The Multisport Athlete: Risks, Injury & Prevention

1. The Multisport Athlete: Risks, Injury & Prevention Marc Silberman, M.D. Gillette, NJ

2. Disclosure I declare no conflict of interests I do not have any financial disclosures

3. Objectives • Identify the riskiest portions of the triathlon for the athlete and medical director • Name the most common locations of injuries and disciplines that cause them • Teach common injury preventative strategies to multisport athletes for each discipline

4. Introduction

5. You don’t know Bo

6. The Multisport Athlete

7. 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

8. Medical Preparation for Triathlon • 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

9. Medical Personnel Dallam et al. “Medical Considerations in Triathlon Competition. Recommendations for Triathlon Organizers, Competitors, and Coaches.” Sports Med 2005; 35 (2): 143-161.

10. Incidence of Triathlon Injuries • NO CONSENSUS DEFINITION OF INJURY • The strongest correlate with overuse injury in triathletes is previous injury occurrence • 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

11. 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?

12. 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

13. Severity of Injuries • Vleck (retrospective) • 17% injuries stop swimming • 26-75% stop cycling • 42-67% stop running • Korkia (prospective) • 21% injuries stop swimming • 37% stop cycling • 78% stop running • 16% stop all 3 • 17% missed competition

14. 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

15. 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

16. Medicine is more art than science

17. The Triathlon

18. The Triathlon • Swim • T1 • Bike • T2 • Run • Nutrition

19. Distances

20. The Swim

21. The Swim

22. The Swim

23. The Swim

24. The Swim

25. The Swim

26. The Swim Risks • Collisions, incidental and purposeful • Tympanic Membrane perforation • Drowning / Near Drowning • Panic Attack / Anxiety • Cramping • Hypothermia/Hyperthermia • Sudden Cardiac Death • Infections

27. The Water • Temperature • Weather • Body of water • Swim course organization

28. 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

29. Wetsuit Guidelines 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)

30. Course Organization • 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

31. Athlete Swim Preparation • 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

32. Swimmer’s Shoulder Prevention Push up plus No Money Ball on wall USA Swimming Task Force YTWL Dead Bug

33. T1

34. T1

35. T1

36. T1

37. The Bike

38. The Bike

39. The Bike

40. Road vs. Time Trial Position Plumb bob falls over pedal spindle and 1st metatarsal Steeper Seat Tube More Forward Position Higher Saddle

41. The Bike Elements • Water Temperature • Hypothermia, Hyperthermia, Dehydration • Environment weather and temperature • Sun exposure • Nutrition – GI distress, hyponatremia • Crashes • Cycling Course, drafting or non-drafting • Bike equipment • Fatigue

42. The Bike

43. The Bike

44. The Bike Feed Station

45. Knee Pain • Anterior Knee Pain • 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 • MCL bursitis • Medial plica syndrome • Pes Anserine Syndrome • Medial meniscus tear

46. Athlete Bike Preparation • 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

47. 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

48. T2

49. T2

50. T2