Triathlon Injuries – 3 Common Injuries & Physiotherapy Treatment

Triathlon season is upon us again with many races in Singapore between March and April. Triathlons are an intense sport that requires exceptional endurance and adequate preparation. However, the intense training required to participate in triathlons can lead to overuse injuries due to athletes pushing themselves to their limits. In this article, we will discuss the top three overuse triathlon injuries experienced by triathletes and how to prevent them.

Top 3 Triathlon Injuries

1) Swimmer’s Shoulder

Swimmer’s Shoulder is the most common condition affecting the shoulder joint that often occurs due to repetitive overhead movements during swimming. As the shoulder is the most mobile joint of the body, there comes with a greater risk of instability hence the surrounding rotator cuff muscles and ligaments are crucial to provide additional support to the shoulder. As the arm pulls through the water resistance over many repetitive strokes, these muscles and tissues get fatigued over time, leading to reduced control of the arm bone within the ball socket. This can cause repeated pinching of the tendons against the acromion and give a sudden catching kind of pain, leading to inflammation and fraying of the soft tissues.

Symptoms of Swimmer’s Shoulder

Symptoms of swimmer’s shoulder can include:

Pain during overhead arm movements or reaching behind back
Swelling or tenderness in the front or back of the shoulder
Weakness in the shoulder joint muscles
Decreased range of motion
Shoulder stiffness

Causes of Swimmer’s Shoulder

Swimmer’s shoulder may occur due to:

Overtraining – due to the high volume of strokes the shoulder undergoes, the stabilizing muscles of the shoulder blade get early fatigue and subsequently unable to restrict the head of the arm bone from translating upwards into the space containing the rotator cuff muscles, causing inflammation and pain.
Poor stroke technique – If a swimmer’s arm crosses his body’s midline and enters the water with the thumb pointing down and the palm facing outwards, this may cause impingement of the long head of the biceps tendon. By addressing proper entry, this condition may be avoided.
Unilateral breathing – Swimmers who consistently turn their heads to the same side to breathe during the stroke are risking shoulder pain in the opposite shoulder. Due to decreased movement in tilting and rotating the trunk to the non-breathing side, this shoulder has to work harder to support forward movement, leading to muscle fatigue and higher chances of impingement.
Past injuries – depending on the nature and extent, previous traumatic or overuse injuries may cause weakening of the shoulder muscles and cartilage support, which can be easily aggravated during intense training

Managing Swimmer’s Shoulder with Physiotherapy

A Physiotherapy session will help in managing the pain symptoms through:

Assessment of posture at the head, middle back and shoulder girdle region for muscle imbalances, strength weakness or stiffness or flexibility issues.
Managing inflammation, pain and swelling symptoms through cryotherapy or electrophysical agents
Stretching and soft tissue release of tight muscles pulling the joint out of position
Joint mobilisation techniques to reduce stiffness and improve movement mechanics within the socket of the shoulder joint
Strengthening of the rotator cuff muscles and scapular stabilisers muscles that are important to centralize the humerus at different shoulder positions for better stability

2) Cyclist’s Back – Lower Back Pain

Lower back pain is the most common complaint for cyclists of all levels. Prolonged bent-over positions while holding the handlebar can cause back pain. This position leads to back pain because the surrounding muscles of the lower back cannot generate force for back support. Overstretched and lengthened muscles result in reduced force-producing capabilities, leading to back pain. Additionally, thigh muscles are connected to the lower back. Tight thigh muscles during pedalling gradually pull the lower back into a more curved position, resulting in increased strain on the lower back muscles.

Symptoms of cyclist’s back

Over time, cycling in such a flexed trunk position may result in:

Back pain persisting the day after cycling
Pain from the lower back running down one or both legs, especially if it goes down the knee
Weakness, numbness or tingling in one or both legs
Limited or guarding during movement of the lower back during normal activities

Managing Cyclist’s Back with Physiotherapy

A physiotherapy session will help manage your lower back pain symptoms through the following methods:

Bike fitting – analysis of proper foot placement, seat height position and handlebar placement
Lower back movement assessment to establish possible faulty biomechanical factors and compensatory behaviours
Testing for muscle imbalances that can put undesirable strain on the lower back, such as tight trunk or lower leg muscles that limits optimal movement; as well as weakness of the supporting trunk, core, hip muscles
Core abdominal training along with hip and thigh muscles will be the foundational approach, so that they can be strong enough to withstand external forces of cycling, taking load and tension of the lower back
Soft tissue release targeting the tight muscles along with joint mobilization techniques to increase tissue and joint flexibility to allow optimal transfer of load across the body, reducing overloading on the lower back

3) Shin Splints

Shin splints refer to pain along the shin bone. It is common along the inner border of the shinbone or on the outer border along with the muscles. Running or any physical activity that involves high or repetitive impact can cause this condition. The pain from shin splints comes from the periosteum, a thin sheath that covers all bones. This sheath is rich in nerve endings and can detect pain. When the periosteum is over-strained and irritated, it gets inflamed, causing pain.

Symptoms of Shin Splints

Symptoms of shin splints include:

Localised dull, achy pain felt in the lower third of the shinbone during the start of the run, but disappear as the activity progresses or when at rest.
There can be mild swelling in the lower shin area that can be tender to touch after physical activity for up to several days and resolved with rest
If left untreated, shin splints may progress to the development of a tibial stress fracture.

Causes of Shin Splints

Shin splints can result from:

Overuse – Due to inadequate fitness conditioning, and sudden increase in training intensity can cause the muscles and bones in the leg to overwork with repetitive and stressful motions beyond the body’s tolerance level
Running on uneven surfaces, where more shock will be dissipated back to the shinbone compared to flat surfaces
Poor running biomechanics – The human body absorbs and distributes force through the skeletal and muscular systems, with a tolerance level to compensate for additional stresses. When this coping mechanism is exceeded, injury can occur. This can happen when certain parts are not functioning optimally such as having tight calf muscles, weak hip muscles and poor balance control; hence other parts of the system have to compensate and become overloaded over time.

Managing Shin Splints

Physiotherapy of shin splints will focus on:

Movement analysis of the lower chain of the hip, knee and ankle during walking and running to see for compensations that may contribute to pain, such as muscle tightness or imbalances
Pain management with the application of cryotherapy along with electrophysical modalities like ultrasound therapy and electrical stimulation to ease the pain.
Manual techniques like soft tissue release and joint mobilisation on the calf muscles to improve ankle flexibility and optimise load transfer to the shinbone
Building up progressive tissue-loading of the shinbone by modifying training intensity and frequency, along with developing strong core, hip, and gluteal muscles balance training to help you adapt to running surface incongruities.

Seek Physiotherapy Treatment for Triathlon Injuries

Overuse triathlon injuries are common due to the intensive training regimes of triathletes. The most common injuries are swimmer’s shoulder, cyclist’s back, and shin splints. Regular sports physiotherapy sessions can help prevent these injuries by assessing posture, managing inflammation, pain and swelling symptoms. Your physiotherapist can help with stretching and soft tissue release, joint mobilisation techniques, and strengthening of the rotator cuff muscles and scapular. If you are experiencing pain or think you may be experiencing an injury, do seek help from a physiotherapist.

If you are a triathlete looking to improve your transition timing, have a read of this article we wrote with a seasoned triathlete on speedy triathlon transitions