How Should Bike Helmets Be Fitted?

Patient Presentation
An 8-year-old male came to clinic for a health supervision visit.
During the visit, the nurse practitioner asked about his bicycle helmet use.
He and his mother said that he sometimes used the helmet but not consistently.
He said that it didn’t fit well and hurt his mouth so he didn’t use it.
His mother said the she had just tightened the straps once when he first started using it but didn’t actually fit the helmet to him
She also wasn’t sure how to fit the helmet.
The pertinent physical exam showed a healthy male with normal vital signs and growth parameters.
The diagnosis of healthy male was made.
The nurse practitioner was aware of the Bicycle Coalition of Maine’s “Eye-Ear-Mouth” fitting guidelines.
She was able to find the fitting instructions for the family and printed them out to take home.
She recommended keeping the helmet near the bicycle so that he would remember to wear the helmet.
She also recommended that he use it for other wheeled activities such as riding a scooter, skate boarding, and in-line skating.
She reminded him to make sure that he took the helmet off for other non-wheeled activities especially playing on playground equipment and climbing trees where the helmet potentially could become caught.

Bicycling and other wheeled sports are great exercise and fun family activities. But to maintain the fun, safety must be a consideration.
There are ~540,000 emergency room visits for bicycle injuries every year. Of those visits, ~67,000 involve head injuries and ~27,000 require hospitalization.
About 770 people died from bicycle injuries in 2006, mainly from head injuries. It is estimated that a bicycle helmet could prevent 45-88% of brain injuries.

Unfortunately many people do not wear a helmet or it is improperly fitted.
In a cross-section study of 8 communities in Texas in 2002 that evaluated helmet use for wheeled activities, only 13.6% of people observed wore a helmet.
Of those that wore a helmet, only 72.5% wore them correctly. Wearing of the helmets was dramatically increased if companions wore helmets, particularly adults.

Learning Point
It takes ~ 10-15 minutes to properly fit a helmet. Taking the initial time makes it easier to later just put on the helmet, do a quick check and then be off for a great time with the bicycle or other wheeled activity.

  • Size
    • Measure the head when buying the helmet to get the approximate size. Sizing charts are available.
    • Put the helmet on and make sure it fits snugly and doesn’t rock from side to side.
    • Use different sizing pads to adjust the helmet so it doesn’t rock and fits snugly.
    • A sizing ring is sometime used and can be adjusted by clicking it in place (like using cable ties) or by turning the adjustable knob
    • The helmet should be comfortable and not squeeze the head.
  • Position
    • The helmet should be level on the head and low on the forehead – basically straight across the eyebrow about 1-2 finger-widths above the eyebrow.
  • Straps and Buckles
    • Pull the straps (usually from the back of the helmet) and center the left buckle under the chin.
    • When adjusting the straps and buckles it may be easier to do this with the helmet off the head and then replacing it on the head to check the adjustment.
    • The side straps should be adjusted so both form a “V” shape under and just in front of the ears. The slider should be locked if possible.
    • Buckle the chin strap and tighten it until it fits snugly with no more than 1-2 fingers under the strap. The buckle should be centered under the chin.
  • Checking the adjustments – “Eyes-Ears-Mouth”
    • Does the helmet rock forward into the EYES? If yes, unbuckle the helmet and tighten the back strap by moving the slider back toward the EAR.
      Buckle the helmet again, retighten the chinstrap, and test the helmet again.

    • Does the helmet rock back more than two fingers above the EYEbrows? If yes, unbuckle the helmet and shorten the front strap by moving the slider forward from the EAR.
      Buckle the helmet again, retighten the chinstrap, and test the helmet again.

    • Open the MOUTH wide. The helmet should pull down on the head. If not, readjust and tighten the chinstrap.
    • A rubber band is found on the chinstrap. Roll the rubber band down to the buckle and place all four straps through the rubber band. The rubber band must have all four straps and be close to the buckle to prevent slipping.

Helmets should be checked each time they are used and refitted as necessary. Helmets should not be used for non-wheeled activities such as playing on playground equipment, climbing trees, and for other activities where the helmet potentially could become caught.

They usually are cleaned by water and a cloth but manufacturers recommendations should be followed. Helmets should be stored in a place with convenient access so they will be used and a place where they will not be damaged accidentally.
Helmets should be replaced if they are involved in a crash whether or not any damage is visible. They should also be replaced if they have been damaged in any way.

Suggestions for specific needs of young children, small or large heads, etc. can be found at the Bicycle Helmet Safety Institute.

Questions for Further Discussion
1. What are my state’s laws regarding bicycle helmet use or helmet use for other wheeled activities?
2. Should children riding as passengers on a bicycle or being towed by a bicycle wear a helmet?
3. What is the cost for a bicycle helmet and where can families obtain low-cost ones in the community?
4. When is a child old enough to ride a bicycle and how should a bicycle be fitted?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sports Safety and Exercise and Physical Fitness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Centers for Disease Control. Revised Final FY 1999 Performance Plan And FY 2000 Performance Plan
X. Injury Prevention and Control.
Available from the Internet at (rev. 1/12/2000, cited 8/18/08).

Forjuoh SN, Fiesinger T, Schuchmann JA, Mason S.
Helmet use: a survey of 4 common childhood leisure activities.
Arch Pediatr Adolesc Med. 2002 Jul;156(7):656-61

National Highway and Transportation Safety Administation. Easy Steps to Properly Fit a Bicycle Helmet.
Available from the Internet at (rev. 9/2006, cited 8/21/08).

American Academy of Pediatrics Policy Statement. Bicycle Helmets. Pediatrics. 2001;pp. 1030-1032. Available from the Internet at:;108/4/1030 (rev. 8/1/08, cited 8/21/08).

Bicycle Helmet Safety Institute. Helmet Related Statistics
from Many Sources.
Available from the Internet at (rev. 8/20/08, cited 8/22/08).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills

    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    September 29, 2008