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Understanding and preventing the 10 most common injuries suffered by triathletes.
Physical therapy for athletes has evolved in the past decade with a shift in understanding where the root causes lie and how to best deal with them. Gone are the days when everything could be cured by orthotics; now more attention is on hip strength, mobility and practicing good technique when you swim, bike or run.
We talked to four top sports physical therapists from around the country (read about them on page 80) and got their insight on which injuries might be lurking around the corner—and how you can prevent them in the first place.
The deal: “Somewhat obviously, this is usually an overuse injury from swimming,” says Nate Koch. “It’s a result of improper biomechanics resulting in the stroke technique being off: The swimmer may not be using enough body roll and the reach isn’t proper.” Koch says that the internal rotation of the arm compresses tendons and bursa. A sign of shoulder impingement is that the morning after a hard swimming workout you wake up and your shoulder is sore.
First aid: “Lots of people don’t want to miss workouts,” Koch says. “The coach has it on the schedule and they can’t bring themselves to take the break.” But rest is exactly what you should do, Koch explains. Because an impingement comes from tightness and lack of “space” in the shoulder, work on mobility around both the shoulder blade and scapula.
Prevention: In addition to refining your stroke mechanics, consistent mobility and flexibility in the shoulder complex is the No. 1 prevention tool. Koch says to follow the example of most collegiate swimmers and spend time before and after each swim workout performing simple rotator cuff and mid-back mobility exercises to help counter all of the muscular imbalance created during a swim workout.
The deal: Sharp pain deep in the hip or in the lower back can be caused by any number of things, Koch says. “Diagnosing the specific problem is hard even for the trained eye,” he says. “It could be 20 different things, but all that stuff is usually related to spine. Sometimes we feel like a sacroiliac joint clinic.” Back pain usually originates from somewhere else—typically the hip, says Bryan Hill.
First aid: Figuring out the cause is important. A professional bike fit will ensure it’s not your cycling mechanics. “Flexibility is key,” Hill says. “If you work on hip mobility, the back pain will likely decrease. Alternate heat and ice, and warm up and stretch before and after workouts—especially rides.”
Prevention: “Spinal mobility is important,” Koch says. “This means improving your core strength and the mobility of the pelvis and spine.” This is particularly important if you have an office job and are stuck in a chair all day. “When you’re sitting, the pressure on the discs in your lower back is up 30 percent compared to when you’re standing,” he says. The solution? Get up from your chair on the hour, walk around and perform a few light stretches. A proper bike fit and a look at your swim and run mechanics by a professional are also great preventors.
The deal: Femoral acetabular impingement (FAI), or pain in the groin and front of the hip areas, are problems that can arise from being on the bike a lot. Groin sprains are more common than FAI, and usually a result of being hypomobile or inflexibile.
First aid: “Massage or ART (Active Release Technique) are great in the acute phase, as well as ice or modalities,” Hill says. “Adjusting bike fit or seat height may be a factor that will help overall. Long-term, there is no substitute for consistent stretching and flexibility work through yoga, personal training, physical therapy, etc.”
Prevention: Koch says that a less aggressive aero position on the bike is a smart way to ward off the potential for FAI. Similar to how you prevent shoulder impingement in your swim program, be sure to follow up your bike workouts with stretches to mobilize the joints and bring your muscle tissues back to center.
Iliotibial band syndrome
The deal: In addition to triathletes and runners, Jill Boorman works with professional baseball players in the off-season, when she sees a lot of ITBS problems. “They’ve just come off playing 162 games where they’ve always been moving forward,” she says. The result is a pelvic instability—tight hips that are lacking lateral mobility, and the IT band pays the price. Runners and triathletes, Koch adds, who spend a lot of time running downhill can be especially vulnerable to developing IT band pain, which can show up on the outside of the knee or at the origin of the IT band in the hip. Also, Hill says, a foot dysfunction can be a sneaky reason for the knee and hip relationship to be off in running.
First aid: “I love ice for this,” says Boorman. Icing can reduce the inflammation and the pain. She also encourages her clients to follow hard runs with swimming to “massage” the legs. Using a foam roller on the legs, massage and ART are also useful.
Prevention: To prevent ITBS problems, Koch teaches his clients exercises that improve lateral hip mobility, like monster walks and clam exercises. He also advises them to adopt a foot strike that is light and fast. “The more time your foot spends on the ground, the more forces the leg has to absorb,” he says. “The less time you’re on the pavement the better.” Hip mobility is the key, but making sure that alignment while running is important, adds Hill. “Have a professional do a video run assessment, work on form and run with experienced runners to model their mechanics.”
Patellar tendinitis or PF syndrome
The deal: According to Steve Berkey, “Patellar tendinosis is a pain that occurs under the kneecap from the knee not tracking correctly.” Because there are so many causes, it’s important to have a professional assess your lower body. Hill says the primary “big rocks” to assess are (1) foot position (flat or high arch) (2) knee strength on a single leg (using the simple single-leg squat test for range) and (3) hip mobility, primarily the hip flexor. “If any of the three or a combo are not biomechanically efficient, the risk for knee pain rises,” Hill says.
First aid: Ice with a bag that conforms to the knee, Berkey says—like a bag of frozen peas. Do 15 to 20 minutes of icing per treatment. Stretching, massage and, in some cases, orthotics can solve the problem.
Prevention: Berkey says that patellar tendinitis is usually related to weak hip muscles and poor running technique. Exercises to strengthen and mobilize the hips should be paired with a focus on improving your running technique. “These are the things you can work on with a PT so you can steer clear of the surgical options that can come up with knee pain,” Berkey says.
The deal: “Achilles tendinosis is composed of micro-tears along the tendon,” Berkey says. Typically the pain is focused right on the attachment of the tendon to the heel, or up in the lower calf muscle where muscle attaches to the tendon.
First aid: “Ice is your safest remedy,” Berkey says. “Ice two to three times per day for two or three days.” Berkey also suggests that if the pain is in the fleshy part of the lower calf to use a bag of ice that conforms to the area, like a bag of frozen peas. But if the area is localized on the back of the heel, use ice to massage the area for a few minutes at a time, or until the area is numb.
Prevention: Achilles problems are typically the result of tight calves, says Berkey. In addition to stretching out the lower-leg muscles, choose your footwear well. “If you’re walking around day after day in heels, you’re going to pay a price in terms of a shortened tendon,” Berkey says. Choose flatter-soled shoes or aim to stretch throughout the day.
Hamstring muscle tear
The deal: Koch says that the hamstring tears suffered by triathletes are different in nature than the image that a sprinter tearing a hamstring might impart. “It’s an easy diagnosis with a sprinter,” he says. “They tore it in a dramatic way and there’s bruising in the area. But with triathletes we’re talking about small tears, micro-tears, so it’s more like a tendinosis than a tear.” A common cause of chronic hamstring tears, Koch says, is when a newer triathlete adds track workouts to the program. “They’re suckered into going too hard by the glory days,” he says.
First aid: Rest and ice as soon as possible, Koch says. “Gentle massage will help, too.” If the problem doesn’t go away, Koch might suggest noninvasive ASTYM treatments that aim to rid scar tissue from the problem area.
Prevention: “Shorten the stride,” Koch advises. By shortening the stride you expose the hamstring to less overall tension and lessen the risk of tearing things. Preventing hamstring problems is also an area where you need to take measures throughout the workday to get up, move around and introduce spells of light mobility work to your day. “If you sit all day and then go run intervals on the track at night,” Koch says, “you’re going to have trouble getting full hip extension.”
Med Tent: How To Heal A Hamstring Strain
The deal: Stress fractures are a common overuse injury when the tissues can no longer absorb the punishment and the bone subsequently breaks. The result can be a tiny crack that usually takes weeks to heal.
First aid: It’s time to take a break from impact exercise, like running. “Endurance athletes hate taking any time off, but they have to with a stress fracture,” Boorman says. She offers her clients a solution: “I have them do their running in a pool and I work them hard. I’ve had clients use pool running while the stress fractures healed and then still be in good racing shape after their rehabilitation is complete.”
Prevention: “The thing I’ve seen over the years is that the athletes who get stress fractures always have terrible nutrition habits,” Boorman says. “They just aren’t eating well. So I’ll first talk to them about their diet and advise them to get enough protein and vitamins. Their bones just can’t handle the stress without them.” Boorman tells endurance athletes to pay special attention to recovery meals following long or difficult workouts. “Chocolate milk and a turkey sandwich will do the trick,” she offers as an example.
The deal: Shin splints are a member of the overuse injury family, caused by inflammation of the muscles, tendons and tissues around the tibia (shinbone), which results in a pain along the front or side of the lower leg. Contributing factors include overstriding, excessive pronation (flat foot) or rotation (high-arched foot). If not treated, shin splints could lead to a stress fracture.
First aid: Ice the area and work on calf mobility. Use specific trigger point massage to increase blood flow (try a tennis ball), foam roll or get ART (page 84).
Prevention: Follow the 10 percent rule, only increasing run volume by 10 percent per week. Find the right shoe and replace it often—rule of thumb is 300–500 miles, depending on your weight—and don’t make any abrupt changes in terrain, such as running on trails for weeks and then switching to mile repeats on pavement. Having an expert check your running form also applies here. Hill also recommends working on flexibility of the big-toe extensors: Stand with your foot flat on the ground and lift only the big toe, or just use your hand to stretch your big toe in both directions.
The deal: Here’s what happens with plantar fasciitis, according to Berkey: “The tissue has had enough,” he says, referring to the tissues of the arch in the foot. “Micro-tears accumulate and a painful tightening occurs. The adhesions tighten as well, and you wake up one morning with a sharp pain in the heel after you take your first step out of bed.”
First aid: Berkey advises rolling out your foot with a frozen water bottle several times a day. “Ice to the point of numbness and then stop,” he says. Any more and you might burn your skin.
Prevention: “We used to always treat this with a night splint,” Boorman says. “But the issue is you’re pushing off over and over again with your foot.” Boorman recommends “plantar flexion” stretches to open up the talus joint, like sitting back on your heels. Berkey has patients focus on the flexibility of the big toe and believes that massaging the arch and foot—self-massage works here as well—will really help prevent arch pain issues if you’re regular about it.
Steve Berkey is a doctor of physical therapy and the director of 90 Revolutions in Falls Church, Va., where 75 percent of his clients are triathletes.
Nate Koch is the director of rehabilitation at Endurance Rehab in Scottsdale, Ariz.
Bryan Hill is a physical therapist and co-owner of Rehab United in San Diego.
Jill Boorman has been practicing physical therapy since 1994 and is currently the clinical manager at Premiere Physical Therapy in Charleston, S.C.