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Triathlon Injury - An update

Article in Schweizerische Zeitschrift fur Sportmedizin und Sporttraumatologie · January 2013

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Review

Triathlon Injury - An update.

Veronica Vleck1, Gregoire P Millet2, and Francisco Bessone Alves1
1 CIPER. Faculty of Human Kinetics, Technical University of Lisbon, Cruz Quebrada- Dafundo, Portugal.
2 ISSUL Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland.

Abstract Résumé

Although the variety of distances, formats and age-groups Bien que la variété des distances, des formats et des tranches
that are involved in triathlon make it a useful model to inves- d’âge qui sont impliqués dans le triathlon en font un modèle
tigate the effects of multi-discipline endurance training and utile pour étudier les effets de l’entraînement en endurance
competition on injury risk across the life-span, this opportu- multi-discipline et la compétition sur le risque de blessures
nity has not been taken advantage of. Most studies are limit- au fil du temps, cette possibilité n’a pas été mise à profit. La
ed by their retrospective nature, recall periods; and failure to plupart des études sont limitées par leur nature rétrospective,
consistently or adequately report subject age-group, gender, les périodes de rappel, leur manque de consistance et ne
ability level, and event focus; injury occurrence, distribution, tiennent pas compte des groupes d’âge, du sexe ou du niveau
outcome, and or potential risk factors. The sudden death rate de capacité, ni des particularités telles que la survenue des
for competition is 1.5 (0.9–2.5) deaths per 100 000 participa- blessures, leur distribution, leur évolution et ou des facteurs
tions but 29–91% of triathletes may be affected by injury de risque potentiels. Le taux de mort subite en compétition
‘causing cessation or reduction of training or seeking of med- est de 1,5 (0,9 à 2,5) décès pour 100 000 participants, mais
ical aid’ at any one time. Most such injuries are minor to 29 à 91% des triathlètes peuvent être affectés par une bles-
moderate severity overuse, or abrasion injuries. The knee, sure, cause d’une cessation ou d’une réduction de l’entraîne-
ankle/foot and lower back are commonly afflicted, with in- ment et rechercher l’aide médicale à un moment donné. La
creasingly less effect on running, cycling and swimming plupart de ces blessures sont de gravité mineure à modérée et
training. As many injured athletes continue training, recur- sont en relation avec un over-use, ou sont des blessures
rence is likely to be high. A consensus statement on the defi- d’’abrasion. Le genou, cheville/pied et le bas du dos sont sou-
nition and reporting of both first time and recurrent injury vent concernés, avec de plus en plus d’impact sur la capacité
must be developed, and longitudinal prospective studies need à s’entraîner en course, en cyclisme et en natation. Malgré
to be conducted, before the extent of, and ways to ameliorate, leurs blessures, de nombreux triathlètes poursuivent leur en-
the injury problem can become clear. traînement, le risque de récidive est potentiellement élevé.
Une déclaration de consensus sur la définition et la survenue
Keywords: des blessures récurrentes doit être développée, et des études
triathlon, triathlete, injury, risk factors, multi-sport. prospectives longitudinales doivent être réalisées dans le but
d’améliorer les connaissances et de prévenir la récidive des
blessures en triathlon.

Schweizerische Zeitschrift für Sportmedizin und Sporttraumatologie 61 (3), 10–16, 2013

Introduction fore provides a model not only for the effects of cross-training
[4], but also for the influence of long-term endurance swim-
Injury research can be said to undergoing a quantum shift. ming, cycling and running exercise on injury risk both across,
Work presented at the 2011 IOC World Conference [1] on the and at various stages of, the life-span.
Prevention of Injury and Illness in Olympic Sports demon- Although training and competition focus may change with
strated increased awareness of the need both for increased both age and years of competitive experience, at any given
quality in research design and to persuade sports policy mak- life stage the triathlete is likely to be focusing on performance
ers to support ensuing attempts to translate research results over either short (Sprint- Olympic distance (OD) or long
into improvements in practice. (half-Ironman (½IM) – Ironman (IM)) distances. The relative
Triathlon encompasses three of the highest participation extent to which such athletes may be participating in other
sports worldwide and is itself becoming an increasingly pop- single and multi-sport competitions has only been reported
ular ‘lifestyle’ sport [2]. Although no supporting evidence for for OD athletes [5]. Nevertheless, several intrinsic and extrin-
this exists in the academic literature, it is said that those who sic differences likely exist between short (SD) and long dis-
start triathlon tend to stay with it. Not only Elite athletes, but tance (LD) specialists [5, 6]. It is unclear to what extent these
also ‘age-group’ athletes- from under fourteen to over eighty differences may impact on the extent, distribution and sever-
five years of age- compete in the various triathlon formats ity of training related injury in these groups. The different
and distances that are available to them [3]. The sport there- durations and work intensities that SD and LD athletes com-
Triathlon injury – An update. 11

pete at [7, 8], do, however, have a differential effect on their (0.01–0.07), and 0.0 (0.0–0.3) deaths per year per 100 000
race injury profiles. participations, respectively). Slightly higher death rates were
Previous triathlon specific reviews published in 2001 [9], recorded for the races that involved short (<750m) or longer
2006 [10], 2008 [11], and 2010 [12], have all detailed the (>1500m) swims than for those with swims from 750 to
methodological problems with the literature that are the main 1500m in length.
reason for the exact extent of the injury problem in triathletes Incidence rates of self-assessed overuse and traumatic in-
being unclear. Said problems include inconsistencies in the jury per 100 athletes of 0.74–76.7, and of 10.0–23.8 per 1000
definition and recording of injury, as well as inadequate dif- training hours (depending on the month of the year) have
ferentiation of study subject groups by age, gender, ability, been obtained prospectively for small (n=11–43) samples of
experience, and or distance specialization. Mainly case stud- OD triathletes [5]. Presentation rates for medical assistance
ies, and few original papers, have been published, since the of 20.1 per 1000 hours of Sprint, OD and or fun distance
last major such analysis was conducted. The impact of the competition have also been recorded [15]. No prospective in-
various problems that have already been acknowledged on ter- or intra- (age, gender, ability or event distance-) group
the triathlon injury literature therefore remains relatively un- comparisons of injury incidence rates, using the same injury
changed [9–12]. We consequently refer the reader to said re- definitions and data collection methods, exist for the endur-
views for the details of the aforesaid problems, rather than ance base, base transition, pre-competitive and competitive
repeat them extensively here. periods of the athlete’s year. Injury rates are thought to be
higher within competition than within training, however [17,
18], as may be the incidence of (traumatic) crowding-, hydra-
Methodology tion- and or heat- related injuries. However, none of the train-
ing studies thus far appear to have obtained any hydration and
A total of fifty five peer reviewed original publications and heat stress related data. These tend to be reported by the stud-
eight reviews were sourced via PubMed and Google Scholar ies that involve clinical assessment- and most of these are race
using combinations of the terms ‘triathlon’, ‘triathlete’, ‘inju- studies. The discrepancy between training and race related
ry’, ‘overuse’, ‘traumatic’, ‘hydration’, and ‘medical’, as well studies in the relative proportions of reported injuries that
as by hand-search of the reference lists of all the work so have been self-assessed by non-specialists as opposed to by
obtained. Only papers in English, French, Portuguese, or a clinician complicates the comparison of their results.
those with an English abstract that had their main text in any Only one study [19] has tracked the temporal prevalence
of the aforesaid languages were used to compile this docu- and incidence of injury within competition, in this case for
ment. non-elite participants in ½-IM and IM triathlons conducted at
the same location. The weather for the event was dry with
wind speeds from 1–8 miles per hour, humidity from 37–87%,
Injury Data and temperature from 16–28 ºC; but it is not clear from the
paper to what extent environmental conditions differed be-
Prevalence/incidence. tween the two events. Injury affected 10.8% of ½IM and
37.7% of IM age-groupers, respectively, as compared with
Prevalence of injury ‘causing cessation of training for at least previously reported values of 15 to 25% of Elite IM compet-
one day, reduction of training, or seeking of medical aid’ has itors [20, 21]. The normal finishing time window, across both
been reported to be between 29% [6] and 91% of adult triath- the ½IM and the IM, was 5 to 9 hours. A total of 72.2% of
letes [12, 13]. Only one, retrospective, study has directly com- ½IM injuries, corresponding to 78 per 1000 race starters, were
pared prevalence of overuse and traumatic training related sustained during hours 6 and 7. The IM had a much higher
injury (using the same injury definition) between 25-45 year rate of severe injuries than the ½-IM, at 38.2% ± 6.0% (95%
old males and females, top 50 finishers at their non-drafting confidence interval), and longer average treatment durations.
National Championships and competitive age-groupers, and Although average injury treatment duration increased with
OD and IM specialists [5, 6], and found it not to differ be- finishing time the highest proportion of severe injuries were
tween said groups. No comparative data for training related seen in those ½ IM athletes who took longer, or in those IM
injury prevalence exist across all the various triathlon age- athletes who were faster, to finish than the rest of their cohort.
groups. Age, gender, and years of competitive experience do
not appear to affect the proportions of athletes who report for Injury distribution.
medical aid at Sprint distance events [14] but it has not been
fully established [15] whether this also applies to other dis- Over the Sprint distance and OD distances, contusions, and
tances and formats. abrasions/grazes blisters are the most commonly reported
The procurement of injury incidence values has also race [15]. The most common primary medical diagnoses over
proved problematic, partly because of the inherent difficulties the ½IM format appears to be dehydration followed by mus-
that exist with prospective data collection, and partly because cle cramps (50.8% vs. 36.1 %). Muscle cramps and dehydra-
of difficulties in quantifying overall training stress across the tion occurred in almost equal proportions (38.9 vs. 37.7%),
various disciplines and intensity levels that are involved in in an IM event occurring at the same location [19]. Gradual
triathlon training. No sudden death rates for triathlon training onset overuse injuries are the most common training injuries
exist but sudden death rates for United States triathlete sanc- and occur in three times as many athletes as do acute injuries
tioned events over the period 2006-2008 [16], involving [22–24].
959 214 participants, were estimated by Harris et al. [16] at Although there is an issue with the existing literature as
1.5 (0.9–2.5) deaths per 100 000 participations. The majority regards both grouping and restriction of injury to only some
of such deaths occurred during the triathlon swim (i.e. 1.4 anatomical areas, clearly most overuse injuries are lower ex-
(0.8–2.3) deaths as opposed to cycle and run rates of 0.1 tremity injuries. The most detailed incidence rates per 1000
12 Vleck V. et al.

training/racing hours thus far available for the anatomical letes rating their injuries as ‘minor’ (i.e. resulting in <7 days
locations that are most commonly assayed by the literature. off) to ‘moderate’ (i.e. leading to 7–21 days off).
The risk areas for which the highest prevalence values are However, the information thus far available may only rep-
usually reported, accounting for up to 43% [18], 23% [25] and resent ‘the tip of the iceberg.’ Injuries that are not serious
31% of injuries [18], are the knee, ankle/foot and lower back. enough to be recorded within the time-span that the athlete is
The only retrospective study to directly compare anatomical on the race site, or to be remembered over the recall periods
distribution of injury between small (<50) numbers of ath- that are used in many training studies, go un-reported. Many
letes in different event distance, ability and gender groups [5] studies focus on injury to one or several specific anatomical
found the most commonly injured sites (expressed as a % of locations, rather than report severity for all the sites that have
the total number of athletes affected over the previous five been seen to be affected in triathletes. It is therefore difficult
years) to be the Achilles tendon (50.0%), knee (41.7%) and to assess which anatomical sites are usually most severely
lower back (41.7%) in Elite OD males; the calf, knee and injured, or which types of injury have the worst consequenc-
‘other’ (than the Achilles tendon, ankle, anterior thigh, calf, es. Moreover, only a minority of the athletes who sustain in-
hamstring, knee, lower back, upper back, shoulder and neck) jury whilst training consequently seek professional help [18,
in Elite OD females; the knee (47.1%), lower back (29.4%) and 30], and many triathletes may continue to train whilst injured
shoulder (23.5%) in sub-elite males, and the calf (30.0%), [5, 24, 30, 31]. Anecdotal reports that athletes may react to
Achilles tendon (30.0%) and knee/other sites (20.0% each) in injury that has been sustained in one discipline by increasing
sub-elite females. IM males and females were most affected their training in one or more of the remaining triathlon disci-
by knee (44.0%), lower back (20.0%) and calf (20.0%) inju- plines over what they would otherwise have done are wide-
ries; and by knee (50.0%) injuries, respectively. The anatom- spread- but the extent to which this phenomenon actually oc-
ical distribution of traumatic injury is likely to be somewhat curs is unreported. Although injuries may lead to cessation of
different from that of overuse injury but no direct compari- work, or to permanent loss of function, in 15.3% and 4.2% of
sons have been carried out by any of the studies to date. cases, respectively [22], the extent to which this is due to first
Of 17 studies undertaken before 2010 [12] that listed the time or to recurrent injury has not been determined. Recurrent
anatomical sites that were affected by injury in their athletes, injury appears to be a widespread issue [12].
less than a quarter appear to have involved clinical diagnosis
of said injury in question. According to Korkia et al. (1994)
[25], 35%, 25% and 22% of ankle/foot, knee and lower leg Risk Factors
injuries involve a strain, tendinitis and a tear, respectively.
Discussion of the potential mechanisms of development of Minimal examination of what specific aspects of triathlon
triathlon injury, including how this may be due or exacer- training may engender an increase in rehabilitation time, or
bated by the demands of cross-training, can be found in the to injury risk, has been carried out. Those data that do direct-
December 2012 special issue of ‘Sports Medicine and Ar- ly link specific risk factors to the occurrence of specific inju-
throscopy Review’ [26-29]. The latter articles are mostly ries are insufficiently detailed, and although various potential
‘Level 5’ discussions (i.e. expert opinions without explicit mechanisms of injury have been speculated upon [9, 10, 26-
critical appraisal, or based on physiology, bench research or 28], it is not yet possible to verify them. For example, drown-
‘first principles’). Little supporting information has been ob- ing was the reported cause of death for each of the swim fa-
tained from the original research studies thus far conducted, talities reported in a 2010 study [16], but drowning lacks the
other than that running, followed by cycling and then swim- accurate methods of risk exposure that are needed to establish
ming, is the triathlete’s first time choice of blame for (?) (non aetiology [32]. Most injuries are broadly attributed to ‘a result
differentiated) triathlon training and/or racing knee, lower of failure to adjust pace within safe limits for specific envi-
back and shoulder injuries [12]. However, in the only study ronmental conditions’ [22–23] or to ‘inadequate implementa-
thus far to track multiple occurrences of injury to a given tion of (race) safety precautions’ [33]. The risk factors that
location over time, some athletes were found to attribute the have been directly investigated are detailed in the first au-
first occurrence of the injury to training/racing in one disci- thor’s 2010 review [12].
pline and its subsequent occurrences to exercise in another or
more than one discipline [5]. Intrinsic risk factors
The extent to which reported injuries may be first time as
opposed to recurrent injuries has barely been acknowledged Pre-event cardiovascular screening is not standard practice.
by the triathlon injury literature. Few studies to date appear Although the percentage of triathletes who are likely to have
to have discriminated between them, making it difficult to an inherent genetic susceptibility to cardiac problems is like-
get a true picture of both the actual extent and the chronology ly to be very low, most of those athletes who have died sud-
of triathlon related injury. For example, the extent to which denly within the swim section of competition have been
race injuries are actually existing training related injuries that found on autopsy to possess an cardiac abnormality. Type 1
have been exacerbated by the demands of competition [5] is long QT syndrome [34], and to a lesser extent catecholamin-
unknown. ergic polymorphic ventricular tachycardia, may be associated
with malignant arrhythmias during swimming [35]. The one
Injury outcome. athlete reported by Harris et al. [16] who died within the cy-
cle section of competition did so as a result of cervical inju-
In addition, the extent to which injury leads to modification ries sustained from a fall. The degree to which said fall was
or time off training/competition, as well as average treatment due to insufficient technical ability on either or both the part
duration, is under-described. Running, cycling and swim- of the athlete or his co-competitors is unknown.
ming training appear to be increasingly less affected (i.e. in Nevertheless, the strongest correlate with overuse injury in
17–21%, 26.2–75% and 42–78% of cases [12]), with most ath- triathletes is previous injury occurrence [13, 17].
Table 1: Percent comparison of injury type in triathlon (updated from [11])
Site/Paper Murphy O’Toole et Ireland Massimino Hiller et O’Toole Jackson Migliorini Korkia Egermann Villavicencio Gosling Junge et Rimmer &
al. & et al. al. et al. et al. et al. et al. et al. al. Coniglione
Micheli
1987 1987 1987 1988 1989 1989 1991 1991 1994 2003 2006 2007i 2009 2012
½IM IM
Neck pain – – – – – – – – 48.3 –
Contusions – – 4.7 – – – – –12 40.982%B, – 3
77% Tr
Abrasions – – 1.9 – – – – – 28 [21.3, 2.4 6.5
Triathlon injury – An update.

–3.4 17.8]
Capsule/ligament/ joint – – 1.9 5.5 – – (4.2)R –28 23.2 –
Tendinitis/ Foot – Tendonitis All 6.9 15.3 tendo- –7 (≈60) Mc – 6.9 – – Sprain 4
tenosynovitis/ most com- nitis [3.3, 8.9]
tendonitis Ankle – mon (6)g – – – – – –
Achilles – – – (6.5) R – – – –
Supraspinatus – – – (3.2)S – – – – 1.18 4.3

Knee – (19)e,b (≈ 60)c (9.7)Tr, b – – – –

(1/109)
Shin splints – – 13.1 8.6 – 9 –
Patellar chondromalacia – Maybe 4.7 3.7 – – – (16.1)Tr, – – – –
20%B, 60%R,
20%B+R

Muscle tendon injury – – – – – – – – 26.466%r, – –

14%b, 14%s

Muscle sprain – – – – – – – 12.6 – –

Muscle strain – Yes 15 31.3 – – – –6.5 25.3 – – 10 [3.3,
8.9]
Inflammatory Iliotibial band – – 2.8 (10)b – – (19.3)Tr, 16.1 – – –
pain syndrome syndrome 33.3%r, 33.3%b,
33.3%R+B

Patello-femoral – – – All 15.3 (14)b – – – – – – –

Plantar fasciitis – – 1.9 PF 8.0 –15 – – (6.5)R – – – –

Sesamoiditis – – – – – – – 1R – – – –
Fracture – – – – – – – 9.589%Tr, – – (2/109) 2.2
76%B, 12%R

Stress fracture Foot and ankle – – 4.7d 12.3 (10)M – – – – – – –

Lower leg – – 4.7 – (7)M – Yes (13) R – – – 9

Hip/pelvis/spine – – – – (<1) – – – – – – –
13
 14
Site/Paper Murphy O’Toole et Ireland Massimino Hiller et O’Toole Jackson Migliorini Korkia Egermann Villavicencio Gosling Junge et Rimmer &
al. & et al. al. et al. et al. et al. et al. et al. al. Coniglione
Micheli
1987 1987 1987 1988 1989 1989 1991 1991 1994 2003 2006 2007i 2009 2012
Low back pain With sciatica – – 1.9 – S±BP(15) (72)b – – – 21.8+s, 46.0– –
S62%SR, 65%B
Without sciatica – – – – – – – – –

Not clear – – – – –62 – 2 (6.5) R – – – –

Sciatica ± back pain – – 12.1 – –15 – – –
–
Unknown – – 12.1 – – – – – – –
–
Multiple – – 12.1 – – – See paper – – – –
Laceration – – – – – – – – – 9 [11.5,
15.6]
Temperature Non-severe – – – – – – – – – 4 36.5 21.7
related problem
Severe 2 – – – – – – – – 1 1.2
Envenomation – – – – – – – – – 4 [0,
24.4]
Blister – – – – –43 – – 4.5 – 15 [27.9, 4.7 2.2
4.4]
Costochondritis 2.2

Metatarsalgia 2.2

Other 8.6 JI/ bursitis 13.1 – – – – 4.2 R – 9 15 [8.2, 25.9 30.4

15.6]

* Values are expressed as % of cases unless they are enclosed in round () brackets, in which case they refer to % of athletes. Superscripts denote % of cases attributed to each discipline. See [11] for references.

Key: M male, F female; PF plantar fasciitis, S sciatica, LB Low back pain, BP back pain, NP neck pain, JI joint inflammation, SR sports related pain, Tr Training related; S, B, R, R + O attributed to swim, (‘bike’)
Cycle, Run, Other, or Run + Other training, respectively.
b More common in females
c Approximate values from figure,
d Worst cases,
e (patella/ popliteal)
f Of the 3 most common injuries (i.e. ankle/foot, knee and lower leg) 35% involved a strain, 25% tendinitis & 22% a tear,
g More common in males,
h Details given in paper as to normal recovery times/ recurrence.
i dislocation and rupture of tendon or ligament.
I Values in square brackets are for 2 sprint races in the same dataset
Vleck V. et al.
Triathlon injury – An update. 15

Extrinsic risk factors Corresponding Author:

Exercise induced oxidative stress in an IM competitor was Dr. Veronica Vleck. CIPER, Faculty of Human Kinetics.
recently linked [36] to the occurrence of acute lung injury. Technical University of Lisbon. Estrada da Costa. Cruiz-Que-
Most of the literature relating to any potential relationship brada-Dafundo. 1499-002 Portugal.
between specific injury types/sites, and or intensities of train- Telephone (int + 351) 21 414 91 00, Fax (int + 351) 21 415 12
ing and injury occurrence is, however, equivocal. This is un- 48, Email: [email protected]
surprising given its general lack of quality [10-12]. (Individ-
ual specific) inappropriate increases in training load and or
stress, and higher intensities of run and cycle work, may, how-
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