bouamra O, Yates D, et al. Evaluating the impact of cycle helmet use on severe traumatic brain injury and death in a national cohort of over 11000 pedal cyclists: a retrospective study from the NHS England Trauma Audit and Research Network dataset. BMJ Open. 2019:9;e027845. Accessed 12/15/2023.
[16] American College of Surgeons Committee on Trauma and Subcommittee on Injury Prevention and Control. Statement on bicycle safety and the promotion of bicycle helmet use. American College of Surgeons. March 15, 2023. Accessed 12/15/2023.
