The Multisport Athlete:
Risks, Injury & Prevention
Marc Silberman, M.D.
Gillette, NJ
Disclosure
I declare no conflict of interests
I do not have any financial disclosures
Objectives
1. Identify the riskiest portions of the
triathlon for the athlete and medical
director
2. Name the most common locations of
injuries and disciplines that cause them
3. Teach common injury preventative
strategies to multisport athletes for each
discipline
Introduction
You don’t know Bo
The Multisport Athlete
The Multisport Athlete
• Participates in more than one sport
• Swim + Bike + Run = Triathlon
– Former runners > swimmers > cyclists
• Swim + Bike = Aquavelo
– Former triathletes with arthritis/joint replacements
• Bike + Run = Duathlon
• Triathlete who competes in Swimming races,
Cycling races, and/or Running races
Medical Preparation for Triathlon
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Hyperthermia/hypothermia
Gastrointestinal problems, GI bleed
Dehydration/hypovolemia
Fluid/electrolyte imbalance/Hyponatremia
Bronchospasm, Anaphylaxis
Exercise Associated Collapse, Exhaustion
Cardiac arrythmias
Pneumothorax
Drowning/near drowning
Closed head injury / C spine injury
Road rash, sun burn, abrasions, blisters
Stings, bites
Musculoskeletal trauma, cramping
Medical Personnel
Personnel
Recommendation
Medical Director
Physician experience in events
Additional physician
1 / 200, with minimum of 2
Nurses
1 / 100
Massage Personnel
Adequate to serve race population
Dallam et al. “Medical Considerations in Triathlon Competition.
Recommendations for Triathlon Organizers, Competitors, and Coaches.” Sports
Med 2005; 35 (2): 143-161.
Incidence of Triathlon Injuries
• NO CONSENSUS DEFINITION OF INJURY
• The strongest correlate with overuse injury in triathletes is
previous injury occurrence
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37% to 91% of triathletes surveyed (Burns, O’toole)
75% to 83% training injuries (Cipriani, Wilk, Ireland)
8% to 28% competition injuries (Wilk, Ireland)
17.4 injuries / 1000 h of competition (Korkia)
.7 – 5.4 injuries / 1000 h of training (Burns, Korkia)
• You can bend statistics any way you want
Injury Rates
• Do multisport athletes sustain less injuries as a
result of ‘cross training’?
• Greater than those observed in athletes who participated in
only swimming, cycling, or running (Levy)
• Similar to rates observed in runners (Burns, Korkia)
• Overuse injuries are the most common (Korkia, O’Toole)
• Running and cycling more commonly associated with
injuries than swimming
– Is this due to increased risk? Or increased exposure time?
Site of Injuries
• Most common lower limb (36 - 85%)
(Williams, Ireland)
– Knee 14 - 63% (Vleck, O’Toole)
– Ankle 9 - 35% (Manninen, Egerman)
• Back 72% (O’Toole)
• Shoulder 19% (Egerman)
• Literature lacks specificity of these injuries
Severity of Injuries
• Vleck (retrospective)
– 17%
injuries stop swimming
– 26-75% stop cycling
– 42-67% stop running
• Korkia (prospective)
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–
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21%
37%
78%
16%
17%
injuries stop swimming
stop cycling
stop running
stop all 3
missed competition
Severity of Injuries
• Time lost by club level athletes (Vleck)
– 13 +- 58 days of swimming
– 21 +- 65 days of cycling
– 71 +- 174 days of running
• Duration of lost time less for elite
The Science or Lack of
Triathlon related musculoskeletal injuries: The status of injury prevention
knowledge (Gosling 2007)
• There is no consensus definition of injury
• Retrospective recall of injury information
• Recall periods greater than one year
• Failure to validate the self reporting of injury of diagnosis
• Inability to differentiate injury sustained in training or competition
• Confounding multiple or recurrent injuries
• Selection biases
• Exclusion of traumatic injuries
• Mixed race distance/type and athlete demographics
• Nature of injury is misrepresented
• Summary: Lack of quality, prospective studies
Medicine is more art than science
The Triathlon
The Triathlon
1.
2.
3.
4.
5.
6.
Swim
T1
Bike
T2
Run
Nutrition
Distances
Name
Swim
Bike
Run
Sprint
0.5 mile
750 m
12.4 mile
20 km
3.1 mile
5 km
Olympic / 5150
(International)
0.93 mile
1.5 km
24.8 mile
40 km
6.2 mile
10 km
ITU Long
1.86 mile
3 km
49.6 mile
80 km
12.4 mile
20 km
Half / 70.3
1.2 mile
1.9 km
56 mile
90 km
13.1 mile
21.09 km
Full / 140.6
2.4 mile
3.8 km
112 mile
180 km
26.2 mile
42.195 km
The Swim
The Swim
The Swim
The Swim
The Swim
The Swim
The Swim Risks
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Collisions, incidental and purposeful
Tympanic Membrane perforation
Drowning / Near Drowning
Panic Attack / Anxiety
Cramping
Hypothermia/Hyperthermia
Sudden Cardiac Death
Infections
The Water
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Temperature
Weather
Body of water
Swim course organization
Water Temperature
• Single most significant variable
• Acceptable range 25.5 – 28 degrees celsius
– (77.9 F to 83.8 F)
• Gradient for heat loss exceeds that for exercise in
the air
• Triathlete body composition is the leanest in
competitive sport
• Risk of hyperthermia magnified by
lack of fluid intake, exertion, and wet suits
Wetsuit Guidelines
ITU Guidelines
Water Temp C
Distance
Guide
<= 13
All distances
Cancel
14
<= 2000m
Wetsuit mandatory
<= 15
2000-3000m
Wetsuit mandatory
<= 16
3000-4000m
Wetsuit mandatory
13-22
All distances
Allow wetsuits
USA Triathlon allows elite to use wetsuit up to 25.5 Celsius (77.9)
WTC Prohibit wetsuits in temps greater than 28.8 C (83.8F)
WTC Allows wetsuits in temps up to and including 24.5 C (76.1 F)
Course Organization
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Large, visible buoys 100m apart
Rolling or wave starts safer than mass start
USAT 150 / wave at 3 minute intervals
Separate novice category
Triathlon Canada 400 / wave
USAT One lifeguard / 50 in non-ocean
USAT One lifeguard / 35 in ocean
Triathlon Canada one lifeguard / 25
Athlete Swim Preparation
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Practice open water swimming
Be prepared to swim without a wetsuit
Beginner should have a mentor for anxiety
Know the course, conditions, entry, exit
Swim technique coach
Learning balance is the most important lesson
Good shoulder, scapula, back, and core
Swimmer’s Shoulder Prevention
Push up plus
No Money
USA Swimming Task Force
Ball on wall
YTWL
Dead Bug
T1
T1
T1
T1
The Bike
The Bike
The Bike
Road vs. Time Trial Position
Plumb bob falls over
Steeper Seat Tube
pedal spindle and 1st metatarsal More Forward Position
Higher Saddle
The Bike Elements
• Water Temperature
– Hypothermia, Hyperthermia, Dehydration
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Environment weather and temperature
Sun exposure
Nutrition – GI distress, hyponatremia
Crashes
– Cycling Course, drafting or non-drafting
– Bike equipment
– Fatigue
The Bike
The Bike
The Bike Feed Station
Knee Pain
• Anterior Knee Pain
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Patella Femoral Pain Syndrome
Chondromalacia patella
Cartilage lesion
Patella tendonopathy
Pre-patellar bursitis
• Lateral Knee Pain
– Iliotibial Band Syndrome
– Biceps Femoris tendonopathy
• Medial Knee Pain
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MCL bursitis
Medial plica syndrome
Pes Anserine Syndrome
Medial meniscus tear
Athlete Bike Preparation
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Practice swim - bike
Get a bike fit
Train on your race bike
Practice your nutrition strategy in training
Longer races, consider added sodium
Train the distance
Know the course
Knee and back pain prevention
• Listen to your body not your coach or training
program
• Training rest days, easy days, cycles
• Caution with brick work outs
• Get a bike fit
• Regular massage, manual therapy, chiropractic
• At the first sign, swim
T2
T2
T2
T2
The Run
The Run
The Run
• 85% of medical problems during long
distance races occur on the run or finish
• Exhaustion, dehydration, postural
hypotension, blisters, muscle cramping
• GI Distress
• Hyponatremia (long races)
• Hyperthermia (short races)
The Run
The Run
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Dehydrated and fatigued
Hottest portion of the day
Elevated body temp, low plasma volume
Unable to consume fluids (shorter)
Elite competitors run at 90% of VO2 max
Drink to much (longer)
Hyponatremia (10-40%) in long distance
with no symptoms
The Run
The Run Risk Factors
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The distance (run shorter, walk longer)
Ambient temperature and humidity
The nature and design of the course
Provision of fluids
UV Radiation
The Run GI Distress
• 30% of high performance athletes
• Pain, bloating, N/V/D, GERD, ischemic
gastritis, Cecal slap syndrome, GI bleeding
• Endotoxins, cytokines (Jeukendrup)
• French Triathletes (Lopez 1989)
– Nausea, pain, vomitting 8.9%
– Diarrhea, pain 8%
Athlete Run Preparation
• Listen to your body in training
• Practice brick workouts (but be careful)
• Running technique
– Stability and alignment
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Heat acclimatize
Strengthen abductors and adductors
Practice your race day nutrition plan
Take a break from run training after races
Studies
Overuse Injury in Iron-Distance Training
• 26 week prospective cohort 2011 Norseman
Xtreme Triathlon (n=274, 174 participated)
• OSTRC shoulder, lower back, thigh, knee,
and lower leg
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11.1 hours / week training
1.4 hours / week swimming (12% time)
5.8 hours / week cycling (58% time)
2.9 hours / week running (24% time)
16% weights, skiing, other
Anderson 2013
The Norseman
• If you do the race, you will probably tell your friends
afterwards that Norseman was more beautiful, demanding,
personal, camaraderie, frightening, and to reach the finish
line was a greater victory and joy than any other race you
have ever done. You will probably tell your friends that
everybody should do the race once in their lifetime.
• If, on the other hand, a friend told you this story, then it is
time to warn you. During the Norseman, you will probably
be cold, you will hate the hills, sometimes you will feel
lonely and you will probably experience being unusually
emotional during the weekend.
Nxtri.com
Norseman
Water temp 13-15 degrees C (55 – 59 F)
Norseman Bike Course
Norseman Run Course
Overuse Injury in Iron-Distance Training
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Average prevalence of overuse injury 56%
Average prevalence of substantial injury 20%
87% reported some form of overuse problem
Shoulder problems 42% of the time
Knee problems 44% of the time
Lower back problems 46% of the time
Lower leg problems 27% of the time
Thigh problems 34% of the time
Anderson 2013
Acute Injury in Iron-Distance Training
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41 acute injuries out of 174 athletes
Contusions 17%, Fracture 10%, Sprains 10%
22% from alternative training (weights, etc)
Vast majority were bike accidents
(25 injuries sustained by 12 athletes)
• Zero acute swim injuries
• Only 3 acute running injuries (ankle sprain,
thigh strain, pelvis contusion from a fall)
Anderson 2013
Illness in Iron-Distance Training
• 156 cases of illness reported
• 104 athletes affected (60%)
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9% no time loss
34% 1-3 days loss
36% 4-7 days loss
19% 8-28 days loss
3% more than 28 days
• Lower than team sports, similar to individual
sports
Anderson 2013
Norseman Finish Line
Knee Injury in Triathletes
• Closed ended, oral, questionnaire of 58 athletes
at a triathlon event
• Recall 1994-1997, 46 men, 12 women
• Injury had to cause the athlete to reduce, or
refrain from, training for at least 2 days
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No knee injuries in swimming
22% in cycling
72% in running
6 % felt to be from both
Similar to studies by Cipriani and Massimino
Clements et al
Location of Knee Injury
Location
Swim
Cycle
Run
Cycle+Run
Lateral
0
5.5
33.3
0
Medial
0
5.5
16.6
5.5
Anterior
0
5.5
11.1
0
Anterior Lateral
0
0
11.1
0
Medial Lateral
0
5.5
0
0
Posterior
0
0
0
0
Values are percentages
Clements et al
Knee Injury in Triathletes
• Highest number of injuries observed in athletes
who ran on a mixture of terrains (10/20)
• The group who trained solely on roads
accounted for 25% of the injured
• Further research needed
Clements et al
Injury in British Triathletes
• Prospective questionnaire of 155 athletes
over 8 weeks during the competitive season
• Injury was defined as an event that ended a
training session or race and caused the
athlete to rest the day after
– Minor 7 days or less
– Moderate 8 – 21 days
– Severe over 21 days
Korkia
Injury in British Triathletes
• Limited by self assessment of injuries
• 37% sustained at least one injury
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27% ankle/foot
20% thigh
19% knee
16% lower leg
14% back
Korkia 1994
Injury in British Triathletes
• Self classified as
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41% overuse
27% ‘other’ ?????
12% twist or turn
10% contact / collision
9% overstretching
• 65% during running
• 16% during cycling
• 12% during swimming
Korkia 1994
Injury in British Triathletes
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84% minor 7 days or less
13% moderate 8 – 21 days
3% severe more than 21 days
78% stop running
37% stop cycling
21% stop swimming
16% stop all three
33% stop cycling and running
18% swimming and running
16% swimming and cycling
Korkia 1994
Injury in British Triathletes
• No association between incidence of injury
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–
amount of training
training intensity
running surface
increase in training load
strength training, warm up, cool down, stretching
• Rate of injury increased with experience
– 45% with over than 4 years
– 33% between 2 to 3 years
– 14% trained less than one year
Korkia 1994
Injury in British Triathletes
• Athletes who sustained an injury in the
previous year were more likely to sustain an
injury during the 8 week study
• 65% of athletes who sustained an injury in the
past year, sustained an injury in the same site
during the study
• 45% of athletes who sustained an injury in the past
year, sustained an injury in a different site during
the study
Korkia 1994
Low back pain and Injuries in
Japanese Triathletes
• Questionnaire of 92 athletes in different
clubs, 6 smoked cigarretes, 63% age 26 - 35
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Training for 4 years
Swim 29% time
Bike 38% time
Run 33% time
57% training for half or full distance
27% were former runners
12 % were former swimmers
4% were former cyclists
Manninen 1994
Low back pain and Injuries in
Japanese Triathletes
• 37% experienced low back pain
• Age 23.7 was average age of onset
• 51% began for ‘no reason’
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54% lasted less than 7 days
27% lasted one week to 3 months
19% more than 3 months
74% associated pain with cycling
45% associated pain with weight training
43% associated pain with running
Manninen
Low back pain and Injuries in
Japanese Triathletes
• Back pain was associated with
– Greater weekly trunk flexor muscle training
– Incidence of back pain in the previous year
– Greater cycling time, training load, weight lifting
Manninen
Overuse Injuries in Japanese
Triathletes
• No definition of injury was given
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72% sustained one injury in the previous year
30% sustained 2 injuries, 14% 3 or more
61% lower limb, 54% of those in the knee
8% upper limb, all shoulder, all from swim
Reasons given by athletes: overtraining, run
technique, inadequate stretching, hard running
surface
Manninen
Back pain in Japanese Triathletes
• While running causes the most overuse injuries, it
may not be the primary cause of low back pain
• Cycling felt to be the key component predisposing
to low back pain
• Sitting in a flexed position for prolong length of time
• Change from “off” load to “on” load weight bearing
(Migliorini)
• Muscle activity changes from concentric (cycling) to
eccentric (running)
• Postulated time lag exists before neuromuscular and elastic
efficiency can reach optimal level at start of run
Manninen
References
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Andersen CA, Clarsen B, Johansen TV, et al. “High prevalence of overuse
injury among iron-distance triathletes.” Br J Sports Med 2013; 47:857-861.
Bales et al. “Training on a Knife’s Edge: How to Balance Triathlon Training
to Prevent Overuse Injuries.” Sports medicine and arthroscopy review 20.4
(2012): 214-216.
Dallam et al. “Medical Considerations in Triathlon Competition.
Recommendations for Triathlon Organizers, Competitors, and Coaches.”
Sports Med 2005; 35 (2): 143-161.
Gosling et al., “The Perception of injury risk and safety in triathlon
competition: an exploratory focus group study.” Clinical Journal of Sport
Medicine 23.1 (2013): 70-73.
Migliorini S. “Risk factors and injury mechanism in Triathlon.” Journal of
Human Sport and Exercise 2011; Volume 6, Issue 2.
Vleck V et al. “Triathlon Injury-An update.” Schweizerische Zeitschrift fur
Sportmedizin und Sporttraumatologie 61.3 (2013): 10-16.
newjerseytriathloncoach.com
Marc Silberman, M.D.
drbicycle@njsportsmed.com