By Helen Jewell
Endurance athletes and triathletes put a massive strain on their body by spending hours upon hours doing continuous, repetitive movements. The hours spent training will increase the likelihood of injury, but as a serious athlete it is necessary to push the body and test limits in order to progress and move forward. Therefore, we must be smart and look at ways to minimise risk and try to prevent injuries from occurring.
The most common injuries in endurance athletes and triathletes are overuse injuries. A few of these are listed below and fall in the top 6 for most prevalent injuries sustained.
Runners Knee (chondromalacia patellae)
Swimmer’s shoulder (shoulder impingement)
As we have covered Achilles Tendinopathy in our previous blog, I will focus on the other injuries in this article. For each condition I will give a brief overview of the condition, along with common symptoms and risk factors and provide a few exercises and stretches to help avoid injury or rehabilitate from injury. So let’s begin!
Iliotibial Band Syndrome (ITBS)
The ITB is a strong fibrous tissue that runs down the lateral aspect of the leg with ligamentous, tendinous and muscular components and it has been reported that it cannot be stretched.
ITBS is a thickening and remodelling-like tendinopathy, and the highly vascular adipose tissue beneath the ITB gets compressed against the femur which causes pain.
What does ITB syndrome feel like?
ITBS is the most common form of lateral (outer) knee pain in runners and can be described as a sharp pain or a tightness that increases during running and tends to happen at a specific point of the run.
Pain may also be felt on the inner side of the knee, below the patella (knee cap) or higher up in the lateral aspect of the thigh or hip. Running downhill or on a camber, doing squats and descending stairs can be provocative for this condition. Speed can also have an effect and the worse pain is usually experienced around 30 degrees, so from foot strike to knee flexion throughout the running gait.
It is important for the athlete to understand that pain does not always mean there is damage in the knee, however it is a sign that something is not functioning optimally, and it needs to be addressed.
What to do about ITB Syndrome
If an athlete is suffering with ITBS or would like to avoid getting it, they should seek professional help for gait analysis and static alignment which will include assessment of the joints above and below (hip and ankle).
Fatigue and recovery within and between training sessions is a factor to consider and having the correct footwear can make a massive difference. The athlete should implement a stretching and mobility regime alongside strengthening of the gluteus medius.
Stretching or by using a ball, or the foam roller on the muscles surrounding the ITB may help to relieve tension and offload the fascia connecting into the ITB. Releasing through the Quadriceps, glutes and tensor fascia lata (TFL) will be most beneficial in this circumstance.
Exercises to Prevent Iliotibial Band Syndrome (ITBS)
Below are some suggested exercises that can be carried out by the athlete and can either be implemented as part of a warm up to fire the muscles up and help prevent injury or 3 times a week as part of a strengthening programme for more specific rehabilitation.
Place the band around your ankles with feet hip width apart and pointing straight forward. Keep a slight bend in the hips and knees. The band should already be slightly tensioned.
Step sideways increasing tension on the band, keeping the hips level, knees out over the toes and feet pointing forwards. Maintain this alignment throughout the exercise and as you bring the feet back together. Step 10 times in each direction for 3 sets.
Lie on your side with your hips slightly flexed and knees bent so your feet are in line with your bottom. Roll the hip forward so the knee on top is slightly in front of the bottom knee.
Keeping the ankles together open the knees as high as possible without letting the hips open or roll back. Hold the top position for a second, then slowly lower back down to the start position. Complete 3 sets of 20reps on each side depending on your abilities and how you fatigue. Quality over quantity!
Hip Drop Outs
Standing on the floor or a step, start with your hips level and then let one hip drop out to the side (stance leg) and the other leg (the leg off the edge of the step) drop down.
From this position squeeze your bottom on the side of your stance leg to bring the hip back underneath you and raise the dropped leg back up to neutral.
Lying Hip Abduction
Lie on your side with your bottom leg bent for stability and the top leg out straight with it slightly behind your body. Try to keep the hip rolled forward slightly.
Raise the top leg up to 45 degrees keeping your leg straight and hold for a second at the top position before slowly lowering back down. Complete 3 sets of 20reps on each leg.
Shin splints can be due to many different conditions, but medial tibial stress syndrome (MTSS) is the most common, which refers to pain along the mid line of the tibia (shin bone).
The muscles, tendon and bone tissue get overworked and inflammation occurs as a result of the repetitive exercises. Weakness in the muscles around the shin, and incorrect training or running form may also be a cause. There will be pain during running and tenderness to the touch along the inside part of the shin. It is important that you recognise the signs and symptoms and start treatment early, otherwise the pain may worsen and potentially develop into a stress fracture.
What to do about shin splints?
Usually MTSS occurs in runners or triathletes that are beginners and just starting out, or after intensifying or changing training. Excessive pronation (rolling to the inside of the foot) during running can lead to MTSS and if this is a problem it can be helped by using arch supporting insoles and by strengthening the muscles under the foot.
Most cases of MTSS can be treated with rest, ice, anti-inflammatories and some exercises and stretches. A physiotherapist will be able to advise on this and provide other treatment such as massage, ultrasound and kinesiotaping to help speed recovery.
The correct footwear is also important in preventing injury as it should help support the foot and aid in shock absorption. A Cho Pat compression strap can be helpful in alleviating mild shin pain, but structuring your training appropriately is essential, so your body can gradually get conditioned to the loading and stress going through it.
Exercises to Prevent Shin Splints
Below are a few exercises and stretches you can perform daily to stay mobile and strengthen the areas needed to prevent injury.
Place your foot flat on top of a t-towel, then scrunch your toes up to wrinkle the t-towel and drag it in towards you underneath the foot. Continue to relax and scrunch up your toes until you reach the end of the t-towel. Unravel the t-towel and Repeat this process 3 times.
Roll your foot over a hard ball to help release tension through the plantar fascia and muscles in the foot. If you find a tender area, stop and hold that position until the discomfort begins to ease.
Place hands on wall and one foot in front of the other.
Bend the knee of the front leg, keep the back leg completely straight and heel on the floor.
Push into the wall and force your back heel down into the floor so you can feel a stretch down the calf on the back leg.
Do 3x30seconds holds on each leg.
Place one foot in front of the other and bend the knee of the back leg keeping the front leg completely straight.
Support your weight on the bent leg and stick your bottom up/back behind you so you can feel a stretch down the back of your thigh (hamstring) on the straight leg.
Do 3x30 second holds.
Stand with your ball of foot on the edge of a step and let your heels drop down past neutral.
Lift up on to your toes as high as you can and hold the top position for a second or two before very slowly lowering back down so your heels are below the step. Maintain good alignment without any twisting of the ankles.
Complete 3-5 sets of 20-30 reps if able. If easy progress to single leg.
Runners Knee (Chondromalacia Patellae)
Runners Knee refers to pain on the inner side (anterior aspect) of the knee, under and around the Patella (kneecap). It is also known as Patellofemoral Syndrome which can then lead on to Chondromalacia Patellae. Runners knee is one of the most common causes of anterior knee pain and is due to the way in which the patella moves and causes friction and changes to the cartilage covering the back of the patella as it rubs over the femur (thigh bone).
The Patella sits in a groove (patella / trochlear groove) on the end of the femur (thigh bone) in front of the knee joint. Many factors can affect how the patella sits in the groove and the movements that occur:
- The Patella can glide, tilt, rotate up or down or move sideways. Weakness in muscles surrounding the knee reduces the support and increases the force and weight going through the patella.
- Imbalances in the muscles either side of the knee and tightness within the quadriceps and ITB can cause a shift in the patella pulling it upwards and to the side slightly. This increases friction resulting in pain.
- Flat feet and/or a larger Q angle (angle of femur from hips or knees) can increase the force on the patella, and anatomical differences can also occur in which there is an abnormality in the groove and/or patella which results in the two surfaces not fitting together very well. This restricts movement or increases friction, resulting in increased likelihood of patellofemoral pain.
What does Runner's Knee feel like?
The symptoms of Runners knee tend to come on gradually and may vary on and off depending on the movement or activity you are doing. It is often described as an ache around and behind the patella. Crepitus (grinding and crunching) can be heard and occasionally there may be mild swelling. It tends to be worse with prolonged activity (long distance running), stairs (particularly downstairs) and after sitting for longer periods.
Exercises to Prevent Runner's knee
Runners Knee can take anywhere from 6 weeks to 6 months to resolve. The first step is to ease back slightly on activities that aggravate the knee to allow it to settle and get some soft tissue work done by a qualified therapist. Stretching / foam rolling of tight, overactive muscles can be performed alongside strengthening exercises, particularly Vastus Medialis Oblique (VMO) as shown below. Continue with these exercises for a few weeks before building up again and try to avoid prolonged postures. During the early stages of rehabilitation, lower impact activities such as cycling or swimming can be used. Try to avoid running on concrete / harder surfaces. In some cases, it may be that the athlete needs orthotics to help with proper foot alignment which will offload the knee stress.
Foam rolling Lateral aspect of quad and iliotibial band (ITB)
Lie face down with the roller placed just above your kneecap and have all your bodyweight (if able) going down through the roller. Bend and straighten your knee and allow the roller to move up the quad as you do so. Repeat 3-5times and change the angle of your body/leg to hit different aspects of the quadriceps.
Lie on your side over the roller, start above the knee and use your top leg to add extra pressure down over the roller. If possible, bend and straighten the bottom leg and move all the way to the top of the leg.
Leg extensions for strengthening of VMO
This exercise can be performed double or single legged and can be done at home with resistance bands or ankle weights instead of a machine. Sit with your knee crease just over the edge of the seat and place your feet under the pad with toes pointing up towards your shins. Hold on to the handles and maintain an upright posture whilst straightening the knees to full extension. Do 3-5 sets of 10-20 reps on a weight that is challenging and fatigues the legs, so the last few reps are quite difficult.
Clam - Gluteus Medius strengthening
Lie on your side with your hips slightly flexed and knees bent so your feet are in line with your bottom. Roll the hip forward so the knee on top is slightly in front of the bottom knee.
Keeping the ankles together, open the knees as high as possible without letting the hips open or roll back. Hold the top position for a second, then slowly lower back down to the start position. Complete 3 sets of 20reps on each side depending on your abilities and how you fatigue.
Swimmer’s Shoulder (Shoulder Impingement)
Swimmer’s shoulder (also known as shoulder impingement) involves tendonitis / inflammation of the rotator cuff tendons, particularly the supraspinatus as they pass through the subacromial space, beneath the acromion. The long head of the bicep tendon may also be involved in this condition. As the arm is raised, the gap between the acromion and the head of the humerus (subacromial space) narrows. The supraspinatus tendon passes through this space and anything else causing narrowing can impinge the tendon and cause an inflammatory response.
What does Swimmer's Shoulder feel like?
Symptoms include pain, weakness and in some cases a loss of movement / function. Pain is often worse with overhead movements and at night, particularly if the affected shoulder is laid on. The pain is usually a dull ache, but other symptoms include a popping or grinding during certain shoulder movements. The pain can be localised closer to the shoulder joint or it may also travel up the neck or down the arm.
High level swimmers require full range of movement at the shoulder and they will perform hundreds of arm rotations per session which puts a huge stress on the shoulder joint and surrounding musculature. The shoulder joint is an inherently unstable joint, it is like a golf ball (large ball - head of humerus) on a golf tee (small shallow socket – glenoid cavity). Therefore, the shoulder is reliant upon the muscles, tendons and ligaments crossing the joint to all work together to provide stability throughout all planes of movement. If anything is out of sync or not functioning properly it can cause big problems.
Exercises to prevent Swimmmer's Shoulder
Shoulder related injuries in swimmers are usually a result of poor posture and faulty / sloppy mechanics in the water. This combined with the repetitive motion of arm rotations is highly likely to cause injury compared to if the athlete had proper alignment and posture. Due to the nature of swimming, it is likely that the internal rotators and adductors of the arm become over developed and the scapula stabilisers and external rotators become weak as they are not used as much.
Treatment for shoulder impingement will include reducing the inflammation and restoring full range of movement and then strengthening the rotator cuff and scapular stabilisers (shown below) to restore proper mechanics. Perform these exercises 3 times a week or before a swim session as part of a warm up.
Thoracic Spine mobility exercises
Lie back over the roller so it runs across the bottom of your rib cage and take your arms overhead. At this level the bottom can maintain in contact with the floor but as you move the roller higher up the thoracic spine you will need to raise the hips to get more pressure down through the roller.
Start in the recovery position with arms outstretched or with your bottom arm holding your top knee down and slowly open the shoulders, rotating in the opposite direction. Repeat this movement 10-20 times on both sides.
Start on your hands and knees with hands under your shoulders and knees under your hips, pushing strong through your shoulders so your back is flat. Maintain this back alignment whilst outstretching one hand and the opposite leg and then return to the start position again. Repeat 10-20 times on each side. If you lose control or end up twisting start by just taking one arm away and keep both knees on the floor.
Face pulls - lower traps
This exercise can also be performed at home using a resistance band by attaching it to something up high, above eye level. Pull the band back and down towards the eyes focusing on squeezing the lower trapezius. Complete 3-5 sets of 20reps.
Start on hands and knees and push your scapula apart, rounding your upper back pushing it up towards the ceiling. Return to neutral and then arch into extension, dropping your chest to the floor and pinching scapula together. Repeat 10-20 times.
Rotator cuff exercises – external rotation and abduction
Hold the band in one hand or tie to something that won’t move and with the other hand hold it so the thumb is pointing up. Keep the elbow in to your side externally rotate the shoulder taking the hand away from the body. Return to the start and repeat for 3-5 sets of 10 reps.
Stand on one end of the resistance band and hold the other end with thumb pointing up towards the ceiling. Raise the arm up sideways away from the body to shoulder level and hold for 2 seconds before lowering. Repeat this in a controlled manor for 3-5 sets of 10reps.
Plantar fasciitis is inflammation of the thick band of tissue (plantar fascia) that connects your heel bone to your toes. The plantar fascia is like a bowstring, supporting the arch of your foot and absorbing shock as you walk or run. If there is too much stress or tension on the plantar fascia small tears can occur and repeated stretching can cause irritation and inflammation.
What does Plantar Fasciitis feel like?
Symptoms can include pain under the arch of your foot or around the heel and it is often worse in the mornings. It is characterised by a stabbing pain which may ease once you get moving but worsen again after long periods of standing or if you stand up after sitting. This may also be accompanied by stiffness and tenderness and the bottom of the foot may feel warm and swollen.
How to treat Plantar Fasciitis
Exercising on hard surfaces with improper footwear or footwear with insufficient cushioning may lead to plantar fasciitis, and being overweight will also increase the likelihood of developing this problem.
Plantar fasciitis can sometimes be helped by ice and rest. Correct footwear with appropriate support will also help or orthotics may be required. Stretching / foam rolling of the calves and rolling your foot over a golf ball or cold can will also decrease the tension on the plantar fascia. A physiotherapist may also use ultrasound or shockwave to help speed up recovery and kinesio-tape to support the foot and offload the plantar fascia.
Does Stretching and Conditioning for Triathlon Work?
It is inevitable that during any competitive sport you are subject to risk of injury, and performing at a high standard means more practice and training, hence more repetition which increases likelihood of injury further. This is not something to just lay down and accept or expect to happen, but it is something to be aware of and be proactive about.
To minimise risk of injury, triathletes must ensure that the training is progressive and the recovery is sufficient. The strength and conditioning aspect of training and doing assistance exercises such as the ones shown above are also important in injury prevention. These exercises may not mimic the movements you undergo during your usual training but they will allow you to work on specific weaknesses and prevent or at least minimise any imbalances.
Stretching and mobility is also key, because if you are not in good alignment or have poor posture your muscles won’t be able to function as efficiently or in the correct range that is required, therefore leading to a leak of power and suboptimal performance. This aspect of training is not always fun and enjoyable, but it is crucial for staying healthy and allowing everything to work together as one unit.