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Top Three Triathlon Injuries: Runner’s Knee, Achilles Tendinitis and Swimmer’s Shoulder

Triathlon Injuries: What to Expect, How to Treat, and How to Prevent Runner’s Knee, Achilles Tendinitis and Swimmer’s Shoulder

Our body is composed of a series of structural kinetic chains, in which dysfunction or imbalance in one area can quickly lead to dysfunctions in other parts of the body.

Pattern overload describes injury to soft tissues and joints resulting from repetitive motion in one pattern of movement, or restricted movement in one or more planes of motion. Pattern overload results primarily from faulty movement patterns and repetitive stress.

A matter of load exceeding capacity

Unhealthy tissues have less capability to handle the load placed upon them. Repetitive motions cause tightening of the muscles, making them less able to handle loads during movement.

With the rigorous training volume of triathlon, the body often suffers from accumulation of load. This often results in a repetitive strain injury. The repetitive motion is the cause of chronic irritation to soft tissue. This can occur when swimming, biking, and or running. This irritation creates a friction and pressure, which eventually leads to small tears within the soft tissue. These in turn cause hypoxia (decreased circulation). This leads to decreased oxygen in the tissues which is a catalyst for biochemical changes that lead to fibrous scar tissue formation, called adhesions. These adhesions in turn create further restrictions in motion, muscle imbalances, inflammation and swelling. This cycle repeats itself, and escalates in pain, inflammation, and new injuries caused by the restrictive scar tissue.

Iliotibial Band Syndrome (ITBS) or Runner’s Knee

This condition frequently occurs in triathletes. It usually presents as sharp or burning pain on the outside part of the knee. It can also cause pain to radiate up the side of the hip or thigh. Correct and immediate rehabilitation is vital for this injury as, if ignored it becomes very difficult to treat.
There are a number of causes that can lead to abnormal stress of the IT Band including: overloading of hip and quadriceps muscles due to training, pronating or “flat” feet, and muscle imbalance. The quadriceps muscle group is responsible for the movement of the patella itself. If the lateral (outer) fibers are stronger or tighter than the medial fibers, or if the iliotibial band (ITB) is very tight this can lead to problematic patella tracking.
It is important to note that IT band tightness is caused by tightness (adhesions) in the outer hip muscles (gluteus maximus, medius, and TFL) which insert directly onto the IT band. Tight outer hip muscles result from repetitive overuse; usually secondary to muscle imbalance, weak core strength, pronated (flat arched/ hyper-flexible foot) or supinated (high arched/ rigid foot) feet and poor biomechanics.
Many people with weak core stability have weak gluteal muscles. These muscles are necessary for keeping the entire lower leg in normal alignment. When they are weak, they allow the knee to drift inward, thus resulting in tracking problems in the knee. Combined with faulty foot mechanics (either too flexible or too rigid) and the knee suffers repetitive stress and ultimate injury.
Addressing these core issues is crucial to permanent correction and recovery from injury. RICE treatments are effective only at alleviating acute inflammation. Correction of faulty biomechanics is the only way to prevent the repetitive stress from reoccurring.

What can the athlete do to resolve/ prevent IT Band syndrome?

The first thing is to deload the tissue. This means decreasing volume of offending activity (running, biking etc.)
A Selective Functional Movement Assessment by a sports medicine professional will help uncover faulty movement, usually due to soft tissue and joint dysfunction.
Then, adhesions must be released and joint dysfunction must be corrected. Active Release Techniques® is a fast and effective way to release adhesions and restore normal gliding of tissues. Manipulation of the hip, pelvis, lumbar spine, or foot and ankle may be needed to restore normal joint motion.
Apply RICE (Rest, ice compression and elevation) to the injured knee. This will help reduce swelling that occurs after training.
Active Rest until there is no pain (this is very important). This means decreasing volume which will decrease load through the tissues.
Use a knee support or patellar tendon strap (Use caution when using). Straps provide additional support to injured tendons. They may reduce pain and allow you to exercise more, but the overuse cycle continues and more serious injury may result.
Perform foam roller and stretching 3 times week focusing on gluteals, quadriceps, hamstrings, groin, and deep compartment tibial muscles.

Achilles Tendinosis 

Tendinitis is an acute injury with inflammation of the paratendon- a sheath surrounding the tendon. Tendinitis is often caused by overuse or repetitive strain and is commonly occurs in triathletes and runners.
More common is tendinosis, which is a chronic degeneration of tissue. Circulation to the Achilles tendon is poor, which results in poor oxygen supply. This results in poor healing and formation of microtears, causing the tendon to thicken. Chronic Achilles tendinosis can lead to a complete rupture of the tendon if it is not treated and rehabilitated correctly.
Often times it is necessary to have an evaluation from a physical therapist or sports medicine physician. It is important to look past the point of pain and identify all other structures that are involved in the kinetic chain.

What to do

The first thing is to deload the tissue. This means decreasing volume of offending activity (running, biking etc.)
A Selective Functional Movement Assessment by a sports medicine professional will help uncover faulty movement, usually due to soft tissue and joint dysfunction.

For both the above conditions, as well as swimmers shoulder, soft tissue treatment such as Active Release Techniques® is an essential part of treatment. It is simply the best way to break down scar tissue in the muscles and tendons that affect the leg and knee function, particularly the gluteals, quadriceps, hamstrings, groin, and deep compartment tibial muscles.

Perform foam roller and stretching 3 times week focusing on gluteals, quadriceps, hamstrings, groin, and deep compartment tibial muscles, followed by stretching.

Instrument Assisted Release to tendon (patellar or Achilles) can help directly to break down scar tissue and aid healing, followed by ice massage for 5-10 minutes.

Swimmer’s Shoulder

Pain in the shoulder is common in swimmers. Shoulder function is highly dependent on the coordinated function of many muscle groups. These include the rotator cuff muscles, those that control the scapula or shoulder blade, pectorals and latissimus dorsi, muscles in the upper and lower back, as well as abdominal and pelvic muscles.

Since the shoulder is an inherently unstable, but highly mobile joint, muscle forces are critical for maintaining stability, proper motion, and painless function. The repetitive overhead activity of the swimming stroke can result in fatigue of these muscles. This in turn can lead to distinct changes in the function of the shoulder, resulting in the pain that is commonly known as “swimmer’s shoulder”.

One of the major factors causing shoulder pain is overuse and subsequent fatigue of the rotator cuff muscles, scapular muscles, and muscles of the upper and lower back. Consequently, this fatigue can lead to shoulder instability and predispose a swimmer to shoulder pain. The risk of injury and pain is especially true for swimmers who swim with poor technique.
Swimmers typically develop poor posture because of tight latissimus dorsi, pectorals, and internal shoulder rotators. These muscles are overused during swimming. Protracted shoulders disrupt the normal axis of rotation of the shoulder joint. The subscapularis (the rotator cuff muscle located in front of the shoulder blade) often becomes overworked, tightens, and then becomes weak. This muscle is needed to create a force couple that stabilizes the ball and socket joint during swimming and overhead movements. Losing this force couple results in shoulder impingement, commonly known in swimmers as “swimmers shoulder”.

It should be noted that several of these muscles are overloaded during the bike. Triathletes often think they are cross training but the reality is several muscle groups are worked in all three disciplines.

It is well-established that a comprehensive program to develop strength, endurance, balance, and flexibility of the muscles is the most important way to prevent “swimmer’s shoulder”. Releasing all the adhesions in the muscles of the shoulder prior to engaging in strengthening exercises is essential to ensure that they work properly.

The Big Picture

The common thread to all three of these injuries is overuse of muscles, accumulation of load from high volume training for triathlon, and repetitive strain injury. Repetition motion leads to adhesion formation in the muscles, leaving them unhealthy and with less capacity to handle load. Continued loading of unhealthy tissue leads to more injury and more soft tissue and joint dysfunction.
Of utmost importance is treating these soft tissue and joint dysfunctions. A Selective Functional Movement Assessment with help the sports medicine physician detect faulty movement and identify these dysfunctions. Once that is done, Active Release Techniques provides a means to effectively and rapidly resolve these stressful repetitive strain injuries without surgical intervention, and allows the patient to quickly return to training. Manipulation will correct joint dysfunctions and THEN corrective exercise can be added to help rehabilitate the injury and prevent recurrence.
Remember that once symptoms of injury have cleared, future prevention should begin by including regular foam roller self massage, stretching as well as strengthening exercises. Be sure to get proper fitting equipment and coaching or instructions if needed.

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