Lower Extremity Injuries and Risk Factors in Triathlon: Traditional Review

Year 2025, Volume: 7 Issue: 1, 162 - 168, 28.03.2025

Eren Akdağ , Ali Işın

https://doi.org/10.56639/jsar.1573811

Abstract

Triathlon is a popular sport that combines swimming, cycling and running in a single competition. These three disciplines have high demands on training and stress on the body. Therefore, overusing the body causes an increased risk of injuries. Furthermore, triathletes spend most of their training time on cycling and running. This leads to most injuries occurring in the lower extremities. Previous studies in the relevant literature have examined the injury incidence of different lower extremity injuries, the profile of injuries, and the factors contributing to triathlon injuries. This current review addresses an important gap in the published literature describing the incidence of lower extremity injuries in triathlon, the profile of injuries that occur, and recommendations for injury prevention. The most common lower extremity injuries in triathletes are Achilles tendinopathy, plantar fasciitis, medial tibial stress syndrome, iliotibial band syndrome and patellofemoral pain syndrome. Most of such injuries in triathletes are caused by high training load frequency or training scope. For this reason, it is recommended to consider the contributing mechanisms of these injuries when planning training programs. In addition, individual and optimum planning of loading and rest intensity within the training program may be effective in preventing injuries. Another important point to reduce triathlon injuries is to improve the swimming, cycling and running technique of athletes. Improper technique contributes significantly to the incidence of injury in athletes. Finally, a periodic medical check-up is recommended to reduce injuries in athletes.

Keywords

lower extremity, injury, swimming, running, triathlon

Triatlonda Alt Ekstremite Yaralanmaları ve Risk Faktörleri: Geleneksel Derleme

Abstract

Triatlon, yüzme, bisiklet ve koşuyu tek bir etkinlikte birleştiren popüler bir spordur. Bu üç disiplinin antrenman talepleri ve vücut üzerindeki stresleri yüksektir. Bu nedenle vücudu aşırı kullanmak yaralanma riskinin artmasına neden olmaktadır. Ayrıca, triatletler antrenman zamanının büyük bölümünü bisiklet ve koşudan oluşturur. Bu da oluşacak yaralanmaların büyük çoğunluğunun alt ekstremitede meydana gelmesine neden olur. Literatürde yapılan çalışmalar alt ekstremitede görülen farklı yaralanmaların yaralanma sıklığını, yaralanmaların profilini ve triatlon yaralanmalarına katkıda bulunan faktörleri araştırmıştır. Bu derleme, triatlonda alt ekstremitede görülen yaralanma sıklığını, meydana gelen yaralanmaların profilini ve yaralanmanın önlenmesine ilişkin önerileri tanımlayan yayınlanmış literatürde var olan önemli boşluğunu vurgulamaktadır. Triatletlerde en yaygın görülen alt ekstremite yaralanmaları başlıca Aşil tendinopatisi, plantar fasiit, medial tibial stres sendromu, iliotibial bant sendromu ve patellofemoral ağrı sendromudur. Triatletlerde meydana gelen bu yaralanmaların büyük çoğunluğu yüklenme sıklığının veya antrenman kapsamının yüksek olmasından kaynaklanmaktadır. Bu nedenle antrenman planlamaları yapılırken bu yaralanma türlerine katkıda bulunan mekanizmaların dikkate alınması önerilmektedir. Ayrıca antrenman programı içerisinde yüklenme dinlenme şiddetinin bireysel ve optimum planlanması, yaralanmaların önlenmesinde etkili olabilir. Triatlon yaralanmalarını azaltmak için bir diğer önemli nokta ise sporcuların yüzme, bisiklet ve koşu tekniğinin geliştirilmesidir. Yanlış teknik sporcularda yaralanma insidansına önemli düzeyde katkıda bulunmaktadır. Son olarak, sporcularda yaralanmaları azaltmak için periyodik bir sağlık değerlendirmesi yapılması önerilmektedir.

Keywords

alt ekstremite, yaralanma, yüzme, bisiklet, koşu, triatlon

References

• Aicale, R., Tarantino, D., & Maffulli, N. (2018). Surgery in tendinopathies. Sports Medicine and Arthroscopy Review, 26(4), 200-202. https://doi.org/10.1097/JSA.0000000000000214
• Aicale, R., Tarantino, D., & Maffulli, N. (2019). Non-insertional achilles tendinopathy: State of the art. In Sports Injuries of the Foot and Ankle: A Focus on Advanced Surgical Techniques (pp. 359–367). https://doi.org/10.1007/978-3-662-58704-1_32
• Alba-Martín, P., Gallego-Izquierdo, T., Plaza-Manzano, G., Romero-Franco, N., Núñez-Nagy, S., & Pecos-Martín, D. (2015). Effectiveness of therapeutic physical exercise in the treatment of patellofemoral pain syndrome: a systematic review. Journal of physical therapy science, 27(7), 2387-2390. https://doi.org/10.1589/jpts.27.2387
• Andersen, C. A., Clarsen, B., Johansen, T. V., & Engebretsen, L. (2013). High prevalence of overuse injury among iron-distance triathletes. British journal of sports medicine, 47(13), 857-861. https://doi.org/10.1136/bjsports-2013-092397
• Baldassin, V., Gomes, C. R., & Beraldo, P. S. (2009). Effectiveness of prefabricated and customized foot orthoses made from low-cost foam for noncomplicated plantar fasciitis: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90(4), 701–706. https://doi.org/10.1016/j.apmr.2008.11.002
• Batt, M. E., Tanji, J. L., & Skattum, N. (1996). Plantar fasciitis: A prospective randomized clinical trial of the tension night splint. Clinical Journal of Sport Medicine, 6(3), 158–162. https://doi.org/10.1097/00042752-199607000-00004
• Behrens, G., Mauch, M., Ritzmann, R., & Paul, J. (2019). Achillessehnenläsionen im Sport. Sports Orthopaedics and Traumatology, 35(3), 272-279. https://doi.org/10.1016/j.orthtr.2019.07.009
• Bentley, D. J., Millet, G. P., Vleck, V. E., & McNaughton, L. R. (2002). Specific aspects of contemporary triathlon: implications for physiological analysis and performance. Sports Medicine, 32, 345-359. https://doi.org/10.2165/00007256-200232060-00001
• Bhandakkar, P. A., Naqvi, W., & Burhani, T. S. (2020). Impact of physiotherapy rehabilitation on patients with bilateral osteoarthritis knee pain: A case report. Journal of Evolution of Medical and Dental Sciences, 9(32), 2316–2317. https://doi.org/10.14260/jemds/2020/502
• Bhusari, N., & Deshmukh, M. (2023). Shin splint: a review. Cureus, 15(1). https://doi.org/10.7759/cureus.33905
• Bolgla, L. A., & Malone, T. R. (2004). Plantar fasciitis and the windlass mechanism: A biomechanical link to clinical practice. Journal of Athletic Training, 39(1), 77.
• Burns, J., Keenan, A. M., & Redmond, A. C. (2003). Factors associated with triathlon-related overuse injuries. Journal of Orthopaedic and Sports Physical Therapy, 33(4), 177–184. https://doi.org/10.2519/jospt.2003.33.4.177
• Cheatham, S. W., Kolber, M. J., Cain, M., & Lee, M. (2015). The effects of self-myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery, and performance: A systematic review. International Journal of Sports Physical Therapy, 10(6), 827.
• Crossley, K. M., Stefanik, J. J., Selfe, J., Collins, N. J., Davis, I. S., Powers, C. M., … Callaghan, M. J. (2016). 2016 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. British Journal of Sports Medicine, 50(14), 844–852. https://doi.org/10.1136/bjsports-2016-096384
• Dedes, V., Stergioulas, A., Kipreos, G., Dede, A., Mitseas, A., & Panoutsopoulos, G. (2018). Effectiveness and safety of shockwave therapy in tendinopathies. Materia Socio Medica, 30(2), 131. https://doi.org/10.5455/msm.2018.30.141-146
• DiGiovanni, B. F., Nawoczenski, D. A., Malay, D. P., Graci, P. A., Williams, T. T., Wilding, G. E., & Baumhauer, J. F. (2006). Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. The Journal of Bone & Joint Surgery, 88(8), 1775–1781. https://doi.org/10.2106/jbjs.e.01281
• Donley, B. G., Moore, T., Sierra, J., Gozdanovic, J., & Smith, R. (2007). The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: A randomized, prospective, placebo-controlled study. Foot and Ankle International, 28(1), 20–23. https://doi.org/10.3113/FAI.2007.0004
• Drew, M. K., & Finch, C. F. (2016). The relationship between training load and injury, illness and soreness: a systematic and literature review. Sports medicine, 46, 861-883. https://doi.org/10.1007/s40279-015-0459-8
• Ellis, R., Hing, W., & Reid, D. (2007). Iliotibial band friction syndrome—a systematic review. Manual therapy, 12(3), 200-208. https://doi.org/10.1016/j.math.2006.08.004
• Etxebarria, N., Mujika, I., & Pyne, D. B. (2019). Training and competition readiness in triathlon. Sports, 7(5), 101. https://doi.org/10.3390/sports7050101
• Fick, D. S., Albright, J. P., & Murray, B. P. (1992). Relieving Painful ‘Shin Splints’. The Physician and sportsmedicine, 20(12), 105-113. https://doi.org/10.1080/00913847.1992.11947542
• Fredericson, M., & Misra, A. K. (2007). Epidemiology and aetiology of marathon running injuries. Sports Medicine, 37, 437-439. https://doi.org/10.2165/00007256-200737040-00043
• Fredericson, M., & Wolf, C. (2005). Iliotibial band syndrome in runners: innovations in treatment. Sports medicine, 35, 451-459. https://doi.org/10.2165/00007256-200535050-00006
• Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral pain syndrome. American family physician, 99(2), 88-94.
• Guevara, S. A., Crunkhorn, M. L., Drew, M., Waddington, G., Périard, J. D., Etxebarria, N., ... & Charlton, P. (2024). Injury and illness in short-course triathletes: a systematic review. Journal of Sport and Health Science, 13(2), 172-185. https://doi.org/10.1016/j.jshs.2023.03.002
• Hadeed, A., & Tapscott, D. C. (2023). Síndrome de fricción de la banda iliotibial. Current Reviews in Musculoskeletal Medicine, 3(1–4), 153–158.
• Hadeed, A., & Tapscott Affiliations, D. C. (2023). Iliotibial band friction syndrome: Continuing education activity. Study Guide from StatPearls Publishing, Treasure Island
• Heinemeier, K. M., Øhlenschlæger, T. F., Mikkelsen, U. R., Sønder, F., Schjerling, P., Svensson, R. B., & Kjaer, M. (2017). Effects of anti-inflammatory (NSAID) treatment on human tendinopathic tissue. Journal of Applied Physiology, 123(5). https://doi.org/10.1152/japplphysiol.00281.2017
• Hutchinson, L. A., Lichtwark, G. A., Willy, R. W., & Kelly, L. A. (2022). The iliotibial band: a complex structure with versatile functions. Sports Medicine, 52(5), 995-1008. https://doi.org/10.1007/s40279-021-01634-3
• Hutchinson, A. M., Evans, R., Bodger, O., Pallister, I., Topliss, C., Williams, P., ... & Beard, D. (2013). What is the best clinical test for Achilles tendinopathy? Foot and Ankle Surgery, 19(2), 112–117.
• Jayaseelan, D. J., Kecman, M., Alcorn, D., & Sault, J. D. (2017). Manual therapy and eccentric exercise in the management of Achilles tendinopathy. Journal of Manual and Manipulative Therapy, 25(2), 106–114. https://doi.org/10.1080/10669817.2016.1183289
• Johnson, U., & Ivarsson, A. (2017). Psychosocial factors and sport injuries: prediction, prevention and future research directions. Current opinion in psychology, 16, 89-92. https://doi.org/10.1016/j.copsyc.2017.04.023
• Johnston, E., Flynn, T., Bean, M., Breton, M., Scherer, M., Dreitzler, G., & Thomas, D. (2006). A randomized controlled trial of a leg orthosis versus traditional treatment for soldiers with shin splints: A pilot study. Military Medicine, 171(1), 40–44. https://doi.org/10.7205/MILMED.171.1.40
• Kale, N. N., Wang, C. X., Wu, V. J., Miskimin, C., & Mulcahey, M. K. (2022). Age and female sex are important risk factors for stress fractures: A nationwide database analysis. Sports Health, 14(6), 805–811. https://doi.org/10.1177/19417381221080440
• Kienstra, C. M., Asken, T. R., Garcia, J. D., Lara, V., & Best, T. M. (2017). Triathlon injuries: Transitioning from prevalence to prediction and prevention. Current Sports Medicine Reports, 16(6), 397–403. https://doi.org/10.1249/JSR.0000000000000417
• Lepers, R., Rüst, C. A., Stapley, P. J., & Knechtle, B. (2013). Relative improvements in endurance performance with age: Evidence from 25 years of Hawaii Ironman racing. Age, 35(3), 953–962. https://doi.org/10.1007/s11357-012-9392-z
• Lim, A. T., How, C. H., & Tan, B. (2016). Management of plantar fasciitis in the outpatient setting. Singapore Medical Journal, 57(4), 168–173. https://doi.org/10.11622/smedj.2016069
• Lopes, A. D., Hespanhol, L. C., Yeung, S. S., & Costa, L. O. P. (2012). What are the main running-related musculoskeletal injuries? A systematic review. Sports medicine, 42, 891-905. https://doi.org/10.2165/11631170-000000000-00000
• Maclachlan, L. R., Collins, N. J., Matthews, M. L., Hodges, P. W., & Vicenzino, B. (2017). The psychological features of patellofemoral pain: a systematic review. British journal of sports medicine, 51(9), 732-742. https://doi.org/10.1136/bjsports-2016-096705
• Magnan, B., Bondi, M., Pierantoni, S., & Samaila, E. (2014). The pathogenesis of Achilles tendinopathy: a systematic review. Foot and Ankle Surgery, 20(3), 154-159. https://doi.org/10.1016/j.fas.2014.02.010
• Martin, R. L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., McDonough, C. M., ... & Carcia, C. R. (2018). Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2018: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 48(5), A1-A38. https://doi.org/10.2519/jospt.2018.0302
• McNally, E. G., & Shetty, S. (2010). Plantar fascia: Imaging diagnosis and guided treatment. Seminars in Musculoskeletal Radiology, 14(3), 334–343. https://doi.org/10.1055/s-0030-1254522
• Mujika, I. (2014). Olympic preparation of a world-class female triathlete. International Journal of Sports Physiology and Performance, 9(4), 727–731. https://doi.org/10.1123/IJSPP.2013-0245
• Murphy, K., Curry, E. J., & Matzkin, E. G. (2013). Barefoot running: does it prevent injuries?. Sports Medicine, 43, 1131-1138. https://doi.org/10.1007/s40279-013-0093-2
• Nielsen, R. Ø., Parner, E. T., Nohr, E. A., Sørensen, H., Lind, M., & Rasmussen, S. (2014). Excessive progression in weekly running distance and risk of running-related injuries: An association which varies according to type of injury. Journal of Orthopaedic and Sports Physical Therapy, 44(10), 739–747. https://doi.org/10.2519/jospt.2014.5164
• Noehren, B., Davis, I., & Hamill, J. (2007). ASB Clinical Biomechanics Award Winner 2006. Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clinical Biomechanics, 22(9), 951–956. https://doi.org/10.1016/j.clinbiomech.2007.07.001
• Nunes, G. S., Stapait, E. L., Kirsten, M. H., de Noronha, M., & Santos, G. M. (2013). Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis. Physical Therapy in Sport, 14(1), 54-59. https://doi.org/10.1016/j.ptsp.2012.11.003
• Orchard, J. W., Fricker, P. A., Abud, A. T., & Mason, B. R. (1996). Biomechanics of iliotibial band friction syndrome in runners. American Journal of Sports Medicine, 24(3), 375–379. https://doi.org/10.1177/036354659602400321
• Pawar, A. (2021). A case report of fractured tibia with improved outcomes through early physiotherapy approach. Bioscience Biotechnology Research Communications, 14(6), 57–61. https://doi.org/10.21786/bbrc/14.6.14
• Petraglia, F., Ramazzina, I., & Costantino, C. (2017). Plantar fasciitis in athletes: diagnostic and treatment strategies. A systematic review. Muscles, ligaments and tendons journal, 7(1), 107. https://doi.org/10.11138/mltj/2017.7.1.107
• Pietrzak, M. (2014). Diagnosis and management of acute medial tibial stress syndrome in a 15-year-old female surf life-saving competitor. International Journal of Sports Physical Therapy, 9(4), 525.
• Powers, C. M., Bolgla, L. A., Callaghan, M. J., Collins, N., & Sheehan, F. T. (2012). Patellofemoral pain: Proximal, distal, and local factors, 2nd International Research Retreat. Journal of Orthopaedic and Sports Physical Therapy, 42(6), A1–A54. https://doi.org/10.2519/jospt.2012.0301
• Prins, M. R., & van der Wurff, P. (2009). Females with patellofemoral pain syndrome have weak hip muscles: A systematic review. Australian Journal of Physiotherapy, 55(1), 9–15. https://doi.org/10.1016/S0004-9514(09)70055-8
• Shaw, T., Howat, P., Trainor, M., & Maycock, B. (2004). Training patterns and sports injuries in triathletes. Journal of Science and Medicine in Sport, 7(4), 446–450. https://doi.org/10.1016/S1440-2440(04)80262-7
• Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020). Current clinical concepts: Conservative management of achilles tendinopathy. Journal of Athletic Training, 55(5), 438–447. https://doi.org/10.4085/1062-6050-356-19
• Silbernagel, K. G., Thomeé, R., Eriksson, B. I., & Karlsson, J. (2007a). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with achilles tendinopathy: A randomized controlled study. American Journal of Sports Medicine, 35(6), 897–906. https://doi.org/10.1177/0363546506298279
• Silbernagel, K. G., Thomeé, R., Eriksson, B. I., & Karlsson, J. (2007b). Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy. British Journal of Sports Medicine, 41(4), 276–280. https://doi.org/10.1136/bjsm.2006.033464
• Sisk, D., & Fredericson, M. (2020). Taping, bracing, and injection treatment for Patellofemoral pain and patellar tendinopathy. Current Reviews in Musculoskeletal Medicine, 13, 537-544. https://doi.org/10.1007/s12178-020-09646-8
• Soligard, T., Schwellnus, M., Alonso, J. M., Bahr, R., Clarsen, B., Dijkstra, H. P., … Engebretsen, L. (2016). How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. British Journal of Sports Medicine, 50(17), 1030–1041. https://doi.org/10.1136/bjsports-2016-096581
• Spiker, A. M., Dixit, S., & Cosgarea, A. J. (2012). Triathlon: running injuries. Sports medicine and arthroscopy review, 20(4), 206-213. https://doi.org/10.1097/JSA.0b013e31825ca79f
• Strauss, E. J., Kim, S., Calcei, J. G., & Park, D. (2011). Iliotibial band syndrome: evaluation and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 19(12), 728-736. https://doi.org/10.5435/00124635-201112000-00003
• Tarantino, D., Palermi, S., Sirico, F., & Corrado, B. (2020). Achilles tendon rupture: mechanisms of injury, principles of rehabilitation and return to play. Journal of functional morphology and kinesiology, 5(4), 95. https://doi.org/10.3390/jfmk5040095
• Taunton, J. E., Ryan, M. B., Clement, D. B., McKenzie, D. C., Lloyd-Smith, D. R., & Zumbo, B. D. (2002). A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine, 36(2), 95–101. https://doi.org/10.1136/bjsm.36.2.95
• Tenforde, A. S., Sayres, L. C., Sainani, K. L., & Fredericson, M. (2010). Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature. Pm&r, 2(10), 945-949. https://doi.org/10.1016/j.pmrj.2010.05.006
• Thacker, S. B., Gilchrist, J., Stroup, D. F., & Kimsey Jr, C. D. (2004). The impact of stretching on sports injury risk: a systematic review of the literature. Medicine & Science in Sports & Exercise, 36(3), 371-378. https://doi.org/10.1249/01.MSS.0000117134.83018.F7
• Tuite, M. J. (2010). Imaging of triathlon injuries. Radiologic Clinics of North America, 48(6), 1125-1135. https://doi.org/10.1016/j.rcl.2010.07.008
• Van der Vlist, A. C., Breda, S. J., Oei, E. H., Verhaar, J. A., & de Vos, R. J. (2019). Clinical risk factors for Achilles tendinopathy: a systematic review. British journal of sports medicine, 53(21), 1352-1361. https://doi.org/10.1136/bjsports-2018-099991
• Walli, O., McCay, M., & Tiu, T. (2023). Patellofemoral syndrome: a review of diagnosis and treatment. Current Physical Medicine and Rehabilitation Reports, 11(2), 139-143. https://doi.org/10.1007/s40141-023-00385-8
• Wu, S. S., Peiffer, J. J., Brisswalter, J., Nosaka, K., & Abbiss, C. R. (2014). Factors influencing pacing in triathlon. Open Access Journal of Sports Medicine, 5, 223-234. https://doi.org/10.2147/oajsm.s44392
• Young, C. (2012). Plantar fasciitis. Annals of Internal Medicine, 156(1). https://doi.org/10.7326/0003-4819-156-1-201201030-0100