Keys To Treating Common Triathlon Injuries

Marybeth Crane, DPM, MS, FACFAS

   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.6 Training 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.

Why Blisters Can Be A Bigger Problem Than Athletes Realize

You may think that blisters are not a big deal. Think again. Blisters will sideline an athlete quickly. After Ironman Texas, the most painful thing I had was a large blister on the back of my heel. Spectators were trying to be helpful and cool off the athletes by spraying us with their water hoses. Yes, it helped cool us down on a hot, humid day but try running a marathon in wet shoes.


Allow sufficient "float of the shoe cleat" check on the pedaling down stroke, not too much "dropping the heel."

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