Strength Training for Triathletes: The Model for Injury Prevention by Dr. Craig Smith
When I read online or discuss the concept of injury prevention, I feel there is a common misunderstanding in athletes and coaches about the concept. Injury prevention is not a series of exercises. Nor is it a massage after a particularly hard week of training. It may include both but it fails to look at the big picture. Injury prevention is a system meant to first look at the most common injuries in the triathlon community, the biggest risk factors that contribute to injury, the most common mechanisms of injury, and finally the methods and initiatives to address each of these issues with reassessment to see how it worked.* Take a look at the Figure 1 to see the basic concept.
Now, the first step is never complete because sport is always evolving. There is new tech, new shoe types, different bike design, changing strategy, etc which modify the epidemiology of injury in triathlon. Our best available evidence in triathlons is quite limited.** Step 2 is being grown, especially by a group in Australia.***
However, there is still not enough information to make a fully evidence based program for injury prevention in triathletes through a strength program coupled with the specific triathlon training. In my opinion and the goal today, is to use the information available and meld it with the experience of the triathlete and coach.
Here is a case study:
A triathlete comes into camp looking to increase her speed on the bike. An injury history form is filled out, which indicates that the athlete had an anterior cruciate ligament injury 5 years ago. The athlete has been fully cleared for activity and has no current pain, but will normally experience pain with a volume increase in running. She has competed successfully in multiple ironman races over the last 4 years.
Based on this information alone, we can say that this athlete is predisposed to injury (Figure 2). These are known as intrinsic risk factors. Now, she wants to use her new tri bike that puts the body in the typical flexed and aerodynamic position. This is an extrinsic risk factor that needs to be included in our thought process because it will increase risk for her having an injury especially at the hip and low back.
From this basic profile we can complete our injury prevention model by screening movements.****
Now according to the best available evidence and my experience in running, swimming, and biking, a triathlete needs to have basic amounts motion in the neck, thoracic spine, shoulders, hips, knees, ankles and big toes. Showing all of these would take too long for the blog post today, so instead I will touch one screen that should definitely be included based on the information above.
For this hypothetical athlete, we really need to assess for the presence of a hip impingement or she will likely experience a break down with the new tri bike.
Now if this test is positive, the tri bike makes no sense. Another easy impingement test to do on your own is a deep squat. If you feel pain or discomfort in the front of the thigh, you may have an impingement as well.
This is a long winded approach to help you see why basic principles on injury prevention show multiple areas that can be approached to reduce injury while improving performance. In this example, we could target the long lasting complications of ACL injury (gluteal amnesia, gait abnormality, poor power generation in single leg tasks, etc), the recurrent pain with running, or what bike is best. Failure to look comprehensively at the big picture is a huge problem in the triathlon community because a performance only view can lead to no performance. A tri bike may make you faster and save time, but if it aggravates an underlying impingement, then you may have surgery in your future.
Each decision you make during the off season and during training, should support this overall view of injury prevention, including how long you take to ramp up, the volume during a week, how to schedule recovery into your week, if multiple triathlons are smart (races increase the rate of injury compared to just training), and equipment selection.
* As a researcher in this area, there is one paper I constantly reference on injury prevention methodology. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 1992;14(2):82–99.
** This type of research is not easy -which is why it’s so limited.
*** Vicenzino, Chapman, Bonacci
****Screening is a term used in medicine. When a screening test is used, we want it to be highly sensitive. A sensitive test will have low rates of false negatives (people who are found to not have the problem by the test, but really do!), meaning that while false positives (people found to have the problem, who really don’t) may also be found, we won’t miss people that are at risk because the harm of false negative is much higher than false positives.
Dr. Craig Smith PT DPT is the Owner and director of Smith Performance Center. He is a physical therapist, strength coach, researcher, and adjunct faculty at Northern Arizona University. He is a researcher and has authored many papers that have appeared in clinical trade publications. He focuses on movement impairments, dysfunctional gait, and running analysis along with long term athletic development with a focus on injury risk reduction and screening. His specialties include strength and conditioning programming, return to play evaluations, running and foot biomechanical analysis, and physical therapy.