Each triathlon discipline comes with its own hazards, but these common injuries can be avoided if you know what causes them.
The article below was originally published for Triathlete Magazine Online on June 14, 2021 and is written by Ashley Lauretta. Christopher Breen was asked to share his knowledge on injuries and contributed his opinion to the article. The original article can be accessed via the link below:
Triathlon comes with three disciplines, all which have their own set of prevalent injuries—giving you even more opportunities to be sidelined. No athlete is immune; while some injuries are more common in beginners, many occur with overuse to areas of the body that are constantly working in the sport (protect those knees!). There are many reasons you may find yourself injured, but being able to put a name to the pain you are experiencing can help make the injury a little less frustrating and help you recover faster.
We’ve broken down the most common injuries you may encounter—organized by triathlon discipline—so you can not only identify any weaknesses, but also work to prevent the pain before it happens.
Most Common Swim Injuries for Triathletes
Due to the continual rotation of the shoulders, that’s the site of the most common swim injuries that triathletes face. The two potential injuries you should be most aware of co-occur, so seeing a specialist should you have any shoulder pain can help treat the entire structure.
“In sports medicine, shoulder impingement and swimmer’s shoulder go hand-in-hand,” according to Chris Breen, PA-C, ACSM EP-C, founder of Aria Endurance Coaching, LLC. “When one occurs, both occur.”
There are subtle differences between the two injuries that you should be aware of, though they both can occur from overuse.
Swimmer’s Shoulder
What it is: “Swimmer’s shoulder—or shoulder bursitis—is an inflammation of the bursa that sits under a bone called your acromion, part of your scapula (shoulder blade),” Breen said. “A bursa is a fluid filled sac that lubricates tendons where they attach to bone. In the shoulder, this bursa lubricates the tendons of the rotator cuff.”
How it happens: Swimmer’s shoulder is an overuse injury, which occurs most frequently due to the overhead rotation in swimming.
“Pain usually occurs as a result of repetition with overhead activities, such as with the recovery phase of swimming (when your arm is out of the water),” Breen said. “It can also occur from repeatedly crossing over your midline during your catch phase. Over time, this bursa gets irritated because the space between your humerus and the acromion is so narrow and it narrows even further with overhead activities.”
Common symptoms: Pain and tenderness—especially when reaching the arm overhead—and a decrease in range of motion.
What to do: “Outside of the pool, prevention starts with well-conditioned muscles,” Breen said. “[Do] exercises that strengthen your rotator cuff muscles and the other surrounding shoulder muscles, [such as] external rotation, scapular raises, push-ups and pull-ups. Shoulder work must be in balance, so work opposing muscles. If you do a push-up, make sure to do a pull-up to avoid muscle imbalances.”
Additionally, reducing inflammation with over-the-counter pain medication is advised. If pain and inflammation still occur, see a specialist to get prescription medication and evaluation, should additional therapies—such as physical therapy or steroid injections—or surgery be indicated.
Shoulder Impingement
What it is: One of the most common causes of shoulder complaints, it is also known as impingement syndrome, and is caused by your rotator cuff and a part of your shoulder blade rubbing together internally with movement.
How it happens: “This involves the tendons of the rotator cuff, a group of muscles that extend from the scapula (shoulder blade) to your humerus (upper arm bone) and hold the humerus in its shoulder socket,” Breen said. “Impingement occurs when you lift your arm and the acromion digs in or impinges the rotator cuff tendons and the subacromial bursa.”
You may remember that same subacromial bursa mentioned in swimmer’s shoulder, which is why the two go hand-in-hand.
Common symptoms: Pain is present when lifting the arm overhead or when lying on the painful shoulder, and there may be reduced range of motion.
What to do: As with a diagnosis of a swimmer’s shoulder, reducing inflammation with over-the-counter medications may help. Upon a physical evaluation, conservative treatment options include NSAIDS, cortisone injections, physical therapy and more, with the goal of restoring function. If unsuccessful, surgery may be indicated.
Other Swim Injuries to Look Out For
“Muscular neck pain is also seen in swimmers,” Breen said. “It often occurs because of muscle weakness and also poor swim technique, such as poor head position in the water and only breathing to one side.”
Most Common Bike Injuries for Triathletes
Unlike swimming, the most common injuries on the bike occur don’t all occur in the same spot of the body. We didn’t include the most common—acute injuries due to crash—on this list, since in that case you’ll immediately be able to identify the cause of the pain!
If you’re new to the sport and worried about encountering injuries on the bike, Stefanie Cain, owner of Cain Coaching in Lexington, South Carolina, advises that you get a professional bike fit from day one.
“A lot of athletes skip this very important part of purchasing a bike because it can be expensive, but as a coach, I can’t recommend it enough,” Cain said. “Most fitters will give you a fit, tell you to ride, and then have you come back in to reassess and make any tweaks or changes to the fit based on what you tell them.”
As you’ll see, poor bike fit and posture are a recurring theme in these most common triathlon bike injuries.
RELATED: Critique My Fit
Knee Pain
What it is: Knee pain is, of course, a broad term; the location of your pain can help determine an exact diagnosis. For example, anterior knee pain is commonly caused by patellofemoral pain (PFP), while medial knee pain could be medial collateral ligament bursitis.
How it happens: Most knee pain is sustained by poor technique and poor fit, due to overuse and pressure placed on the knee during rides.
“Knee pain can result from a myriad of scenarios from overuse, neuromuscular compensation and/or position on the bike,” said Tim Fleming, MSc, of Endurance Performance Training Center in Mill Valley, California. “A bike fit isn’t always the panacea; however, honing in on fit-related issues—saddle height, saddle fore-aft, and cleat placement—can all be contributing factors. These three points can cause too much knee flexion or extension and/or lateral or medial torque on the knee if the cleat isn’t set correctly.”
Common symptoms: Pain, often localized, along with swelling and tenderness can occur; in some cases, you may have limited range of motion.
What to do: Over-the-counter medications can help ease some pain and discomfort, but evaluation by a sports physician will likely include a single-leg squat test. Additionally, depending on the location and severity, pain management and taping may be recommended, along with training modifications and physical therapy.
Wrist, Hand and Forearm Pain
What it is: Depending on the level of pain and location, diagnosis may vary; however, nerve compression in cyclists—known as cyclist’s palsy—can occur and cause dysfunction in the hands.
How it happens: Poor bike fit, posture and grip can cause the occurrence of pain in the wrist, hand and forearm, affecting the ulnar nerve, a frequent point of injury as it is the largest nerve not “protected” by muscle or bone.
“Sometimes, there’s too much drop between the handlebars and the saddle, causing weight shift onto the handlebars, putting unnecessary pressure on the hands/wrists/elbows/shoulders,” Fleming said. Handlebar width and brake hood position can also cause some trouble with excessive deviation at the wrist joint. Especially in situations where the athlete is putting in a lot of miles, or just starting to increase their time on the bike if coming back from a recovery period or starting as a new cyclist.”
Common symptoms: Motor and sensory issues, including pain, numbness and tingling, may be present.
What to do: An exact diagnosis is needed to develop a treatment plan, though in the case of cyclist’s palsy having a professional evaluate—and change—your bike fit, wearing cycling gloves, and changing hand positions throughout each ride is recommended.
Neck and Low Back Pain
What it is: Exact diagnosis can vary due to the cause and location of pain, though flexion pattern disorder of the spine and ligament strain are common in cyclists.
How it happens: This pain is sustained by overuse, often by the posture on the bike (and exacerbated by all of the sitting we constantly do in our everyday lives).
“Most neck/low back pain on the bike is due to a poor bike fit, however, there are certainly times when an athlete’s posture plays a role in causing overuse injuries on the bike,” Cain said. “Athletes often have muscle imbalances, as the majority of us do, that are very pronounced and if they aren’t corrected through strength and flexibility training, they can lead to postural issues and pain on the bike. Also, any muscular weaknesses that are present will be exacerbated by having to maintain the same position on the bike for an extended period of time.”
Common symptoms: Pain, tingling, and muscle stiffness and fatigue may be present.
What to do: Conditioning and building core stability is one way to help with muscle imbalances occurring to the spine when riding. Additionally, getting a proper bike fit to improve posture may help decrease any pain. Should pain continue, seek treatment that may include physical therapy and similar therapeutic modalities.
Other Bike Injuries to Look Out For
“Aside from neck and back pain, the most common overuse injuries on the bike are Iliotibial Band Syndrome (ITBS) and patellar tendonitis,” Cain said. “Both of these overuse injuries or issues are generally a direct result of poor bike fitting and an athlete trying to do too much too fast. The good news is, after a professional bike fit, these issues will often subside, and a few sessions with a physical therapist can be very helpful as well, depending on the severity of the pain or injury.”
Most Common Run Injuries for Triathletes
Of all the disciplines, research has found that running has the highest occurrence of injuries in triathletes. Overuse injuries are common here, especially as athletes push to make up for any time lost on the swim or bike.
While there are a number of common run injuries, going into triathlon with guidance and a solid training plan is key to avoiding injury. “Work with a coach, follow a structured training plan that balances training loads and have a gait analysis to ensure your form is solid,” said Angie Ferguson, owner of Geared Up Multisport Specialists in Fort Myers, FL.
Shin Splints and Shin Pain
What it is: “Shin splints originate from pain along the shin bone or tibia, which is the large bone in the front of the lower leg,” said Tiffany Gust, owner of TG Triathlon & Fitness Coaching in St. George, Utah. “Shin splints typically fall into two categories: 90% comes from pain along the bony part of the shin and is referred to as medial tibial stress syndrome, which is a term that covers a wide range of alignments that could affect the triathlete; the other 10% is caused by muscular shin pain.”
How it happens: From a research standpoint, the exact cause is yet to be pinpointed, though pressure in the tibial cortex is believed to be involved. “Body mechanics, bone density, and hours running per week can all play a factor,” Gust said.
Common symptoms: Pain in the front of the leg will occur, with Gust noting that it tends to be more severe at the beginning of the run and decrease as the muscles begin to warm up.
What to do: Common treatment options include over-the-counter medications, ice, stretching and even use of compression socks; in a physician’s office, you can expect graded running, strengthening and stretching exercises for the calf muscles to be prescribed.
“Other conditions can mimic a shin splint such as achilles tendon rupture, stress fracture, tendonitis and sprains,” adds Gust. “Seeking professional advice and perhaps imagining such as MRI, or x-ray can help you get the correct diagnosis. Exercises such as calf raises and hip adduction strengthening can be most effective as a way to get you back out on the course and racing again.”
Heel Pain
What it is: Heel pain most commonly occurs from Achilles tendinopathy, which has been found to be degenerative in nature, with pain occurring anywhere along the Achilles tendon, which runs from the calf down to the heel.
How it happens: Research has determined that sudden changes in training—including running surface—can lead to added pressure on the Achilles tendon. Additionally, when pain is located in the heel, it is commonly due to running gait and heel strike. Running shoes can also play a role, with poor padding along the heel causing added pressure and more friction on the tendon.
Common symptoms: Heel pain, changes in gait and limited flexibility may occur.
What to do: Because shoes play a key role in this injury, getting fit for or replacing old running shoes is recommended. Studies note that the severity of the tendinopathy will determine the exact treatment plan. However, rest and physical therapy, including calf strengthening, may be recommended.
Iliotibial Band Syndrome (ITBS)
What it is: Iliotibial band syndrome—or ITBS—is caused when repetitive friction occurs between the iliotibial band over the lateral epicondyle in the femur. This can also occur due to weak glute muscles that cause a chain reaction on the pelvis and, in turn, femoral structure.
How it happens: “It is most frequently caused by increasing training loads too quickly,” Ferguson said. “This includes pace, distance, intensity and frequency. It can also result from poor mechanics/structural imbalances (weak glutes/hips) and worn out equipment (shoes that no longer provide proper support).”
Common symptoms: Lateral knee pain, lateral hip pain, and inflammation may occur.
What to do: With IT Band Syndrome, you will want to reach out to a physician who will work to reduce inflammation with medication and, once that is under control, have you do stretching and strengthening exercises. Corticosteroid injections may be indicated in extreme cases.
“If you do experience ITBS pain, the first course of action is that dreaded word: REST,” Ferguson said. “Continuing to exercise with an injury is counterproductive and can lead to far worse and/or permanent problems. Treatment may include over-the-counter NSAIDS, ice and physical therapy/ultrasound/massage, stretching and strengthening of weaker muscles.”
RELATED: Med Tent: IT Band Syndrome
Other Run Injuries to Look Out For
Other common running injuries that triathletes experience include plantar fasciitis—an overuse injury in the foot—and tibial stress fractures (the most common area of the leg for stress fractures to occur).
“Runners should also take to heart the importance of rest and realize that too frequent training runs can easily become detrimental to overall training,” said Andrea M. Spiker, MD, Sameer Dixit, MD, and Andrew J. Cosgarea, MD, in their conclusions on running injuries specific to triathletes. “Injuries can sideline a runner for days, weeks, or even months at a time, and awareness of this possible outcome should provide incentive for building rest into one’s training schedule.”