Triathlon : medical considerations

1. Triathlon: medical considerations Dr Tom Cross FACSP,MBBS,DCH

2. Outline of talk • Introductory concepts • Musculo-skeletal Injuries • Illness/Medical conditions • Conclusion

3. Introduction • Triathlon started in California in 1970’s • Sport began in Australia in early 1980’s • International sport: more than 120 nations • Olympic sport since 2000 Sydney games • 160,000 Australians compete • 180 Tri clubs in Australia • National and State Federations

4. Australian Success • Greg Welch • Michellie Jones • Chris McCormack • Emma Moffatt • Craig Alexander • Emma Snowsill • Miranda Carfrae

5. 3 Disciplines • Swim-Bike-Run • Competitors: recreational and elite/pro series • Athletes often very successful in other sports • Differing Distances • Sprint 750/20/5 • Olympic 1.5/40/10 • Half Iron Man 1.9/90.1/21.1 • Iron Man 3.8/180.2/42.2

6. Medical Team • Physiotherapist • Soft tissue therapist • Chiropractor/Osteopath • Doctor • Nurse • Dietician • Podiatrist • Bike Mechanic • Biomechanist • St John’s Ambulance

7. Injuries and Illness • Musculoskeletal (MSK) injuries • Acute • Overuse • Illness • Dehydration/Heat Illness • Hypothermia • Water Intoxication • Cardiovascular • Female athlete triad • Overtraining Syndrome/Fatigue • Infectious Disease

8. Injuries • Sport specific injuries • Discipline specific • Swimming • Cycling • Running: causes most injuries Paucity of Evidence Based Medicine regarding Injuries!

9. Injuries • Swimming • Shoulder • Rotator cuff tendinopathy • Common causes • Training error • Technique flaw • Dropping the elbow • Insufficient body roll • Unidirectional breathing • Pull through phase • Using paddles and pool buoys • Prevention • Correct technique flaws • Periodize training • Theraband exercises/gym training/stretching programme • Scientific approach to training

10. Injuries • Cycling • Acute • Falls • Head and Spine • Shoulder girdle (fractures/dislocations) • Abrasions/lacerations • Prevention • Familiarize self with course • Helmet • Exercise caution • Overuse • Spine (neck, thoracic, low back) • Knee –patellofemoralpain,ITB friction syndrome • Pressure neuropathies (wrist ,perineum) • Prevention • Bike set up • Core Stability on Bike • Scientific approach to training

11. Injuries • Running • Acute • Muscle strain injury • Muscle cramping • Joint sprains (ankle,knee etc) • Overuse • Tendinopathy (achilles,patellar etc) • Stress Fractures (foot, tibia, femur etc) • Myofascial pain e.g. Plantar fasciitis

12. Injuries • Running overuse injuries • Causes • Training Error (volume, frequency, intensity, surfaces) • Biomechanics (alignment, running efficiency) • New coach/club/training group • Footwear • Poor Bone health • Inadequate warm up/cool down, stretching, massage • Prevention • Scientific approach to training • Podiatry • Optimize running technique • Optimize Bone health • Recovery strategies

13. Illness • Thermal stress • Heat illness/dehydration • Hypothermia • Water Intoxication • Cardiovascular • Female athlete triad • Overtraining syndrome • Infection

14. Illness • Heat Illness/Dehydration • Wet bulb globe temperature: measure of thermal stress • Risk factors • Individual susceptibility • Recent illness • Inadequate fluid intake • Sleep deprivation/jet lag • Failure to acclimatize • Clothing • Medications (amphetamines, alcohol) • Prevention • Hydration • Acclimatize • Clothing choice (high “wicking” factor) • Modify other risk factors

15. Illness • Hypothermia • Swim: most at risk! • Cycling • Prevention • Wetsuit choice • Clothing on bike

16. Illness • Water Intoxication • Fluid and electrolyte disturbance • Drinking yourself to death • Exercise associated Hyponatraemia • Serum sodium <135 mmol/litre • Risk Factors • longer endurance events > 4 hours • Female • Slower runners (more time to drink) • Occurred secondary to perception • Drinking caused performance enhancement • Drinking reduces risk of Dehydration/heat illness • Symptoms • Nausea/vomiting, shortness of breath, confusion, coma and death

17. Illness • Water Intoxication • Prevention • Fewer drinking stations • Education: dangers of over-drinking • Aim to drink 400-800 mls per hour • No difference if water or sports drinks or take salt tablets • Medications: avoid Anti-inflammatories

18. Illness • Cardiovascular • Recreational • Sudden cardiac death • <35 Congenital heart disease • >35 Coronary artery disease • Elite/Pro Triathletes • Pathological variant of Athlete’s heart: Cardiomyopathy: conduction disorders/arrhythmias • Greg Welch: “ventricular tachycardia” requiring an implantable defibrillator

19. Illness • The Female Athlete Triad • Disordered eating (much more common in elite athletic women than normal population) • EDNOS, Anorexia,Bulimia • Menstrual disturbance (Caloric restriction + Intensive exercise) • Amenorrhea, Oligomenorrhoea, luteal phase defects • Poor Bone heath (inadequate estrogen) • Osteopenia, Osteoporosis: Increased risk of STRESS FRACTURES and OSTEOPOROSIS in later life! • At risk sports • Endurance (running, triathlon) • Aesthetic (gymnastics, diving, figure skating, synchronized swimming) • Weight divisions (Martial arts) • Bone health • Accrual occurs in teenage/early 20’s • Peak Bone mass by 25-30 • Can assess with BMD testing (Anthropometric assessment) • Bone mineral density deficit only partially reversible

20. Illness • Female Athlete Triad • Treatment • Multi-disciplinary • Treat the disordered eating and compulsive exercise • Aim to restore menstrual cycle, if not use OCP • Use of Calcium and Vit D supplementation • Prevention • Educate female athletes • Screening of athletes: identify at risk athletic women

21. Illness • Overtraining syndrome/Fatigue • Definition: continued fatigue after 2 weeks of rest. • Causes • Excessive exercise TRAINING ERROR • Over-crowded lifestyle/Time poor individual (Psycho-social stressors) • Poor nutrition: “running on empty” ! • Inadequate recovery from viral illness • Sympathetic nervous system exhaustion ! • Symptoms • Training and performance decrement • Increased perceived level of exertion • Increased muscle soreness • Exclude other causes of fatigue • Iron deficiency • Other Nutritional deficiencies (COH, Dehydration etc) • Depression • Disordered eating • Other medical causes (Cardiac, respiratory, endocrine etc)

22. Illness • OTS/Fatigue • Treatment • Relative rest • Simplify lifestyle/minimize stressors • Optimize diet/recovery strategies/meditation • Prevention • Periodize training (micro/macro cycles) • Monitor symptoms (energy, mood, muscle soreness, sleep quality etc) • Optimize diet/recovery strategies

23. Illness • Infection • Exercise and Immunity • Inverted “U curve” • Moderate exercise improves immune function (<60% of VO2 max) • Excessive/intensive exercise (>80% VO2 max) causes a transient depression of immunity: The “open window” theory • Decrease in mucosal immunity • Decrease in cellular function • Micro-organisms get the “upper hand” !

24. Illness • Infection • Can I train when I am sick? • Do a “neck check”! • Symptoms above the neck? (sore throat/running nose) • Either train at 50% of usual intensity/duration • Wait until symptoms resolve and recommence usual training • Symptoms above and below neck (fever, cough, muscle soreness, nausea etc) • Wait until symptoms resolve and then wait a further 2 days and then slowly recommence training

25. Illness • Infection • Prevention • Immunization (Routine + Hep A/B, Influenza, meningococcal ) • Periodize training • Optimize diet/recovery strategies • Universal precautions while traveling (e.g. sharing drink bottles etc.) • Increased risk with adverse environmental conditions (cold and heat stress) • Avoid/isolate sick athletes • Supplements: Lactobacillus Yogurt, Echinacea, Multivitamins

26. Concluding remarks • Beware “Drugs in sport” • If concerned check WADA website • Seek medical screening (Doctor/Physiotherapist) if concerned about past medical history &/or injury history • Report injury/illness early! • Educate yourself about Periodization of training and practice other PREVENTATIVE strategies to prevent both injury and illness!!

27. Thank you