Keys To Treating Common Triathlon Injuries

Marybeth Crane | April 2014.

The combination of a diehard mindset and the stresses triathletes must endure can lead to repetitive injuries. Accordingly, this author provides a treatment guide for common triathlon injuries such as stress fractures, blisters and Achilles tendonitis.

Participation in triathlons has grown at an enormous rate in the last 15 years worldwide. USA Triathlon publishes a demographic study each year and cites over 500,000 participants in races in the United States in 2012 with almost double-digit growth each year since 2000.1

   In discussing triathlon-related injuries, the best approach is to start with a window into the unique world of triathletes. It is necessary to have an understanding of the sport and the stubbornness that is ubiquitous to triathletes to be able to treat this group of athletes successfully in your practice.

   Let us start with the basics. A common perception of what the average triathlete looks like is what people see on TV watching the Ironman World Championships. Namely, people tend to envision an extremely fit, 30- to 45-year-old male with six-pack abs and less than 10 percent body fat. This is simply not the case. There is no “average” triathlete. In my practice, the youngest competitive triathlete is a 9-year-old girl and the oldest is a 78-year-old man. They come in all ages, sizes, shapes and socioeconomic as well as ethnic backgrounds.

   This was extremely apparent when I competed in my first Ironman event. The diversity of the field was amazing to me but the one thing triathletes all have in common is an underlying stubbornness that equates quitting with personal failure. Triathletes quit when their bodies (or equipment) can no longer function. In fact, Chris McCormack (a.k.a. Macca, a multiple Ironman world champion) coined a mantra that pretty much explains the attitude of most triathletes. The mantra is “embrace the suck,” which means that in a race, you look your inner weakness in the eye and embrace the suffering to make it to the finish line. Quitting is not an option.

   This is a tough group to treat because of this underlying stubborn nature. It is important to understand this psyche to be able to speak athletes’ language, and have the ability to educate them and validate your comprehensive treatment plan. No, not all triathletes are sadomasochists but a degree of determination and ability to withstand pain is an inherent part of most endurance sports.

   This being said, not all triathletes are competing in the Ironman distance. In fact, currently the most popular distance is the “sprint triathlon.” This is a 300- to 500-meter swim, a 12- to 17-mile bike and usually a 5K run. This takes most people one to two hours or so to complete, and requires minimal training (a few hours a week) to make it to the finish line in one piece. The other most common distances are the “Olympic triathlon” (1,500-meter swim, 40K bike ride and 10K run), the “Half-Ironman” (1.2-mile swim, 56-mile bike and 13.1-mile run), and the full “Ironman” (2.4-mile swim, 112-mile bike ride and a 26.2-mile run).

   It is important to understand the distances so you can characterize your patients better. A sprint triathlete is training just a few hours each week in each discipline whereas an athlete training for an Ironman event may be spending 20-plus hours per week swimming, biking and running.

Running is by far the culprit of the most triathlon-related injuries. Studies relate up to 78 percent of injuries as overuse.3 A review of the literature shows little agreement on the “most common” injury but shows an injury rate of up to 75 percent of runners.4,5 One study did find a small correlation with a cavus foot type and an increased rate of injury, but did not confirm this as a major risk factor.6Training time and errors seem to lead to the greatest number of injuries.

   Since there is little agreement except for the fact that triathletes get injured at a rate that is comparable to long distance runners, here is a practical top ten lower extremity injury list for discussion.

1. Stress fractures
2. Blisters
3. Subungual hematoma
4. Achilles tendonitis
5. Plantar fasciitis
6. Metatarsalgia/Morton’s neuroma
7. Iliotibial band syndrome
8. Patellar tendonitis/chondromalacia patella
9. Medial tibial stress syndrome
10. Sacroiliac joint dysfunction

Pertinent Pearls On Treating Stress Fractures In Triathletes

Metatarsal stress fractures are the most common injury I see in triathletes in my office. Of course, stress fractures of the tibia and calcaneus as well as the occasional cuboid fracture are also common. One study in the literature did correlate age with an increased incidence of stress fractures but this is not unique to the triathlon.3

   In my office, I correlate the rate of stress fractures with a rapid increase in training volume as well as shoe gear. The barefoot running phenomenon has infiltrated the triathlon to the point that many triathletes are shedding their stability running shoes for much lighter and “barefoot feel” shoes. If athletes make this transition too drastically and increase the volume of running at the same time, this is a recipe for a stress fracture.

   Personally, I think we see stress fractures more often than anything else because triathletes are notorious for “running through” an injury. You can’t “run through” a stress fracture. I have tried. It hurts too much.

   The diagnosis of a stress fracture can be difficult in the early stages. Accordingly, if your athlete has pinpoint tenderness on the bone and the plain film X-ray is inconclusive, I recommend a magnetic resonance image (MRI) for definitive diagnosis.7 Be aware that if you do not have a definitive diagnosis, this group will try to run anyway.

   Treatment for stress fractures is relative rest for six to eight weeks. I recommend placing the athlete in a below-knee walking boot type cast to rest the fracture for at least four weeks. If you place patients in a post-op shoe, they will try to run on it. I have actually had several athletes complete up to a marathon distance in a below-knee walking cast, which is crazy. I also give athletes a steel shoe insert similar to a turf toe insert for their cycling shoes and make them promise to cycle indoors on a trainer and stay in the saddle. They can swim as much as they want but they shouldn’t perform any flip turns or use flippers.

   Remind them that a stress fracture can lead to a displaced fracture if they are non-adherent. Have them picture a plate and six screws. This will usually instill the need for adherence.




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