Training in Vain, Through Pain – How to Manage Triathlete Treatment Expectations

“If it hurts, don’t do it.” This may be great advice for your everyday patient, but it’s one of the fastest ways to lose a triathlete or endurance athlete client. Here’s an example of how this might play out:

You: How can I help you today?
Patient: Well, I’m having pain in the front of my shoulder, and also in the front of my knee.
You: Are you in pain now? And if so what severity?
Patient: No – I feel fine right now.
You: What types of motions bother you?
Patient: Nothing really specific at the moment. It just hurts after I workout, and sometimes when I workout.
You: Ok – what type of sports do you participate in and how much volume per week?
Patient: I’m a triathlete, and train almost every day. I swim 12 miles a week, bike about 160 miles a week, and run 45 per week.
You: Wow, that’s a lot of overuse stress on your body. Sounds like we should shut down your training for a while and let your body rest.

Congratulations, you just had your first triathlete patient, and quite possibly your last.

Know Your Clients

Treating these athletes requires more than a simple musculoskeletal exam and a few exercises to correct movement imbalances. It’s not just the quantity of volume they put their body through each day, it’s the quality of that volume. Successful care and treatment of these athletes requires an intimate knowledge of the sport to ensure that your clinical goals transfer into their technique.

Sink or Swim

You may be comfortable treating your high school baseball pitcher, or other throwing athletes, and hope your strategies for treating those overhead athletes will help your swimmers. The problem is swimmers aren’t pitchers.

While all overhead athletes can experience impingement, the mechanics of each sport are completely different. A swimmer’s shoulder goes through upwards of 10,000 revolutions each swim practice. During each revolution, it’s possible to experience impingement in roughly 75% of the arc of motion in each and every stroke. To fix a swimmer, you need to understand swimming.

Swimming is both an open and closed chain sport. If the precise control of their glenohumeral and scapula are off, it can create imbalances in the tissues at specific times in the stroke. The spine position and kicking pattern also have an insurmountable effect on a swimmer’s upper body mechanics as well.

While you can learn a lot from an exam table, you ultimately need to be able to assess their stroke. The set of courses featured below will help you address the unique concerns of musculoskeletal mobility and stability swimmers need and learn how posture and lower body propulsion affect those constraints.

Swimming Courses

The author recommends the following MedBridge courses for more information on working with swimmers. Click the thumbnails below to watch a preview of each:

The Swim Stroke Analysis by Jay Dicharry, MPT, SCS

The Swimmer’s Shoulders: Swimmers Aren’t Pitchers by Jay Dicharry, MPT, SCS

Pedaling in Circles vs. Pedaling in Pain

Cycling related pain also requires a detailed look at a rider’s positioning and mechanics. Compared to a sport like running, the respective tissue strain is significantly lower, but the volumes are exponentially higher.

We are creatures of our environment. If that environment is a poorly set up cycling position, your patient will never be able to move at their peak. Subtle imbalances on the bike for 8-15 hours a week no longer produce subtle tissue loads. The lower body stress depends on the location of the rider in relation to the pedals. These postural considerations must be addressed to ensure that they can hold this position not just for five minutes, but for all 160 miles of their training each week.

There is a systematic way to assess a cyclist’s position and ensure that their fit respects their individual structural alignment, mobility, and stability. While many bike shops offer bike fits this stops short. As musculoskeletal experts its our job to fit the bike to the rider, but more importantly fit the rider to the demands of their bike to optimize loads through the body. The courses below will get you started with offering bike fit adjustments to your cycling clients:

Cycling Courses

The author recommends the following MedBridge courses for more information on working with cyclists. Click the thumbnails below to watch a preview of each:

Clinical Bike Fit Case Studies by Jay Dicharry, MPT, SCS

Clinical Bike Fit Process by Jay Dicharry, MPT, SCS

Bike Anatomy: The Bike and Bike Fit Rationale by Jay Dicharry, MPT, SCS

Off and Running

What is the best way to run? While the media loves to discuss polarizing headlines such as “everyone must land on their forefoot,” there is a lot more to efficient running form than a foot strike. Mobility, stability, and posture all contribute to running form and an individual’s susceptibility to running-related injury. Simple exercises or changes to running form or footwear can make a world of difference for any runner, no matter their weekly mileage.

It’s important to work with athletes to make sure they’re integrating strength training and exercise progressions into their training. These additional pieces of preparation can optimize neuro-muscular recruitment, boosting running performance and efficiency. Adding these exercises to a weekly training can go a long way toward injury prevention and ensuring longevity in the sport.

While running may seem straightforward, it’s important to understand the nuances and unique biomechanics of each athlete’s running form. To get started with gait analysis, strength development, and a detailed look at shoe selection, check out the featured courses below:

Running Courses

The author recommends the following MedBridge courses for more information on working with runners. Click the thumbnails below to watch a preview of each:

‘Tri-ing’ for Success

Let’s revisit the above patient scenario again. Right after your patient told you how much volume they train in each sport every week instead of essentially saying “stop doing that and rest”, you offer this:

“Ok, today, I’d like to look at some musculoskeletal aspects of the way you move to see if any of the pain you have is related to the way your body moves. Next visit, I’m going start looking for technique problems. Bring in your bike and we are going to perform a medical bike fit to see how your position affects your knee. And also, I’d like you to bring in some video of your swim stroke so we can determine flaws that overstress your shoulder.” 

Your patient is impressed. With the knowledge you learned from the MedBridge Triathlete Series outlined above, you treated relevant musculoskeletal concerns relate to their scapula-thoracic movement patterns. You used the Visual Swim Tool to systematically break down their swim stroke imbalances and prescribe specific swim drills to unload the shoulder. You performed a medical bike fitting to minimize patellofemoral shear and resolve their knee pain. The local bike shop is now sending you bike fits, adding an extra revenue stream that you can offer in your clinic. And, your patient just signed up for a running gait analysis with you next week. All of these steps have improved your patient’s race times and they have you to thank. These are a passionate group of athletes who often live in a tight circle. The word of your success and knowledge will spread quickly.

Endurance athletes are highly motivated. Since their training volume is so high, they know rest will only result in short-term relief rather than a long-term solution. It’s our responsibility to embrace the fundamentals of their chosen sports and to ensure that their goals are now our goals as we work together to set them up for success.

References Swim References
  1. Yanai T, Hay JG, Miller GF. Shoulder impingement in front-crawl swimming: I. A method to identify impingement. Med Sci Sports Exerc. 2000 Jan;32(1):21-9.
  2. Yanai T, Hay JG. Shoulder impingement in front-crawl swimming: II. Analysis of stroking technique. Med Sci Sports Exerc. 2000 Jan;32(1):30-40
  3. Wadsworth DJ1, Bullock-Saxton JE. Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement. Int J Sports Med. 1997 Nov;18(8):618-24.
  4. Struyf F, Tate A, Kuppens K, Feijen S, Michener LA. Musculoskeletal dysfunctions associated with swimmers' shoulder. Br J Sports Med. 2017 May;51(10):775-780
Bike References
  1. Rendos NK1, Harrison BC, Dicharry JM, Sauer LD, Hart JM. Sagittal plane kinematics during the transition run in triathletes. J Sci Med Sport. 2013 May;16(3):259-65.
  2. Vrints J1, Koninckx E, Van Leemputte M, Jonkers I. The effect of saddle position on maximal power output and moment generating capacity of lower limb muscles during isokinetic cycling. J Appl Biomech. 2011 Feb;27(1):1-7.
  3. Bini R1, Hume PA, Croft JL. Effects of bicycle saddle height on knee injury risk and cycling performance. Sports Med. 2011 Jun 1;41(6):463-76.
  4. Wanich T, Hodgkins C, Columbier JA, Muraski E, Kennedy JG.Cycling injuries of the lower extremity. J Am Acad Orthop Surg. 2007 Dec;15(12):748-56.
Run References
  1. Dicharry, J. Kinematics and Kinetics of Gait: From Lab to Clinic. Clin Sports Med. 2010 Jul;29(3):347-64
  2. Teng H, Powers, C. Sagittal Plane Trunk Posture Influences Patellofemoral Joint Stress During Running. JOSPT 2014;44(10):785-792
  3. Clermont CA, Osis ST, Phinyomark A, Ferber R. Kinematic Gait Patterns in Competitive and Recreational Runners. J Appl Biomech. 2017 Mar 2:1-26
  4. Kotecki K; Pipkin M A; Hetzel S; Heiderscheit, B. RELIABILITY OF A QUALITATIVE VIDEO ANALYSIS FOR RUNNING GAIT JOSPT. 45(1):A63, Jan 2015