First and foremost have your swim technique evaluated, looking for common errors.Three out of four people reading this chapter have already suffered an injury while training for, or competing in, a triathlon. Although many of you are former runners, cyclists, or swimmers, becoming a triathlete will not lower your risk of injury. In fact your injury risk is higher than it was before you took up triathlon.
Triathletes tend to train more hours per week than their single-sport counterparts. Triathletes training at both the lower and higher ends of the spectrum are more likely to be injured, meaning there is a “sweet spot” in which injuries are least likely to occur. In one study of nonelite triathletes, those training a total of 8 to 10 hours per week were less susceptible to injury (Shaw et al. 2004).
That being said, overuse injuries are more common in triathletes than in single-sport athletes because of the cumulative stress of training concurrently for three sports (Tuite 2010). Nearly 75 percent of triathletes have sustained at least one injury since starting the sport (Vleck 2010; Egermann 2003). When looking at goal-race distances, Ironman-distance triathletes have about twice as many recurrent injuries as Olympic-distance triathletes (Vleck 2010). One study of Hawaii Ironman finishers revealed an incredible 90 percent injury rate in the year before the event (O’Toole et al. 1989).
Also, triathletes may be more likely to train through a minor injury—leading to chronic pain or recurrent problems—especially if the pain is viewed as minor or a nuisance such as a grade 1 shoulder separation. Triathletes tend to increase training time in another activity rather than decrease training overall when suffering from overuse injuries. Many overuse injuries from cycling, especially of the knee, are also caused by running and vice versa. Adding additional hours of cycling when someone has runner’s knee may not actually lead to any improvement in pain (Tuite 2010; Vleck 2010).
Surprisingly, the presence of coaching or seeking out medical care made no difference in the injury rate of a group of German Ironman finishers. Egermann (2003) found no difference in the injury rates of coached versus noncoached athletes. Although a coach can help an athlete improve technique and design good training plans, the athlete is the one who must pay close attention to her body and take action toward recovery as soon as an injury pattern is identified.
In addition, triathletes may have suboptimal technique or equipment than their single-sport counterparts (Tuite 2010). Taking up a new sport as an adult makes it extremely difficult to develop good muscle memory in the same way as an athlete who has been coached for years. Swimming provides probably the best example of technique differences among adult triathletes and competitive swimmers of any level. Young swimmers benefit from daily poolside coaching, with every stroke monitored. Those who start swimming competitively as adults, however, usually don’t have the benefit of technique feedback in the same way.
The spectrum of injuries in triathletes is similar to the spectrum of injuries seen in the single-sport events. In a study of the British Elite Squad comparing event distance with injury patterns (Olympic distance vs Ironman distance), most injuries were attributed to running (65 vs 60 percent), followed by cycling (26 vs 32 percent) and then by swimming (15 vs 16 percent). In some cases athletes attributed more than one sport to an injury (Vleck 2010).
The location of injury seems to vary depending on the race distances being trained for. Elite athletes focusing on Olympic-distance triathlon complained of injuries to the lower back (18 percent), Achilles tendon (14 percent), and knees (14 percent), whereas long-course triathletes complained primarily of pain in the knees (44 percent), followed by the calf (20 percent), hamstrings (20 percent), and lower back (20 percent). In other groups, the knee seems to account for more than half the injuries reported (Tuite 2010).
Swimming injuries account for 5 to 10 percent of all injuries in triathlon (Tuite 2010). Freestyle swimming requires two motions that can be stressful for the shoulder joint, including overhead reaching and internal rotation of the joint. This can result in three varieties of overuse injuries that cause shoulder pain in swimmers: shoulder impingement syndrome, rotator cuff tendinitis, and swimmer’s shoulder. The shoulder is a highly mobile ball and socket joint that is sometimes described as “a golf ball on a tee.” The upper part of the arm bone is shaped like a large ball several inches in diameter. This ball sits in the shoulder socket nestled underneath the collarbone, in front of the shoulder blade and adjacent to a tiny cup called the glenoid. The glenoid is “the golf tee.”
Impingement refers to the pinching or trapping of the rotator cuff tendons between the head of the humerus and the part of the shoulder blade that extends forward and over the top of the shoulder joint. Reaching overhead; slouched, rounded shoulders; and internal rotation of the upper arm can all narrow this space and cause repetitive irritation of the small tendon. Impingement pain can be worsened while riding in the aero position on the bike (Tuite 2010).
Tendinitis is a more general inflammation and swelling of the rotator cuff tendons. Because these rotator cuff muscles are much smaller than the muscles which help move the arm overhead (deltoids), across the chest (pectoralis) and pull it back down to the side (latissimus), these larger movements can cause the ball-and-socket alignment to shift, especially when the rotator cuff is relatively weak. In swimming this happens when the pulling force is too strong relative to the ability rotator cuff muscles to stabilize the joint. Rotator cuff tendinitis frequently causes pain when the arm is lifted to the side or when lowering the arm from the same position. In more severe cases it may be impossible to lift the arm more than a few inches (several centimeters) away from the side of your body.
Swimmer’s shoulder is more common in competitive swimmers and refers to a combination of rotator cuff tendinitis and impingement along with laxity (looseness) of the shoulder joint. Excessive and aggressive stretching of the shoulder joint is common in competitive swimmers and may contribute to joint laxity.
If you begin to develop shoulder pain while swimming, don’t ignore it. If you have just started swimming after a layoff period, consider taking a few days off. Resume swimming at a much lower volume and intensity, and build up gradually. Swimmers of all abilities can benefit from having their technique evaluated. One of the most common swimming errors is pushing down on the water with your arm in full extension (i.e., when your arm is extended towards the wall in the direction you are swimming), placing high forces on the shoulder joint. Correcting this common error with improved technique will not only relieve pain and pressure in the shoulder joint but lead to more enjoyable swimming as well.
Here are a few tips for good shoulder health:
First and foremost have your swim technique evaluated, looking for common errors.
Ice the area that’s painful. A typical regimen is ice for 20 minutes on and 20 minutes off for three cycles. Some recommend icing once per hour for 20 minutes at a time.
Consider short-term use of over-the-counter pain relievers such as ibuprofen or naproxen. Always use the smallest dose that is effective.
When initial pain resolves, add shoulder-stabilizing exercises to your training on alternate days from swimming. In other words, don’t fatigue your rotator cuff muscles in the gym and then go swim hard or you’ll be asking for trouble.
If your pain doesn’t resolve within 7 to 10 days (the length a typical sprain or strain lasts), see a medical professional.
Bicycling injuries account for 10 to 20 percent of injuries in triathletes. Most are overuse injuries, but each year, about one-third of cyclists fall off their bikes either in training or competition. Common traumatic versus overuse injuries are discussed in this section.
Traumatic cycling injuries result from falls or crashes while riding the bicycle. Whether from a collision with another rider, falls due to road or trail hazards, or automobile collisions, the injuries range from minor scrapes to catastrophic injuries. Traumatic cycling injuries can be minimized by improving bike-handling skills, practicing communication with riding partners, and riding predictably in traffic while being very visible to automobiles. One rider I know waves at drivers at every stop sign intersection to be sure they see her.
Traumatic cycling injuries include injury to the skin, sprains, and fractures. If you have severe pain and swelling over a joint or decreased movement after a fall, seek medical evaluation.
Your skin is your body’s largest organ. It protects you from outside elements, it’s waterproof, it keeps out bacteria, it keeps in fluids, it regulates body temperature by sweating, it has built-in glands to keep the skin hydrated and nourished, and it contains the tiny factories that produce hair. Common cycling injuries to the skin include abrasions and cuts. This section also discusses sunburn and increased risk of skin cancer.
An abrasion results from contact with the ground while moving at high speeds. The friction between the skin and the road surface tears away layers of the skin, sometimes very deeply. “Road rash” typically refers to a large area of skin that is scraped away in a high-speed fall, frequently over the hip, thigh, calf, shoulder, or shoulder blades. Treatment of abrasions and road rash is something every cyclist should be well versed in.
1. Clean the wound and surrounding skin.
The first step is to clean the area with soap and water. As soon as you can get to running water, irrigate open wounds for a few minutes to further decontaminate the area. Gentle soap will help lift out dirt particles that may be embedded in the skin. Putting full-strength peroxide and iodine directly onto a wound is not recommended because they can damage healthy skin cells that are needed for repair. Both are safe to use on the surrounding intact skin, or they can be used on the wound if they are diluted with water. Surrounding skin should be cleaned and scrubbed.
2. Apply a three-layer dressing.
The next step is to protect the abraded area from further contamination and allow the body’s natural healing process to begin.
– Layer one: the nonstick layer. Because open wounds usually leak clear to yellowish or yellow-red fluid in the first few days, you’ll need to use a nonstick dressing as the first layer on the injury. If none is available, you can also spread a very thin layer of antibiotic ointment on a plain gauze pad and place that over the wound to provide both protection from bacteria as well as prevent sticking.
– Layer two: the absorbent layer. Use an even layer of additional plain gauze squares to cover the entire injured area. The purpose of this layer is to absorb the fluids that ooze from the injured skin. If the fluid becomes cloudy, white, or greenish, the wound may be infected, and you should see a health professional right away.
– Layer three: holding it all together. Paper tape can be used to hold down the edges of the top layer of gauze. For larger wounds, an ABD pad can be placed on top. ABD pads are large dressings frequently used after abdominal surgery that can be taped down at the edges. Stretchy tubular netting is perfect for arms and legs. It comes in several diameters and can be cut to the length needed and stretched over the entire wound dressing to hold it in place.
3. Maintain ongoing care.
Wash the wound daily with soap and water, and redress as needed. The wound will heal the best if the surface of the injury is not allowed to dry out and scab. The new cells require a lubricated surface as they grow and slide into place from the edges of the wound. A bright red appearance at the bottom of the wound is healthy and normal and does not indicate infection. However, if you see bright red or pink skin surrounding the wound, then you may have a wound infection and should see your physician.
Cuts, also called lacerations, can be caused by an impact over a bony area such as the chin, elbow, or knee resulting in the overlying skin splitting open. They can also be caused by cutting forces such as broken glass, metal, or other road debris.
Cuts should be immediately assessed for rapid bleeding; if present, apply firm, direct pressure over the bleeding area for about 10 minutes at a time until bleeding has stopped. If sterile gauze is not available, pressure can be applied with any clean fabric including a jersey or T-shirt. Use the fingers to compress directly over the bleeding wound. In severe cases, you may need to apply pressure over a nearby artery to slow bleeding. Tourniquets are no longer recommended because other methods almost always suffice. If bleeding can’t be stopped, continue holding direct, firm pressure and call 911, or go directly to medical care such as the ER or an urgent care center.
Once bleeding is well controlled, the cut should be cleaned with running water if possible in order to remove both visible as well as smaller particles in the wound. Holding the injured part under running tap water for a minute has been shown to be as effective as high-pressure sterile irrigation.
Once the wound has stopped bleeding and has been cleaned, you have a few hours to get to medical care before the window for stitches has passed. A good rule of thumb is, if you think it might need stitches, it probably does. In addition, personnel at a clinic or ER can numb the wound, do further cleaning if needed, and evaluate for related injuries.
Outdoor athletes are at a higher risk for skin cancer. Ultraviolet radiation from the sun is one of the biggest risk factors for several different types of skin cancer. Studies have shown extreme ultraviolet exposure in cycling and triathlon. In addition, sweating while participating in sports has been shown to increase the sensitivity of the skin to injury from ultraviolet rays. Endurance athletes with sun exposure have more abnormal skin findings including melanocytic nevi (developing moles, not present at birth) and solar lentigines (flat areas of darker pigmentation, commonly referred to as age spots caused by the sun). Although both of these findings are nonharmful by themselves, they are both risk factors for melanoma, a type of skin cancer.
Always use skin protection of at least SPF 30, especially in the colder weather when you can still get burned from UV rays even though it’s not hot out. Don’t forget to use lip balm with SPF protection as well, and reapply frequently during a ride. Seek a medical opinion for any skin changes including new moles or spots or discolored patches of skin, particularly if they are growing in size.
Common sites of sprains include the shoulder and the wrist. A separated shoulder is a sprain of the acromioclavicular (AC) joint, where the collarbone and shoulder blade meet on the top outer edge of the shoulder. Wrist sprains can occur in a variety of locations depending on the position of the wrist and site of impact during a fall. A fall on an outstretched hand, humorously referred to as FOOSH by ER physicians, is the most common mechanism resulting in sprains and fractures.
A separated shoulder is an injury to a small band of tissue (ligament) that holds the end of the collarbone down against the top of the shoulder on the outside edge. When a triathlete falls to the side and lands directly on the outside of the shoulder, this ligament can get stretched to varying degrees. The mildest form of a separated shoulder is simply a sprain of the ligaments with no tearing. This causes pain immediately over the acromioclavicular joint and may cause pain with overhead arm use. Treatment is rest, ice, and anti-inflammatory medicine.
More severe shoulder separations involve tearing of the ligaments holding the collarbone down, resulting in a bump at the far end of the collarbone where the torn ligament is no longer able to hold the collarbone in contact with the shoulder blade. Treatment is usually the same as for a mild separation, but healing time is longer. Rarely do shoulder separations require surgery.
If you think you have suffered a shoulder separation or related shoulder or collarbone injury, place your arm in a sling to gently rest it at the side of your body, and proceed to medical care as soon as possible. Icing the most painful area will help reduce the pain as well as the swelling.
Wrist pain after a fall deserves special discussion. The navicular or scaphoid bone is a small triangular bone at the base of your thumb. This bone gives your thumb its full range of motion. Since having opposable thumbs is one of the great things about being human, taking care of an injury to this area is important.
The navicular bone is different from most others in that it has a narrow “waist” and receives its blood supply from the distal (far) end of the bone. If there is a fracture across the narrow waist, it’s possible that the bone won’t heal properly. If you have persistent pain in the “snuffbox” area of the wrist after a fall, it’s vital that you have it examined by a physician. You’ll probably be placed in a spica splint and asked to follow up with an orthopedic doctor if the initial X-rays show no fracture.
Common fractures include fractures of the wrist, the elbow, and the collarbone. Many people know immediately if they have broken a bone because they hear a “snap,” feel the bone break, or see an obvious deformity of the bone or joint. However, small cracks in certain places may not be so obvious. Almost all broken bones will cause immediate pain, but some may not begin to ache until after a few hours and over the next day.
If you are unable to move a joint in its normal range of motion, if there is obvious deformity of the bone or a joint, or if there is angulation of a long bone in the arm or leg, a broken bone is a strong possibility. Obvious fractures with the bone protruding through or “tenting” the surface of the skin require immediate care by a trained professional such as a paramedic followed by a visit to an emergency or orthopedic physician. Left untreated for too long, angulated or open fractures (bones sticking through the surface of the skin) can cause permanent nerve damage or infection. In addition, severe pain or persistent aching that is undiminishing should be a signal that an X-ray is warranted even if no deformity is seen initially.
Immediate treatment for broken bones includes evaluating for good pulses and movement of the hand or foot beyond the injury, as well as immobilizing the injured area with a temporary splint or sling. These can be improvised from many items you may have with you such as a frame pump and arm warmers to splint an arm or a wrist until medical help can be reached.
It follows that triathletes have the same knee problems that pure cyclists do. Although pedaling technique is certainly important, there is much less variation in technique on a bicycle as compared with swimming and running. If the bike is not properly fit to the rider, the repetitive motion can accumulate stress on the hips, knees, ankles, and feet, with the knee being the most common area of complaint for a triathlete (Tuite 2010).
Knee The knee is a hinge joint. Although the motion is simple, the structure is somewhat complex. In addition to the contact areas of the upper and lower leg bones (the femur with the tibia), there are two discs of cartilage on either side of the joint called menisci (singular: meniscus), a protective kneecap (the patella) embedded in the tendon of the quadriceps muscle, ligaments that run on either side and through the middle of the joint, and many different groups of muscle attachments from both the upper and lower leg.
Common causes of knee pain in cyclists and triathletes are overuse, a poorly fitting bike, or a combination of both. The top three knee injuries are patellar tendinitis, patellofemoral syndrome, and iliotibial band syndrome.
Patellar tendinitis is an inflammation of the tendon just below the kneecap. When the quadriceps contracts, such as on the downstroke of the pedal, the knee straightens as the force is transmitted through the patellar tendon to the attachment at the tip of the tibia (shinbone). This can cause irritation of the patellar tendon, especially in the spring when enthusiastic cyclists embark on too much mileage or intensity too soon.
Patellofemoral syndrome refers to a misalignment of the kneecap in relation to the groove at the end of the femur (thigh bone). When biking causes PF syndrome, it’s called biker’s knee. When the same syndrome occurs from running, it’s called runner’s knee. PF syndrome is caused by a relatively stronger lateral (outside) group of the quadriceps muscles. The patella (kneecap) is pulled toward the outside of the knee with every pedal stroke.
Over time, this causes pain from repeated wear and tear. The condition is more common in women because of a larger angle of the thighbone from the pelvis to the knee. Treatment can include adjustment of cleats and shoes as well as strengthening the medial or inside group of the quadriceps muscles with physical therapy exercises.
Iliotibial band syndrome is also known as ITBS or IT band syndrome. The IT band is a thick band of tissue that originates at the hip and connects below the knee. During cycling, the IT band rubs against the outside of the thighbone just above the knee near the bottom of the pedal stroke. A seat that is too high or too far back can make this condition worse (Tuite 2010; Farrell, Reisinger, and Tillman 2003).
Head and Spine The head, neck, and low back are quite literally at the core of your function as a human. The bony skull and vertebrae house your brain and spinal cord, which make up the central nervous system. Protecting the head and spine is important for triathletes in preventing both traumatic and overuse injuries.
In a study of triathlon injuries, 17 to 20 percent of triathletes reported low back pain in the previous training year. More long-distance triathletes reported pain than Olympic-distance triathletes, suggesting a relationship with overall time spent training (Vleck 2010). In another study of Hawaii Ironman finishers, an incredible 72 percent reported low back pain in the previous year (Villavicencio 2007). Finding ways to evaluate, treat, and prevent low back pain is a big concern for all triathletes.
Up to 45 percent of triathletes experience neck pain at some point in their careers (Villavicencio et al. 2007). Sources of pain in the neck can be any of the structures mentioned for the low back. Pain can begin as a result of injury (falling off the bike) or strain from looking forward while hunched (hyperlordosis) in the aero position. Triathletes who have had previous sports-related injuries and have been participating in triathlons longer are at higher risk for neck pain.
If you begin to experience low back or neck pain, first take a few days off from training the activity that flared up the pain. Consider the use of over-the-counter anti-inflammatory medications and ice for the first 48 hours. If your pain is severe and does not respond to rest and anti-inflammatories, your physician may recommend a short course of steroids with or without muscle relaxants.
Have your bike fit evaluated by a professional or a knowledgeable friend or coach. If you’ve been riding a triathlon or aero bike frequently in recent weeks, consider switching to a more upright position, possibly cross-training on a mountain bike or touring bike to maintain fitness.
Getting to the root of pain in the neck and back can be difficult, even for experienced physicians. Although such pain is often minor, there are some warning signs that should prompt you to see a physician right away. In three-quarters of triathletes experiencing low back pain, the pain resolves on its own within a few weeks. About one-quarter of triathletes had low back pain that lasted longer than 3 months, and about 10 percent had neck pain that lasted longer than three months (Villavicencio et al. 2007).
Pain that lasts longer than 3 months is most likely originating from either the discs or the joints that make up the spine. As people age, the disc material can get brittle and develop small tears. If severe, the tear can cause fluid to leak from the disc itself and put pressure on the spinal nerves. This is commonly known as a herniated disc (herniated nucleus pulposus, or HNP, in medical terms).
If at any time you experience sharp, shooting pain; numbness; or weakness from your spine to your extremities, see a doctor immediately for evaluation because this could suggest a herniated disc with pressure on a nerve. Red flags for back pain include difficulty urinating, loss of control of your bowel movements, or numbness around the anus. These symptoms are rare but require you to proceed immediately to the nearest emergency room for evaluation.
Head Injuries and Concussions Your brain is arguably the most important organ in your body. Helmets help prevent brain injuries by dissipating the impact of falls to the helmet instead of to your skull. A concussion causes a complex spectrum of symptoms as a result of a head injury, and it cannot be identified with X-rays, cat scans, or MRIs. Symptoms can include problems with memory, judgment, reflexes, speech, balance, coordination, and sleep patterns (PubMed Health 2011).
Seek immediate medical evaluation if you or a training partner has one or more of the following symptoms. This is not an exhaustive list; if in doubt, go to the hospital.
Persistent vomiting
Prolonged loss of consciousness
Trouble with coordination
Difficulty speaking
Difficulty seeing
Seizures
Pupils of unequal size
Clear or bloody fluid draining from the nose, ears, or mouth
Once more significant head injury such as bleeding of the brain and fractured skull are ruled out, treatment of a concussion involves brain rest.
Stay safe when riding, and keep your brain intact! Always wear a helmet when riding, even when riding on trails without traffic. Be predictable, and do not weave in and out of traffic or bike lanes. Learn traffic hand signals. Be visible. Wear bright and reflective clothing. Use flashing LED blinker lights when riding at night.
The Ankle The most common ankle injury from bicycling is Achilles tendinitis. The Achilles tendon is a thick band of fibrous tissue that connects both calf muscles (the gastrocnemius and the soleus) to the heel bone. The Achilles transmits all the force of the downstroke to the pedal.
In triathletes, one possible contributor to Achilles pain is swimming followed by biking. In swimming, the Achilles is shortened because the toes are pointed during the swim. Transitioning immediately to bicycling, where the tendon is stretched, can cause irritation. Severe cases of Achilles tendinitis can progress to a painful lump or swelling that is liable to rupture if the cause is not addressed (Tuite 2010).
If you are suffering from Achilles pain, in addition to treatment with rest, ice, and anti-inflammatories, you should have your bike-fit evaluated to make sure your seat height, fore and aft saddle placement, and cleat adjustment are not contributing to ongoing strain of the Achilles.
Because running involves full-body-weight support with every foot strike, it’s also the most likely to cause long-term injury or overuse. Running injuries account for up to three-quarters of all missed workouts in triathletes.
Just as in cycling, the knee accounts for the majority of reported injuries in running. Running causes one-third of reported overuse injuries in triathletes. The spectrum of injuries is similar to those reported by cycling and includes patellofemoral syndrome, iliotibial band syndrome, and runner’s knee (patellar tendinitis), which were discussed under cycling injuries.
Aside from what was already mentioned about these three knee conditions in the section on cycling, factors contributing to running injuries include the following:
Rapid increase in mileage on hard surfaces (patellar tendinitis)
Running on a crowned road with a slope (ITBS)
Hill running (patellofemoral syndrome) (Tuite 2010)
The ankle is a hinge joint that connects the lower leg with the foot. Ankle injuries can be acute (sprained or twisted ankle) or chronic, such as Achilles tendinitis. Ankle injuries are common in runners and triathletes and account for 15 to 25 percent of running injuries reported by triathletes (Tuite 2010). Foot injuries include metatarsalgia and plantar fasciitis.
Metatarsalgia is a general term for pain that occurs in the long bones of the foot, typically on the underside of the foot just behind the toe joints. Either running or cycling can cause this injury. The foot bones (metatarsals) absorb a lot of energy, and repetitive stress can cause a stress reaction of localized injury along the shaft of the bone. Occasionally, a stress fracture can occur. Cycling cleats can also cause increased pressure in this area, contributing to pain. Pedal and cleat combinations with a larger surface area may help diminish pain. One of the treatments for metatarsal pain and stress fractures is a shoe that does not flex along the sole, a characteristic of many high-end cycling shoes. Wearing stiff-soled shoes while cycling with a pedal and cleat combination that provides a large surface area can be good cross-training while the metatarsal injury heals.
Plantar fasciitis accounts for about 50 percent of running injuries in the foot and ankle (PubMed Health 2011). The plantar fascia is a tough sheath of tissue that runs along the sole of the foot, helping it maintain the arched shape, providing some shock absorption for the foot, and allowing for elastic recoil to return energy to the stride. When this tissue becomes inflamed, it can cause pain and burning along the sole of the foot, particularly right in front of the heel. The pain is usually worse in the morning, especially when getting out of bed, and tends to improve as the day goes on.
Treatments for plantar fasciitis include wearing shoes with arch support, especially when first getting out of bed in the morning or when getting up at night. You can stretch the plantar fascia by rolling the foot on a tennis ball or on a can of soda. Keeping several cans of soda in the refrigerator lets you combine cold therapy and stretching at once.
Tight calf muscles can contribute to the pain since the foot will tend to naturally point downward when sleeping because the calf muscle pulls on the heel. Night splints can be used; they work by keeping the plantar fascia stretched in a neutral position overnight.
Lower leg injuries account for about 10 percent of injuries seen in triathletes. The lower leg consists of two bones, the tibia and the fibula. The two most significant injuries to the lower leg are shin splints and stress fractures to the tibia.
Shin splints cause pain in the front part of the shin. The pain can be caused by irritation and swelling of the covering of the shinbone, known as the periosteum, where muscles attach. With each stride, these muscles pull against the area of the bone where they are attached and can cause the underlying tissue to become tender and swollen. The most common area is usually along the inner edge of the middle portion of the shin. Treatment includes rest and modification of activity (cycling and swimming are probably fine), ice, and anti-inflammatory medication.
Shin splints can sometimes progress to a stress fracture in the tibia if the underlying cause is not treated and if adequate rest isn’t obtained. The pain will be sharp and very focused in a small area. Differentiating between a stress fracture and shin splits requires an MRI. Treatment of stress fractures includes rest for 4 to 6 weeks or even longer.
Injuries to the pelvis, hip, and upper leg account for about 10 to 20 percent of injuries in triathletes (Tuite 2010). The hip is a ball and socket joint with far more stability than the shoulder, the other ball and socket joint in the body.
The most important injury to be aware of in this area is a femoral stress fracture. Stress fractures from overuse can occur in the neck of the femur where the bone narrows just before entering the hip socket. An undiagnosed femoral neck stress fracture can result in long-term damage to the hip. In severe cases, athletes may need to have hip replacement surgery to regain full function.
Femoral neck stress fractures are most common in long-distance and ultradistance runners and triathletes. These athletes are used to running through discomfort, and it can be very difficult for them to modify their activity level enough when pain first appears. By the time a stress fracture is diagnosed, the athlete will not be allowed to do any running at all until full healing takes place, which can take 6 weeks or longer.
Injuries in triathletes tend to mirror the injuries seen in single-sport athletes. Even though triathletes are always cross-training, they tend to have higher injury rates than their counterparts in single sports. Triathletes with the fewest injuries tend to train in the range of 8 to 10 hours per week. Those training fewer than 8 or more than 10 hours had higher injury rates. Hopefully these brief descriptions of various injuries in triathletes will help guide you in discovering the cause when you experience symptoms and in seeking medical treatment when needed.