Triathlon And Multisport Injuries

If I was given a dollar for each time I have pondered to myself why I seem to always carry an injury, when other triathletes are able to keep training and racing injury free I would be able to afford all those expensive toys on my Christmas list. It becomes constantly clearer to me that as I see a variety of clients, all shapes, sizes and abilities, and from many different sporting backgrounds that the answers began to make themselves clear. Quite simply, the ones who are constantly injured may be predisposed to certain types and mechanisms of injury. This is most likely related to biomechanical alignment, training practices, gender, age, underlying medical conditions and genetics.

From what I have heard around the transition area and at the post race functions, triathletes and multisporters are becoming more and more aware of the injuries they may experience, what they should do to avoid them and who they should consult about them. This appears to be a vast improvement on some years ago.

As a Podiatrist, I attempt to explain both intrinsic and extrinsic reasons for the development of lower limb injuries. It must be emphasised that in some cases a Podiatrist should be used as part of a holistic approach, not necessarily as the sole practitioner. This means that regular communication should occur between the Podiatrist, GP, Physiotherapist, Masseuse, Coach, and other practitioners and of course you, the athlete.

One of the few surveys on the epidemiology of triathlon injuries was taken after the 1986 Hawaii Ironman World Championships. This concluded with a very generalised and inaccurate statement, stating that the incidences of overuse injuries were not associated with excessive training distances, pace or time, but instead that biomechanical factors solely lead to injury. The incidence of injury in the triathlete and multisporter seems to be steadily increasing across all levels of competition. Therefore, it is not surprising that questions arise as to the reason for their development, the treatment for and the prevention of such injuries. Recent studies and current theory has contradicted the 1986 Ironman survey, indicating that there is in fact a distinct cause-and-effect relationship between training error and the development of an overuse injury.

So why is it that injuries occur in the multisport athlete when much of the training involves a high proportion of low impact exercise - swimming, cycling and kayaking? Acute injury is associated with a defined incident, such as losing balance on a camber, and spraining an ankle for example. A chronic injury is associated with an insidious onset of symptoms, which cannot be identified to a defined incident. However, there may have been an identified alteration in training, running surface, footwear, bike position or nutrition that has bought on the injury, this is often discovered early on in the initial consultation with the Podiatrist. The chronic injury is more commonly termed ‘overuse’. It is believed that the overuse injury is due to the cumulative effects of multisport training, in all disciplines.
In the past it was hypothesised that concurrent multidiscipline training reduced the chance of an overuse injury, because it was thought that it would decrease excessive stress to specific areas of the body. Today it is clearly understood that the regular back-to-back training sessions required for effective multisport training probably do not provide the body sufficient time to recover. This, combined with biomechanical, physiological and training factors, may result in the development of an injury if the athlete is not in-tune with their body, and/or has a poorly constructed training program.

It has been reported that well over half of all triathletes have sustained an injury during training for competition. The majority of injuries involve the lower limb, a pattern that is probably secondary to the excessive impact during running, and the repetitive motion of cycling. Over 75% of injuries are incurred during training, perhaps due to over training in the running discipline. It has also been found that in only 42% of injuries medical advice is sought. Unfortunately there is no epidemiological data for multisport athletes, because there may be some interesting variability in injury statistics. Training and racing in the run discipline for multisport is often performed on an off road surface, therefore different levels of impact are applied to the body, however acute injuries may be more common due to the uneven running surface the athletes must negotiate.

A major cause for concern is the fact that not even half of all injuries were treated with the appropriate medical advice, if any at all. In the early stages, an injury is often very easily and effectively treated, with few complications, especially if the cause of the injury is identified. The short-term medical plan will often aim to remove the causative factors before anything other exercise is performed. Ignorance of developing injuries will in many cases result in total cessation of training. This may be particularly true in the development of stress fractures of the lower limb.

Another major risk factor for severe injuries is to return to activity too early, before the body has been able to regenerate the damaged tissue, and remodel it to withstand high loads again. Just because the pain is not there it does not mean that the injury is totally healed. Although, one of the biggest challenges for a medical team is to convince the athlete to stay on the side-lines for one more week, or to take it easy for the early training stages, because REST is the athlete’s four-letter-word. It cannot be emphasised enough that many stress fractures may take at least 6 weeks to fully recover, and a further 3-4 weeks to build the body back up to a level close to one that can return to normal training. Some stress fractures, such as those of the navicular bone (which is located in front of the ankle joint, at the top of the foot’s arch) will require a period of non-weight bearing casting, until it is deemed safe by the practitioner to remove the cast. The disadvantage of periods of non-weight bearing is that the body senses that the area of bone in cast does not require as much strength because it is not bearing high loads of weight. The muscles that work on the casted area too will begin to weaken and reduce in size and tone, because they too are not being used as much. This resorption and degeneration must be replaced with normal healthy tissue before it is suitable to carry the loads required for training and racing.

Almost half of all triathletes have a background in running, so this discipline may be the one that is concentrated on more regularly. Training principles today have undoubtedly changed since the 1986 Hawaii Ironman, but there were still some interesting findings reported in the aforementioned research paper: Cycling training comprises of an average 350km per week over 4-5 days, whereas running comprises of 72km per week average over 4-6 days. This shows that there is more high impact (running) than low impact activity (cycling), which indicates there is a great deal of stress placed on the muscles/tendons, bones and ligaments of the lower limb. These figures would no doubt differ for athletes competing in shorter events, they may also alter for multisport training. It is important to find a balance between the intense sessions and lighter/recovery sessions, and not to neglect the rest days. Multiple session training days for most of us should alternate between activities that use different muscle groups and actions.

During running the body’s tendons, ligaments and bones all have their own threshold of elasticity, they can withstand regular stresses up to, but not exceeding, this level. Once the maximal elasticity has been breached the tissue begins to have small tears or areas of inflammation - this is often encountered during speed or long training sessions; if the body has not been gradually built up to the required level. Early symptoms may be felt at this stage, especially areas of pinpoint tenderness or along the length of a bone’s border, pain at a tendon’s insertion to a bone, or pain within the tendon itself. Continued training, without removal of causative factors and appropriate treatment at this stage will eventually cause the tissue to deform or weaken. This often manifests as a stress fracture or a partial or total rupture of a tendon.

The aforementioned scenario is over-generalised and not experienced in all cases, however it does highlight the result of ignorance of symptoms and incorrect training. If medical advice is sought at an early stage then the necessary measures can be taken to ensure the injury does not develop further.

Treatment may involve:
• The reduction of inflammation at the site of injury with physical therapy and/or anti-inflammatory medication.
• Alteration of exacerbating factors such as poor footwear or training surface.
• Alteration of biomechanical position, with the use of orthoses, if necessary.
• Alteration of training regime if it seems too excessive.
• Active rest, which involves continuing moderate exercise but not to stress the injured structures. Total rest should be avoided as this may weaken tissue and result in another injury when training is commenced.
• Advice on prevention of injury recurrence
• Communication with other involved practitioners.

So why is it some people can train at a high level and still remains injury free, such as: elite athletes, Ironman competitors, Coast to Coast competitors and Mizone Endurazone competitors?
In most cases these people have been able to gradually increase their training intensity over a longer period of time, to allow their bodies to adapt to the increased stress. Most of these athletes are smart trainers, they may get injured but they are able to control the progression of the injury. These athletes do not push themselves too much all the time. Lance Armstrong, in his autobiography ‘Its not about the bike’ discusses how he trains at a very low intensity for the majority of his program, with the perfect mix of speed sessions. However, their ability to train effectively and remain injury free is not just due to training principles. A lot of it comes down to the old favourite - genetics. Essentially, an athlete’s physiology and lower limb biomechanical position is largely determined by genetics, this will affect the way the legs adapt to the stress applied during the running and cycling discipline. This, in conjunction with an effective training and medical plan may explain why the Clode, Reed, Docherty siblings and Bozone boys are able to race successfully on the world stage, over many seasons, with out any major injuries.

The beauty and uniqueness of our sport is that any level of athlete can compete on the same course at the same time as the country’s and the world’s best athletes. At the end of the day, if we have finished the race then we have won our own championship. Just because some of us may not have been born with Superman’s or Wonder Woman’s genes is no reason for us not to be able to race at a high level consistently. The process of natural selection probably determines whether or not promising junior athletes will make it onto the elite international stage, the rest will just have to rule the age groups back home.

It is crucial to understand that we as multisporters and triathletes compete in a sport that requires very effective management of our training regime. Our bodies may be more susceptible to injury than other athletes because in some cases we are required to pack in more than one training session per day. This does not give our bodies much time to recover properly to prepare for the next session. We must listen to our bodies and be aware of what action to take if an injury is apparent. We should also be cautious not to neglect our rest days. It is always better for our body and our mind to stand on the start line with the confidence that we are injury free, and have trained with our brains, not just with our legs.

References
1. O’Toole, M.L., Douglas, W., Hiller, B., Smith, R.A., & Sisk, T.D. (1989). Overuse injuries in ultra endurance triathletes. The American Journal of Sports Medicine, 17 (4). 514-518.
2. Cipriani, D.J., Swartz, J.D., & Hodgson, C.M. (1998). Triathlon and the multisport athlete. Journal of Orthopaedic and Sports Physical Therapy, 27 (1). 42-50.