By: Lai Chi Kit Jerry, Lam Kit Yan Wendy,
Tang Wing Yan Tracy, Yiu On Yee Annie
Outline
• Overview of Trailwalker
• Physiologic demand and common injuries
• 2 Case scenarios
– assessment, treatment and advice
•
•
•
•
Training guidelines
Nutrition in Sports
General advice
Q&A
Overview of Trailwalker
• An annual fundraising walkathon organised
by Oxfam Hong Kong since 1981.
• The 100-km MacLehose Trail
• To develop their potential and abilities of
disadvantaged people in Hong Kong and
poor people in Asia and Africa.
• From 1981, $80,000 raised increase to over
$16 million in 2000.
Interest Arouse
1985 Five non-military teams join.
1986 1st year opened to public
Oxfam Hong Kong co-organise the event.
1989 350 teams (75 Gurkha, 230 civilian) – 1st year with
more civilian teams than military.
1993 Registration of 600 teams was full in 6 weeks.
1996 Registration was full in a fast 12 hours.
1997 The 700-team quota was full within 3 hours.
1999 Quota increased from 760 teams to 900.
2000 918 teams participated
Exercise Physiology of
Endurance Sports
• High oxygen transport capacity
– VO2max
• High fatigue resistance in working muscles
– lactate threshold (Tanaka, 1995)
• Muscle fibre composition
– type I > type II
• Energy utilization
– carbohydrate + fat
Common Injuries
Medical
(59%)
Dermatologic
(21%)
•Exercise-associated
collapse (EAC)
•Blisters
•Sprains
•Abrasions
•Strains
•Hyponatremia
(Roberts W.O., 2000)
Musculoskeletal
(17%)
•Fracture
Dehydration, exhaustion,
syncope, hyperthermia &
hypothermia
Musculoskeletal Injuries
• Knee > Ankle (31.3% vs 28.1%)
• Injuries (in descending order)
– PFJ pain
– Tendinitis of tendons passing under extensor
rectinaculum
– Muscle cramp
– Achilles tendinitis
– Ankle sprain
(Fallon K.E.,1996)
Case scenario
• Team A
– 4 long-distance runners who have no
experience in Trailwalker before. Fitness level
for the 4 members is good. However, one
suffers from chronic TA tendinitis and one
claims that has sore heel after 8-hour hiking
practice. He wonders if it is to do with shoewear.
Case scenario
• Team B
– Mixed team – 2 females & 2 males of average
fitness. One female team member suffers from
symptoms of nausea and vomiting in her last 3
Trailwalker events, possibly suffering from
hyponatremia. One male team member suffers
from patellofermoral pain after going up &
down hills for 4 hours. He is slightly
overweight.
General Assessment of Physical
Fitness
Physical Fitness Component
Body composition
Assessment Method(s)
BMI
Aerobic endurance
Muscular strength
12 min run test /
1.5 mile walk test (HR)
Bench press & Leg press
Muscular endurance
Flexibility
Push up & Curl up tests
Sit & Reach
(ACSM)
Chronic Achilles Tendinitis
• Signs & symptoms:
– Persistent pain over TA
– Pain occurs especially in the morning, after exercise &
hill walking
– Nodules around TA on palpation
Chronic Achilles Tendinitis
• Intrinsic factors
– stiff MTP joints
– tightness of calf and
hamstring muscle
– flat foot / overpronation
• Extrinsic factors
– sudden increases in
training
– excessive downhill
running
– improper footwear
Sore Heel
Structures underlying symptomatic area:
a) bone: calcaneus
b) plantar aponeurosis
c) plantar fat pad
d) nerve: post tib n, med calcaneal n, med and
plantar n, which pass thro tarsal tunnels
e) mm tendon: peroneal and tib mm
f) bursa: retrocalcaneal bursa
Differential Dx of Heel Pain
Plantar (inferior)
-
plantar fasciitis/ plantar fascia
rupture
fat pad syndrome
calcaneal spur
-
calcaneal periostitis
compression of the n. to abductor digiti
quinti
Medial
-
tarsal tunnel syndrome
medial calcaneal neuritis
-
post. tibial tendon disorders
Lateral
-
lat. calcaneal neuritis
-
peroneal tendon disorders
retrocalcaneal bursitis
calcaneal apophysitis
-
Halgund’s deformity
calcaneal exotosis
Posterior Diffuse
-
calcaneal stress #
-
calcaneal #
Others
-
systemic disorder(often bil)
Reiter’s syndrome
AS
Lupus
-
Gouty arthropathy
Pseudogout
R.A.
S.L.E.
Plantar Fasciitis
• an overuse condition
• Repetitive stress on the
plantar fascia results in
inflammation at its
attachment to the calcaneus
Plantar Fasciitis
• Signs & symptoms:
– Heel pain
– Pain is worse usually at 1st few steps in
morning
– Pain is common at start of exercise & resuming
activity after rest
– Pain aggravated by standing, walking, running,
with running most painful
Plantar Fasciitis
• Predisposing factors
–
–
–
–
–
–
–
Flat foot/high arch
Excessive pronation
Obesity
Tight TA
Training error
Improper footwear
Occupation with prolonged standing
Assessment
•
•
•
•
Training habit
Alignment of whole LL, esp TA
Observe foot arch
Muscle length esp calf
• Test plantar fascia in a stretched position
(toes ext with ankle PF) + WB position
Assessment - Shoes
Shoe design flaws
Achilles tendinitis
Plantar fasciitis
Inflexible soles
Excessive or insufficient
cushioning
Too flexible in the middle sole
Lack of stability (transverse
and longitudinal)
Management
• Acute
• PRICE, US, tapping, NSAID
• Chronic
•
•
•
•
•
stretching / transverse friction
tapping
removal of triggering factors
proper footwear
addition of heel pad or other orthotics
– eccentric loading
– foot intrinsic muscle strengthening
Exercise-induced Hyponatremia
• Plasma Na level < 135 mmol/L
• BW loss is less than that of normal athletes
– % Median weight change (Speedy et al. 2000)
– Normal: - 3.9%
– Hyponatremia: - 0.5%
• Common in ultra-endurance exercise
– marathon
• S/S
– Ranges from asymptomatic to life threatening
conditions eg seizures, coma, even death
– Common: headache, nausea, vomiting, muscle cramps,
disorientation, confusion
Exercise-induced Hyponatremia
• Idiopathic
• 2 common hypotheses
– Loss of large amount of salts through sweating
without replacement
– Excessive pure water consumption (10L / 4hr)
Exercise-induced Hyponatremia
• Management
– Na containing sport drink
– Salty foods
– Seek professionals if necessary
Exercise-induced Hyponatremia
Prevention
methods
Before event During event
 salt intake
by 10-25 g

Avoid use of
NSAIDs

Na containing
sport drinks


Salty foods


Weighing

After event

Patellofemoral Pain
• Etiology:
• biomechanical problem (patella tracking),
malalignment, overuse & muscular
dysfunction of PFJ
• Training errors
Patellofemoral Pain
• S/S: - pain ↑by prolonged sitting,
↑duration of activity
(esp. squatting &↓ stairs)
- swelling
- crepitus
Assessment of PFJ pain
• S/E: activity pattern, training techniques,
footwear, details of onset, SAND etc.
• O/E: observation of whole LL alignment (?
Ant/post pelvic tilt, ↑Q-angle, genu
valgum/varum, patellar position, flat foot,
pes cavus, leg length discrepancy)
Assessment of PFJ pain
• Palpation: bursa, tendon, ligament, jt line, patellar
facets & retinaculum
• ROM, MMT (∵ weak VMO  poor tracking of
patella), patellar gliding movt, ligament stress test,
McMurray test
• Test for mm tightness e.g. hamstring, quads, hip
flexors, ITB
Management of PFJ pain
• Acute phase
- PRICE
- Symptomatic relief e.g. use of EPT
- NSAID
- Avoid stair walking, inclined slope & squatting
• Chronic phase
- Stretch tight mm
- Strengthening ex esp VMO
- Taping
- ↑proprioception training
- Balance training e.g. bouncer, wobble board
Hiking poles
•  joint loading, especially knee
•  knee flexion moment
–  quads eccentric loading
•  shearing force on TFJ
–  stress on ligaments
(Muller et al, 1999)
Prevention of PFJ / TFJ problems
& traumatic injuries on uneven
terrain
Overweight
• Assessment: BMI
• Implication
– limits endurance & speed
–  loading on knees
– Predispose to PFJ pain
• Management
– Weight control
• Endurance exercise + diet
Overweight
• Weight reduction guidelines (Axe 1995, ACSM 2001)
– Reduce dietary fat intake to < 30% of total energy
intake per day
– Lose 1-2 lb/week is safe
– Min of 2.5hr of moderate intensity ex per week
Training
Training Guidelines
• Overload
– 10% rule (Patti F)
– Hard/Easy system
• Specificity
Minimize injury
Training Guidelines
• Mainly focus on aerobic training
• Beginning: slow pace  progress to
competition pace
• Longest distance to train should not exceed
total distance
• Combination of distance & difficulty of
different sections
Training Guidelines
• Incorporate appropriate amount of weight training
(back, UL & LL) & stretching
– general fitness
– avoid injury
• Weight training: min 1 set of 8-12 reps;
2-3 sessions/wk
• A period of rest at last couples of weeks
– called taper
– for carbohydrate loading
Training Suggestion
Initial 4 wks…(conditioning through track running)
• Team A
70-80% HRmax; 3-5 sessions/wk;
35-40 mins
• Team B
60-70% HRmax; 3-4 sessions/wk;
30-35 mins
Training suggestions
• Next 4 wks,
– Walk practice + running x 15-20 mins alt day
– Walk at least one day per week minimum of 4-6
hrs (about 15-25km)
Checkpoint Distance
From
Start
CP1
CP2
CP3
CP4
CP5
CP6
CP7
CP8
CP9
To
CP1
CP2
CP3
CP4
CP5
CP6
CP7
CP8
CP9
Finish
Distance (km)
16.5
8.2
9.4
13.3
7.2
6.5
8.7
9.8
10.6
9.8
Difficulty
*
**
***
***
**
*
**
**
*
*
Training Suggestion
Last 4 wks…(at least once per wk)
• Sections 1 & 2 or 9 & 10
Sections 6, 7 & 8
Sections 3 & 4 or 4 & 5 (night training)
NUTRITION IN SPORTS
Nutrition needs
Sportsmen
More calorie & water required
Protein
1.2 – 1.4 g/kg of BW
Fat
20-25% calorie
Carbohydrate
60-70% calorie
Diet before competition
Diet before competition-- Glycogen Loading
• 7 days before….
– Take in 6-10 g/kg of complex CHO, and progressive  in
training intensity daily
• 1-6 hrs before….
– Low fat, low fiber, high CHO food e.g. bread, congee
–  time for food to day in stomach and so the chance of
getting stomache
– keep blood glucose level stable
– choose the food that the athletes like
• Within 1 hr before….
– Don’t eat ‘.’ diverts blood from mm to stomach
Diet during competition
Energy and Fluid Replacement
• 30-60g/kg CHO every hr
• 150-350 ml water every 15-20 min
– little glucose concentration (otherwise easy dehydration ‘.’
high osmolarity)
• ~ 6 % glucose concentration
•  : Maltodextrin, surcose, glucose
– Sodium
• 0.5-0.7 g/L
• prevent hyponatremia
• don’t drink water until feel thirsty
After Exercise…..
Replacement
• CHO (~ 600 g) replacement when
– 30 min after exercise and
– every 2 hrs after exercise
• Sodium replacement helps water
replacement
– e.g. soup, cheese, meat…….
• Every pound weight loss needs at least 16
oz water replacement
General Advice
Risk Factors
Heat Illness
Hypothermia
Obesity
High wind chill factor, altitude,
moisture content of air
Low degree of physical fitness
malnutrition
Dehydration
Excessive alcohol consumption
Lack of heat acclimatization
Medications eg antidepressants,
tranquilizers
Hx of heat stroke
Sleep deprivation
Medications eg. Diuretics &
antidepressants
Prevention of EAC
• Adequate fluid replacement
• High-energy snacks
• Spare clothes, windbreaker
Strategies for sleep deprivation
• Event last for > 24hr  no sleep
• Figure out which route might be
doing in the dark & practice in night time
• Get information on how your body react on
race day
Blisters
• Cause:
– heat or friction
• Prevention:
–
–
–
–
lubricant
socks (synthetic fabrics & double-layer)
cushion pad
fit-size shoes
Footwear
• ∵long trips, uneven trails & require to carry extra
weight on back
• need higher & stiffer boot with a hard plastic or
steel shank to avoid twisting and gives extra
stability to feet and ankle
• appropriate heel cushioning to reduce repetitive
impact force onto the joints
• Light materials
References
• Noakes, T.D. (2000). Hyponatremia in Distance Athletes Pulling the IV on
the ‘Dehydration Myth’. The Physician and Sportsmedicine, 28 (9): pp 1-7
• Sports Medicine. (2001). Sodium Needs for Athletes.
http://sportsmedicine.about.com/library/weekly/aa030101a.htm
• Canadian Medical Association Journal. (2000). Public Health Ultraendurance exercise and hyponatremia. http://www.cma.ca/cmaj/vol163/issue-4/0439.htm
• Speedy, D.B., et al. (2000). Exercise-Induced Hyponatremia in
Ultradistance Triathletes Is Caused By Inappropriate Fluid Retention.
Clinical Journal of Sport Medicine, 10 (4): pp 272-278
• Speedy, D.B., et al. (1999). Hyponatremia in ultradistance triathletes.
Medicine & Science in Sports & Exercise, 31 (6): pp 809-815
• Axe, M.J. & Gibney, S. (1995). Nutrition. In: Baker, C.L. (Ed). The
Hughston Clinic Sports Medicine Book.
References
• Tanaka K., Takesshima N., Predication of endurance running
performance for middle-aged and ploder runners. Br. J. Sports. Med.
1995;29(1):20-23
• Roberts W.O., A 12-yr profile of medical injury and illness for the
Twin Cities Marathon. Med. Sci. Sports Exerc. 2000;32(9):1549-1555
• Fallon K.E., Musculoskeletal injuries in the ultramarathon: the 1990
Westfield Sydney to Melbourne run. Br. J. Sports. Med. 1996;30:319323
• Muller E., Schwameder H., Roithner R.et al, Knee joint forces during
downhill walking with hiking poles. Journal of Sports Sciences.
1999;17:969-978
• Deid D.C., Sports Injury Assessment and Rehabilitation. New York:
Churchill Livingstone, 1992
• Balady G.J., Berra K.A., Golding L.A. et al, ACSM’s Guidelines For
Exercise Testing And Prescription 6th Ed. USA: Lippincott Williams &
Wilkins, 2000
More Water….
• 24 hrs before…
– drink lots of water
• 2-3 hrs before…
– drink 400-600 g of water
– let water pass out from the body before
competition