Training on a Knifes Edge

Great article fome Sports Medicine and Arthroscopy Review, December 2012 - Volume 20 - Issue 4 - p 214–216 With the need to train in 3 different disciplines, many triathletes walk a so-called “knife’s edge.” They must try to balance ideal training to maintain optimal fitness in 3 sports at the best of their abilities, versus risking an overuse injury and not being able to race, finish, or even participate in a triathlon.1,2,3,4An overuse injury is a damaged tissue that occurs so gradually that the triathlete often can not remember the exact onset.5 The damage is the result of a series of repetitive microtraumatic events that is too much for the tissue to repair itself before it is required to perform again.5 Over time, this constant breakdown without a corresponding recovery and repair period can overwhelm tendon, cartilage, bone, or muscle and lead to an overuse injury.5The initial treatment for most overuse injuries is to temporarily stop training or reduce training mileage, take medication, and seek medical aid.3,5,6 Follow-up treatment and prevention should focus on correcting training errors, strengthening tissues, and evaluating volume and/or intensity devoted to each discipline.3,5,6 From the beginner to the elite, all triathletes can place themselves at risk for overuse injuries. One study identified the risk of overuse injury increasing as the volume increased in Olympic distance triathletes and as intensity increased in Ironman distance triathletes.4One advantage of the sport of triathlon is the triathlete’s ability to rebalance training volume and intensity over 3 separate sports.3 Many triathletes, over the course of a season, suffer an overuse injury in 1 discipline, but they may be able to avoid aggravating the injured tissue by switching their focus to the other 2 disciplines. Thus, they have the potential opportunity to avoid significant loss in cardiovascular fitness.3It is not uncommon to find injured triathletes logging extra yardage in the pool while they rest and rehabilitate overuse injuries they might have sustained running or cycling. In fact, the senior author of this article, also a professional/elite triathlete, can attest to triathletes who are required by sponsorship obligations to race at specific venues and commonly race with minor overuse injuries throughout the entire season. Some even manage to perform quite well, despite limited ability to train a specific discipline outside of race day. This approach is not recommended for the amateur triathlete as it can lead to further injury, frustration, and burn out in the sport.2 Back to Top | Article Outline DISCUSSION The sport of modern triathlon consisting of swimming, biking, and running segments was first raced in September, 1974 in Mission Bay, San Diego, CA by members of the San Diego Track Club.7 The first Ironman distance race was the Hawaiian Ironman Triathlon held on February 18, 1978.7 Triathlon has continued to grow significantly since its founding. It now includes thousands of races with millions of competitors worldwide each year. In 2010, USA Triathlon boasted a membership of >150,000, and worldwide an estimated 2.3 million unique individuals completed a triathlon in 2010.8 Many runners, cyclists, and swimmers began their triathlon career after an injury in their primary sport derailed their training, and they logged a significant amount of time in another discipline. Some athletes stick to the sport of triathlon because the training is spread over 3 separate disciplines, and they can adjust their training to suit their lifestyle needs.Part of triathlon training is becoming accustomed to changing the discipline with each workout or even within a given workout. Triathletes often perform elements of training in multiple disciplines in any given day. For example, this may require a triathlete swim in the morning and cycle and run in the evening, thus performing each of 3 disciples within a 24-hour period. The ease by which a triathlete is able to mix the 3 sports is met with the ever present need to maintain fitness across 3 disciplines. Because of the spread between the 3 sports, many triathletes have an overall training volume and/or intensity that are higher than single-sport athletes.9,10 One study looking at increased volume and intensity in cycling and running found that it may have a “cumulative stress,” with triathletes having a higher risk of recurrence and a longer rehabilitation. However, there was not the same “cumulative stress” when the increased load was shifted to swimming.4Generally, triathlon training programs have the same aim as a regime focused only on swimming, cycling, or running. The goal in endurance sports is to stress the musculoskeletal system to the point of fatigue, with the idea that after a period of recovery, the muscles and tendons will adapt by becoming stronger, bigger, and more fatigue resistant.5 In triathlon, unlike the focus in a single sport, the triathlete has the ability to stress the cardiovascular system in 3 disciplines, with swimming not adding to overstress of the musculoskeletal system.4 For example, a triathlete may swim hard in the morning, and then be able to relatively rest the upper body while stressing the legs in a cycling practice in the evening. Of note, the heart also gets stressed differently with different disciplines. Research on myocardial adaptation in endurance athletes has shown that athletes have sport-specific left ventricular adaptation.11 The heart of a triathlete and the heart of a cyclist have been shown to differ significantly from a marathoner’s heart.11 Specifically, left ventricular mass was higher in triathletes than marathoners, and left ventricular wall stress was lower in triathletes than marathoners.11As is the case for single-sport athletes if the training is not structured and balanced appropriately, a musculoskeletal system that is unable to completely recover from the stresses of training could lead to an overuse injury. The symptoms of fatigue and the inability to recover from a workout or race are commonly lumped into the term “overtraining.” Overtraining can precede and signify the need for increased rest and recovery.5 Specifically in triathlon, a history of high running mileage, previous injury, inadequate warming-up and cooling-down regimes, and increasing years of experience appear to have individual associations with injury incidence.1Swimming and cycling have been shown to have a significantly lower injury rate per 1000 training hours when compared to running.1 During the competitive season the volume of running mileage has been shown to be the most significant predictor of injury.1 Again, to emphasize that triathletes are not immune from overuse injuries, in 1 survey of 72 amateur triathletes, 75% of them reported sustaining triathlon-related overuse musculoskeletal injuries during a competitive season.12In another study, the incidence of triathlon overuse injury was reported based on training hours, showing 2.5 per 1000 training hours in the preseason and 4.6 per 1000 training hours during the competition season.1 This is similar to running injuries, which have been reported in the literature to have an incidence varying between 2.5 to 12.1 injuries per 1000 hours of running.13 A more recent study looked at all injuries (traumatic and overuse) sustained during triathlon competition and found it to be 20.1 per 1000 hours of competition. They also found that the injuries were predominantly sustained during the run (38.4%) and cycling (14.3%) disciplines. Lower limb injuries accounted for 59.5% of all injuries. The competitors at highest risk of injury were elite/junior elite, Olympic distance, and 12- to 19-year-olds.14 Back to Top | Article Outline Symptoms/Factors of Overtraining The key to avoiding a potential season ending overuse injury is to identify the symptoms early and make appropriate training adjustments.5 With overtraining, a triathlete may continue to feel fatigued despite what would normally be an adequate period of rest.5 Besides fatigue, other symptoms may signify the onset of overtraining including: irritability, increased resting heart rate, poor sleep, frequent illness, depressed mood, and decreased performance.5There are several recognized physical and psychological factors that contribute to overtraining. Although every triathlete is different in his/her ability to handle increases in training volume and intensity, some authors advocate a starting place for many is to avoid increasing volume or intensity by >10% per week.15 For most triathletes, increases of >10% a week are thought to pose too high a physical stress to appropriately recover from.15 With the need to maintain proficiency across 3 sports, this can be a challenging rule for many triathletes to abide by. Many triathletes feel the need to train because they enjoy the β-endorphin and corticotropin-releasing hormone increase linked to endurance sports and resulting in positive mood changes.16 In addition, other triathletes may be motivated to train by general physical bodily adaptations such as weight loss and increased muscular tone. They may feel if a little more is good, a lot more is better, and they further increase their training volume and/or intensity. Finally, it is common to see beginner triathletes so excited to start their new training program that they go all out without any restraint in their training, doing too much too soon. As many North American Ironman distance triathlons require registration a year or more in advance of the race, the authors have seen it commonplace that a beginner triathlete sign up for that race and then, in his/her excitement increase volume and intensity too rapidly.In 2009, USA Triathlon sanctioned research on all of its annual members showing that the average income of a USA Triathlon member was $126,000 with a very high percentage of professional workers.17 It is possible that the high socioeconomic standing of many triathletes may add into the training mix a dose of long work hours, sleep deprivation, and travel. Combined stresses can quickly overwhelm a triathlete and make them susceptible to overuse injuries. Heaped on top of the physical stress is the additional psychological stresses of school, job, and financial or family pressures. Triathlon is a time-intensive sport with amateur Ironman triathletes spending, on average, 7.7 h/wk training for the cycling portion alone and amateur half Ironman triathletes spending 5.8 h/wk training for the cycling portion alone.18 Pressure to balance life along with maintaining fitness in the 3 disciplines can contribute to the triathlete slipping over the knife’s edge onto the risks of overtraining. Back to Top | Article Outline Management of Overtraining Knowledge of the symptoms and prompt identification of overtraining is the first step to prevention and treatment.5,19 Once the symptoms are identified, cutting back on volume and intensity is required.5 First, recognize the symptoms. In the setting of a poor performance do not make the mistake of pushing harder.5,19,20 Sometimes further training can only compound the problems and lead to an even poorer performance.19,20 Increasing sleep, avoiding dehydration, and maintaining an appropriate diet, all promote muscle fueling and tissue repair and rebuilding.5,19,20Basic science on the musculoskeletal system supports the modification of activities for 3 to 4 weeks after an overuse injury.5 In light of this, some authors advocate the “Rule of Sevens,” ideally suited to multisport training.15 In essence, at the onset of an overuse injury, it is recommended to take 7 days completely off from any aggravating activity, and focus on cross training in the other major muscle groups. If, after 7 days, the athlete is pain free, move into the next 7-day period, which consists of 7 days of slow and easy training while performing the activity that caused the injury. If there is still no pain after 7 days in the second phase, move into the third phase. The third phase consists of a gradual increase in intensity and duration over 7 days. By the end of this 21-day period, the athlete should be ready to train back at full speed and intensity. If, at any point in any 7-day phase the athlete feels any pain, he should back up to the previous phase and extend it as long as necessary.15 Alternatively, the option for complete cessation of activity for 3 to 4 weeks can be followed.5 It is likely, however, that the latter treatment may lead to poor compliance among triathletes. These are general guidelines for self-management of overuse injuries specific to triathlon, and it can easily be altered depending on the diagnosis and the triathlete’s and treating practitioners’ experience. Practitioners who have triathletes who refuse complete cessation may find the Rule of Sevens as a reasonable approach to increase triathlete compliance. Back to Top | Article Outline Balance Between 3 Sports Swimming and cycling offer great nonimpact alternatives to running and have been shown to have lower rates of injury.1,12,14 Someone who has been constantly sidelined by a running injury during preparation for a 5k, 10k, half-marathon, or marathon may have slightly less injury rates in the sport of triathlon.1,12,13,14 In triathlon, they can tailor their training to be focused more heavily on swimming and can thus avoid the cumulative stress that has been seen with cycling and running.4The strengthening of other surrounding and core muscle groups is a mainstay in overuse injury prevention.5 It seems intuitive that triathlon, with the need to strengthen different muscle groups, would aid in injury prevention. Specific studies looking at triathlon for rehabilitation purposes are lacking, but inferring data from other studies show that triathlon has shown equivalent and slightly less injury rates when compared to running, and higher injury rates than solely swimming or cycling.1,2,12,13,14 Back to Top | Article Outline CONCLUSIONS Triathlon gives athletes 3 sports to attempt to master and maintain fitness, strength, and optimal weight. The sport has grown tremendously in recent years into an Olympic sport with millions of participants worldwide. The overuse injuries associated with swimming, biking, and running also occur in triathlon. The data supports a similar rate of injury between triathlon and running, with running comprising the majority of injuries in triathlon.1,12,13,14 Triathlon has shown increased positive manifestations on the heart, more so than marathon running, but similar to cycling.11 Knowing and avoiding the symptoms of overtraining and focusing on the disciplines that do not cause pain may help athletes continue to train and race.5,15 Early identification of overtraining symptoms, and a corresponding reallocation of balance between each discipline may help prevent many overuse injuries.15 Back to Top | Article Outline