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During vigorous and prolonged exposure to the heat there is an increased risk of heat-related illness and injury for athletes, officials, volunteers, and spectators. If warning signs are ignored or weather conditions extreme, heat-related episodes can quickly escalate to heat stroke with the potential for permanent injuries or even death. Although the incidence of exertional heat stroke is rare, sporting bodies and event organisers are encouraged to mitigate against the risk of heat illness and prevent situations that could exacerbate conditions.

Case studies

Tennis

2014 Australian Open, Melbourne

Swimming

2010 FINA Open Water Series, Fujairah

Olympic and Paralympic Games

Tokyo 2020

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Additional resources

  • Heat Stress in Sport and Exercise: Thermophysiology of Health and Performance, Julien D. Périard and Sébastien Racinais (eds.), Springer, (2019). The book is designed to provide a flowing description of the physiology of heat stress, the illnesses associated with heat exposure, recommendations on optimising health and performance, and an examination of Olympic sports played in potentially hot environmental conditions. Includes sport-specific chapters including: football/soccer, Australian football and rugby; American football; tennis; athletics; cycling; open-water swimming; and, triathlon and ultra-endurance events in tropical environments.
  • Australian community sport extreme heat policies: Limitations and opportunities for improvement, Samuel Chalmers and Ollie Jay, Journal of Science and Medicine in Sport, (February 07, 2018). The importance of sport in Australian culture is evidenced by 79% of the population aged ≥15 years participating in sport or physical activity one or more times per week.  Another defining feature of Australia however is its hot climate. Notably, 2013 was the hottest year on record in Australia and the risk of experiencing extreme heatwaves in summer has increased two-fold in the past few decades.  The aims of this editorial are to summarise the Sports Medicine Australia (SMA) heat policy and a representative sample of existing heat policies issued at the community level by the six most popular club sports in Australia (according to the 2016 AusPlay survey); and discuss the limitations of these existing policies while highlighting opportunities for improvement through future research.
  • Mandatory pre-season guidelines reduce heat illness among high school football playersScience News/University of North Carolina, (10 April 2019). Researchers have found strong evidence that rates of heat-related illnesses, such as heat cramps and heat strokes, were reduced by half in states that had mandated guidelines to reduce exertional heat illness among high school football players. This is one of the first studies examining the effectiveness of state-mandated guidelines for reducing exertional heat illness among high school football players.
  • Mitigating Climate Impacts on Athletes: Sports Guidelines May Prevent Exertional Heat Illness, Wendee Nicole, Environmental Health Perspectives, (25 October 2019). The incidence of heat-related illnesses and deaths is expected to rise as heat waves become more frequent in some areas. Can policies that mandate risk-reducing behaviours lower the likelihood of heat illness and save lives? Few studies have addressed this issue, but recent research in Environmental Health Perspectives found that when states implemented guidelines to help ward off exertional heat illness (EHI) in student athletes, rates did, in fact, fall dramatically.
  • ‘This Was Preventable’: Football Heat Deaths and the Rising Temperature, James Bruggers, Inside Climate News, (20 July 2018). Most states rank poorly on heat safety for their high school football players. Too many teens have paid the price, and temperatures are only getting worse. Includes information from the United States relating to which States take heat risk seriously for high school sports (i.e. by mandating heat safety measures).
  • Caught behind: Climate change, extreme heat and the Boxing Day TestAustralian Conservation Foundation and Monash Climate Change Communication Research Hub, (December 2019). This report brings together climate, media and sports research to: Review the current management of extreme heat in Australian cricket; Investigate cricket's contributions to the risks posed by climate change; and, Question the viability of continuing to host the Boxing Day Test in December under a "business as usual" greenhouse gas scenario.
  • Reducing Heat Illness in College and High School SportsUnited Educators Insurance, (2019). Heat-related illness is preventable, yet it's a leading cause of death and injury among college and high school athletes. All athletes are susceptible to the risks of exercising in a hot environment, but particularly those in high-exertion sports such as football, where studies show the majority of heatrelated illnesses occur. A review of United Educators (UE) claims arising from heat-related illnesses in athletes reveals that the primary cause of liability is poor planning for reduction of and response to this risk. Professional football provides a model for high school and college athletics. Since the NFL overhauled its practices around heat-related illnesses following the death of Korey Stringer in 2001, not a single player has died from heat exertion. By implementing heat-illness reduction programs, institutions can decrease or eliminate risk and enhance the overall safety of their athletic practices and competitions. Use this publication to help inform or assess your institution’s heat-illness reduction practices.
  • The Application of Heat Stress to Team Sports: Football/Soccer, Australian Football and Rugby, Katie Slattery and Aaron J. Coutts, in 'Heat Stress in Sport and Exercise: Thermophysiology of Health and Performance', Julien D. Périard and Sébastien Racinais (eds.), Springer, pp.181-202, (7 March 2019). This chapter addresses how an added heat stress affects football, Australian football and rugby players during both training and competition. Although these sports are typically played in the cooler winter months, players can still be exposed to hot conditions and this may affect health and performance. It is therefore important to understand how an increased thermal load influences the tactical, technical, physical and psychological constructs that contribute to team sport performance.
  • The Association between Mandated Preseason Heat Acclimatization Guidelines and Exertional Heat Illness during Preseason High School American Football Practices, Zachary Y. Kerr, et.al., Environmental Health Perspectives, (10 April 2019). The risk of heat-related illness and death may continue to increase in many locations as a consequence of climate change, but information on the effectiveness of policies to protect populations from the adverse effects of excessive heat is limited. In 2009, the National Athletic Trainers’ Association Inter-Association Task Force (NATA-IATF) released guidelines to reduce exertional heat illness (EHI) among U.S. high school athletes participating in preseason sports activities, including preseason practice sessions for American football. A subset of state high school athletic associations have implemented state-mandated guidelines consistent with the 2009 NATA-IATF recommendations, but their effectiveness for reducing preseason EHI is unknown. Our findings suggest that high school athletes would benefit from enactment of the 2009 NATA-IATF guidelines. Similar analyses of the effectiveness of other public health policies to reduce adverse health effects from ambient heat are warranted.
  • Considerations for the development of extreme heat policies in sport and exercise, Chalmers S, Anderson G, Jay O, BMJ Open Sport & Exercise Medicine, (2020). Key considerations for the development of extreme heat policies in sport and exercise are detailed. Policies should account for the four environmental parameters (ambient temperature, humidity, air velocity, and mean radiant temperature) and two personal (activity and clothing) parameters that determine the prevailing thermoregulatory strain during exercise in the heat. Considerations for how to measure environmental stress and convey the level of risk are discussed. Finally, the need to include feasible cooling strategies that are relevant for the prevailing environmental conditions are highlighted.
  • Document analysis of exertional heat illness policies and guidelines published by sports organisations in Victoria, Australia, Gamage PJ, Finch CF, Fortington LV, BMJ Open Sport & Exercise Medicine, (2020). This study conducted a document and content analysis of exertional heat illness (EHI)-related documents published by sports organisations in Victoria, Australia, in order to determine their scope and evidence base against current international best practice recommendations. There is considerable variation in formal documents with regard to their content and quality of information. Continued efforts to bridge the evidence to practice gap in sports safety are therefore important. This study highlights the challenge for community sport, which relies on high-level policy and governance, across settings and populations that can differ substantially in their needs.
  • E-edition: #OlympicsInTheHeat, British Journal of Sports Medicine, (2020). This current e-Edition aims to provide a summary of the main information to protect athlete health during an #OlympicsInTheHeat. Importantly, this concern goes beyond Tokyo 2020, as Paris (2024) is regularly facing heat waves during the Olympic period and a new world record for the hottest temperature ever recorded on earth was reached this year in California (~200 miles from the site of the Los Angeles 2028 Games).
  • Exercise in the Heat for Children and Adolescents. Statement from the Commission for Pediatric Sports Medicine, German Society for Sports Medicine and Prevention, Lawrenz, W., German Journal of Sports Medicine, Volume 70, pp.265-268, (November 2019). › Exertional heat illness in children and adolescents is preventable by different measures. There should be sufficient time for recovery between repeated exercise bouts. Children and adolescents should drink sufficient quantities regularly and provide for sun protection of head and skin. During all athletic events in the heat with participation of children and adolescents, trained personnel and facilities capable of effectively treating all forms of heat illness, should be readily available on site.
  • Fatal Exertional Heat Stroke and American Football Players: The Need for Regional Heat-Safety Guidelines, Andrew J. Grundstein, Yuri Hosokawa, Douglas J. Casa, Journal of Athletic Training, Volume 53(1), pp.43-50, (2018). Weather-based activity modification in athletics is an important way to minimize heat illnesses. However, many commonly used heat-safety guidelines include a uniform set of heat-stress thresholds that do not account for geographic differences in acclimatization. The combination of lower exposure WBGTs and frequent extreme climatic values in milder climates during fatal EHSs indicates the need for regional activity-modification guidelines with lower, climatically appropriate weather-based thresholds. Established activity-modification guidelines, such as those from the American College of Sports Medicine, work well in the hotter climates, such as the southern United States, where hot and humid weather conditions are common.
  • Heat Policy Revision for Georgia High School Football Practices Based on Data-Driven Research, Cooper ER, Grundstein AJ, Miles JD, et al. Journal of athletic training, (2020) 55(7):673-681. Interscholastic heat policies for football have not been evidence based. Therefore, their effectiveness in mitigating exertional heat illness has not been assessed. This study aims to discuss the development of the Georgia High School Association heat policy and assess the effectiveness of revised guidelines.
  • Implementing exertional heat illness prevention strategies in US High School Football, Kerr Z, Marshall S, Comstock R and Casa D, Medicine & Science in Sports & Exercise, Volume 46(1), pp.124-130, (2014). Approximately 6500 high school football athletes are treated annually for exertional heat illness (EHI). In 2009, the National Athletic Trainers Association (NATA)-led Inter-Association Task Force (NATA-IATF) released preseason heat acclimatization guidelines to help athletes become accustomed to environmental factors contributing to EHI. This study examines compliance with NATA-IATF guidelines and related EHI prevention strategies. A low proportion of surveyed high school football programs fully complied with all 17 NATA-IATF guidelines. However, many EHI prevention strategies were voluntarily implemented. State-level mandated EHI prevention guidelines may increase compliance with recognized best practices recommendations. Ongoing longitudinal monitoring of compliance is also recommended.
  • Managing heat and immune stress in athletes with evidence-based strategies, Pyne D, Guy J and Edwards A, International Journal of Sports Physiology and Performance, Volume 9, pp.744-750, (2014). Heat and immune stress can affect athletes in a wide range of sports and environmental conditions. The classical thermoregulatory model of heat stress has been well characterized, as has a wide range of practical strategies largely centered on cooling and heat-acclimation training. In the last decade evidence has emerged of an inflammatory pathway that can also contribute to heat stress. Studies are now addressing the complex and dynamic interplay between hyperthermia, the coagulation cascade, and a systemic inflammatory response occurring after transient damage to the gastrointestinal tract. Damage to the intestinal mucosal membrane increases permeability, resulting in leakage of endotoxins into the circulation. Practical strategies that target both thermoregulatory and inflammatory causes of heat stress include precooling; short-term heat-acclimation training; nutritional countermeasures including hydration, energy replacement, and probiotic supplementation; pacing strategies during events; and postevent cooling measures. Cooperation between international, national, and local sporting organizations is required to ensure that heat-management policies and strategies are implemented effectively to promote athletes' well-being and performance.
  • New guidelines are needed to manage heat stress in elite sports – The Fédération Internationale de Volleyball (FIVB) Heat Stress Monitoring Programme, Roald Bahr and Jonathan C Reeser, British Journal of Sports Medicine, Volume 46(11), pp.805-809, (2012). The goal of this research was to monitor heat stress and record cases of heat-related medical forfeits on the Swatch FIVB Beach Volleyball World Tour. The incidence of significant heat illness among athletes competing on the FIVB Beach Volleyball World Tour appears to be quite low, even though weather conditions frequently result in a WBGT index >32°C. Currently available guidelines appear to be inadequate to fully assess the risk of heat stress and too conservative to inform safety decisions in professional beach volleyball.
  • Novel Acclimatization and Acclimation Strategies for Hot Climates, Song, Kaoru; Richter, Madeline; Waxenbaum, Joshua; Samblanet, Kyle; Lu, Myro DO, Current Sports Medicine Reports, Volume 19(4) p 142-145 (April 2020 ). Exercising in hot, humid temperatures increases the risk for heat-related illnesses, ranging from mild heat edema to severe heat stroke. With increasing globalization in the world of sports, athletes are sometimes expected to compete in unforgiving conditions that expose them to these risks. In an effort to improve exercise capacity and reduce the risk of serious heat injury, many athletes are recommended to undergo heat acclimatization program prior to competing in climates with elevated average temperature. This article will look at current recommendations as well as studies on differing techniques for acclimatization and acclimation, with hopes to provide guidance for the modern-day clinician and athletes.
  • Practical recommendations for endurance cycling in hot/humid environments, Nichols D, Aspetar Sports Medical Journal, Volume 5, (2016). It is well documented that exercise in a warm environment poses a significant thermal challenge to the body and has the potential to reduce exercise performance. The combination of heat production from working muscles and reduction in the rate of heat loss due to high ambient temperatures and/or humidity results in an exacerbated rise in core temperature (hyperthermia) for any given exercise intensity. Hyperthermia per se impairs aerobic performance and consequently decreases power output compared with temperate environments. In addition, dehydration during exercise in the heat further exacerbates the thermal and cardiovascular strain and further impairs aerobic performance. This article provides practical recommendations for athletes and race organisers.
  • Practice beliefs of team physicians regarding the recognition and treatment of exertional heat stroke, Mazerolle S, Pagnotta K, Casa D, McDowell L and Armstrong L, Athletic Training & Sports Health Care: The Journal for the Practicing Clinician, Volume 5, Number 1, p20 (2013). The purpose of this basic inductive research study was to investigate team physicians’ practice beliefs regarding the recognition and immediate treatment of EHS and the ways to increase and promote the use of best practices within the athletic training profession. Many of the participants recognized that in their role as a team physician, they were responsible for promoting best practices, which they believed were Tre and CWI. However, they did not believe it was their professional responsibility to provide educational training for either skill to athletic trainers, but rather that the 2 parties must work together to develop appropriate patient care policies.
  • Preventing heat illness in the anticipated hot climate of the Tokyo 2020 Summer Olympic Game. Takeyasu Kakamu, Koji Wada, Derek R. Smith, Shota Endo and Tetsuhito Fukushima, Environmental Health and Preventive Medicine/BioMed Central, ( published online 19 September 2017). Overall, our study suggests that the Tokyo 2020 Summer Olympics will be held amid extremely high WBGT conditions, including at levels deemed poorly suited for conducting sporting events. Combined efforts by all stakeholders during these events will therefore be necessary to deal with these challenging conditions so that athletes can perform their best and so heat illness can be minimized among individuals taking part in these activities. Sporting committees and the Olympic organizing committee should also consider WBGT in selecting venues and the timing of events to help minimize heat illness and enable maximum performance by athletes. Similarly, the organization of the 2020 Tokyo Olympics will need to manage heat as an occupational safety issue for staff and also provide multiple solutions to help heat illness among spectators and tourists.
  • Sports Medicine Staff Size Influences Exertional Heat Illness Policies in High School Football, Riana R. Pryor, Douglas J. Casa, Susan W. Yeargin and Zachary Y. Kerr, International Journal of Athletic Therapy and Training, Volume 23(4), pp.172-177, (2017). All high schools should implement exertional heat illness (EHI) safety strategies. We determined if there were differences in the implementation of EHI safety strategies between schools with and without additional paid athletic trainers (ATs) or a team physician present at preseason football practices. High schools with multiple ATs or a team physician implemented more EHI prevention and management strategies than schools with only a single AT, including training staff in EHI recognition and treatment and having an emergency action plan. However, schools with a paid team physician were more likely to have double practices in the first week of football practice. Schools with additional medical personnel at football preseason practices were more likely to implement EHI safety strategies.
  • The Use of Technology to Protect the Health of Athletes During Sporting Competitions in the Heat, Borja Muniz-Pardos, et.al., Frontiers in Sports and Active Living, (3 October 2019). Due to the metabolic demands of the sporting events and the high environmental temperatures, the risk of exertional heat stroke (EHS) is high. Careful planning by event organizers are needed to ensure that athletes are protected from irreversible long-term health damage, or even death during sporting competitions in the heat.

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