Avoid Overuse Injury By Staying Within Your Limits

Written by: Jordan D. Metzl, MD

Dr. Jordan D. Metzl explains the importance of keeping your training at a reasonable level to avoid overuse injuries.

It’s almost summer, the best time of year for triathletes. It’s that all-too-brief window of opportunity, for those of us who don’t live in Florida, California or other places where it’s warm all the time, to “let it rip” in our training.

Jason is a 32-year-old newbie who came in to see me last month. Last year he signed up for his first triathlon, an Olympic-distance race, and like many of us, he was bitten by the tri bug. With the best of intentions, Jason decided that this year he wanted to tackle an Ironman as his next race. He signed up, hired a coach and started training.

So far, so good? Yes and no.

Jason’s enthusiasm is great—exactly what I like to see in triathletes who are just getting into the sport. What I tell my patients is to set a goal and work toward it. I generally find that it doesn’t matter what the sport or level of athlete is; from triathlon to ballroom dancing, everyone needs a goal. Athletes who exercise just to exercise, without a specific goal in mind, are much less productive than those who set goals.

How did I meet Jason?

He came into my office complaining of foot pain. “Dr. Metzl”, he said, “my foot is hurting and I’m having trouble running. It used to bug me only when I ran, but now I’m having some pain when I walk too.”

When I examined Jason’s foot, it was immediately clear that his pain was coming from the middle of his foot, the result of a stress fracture in his third metatarsal. Stress fracture, an injury that comes from putting too much pressure on a bone, is caused by at least one of a few factors: poor biomechanics, low bone density or a rapid increase in activity that places loading forces on the bone that exceed its absorption capacity. Often, all three of these factors occur at once.

Among the most common biomechanical and structural issues leading to stress fractures are overpronation of the feet and weakness in the core muscles. Most women who suffer stress fractures have low bone density (osteopenia or osteoporosis), which predisposes the bone to injury. (See my article, “Stressed Out,” in the May 2006 issue.)

With Jason, however, neither of these factors was the case. Jason’s stress fracture was volume-based. He had never really been much of a runner; he was a former college swimmer. Instead of spending his teen and collegiate years making his bones stronger through high-impact sports like soccer and basketball, Jason spent every waking hour in the pool. The result was that he had good cardiac fitness, but his bones weren’t strong enough to withstand miles of run training. While his great cardiac fitness enabled him to make a quick jump from Olympic-level training to Ironman-distance training, his bones weren’t strong enough to hold up to the load of training he had taken on. In the words of a local triathlon coach, Jason made the mistake of the toos: too much, too soon, too fast.

To fix Jason, I had to stop him from running for about six weeks until the bone healed, and despite our best efforts, his healing rate wasn’t fast enough to allow him to do his race. Jason would have to wait until next year.

What is the take-home message that we can learn from Jason’s injury?

In the summer, when the weather is good, you can find many athletes like Jason out training. They have been doing just a little training in the winter and quickly try to ramp up their activities. Their enthusiasm is terrific: They want to go as fast and far as they can. I often see these people in my office, however, with overuse injuries such as Achilles tendonitis, shoulder impingement and stress fractures.

The moral of the story is to listen to your body and increase your efforts slowly. Only a few triathletes can successfully jump from Olympic to Ironman-distance races. Many more break down in their training. Advance your training slowly, however, and you will be great!

Jordan Metzl, MD, is a nationally recognized sports medicine physician at Hospital for Special Surgery in New York City. In addition to his medical practice, Dr. Metzl is a 27-time marathon runner and six-time Ironman finisher. For more information, visit Drjordanmetzl.com.