Essential Keys To Treating Triathletes

Given the rigors of training regimens for triathlons, these athletes are prone to various injuries, particularly lower extremity injuries. Accordingly, this author discusses key risk factors that contribute to running and cycling injuries, and offers salient pointers on effective treatment.

   It is clear that multi-sport endurance events such as the triathlon are growing in popularity worldwide. In North America alone, USA Triathlon sanctions over 2,500 races annually and boasts of a membership exceeding 110,000 athletes, which reflects a growth of over 100 percent in the past five years.

   Mastery of swimming, cycling and running places high physical, physiological and psychological demands on the triathlete. Whether they are recreational athletes, age class competitors or professionals, triathletes are at a high risk of suffering an injury.

   Researchers have estimated that seven out of every 10 triathletes, during the course of their triathlon career, will suffer from an overuse injury, which requires medical treatment, the modification of training habits and/or an extended period of rest.1 Studies have shown injury rates ranging from 37 percent among British triathletes during eight weeks of training to 91 percent for ultra-endurance triathletes completing the 1986 Hawaii Ironman Triathlon.2,3

   Korkia et al., concluded that the foot/ankle, lower leg, knee, thigh and low back were the most common areas of injury for triathletes.2 Collins et al., and Cipriani similarly concluded that the lower extremity was the most vulnerable region of the body for injuries.4,5

   Dominated by the lower extremity, overuse injuries account for up to 78 percent of injuries suffered by triathletes.6 During the six months leading up to a competitive season, triathletes suffer an estimated 2.5 injuries per 1,000 training hours. During a typical 10-week competitive season, triathletes suffer 4.6 injuries per 1,000 training hours.6 Among the three disciplines for a triathlon, run training appears to be more strongly associated with triathlon overuse injuries.1,2,3,7

   Athlete comfort and performance have improved with advances in training systems, performance monitors, nutritional guidelines, endurance supplements/fluid replacements, cycling equipment, clothing and shoes. However, the risk of injury remains high.

   Contributing to this problem are the swelling ranks of triathletes, particularly adults who take up the sport in their 30s to 50s. Many of these adults are ex-athletes from other disciplines with hidden and long forgotten musculoskeletal injuries. While training may offer the triathlete the benefits of cross-training, the long and rigorous hours required, coupled with the demands of preparation for multiple disciplines, can place the amateur and professional alike at risk of injury.

What Are The Risk Factors For Overuse Injuries?

   Triathletes may fall victim to one or more frustrating and sometimes devastating injuries that require weeks and sometimes months for recovery. While some of these injuries can be acute, the majority of injuries are classified as overuse injuries impacting the musculoskeletal system. Advising and educating the triathlete and other medical care providers has become key for effective management and care.

   The injuries confronting triathletes are frequently progressive in nature. Overuse injuries initially present as a mild, nagging pain that slowly worsens to the point of requiring rest, medical attention or modification of training.

   Extrinsic and intrinsic factors contribute to the evolution of overuse injuries. Common extrinsic factors include improper nutrition (dehydration), inadequate rest/recovery and environmental conditions (temperature, humidity, wind, etc.). Intrinsic factors frequently associated with overuse injuries may include gender, weight, age, experience, psychological factors and poor/inadequate fitness level. Other intrinsic factors including anatomical and morphological factors, biomechanical factors, neuromuscular factors and a history of overuse injury may compound the development of an injury (see “What You Should Know About Intrinsic Risk Factors” at the right).

   While researchers have widely discussed these risk factors, current sports medicine literature does not adequately equip the sports medicine specialist with the necessary tools for accurate prediction of the evolution of an overuse injury.3 However, when presented with a history of high training volume and previous lower extremity overuse injuries including blistering of the foot, the sports medicine specialist should consider the triathlete to be at greater risk of yet another lower extremity injury or a more serious injury. Such serious injuries may include fractures, tendon and ligament ruptures, nerve impingements, severe sprains, strains and tendinitis.3,4

   The higher training volume required to become proficient in disciplines as diverse as swimming, cycling and running can significantly stress the athlete. It is this high training volume that serves as the most common backdrop for overuse injuries among triathletes.

A Guide To Common Overuse Injuries With Cycling

   Overuse injuries linked to the cycling discipline of the triathlon can be associated with improper preparation for the rigors of race day. Extrinsic risk factors include terrain, training errors, poor or improper bike setup and inadequate physical preparation, including strength and inadequate flexibility (range of motion). Other factors are frequent high cadences and frequent riding with a gear resistance combination that is too high.

   While each of these factors can lead to an overuse injury, most triathlete injuries are linked to the combination of high gear resistance at high cadences. Typically, this occurs with poor and/or inadequately developed strength and flexibility to spin these high gear combinations.

   Cycling over level terrain at a moderate cadence in a mid-gear range will offer minimal musculoskeletal stress. However, most triathletes will attempt to push well beyond this level in an effort to achieve higher sustained speeds. The athletes will do so by achieving sustained cadences of 90 to 120 RPM and by gearing up without the base conditioning necessary to produce the higher power outputs required to maintain higher speeds (20 to 24 mph).

   Musculoskeletal stress and overuse injuries can also result from improper riding techniques. These include improper rider position in the cockpit (front of the bike, including stem, handle bars, aero bars, brakes and shift levers), excessive standing during riding, and failure to downshift into headwinds and on hill climbing.

   Proper setup of the bike includes attention to frame sizing, aero/pursuit bar positioning, saddle positioning, crank arm, pedal system and shoes, cleat and insole systems. This setup can enhance comfort, optimize biomechanical transfer of power to the bicycle’s drive train and reduce the development of overuse injuries.

   Improper frame sizing, aero bar setup and saddle positioning frequently lead to complaints of low back pain and stiffness, strains to leg muscles and complaints of knee pain.

   Anatomical factors may manifest as abnormal movement pathways of otherwise stable joints such as the knee. After identifying the contributing anatomical factors, one can often address them through the appropriate selection of a pedal system, shoe, foot orthoses and pedal/cleat shims and wedges.

   By neutralizing the influences of anatomical and biomechanical abnormalities during cycling, the power output (watts) for the triathlete will improve. This will resolve or minimize many nagging lower extremity overuse injuries.

Assessing Key Factors That Contribute To Running Injuries

   Overuse injuries linked to the running discipline of the triathlon have been associated with numerous contributing factors. These factors range from terrain and training errors to anatomical and structural abnormalities.

   Impact forces and biomechanical abnormalities that manifest during running may contribute to the development of overuse injuries. When running across a level, uniform surface at a slow to moderate speed, most runners will exhibit a heel strike running gait. The resulting bimodal time-force integral curve reflects the impact forces generated by the interaction of the foot with the support surface from heel contact through toe-off. These forces dissipate through a complex neuromusculoskeletal feedback pathway that interlinks the mechanoreceptors of skin, muscle, tendons, ligaments, bone and joints with the movement of the body over the lower extremity.

   When this complex movement pathway is disturbed due to compensation for extrinsic factors (terrain, training surfaces and shoes, etc.) or intrinsic factors (anatomical and biomechanical abnormalities, etc.), the risk of developing an overuse injury may rise.

   Biomechanical abnormalities, malalignment and functional deficits thus may serve as focal points for the accumulation of abnormal forces capable of triggering tissue injury. The careful selection of pathology specific running shoes and foot orthoses can serve to neutralize many of these stresses and augment the triathlete’s ability to avoid overuse injuries.

   Injury patterns among triathletes mirror those experienced by their counterparts in single sport disciplines. The injury patterns remain relatively stable despite improvements to training programs, athlete education, shoes, bicycles and other equipment. Running is the triathlon discipline most frequently associated with overuse injuries that are severe enough to reduce or stop training, and drive the triathlete to seek medical assistance.

Assessing Running Injury Severity

Running injuries can be subdivided into five stages of severity that include:

   • pain upon exertion;
   • pain at rest;
   • pain that interferes with activities of daily living;
   • pain that is managed with medication; or
   • pain that is severe and crippling.8

   By staging the severity of an injury, the medical team may better triage the injured triathlete as well as formulate an evidence-based functional approach to the triathlete’s recovery and return to activity.

Key Principles With Initial Treatment

   In regard to treatment, one can employ an evidence-based plan to facilitate triathlete adherence, hasten recovery and work toward an unrestricted return to activity. When treatment plans focus on an injury and not the athlete, this frequently triggers a series of escalating recurrences that often lead to a catastrophic meltdown of the triathlete’s physical and emotional focus.

   Physical and emotional preparation are key for the triathlete. When either of these is compromised, the triathlete may backslide into a self-destructive routine of overtraining in hopes of recovering from time lost to treatment. The treating physician and triathlete must agree on a realistic plan of care based upon available functional evidence and common goals. Once the plan is in place, one can effectively proceed with care and minimize the potential delays in recovery, and speed the return to activity.

   After establishing the severity of an overuse injury, prompt stabilization of the injury is necessary. The mnemonic PRICE (protect, rest, ice, compress and elevate) serves as the most practical entry point to any well-conceived, evidence-based functional plan of care. This also serves as the springboard to the remaining steps in a treatment plan. These steps include:

   • managing musculoskeletal imbalances and pathomechanics;
   • managing functional strengthening; and
   • managing a return to running and cycling.

   During this initial period of management, one should consider decisions regarding additional imaging, laboratory studies and consultations. As further details relating to the extent of the injury become available, the physician can select an injury management pathway with either a surgical or non-surgical focus.

   Prompt treatment and outcome goal setting with input from the triathlete can set the stage for recovery with a low risk that the triathlete will abandon the plan and prematurely attempt to resume activity.

Inside Insights On Addressing Musculoskeletal Imbalances And Pathomechanics

   Once the acute inflammatory phase has passed and the triathlete can safely conduct range of motion activities of daily living, it is appropriate to address musculoskeletal imbalances. One can best accomplish this with the assistance of a physical therapist who is skilled with cyclists and runners.

   The physician can then address abnormalities in functional biomechanics that have been previously identified. Changes to cycling shoes, the cycling pedal/cleat system, cleat wedges and shims, cycling orthoses, running shoes and running orthoses all become important treatment modalities. Specifics of each should be based upon the pathology of the injury.

   Pathology specific shoe recommendations, including running shoes and cycling shoes, may provide the triathlete with a more optimal base of function. When one carefully matches shoe recommendations to the athlete and gives due consideration to his or her pathomechanics, anatomy, biomechanics, running gait and current or future orthoses requirements, the athlete may achieve resistance to re-injury, tolerance to continued training and greater comfort. The above table “How To Select Running Shoes Based On Biomechanical Factors” may provide a basic organizational system from which to predict the functional running shoe needs of an athlete based upon known rearfoot and forefoot structural properties.

   When appropriate, one should also consider matching the triathlete with an optimal cycling shoe and cleat/pedal system. One may consider a cleat/pedal system that supports transverse plan adjustments, also referred to as “float.” This float is especially worth considering for triathletes suffering from knee injuries or for those with moderate to high levels of internal position of the hip, knee and/or tibia.

   Foot orthoses can serve as a cornerstone for treatment and recovery. This is especially the case with custom foot orthoses (CFO) that specifically address established abnormal biomechanics and the specific requirements of an injury. Foot orthoses have been long considered an important component to the treatment of running overuse injuries. Similarly, a CFO prescribed for use in the cycling shoe can address many foot and lower extremity injuries.

   However, one must direct considerable attention at developing a prescription that will meet the needs of the injury and the restrictive cycling shoe environment. Fortunately, a wide array of prescription alternatives and materials are now available for the fabrication of prescription CFOs for running and cycling.

What You Should Know About Functional Strengthening

   One can manage functional strengthening by developing a plan that stimulates proprioceptors, mobilizes joints and improves muscle coordination while providing multi-planar isometric, concentric and eccentric contractions.

   Plyometric rehabilitation routines initially performed as an aquatic-based exercise program effectively introduce closed kinetic chain exercises that are critical for returning the triathlete to athletic activities.

   For most triathletes, access to a swimming pool will not be a problem. Aquatic-based plyometric exercises composed of hops, jumps and bounding activities will safely augment other rehabilitation activities. The athlete can transition to a land-based plyometric exercise routine when he or she can demonstrate basic proprioceptor skills such as stable controlled squats, heel-to-toe walk and low speed lunges.

   Avoiding reliance on open kinetic concentric exercises will accelerate the triathlete’s recovery. Mobilizing the rested or immobilized limb or structure becomes the cornerstone of functional strengthening.

How To Ensure A Safe Return To Competition

The final and perhaps most difficult phase of recovery from an overuse injury is managing the return to swimming, cycling and running. The athlete feels a resurgence of strength, freedom of movement and elimination of pain. Naturally, he or she is eager to return to participation in all three sport disciplines.

   At this point, the physician and triathlete can discuss a conservative return to activity built around a mix of swimming, cycling and running. A plyometric exercise routine should continue. Improvements to the running and cycling muscle groups, and continued activation of neuromusculoskeletal coordination are important to the sustained physical output required of the triathlete. As strength and exercise efficiency improve, one may allow a return to full activity for the triathlete.

In Conclusion

   Many intrinsic and extrinsic factors exert an influence upon the triathlete, and may contribute to the development of an overuse injury. While the exact causes for overuse running and cycling injuries are yet to be identified, one can postulate that the etiology is multifactorial. In general, the etiology may involve intrinsic and extrinsic factors. Training errors, anatomical abnormalities and lower extremity biomechanics are widely accepted as common factors contributing to the development of overuse injuries.

   Careful selection of running and cycling shoes may help the athlete reduce the overall risk of overuse injury, improve comfort and enhance performance. Improper, damaged and/or worn-out shoes have been implicated in the development of overuse injuries. Additionally, the manner in which the foot is cradled within the shoe by way of an orthosis can contribute to enhanced comfort, avoidance of overuse injury and extended tolerance to sustained training/racing efforts.

   Treatment strategies for the management of acute and overuse triathlon injuries vary widely, and are typically dependent upon multiple factors. These factors include the nature, severity, onset and duration of the injury; prior treatment efforts and injury history; results of imaging, laboratory tests and consultations; interpersonal athlete-driven needs and prior experiences (successes and failures).

Dr. Herring is a Fellow of the American College of Foot and Ankle Orthopedics and Primary Podiatric Medicine, and the American Academy of Podiatric Sports Medicine. He is a team podiatrist for several college and professional teams, and has a private practice in Spokane, Wash.

Editor’s note: For related articles, visit the archives at www.podiatrytoday.com

References:

1. Wilk BR, Fisher KI, Rangelli D. The incidence of musculoskeletal injuries in an amateur racing club. J Orthop Sports Phys Ther 1995; 22(3):108-112. 2. Korkia PK, Tunstall-Pedoe DS, Maffulli N. An epidemiological investigation of training and injury patterns in British triathletes. 1994; Br J Sports Med 28(3):191-196. 3. O’Toole MI, Douglas PS, Hillier B, et al. Overuse injuries in ultraendurance triathletes. Am J Sports Med 1989; 17(4):514-518. 4. Collins K, Wagner M, Peterson K et al. Overuse injuries in triathletes. Am J Sports Med 1989; 17(5):675-680. 5. Cipriani DJ, Swartz JD, Hodgson CM. Triathlon and the multisport athlete. J Orthop Sports Phys Ther 1998; 27(1):44-48. 6. Burns J, Keenan AM, Redmond AC: Factors associated with triathlon-related overuse injuries. J Orthop Sports Phys Ther 2003; 33(4):177-184. 7. Migliorini S. An epidemiological study of overuse injuries in Italian national triathletes in the period 1987-1990. J Sports Traumatology 1991; 13(4):197-206. 8. O’Connor FG, Wilder RP. Textbook of Running Medicine. McGraw-Hill Professional Publishing, New York, 2001.