1. Triathlon : medical considerations Dr Tom Cross FACSP,MBBS,DCH

2. Outline of talk Introductory concepts Musculo-skeletal Injuries Illness/Medical conditions Conclusion

3. Introduction Triathlon started in California in 1970s Sport began in Australia in early 1980s International sport: more than 120 nations Olympic sport since 2000 Sydney games 160,000 Australians compete 180 Tri clubs in Australia National and State Federations

4. Australian Success Greg Welch Michellie Jones Chris McCormack Emma Moffatt Craig Alexander Emma Snowsill Miranda Carfrae

5. 3 Disciplines Swim-Bike-Run Competitors: recreational and elite/pro series Athletes often very successful in other sports Differing Distances Sprint 750/20/5 Olympic 1.5/40/10 Half Iron Man 1.9/90.1/21.1 Iron Man 3.8/180.2/42.2

6. Medical Team Physiotherapist Soft tissue therapist Chiropractor/Osteopath Doctor Nurse Dietician Podiatrist Bike Mechanic Biomechanist St Johns Ambulance

7. Injuries and Illness Musculoskeletal (MSK) injuries Acute Overuse Illness Dehydration/Heat Illness Hypothermia Water Intoxication Cardiovascular Female athlete triad Overtraining Syndrome/Fatigue Infectious Disease

8. Injuries Sport specific injuries Discipline specific Swimming Cycling Running: causes most injuries Paucity of Evidence Based Medicine regarding Injuries!

9. Injuries Swimming Shoulder Rotator cuff tendinopathy Common causes Training error Technique flaw Dropping the elbow Insufficient body roll Unidirectional breathing Pull through phase Using paddles and pool buoys Prevention Correct technique flaws Periodize training Theraband exercises/gym training/stretching programme Scientific approach to training

10. Injuries Cycling Acute Falls Head and Spine Shoulder girdle (fractures/dislocations) Abrasions/lacerations Prevention Familiarize self with course Helmet Exercise caution Overuse Spine (neck, thoracic, low back) Knee –patellofemoral pain,ITB friction syndrome Pressure neuropathies (wrist,perineum) Prevention Bike set up Core Stability on Bike Scientific approach to training

11. Injuries Running Acute Muscle strain injury Muscle cramping Joint sprains (ankle,knee etc) Overuse Tendinopathy (achilles,patellar etc) Stress Fractures (foot, tibia, femur etc) Myofascial pain e.g. Plantar fasciitis

12. Injuries Running overuse injuries Causes Training Error (volume, frequency, intensity, surfaces) Biomechanics (alignment, running efficiency) New coach/club/training group Footwear Poor Bone health Inadequate warm up/cool down, stretching, massage Prevention Scientific approach to training Podiatry Optimize running technique Optimize Bone health Recovery strategies

13. Illness 1. Thermal stress 1. Heat illness/dehydration 2. Hypothermia 2. Water Intoxication 3. Cardiovascular 4. Female athlete triad 5. Overtraining syndrome 6. Infection

14. Illness Heat Illness/Dehydration Wet bulb globe temperature: measure of thermal stress Risk factors Individual susceptibility Recent illness Inadequate fluid intake Sleep deprivation/jet lag Failure to acclimatize Clothing Medications (amphetamines, alcohol) Prevention Hydration Acclimatize Clothing choice (high wicking factor) Modify other risk factors

15. Illness Hypothermia Swim: most at risk! Cycling Prevention Wetsuit choice Clothing on bike

16. Illness Water Intoxication Fluid and electrolyte disturbance Drinking yourself to death Exercise associated Hyponatraemia Serum sodium <135 mmol/litre Risk Factors longer endurance events > 4 hours Female Slower runners (more time to drink) Occurred secondary to perception Drinking caused performance enhancement Drinking reduces risk of Dehydration/heat illness Symptoms Nausea/vomiting, shortness of breath, confusion, coma and death

17. Illness Water Intoxication Prevention Fewer drinking stations Education: dangers of over-drinking Aim to drink 400-800 mls per hour No difference if water or sports drinks or take salt tablets Medications: avoid Anti-inflammatories

18. Illness Cardiovascular Recreational Sudden cardiac death <35 Congenital heart disease >35 Coronary artery disease Elite/Pro Triathletes Pathological variant of Athletes heart: Cardiomyopathy: conduction disorders/arrhythmias Greg Welch: ventricular tachycardia requiring an implantable defibrillator

19. Illness The Female Athlete Triad Disordered eating (much more common in elite athletic women than normal population) EDNOS, Anorexia,Bulimia Menstrual disturbance (Caloric restriction + Intensive exercise) Amenorrhea, Oligomenorrhoea, luteal phase defects Poor Bone heath (inadequate estrogen) Osteopenia, Osteoporosis: Increased risk of STRESS FRACTURES and OSTEOPOROSIS in later life! At risk sports Endurance (running, triathlon) Aesthetic (gymnastics, diving, figure skating, synchronized swimming) Weight divisions (Martial arts) Bone health Accrual occurs in teenage/early 20s Peak Bone mass by 25-30 Can assess with BMD testing (Anthropometric assessment) Bone mineral density deficit only partially reversible

20. Illness Female Athlete Triad Treatment Multi-disciplinary Treat the disordered eating and compulsive exercise Aim to restore menstrual cycle, if not use OCP Use of Calcium and Vit D supplementation Prevention Educate female athletes Screening of athletes: identify at risk athletic women

21. Illness Overtraining syndrome/Fatigue Definition: continued fatigue after 2 weeks of rest. Causes Excessive exercise TRAINING ERROR Over-crowded lifestyle/Time poor individual (Psycho-social stressors) Poor nutrition: running on empty ! Inadequate recovery from viral illness Sympathetic nervous system exhaustion ! Symptoms Training and performance decrement Increased perceived level of exertion Increased muscle soreness Exclude other causes of fatigue Iron deficiency Other Nutritional deficiencies (COH, Dehydration etc) Depression Disordered eating Other medical causes (Cardiac, respiratory, endocrine etc)

22. Illness OTS/Fatigue Treatment Relative rest Simplify lifestyle/minimize stressors Optimize diet/recovery strategies/meditation Prevention Periodize training (micro/macro cycles) Monitor symptoms (energy, mood, muscle soreness, sleep quality etc) Optimize diet/recovery strategies

23. Illness Infection Exercise and Immunity Inverted U curve Moderate exercise improves immune function (<60% of VO2 max) Excessive/intensive exercise (>80% VO2 max) causes a transient depression of immunity: The open window theory Decrease in mucosal immunity Decrease in cellular function Micro-organisms get the upper hand !

24. Illness Infection Can I train when I am sick? Do a neck check! Symptoms above the neck? (sore throat/running nose) Either train at 50% of usual intensity/duration Wait until symptoms resolve and recommence usual training Symptoms above and below neck (fever, cough, muscle soreness, nausea etc) Wait until symptoms resolve and then wait a further 2 days and then slowly recommence training

25. Illness Infection Prevention Immunization (Routine + Hep A/B, Influenza, meningococcal ) Periodize training Optimize diet/recovery strategies Universal precautions while traveling (e.g. sharing drink bottles etc.) Increased risk with adverse environmental conditions (cold and heat stress) Avoid/isolate sick athletes Supplements: Lactobacillus Yogurt, Echinacea, Multivitamins

26. Concluding remarks 1. Beware Drugs in sport 1. If concerned check WADA website 2. Seek medical screening (Doctor/Physiotherapist) if concerned about past medical history &/or injury history 3. Report injury/illness early! 4. Educate yourself about Periodization of training and practice other PREVENTATIVE strategies to prevent both injury and illness!!

27. Thank you