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Racing in Rising Global Temperatures: A Scoping Review of Heat-related Illnesses in Endurance Running

Published online by Cambridge University Press:  24 July 2025

Sophia GörgensOpen the ORCID record for Sophia Görgens[Opens in a new window],
Attila J. HertelendyOpen the ORCID record for Attila J. Hertelendy[Opens in a new window],
Fadi Issa,
David Fernandez,
Ahmad AlshadadOpen the ORCID record for Ahmad Alshadad[Opens in a new window],
Lindsay DavisOpen the ORCID record for Lindsay Davis[Opens in a new window],
Jeffrey M. FrancOpen the ORCID record for Jeffrey M. Franc[Opens in a new window],
Janice Kung,
Christina Ann WoodwardOpen the ORCID record for Christina Ann Woodward[Opens in a new window] and
Amalia Voskanyan
...Show all authors
Sophia Görgens*
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA
Attila J. Hertelendy
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USADepartment of Information Systems and Business Analytics, College of Business, Florida International University, Miami, FL, USA
Fadi Issa
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA
David Fernandez
Affiliation:
Simulation and Education Fellowship, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
Ahmad Alshadad
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA
Lindsay Davis
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA
Jeffrey M. Franc
Affiliation:
Department of Emergency Medicine, University of Alberta , Alberta, Canada
Janice Kung
Affiliation:
Geoffrey & Robyn Sperber Health Sciences Library, University of Alberta , Alberta, Canda
Christina Ann Woodward
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA
Amalia Voskanyan
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA
Greg Ciottone
Affiliation:
BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA
*
Corresponding author: Sophia Gorgens; Email: sgorgens@bidmc.harvard.edu
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Abstract

Objectives

As temperatures globally continue to rise, sporting events such as marathons will take place on warmer days, increasing the risk of exertional heat stroke (EHS).

Methods

The medical librarian developed and executed comprehensive searches in Ovid MEDLINE, Ovid Embase, CINAHL, SPORTDiscus, Scopus, and Web of Science Core Collection. Relevant keywords were selected. The results underwent title, abstract, and full text screening in a web-based tool called Covidence, and were analyzed for pertinent data.

Results

A total of 3918 results were retrieved. After duplicate removal and title, abstract, and full text screening, 38 articles remained for inclusion. There were 22 case reports, 12 retrospective reviews, and 4 prospective observational studies. The races included half marathons, marathons, and other long distances. In the case reports and retrospective reviews, the mean environmental temperatures were 21.3°C and 19.8°C, respectively. Discussions emphasized that increasing environmental temperatures result in higher incidences of EHS.

Conclusion

With rising global temperatures from climate change, athletes are at higher risk of EHS. Early ice water immersion is the best treatment for EHS. Earlier start times and cooling stations for races may mitigate incidences of EHS. Future work needs to concentrate on the establishment of EHS prevention and mitigation protocols.

Keywords

heat-related illnessesexertional heat strokeprehospital medicineevent medicineclimate change

Information

Type
Original Research
Information
Disaster Medicine and Public Health Preparedness , Volume 19 , 2025, e206
Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of Society for Disaster Medicine and Public Health, Inc

Heat-related illnesses refer to any pathology arising from high temperatures, with exertional heat stroke (EHS) being the most extreme presentation. EHS is generally defined as a core body temperature of >40 °C with mental status changes.Reference Nichols 1 Other symptoms of EHS or of its milder form, heat exhaustion, include syncope, lightheadedness, dizziness, and nausea.Reference Nichols 1 In its extreme, EHS can result in death, and sports-related EHS deaths have more than doubled since 1975 in the US.Reference Nichols 1 Although most people are able to adequately thermoregulate through conduction, convection, radiation, and evaporation, the stress of exercise and the environment (i.e., air temperatures) can overwhelm the body’s homeostasis. This can especially affect amateur athletes who have lower fitness levels or have not acclimatized to their environment.Reference Nichols 1 Running is a sport with a low barrier to entry (little specialized equipment beyond running shoes and clothes are needed) and is increasingly popular, meaning that its participants may be at higher risk for EHS.

Meanwhile, global temperatures continue to rise due to climate change, meaning that sporting events such as endurance running will take place on warmer days, further increasing the risk of EHS.Reference Zhao, Yu and Mahendran 2 Data from medical tents at events such as half marathons and marathons remain sparce, leaving the exact incidences of EHS and other heat-related illnesses unknown outside of a few choice races. As companies providing medical care at these events often vary, there is also no standardized protocol or treatment procedure for patients with EHS. This scoping review sought to answer the following research question: What is the current state of affairs regarding EHS at endurance running events, from patient characteristics and numbers to treatment plans and protocols?

Methods

In collaboration with the research team, the medical librarian (JYK) developed and executed comprehensive searches in Ovid MEDLINE, Ovid Embase, CINAHL, SPORTDiscus, Scopus, and Web of Science Core Collection on August 14, 2024. To capture all relevant literature pertaining to heat-related illnesses in marathon runners, relevant keywords and controlled vocabulary were carefully selected. Searches were limited to the English language. Refer to the appendices for full search strategies. A total of 3918 results were retrieved and when all duplicates were removed, 1698 unique results remained for the initial title and abstract screening in a web-based tool called Covidence (www.covidence.org). Bibliographies from included studies were also reviewed. This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).Reference Tricco, Lillie and Zarin 3

Inclusion criteria included research articles pertaining endurance runners experiencing heat-related illnesses. Endurance runners included any runners, athletes, or participants in half-marathons, marathons, endurance or long-distance races (longer than a half marathon), or ultra-marathons runners. Heat-related illnesses were defined to include EHS, heat exhaustion, and heat syncope. Relevant outcomes included characteristics or demographics, patient care, lessons learned from patients and events, prevalence of heat-related illness in endurance runners. Exclusion criteria included any articles that were not research (i.e., conference abstracts, letters to the editor, book chapters), were on races shorter than a half marathon, were not about runners, or did not look at heat-related illness as an outcome.

Two members of the research team assessed each title and abstract for inclusion or exclusion, with all conflicts resolved by a third person. After title and abstract screening, the remaining articles went through full-text review by 2 members of the research team, with all conflicts resolved by a third person. The final set of articles for inclusion were then analyzed and relevant data extracted.

Results

A total of 3918 results were retrieved and when all duplicates were removed, 1698 unique results remained (figure 1). These underwent title and abstract screening followed by full text screening in a web-based tool called Covidence. Two reviewers screened each title and abstract and each full text, with all conflicts resolved by a third reviewer. This resulted in 38 articles for inclusion in the study.Reference Asserraji, Benameur and Maoujoud 4 –Reference Seth and Juliana 25 Of these, 22 were case reports or case series (Table 1),Reference Asserraji, Benameur and Maoujoud 4 –Reference Seth and Juliana 25 12 were retrospective reviews (Table 2),Reference Breslow, Collins and Troyanos 26 –Reference Yankelson, Sadeh and Gershovitz 37 and 4 were prospective observational studies (Table 3).Reference Gerardin, Guedeney and Bellemain-Appaix 38 –Reference Stacey, Hill and Parsons 41

Figure 1.

PRISMA flow diagram of records identified through the database search, screened, and included for the scoping review.

Table 1.

Case reports and case series of heat-related illnesses in endurance running

EHS, exertional heat stroke; rhabdo, rhabdomyolysis; AKI, acute kidney injury; ALF, acute liver failure; DIC, disseminated intravascular coagulation; PRES, posterior reversible encephalopathy syndrome; NR, not reported.

Table 2.

Retrospective observational studies of heat-related illnesses in endurance running

NR, not reported; EHS, exertional heat stroke; temps, temperatures; pts, patients; Env, environment.

Table 3.

Prospective studies of heat-related illnesses in endurance running

In the 22 case review articles (Table 1),Reference Asserraji, Benameur and Maoujoud 4 –Reference Seth and Juliana 25 only 5 articles examined more than a single patient encounterReference O’Donnell 13 , Reference Robertson and Walter 15 , Reference Roberts, Dorman and Bergeron 18 , Reference Smith, Jones and Martin 19 , Reference Stearns, Casa and O’Connor 21 and only 1 articleReference O’Donnell 13 presented a series of more than 3 patient encounters. The cases represented 15 marathons (68.1%)Reference Asserraji, Benameur and Maoujoud 4 –Reference Gessel and Lin 7 , Reference Koh 10 –Reference O’Donnell 13 , Reference Roberts 16 , Reference Roberts 17 , Reference Smith, Jones and Martin 19 –Reference Stearns, Casa and O’Connor 21 , Reference Whitworth and Wolfman 23 , Reference Seth and Juliana 25 and 6 half marathons (27.3%),Reference Epstein, Roberts and Golan 8 , Reference Poggiali, Cervellin and Valenti 14 , Reference Robertson and Walter 15 , Reference Roberts, Dorman and Bergeron 18 , Reference Weigand, Riediger and Stremmel 22 , Reference Yoshizawa, Omori and Takeuchi 24 with 1 ultramarathon (4.5%).Reference Heneghan, Nazirawan and Dorcaratto 9 A total of 34 patient encounters were reviewed with 3 (8.8%)Reference Asserraji, Benameur and Maoujoud 4 , Reference Epstein, Roberts and Golan 8 , Reference Whitworth and Wolfman 23 dying and the remaining 31 (91.2%)Reference Azzopardi, Chetcuti and Sant 5 –Reference Gessel and Lin 7 , Reference Heneghan, Nazirawan and Dorcaratto 9 –Reference Weigand, Riediger and Stremmel 22 , Reference Yoshizawa, Omori and Takeuchi 24 , Reference Seth and Juliana 25 making a full or near-full recovery. The majority (88.2%) of cases involved male patients and the mean age is 26.5 years. The mean environmental temperature was 21.3 °C, and the mean presenting patient temperature was 40.5 °C. Where studies varied in how temperature was reported, the authors standardized by converting to Celsius, using mean average, and wet or dry bulb temperature depending on availability of data. Not all case reports recorded the environmental temperature of the race or the presenting patient temperature.

In the 12 retrospective review articles (Table 2),Reference Breslow, Collins and Troyanos 26 –Reference Yankelson, Sadeh and Gershovitz 37 there were 5 about marathons (41.7%),Reference Breslow, Collins and Troyanos 26 , Reference Chan, Constantinou and Fokas 28 , Reference Driscoll, Cripps and Brotherhood 30 , Reference Finch and Boufous 31 , Reference Sugawara, Manabe and Yamasawa 36 2 about half marathons (16.7%),Reference Hawes, McMorran and Vallis 32 , Reference Sloan, Kraft and Clark 35 4 about mixed races (i.e., including various distances) (33.4%),Reference Chan, Mok and Wong 27 , Reference Divine, Daggy and Dixon 29 , Reference Hostler, Franco and Martin-Gill 33 , Reference Yankelson, Sadeh and Gershovitz 37 and 1 about an ultramarathon (8.4%).Reference Joslin, Mularella and Bail 34 The mean environmental temperature was 19.8 °C, and the mean presenting patient temperature was 40.7 °C. Not all case reports recorded the environmental temperature of the race or the presenting patient temperature. Where studies varied in how temperature was reported, the authors standardized by converting to Celsius, using mean average, and wet or dry bulb temperature depending on availability of data. Discussion points among these papers emphasized that increasing environmental temperatures did result in higher incidences of EHS, though EHS can present in milder temperatures as well. The best treatment for EHS uniformly was on-site immediate ice water immersion, and patients often recovered enough at the medical tent that they did not have to be sent to the hospital. Earlier race start times, acclimatization, and, for ultramarathons, mandatory rest breaks were strategies discussed to mitigate heat stress.

Of 4 prospective observational studies (Table 3),Reference Gerardin, Guedeney and Bellemain-Appaix 38 –Reference Stacey, Hill and Parsons 41 3 (75%)Reference Hollander, Klower and Richardson 39 –Reference Stacey, Hill and Parsons 41 concentrated on marathons while 1 (25%)Reference Gerardin, Guedeney and Bellemain-Appaix 38 included a mixture of race distances. The incidence of EHS was relatively low across all studies (0.01 people per thousand, 71.76 people per thousand, and 79.35 people per thousand, with 1 study not reporting incidence), but neither environmental nor patient temperatures were reported. In the discussion section, only 1 study delved deeply into heat-related illnesses, noting that higher temperatures result in higher incidences of heat illness.Reference Hollander, Klower and Richardson 39 Therefore, race schedules might need to be adjusted depending on the weather, and cooling measures and medical tent preparedness would be vital to any such event.Reference Hollander, Klower and Richardson 39 One study focused on cardiac arrestReference Gerardin, Guedeney and Bellemain-Appaix 38 rather than heat-illness and another examined blood biomarkers in EHS.Reference Stacey, Hill and Parsons 41 Another study examined all injuries in a marathon and concluded that while heat-illnesses were common, even a limited-resource country could safely host such races if properly prepared.Reference Ogwumike and Adeniyi 40

Discussion

This scoping review revealed that there is a lack of research in heat-related illnesses in endurance running. Most articles were case reports and are, therefore, limited in generalizability. The few retrospective observational studies varied in size and methodological robustness. The handful of prospective studies were all also observational in nature and again varied in size and methodological robustness. The literature concentrated on EHS more than general heat-related illnesses and demonstrated marked variability in incidence rates of EHS across different study designs. It is unclear what caused this variability, though it may be due to the focus of the study (i.e., if EHS was the primary outcome they were assessing), potential variability in race medical record keeping for retrospective reviews, and the time and place of the chosen race for the study. EHS patients were more often young and male, and treatment plans universally emphasized early, pre-hospital intervention with ice water immersion when available. Medical tent protocols were not often laid out or defined. Guidelines for mitigation or preparation for heat-related illness at these racing events were sparsely discussed but did emphasize earlier race start times, different race days, cooling stations, heat acclimatization, and mandated breaks. Although EHS occurred in milder temperatures as well, there was a correlation between increasing environmental temperatures and increasing cases of EHS.

Due to climate change, global temperatures continue to rise and the extremes of weather become more common, including increasingly hot days.Reference Zhao, Yu and Mahendran 2 The National Aeronautics and Space Administration (NASA) states that 2023 was the warmest year on record since record keeping began in 1880 and that the 10 most recent years are the warmest on record. 42 Even without the additional strain of exercise, people are at risk for poor health outcomes in rising temperatures, as evidenced prominently in the 2021 heatwave in Washington State that resulted in the deaths of 159 people.Reference Casey, Parks and Bruckner 43 The Center for Disease Control and the Environmental Protection Agency have noted an increase in heat-related deaths over the past 2 decades. 44 , 45

EHS is generally defined as a core body temperature of >40 °C with mental status changes, although heat-related illnesses can have normal mental status with milder symptoms such as syncope, extreme fatigue, lightheadedness, and vomiting.Reference Nichols 1 Exertional exercise of any sort can increase a person’s risk for EHS. In the US, sports participation, in general, has been increasing over the years, and running has become a popular sport worldwide.Reference Hulteen, Smith and Morgan 46 , Reference Woods 47 This may be due to higher awareness and emphasis on physical wellbeing and to the low barrier to entry for running, as no specialized equipment other than running shoes and clothes are necessary. As a result, running (and many other sports) is no longer reserved for elite or professional athletes but draws a wide variety of amateurs. Because endurance running involves prolonged exercise, this increases the risk of EHS, especially in runners who are not acclimatized to the conditions or lengths that they are attempting to run. Therefore, endurance running is not only one of the most popular sports but also one the most at-risk sports for heat-related illnesses. Due to a paucity of data, it cannot be concluded specifically that heat-related illnesses are an increasing public health issue in endurance running; however, given the increase in heat waves and heat-related illnesses in general, it is likely that athletes are at increased risk and further studies to investigate this would be prudent.

This scoping review was not without its limitations. Its focus was on endurance running, as defined as a half-marathon length or longer. While longer time spent exercising increases risk for exertional heat illnesses, shorter races (such as 10-kilometer or 5-kilometer races) attract less-trained athletes and participants, which could potentially result in a high incidence of heat illnesses, but this review had a narrower focus and cannot comment on these shorter races. Additionally, other forms of endurance racing – such as triathlons or long cycling events – expose athletes to similar heat stresses as endurance running but were not included in this review. One study of triathlons showed an incidence of 1.74 cases of EHS per 10 000 participants.Reference Knight, Parkin, Smith and Kipps 48 Another study reported that while running had an incidence of 674.0 of exertional heat-related illness cases per 10 000 participants, cycling only had 1 of 401.1 per 10 000.Reference Gamage, Fortington and Finch 49 Although the variability in EHS and heat-related illnesses incidences in studies has already been discussed, endurance running and running, in general, appear to have a higher incidence, which may be due to the fact that triathlons include swimming and cycling portions which, generally, are lower intensity than running.

Athletic events, such as endurance racing, put athletes at risk for several life-threatening injuries or illnesses, such as cardiac arrest, hyponatremia, and rhabdomyolysis, inducing kidney failure. The 3 observational studies in our scoping review found a prevalence of heat-related illness of 10 cases per 100 000 participants, 7176 cases per 100 000 participants, and 7935 cases per 100 000 participants, respectively; and a prevalence of cardiac arrest during marathons of around 1.04 per 100 000, and in half marathons, 0.47 per 100 000.Reference Gerardin, Guedeney and Bellemain-Appaix 38 –Reference Ogwumike and Adeniyi 40 , Reference Kim, Rim and Miller 50 Therefore, although cardiac arrest has higher morbidity, it is not nearly as common. On the other hand, hyponatremia and rhabdomyolysis are more common and may sometimes be associated with heat-related illnesses.Reference Klingert, Nikolaidis and Weiss 51 –Reference Kruijt, van den Bersselaar and Hopman 53

Mortality from EHS ranges depending on recognition, intervention, and patient characteristics, but can be as high as 14.5%-27%.Reference Liu, Xing and Wang 54 , Reference Garcia, Renteria and Leite-Santos 55 Multiple studies have shown that higher environmental temperatures result in higher incidences of EHS.Reference Leyk 56 , Reference DeMartini, Casa and Belval 57 In light of climate change continuing to increase global temperatures, it must be recognized that the risk of EHS is likely to increase comparatively. Regarding heat-related illnesses in endurance running, this scoping review has exposed not only the dearth in research on patient characteristics and care but also medical tent preparedness and protocol, which few of the articles remarked upon. The best care for EHS is early cooling, often in the prehospital setting.Reference Leyk 56 While medical tents at events need to develop a standardized protocol for treating and reporting cases of EHS, event directors need to be cognizant of the heat risk their athletes are exposed to so that they can take steps to mitigate this. Mitigation strategies could include earlier start times for races, mandatory breaks for athletes in longer races such as ultramarathons, cooling stations, and shaded racecourses. Public awareness initiatives, especially targeting all participants of the race, could further decrease morbidity and mortality. Local emergency medical services (EMS) systems and hospitals should also be updated on EHS protocols and treatment prior to race day.

Although this scoping review focused on endurance running, with its high risk of EHS from prolonged exertion and its low barrier of entry for amateur participants, other sports and exertional activities, especially those involving endurance such as long-course triathlons, could also benefit from racecourse mitigation strategies and standardization of medical tent treatment and tracking. Perhaps due to the fragmented nature of companies providing medical care at athletic events or due to the concern for bad public press, reporting and publishing athletic event injuries and illnesses remains sparse. However, to prevent further harm to athletes, especially in increasingly extreme weather conditions, transparency of data reporting and protocol standardization at these athletic events are called for. Warming global temperatures can create dangerous race conditions for amateur and professional athletes alike, but with the proper strategies for mitigation and preparedness, the race can go on.

Limitations

Our study had several limitations. Studies included were limited to those in English, so some relevant studies published in other languages may have been missed. Case reports and series, which made up most of the studies included in this scoping review, are limited in number of patients, making generalizability difficult. Shorter race distances were not included, though these shorter races may attract more inexperienced participants and may, therefore, have a high incidence of exertional heat-related illness. Moreover, other endurance racing events, such as triathlons and cycling, were not included in this study, which again limits its generalizability.

Conclusion

With rising global temperatures from climate change, athletes are at higher risk of heat-related illness, especially EHS. This scoping review reveals that younger, male patients are at higher risk and early ice water immersion is the best treatment for EHS. Acclimatization, earlier race start times, and cooling stations may mitigate incidences of EHS; however, data on event medicine preparation for hotter temperatures remain scarce. Future work needs to concentrate on more open and universal reporting of injuries and illnesses in sporting events as well as the establishment of heat-related illness prevention and mitigation protocols.

Author contribution

Sophia Görgens MD: Conception and design of the study, scientific write-up, collaboration on analysis, and presentation of results.

Attila J. Hertelendy PhD: Project steering, scientific write-up, collaboration on analysis, and presentation of results.

Fadi Issa MD: Conception, design, and execution of the study.

David Fernandez MD: Data collection and entry.

Ahmad Alshadad MBChB: Data collection and entry.

Lindsay Davis DO: Data collection and entry.

Jeffrey Franc MD, MSc, MS. FCFP: Conception, design, and execution of the study.

Janice Y. Kung: Creation and execution of the study methods, scientific write-up, creation of figures and tables.

Christina Woodward MD: Conception, design, and execution of the study.

Amalia Voskanyan RN: Conception, design, and execution of the study.

Gregory R. Ciottone MD: Conception, design, and execution of the study.

Competing interests

None.

Appendices: Search Strategies

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Figure 0

Figure 1.PRISMA flow diagram of records identified through the database search, screened, and included for the scoping review.

Figure 1

Table 1.Case reports and case series of heat-related illnesses in endurance running

Figure 2

Table 2.Retrospective observational studies of heat-related illnesses in endurance running

Figure 3

Table 3.Prospective studies of heat-related illnesses in endurance running

Figure 4

1.