Four Common Triathlete Injuries: what you're really lookin' at
by CBCG athlete, Amy VT
Have you ever wished there were Injury Gods? Like, so you could know if it’s OK to run with pain, so long as you’re not making it worse? Or so you could rest assured that not training is totally necessary? Unfortunately, the injuries that triathletes tend to incur are nuanced, variable, and impossible to diagnose with pinpoint certainty. They’re more metaphysical than physical, in a sense, so even the best practitioners cannot predict when you can be back in your running shoes.
Let’s take a looky at what we can control, what to expect, and how we might prevent four common triathlete-prone injuries. I sought the expert advice of three world-class practitioners who unpacked what to do (clamshells) and what not to do (download the app that rhymes with ebemdee) to prevent getting benched, and how to comply while we’re sitting on it.
CBCG athlete Elsa Hume diligently foam-rolling at the CBCGym
1. Plantar Fasciitis
WHAT IT IS
No, it is not a draconian, anti-social peanut brand. It feels that sinister to me, however, since I am currently grappling with PF. The Harvard Medical School explains that “the cause of the pain is inflammation of the plantar fascia, a band of tendon-like tissue that extends along the bottom of the foot (the plantar surface) from the heel bone to the ball of the foot, where it fans out to attach to the toe bones.” Ergo, when you run a lot in a wrong way or in the wrong shoes (see below) you can totally damage the fascia in your heel, or even tear it. Owee!
Our good friend and extremely adept Sports Physician Dr. Brad Farra, D.C., CCSP, CSCS tells us what’s really up with this common prob, “Plantar fasciitis is actually a misnomer. Often misconstrued as an inflammatory problem, it’s a chronic, repetitive issue which would be more aptly named plantar fasciosis.” Brad regularly treats athletes with said fasciosis at Evolution Healthcare and Fitness in Portland, and is all-too familiar with its cause. “It is often a condition of poor footwear choices and a weak kinetic chain. Narrow toe boxes and too much heal lift, followed closely by the unneeded arch support are the culprits in most problematic running shoes. Footwear issues are compounded by weakness anywhere from the foot to the core, causing a perfect storm setting for injury.”
One of the best practitioners in the world, Brad Farra D.C., CCSP, CSCS
WHAT TO DO
Get new shoes, and do these exercises. Actually, for all injuries, the first thing to do is tell your coach immediately, which will result in making a first-avail appointment with your physical therapist or related doc. So, let’s call that implicit for the below three injuries. For shoes, PF’s biggest culprit is old running shoes that lose their cushion or drop with wear. That was my prob. I know I shouldn’t run in zero-drop shoes because of my over-pronation, but I was obstinate about getting new running kicks. Hours this winter on the treadmill in my very old locker standbys was the surefire cause of my PF.
New kicks in da house, you might also need special inserts, heel cups, or cushions to re-introduce running. Only in extreme cases might you need injections or surgery, so most likely you’ll just be facing the specter doing these exercises indefinitely: toe curls, ankle circles, and plantar-specific massage and rolling. Or perhaps you’ll be confined to the beautiful “plantar fasciitis boot,” forcing your foot to stay flexed in bed. Our feet tend to point while we sleep, which ain’t good. The boot forces a flex in addition to looking so sexy.
THE HIT ON YOUR TRAINING
no hit whatsoever - 12 months
Most PF sufferers can still run if their cleared by their doc. If your pain is too acute, you’re looking at 6-12 weeks before you can run outside, but behold the “blessing of the triathlete!” You can still ride and swim, and even if you can’t run outside you might be able to watch the presidential debates from the convinces of the treadmill or elliptical. There’s always, always, aqua-jogging, too. Your coach will help! So, after procuring new kicks, adjusting your sched with your coach and getting treated by your doc, just thank the Injury Gods you don’t have Achilles Tendonitis - d’oh!
CBCG coach Molly Balfe rocking her calf exercises
2. Achilles Tendonitis
WHAT IT IS
Ever wonder why your autocorrect always capitalizes “Achilles?” This exasperating injury gets its name from the Greek mythological figure. (Ed. note: I’m pretty sure Brad Pitt played Achilles in Troy - not sure why I’d remember that imagery.) The tendon is named after him because it’s only part of his body that was still vulnerable after his mother Thetis had dipped him into the River Styx. Darnnit - why didn’t she hold him by his pinky?
The Achilles tendon is the thickest and most powerful tendon in the body. What Thetis didn’t consider was that because of its size, it’s also singularly susceptible to tearing or rupturing. It’s also just plain susceptible to agitation from tweaking or over-using, presenting as Achilles Tendonitis.
Über pain with heel strike, when running up hills or stairs, or with a sudden change of direction is how you know if you’ve got it. And since our calf muscles are (see also: Plantar Fasciitis) shortened as we point our toes in bed, the pain is often more prominent in the morning.
Again to Brad Farra’s expertise to explain this gnarly injury, “Achilles tendinitis is also a misnomer; achilles tendinopathy is a more appropriate name. Also a repetitive use condition, it’s possible to have five different people with achilles tendinopathy, and five different causes. The problem lies somewhere in the kinetic chain, commonly in the foot and/or the hip, which can incite inappropriate repetitive stress at the achilles tendon.”
Training errors are the worst culprits, which should be a null issue if you have a coach. AT can be caused by increasing intensity or mileage too quickly, transitioning from the treadmill to the streets or trails to soon, or excessive or steep hill climbing. So don’t do that stuff. Biomechanics are also a huge factor, as poor form, incorrect shoe type, or worn shoes can incite this injury.
WHAT TO DO
Implicit is telling your coach and seeing your doc straight away, of course. It’s possible to heal AT with PT, acupuncture, massage, other treatments, and exercises. You’re looking at calf stretches galore, and possible gear adjustments in the way of arch supports or insoles. If your tendon is totally torn or ruptured, sorry but you’re looking at total immobilization and/or surgery. Incidentally, to prevent AT, get your running and cycling (!) biomechanics analyzed by an expert who will, in turn, prescribe the optimal insoles, gear, and corrections for you.
THE HIT ON YOUR TRAINING
four weeks - six months
In most cases, you must wait until your totally pain-free, then wait another day, and then you can run outside again. Your doc might prescribe reintroducing running on a treadmill at an incline. Fortunately, there’s aqua-jogging - hooray! - so you can still race if your next one is a month or more out.
If the tendon is ruptured or torn, though, you will at least be immobilized for several weeks. If you need surgery, it might take up to three months before you can run again, so you’ll obvi be re-mapping your race sched with your coach. Go ahead and cry...they’re there for you, buddy...there, there.
CBCG athlete Becky Bader facing indefinite time off with a smile
3. Piriformis Syndrome
WHAT IT IS
Got butt pain? Our friend and world-class acupuncture therapist Ian Wilkinson, LAc, is the first to tell you “It’s not your piriformis, it’s your back.” Thus the “syndrome” in PS, since it’s a complex and typically chronic condition that is often misinterpreted. The sciatic nerve connects the lowermost vertebrae with the leg via the "sciatic notch.” If it’s irritated or compressed, pain can radiate anywhere from the back to the glutes to the hips to the legs. For cyclists and triathletes, it seems to especially haunt our hips and butt.
Ian treats (and heals) tons of athletes presenting this issue. “Lumbar instability is found in 90% of my patients complaining of ‘piriformis,’ or ‘strange hip or sciatic pain.’ One may say, ‘I have a tight low back, how can it be unstable?’ when in actuality those are the superficial muscles and fascia locking up trying to stabilize everything, creating tons of neural tension at the nerve roots of your lumbar. These nerves come back together deeper in the hip, which can feel like the piriformis when irritated. Once we stabilize the deeper low back muscles and loosen up the mid back, the pain goes away. Needling piriformis alone almost never works. The problem is always upstream.”
Miracle worker Ian Wilkinson, LAc at work on an elite athlete
WHAT TO DO
Welp, first go see Ian, of course. No, first tell your coach, then go to your doc who’ll assess your complex and unique injury to prescribe your treatment. As Ian stated, one visit or one approach rarely solve the issue, and unfortunately, it is often chronic. According to Ian, you’re likely in for daily, indefinite, repetitive hip exercises focussing on thoracic rotation, which is essential to improve flexion and your biomechanics in general to both address your injury and prevent its recurrence.
THE HIT ON YOUR TRAINING
no hit whatsoever - one month
Of the four injuries, PS is probably the least likely to keep you from training, and only in extreme cases or in case of surgery will it keep you from cycling or swimming. The prognosis is wildly variable dependent, as is each athlete’s response to treatment.
That stated, of the four injuries, PS is probably the one that will haunt you the most long-term. If you’ve got it, you’re facing clamshells for life. Let’s look at the case of CBCG coach and professional triathlete, Chris Bagg. Chris was plagued with such acute glute pain that it rendered him unable to run at several races. Not one to DNF, Chris decided to take extreme action and devote one full year to recovering is injury!
Every single morning Chris performs an involved and choreographed exercise routine while the coffee is brewing. He also sees all the practitioners whom I quoted, receiving constant treatment and updated prognoses. He’s assiduously followed this recovery program for well over a year, and you’ll see him back on the long-distance triathlon scene in 2020! #clamshellsforlife
Coach Chris Bagg practicing self-care aprés run
4. Shoulder Issues
WHAT IT IS
The confluence of muscles that meet at our shoulders is as complex as a subway system map. I, personally, have had every level of shoulder prob, from needing immediate surgery, to maybe needing surgery to it not being clear and ending up getting it, to healing it on my own. I will always have a “relatively f’d up shoulder,” according to my docs, since all my injuries have led to chronic tendonosis, read: an ornery shoulder for life.
Many shoulder issues stem from one-time events, like a crash or sudden move, but triathletes are at risk with overuse or misuse. Brad Farra explains, “There are a myriad of potential shoulder problems with triathletes, primarily due to the swimming, although the aero position on the bike has also caused problems for some with poor fits. Technique issues can lead to greater problems, i.e. allowing the arm to cross over the midline, or having a thumbs-down position upon entry, both of which can cause repetitive type injury on the shoulder.”
So, poor swim technique, mega swim volume without fitness, and certainly a crash can cause a pull or tear. Your poor web of muscles around your shoulder don’t like being jerked or jerked around, and can relatively easily get pulled or torn. Your biceps tendon and labrum are the most vulnerable. In my original case, my surgeon went in to patch up the former and found a bonus tear in the latter. Yeah, I got BOGO surgery.
CBCG athlete Jenny Greeve is ready for surgery
WHAT TO DO
Always with the tell your coach and see your doc directive, it’s also clutch to stop swimming (or pitching or serving or climbing or swinging kettle bells). If pain decreases to nil in a week or so, you can re-introduce swimming. If it doesn’t, your doc will likely a good guess at what’s going on in there, but won’t pinpoint the deets. In that case, I’m sorry to inform you only an MRI (so expensive and hard to schedule) can reveal your sitch and inform your treatment.
THE HIT ON YOUR TRAINING
no hit whatsoever - four months
You can still run and ride! If you have a short-term minor pull or tear that you can heal yourself, you’ll be back in the pool when your pain ceases and your coach clears you. Maybe as short as two weeks.
If you have a major tear that’s chronic, but you can still heal it yourself, your marching orders will vary tremendously, and you might constantly be adjusting or omitting swimming. I, personally, spent many meters one arm swimming, and kick-boarding.
If you need surgery, it’s possible you’ll be back in the pool using both arms within a month! You’ll also be able to run and ride as soon as you’re recovered from the operation. I, personally, ran a full training schedule in a sling after one of my shoulder surgeries, fielding surprised looks during a 20-mile trail run. The treadmill is a safer bet to avoid falling, of course, and you’re restricted to indoor riding, of course, but at least your training will be largely uninterrupted, save for the days around the procedure.
For general best practices for all of the above injuries and more, I sought the advice of my friend Kurt Marion, LMT, accomplished cyclist and legendary therapist out of P.A.C.E, Portland. Kurt avers that he’s constantly witnessing athletes doing the wrong things, including but not limited to the following.
KURT MARION’S LIST OF CLASSIC BAD BEHAVIOR:
minimize the significance of their injury, at least at first, especially if it is “not too bad”or comes and goes
due to the above attitude, wait too long to tell their coach and see a practitioner
adopt the cycle of rest-it > better use it > sore > pain...rest-it > better use it > sore > pain
over-stretch or over-roll, i.e. stretching or foam rolling the sheeeeit out of something when that is just continuing to irritate already irritated tissues. Much like picking a scab, you should let the tissue settle down before aggressive self-treatment
either fail to ice or wait too long to ice. It should be in that first few hours after you work out or feel sore. N.B.: there is much contradictory evidence on icing. My philosophy is unless you give yourself frostbite, it is unlikely icing will hurt you.
On the other hand, most people don't think about heat. If you have an injury that feels much better once you're warmed up, try heat before training (if approved by your doc, and not swollen or agitated), since a bit of blood-flow to the area can be good.
go to the app that rhymes with ememdee or Google their symptoms and then assume they have “pneumonoultramicroscopicsilicovolcanoconiosis,” which they probably don't. The sky is not always falling.
Role reversal! Kurt Marion, LMT getting a little work from his favorite client
Brad Farra sums-up these four pesky injuries and more, “All of the above are repetitive-use injury, which are certainly the most common amongst triathletes. Generally speaking, when you start to have pain the problem has already been going on for a while, so never let these problems linger before seeking help - see a good Sports Chiropractor or PT before you dig the hole too deep! Think preventively, too, since those same professionals can look at the way you move and do some screening to help you develop a plan to prevent injury. Strength training is one of the best ways to create less vulnerability to injury as well as increasing performance. Don’t fall victim to the untrue myth that ‘you’ll build too much bulk’ if you strength train. Expert coaches will know how to properly build your strength training program to allow for increases specific to your training and racing goals.”
Until the Gods of Injury rear their heads, we have Jon, Kurt, and Brad. Of all the above lessons the most salient takeaway should be ironclad: tell your coach immediately. Much to your chagrin, your coach won’t be able to diagnose you over the phone. In fact, she won’t be able to diagnose you even in person unless she’s also a physical or medical professional. She will, however, have a general familiarity with the injury, adjust your training accordingly, and send you straight to your physical therapist. Your in their hands, then, but in the meantime, keep on clam-shelling so you don’t have to see Jon, Kurt, or Brad unless they invite you to dinner. Bring your foam roller.