The Most Common Injuries for New Triathletes (and How to Treat Them Yourself)
You're excited for your first race - so excited, you overdid it in training and now you're paying for it. From plantar fasciitis to swimmer's shoulder, we've got your guide to identifying and treating the most common injuries new triathletes encounter.
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It’s no secret that one of the biggest challenges of successful triathlon training is the ability to avoid injury. Most triathlon-related injuries are due to overuse from hours of swim/bike/run, with an incidence range of 37-91% of athletes. While injuries to elite athletes may garner more attention, in reality, non-elites are more likely to sustain an overuse injury, and new triathletes are most likely of all to become injured. In studies of runners, no previous running experience and lower training volumes have been linked to a higher injury risk.
Novice triathletes may find that enthusiasm and self-induced pressures to “catch up” to their more experienced counterparts can lead to overexuberance in ramping up training volumes on bodies not yet equipped to handle the demands of triathlon. Indeed, large jumps (greater than 30%) in running volume are linked to injury risk. Most triathlon-related overuse injuries are running-related, although it can be hard to distinguish due to the varied demands of the sport.
As for most common injuries? Body part-wise, the knee and lower back are commonly implicated in triathletes. In studies of runners, including novice ones, shins, feet, and Achilles tendons are all commonly injured body parts, as well.
So what specific issues should new triathletes look out for, and how can they be addressed on your own? Read on, starting from the ground up.Section divider
Plantar fasciitis (or, more appropriately, plantar fasciopathy, as typically the condition is due to degeneration, not acute inflammation) refers to pain within the plantar fascia. The plantar fascia is a thick band of connective tissue that runs along the bottom of the foot from the base of the heel to the toes, and acts to support the arch of the foot, playing an important role in force absorption while running.
Symptoms typically present as pain at the plantar fascia’s insertion on the medial (inner) aspect of the heel, sometimes radiating into the arch of the foot. Pain is often worse immediately upon standing first thing in the morning, when initiating walking after a period of prolonged sitting, and at the end of the day. Prolonged standing and walking may exacerbate pain, and pain with running is normally at its worst early in the run, and again afterwards.
Causes of plantar fasciitis
Risk factors for plantar fascia issues can include both high or low arches, a lack of calf mobility, older age, and weakness and instability in the calf and smaller foot muscles. While some of these factors cannot be changed, newer athletes may be more prone to a lack of strength in their feet and ankles. Extrinsic risk factors include, as is the case with most injuries in novice triathletes, ramping up the duration, intensity, or frequency of run training too quickly.
How to treat plantar fasciitis at home
A variety of treatments for plantar fasciitis exist, and while evidence can be mixed, many options are easy to try on your own. The American Physical Therapy Association clinical practice guidelines recommend stretching the calves and plantar fascia, soft tissue therapy, night splints, and taping.
Soft tissue therapy that can be performed on your own includes foam rolling of the calves, and self-massage of the arch of the foot using tennis or lacrosse balls, or frozen water bottles. Night splints, which can be sock or boot varieties, hold the foot and ankle in a flexed position overnight, preventing adhesions and tissue tightening. Orthotics have been found to be useful for pain reduction in the short to medium term. Additionally, exercises to strengthen the calves, such as heel raises, and intrinsic foot muscles, such as toe yoga should be incorporated.
How long does it take for plantar fasciitis to heal?
Plantar fasciitis can be a slow-healing injury, with one study of novice runners finding a median recovery time of about six months. Most (85-90%) plantar fasciitis cases can be successfully treated conservatively, but this can take a year or two. As is the case with most connective/soft tissue injuries, activity can continue during treatment using the Pain Monitoring Model, which will be described in more detail with Achilles tendinopathy.
When to see a doctor
If pain is not improving with the above conservative methods within about six months, then it’s probably time to follow up with your doctor. Additional interventions may include extracorporeal shock wave therapy, platelet-rich plasma injections, and, in very recalcitrant cases, surgical interventions. Bone stress injuries in the heel also can occur, so it’s a good idea to rule that out if pain persists as well.
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Achilles tendinopathy refers to reactivity, degeneration, and pain within the Achilles tendon, which attaches the calf muscles to the heel. The Achilles tendon is the largest tendon in the body, and plays a crucial role in the run gait, storing and releasing energy while acting like a spring with each step. Pain can occur along the midportion of the tendon, at the insertion on the heel, or at the junction between the tendon and the calf muscles.
Symptoms usually begin gradually as a soreness or stiffness within the tendon after prolonged inactivity, and then progress from pain with running that decreases or subsides as the tendon “warms up”, to pain that returns after activity or persists throughout. Eventually, weakness and performance deficits may result.
Causes of Achilles tendinopathy
The Achilles tendon experiences high loads (6-8 times body weight) during running, and is thus vulnerable to overuse injury, particularly in newer athletes who have not developed adequate tendon stiffness and strength. Some intrinsic factors that may increase risk of developing Achilles tendinopathy include decreased plantarflexor (calf) strength, deficits in ankle range of motion, and increased rearfoot pronation. Most often, though, like with any tendinopathy, Achilles tendinopathy occurs when too much load is placed upon the tendon with too little recovery-, leading to degeneration so, sudden jumps in training duration or intensity are typically the culprit. Uphill running can also be to blame.
How to treat Achilles tendon injuries yourself
Tendons require load to remodel and heal, and the Achilles is no exception. In the early reactive stages usually encountered by novice triathletes, though, a balance needs to be found between protecting the tendon from loads that further irritate it, while exposing it to loads that will assist it.
Practically, what does this mean? Tendons don’t like compressive load – -with the Achilles, this means that anything that stretches (compresses) the tendon up against the heel will worsen the condition. So, avoid heavy stretching of the calf, and consider temporarily using a higher drop shoe or heel lift to decrease irritating compressive loads on the tendon. If loosening the calf is desired, foam roll instead (just not directly over the tendon). Orthotics may also help.
Then, start to load the tendon and calf muscle complex to tolerance! More recent research has shown that the type of muscle contraction does not matter as long as loads are progressive. Loading progressions may start with double leg isometric (no movement) calf raise holds in more reactive tendons, and then progress from double leg calf raises to single leg, weighted varieties as healing progresses. Eventually, light plyometric (hopping) exercises can be added in as well.
Do I have to stop running with Achilles pain?
Median recovery time for Achilles tendinopathy in novice runners was found to be about 12 weeks, although this can vary widely depending upon athlete characteristics and underlying degeneration-don’t be surprised by far longer timelines, as tendons may need six months to recover structurally.
Often, in the early going when the tendon is at its most reactive, rest from inciting activity (i.e. running) may be indicated. After the acute stages (and at all points when loading the tendon), the Pain Monitoring Model can be used to guide activity. Under this model, pain levels of 0-2 are considered “safe” during activity, while pain levels up to 5/10 are considered “acceptable”, provided that pain after activity and the following morning do not exceed 5/10, and the pain is not worsening on a weekly basis.
When to see a doctor
Rehabilitation with exercise is the most effective way to treat Achilles tendinopathy, but should symptoms persist or worsen beyond six months or so, see a doctor, as other treatments such as extracorporeal shock wave therapy or injections may need to be considered.
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Medial tibial stress syndrome
Medial tibial stress syndrome (MTSS), commonly called shin splints, is often implicated as the most common running-related injury in novice runners. MTSS refers to pain along the edge(s) of the tibia (shin bone), with associated inflammation of the periosteum, or “covering” of the bone (which serves as the attachment for several deep calf muscles), and microdamage in the underlying cortical bone.
Symptoms include pain along the distal aspect of the tibia with impact activity (i.e. running) that decreases with rest, and associated tenderness to palpation. If not addressed early, MTSS can progress to higher grade bone stress injuries and stress fractures.
Cause of shin splints
MTSS tends to be a classic “too much, too soon” injury, frequently linked with increases in training volume and intensity causing an imbalance between bone microdamage and remodeling. Tension on the bone from muscle actions while running has been implicated. While the link between the ground reaction forces seen while running, tibial load, and injury risk is somewhat unclear, longer stride lengths (which go hand-in-hand with the lower run step rates often seen in beginner runners) have been linked to higher ground reaction forces and loading rates while running.
How to treat shin splints yourself
Management of MTSS mostly involves relative rest from higher impact activities-so, plan to spend more time in the pool and on the bike instead of running while the injury heals. Continuing to run will accelerate bone microdamage, and can lead to higher grade bone stress injuries, including full stress fractures. A trial of orthotics may also be indicated, and icing after activity can help with pain. Strengthening the calf muscles, particularly the ones that attach onto the shin (soleus, tibialis posterior, flexor digitorum longus, tibialis anterior) can help by preventing excessive forces from being transferred to the bone. And while running impact forces have not been conclusively tied to MTSS risk, it still makes sense to adopt a higher step rate to minimize them.
How long does it take shin splits to heal?
In a study of novice runners, median recovery time from MTSS was ten weeks. But this varies with the degree of injury. Early stage MTSS may only require 2-4 weeks away from running, while shin pain that has progressed to higher grade bone stress injuries and fractures may take up to 12-16 weeks to fully heal. As previously mentioned, rest from impact (namely, running) activities is often indicated while recovering.
When to see a doctor
Because of the risk of MTSS progressing to higher grade bone stress injuries, athletes should consider seeing a doctor if pain begins to localize to a more specific point on the bone. MTSS technically involves tenderness along a 5cm span along the bone; more advanced stress reactions and fractures will tend to be most tender within the radius of about a quarter, and pain will become more predictable (won’t “warm up” with activity, increases with increased weight bearing, etc). If this becomes the case for you, see a doctor for advanced imaging and a return-to-running prognosis. Also, if symptoms start to involve any sort of pressure in the calf or numbness or tingling in the foot, get checked out, as this can indicate compartment syndrome, which will require medical attention.
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Patellofemoral pain, or PFP for short, is a catch-all term used to describe pain around and underneath the patella (aka, kneecap). Symptoms of PFP typically involve non-specific pain and possibly grinding in the front of the knee that worsens with activities that increase pressure between the kneecap and the underlying femur, such as squatting, high resistance cycling, pushing off the wall in swimming, stair climbing, or running, particularly on hills.
Causes of knee pain in new triathletes
While PFP is a common injury among all runners and triathletes, newer athletes may be at particular risk-in some studies, the higher run training volumes and faster paces seen in more experienced athletes have actually been shown to be protective against PFP. Decreased quadriceps and hip strength, delayed gluteus medius activation, and run gait characteristics such as landing with the knee overly extended or increased knee flexion in midstance have all been linked to PFP – all of which tend to be more common in newer athletes.
Steps to treat knee pain at home
Steps to treat PFP include just that: steps! Mainly, running step rate, or cadence. Increasing running cadence by 5-10% has been found to decrease patellofemoral joint forces by significant amounts, and thus serves as an immediate, effective intervention. Avoiding excessive hill running is also a good idea.
On the bike, raising the seat height slightly, adopting a higher cadence, and laying off of high tension climbing can also help. Otherwise, strengthening programs focused on the lateral hip, core, and quadriceps and knee musculature have been shown to be effective in the treatment of PFP. Some athletes also may find that soft tissue work on the quadriceps, such as foam rolling or stretching, or kinesiotaping provide relief. In daily life, try to avoid provocative activities, such as deep squatting.
How long does it take for knee pain to go away?
Recovery times for PFP depend on several factors, including initial pain levels, and duration of symptoms prior to interventions. As previously mentioned, gait retraining methods to increase run cadence can provide immediate relief, while strengthening programs may take 4-8 weeks to start making a difference. Complete rest is rarely needed for PFP – symptoms that are stable and low-level (think of the Pain Monitoring Model) can often be trained through, as long as care is taken to avoid the most provocative (high tension cycling, hill running, etc) activities.
When to see a doctor
Appropriate exercise and gait and equipment modifications effectively treat most cases of PFP, and advanced medical intervention is not often necessary. But, if symptoms of joint damage are involved, such as cracking, catching, giving way, or noticeable swelling in the knee, further evaluation is warranted.
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Low back pain
Low back pain is extremely common, with up to 80% of the population experiencing episodes at some point in their lives. Many different etiologies of lower back pain exist, ranging from muscular strains, to lumbar disc disorders, to spinal stenosis, to sacroiliac joint dysfunction. Typically, though, one specific cause cannot be found, and degenerative findings on MRI are common in both symptomatic and asymptomatic individuals.
Symptoms are also variable. In triathletes, low back pain is most frequently associated with cycling, with the bike to run transition (when the back moves from a flexed, non-weight bearing position to an extended weight bearing on) representing another vulnerable point. Pain may be localized, or it can radiate down one or both legs, possibly with weakness, numbness, or tingling as well.
Why does my back hurt?
The lumbar spine requires deep spinal stability and trunk muscle control and endurance in order to protect it from pain, which might not be fully developed in newer triathletes. Both swimming and running require force generation and linkage across the lower back, and cycling places the lower back into prolonged flexion, which makes it more vulnerable. Bike fit can also be implicated, as many athletes adopt an “aero is everything” mentality, and ride in positions beyond the limits of their flexibility.
How to treat back pain at home
The aforementioned bike fit is a good place to start with lower back pain – get fitted by a qualified professional, making sure that you have adequate posterior chain flexibility to handle your position.
Otherwise, again, look to strengthening and stabilization. The “right” exercises can be individual, and depending on underlying issues, specialized approaches such as the McKenzie method may be indicated. In general, though, most lower back pain benefits from spinal stabilization programs that focus on both the local muscles that attach directly onto the spine and provide stability, as well as the global trunk muscles that move the trunk and spine. Specific exercise options are vast, but should begin with learning how to contract the deep spinal stabilizers while adding challenges with arm or leg movement (think dead bugs or bird dogs), progressing to exercises in more functional positions (planks, half kneeling or standing), as well as exercises that challenge rotational stability and involve movement. And don’t neglect heavy lifting when able, as large movements (squats, deadlifts, etc) are also highly effective in activating spinal muscles.
How long does it take for low back pain to heal?
Unfortunately, with low back pain, this question has no clear answer. Because the presentation and underlying issues involved in lower back pain are so vast, so are timelines. Except for rare exceptions, though, the solution for lower back pain is almost never complete rest. A temporary period of time away from the most provocative activity (swim/bike/run) might be needed, but activity to tolerance, even if it’s going for a walk around the block, is encouraged.
When to see a doctor
Some causes of lower back pain are more serious, particularly those that indicate spinal cord or spinal nerve involvement, and should involve medical intervention. Any changes in bowel or bladder control require immediate medical attention. Otherwise, the further away from the spine that symptoms travel, the more important seeing a doctor becomes. Don’t hesitate to schedule an appointment if symptoms of nerve compression develop or worsen, such as leg weakness, or increasing pain, numbness, or tingling in the lower extremities.
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Although swimming is generally thought of as the “safest” triathlon discipline, the repetitive overhead motion can cause shoulder pain and microtrauma to develop. Like with PFP, “swimmer’s shoulder” is a catch-all term that encapsulates a variety of underlying disorders, such as rotator cuff impingement and tendinopathies, labral tears, laxity, and neuropathy. The rotator cuff, which consists of four muscles that originate on the scapula (shoulder blade) and attach on the front of the shoulder is commonly implicated, as these muscles play important roles in counteracting the forces of larger muscles to keep the ball of the shoulder joint centered in the socket throughout the swim stroke. They also assist in rotating and raising the arm.
Symptoms typically include pain in the front or top of the shoulder with overhead movements or throughout the catch phase of the swim stroke, that can refer down throughout the upper arm.
Causes of swimmer’s shoulder
The shoulder joint does not possess much inherent stability, and some athletes naturally have more laxity within it as well. If the powerful propulsive actions of the lats and pecs are not balanced by a stable scapula and strong rotator cuff, the cuff tendons and other structures can get pinched (impinged) beneath the bony arch above the shoulder, causing pain. Newer triathletes who quickly ramp up training yardage without adequate cuff and scapular strength are prone to these issues.
Additionally, certain swim stroke deviations common in newer athletes, such as a narrow hand entry, or entering thumb first create more impingement within the shoulder. Weight bearing through the arms in a narrow TT bike position can also tighten up the front of the shoulder, and predispose triathletes to subsequent issues in the water.
How to treat swimmer’s shoulder
If possible, have someone film your swim stroke, and check to make sure that your hand is entering the water in front of the shoulder (not crossed over midline), and not thumb first. Fins may be a useful adjunct to take some pressure off of the shoulders at times. On the bike, consider moving aerobar elbow pads slightly wider if shoulder pain is an issue-although it might run counter to some triathletes’ beliefs, the slight aero penalty is worth being able to swim train!
Exercise-wise, focus on a program that strengthens the rotator cuff, scapular stabilizers (particularly the middle and lower trapezius and serratus anterior), and core. Stretching the lats and front of the chest (pecs) can also be useful. In day-to-day life, watch posture (try not to spend too much time slumped with the shoulders forward), and limit overhead movement if possible while healing.
How long does the recovery process take?
Depending on the underlying pathology and degree of damage, recovery times vary. Acute irritation may need 4-8 weeks to calm down, while more advanced tendinopathies can need six months to remodel. During this time, the Pain Monitoring Model can be used to determine whether or not swimming can be continued, and to what extent.
When to see a doctor
As with any injury, if pain is persisting or worsening for several months, consider seeing a doctor, as interventions such as imaging or injections might be indicated. Additionally, if mechanical symptoms (catching, locking) develop, make an appointment, as this can indicate internal shoulder joint damage. Also, get checked out for any nerve symptoms (pain that extends past the elbow, numbness, tingling) that could suggest neck involvement.
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Jennie Hansen is a physical therapist, Ironman champion, and USAT Level 1 triathlon coach with QT2 systems. Hansen has a background as a collegiate and professional runner, as well as a number of professional triathlon podiums. She has been in the sport for over a decade.