Triathlon Medicine

Foreword
Preface
Contents
Contributors
1: ITU Triathlon History
Part I: Physiological and Epidemiological Aspects
	2: Physiological Requirements of the Different Distances of Triathlon
		2.1	 Introduction
		2.2	 Energy Systems Specific to Triathlon
		2.3	 Specific Aspects of Triathlon
		2.4	 Draft-Legal Triathlons: Mixed-Team Relay, Sprint and Olympic Distances
			2.4.1	 Swimming
			2.4.2	 Cycling
			2.4.3	 Running
		2.5	 Non-drafting Triathlons: Long Distance, Half-Ironman and Ironman Distances
		2.6	 Conclusion
		References
	3: Epidemiological Aspects of Illness and Injury
		3.1	 Introduction and Definitions
		3.2	 The Extent to Which Injury/Illness Occurs
		3.3	 Where Does Injury/Illness Occur?
		3.4	 When Does Injury Occur?
		3.5	 What Are the Injury Outcomes?
		3.6	 Risk Factors
			3.6.1	 General
			3.6.2	 Risk Factors for Injury to Specific Anatomical Locations
			3.6.3	 Swimming-Related Shoulder Pain
			3.6.4	 Cycling-Related Traumatic Injury (Including Shoulder Pain)
			3.6.5	 Cycling-Related Cervical Spine, Lumbar and Knee Pain
			3.6.6	 Genital Pain
			3.6.7	 Achillodynia
			3.6.8	 Anterior Knee Pain/“Runner’s Knee”
			3.6.9	 Lateral Knee Pain/Iliotibial Band Friction Syndrome (ITBFS)
			3.6.10	 Anterior Tibial Pain/“Shin Splints”
			3.6.11	 Pain to the Sole of the Foot/Plantar Fasciitis
			3.6.12	 Running-Related Lumbar Spine Area Pain
		3.7	 Context, Conclusions and Recommendations
		References
Part II: Environmental Conditions
	4: Heat-Related Illness
		4.1	 Introductory Comments
		4.2	 Exertional Heat Stress: What Have We Learned?
		4.3	 Thermoregulation in Humans
		4.4	 Pathophysiological Factors in Heat Injury
		4.5	 Pathogenesis of Severe Heat Injury
		4.6	 Exertional Heat Illness: A Continuum of Disorder
		4.7	 Susceptibility to Exertional Heat Injury
		4.8	 Concluding Comments
		References
	5: Environmental Conditions: Cold
		5.1	 Introduction
		5.2	 Reponses to Immersion
			5.2.1	 Cold Shock Response (CSR)
			5.2.2	 Neuromuscular Cooling
			5.2.3	 Deep Body Cooling
		5.3	 Transition
		5.4	 Cycling and Running
		5.5	 Prevention, Mitigation and Treatment
			5.5.1	 Rules
			5.5.2	 Physiology
			5.5.3	 Technology
			5.5.4	 Prevention and Treatment
		5.6	 Out of Hospital Treatment
		References
Part III: Acute and Overuse Injuries
	6: Iliotibial Band Syndrome (ITBS)
		6.1	 Introduction
		6.2	 Etiopathogenesis
		6.3	 Patient Evaluation
		6.4	 Imaging
		6.5	 Conservative Treatment and Rehabilitation Programme
		6.6	 Surgical Treatment
		6.7	 Conclusions
		References
	7: Anterior Knee Pain
		7.1	 Introduction
		7.2	 Patellofemoral Pain
			7.2.1	 Etiology and Pathomechanism
			7.2.2	 Symptoms
			7.2.3	 Diagnostics
				7.2.3.1	 Clinical Examination
				7.2.3.2	 Imaging
				7.2.3.3	 Therapy
		7.3	 Patellar Tendinopathy
			7.3.1	 Etiology and Pathomechanism
			7.3.2	 Symptoms
			7.3.3	 Diagnostics
				7.3.3.1	 Imaging
			7.3.4	 Therapy
				7.3.4.1	 Nonoperative Treatment
				7.3.4.2	 Acute Phase: Symptomatic Therapy and Pain Management
				7.3.4.3	 Active Interventions
				7.3.4.4	 Physical Therapy
				7.3.4.5	 Injection Therapy
				7.3.4.6	 Operative Treatment
		7.4	 The Infrapatellar Fat Pad
			7.4.1	 Etiology and Pathomechanism
			7.4.2	 Symptoms
			7.4.3	 Diagnostics
			7.4.4	 Therapy
		7.5	 Plica Injuries
			7.5.1	 Etiology and Pathomechanism
			7.5.2	 Symptoms
			7.5.3	 Diagnostics
			7.5.4	 Therapy
			7.5.5	 Prevention of Anterior Knee Pain
		References
	8: Stress Fractures
		8.1	 Introduction
		8.2	 Pathophysiology of Stress Fractures
		8.3	 Risk Factors
			8.3.1	 Extrinsic Factors
			8.3.2	 Intrinsic Factors
		8.4	 Evaluation
			8.4.1	 Imaging
		8.5	 High and Low Risk Stress Fractures
			8.5.1	 High Risk Stress Fractures
				8.5.1.1	 Femoral Neck
				8.5.1.2	 Anterior Tibial Cortex
				8.5.1.3	 Medial Malleolus
				8.5.1.4	 Tarsal Navicular
				8.5.1.5	 Fifth Metatarsal
				8.5.1.6	 Base of the Second Metatarsal
				8.5.1.7	 Hallux Sesamoids
			8.5.2	 Low-Risk Stress Fractures
				8.5.2.1	 Sacrum
				8.5.2.2	 Pubic Ramus
				8.5.2.3	 Femoral Shaft
				8.5.2.4	 Tibia
				8.5.2.5	 Fibula
				8.5.2.6	 Metatarsal
		8.6	 General Treatment and Prevention Strategy
		8.7	 Conclusions
		References
	9: Operative Treatment of Tendinopathies of Achilles Tendon
		9.1	 Introduction
		9.2	 Indications for Surgery
		9.3	 Effects and Aims of Surgery
		9.4	 Operation for a Chronic Peritendinitis Tendinopathy
		9.5	 Operative Treatment of Tendinosis Tendinopathy
		9.6	 Surgery for Partial Achilles Tendon Tear
		9.7	 Surgery for Distal Enthesitis and Retrocalcaneal Bursitis
		9.8	 Surgery for Achilles Tendon and Heel Enthesitis Calcifications
		9.9	 Achilles Tendon Anomalies
		9.10	 Results of Operative Treatment
		9.11	 Post-operative Care and Rehabilitation Guidelines
		9.12	 Complications of Achilles Tendon Overuse Injury Operations
		References
Part IV: Medical Conditions
	10: Airway Dysfunction in Elite Athletes
		10.1	 Introduction
		10.2	 Clinical Presentation
		10.3	 Diagnosis
		10.4	 Management
		10.5	 WADA
		10.6	 Other Conditions
			10.6.1	 Immersion Pulmonary Edema (IPE)
			10.6.2	 Exercise-Induced Laryngeal Obstruction (EILO)
		References
	11: Cardiovascular Adaptations in Triathlon
		11.1	 Introduction
		11.2	 Endurance Sport and the Heart
		11.3	 Electrical Changes in the Endurance Athlete
		11.4	 Structural and Functional Changes in the Endurance Athlete
		11.5	 Sudden Cardiac Death (SCD) in Athletes
		11.6	 Sudden Cardiac Death in Endurance Events
		11.7	 Cardiac Screening
		11.8	 Conclusions
		Appendix: The ITU PPE
			ITU Medical Documents
				Pre-competition Health Screening
		References
	12: Endurance Anemia, Relevance to Triathlon
		12.1	 Introduction
		12.2	 Sports Anemia
		12.3	 Clinical Manifestations of Anemia
		12.4	 Anemia and Exercise
		12.5	 The Prevalence of Anemia Among Athletes
		12.6	 Etiology of Anemia in Athletes
		12.7	 The Importance of Iron
		12.8	 Etiology of Iron Deficiency in Athletes
		12.9	 Conclusions
		References
	13: The Youth Triathlete
		13.1	 Introduction
		13.2	 Challenges for the Youth Triathlete Across Adolescence
		13.3	 Managing and Monitoring Training and Performance Readiness
		13.4	 Key Points
		References
	14: The Master Triathlete
		14.1	 Introduction
		14.2	 Increase in Participation of Master Triathlete
		14.3	 Improvement of Master Triathletes’ Performances
		14.4	 Effects of Event Duration and Type of Triathlon
		14.5	 Effect of Discipline: The Specificity of Cycling
		14.6	 Sex Difference in Performance with Advancing Age
		14.7	 Age-Related Changes in Physiology of the Master Triathlete
		14.8	 Recovery of Master Triathlete
		14.9	 Conclusion
		References
	15: The Female Triathlete
		15.1	 Introduction
		15.2	 Training
		15.3	 Injury Prevention
		15.4	 Relative Energy Deficiency in Sport (RED-S)
		15.5	 Nutrition
			15.5.1	 Energy and Fluids
			15.5.2	 Micronutrients
			15.5.3	 Supplementation
		15.6	 Bone Health
		15.7	 Menstrual Dysfunction
		15.8	 Pelvic Floor Dysfunction
		15.9	 Mental Health
		15.10	 Non-accidental Violence
		15.11	 Anti-doping
		15.12	 Conclusion
		References
	16: The Travelling Athlete
		16.1	 Introduction
		16.2	 Preparing for International Travel
			16.2.1	 Pretravel Planning
			16.2.2	 Immunisation
			16.2.3	 Travel Kit
				16.2.3.1	 Antibiotics
			16.2.4	 STDs, HIV Infection and International Travel
				16.2.4.1	 HIV Screening of International Travellers
			16.2.5	 Malaria Prevention (Chemoprophylaxis) and Other Mosquito-Borne Diseases
		16.3	 Adaptation to New Destination
			16.3.1	 Exposure and Adaptation to Heat
				16.3.1.1 Acclimatisation
				16.3.1.2 Heat Acclimatisation Protocol in Saunas
				16.3.1.3 Precooling
			16.3.2	 Exposure and Adaptation to Different Time Zone
				16.3.2.1	 Jet Lag (Circadian Dysrhythmia)
		16.4	 Protection from the Sun and Cold
			16.4.1	 Exposure to UV Radiation from the Sun
			16.4.2	 Exposure to Cold
				16.4.2.1 Pre-competition Warm-Up in Cold Environment
		16.5	 Choice of the Right Fluids
		16.6	 Choice of the Right Food
			16.6.1	 Travellers’ Diarrhoea
				16.6.1.1	 Prevention of Diarrhoea (Short-Term Travel, Up to 3 Weeks)
				16.6.1.2	 Management of Diarrhoea
				16.6.1.3	 Procedures of Epidemic Control
		16.7	 Risk of Travel Fatigue and Overstraining
		16.8	 Water Pollution
			16.8.1	 Procedures to Reduce Infection [104]
			16.8.2	 Leptospirosis
		16.9	 Athletes Security Abroad
		16.10	 Dangers of Transportation
		References
	17: Nutrition Strategies for Triathlon
		17.1	 Introduction
		17.2	 Theme 1: Nutrition Goals and Requirements Are Neither Static Nor Universal
			17.2.1	 Application to Triathlon
		17.3	 Theme 2: Energy Availability Sets an Important Foundation for Health and Performance Success
			17.3.1	 Application to Triathlon
		17.4	 Theme 3: The Achievement of the Body Composition Associated with Optimal Performance Is Challenging and Requires a Long-Term Plan
			17.4.1	 Application to Triathlon
		17.5	 Theme 4: Guidelines for Nutrition Need to Consider Training Load, Body Size and Timing of Intake
			17.5.1	 Application to Triathlon
		17.6	 Theme 5: Competition Nutrition Strategies Target the Limiting Factors in Optimal Performance
			17.6.1	 Application to Triathlon
		17.7	 Theme 6: Nutrition for Adaptation and Recovery Is a Targeted Tool
			17.7.1	 Application to Triathlon
		17.8	 Theme 7: High-Performance Athletes Walk a Tight-Rope Between Adequate Training Stimulus and the Risk of Illness/Injury
			17.8.1	 Application to Triathlon
		17.9	 Theme 8: A Pragmatic Approach to Supplements and Sports Foods Is Needed
			17.9.1	 Application to Triathlon
		References
Part V: Training
	18: Quantifying the Training Load in Triathlon
		18.1	 Concept and Components of Training Load
		18.2	 Load Quantification Models
		18.3	 Considerations and Criteria for Quantifying the Objective Load Using the ECOs Model for Endurance Training
			18.3.1	 Training Zones and IF
			18.3.2	 Exercise Mode and EF
			18.3.3	 Density
				18.3.3.1	 Load Percentage
				18.3.3.2	 Weighting Density in High-Intensity Workouts
			18.3.4	 Weighting the Effort Duration against the Standard Time Limit in a Zone
		18.4	 Other LI for Special Cases: Transition (bricks), Indoor Cycling, Draft and Drag, Zone Subdivision, Progressive Workouts, Specific Strength, Extreme Conditions
		18.5	 Considerations and Criteria to Quantify the Objective Load Using the ECOs Model for Strength Training
		18.6	 Special Cases
		References
	19: Science-Based Criteria to Identify Talent Among Triathlon Athletes
		19.1	 Sports Specialization in Triathlon
		19.2	 Relative Age in Triathlon
		19.3	 Optimal Morphology of Triathletes
		19.4	 Physical and Physiological Factors
		19.5	 Performance Indicator in Triathlon
		References
	20: Altitude Training and Endurance Performance
		20.1	 Introduction
		20.2	 A Few Reminders About the Altitude Environment
		20.3	 The Different Methods of Altitude Training
			20.3.1	 Live High—Train High (LHTH)
			20.3.2	 Live High—Train Low (LHTL)
			20.3.3	 Live Low—Train High (LLTH)
			20.3.4	 Other Methods
		20.4	 Altitude Training for Competing at Altitude
		20.5	 Altitude Training for Performance in Triathlon
		20.6	 Practical Recommendations
			20.6.1	 Is There an Optimal Hypoxic Dose for Altitude Training?
			20.6.2	 What Is the Timing of Return from Altitude Training for Optimal Sea Level Performance?
			20.6.3	 Is Iron Supplementation Required During Altitude Training?
		20.7	 Conclusion
		References
	21: The Overtraining Syndrome
		21.1	 Definition
		21.2	 Epidemiology
		21.3	 Pathogenesis
		21.4	 Diagnosis
			21.4.1	 Medical History
			21.4.2	 Specific Tests
		21.5	 Treatment
		21.6	 Triathletes Monitoring
			21.6.1	 Psychological Monitoring
			21.6.2	 Performance Monitoring
			21.6.3	 Physiological Monitoring
		References
Part VI: Special Considerations
	22: Triathlon Race Day Medical Care
		22.1	 Introduction
		22.2	 Pre-Race Planning
		22.3	 Communication on Race Day
		22.4	 Role of the RMD
		22.5	 Medical Staffing for the Race
		22.6	 International Triathlon Union (ITU) Staffing Requirements
		22.7	 Race Day Conditions
		22.8	 Swim Course Safety
		22.9	 Post Swim Medical Problems
		22.10	 Bike Course Safety
		22.11	 Run Course Safety
		22.12	 Finish Line Medical Care
		22.13	 The Medical Tent
		22.14	 Conclusion
		Appendix 1
			Medical and Anti-doping Control Management in ITU Event
				Medical Management
				Doping Control
		Appendix 2
			Swimming ITU Competition Rules
		References
	23: Triathlon Marine Plan in the Olympic Games and in the ITU World Triathlon Series
		23.1	 The Marine Operation Plan
		23.2	 Emergency Action Plan
		23.3	 The Swim Course: Field of Play Medical Plan
			23.3.1	 Medical Treatment
			23.3.2	 Transferring to Hospital
			23.3.3	 Medical Resilience
		23.4	 Swim Course Personnel
	24: ITU Triathlon Water Quality Statement
		24.1	 International Triathlon Union (ITU) Medical Documents
		24.2	 Water Quality Problems
		24.3	 Risk Factors
			24.3.1	 The Commonly Used Indicator
		24.4	 Standards Under Discussion
		24.5	 ITU Water Quality Rules
			24.5.1	 Water Quality Tests Submit to ITU
		References
Part VII: The Paratriathlon
	25: ITU Paratriathlon History
	26: Physiological Considerations for Paratriathlon Training and Competition
		26.1	 Introduction
		26.2	 The Paratriathlete
			26.2.1	 Spinal Cord Injury
			26.2.2	 Cerebral Palsy
			26.2.3	 Amputation
			26.2.4	 Visual Impairment
			26.2.5	 Conclusion
		26.3	 Training Considerations
			26.3.1	 Considerations for Training Load Quantification
			26.3.2	 Training and Illness Risk
			26.3.3	 Intensified Training
			26.3.4	 Conclusion
		26.4	 Thermoregulation and Preparing for Competition in the Heat
			26.4.1	 Thermoregulation and Competition in the Heat
			26.4.2	 Preparing for Competition in the Heat
			26.4.3	 Conclusion
		26.5	 Summary
		References