The combination of a diehard mindset and the stresses triathletes must endure can lead to repetitive injuries. Accordingly, this author provides a treatment guide for common triathlon injuries such as stress fractures, blisters and Achilles tendonitis.
Participation in triathlons has grown at an enormous rate in the last 15 years worldwide. USA Triathlon publishes a demographic study each year and cites over 500,000 participants in races in the United States in 2012 with almost double-digit growth each year since 2000.1
In discussing triathlon-related injuries, the best approach is to start with a window into the unique world of triathletes. It is necessary to have an understanding of the sport and the stubbornness that is ubiquitous to triathletes to be able to treat this group of athletes successfully in your practice.
Let us start with the basics. A common perception of what the average triathlete looks like is what people see on TV watching the Ironman World Championships. Namely, people tend to envision an extremely fit, 30- to 45-year-old male with six-pack abs and less than 10 percent body fat. This is simply not the case. There is no “average” triathlete. In my practice, the youngest competitive triathlete is a 9-year-old girl and the oldest is a 78-year-old man. They come in all ages, sizes, shapes and socioeconomic as well as ethnic backgrounds.
This was extremely apparent when I competed in my first Ironman event. The diversity of the field was amazing to me but the one thing triathletes all have in common is an underlying stubbornness that equates quitting with personal failure. Triathletes quit when their bodies (or equipment) can no longer function. In fact, Chris McCormack (a.k.a. Macca, a multiple Ironman world champion) coined a mantra that pretty much explains the attitude of most triathletes. The mantra is “embrace the suck,” which means that in a race, you look your inner weakness in the eye and embrace the suffering to make it to the finish line. Quitting is not an option.
This is a tough group to treat because of this underlying stubborn nature. It is important to understand this psyche to be able to speak athletes’ language, and have the ability to educate them and validate your comprehensive treatment plan. No, not all triathletes are sadomasochists but a degree of determination and ability to withstand pain is an inherent part of most endurance sports.
This being said, not all triathletes are competing in the Ironman distance. In fact, currently the most popular distance is the “sprint triathlon.” This is a 300- to 500-meter swim, a 12- to 17-mile bike and usually a 5K run. This takes most people one to two hours or so to complete, and requires minimal training (a few hours a week) to make it to the finish line in one piece. The other most common distances are the “Olympic triathlon” (1,500-meter swim, 40K bike ride and 10K run), the “Half-Ironman” (1.2-mile swim, 56-mile bike and 13.1-mile run), and the full “Ironman” (2.4-mile swim, 112-mile bike ride and a 26.2-mile run).
It is important to understand the distances so you can characterize your patients better. A sprint triathlete is training just a few hours each week in each discipline whereas an athlete training for an Ironman event may be spending 20-plus hours per week swimming, biking and running.
Newbie triathletes are the most commonly injured. They are also the ones starving for more information and most likely to get their medical information from Dr. Google. Many people move from just running or cycling to triathlons because of the perception that adding variety to their exercise regimen will reduce overuse injuries. The theory is that the variety of the muscle use in the three sports will ideally minimize the strain on any single muscle set. For runners in particular, adding biking and swimming to their routine means less pounding on the pavement.
It is a great theory but in practical terms, it almost never works. The very nature of a triathlon and an underlying competitive nature lead to training harder and longer. Therefore, these athletes wind up adding more stress to workouts without necessarily subtracting anything. Accordingly, the idea that people can reduce their chance of injury by competing in triathlons is usually a misconception.
Now that you understand a little more about the nature of the sport and its participants, let us talk about these injuries. Triathlon injuries fall into two main categories: traumatic and repetitive stress.
Traumatic injuries for triathletes include sprains, tendon ruptures and fractures, abrasions from falling off a bike, and even puncture wounds from running from the beach to the bike in transition. These injuries are not unique to triathlons and are commonplace in most podiatry practices.
The most common triathlon-related injuries are caused by repetitive stress. These are the “too much, too soon, too fast” injuries. One study of training patterns and injury rates showed that for non-elite triathletes, the likelihood of sustaining an injury is lowest when training for a total of eight to 10 hours per week, specifically cycling for five to six hours and running for three to four hours weekly.2 Time spent on swimming training does not appear to affect injury risk. Less training or more training increased injury risk. A common training tip is that it is better to be 15 percent under-trained than 1 percent over-trained. The literature supports this common sense approach as well.
One might think swimming is relatively free from podiatric injuries but keep in mind that many triathletes will train with flippers on their feet and can actually aggravate a foot or ankle injury with these training aids. Flip turns can also be quite traumatic to an already injured foot or ankle. Do not forget to caution an injured athlete to be less zealous with turns.
Cycling-related injuries are often due to poor bike fit and shoe gear. If the saddle of the bike is too high or too low, and/or the cleat of the bike shoe is too far forward on the pedal or too loose, Achilles tendonitis, patellar tendonitis and iliotibial band syndrome can occur. If the cycling shoes are too tight or not wide enough, Morton’s neuroma and metatarsalgia are not uncommon. Get a professional bike fitting or a Retül (Retül Studios) computerized fitting of your bike to prevent and/or treat these injuries.
I urge every podiatrist who is interested in treating triathletes to spend some time at a good cycling store to learn the basics of troubleshooting a bike fit or at least find a local resource to analyze your athletes’ bike fit. Fit is everything, especially when a long course triathlete can easily spend seven hours in the saddle.
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
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
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.
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.
Making sure your cycling and running shoes are big enough is important for blister prevention. In a long course triathlon, I recommend athletes buy shoes at least a half size to a full size bigger than their street shoes. Feet swell during the race. Fluid balance is also important and runners rarely think of it in the quest to prevent blisters. If you over-hydrate and take in excessive sodium, your toes and feet swell and rub together, which is a recipe for painful blisters. Keeping your feet dry with moisture wicking socks or double layer socks can prevent blisters. Actually, wearing socks in cycling shoes (many triathletes go sock free on the bike) can also help. Liberally applying body glide or another lubricant on the toes, ball of foot and heels also helps.
After the race, to pop or not to pop the blister is always a question athletes ask. The answer is to teach your patients to cleanse the area, drain the corner of the blister and leave the top as a biological dressing. Protect the area with a soft clean dressing. I always instruct my patients that if the blister is larger than a silver dollar or red and irritated, they should come into the office immediately. Debridement with application of a hydrocolloid dressing will quickly decrease their pain. Antibiotics may be necessary for large infected blisters.
Black toenails are almost a badge of honor for the long distance runner. Triathletes are no different. Again, emphasize the need for slightly bigger shoes. An underlying biomechanical issue may be causing their toes to curl, forming a hammertoe and jamming their toenails. Educate your patients not to pick at their black toenails.
I only recommend nail avulsion if the hematoma is almost 100 percent of the nail bed or if the edges are loose already. Using a fine gauge insulin needle to evacuate the hematoma is quick and virtually painless.8 The old school technique of trephining the nail is considered archaic. I also recommend discussing fungal infections that can occur in the damaged toenail so our athletes will be hyper-vigilant with their care of the damaged nail.
Irritation of the Achilles tendon is the most common myotendinous injury in triathlon events. Often, this is due to poor bike fit or old cycling shoes. If the foot is rocking on the pedals, pronation will occur through the bottom of the pedal stroke. The gastroc muscle will fatigue more quickly and the Achilles will be irritated. Changing shoes and/or type of cleats can help quickly.
Achilles irritation can also occur due to the transition from cycling to running. If you have ever gotten off a bike and tried to run, you will understand the biomechanical imbalance that occurs in the first part of the running leg of a triathlon. A late stage pronatory foot type or wearing a racing shoe that is too flexible can also be the cause of irritation. A tight gastroc soleus complex is often the underlying culprit as well as a weak core and tight hamstrings.
Early recognition of the problem and being a good detective is the key to successful treatment. Emphasize that rest is important. This is the time for athletes to work on swimming. Physical therapy with a lot of eccentric stretching and strengthening of the weaker muscle groups is extremely helpful. If the patient is experiencing a nodule within the Achilles paratenon or crepitus upon range of motion, a small period of immobilization in an Aircast AirHeel (DJO Global) or other device is often helpful. A below-knee walking cast with a heel lift or a non-weightbearing fiberglass cast for four to six weeks is useful in those tough cases or non-adherent patients. Functional foot orthotics in both cycling shoes and running shoes can be helpful in those patients with a pronatory foot type.
No one wants to rupture an Achilles tendon so most athletes will listen if you tell them that injury can be the outcome of non-adherence.
Every podiatrist in the United States knows the causes, diagnosis and treatment options for plantar fasciitis. Triathletes are no different.
One should emphasize aggressive conservative treatments plans with liberal use of physical therapy. The only word of advice is to be very specific on the running restrictions and the need for shoe gear modifications and/or functional foot orthotics. Avoid injection therapy in those triathletes who are still running. This is the group that would rupture their plantar fascia. The return to running should be gradual after successful treatment of this common problem.
Again, metatarsalgia/Morton’s neuroma is a common problem we treat in podiatry offices today. Bike shoes and transitioning to very flexible or “barefoot feel” running shoes are often contributing factors. Early signs are usually numbness in the toes after riding for some distance. Patients may not have pinpoint interspace pain at first. Always rule out a stress fracture. It is often very helpful to add metatarsal padding to the cycling shoe and getting wider shoes.
The remainder of the top ten injury list (iliotibial band syndrome, patellar tendonitis/chondromalacia patella, medial tibial stress syndrome and sacroiliac joint dysfunction) are beyond the scope of podiatry in some states. However, remember that one can address most of these injuries with better bike fit, changes in shoe gear and/or functional foot orthotics, and physical therapy.
As you can see, the injuries that occur in triathlons are not unique to the sport but one should understand the psychology of these patients for successful treatment and return to sport in a better condition than when the patient walked in your office. A demand for adherence and upfront vocalization of the risks associated with non-adherence are essential keys. I hope this article has helped you have an understanding of these complex athletes and the need for comprehensive treatment plans.
Dr. Crane is the managing partner of Foot and Ankle Associates of North Texas in Grapevine and Keller, Texas. She is a lifetime distance runner and has finished multiple Ironman triathlons. Her practice focuses on foot and ankle surgery, biomechanics and sports medicine. For more information about running and triathlon injuries, visit www.faant.com  or www.myrundoc.com  .
1. 2012 USA Triathlon Demographics Report. Available at www.usatriathlon.org/about-multisport/demographics.aspx  .
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8. Kaya Tl, Tursen U, Baz K, Ikizoglu G. Extra-fine insulin syringe needle: an excellent instrument for the evacuation of subungual hematoma. Dermatol Surg. 2003; 29(11):1141-3.