OVERTRAINING - NJ Sports Med

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Transcript OVERTRAINING - NJ Sports Med

The Multisport Athlete: Risks, Injury & Prevention

Marc Silberman, M.D.

Gillette, NJ

Disclosure

I declare no conflict of interests I do not have any financial disclosures

Objectives

1. Identify the riskiest portions of the triathlon for the athlete and medical director 2. Name the most common locations of injuries and disciplines that cause them 3. Teach common injury preventative strategies to multisport athletes for each discipline

Introduction

You don’t know Bo

The Multisport Athlete

• Participates in more than one sport • Swim + Bike + Run = Triathlon – Former runners > swimmers > cyclists • Swim + Bike = Aquavelo – Former triathletes with arthritis/joint replacements • Bike + Run = Duathlon • Triathlete who competes in Swimming races, Cycling races, and/or Running races

Medical Preparation for Triathlon

• Hyperthermia/hypothermia • Gastrointestinal problems, GI bleed • Dehydration/hypovolemia • Fluid/electrolyte imbalance/Hyponatremia • Bronchospasm, Anaphylaxis • Exercise Associated Collapse, Exhaustion • Cardiac arrythmias • Pneumothorax • Drowning/near drowning • Closed head injury / C spine injury • Road rash, sun burn, abrasions, blisters • Stings, bites • Musculoskeletal trauma, cramping

Medical Personnel

Personnel

Medical Director Additional physician Nurses Massage Personnel

Recommendation

Physician experience in events 1 / 200, with minimum of 2 1 / 100 Adequate to serve race population

Dallam et al. “Medical Considerations in Triathlon Competition. Recommendations for Triathlon Organizers, Competitors, and Coaches.” Sports Med 2005; 35 (2): 143-161.

Incidence of Triathlon Injuries

• NO CONSENSUS DEFINITION OF INJURY • The strongest correlate with overuse injury in triathletes is previous injury occurrence • 37% to 91% of triathletes surveyed (Burns, O’toole) • 75% to 83% training injuries (Cipriani, Wilk, Ireland) • 8% to 28% competition injuries (Wilk, Ireland) • 17.4 injuries / 1000 h of competition (Korkia) • .7 – 5.4 injuries / 1000 h of training (Burns, Korkia) • You can bend statistics any way you want

Injury Rates

• Do multisport athletes sustain less injuries as a result of ‘cross training’?

• Greater than those observed in athletes who participated in only swimming, cycling, or running (Levy) • Similar to rates observed in runners (Burns, Korkia) • Overuse injuries are the most common (Korkia, O’Toole) • Running and cycling more commonly associated with injuries than swimming – Is this due to increased risk? Or increased exposure time?

Site of Injuries

• Most common lower limb (36 - 85%) (Williams, Ireland) – Knee 14 - 63% (Vleck, O’Toole) – Ankle 9 - 35% (Manninen, Egerman) • Back 72% (O’Toole) • Shoulder 19% (Egerman) • Literature lacks specificity of these injuries

Severity of Injuries

• Vleck (retrospective) – 17% injuries stop swimming – 26-75% stop cycling – 42-67% stop running • Korkia (prospective) – 21% – 37% – 78% – 16% – 17% injuries stop swimming stop cycling stop running stop all 3 missed competition

Severity of Injuries

• Time lost by club level athletes (Vleck) – 13 +- 58 days of swimming – 21 +- 65 days of cycling – 71 +- 174 days of running • Duration of lost time less for elite

The Science or Lack of

Triathlon related musculoskeletal injuries: The status of injury prevention knowledge (Gosling 2007) •

There is no consensus definition of injury

• Retrospective recall of injury information • Recall periods greater than one year • Failure to validate the self reporting of injury of diagnosis • Inability to differentiate injury sustained in training or competition • Confounding multiple or recurrent injuries • Selection biases • Exclusion of traumatic injuries • • Mixed race distance/type and athlete demographics • Nature of injury is misrepresented

Summary: Lack of quality, prospective studies

Medicine is more art than science

The Triathlon

1. Swim 2. T1 3. Bike 4. T2 5. Run 6. Nutrition

The Triathlon

Name

Sprint Olympic / 5150 (International) ITU Long Half / 70.3

Full / 140.6

Swim

0.5 mile 750 m

Distances

Bike

12.4 mile 20 km 0.93 mile 1.5 km 1.86 mile 3 km 1.2 mile 1.9 km 2.4 mile 3.8 km 24.8 mile 40 km 49.6 mile 80 km 56 mile 90 km 112 mile 180 km

Run

3.1 mile 5 km 6.2 mile 10 km 12.4 mile 20 km 13.1 mile 21.09 km 26.2 mile 42.195 km

The Swim

The Swim Risks

• Collisions, incidental and purposeful • Tympanic Membrane perforation • Drowning / Near Drowning • Panic Attack / Anxiety • Cramping • Hypothermia/Hyperthermia • Sudden Cardiac Death • Infections

The Water

• Temperature • Weather • Body of water • Swim course organization

Water Temperature

• Single most significant variable • Acceptable range 25.5 – 28 degrees celsius – (77.9 F to 83.8 F) • Gradient for heat loss exceeds that for exercise in the air • Triathlete body composition is the leanest in competitive sport • Risk of hyperthermia magnified by lack of fluid intake, exertion, and wet suits

Wetsuit Guidelines

Water Temp C

<= 13 14 <= 15 <= 16 13-22

ITU Guidelines Distance

All distances <= 2000m 2000-3000m 3000-4000m All distances

Guide

Cancel Wetsuit mandatory Wetsuit mandatory Wetsuit mandatory Allow wetsuits USA Triathlon allows elite to use wetsuit up to 25.5 Celsius (77.9) WTC Prohibit wetsuits in temps greater than 28.8 C (83.8F) WTC Allows wetsuits in temps up to and including 24.5 C (76.1 F)

Course Organization

• Large, visible buoys 100m apart • Rolling or wave starts safer than mass start • USAT 150 / wave at 3 minute intervals • Separate novice category • Triathlon Canada 400 / wave • USAT One lifeguard / 50 in non-ocean • USAT One lifeguard / 35 in ocean • Triathlon Canada one lifeguard / 25

Athlete Swim Preparation

• Practice open water swimming • Be prepared to swim without a wetsuit • Beginner should have a mentor for anxiety • Know the course, conditions, entry, exit • Swim technique coach • Learning balance is the most important lesson • Good shoulder, scapula, back, and core

Swimmer’s Shoulder Prevention

No Money Ball on wall Push up plus USA Swimming Task Force YTWL Dead Bug

T1

The Bike

Road vs. Time Trial Position

Plumb bob falls over pedal spindle and 1 st metatarsal Steeper Seat Tube More Forward Position Higher Saddle

The Bike Elements

• Water Temperature – Hypothermia, Hyperthermia, Dehydration • Environment weather and temperature • Sun exposure • Nutrition – GI distress, hyponatremia • Crashes – Cycling Course, drafting or non-drafting – Bike equipment – Fatigue

The Bike

The Bike Feed Station

Knee Pain

• Anterior Knee Pain – Patella Femoral Pain Syndrome – Chondromalacia patella – Cartilage lesion – Patella tendonopathy – Pre-patellar bursitis • Lateral Knee Pain – Iliotibial Band Syndrome – Biceps Femoris tendonopathy • Medial Knee Pain – MCL bursitis – Medial plica syndrome – Pes Anserine Syndrome – Medial meniscus tear

Athlete Bike Preparation

• Practice swim - bike • Get a bike fit • Train on your race bike • Practice your nutrition strategy in training • Longer races, consider added sodium • Train the distance • Know the course

Knee and back pain prevention

•

Listen to your body not your coach or training program

• Training rest days, easy days, cycles • Caution with brick work outs • Get a bike fit • • Regular massage, manual therapy, chiropractic

At the first sign, swim

T2

The Run

• 85% of medical problems during long distance races occur on the run or finish • Exhaustion, dehydration, postural hypotension, blisters, muscle cramping • GI Distress • Hyponatremia (long races) • Hyperthermia (short races)

The Run

• Dehydrated and fatigued • Hottest portion of the day • Elevated body temp, low plasma volume • Unable to consume fluids (shorter) • Elite competitors run at 90% of VO2 max • Drink to much (longer) • Hyponatremia (10-40%) in long distance with no symptoms

The Run

The Run Risk Factors

• The distance (run shorter, walk longer) • Ambient temperature and humidity • The nature and design of the course • Provision of fluids • UV Radiation

The Run GI Distress

• 30% of high performance athletes • Pain, bloating, N/V/D, GERD, ischemic gastritis, Cecal slap syndrome, GI bleeding • Endotoxins, cytokines (Jeukendrup) • French Triathletes (Lopez 1989) – Nausea, pain, vomitting 8.9% – Diarrhea, pain 8%

Athlete Run Preparation

• Listen to your body in training • Practice brick workouts (but be careful) • Running technique – Stability and alignment • Heat acclimatize • Strengthen abductors and adductors • Practice your race day nutrition plan • Take a break from run training after races

Studies

Overuse Injury in Iron-Distance Training • 26 week prospective cohort 2011 Norseman Xtreme Triathlon (n=274, 174 participated) • OSTRC shoulder, lower back, thigh, knee, and lower leg • 11.1 hours / week training • 1.4 hours / week swimming (12% time) • 5.8 hours / week cycling (58% time) • 2.9 hours / week running (24% time) • 16% weights, skiing, other Anderson 2013

The Norseman

• If you do the race, you will probably tell your friends afterwards that Norseman was more beautiful, demanding, personal, camaraderie, frightening, and to reach the finish line was a greater victory and joy than any other race you have ever done. You will probably tell your friends that everybody should do the race once in their lifetime. • If, on the other hand, a friend told you this story, then it is time to warn you. During the Norseman, you will probably be cold, you will hate the hills, sometimes you will feel lonely and you will probably experience being unusually emotional during the weekend.

Nxtri.com

Norseman

Water temp 13-15 degrees C (55 – 59 F)

Norseman Bike Course

Norseman Run Course

Overuse Injury in Iron-Distance Training • Average prevalence of overuse injury 56% • Average prevalence of substantial injury 20% • 87% reported some form of overuse problem • Shoulder problems 42% of the time • Knee problems 44% of the time • Lower back problems 46% of the time • Lower leg problems 27% of the time • Thigh problems 34% of the time Anderson 2013

Acute Injury in Iron-Distance Training • 41 acute injuries out of 174 athletes • Contusions 17%, Fracture 10%, Sprains 10% • 22% from alternative training (weights, etc) • Vast majority were bike accidents (25 injuries sustained by 12 athletes) • Zero acute swim injuries • Only 3 acute running injuries (ankle sprain, thigh strain, pelvis contusion from a fall) Anderson 2013

Illness in Iron-Distance Training

• 156 cases of illness reported • 104 athletes affected (60%) • 9% no time loss • 34% 1-3 days loss • 36% 4-7 days loss • 19% 8-28 days loss • 3% more than 28 days • Lower than team sports, similar to individual sports Anderson 2013

Norseman Finish Line

Knee Injury in Triathletes

• Closed ended, oral, questionnaire of 58 athletes at a triathlon event • Recall 1994-1997, 46 men, 12 women • Injury had to cause the athlete to reduce, or refrain from, training for at least 2 days • No knee injuries in swimming • 22% in cycling • 72% in running • 6 % felt to be from both • Similar to studies by Cipriani and Massimino Clements et al

Location of Knee Injury

Location

Lateral Medial Anterior Anterior Lateral Medial Lateral Posterior 0 0 0 0 0

Swim

0 Values are percentages

Cycle

5.5

0 5.5

Run

33.3

16.6

11.1

0 0 0 0 0

Cycle+Run

0 5.5

0 Clements et al

Knee Injury in Triathletes

• Highest number of injuries observed in athletes who ran on a mixture of terrains (10/20) • The group who trained solely on roads accounted for 25% of the injured • Further research needed Clements et al

Injury in British Triathletes

• Prospective questionnaire of 155 athletes over 8 weeks during the competitive season • Injury was defined as an event that ended a training session or race and caused the athlete to rest the day after – Minor 7 days or less – Moderate 8 – 21 days – Severe over 21 days Korkia

Injury in British Triathletes

• Limited by self assessment of injuries • 37% sustained at least one injury – 27% ankle/foot – 20% thigh – 19% knee – 16% lower leg – 14% back Korkia 1994

Injury in British Triathletes

• Self classified as – 41% overuse – 27% ‘other’ ?????

– 12% twist or turn – 10% contact / collision – 9% overstretching • 65% during running • 16% during cycling • 12% during swimming Korkia 1994

Injury in British Triathletes

• 84% minor 7 days or less • 13% moderate 8 – 21 days • 3% severe more than 21 days • 78% stop running • 37% stop cycling • 21% stop swimming • 16% stop all three • 33% stop cycling and running • 18% swimming and running • 16% swimming and cycling Korkia 1994

Injury in British Triathletes

• No association between incidence of injury – amount of training – training intensity – running surface – increase in training load – strength training, warm up, cool down, stretching • Rate of injury increased with experience – 45% with over than 4 years – 33% between 2 to 3 years – 14% trained less than one year Korkia 1994

Injury in British Triathletes

• Athletes who sustained an injury in the previous year were more likely to sustain an injury during the 8 week study • 65% of athletes who sustained an injury in the past year, sustained an injury in the same site during the study • 45% of athletes who sustained an injury in the past year, sustained an injury in a different site during the study Korkia 1994

Low back pain and Injuries in Japanese Triathletes

• Questionnaire of 92 athletes in different clubs, 6 smoked cigarretes, 63% age 26 - 35 • Training for 4 years • Swim 29% time • Bike 38% time • Run 33% time • 57% training for half or full distance • 27% were former runners • 12 % were former swimmers • 4% were former cyclists Manninen 1994

Low back pain and Injuries in Japanese Triathletes

• 37% experienced low back pain • Age 23.7 was average age of onset • 51% began for ‘no reason’ • 54% lasted less than 7 days • 27% lasted one week to 3 months • 19% more than 3 months • 74% associated pain with cycling • 45% associated pain with weight training • 43% associated pain with running Manninen

Low back pain and Injuries in Japanese Triathletes

• Back pain was associated with – Greater weekly trunk flexor muscle training – Incidence of back pain in the previous year – Greater cycling time, training load, weight lifting Manninen

Overuse Injuries in Japanese Triathletes

• No definition of injury was given • 72% sustained one injury in the previous year • 30% sustained 2 injuries, 14% 3 or more • 61% lower limb, 54% of those in the knee • 8% upper limb, all shoulder, all from swim • Reasons given by athletes: overtraining, run technique, inadequate stretching, hard running surface Manninen

Back pain in Japanese Triathletes

• While running causes the most overuse injuries, it may not be the primary cause of low back pain • Cycling felt to be the key component predisposing to low back pain • Sitting in a flexed position for prolong length of time • Change from “off” load to “on” load weight bearing (Migliorini) • Muscle activity changes from concentric (cycling) to eccentric (running) • Postulated time lag exists before neuromuscular and elastic efficiency can reach optimal level at start of run Manninen

References

• • • • • • Andersen CA, Clarsen B, Johansen TV, et al. “High prevalence of overuse injury among iron-distance triathletes.”

Br J Sports Med

2013;

:857-861.

Bales et al. “Training on a Knife’s Edge: How to Balance Triathlon Training to Prevent Overuse Injuries.”

Sports medicine and arthroscopy review

20.4 (2012): 214-216.

Dallam et al. “Medical Considerations in Triathlon Competition. Recommendations for Triathlon Organizers, Competitors, and Coaches.” Sports Med 2005; 35 (2): 143-161.

Gosling et al., “The Perception of injury risk and safety in triathlon competition: an exploratory focus group study.”

Clinical Journal of Sport Medicine

23.1 (2013): 70-73.

Migliorini S. “Risk factors and injury mechanism in Triathlon.”

Journal of Human Sport and Exercise

2011; Volume 6, Issue 2.

Vleck V et al. “Triathlon Injury-An update.”

Schweizerische Zeitschrift fur Sportmedizin und Sporttraumatologie

61.3 (2013): 10-16.

newjerseytriathloncoach.com

Marc Silberman, M.D. [email protected]