Swim. Bike. Run. Repeat.
Welcome to the world of injuries waiting to happen. The successful treatment of triathletes depends on many factors, but to keep things simple, the following will address the most common repetitive ailments you are likely to see with this patient demographic.
The swim
The research shows some alarming numbers pertaining to shoulder pain. And competitive swimming has long been associated with shoulder pain because 90 percent of a swimmer’s propulsion comes from the upper extremities.1-3
Competitive swimmers usually train six to seven days a week, two workouts per day, covering around 12,000 to 16,000 yards daily.4
It has been estimated that a swimmer training 10,000 yards per day takes around 400,000 strokes in a season.4
The amount of distance alone is a risk factor for shoulder injury. Swimmers need a large arm movement to pull through the water, generating high torque. Their shoulders need to have the full available range of motion, as well as coordination and stability, to withstand the repetitive nature of the swim stroke.
When treating these athletes, controlled arm elevation is required. If this does not occur, impingement can result, which will sideline your athlete. This setback can frustrate both the clinician and patient.
Arm elevation needs mobility and dynamic stability. Mobility allows the appropriate thoracic extension, scapular retraction and posterior tilt, and normal roll and glide kinematics of the glenohumeral joint. Stability is required for control around the scapula and coordination through the joint.
In acute pain cases, soft tissue tools can be used in a light feathering fashion over the areas of pain to stimulate the interoreceptors in the fascia. This technique will decrease pain.
Taping the shoulder with a tab technique over the supraspinatus insertion gives these patients significant pain relief. If further assessment reveals deficits in the thoracic or cervical region, additional manual therapy may be warranted.
In more chronic cases, you will want to use your tools in a fast, oscil- lating fashion over the areas of the scapula to stimulate the Pacinian receptors in the fascia to increase tactile acuity and neurosensory input—thus improving control of the scapular stabilizers. To lock in the change here, use kinesiology tape in a postural application to provide feed- back for the next five days, 24 hours a day. Give the athlete two to three corrective exercises to engage these stabilizers. Closed kinetic chain, full contact exercises work well with this population.
The bike
All bikes must be fit to the athlete: This is non-negotiable. These cyclists will spend hours in a flexed position over the bike. With the appropriate bike fit, the spine will be preserved with less strain through the lumbar region. Low-back pain and knee pain seem to trump our ailments with these cyclists.
Due to the excessive flexion, dynamic stability is of utmost importance. You will find that most of these athletes presenting chronic low back pain also exhibit paradoxical breathing patterns. This results in increased neck tension, poor control of the lumbar spine, and hypertonic hip flexors.
Have the patient focus on breathing exercises, as well as appropriate bracing methods coupled with breathing patterns. The use of kinesiology tape over the lumbar spine will decrease pain and delay tissue fatigue. Corrective exercises should be implemented to improve core control. Knee pain is common with cyclists, and you must assess their foot placement when they are clipped into the bike.
Internal and external tibial torsions will affect the way the athlete is clipped in. For example, if your cyclist has external tibial torsion, and they are clipped into the bike in a neutral position, the positioning will drive the knee into valgus, increasing strain along the medial compartment of the knee.
They will have medial knee pain, and possibly ITB and low-back pain on the ipsilateral side. This is a structural issue; you cannot strengthen them out of an external tibial torsion. Adjust the clip. For external tibial torsion, adjust the clip to rotate in as to align the knee in the appropriate position. This change will immediately decrease symptoms. If there is inflammation in the knee, kinesiology tape can be used to decompress the area and provide a change in the fluid dynamics of the tissue.
The foot must be addressed as well. You might do an assessment for fore- foot varus and valgus. Differences in forefoot pronation can lead to posterior tibialis insufficiency among other things.
If the problem is acute, you can tape for pain to alleviate symptoms, which are typically along the medial arch at the rearfoot or around the medial malleolus, and up the medial aspect of the leg. In a more chronic case, the helical postural taping application up the entire lower extremity to improve body representation and increase the “external rotation” sensation of the limb is an excellent adjunct to corrective exercise strategies.
The run
Knee pain is a common complaint among runners, and slightly more than 40 percent experience it. After assessing gait, use these tips to decrease the runner’s knee pain.
First, increase their cadence. We want our runners to be around 170 to 190 steps per minute. This will minimize ground reaction forces and energy loss and injuries while maximizing stride efficiency.
Second, the foot should land as close to the body as possible. Look for a vertical tibia when the runner lands. This positioning will lower the vertical loading rate, and thus decrease pres- sure at the knee.
Third, assess footwear. The more cushion a running shoe has, the more mechanical stress on the skeleton (except at the foot).5
You can treat these runners with barefoot strengthening programs, and specific exercises to control eccentric motion. Taping applications to decrease pain at the knee can be implemented as well as IASTM and dry needling.
Treating the triathlete is no simple task. Many factors like posture, gait, and form are involved, compounded by many hours of repetitive stress to the body. However, these athletes are determined, and they will be highly compliant with your treatment protocols when they are educated properly. Knowing how to successfully treat and prevent pain will keep your athletes at peak performance.
Courtney Conley, DC, graduated from the National University of Health Sciences in 2003. She also holds a BS in kinesiology and exercise science from the University of Maryland. Conley currently owns and operates Total Health Solutions in Golden, Colorado, where she has put together a team of skilled professionals to treat patients ranging from the weekend warrior to the ultra distance athlete. She can be contacted through rocktape.com.
References:
1 Bak K, Faunl P. Clinical findings in compet- itive swimmers with shoulder pain. The American Journal of Sports Medicine. 1997;25(2):254-60.2 Gomez J. Upper extremity injuries in youth sports. The Pediatric Clinics of North America. 2002;49(3):593-626.
3 Pink M, Tibone J. The painful shoulder in the swimming athlete. Orthopedic Clinics. 2000;31(2):247-61.
4 Richardson AB, Jobe FW, Collins HR. The shoulder in competitive swimming. The American Journal of Sports Medicine. 1980;8(3):159-63.
5 Sinclair J. Minimalist footwear does not affect tiobiofemoral stress loading during the stance phase in rearfoot strikers who use conventional footwear. Comparative Exercise Physiology. 2016;12(2):99-103.
