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Heather Smith, PT, DPT, OCS

The Competitive Triathlete: Their Demands and How to

Keep Them Going the Distance

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webinar do not have any financial or other

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• There was no commercial support for this

presentation.

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views and opinions of the presenter.

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information contained in this presentation.

Course Objectives

Participants will be able to define distance

requirements per event for sprint vs Olympic

triathlons, half vs full Ironman

Participants will be able to identify common

acute vs overuse injuries that affect triathletes

Participants will be able to describe common

injuries associated with each event for triathlons

Participants will be able to develop a basic rehab

program to address common overuse injuries in

triathletes

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Triathlon

Endurance race combining three separate sport events

Participation in Triathlons

Increasing participation in triathlons over past 30 years

Roughly 300,000 athletes participating in triathlons/year in US

High variability of training regimens

High volume

Speed vs endurance vs strategy

2000

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The Triathlete

Male & Female participants

Participants encompass a wide age range

Elite triathletes reach peak

performance in Ironman distance ages 33-34

Non elite triathletes achieve fastest times at age 25-44

Performance Predictive Variables

What factors are instrumental in impacting overall race performance and finishing times?

How can you help your patient develop a measured

program after recovery from injury to improve

performance?

What are markers of an elite, competitive

triathlete?

Performance predictive variables –Body Morphology

Low Body Mass

Low BMI

Low Fat

Most important predictor variable

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Performance predictive variables-

VO2 Max

Predictor of performance amongst a group of athletes of mixed

abilities

NOT a predictor in

homogenous group of elite athletes

Performance predictive variables

- Nutrition

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Performance

predictive

variables – Racing

Background

Age Related Change in

Performance

Age Related Changes Impacting Performance -Physiology

Decreased muscle

strength

Decreased oxygen

carrying capacity

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Age Related Changes Impacting Performance - Morphology

Increased body fat

percentage

Lower muscle mass

Age Related Changes Impacting Performance – Functional Capacities

VO2 Max declines

Decreased stroke volume

Decreased heart rate

Decreased a-v O2

Decreased lactate

threshold

Age Related Change in

Performance

Optimize training

Include strength training

Optimize nutrition

Ensure adequate protein

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The Pros of the Multisport

Athlete

Continue training with

injury

Maintain, Increase focus

on other activities

Avoid, Reduce activity

related to injury

The Cons of the Multisport

Athlete

Multiple events leads

to combination of stresses

Prohibitive to healing

Different, but repetitive stress on

certain tissues

Injury

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Acute vs Overuse

Traumatic, or acute, injuries account for 15-54% of injuries

Overuse injury accounts for 41-91% of all injury

Roughly 90% of actively training

triathletes will experience an

acute or overuse injury over the course of their training year

Acute Injury Less common than overuse,

but DOES occur

Instantaneous onset

External and environmental

circumstances may

predispose an acute, traumatic injury within each

event

Can be linked to

accumulating stresses that

have been previously occurring without

symptoms, but have a

sudden presentation

Concussion

• Headache

• Nausea

• Vomiting

• Dizziness

• Temporary loss of consciousness.

• Confusion or feeling as if in a fog.

• Amnesia surrounding the traumatic event.

• Ringing in the ears.

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Heat Injury Heat Cramps

• involuntary mm spasm

Heat exhaustion

• Cool, moist skin

• Heavy sweating

• Faint/dizzy

• Weak, rapid pulse

• Orthostatic hypotension

• Muscle cramps

• Nausea

• Headache

Heat Injury

Heat stroke

• LACK of sweating despite the heat

• Dizzy/faint/loss of consciousness

• Weak

• Throbbing headache

• Red, hot skin

• Rapid heart beat

• Rapid, yet shallow, breathing

• Temperature >104 F

• Slurred speech

• Seizure

Dehydration

Dry skin

Dry mouth/lips

Dizziness

Light-headed/faint

Rapid heart rate

Rapid breathing

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Common Acute InjuriesEvent specific

Acute Injury – Swim Event

Drowning Contact Injury

Acute Injury – Cycle Event

ACJ Separation

Clavicle Fracture

Shoulder Dislocation

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Acute Injury – Run Event

Muscle Strain Injury Related to a Fall

Overuse Injury

Overuse Injury

Site % of all injuries

Foot 10-15

Ankle 10-15

Lower Leg 5-10

Knee 25-30

Thigh 5-10

Hip/Groin 5-10

Shoulder 10-15

Lumbar Spine 10-15

Cervical Spine 5

Other 5

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Risk Factors for Overuse Injury

Extrinsic

Previous history of injury

Years of Experience

Training Errors

Use of paddles during swim training

Rapid increase in distance/intensity of training

Hard gearing during cycling

Low cadence during cycling and/or running

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Risk Factors for Overuse Injury

Intrinsic

Cavus foot OR Pes planus

<10 degrees of dorsiflexion

High Q angle

Limited mobility OR hypermobility

Decreased strength

Injury & Incidence Incidence of injury ranged from 37-91%

Training related injuries account for 75-83% of all reported injury

Competition related injuries accounted for 8-28% of all reported injury

Commonly injured region reported by triathletes

36-85% lower limb

14-63% knee

9-35% ankle/foot

72% Low back

19% shoulder

20% of all injured triathletes have reported injuries severe enough to stop a component of training

17% to stop swimming

26-75% to stop cycling

42-67% to stop running

Swimming & Injury• 5-10% of overuse injuries from

triathlons are related to swimming

• Overuse pain usually due to inefficient swimming

• Swimmers may rely more on UEs for arm pull to save legs for cycle & run

Find a swim coach to help athlete

improve form and increase

streamline position of the

swimmer in water

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Swimming Intervention – Shoulder

Pain

Strengthening: Serratus Anterior

The serratus anterior activation and EMG has been found to be significantly depressed with pull through phase of many swimmers.

Serratus punch at 120° Push up with a plus Supine serratus punch

Swimming Intervention – Shoulder Pain

Strengthening: RTC

Weakness of the RTC can predispose to upward translation of the HH

Undue stress upon the RTC

Internal impingement.

Most swimmers are disproportionally stronger with IR vs ER

Increases risk of injury

ER in 90° of ABD ER in sidelying ER w/ band 0°ABD ER w/ band 30°ABD

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Swimming Intervention – Shoulder Pain

Strengthening: Scapular Stabilizers

Stabilizers shown to be weak via EMG amplitude in research with swimmers with shoulder pain

Swimmers with shoulder pain often demonstrate poor biomechanics

Often due to GHJ laxity secondary to shoulder hypermobility

Prone T Prone Y Prone W Prone I

Swimming Intervention – Low Back Pain

SKTC Stretch TrA Brace Birddog Plank

Swimming Intervention – Hip Pain

Hip Flexor Strain

Hip Flexor Stretch Hip flexor strengthening Dead bugQuadruped hip

extension knee

flexed

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Swimming Intervention – Hip Pain

Adductor Strain

Adductor stretch a) Adductor Isometric

b) Adductor Isotonic

Copenhagen

Adductor Exercise

Video

Cycle Leg

About 20% of injuries sustained due to triathlon training/competition due to cycling

Most training hours spent cycling

Overuse injuries often related to

Poor bike fit

Overtraining

Improper training

Common areas affected by cycling

Knee

Low back & neck

Achilles tendon

Wrist and forearm

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Cycling & Knee Pain

Knee is the most common area of pain with the cycling leg

Incidence of knee pain is reported between 14.8 & 33%

Training and/or bike errors include:

Hill training

Decreased cadence with high gears

Excessive quad force

Poor distribution of force, and altered recruitment of VMO & VL with poor VMO engagement, can lead to knee pain with cycling

Usually due to alterations in cycling form

Alterations include an increased medial projection of the lower limb in a position of dorsiflexion during the power phase of the revolution,

Cycling & Knee Pain – Patellofemoral

Pain Syndrome Due to increased

patellofemoral contact pressure

Excessive quad force

Malalignment

Poor bike seat position

Too low

Too far forward

More common in females

Cycling & Knee Pain –Patellar Tendonitis

Inflammation of patellar tendon due to increase in strain through the PFJ mechanism

Onset correlated with

Low cadence or hard gearing

Hill climbing

Stand pedaling

More common in men

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Cycling & Knee Pain – Iliotibial

Band Syndrome

Inflammation of Distal Iliotibial Band

ITB Syndrome can occur in cyclists due to high repetition of knee flexion and then extension in the impingement zone of the IT Band

Between 10 & 30 degrees of flexion, near the bottom of the stroke

Risk Factors

Excessive seat height

Poor technique

Low Back and

Neck Pain

LBP

67-72% incidence

Tri bike set up causes

increased horizontal

position and thus,

possibly more strain on

the lumbar spine and

SIJ

Neck Pain

Neck Pain

48.3% incidence

Tri Bike causes cervical

spine to hyperextend

and increase strain on

upper 3 levels of

cervical spine

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Achilles Tendon Pathology &

Cycling

Associated with Poor technique

Decreased cadence

Standing out of saddle for hills

Bike fit

Indirect Overuse

Forearm & Wrist

Ulnar nerve distribution most often affect for motor and sensory nerve deficits

Hyperextension of wrists on handle bars may cause wrist pain

Intervention – Gear & Cadence

Correct improper gear and cadence

Light gears with a cadence of >100 RPM

Higher cadences lead to more recruitment hamstrings and hip extensors

With increased loads, increased cadence is needed to decrease the percentage of

overall workload of the quadriceps

Quad & PF stress

Gear

Str

ength

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Exercise Intervention Suggestions

– Low Back PainIncrease flexibility & spinal mobility

Exercise Intervention – Neck Pain

Increase flexibility and cervical strength

Exercise Intervention Suggestions –Knee Pain

Rebalance Quad

Activation – Target VMO

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Exercise Intervention – Knee Pain

Ensure adequate balance between hip ABDuctors

and ADDuctors

Especially if cyclist demonstrates increased adduction during stroke of revolution

Intervention – Assess for Hyperpronation,

Cleat Adjustment

https://www.thebikebutler.com/bike_fitting/knee.html

Tri-Bike

Aerobars

Seat Tube

AngleCockpit

length Arm rest

drop

Crank

Length

Bottom

Bracket

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Bike Fit Areas of bike fit to have

impact on form and contribution to appropriate mechanics

Seat height

Saddle position

Handle bar height and position

Angle of saddle inclination

Angle of handle bar inclination

Pedal position

Ultimately – refer them to a bike shop!

Run Leg

Most injuries incurred by training are related to running

Running >40 mi/wk predictor of injury related to running

Best predictor of overall race time

Training encompasses an average of 37% of total training time

Similar injury rates between single sport running & triathlon running injury

Indications injury may be related just to biomechanics and training

Knee injuries account for more than 1/3 of all run injuries

Hip/Groin

Knee

Lower Leg

Foot/ankle

Hip Pain & Running

Hip accounts for 5-10% of injuries

Total of approximately 160 degrees of motion in the sagittal plane, yet only aout 40 deg arc is used during running for recreational athletes

Elite atheletes may go through slightly (~10 deg) more motion during the running cycle

Regardless of recreational or elite athlete, the running ROM of the hip is a considerably limited range of the overall motion.

This repetitive activity can lead to a high focal load in this region

Especially when considering up to 8x BW can be generated at the hip with running

40°

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Risk Factors for Hip Injury due to

Running

A few predisposing factors for hip injury have been

reported in the literature.

Excessive hip ER

Prev injury

>64 km/wk running distance

Running year round

Narrow tibial width

Decreased strength

Running & Hip Injuries –Stress Fracture of the Femoral Neck

Symptoms include:

Anterior hip/groin pain,

medial knee pain

Onset usually due to increased frequency, intensity and duration of running

Pain exacerbated by running and intensity increases with duration

Running & Hip Injuries – Lateral

Hip Pain ITB Syndrome

Improper eccentric hip abduction of femur during stance

Sudden increased mileage, running on banked surface and/or downhill, MSK abnormalities

Hip Bursitis /Glut med and/or min tendinopathies Interrelated pathologies

Most common symptom is pain with laying on involved side

Other symptoms include:

Pain with running and exercise

Pain with sitting with legs crossed

Pain with climbing stairs

Pain can be localized to side of hip, but it CAN radiate down the leg

Differential diagnosis will be important to rule out lumbar radiculopathy

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Running & Hip Pain – Osteitis Pubis

Inflammation of the pubic symphysis and surrounding muscles

Due to repetitive vertical shear force across pubic symphysis

Alternating foot strike during running can create shear force

Case Study

36 yo male presents to PT with CC of anterior L hip

pain.

Onset x 1 week ago at onset of a run. No noted MOI,

but reports the day before he had just completed his

hardest ride followed by a run as part of his recent

training program as he prepares for 2 upcoming

Ironman competitions. Does not recall specific

incident during the ride and subsequent run. Pain

ONLY with running, he can still cycle and swim

painfree. Pain going UP stairs, but no other pain

with ADLs/IADLs or daily mobility

RIGHT LEFT RIGHT LEFT RIGHT LEFT

ER 45 40 5 4- Quads 64 56

IR 25 17 5 3+ HS 30 23

EXT 10 5 4 3-

FLX 135 135 5 3+ painful

ABD WNL WNL 4+ 3+

ADD WNL WNL 5 3 painful

Hip PROM Hip Strength Thigh Dynamometry

Flexibility

RIGHT LEFT

QUADS110°knee flx in

prone90°knee flx in prone

HS25°knee flx angle in

supine

35°knee flx angle in

supine

Piriformis Reduced Reduced

Hip Flexor Thomas Test (+) Thomas Test (+)

Stabilization

RIGHT LEFT

SLS EO 40 sec20 sec;

trendelenberg

SLS EC 15 sec UNABLE

TTP

(+) Adductor Longus

(+) Adductor Magnus

(+) Iliopsoas

Case Study – Objective Findings

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Case Study - Intervention

PT 2x/wk x 4 weeks then 1x/wk x 2 weeks

MANUAL Intervention

IASTM of ADD Longus, ADD Magnus

PROM hip IR

Exercise & Stabilization

Initial

PNF in prone for increased hip internal rotation

Hip Flexor, Quad, Hamstring & Adductor stretch

Bridge

Adductor Longus Isometric

Reverse clamshell for active hip IR

Case Study – Intervention (continued)

Exercise & Stabilization

Intermediate

SLS dynadisc EO

SLS EC even ground with contralateral hip flexion

Adductor Longus Isotonic exercise

SL Bridge

Clamshell

Plank

Advanced

Copenhagen Hip ADDuctor Exercise

SL step up with KB press

Deadbug

Case Study - Outcome

10 visits with resolution of symptoms and return to running

Management of training

Minimize speed and hill work on bike

No limit on volume of cycling or distance

No limit on swimming

Cessation of running during acute pain, initiation of elliptical for

standing cardio

Resume run training with SLOW progression on time/distance once

patient able to run x 15 minutes painfree.

Patient independently ran 8.5 miles prior to OK from PT and regressed quite

a bit for a week

Last PT session patient able to run x 60 minutes painfree

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Knee Injuries &

Running

Knee pain most common with running related injuries

Accounts for ~30% of running injuries

Anterior knee pain is the most common

5.8x BW transmitted through patellar tendon

9x BW transmitted through the patellofemoral joint

Thorough evaluation of the entire lower extremity must be performed

Limited hip mobility

Limited ankle mobility

Altered foot strike/foot posture

Knee Injuries & Running: Anterior Knee Pain

Anterior Knee Pain includes:

PFPS

Patellar Tendonitis

Chondromalacia Patellae

Due to overuse, abnormal biomechanics

Detailed evaluation of runner with anterior knee pain needed to develop comprehensive plan for correction of impairments

Patellar tracking

VMO recruitment

Flexibility and strength of musculature of the hip/knee/calf

Knee Injury & Running – IT Band

Syndrome Repetitive friction of the IT Band over

the femoral lateral epicondyle

IT Band impingement zone

around 30 deg of knee flexion

Increase in internal rotation moment at the thigh valgus vector at knee

tension on ITB

Onset related to running downhill, running same direction around a track, LLD and high

weekly mileage

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Knee Injuries & Running: Meniscal Tears Repetitive impact

More common in older

triathletes

Commonly affects the

posterior horn

Meniscal tears almost

exclusively occur due to

the run training component

of preparation for a

triathlon

Lower Leg Injuries

& Running

Account for about 10%

of injuries incurred by

triathletes

Injury incidence thought

to be due to the lower

legs shock absorbing

role during impact in

running

Lower Leg Injuries & Running: Stress Fractures

Stress fractures of lower leg most common at tibia

Anterior tibial crest (high risk)

Posteromedial cortex (most common and best prognosis)

MOI: repetitive ankle plantarflexion with continued repetitive stress, leading to lack of time for adequate rest to heal and remodel

Symptoms include onset of pain with running that starts to present earlier and earlier within the run. May also have a limp, rest and night pain as stress fracture progresses

4-8 weeks of rest with gradual return to running

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Lower Leg Injuries & Running:

MTSS Medial Tibial Stress Syndrome

Periostitis about the tibia or tendinopathy of the deep ankle plantarflexors- due to increased traction of deep flexor mm & soleus

Eccentric contractions of the soleus and/or posterior tibialis muscles to resist pronation during stance phase will lead to muscular strain and subsequent inflammation about the muscular attachments

Commonly due to training errors

Increased intensity/duration of training

Poor footwear

Training surface (beach or trail)

Common mechanical findings

Overpronation

Navicular Drop

Valgus Hindfoot

Decreased Hip IR

DIFFERENTIAL

DIAGNOSISMTSS vs Stress Fracture

Palpation

MTSS middle to lower third of tibia & should

involve at least 5cm area that is tender to

palpation; pain is diffuse and characterized as

achy

Stress fractures are usually more isolated to a

focal region of pain; pain is more intense

Symptoms

MTSS pain may start as soon as exercise

begins and should stop as soon as exercise is

finished

Stress fracture pain may not start until

further into exercise and rest pain is common

Swelling may be noted with stress fracture

Clinically, a DDx between the two is

difficult and a referral for imaging is

warranted if suspicious for stress fracture

Lower Leg Injuries & Running: Chronic

Exertional Compartment Syndrome

Exercise induced muscular and nerve syndrome

Aching, burning, cramping/tightness in the calf that begins at specific time after onset of exercise

Increased intramuscular pressure due to fluid accumulation in interstitial space

Most common about anterolateral leg

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Lower Leg Injuries

& Running: Calf

Strain

Sudden dorsiflexion of a

plantarflexed foot with

knee in extension

Most common along

medial head of gastroc

Foot/Ankle Injuries

& Running

Foot and ankle account for 15-25% of running injuries in triathlons

Foot shape is a risk factor for overuse injury

Cavus foot prone to injury because of poor shock absorption capability

Planus foot prone to injury due to inability to appropriately distribute force of contact and body weight

The foots ability to appropriate perform pronation and distribute force during stance is imperative to painfree running

Foot/Ankle Injuries & Running – Achilles Tendinopathy

Intrinsic risk factors:

Regional hypovascularity

Endocrine issues/metabolic disease

Extrinsic risk factors:

Training errors

Decreased flexibility & range of motion

Quad and glut weakness

Excessive lateral heel strike and subsequent increased pronation can increase strain through gastrocnemius and soleus muscles, leading to microtears or excessive strain across Achilles.

12.5x BW transmitted through Achilles during running

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Foot/Ankle Injuries & Running -Metatarsalgia

Umbrella term for

possible

Tendinitis

Capulitis/synovitis of metatarsal-phalangeal joint

Morton’s Neuroma

Foot/Ankle Injuries & Running –Stress fractures of the Foot

Metatarsal heads

2nd and 3rd metatarsal heads most commonly affected

Focal tender to palpation along metatarsal heads

Navicular bone

Tender to palpation along dorsum of navicular bone

Pain with jumping

Proximal 5th metatarsal

High risk of non union due to poor blood supply

Foot/Ankle Injuries &

Running – Plantar

Faciitis

50% of running foot & ankle injuries

Insidious onset of sharp, throbbing pain on medial side of heel

Increased pain with barefoot, up stairs, initial walking after period of rest

Runner will commonly overpronate and/or have <10 degrees of dorsiflexion

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Run

Intervention

EVALUATION OF BIOMECHANICS, STRENGTH AND MOBILITY

RUNNING ASSESSMENT

EXAMINE SHOE WEAR AND CONSIDER

ORTHOTICS

TRAINING VARIABLES FOR CONSIDERATION

Evaluation of Biomechanics,

Strength and Mobility

Running Assessment Normal Running Gait

Foot pronation at midstance

Foot supination at push off

Initial Contact

Foot strike

Forefoot vs Rearfoot strike

Mid Stance

Foot pronation for force absorption

Posture

Center of Body of Mass

Recovery

Toe off

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Foot Strike Forefoot vs Rearfoot

Forefoot is considered to be superior foot strike as it allows for improved force absorption of the musculature of the lower extremity as the foot lands closer underneath the center of mass.

Rearfoot strike generally leads to the limb contacting the ground far in front of the center of mass, leading to increased ground force reaction up the chain and increased impact absorbed by the joints

How to help your athlete change their foot strike?

Increase the step cadence

Cadence

Enhance step rate of the patient

Increasing frequency of steps will shorten stride length and shorten time spent in stance, thereby decreasing the impact and amount of time spent absorbing forces during running gait

The runner’s body experiences less vertical displacement, more knee flexion and plantarflexion upon initial contact, thereby improved force absorption and decreased injury risk

Ideal cadence = 180 steps/minute

Cadence <160 steps/minute puts runner at risk of overuse injury due to overstriding

Research has found the optimal increase in cadence is 10% from patient’s baseline to reduce injury risk

Running Shoes

The athlete’s running shoe should

be replaced every

400-800 km as this

magnitude will

decrease the shock

absorption

capabilities by 60%

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Training Variables

Common training errors include increasing distance and/or intensity too quickly

Take time to increase running distance and speed to avoid injury

A 10% increase per week is appropriate for increasing distance

Have the athlete avoid excessive downhill running, vary direction used on a track, maintain proper shoe wear, perform consistent warm up and cool down

Exercise Suggestions – Hip &

Knee Pain

Exercise Suggestions - Knee Pain

Eccentric Quads

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Exercise Suggestions – Lower leg,

Foot/Ankle Pain

Injury Prevention & Injury

Management

Primary Strategies

Injury Prevention & Injury

Management – Check In

If your patient is a triathlete and is coming less frequently to physical therapy for any number of reasons, keep a line of communication open with them. This helps build the patient-therapist relationship and builds trust

Support the patient and reinforce performance of the home exercise program during communication outside of visits

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Injury Prevention & Injury

Management – Shoe Wear

What make and model

are the shoes?

How old are the shoes?

Ask patient to bring

the running shoes in

for a visual assessment

of wear/tear

Injury Prevention & Injury Management –Warm Up & Cool Down

Educate athletes regarding indications for implementation of dynamic warm up and static stretching.

Injury Prevention &

Injury Management

Opportunity for marketing and/or community outreach by offering screening assessments to local triathlon clubs

Screening tests are good tools to identify asymmetries, decreased stability and/or flexibility

FMS

SFMA

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Injury Prevention & Injury

Management

Educate patients on training and performance variables

Many experienced and competitive triathletes will have a coach. However, if your patient has minimal experience or are beginners, they will need guidance to avoid injury

Educate your patient to avoid pushing heavy gears and low cadence on the bike

Educate to slowly increase intensity and distance of training for all events of the triathlon

Avoid a high volume of hill training for running and cycling

Encourage and reinforce REST days

If they are unsure how to appropriately manage their gear ratios, are motivated to really race competitively, refer them to a triathlete coach

Questions?

Heather Smith

hmsmith85@gmail.com