A current review of literature (research) on injuries in the sport of triathlon reveals a rather shocking statistic concerning the percentage of triathletes that are injured (in training) every year.  This type of data is collected from the triathletes by means of questionnaire, usually at a triathlon event.  While the actual percentages of injured athletes varies from study to study, the trend across all (or most) studies is what is shocking.  

I want to focus on one of the first triathlon studies in particular [1].  In this study, data was gathered from the responses of 95 competitors (75 men, 20 women) in the 1986 Hawaii Ironman Triathlon who completed a training and medical history questionnaire. In this sample, virtually all (91%) sustained at least one soft tissue, overuse injury during the previous year’s training. This trend continues, today.

Keeping this statistic in mind, let me sidetrack to a quote by Mike Boyle, one of the mostly highly respected strength and conditioning coaches in the country [2]. “When dealing with endurance athletes, the truth may be hard to say and even harder for them to hear:  All non-traumatic injuries are training related. All ‘osis’ conditions (chronic tendinitis is known as tendinosis) are caused by overuse. If you didn’t fall off something or get hit by something, you did something wrong in training.”

In a report from Wolf Schamberger, Clinical Associate Professor, Department of Medicine, Division of Physical Medicine and Rehabilitation, and the Allan McGavin Sports Medicine Centre, University of British Columbia, Vancouver, Canada [3].  Schamberger reports: “Pearson [6, 7] undertaking progressive standing radiological studies on 830 children from 8-13 years of age, found some degree of pelvic obliquity in 93%. Longitudinal studies by Klein and Buckley [8] and Klein [9] showed an increasing prevalence of malalignment syndrome on going from elementary (75%) to junior (86%) to senior high school (92%).”

The question of how these malalignments occur (traumatically or developmentally) has been answered by Fowler, [5]  .  “These rotational malalignments are now thought to be the result of muscular imbalances (occurring over time) which secondarily restrict sacroiliac joint motion.”  A particular traumatic incident or mechanical stress later in life is more likely to have made a pre-existing rotational malalignment symptomatic rather than actually having caused the malalignment.”

Schamberger goes on to state, “Medicine has, to date, been relatively unaware of malalignment and its related problems.  Sports medicine, in particular, has failed to recognize the malalignment syndrome as one of the major causes of back pain and other musculoskeletal problems.  The concern in sports medicine relates primarily to the problems caused by the biomechanical changes inherent to malalignment: specific sports injuries, impaired recovery from injury and a failure of athletes to realize their full potential.”

Finally, Cook, [4] states:  “We must separate movement dysfunction from fitness and performance. Aggressive physical training cannot change fundamental mobility and stability problems at an effective rate without also introducing a degree of compensation and risk of injury. Imbalances and limitations within movement patterns are markers that identify greater risk of injury for those involved in exercise and activity. Training poor movement patterns reinforces poor quality and creates greater risk of injury. We should not train fitness over existing movement dysfunction!”

Review

1. As many as 91% of triathletes sustain at least one training injury every year. Many of these sustain more than one injury, or experience co ntinuous training injury throughout the season.

2.  Strength and conditioning experts indicate that there should be virtually NO injuries in training, especially in an endurance sport, other than traumatic (falls or other accidents).  All other injuries are attributed to training mistakes by the athlete, coach, or trainer.

3.  Orthopedic experts indicate that 93% of adults present with a malalignment syndrome that can contribute to specific sports injuries, impaired recovery from injury, and a failure of athletes to realize their full potential.

4.   Current research on the Functional Movement Screen suggests that the test is a reliable way to objectively measure fundamental movement patterns that are modifiable and indicative of an elevated likelihood of sustaining a musculoskeletal injury.

Validity of the Functional Movement Screen as an injury screening tool has been established through the use of an evidenced based cut off score as well as identifying the presence of an asymmetry during the testing. Three studies have utilized screening statistics to establish the cut off score of <= 14 as being appropriate to identify individuals who have greater probability of sustaining an injury (Kiesel et al., 2007, O’Connor et al., 2011, Butler et al., in press).

Summary

Endurance athletes (including triathletes, duathletes, and runners)  should not be sustaining training related injuries…and yet the vast majority are.  Most of these injuries can be attributed to training mistakes made by the athlete, coach, or trainer.  During the last half of the 1900’s, over-training was considered to be the most common mistake made by athletes and coaches.  Over-training can be described as too much training (and/or too much high intensity training), with inadequate recovery.  This mistake most often results in burn-out, fatigue, loss of fitness, and a loss of interest… (but not necessarily injury).  If it goes too far, however, it can result in a serious neuro-endocrine system injury that can take years to recover from.  Over-training and overuse are not the same thing.  Today, the mistake of overuse almost always points to the mistake of ‘too much training, too soon’, and typically results in some form of soft tissue injury.  I find it hard to believe that 90+% of triathletes and their coaches and trainers are all making an overuse training mistake, and continuing to do so, year after year.  There must be some other training mistake taking place that we are unaware of. What could it be?

Physiological (performance) fitness training is based on what is known as the ‘Overload Principle’.  Simply put, we are overloading dysfunctional movement patterns, movement impairment syndromes, and malalignment syndromes…and the results are injury and pain.  THIS, IS A TRAINING MISTAKE!

Lack of awareness of our own movement, impairment, and malalignment problems (and overloading them) is as much a training mistake as being aware of them and choosing to ignore them by:  1. Not correcting them, and/or 2. Training over them.

Most of us don’t know we have a problem until the microtrauma sustained from training over dysfunction becomes macrotrauma, and we feel the resulting pain.  At this point, the worst mistake we can make for ourselves, or our athletes, is to choose to continue to train over (or through) pain.  This is an inappropriate choice if you are making it for yourself, and I would go so far as to say an “unethical” choice if you are applying it to an athlete that you have responsibility for, as their trainer or coach.

Movement-related pain always (or almost always) results in central nervous system (CNS) creation of a dysfunctional (compensating) movement pattern, which is an innate CNS survival strategy that will not return to the functional pattern on its own, even if/when the pain diminishes.  Once a dysfunctional pattern is established and utilized, it becomes the CNS pattern of choice, unless/until it is corrected.  The longer you use it, the more deeply ingrained it becomes, and more difficult to correct.

The number one predictor of injury in triathletes is previous injury.  This is because we haven’t correctly identified and treated the cause of the previous injury. The typical advice to “stop doing whatever is causing the pain” is a pseudo-solution (an avoidance strategy), especially for athletes who want to return to their activity/sport as soon as possible.  It might result in reduction of the symptom (pain), but it will not identify and correct the cause.  When you resume the activity, this symptom and possibly others will return.

Solution…

The best possible solution is one of prevention.  If you are an athlete who trains yourself, you need to take responsibility for becoming aware of and, if need be, making the necessary corrections to your fundamental movement patterns and alignments…before your season is disrupted, or ended due to injury.  If you are a coach or trainer, your first priority is to prevent/reduce injuries to your athletes.  You can only do this if you are aware of their weak link(s), and address them. Only then can your second priority become performance enhancement.  This holds equally true for the vast majority of triathletes who coach/train themselves.

Whatever point you or your athlete is at in training activities (even if there are no apparent problems such as pain/injury), this is the right time to screen for dysfunctional movement patterns and malalignment syndromes.  Correcting a problem before it becomes an injury is much easier and quicker than diagnosing, treating, and rehabilitating.  If you, or your athlete, is already injured and experiencing pain, extend the screening to an assessment for iliosacral/sacroilial fixation and movement impairment syndromes.  Many of these problems can be corrected in as little as a few days or weeks.  The treatment protocols for most ‘full-blown’ overuse injuries require a minimum of 6-8 weeks to rehab.  This will definitely interrupt your training/racing schedule and can even become a ‘season-ender’.  You can easily avoid this by getting screened in the off-season, and if necessary, make the corrective work part of your off-season training.

References

1.  O’Toole ML, Hiller WD, Smith RA, Sisk TD.  Overuse injuries in ultraendurance triathletes.  Department of Orthopaedic Surgery, University of Tennessee-Memphis. Am J Sports Med. 1989. Jul-Aug;17(4):514-8.

2.  Boyle, M.  Advances in Functional Training.  2010.  Aptos:  On Target Publications.

3.  Schamberger, W. The Malalignment Syndrome, Implications for Medicine and Sport.  2002.  Elsevier Science Limited.

4.  Cook, G., Burton, L., Keisel, K., Rose, G., Bryant, M.  2010.  Movement… Functional Movement Systems: Screening, Assessment, and Corrective Strategies.  Aptos: On Target Publications.

5. Fowler, C.  1986.  Muscle Energy Techniques for Pelvic Dysfunction.  In:  Grieve, GP, ed. Modern Manual Therapy of the Vertebral Column.  Edinburgh:  Churchill Livingstone.

6.  Pearson, W.  A Progressive Structural Study of School Children.  J Am Osteopath Assoc 1951; 51:155-167.

7.  Pearson, W.  Early and High Incidence of Mechanical Faults.  J Osteopath 1954; 61:18-23.

8.  Klein, K., Buckley, J.  Asymmetries of Growth in the Legs and Pelvis of Growing Children.  Am Correct Ther J 1968: 22: 53-55.

9.  Klein, K.  Progression of Pelvic Tilt in Adolescent Boys from Elementary through High School.  Arch Phys Med Rehabil 1973; 54:557-59.