Injury prevention for triathletes

Triathlons are increasingly popular and the mix of swimming, cycling and running is thought to reduce injury due to the variation in activities. However triathlon distances vary greatly and injuries can occur as a result of an individual leg of the event or from a combination of the three, the majority of injuries are overuse injuries. The transition between the activities can also lead to injury where the muscles are required to work differently between the different disciplines.

58 -72% of reported triathlon injuries are related to running. Studies revealed the incidence of running injuries in triathletes is similar to that of non-triathlon runners. The most commonly affected site of injury is the thigh, knee, calf and Achilles tendon. A number of studies also reported the low back as an injury site and cycling was a major risk factor for this.

Swimming accounted for the majority of shoulder injuries, which tended to be overuse injuries attributed to the high number of training hours.

SWIMMING PHASE

This is the first leg of the triathlon. The overhead nature of the swim stroke can lead to impingement injuries of the shoulder. This can be exacerbated by stiffness in the thoracic spine and muscle weakness around the shoulder blade leading to poor stabilization of the shoulder blade when the arm is elevated.

To help prevent these injuries thoracic mobilizing exercises and exercises to strengthen the muscles around the shoulder blade should be included in the training programme.

These exercises may include;

Thread the needle

Start in a four point position with your hands directly under the shoulders and the knees under the hips. Keep your chin in, back straight and shoulders back. With your right arm reach under the other as far as possible rotating and rounding your upper back. Bring your arm back and reach back in the opposite direction as far as possible. Repeat with the other armx10 with each arm  x2/day

Thoracic extension

Lie on your back on a small firm rolled towel or ball across your upper back at the level to be mobilized. Both knees must be bent and hands placed on the side of your head with the elbows pointing to the ceiling. Breathe in and breathe out while letting your spine curve over the rolled towel whilst tucking your chin in and extending your upper back. Make sure your lower back does not arch off the floor. Repeat then shuffle to a slightly different level and repeat. Repeat several times in each area

To strengthen the shoulder blade stabilizing muscles

Stand or sit with your arms resting comfortably in front of your body. Pull your shoulder blades together slightly as though you are gently squeezing an orange between the bottom of your shoulder blades. Hold the position for 5 seconds, repeat x5 regularly during the day.

Stand and tie elastic in front of you. Firmly hold the ends of the elastic in each hand and slightly raise your arms forward. Lower and squeeze your shoulder blades together without moving the arms. Return and repeat.x10 x2/day.

CYCLING PHASE

The correct bike set up is a very important factor in preventing overuse injuries.

If the seat is too low the triathlete will have a reduced range of movement in the hip which may overuse and tighten the hip flexors whilst reducing the power of the gluteal muscles in the down phase of the pedaling action. The greater knee flexion may lead to knee pain due to pressure through the kneecap and patello-femoral tracking problems caused by muscle imbalance around the knee.

If the seat is too high there may be a loss of power in the legs from the muscles not functioning in their optimal length-tension range and over extending the knee may lead to anterior knee pain.

Poor bike set up may also lead to back and neck pain from the prolonged bent over position on the bike leading to unwanted loading on the lumbar and neck region.

Research shows a direct link between the degree of muscle fatigue and the subsequent changes in a cyclist’s movement patterns during cycling, specifically changes in the degree of “trunk lean” and hip angles.

These altered muscle movement patterns could lead to lower back pain in cyclists undertaking hard training or competition. Also, constant leaning forward in a fixed position has a negative effect on core stabilizer muscles and other spinal tissue during prolonged pedaling.

Just five minutes of static lumbar flexion weakens the power of important stabilizer muscles of the lower back (multifidus) and induces “tissue creep” (unwanted stretching of tissues) all of which makes it harder to generate the forces needed to maintain spinal stability and correct posture.

This in turn greatly increases the risk of lower back pain or discomfort.

Cyclists who suffer back pain are much more likely to have excessive lower spine flexion with less active lower lumbar stabilizing muscles (multifidus).

Good trunk strength and stability is important in preventing and alleviating low back pain and this can be developed with multi joint exercises and movements see below.

The trunk muscles can fatigue during a bike ride but many riders find that lower back issues improve as they build strength and endurance into these muscles and develop pacing strategies into their training.

To help prevent back and lower limb pain he following stretches are useful.

Hip flexors, Quadriceps, Hamstrings, Piriformis and Gluts

For back mobility – Cat stretch

Thread the needle (shown above), Thoracic extension exercises (shown above)

Shoulder bridge, see below

Trunk and Gluteal strengthing can be achieved through the following exercises

1) Plank

This is a well-known exercise that improves the core and upper limb stability. Lift up your body, creating a straight line with your body. Keep your shoulders blades down and back

Maintain the position without arching the lower back for 30 seconds. Repeat x5. Progress the time and reps as able. It is very important to keep your spine in a straight line with your body throughout the exercise.

2) The following exercise is excellent for core and glut strengthening and for strengthening around the shoulder blade muscles. It will work most of the muscle groups required for swimming, cycling and running.

Standing in a forwards lunge position with the right leg forwards. Front hip and knee flexed approx. 45 degrees and rear leg extended, and toes touching the floor. Hinge the trunk forwards from the front hip to form a long diagonal line from the head to rear foot. Arms lifted to shoulder height, shoulder width apart, palms facing downwards. Neutral spine, draw in lower abdos

Lift the left leg and right arm. Hold for 3 sec then lower. Repeat with the other side. x10 alternate sides x1/day. (This is like doing a superman standing up!).

3) Shoulder bridge

This will help to strengthen your core and gluteal muscles and mobilize your spine.

Lie on your back with your knees bent. Legs hip width apart. Roll up into the shoulder bridge position. Lift and then lengthen your right leg forwards, reaching for the wall in front of you. Hold for 3 seconds. Fold this leg back to the mat to resume the shoulder bridge repeat with the left leg and then roll down one vertebra at a time.Repeat x10 alternate sides x1/day

4) Squats

Stand with both feet hip width apart. While keeping your back straight and your knee caps aligned with your second toes, slowly lower your body into a squat position leaning slightly forward as you would sit in a chair keeping your heels in contact with the ground. Push your weight into your heels and activate your gluts to come back up to the initial position and repeat. x10 x2/day

Pedaling in high gears, excessive hill climbing and faulty foot placement in the pedals can sprain the patello femoral joint and aggravate iliotibial band problems.

The Achilles tendon is also stressed through hill climbing in the standing position and may be aggravated by incorrect toe clip fitting.

The transition from the cycling phase to the running phase can be problematic, as the calf muscle and hip flexors have to change from working concentrically in the shortened position to eccentric work. The calf and Achilles’ tendon are particularly at risk.

To help alleviate/prevent these problems use a foam roller to release the iliotibial band and calves together with calf and hip flexors stretches.

Calf stretch Hip flexor stretch

Running Phase

With the accumulative effects of the previous two legs, the triathlete can be under both physical and mental stress especially in the longer events and there is a great chance of sustaining fatigue based, overuse injuries such as patello-femoral pain, iliotibial band friction syndrome, Achilles tendonopathy, stress fractures, compartment syndrome, tibial periostitis and plantar fasciitis.

These conditions are the result of a combination of factors including the type of training undertaken, footwear and running biomechanics.

At the start of the run leg various studies have found that the most effective way to combat the heavy feeling in the legs and potential injury is to do calf stretches and start the run at a slower pace before building up the pace. Good trunk and pelvic stability together with hip and calf mobility will improve the lower limb biomechanics to help to prevent injuries from this phase.

All the exercises above will help to achieve this.

When choosing shoes it is best to go to a specialist retailer where they can perform a gait

analysis. Shoes should be replaced every 400 to 600 miles or every 6 months.

It is important to maintain good mobility of the foot and ankle to prevent calf and foot and ankle injuries.

This simple exercise moving the foot into dorsi-and plantar flexion 10 times at least once a day

Improves ankle mobility.

If you get pain and your bike set up is 100% correct, you may want to consult a physiotherapist. He/she can examine your functional core stability, paying particular attention to your muscle activation patterns, multifidus function, gluteal (buttock) strength and hamstring strength/flexibility, and prescribe some appropriate remedial exercises if necessary.


References

Triathlon injuries: A review of the literature and discussion of potential injury mechanisms. A.McHardy,H.Pollard, M.Fernandez Clinical Chiropractic (206) 9, 129-138

Am J Sports Med. 2010 Dec;38(12):2494-501 IEEE Trans Biomed Eng. 2008 November; 55(11): 2666-2674.  Spine (Phila Pa 1976). 2009 Aug 1;34(17):1873-8. Man Ther. 2004 Nov;9(4):211-9.

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