Ever since the first modern triathlon competition was conducted in San Diego in 1974, interest in the sport has grown steadily over the years. Currently, millions of amateur athletes participate in thousands of events annually worldwide. Since triathlon competitors perform three events with little or no rest between them, it can be a challenge for podiatrists to treat injuries that athletes sustain in these events.
Race distances vary and finish times range from approximately 30 minutes to several days as athletes compete in swimming, bicycling and running. Although the Ironman distance race is probably the most well known, races of Olympic distance or shorter are the most popular, representing 97 percent of racing opportunities. To support New York City’s bid to host the 2012 Summer Olympic Games, the first New York City Triathlon was conducted last year and the second was held on August 18. Podiatrists served on the medical team at both of these events, rendering care to the injured athletes.
In terms of common injuries, 79 percent of these athletes report an injury of the lower extremity below the knee. Common acute traumatic injuries among triathletes include contusions, abrasions, lacerations, blisters, sprains, strains and fractures.
Treating Acute Injuries In Triathletes
Contusions. Contusions are usually caused by collisions or falls. These injuries can result in hemorrhage and may be marked by ecchymosis. Subsurface damage may extend for varying depths beneath the skin. Blood vessels in the tissues usually tear and varying amounts of blood and plasma leak into the wound, and produce swelling and pain.
Small contusions require no special emergency care. Rest, ice, compression and elevation, along with stretching and range of motion (ROM) exercises, are often all that is needed. When you’re dealing with severe closed soft tissue injuries, be aware that extensive swelling and bleeding beneath the skin may occur. Applying local padding and a soft roller bandage for counter pressure can partially control this bleeding in the extremities. Elevating the extremity and applying ice locally to the area are also helpful in decreasing bleeding of injured tissue and preventing initial tissue swelling. If the athlete has suffered extensive soft tissue damage, you might suspect an underlying fracture.
Blisters. Foot blisters are among the most common injuries for athletes. Blisters result from frictional forces that mechanically separate epidermal cells. Hydrostatic pressure then causes the area of the separation to fill with lymph-like fluid. Small, intact blisters that don’t cause discomfort usually don’t need treatment. The best protection against infection is a blister’s own skin roof. To protect the roof, you can cover this type of blister with a small adhesive bandage or blister guard. You should drain larger or painful blisters without removing the roof.
Follow this by applying an antibiotic ointment and covering it with a bandage. Materials such as a Coban elastic bandage are excellent to use “in the field” since they are capable of securing a gauze dressing to the athlete’s sweaty foot. Blisters that have large tears should be unroofed, cleansed with soap and water or an antibacterial cleanser, and dressed with an antibiotic ointment. Remind the athlete to change the dressing daily.
What About Abrasions And Lacerations?
Abrasions. These injuries are often caused by a crash or fall from the bicycle or by a runner losing his or her footing and falling on a rough surface. The skin is abraded and can become a deep wound. There are three degrees of abrasion-type injuries: first-degree injuries are superficial, second-degree injuries leave some or partial thickness damage to the skin and third degree is full-thickness damage to abraded areas.
In treating the first-degree abrasion, be sure to clean it out, removing all debris (i.e., gravel, sand or dirt) from the skin tissue. You may use hydrogen peroxide and gauze to scrub the area clean. If debris is packed in the tissue, you may need to use a scrub brush. Once it is clean, proceed to use a petroleum-based medicated ointment and cover it with a non-stick sterile dressing. Second-degree abrasions and wounds normally respond to the same care as first-degree wounds. Third-degree wounds require more attention and if they do not respond to this treatment regimen, then skin grafting may be necessary.
Lacerations. These injuries commonly occur from falling off or crashing bicycles as well as from stepping on or rubbing up against sharp objects during the swim. The cut produced may leave a smooth or jagged wound through the skin, damaging the subcutaneous tissue, underlying muscles, nerves and blood vessels. Common sites for lacerations at a triathlon include the hands, arms, legs, feet and head.
You should control bleeding from these wounds with direct pressure. After bleeding is under control, clean the wound with soap and water. Then you can apply an antiseptic solution such as Betadine. Proceed to close the wound by pulling the edges of the wound together with adhesive strips such as Steri-Strips. You may apply tincture of benzoin to the skin around the wound to improve the adhesion of the strips. Quickly assess larger lacerations to determine if suturing is needed. It is important to remember all open wounds should be kept clean and the bandages changed regularly. Observe wounds for signs of infection and review the patient’s tetanus injection status.
How To Handle Strains, Sprains And Fractures
Muscle strains. These are a result of a sudden overload of the musculocutaneous unit, causing the fibers of the muscle and tendon to tear. The signs and symptoms of muscle strain include pain over the site of injury, muscle spasm and loss of strength. Although it is difficult to differentiate between mild and moderate strains, severe strains often result in palpable deformities and the absence of function.
You should manage muscle strains with rest, ice, compression and elevation. This treatment reduces tissue damage from bleeding and swelling. Crushed ice in a plastic bag, held in place with an elastic bandage, may be applied for 20 to 30 minutes every one to two hours. Take extra caution when placing ice directly over subcutaneous nerves, such as on the dorsum of the foot, to prevent damage from cold exposure. Strains that are too painful for normal walking or that cause pain when the athlete moves the injured part should be protected and rested.
Ligament sprains. Ligament sprains, especially of the ankle, are common in endurance races such as triathlons. The management of a ligament sprain depends on the degree of injury.
For first-degree sprains, you’ll see the ligament is stretched but there is no loss of continuity of its fibers. Treatment consists of rest, ice, compression and elevation until the acute symptoms subside.
When the athlete has a second-degree sprain, you’re dealing with a partially torn ligament, which causes some increased laxity to the joint. You would follow the same treatment regimen as you would for first-degree sprains, but you may need to emphasize immobilization of the injured area as well.
Athletes suffering from third-degree sprains have a completely torn ligament, which results in instability of the joint. In addition to the initial acute on-site treatment regimen, these sprains may require either a longer period of immobilization or surgical intervention.
Fractures. Acute fractures are common among cyclists and can be expected at a triathlon. In the initial evaluation of a fracture, the most important factor to identify is the integrity of the overlying skin and soft tissues. This allows you to determine whether the fracture is open (compound) or closed. In an open or compound fracture, you’ll find that the overlying skin has been lacerated by the sharp bone ends protruding through the skin or by a direct blow that breaks the skin at the time of the fracture.
You may or may not see the bone in the wound. The wound may be only a small puncture or a gaping hole exposing much bone and soft tissue. In a closed fracture, the bone ends have not penetrated the skin and no wound exists near the fracture. Compound fractures are often more serious than closed fractures because they may be associated with greater blood loss. Since the bone is contaminated by exposure to the outside environment, the wound is highly susceptible to infection.
When Fractures Are Less Obvious
When you are treating any athlete who has a history of acute injury and complains of musculoskeletal pain, you should suspect a fracture. While bone ends that are protruding through the skin or gross deformity of a limb makes recognition of fractures easy, many fractures are less obvious. Tenderness in a fracture is usually sharply localized at the site of the break. You can locate the sensitive spot by gently pressing along the bone with one fingertip. This “point tenderness” is a most reliable indication of an underlying fracture.
Another good indication that there may be a fracture is the athlete’s inability to use the extremity. An athlete with a fracture or serious injury usually “guards” the injured part and refuses to use it because motion or weight bearing increases pain.
Occasionally, nondisplaced fractures are not very painful and many athletes, especially those participating in triathlons, will continue to use a painful limb and “run through” the pain. Acute fractures are also virtually always associated with rapid swelling and bruising of surrounding tissues as a result of damaged blood vessels.
The management of fractures at the on-site medical area (before sending the athlete to the hospital emergency room) is similar to that of treating severe sprains and includes ice, elevation, compression and immobilization. You should first evaluate the area for arterial circulation and nerve sensation. Cover all open wounds completely with a dry, sterile dressing and apply local pressure to control bleeding. You should splint all fractures before the athlete is moved, unless the athlete’s life is immediately threatened.
Dr. Caselli is Vice-President of the greater New York Regional Chapter of the American College of Sports Medicine and is a Professor in the Department of Orthopedic Sciences at the New York College of Podiatric Medicine.
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