Rob Dallimore is a consultant Podiatrist based in Auckland and has a special interest in multisport athletes. He is able to assess and treat chronic or acute lower limb injuries where there is a biomechanical abnormality, and can perform a bicycle position assessment and correction. His gait and bicycle analysis is with the use of a digital video camera and a great new biomechanics computer programme. Rob also deals with the less glamorous problems that all athletes come across such as removing corns and callous, treating ingrown toe nails etc. He is ACC accredited and is an approved treatment provider for the New Zealand Academy of Sport so can treat carded athletes. For more information on where to find Rob, visit www.foottraffic.co.nz or contact Rob at: rob@foottraffic.co.nz

If I was given a dollar for each time I have pondered to myself why I seem to always carry an injury, when other triathletes are able to keep training and racing injury free, I would be able to afford all those expensive toys on my Christmas list. Over time and after seeing a variety of clients (all shapes, sizes, abilities and from many different sporting backgrounds) the answers have begun to make themselves clear. Quite simply, the ones who are constantly injured may be predisposed to certain types of injury. This is most likely related to biomechanical alignment, training practices, gender, age, underlying medical conditions and genetics.

From what I have heard around the transition area and at the post race functions, triathletes and multisporters are becoming more and more aware of the injuries they may experience, what they should do to avoid them and who they should consult about them. This appears to be a vast improvement on some years ago.

As a Podiatrist, I attempt to explain all reasons for the development of lower limb injuries: internal factors such as genetics and physiology and external factors such as training practices and environment. It must be emphasised that in some cases a Podiatrist should be used as part of a holistic approach, not necessarily as the sole practitioner. This means that regular communication should occur between the Podiatrist, GP, Physiotherapist, Masseuse, Coach, and other practitioners and of course you, the athlete.

A survey on trialthon injuries was done after the 1986 Hawaii Ironman World Championships and it concluded with a very generalised and inaccurate statement that "the incidence of overuse injuries was not associated with excessive training distances, pace or time, but instead that biomechanical factors solely lead to injury". Because the incidence of injury in the triathlete and multisporter seems to be steadily increasing across all levels of competition, it is not surprising that questions arise as to the reason for their development, the treatment for and the prevention of such injuries. Recent studies and current theory has contradicted the 1986 Ironman survey, indicating that there is a distinct cause-and-effect relationship between training error and the development of an overuse injury.

So why is it that injuries occur in the multisport athlete when much of the training involves a high proportion of low impact exercise - swimming, cycling and kayaking?

There are two types of injuries: those caused by accidents (such as spraining an ankle), and those caused by overuse. Overuse injuries may not be identified to a defined incident - however, there may have been a change in training, running surface, footwear, bike position or nutrition that has bought on the injury - this is often discovered early on in the initial consultation with the Podiatrist. It is believed that the overuse injury is due to the cumulative effects of multisport training, in all disciplines.

In the past it was thought that multidiscipline training reduced the chance of an overuse injury, because it was thought that it would decrease excessive stress to specific areas of the body. Today it's clearly understood that the regular back-to-back training sessions required for effective multisport training probably don't provide the body sufficient time to recover. This, combined with biomechanical, physiological and training factors, may result in the development of an injury if the athlete is not in-tune with their body, and/or has a poorly constructed training program.

It is not suprising that well over half of all triathletes have sustained some form of injury during training for competition. The majority of injuries involve the lower limb, probably due to the excessive impact during running, and the repetitive motion of cycling. Although no studies have been done in the area, it is thought that multisport athletes may have different injury lvels as training and racing in the run discipline is often performed on an off road surface, therefore different levels of impact are applied to the body (however injuries from accidents may be more common due to the uneven running surface).

A major cause for concern only 42% of all injuries are treated with appropriate medical advice, if any at all. In the early stages, an injury is often very easily and effectively treated, with few complications, especially if the cause of the injury is identified. The short-term medical plan will often aim to remove the factors causing the problem before any other exercise is performed. Ignorance of developing injuries will, in many cases, result in stopping training all together - this may be particularly true in the development of stress fractures of the lower limb. Another major risk factor for severe injuries is to return to activity too early, before the body has been able to recover - just because the pain is not there it does not mean that the injury is totally healed. One of the biggest challenges for a medical team is to convince the athlete to stay on the side-lines, or to take it easy for the early training stages - in my experience, REST is the athlete's four-letter-word!

Almost half of all triathletes have a background in running, and therefore may be the discipline that is concentrated on more regularly. Although training principles today have undoubtedly changed since the 1986 Hawaii Ironman, there were some interesting findings from the research mentioned earlier: cycling training comprises of an average 350km per week over 4-5 days, whereas running comprises of 72km per week average over 4-6 days. This shows that there is more high impact (running) than low impact activity (cycling), which indicates there is a great deal of stress placed on the muscles/tendons, bones and ligaments of the lower limb. These figures would no doubt differ for athletes competing in shorter events and they may also alter for multisport training. It's important to find a balance between the intense sessions and lighter/recovery sessions, and not to neglect the rest days. Multiple session training days for most of us should alternate between activities that use different muscle groups and actions.

During running, the body's tendons, ligaments and bones all have their own levels of elasticity and can withstand regular stresses up to, but not exceeding, this level. Once the maximal elasticity has been passed the tissue begins to have small tears or areas of inflammation - this is often encountered during speed or long training sessions if the body has not been gradually built up to the required level. Early symptoms may be felt at this stage, especially areas of pinpoint tenderness or along the length of a bone's border, pain at a tendon's insertion to a bone, or pain within the tendon itself. Continued training, without removal of the factors causing the problem and/or appropriate treatment at this stage will eventually cause the tissue to deform or weaken. This often results as a stress fracture or a partial or total rupture of a tendon.

The above scenario is over-generalised and not experienced in all cases, however it does highlight the result of ignorance of symptoms and incorrect training. If medical advice is sought at an early stage then the necessary measures can be taken to ensure the injury does not develop further.

Treatment to that problem may involve:
· The reduction of inflammation at the site of injury with physical therapy and/or anti-inflammatory medication
· Alteration of exacerbating factors such as poor footwear or training surface
· Alteration of biomechanical position, with the use of orthoses, if necessary
· Alteration of training regime if it seems too excessive
· Active rest, which involves continuing moderate exercise but not to stress the injured structures. In most cases total rest should be avoided as this may weaken tissue and result in another injury when training is re-commenced
· Advice on prevention of injury recurrence
· Communication with others involved such as your coach

So why is it some people (such as elite athletes, Ironman competitors, Coast to Coast competitors and Mizone Endurazone competitors) can train at a high levels and still remain injury free?

In most cases these people have been able to gradually increase their training intensity over a longer period of time, to allow their bodies to adapt to the increased stress. Most of these athletes are smart trainers - they may get injured but they are able to control the progression of the injury. These athletes generally don't push themselves too much all the time. For example Lance Armstrong, in his autobiography 'It's not about the bike' discusses how he trains at a very low intensity for the majority of his program, with the perfect mix of speed sessions. However, their ability to train effectively and remain injury free is not just due to training principles, a lot of it comes down to the old favourite - genetics. Essentially, an athlete's physiology and lower limb biomechanical position is largely determined by genetics and this will affect the way the legs adapt to the stress applied during the running and cycling discipline. This, together with an effective training and medical plan may explain why some siblings are able to race successfully on the world stage, over many seasons, with out any major injuries.

It is crucial to understand that we as multisporters and triathletes compete in a sport that requires very effective management of our training regime. Our bodies may be more susceptible to injury than other athletes because in some cases we are required to pack in more than one training session per day and this doesn't give our bodies much time to recover properly to prepare for the next session. We must listen to our bodies and be aware of what action to take if an injury is apparent and be sure not to neglect our rest days. It is always better, for body and mind, to stand on the start line with the confidence that we are injury free and have trained with our brains, not just with our legs.

References
1. O'Toole, M.L., Douglas, W., Hiller, B., Smith, R.A., & Sisk, T.D. (1989). Overuse injuries in ultra endurance triathletes. The American Journal of Sports Medicine, 17 (4). 514-518.
2. Cipriani, D.J., Swartz, J.D., & Hodgson, C.M. (1998). Triathlon and the multisport athlete. Journal of Orthopaedic and Sports Physical Therapy, 27 (1). 42-50.