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Einleitung:
The first Triathlon was hold in San Diego, California, USA in 1947 by members of the
San Diego Track Club. In the beginning of the 1980ies Triathlon got attention by the
TV-Übertragung in the USA. Triathlon was made accepted as an Olympic discipline
in 1994 and was first participated at the Olympic Games in 2000 (https://www.dtu-
info.de/dachverband-dtu/historie.html). In Triathlon the athletes have to preform with-
out any break between the three disciplines, with the fixed order in swimming, cycling
and running. Distances range from sprint triathlons (750m swim, 20km bike, 5 km
run), to Olympic distance triathlons (1,5k swim, 40 km bike, 10 km run), to ITU long-
distance triathlons (3 km swim, 80 km cycle, 20 km run), Half/70.3 Ironman (1,9km
swim, 90 km bike, 21,09km run), to long-distance / full/ ironman (3,8km swim, 180
km bike, 41,195 km run). More variations inspired by Triathlon are getting popular.
The most famous Triathlon Distance, the “Ironman” can be contested in up to 40-fold
execution as an “Quadruple Deca Ultratriathlon” with participating in 30 Ironman’s in
30 days. The Triathlon.org also offers informations about the “Aquathlon” where Ath-
letes have to deal with a 2,5km run, followed by 1km of swimming and another 2,5km
run. “Cross Triathlon”, which is also called “X-tri” is an off-road triathlon discipline with
an 1km swim, 20-30 km mountain biking, and 6 to 10 km trail run. “Duathlon” with
10km of running, 40 km of cycling and another 5 km run. And a “Winter Triathlon”
with running, mountain biking and cross country skiing. Usually Triathlon is an indi-
vidual event, but team triathlons can be found too.
Sport is becoming increasingly popular among people. More and more people realize
the benefits of participating in sport. Especially in Triathlon, including three of the
sports with the highest participating rate, more and more Athletes follow the trend.
Approximately 270.00 Athletes took part in in Triathlon competitions in 2017 in Ger-
many ( https://www.dtu-info.de/triathlon-in-zahlen.html). Triathlon offers many health
benefits but as well as in other sports, athletes can suffer from injuries.
dvs Band ??? © Edition Czwalina 1

The objective of this systematic review is to collect (and appraise) existing literature
surrounding injuries and overreaching syndromes in Triathlon. and this review gives
an overview about common clusters of upcoming injuries and overreaching syn-
dromes in triathletes. In order to better understand injury mechanism it’s important to
consider different aspects linked to the athlete and his environment.
Physiologie Endurance Sport
Endurance in Sports is generalized trough repeated isotonic contraptions by large

skeletal muscle groups. Exercising Endurance Sports is usually performed at sub-
maximal intensity with the main aim of gradually moving the anaerobic threshold
(Morici et al,. 2016). The anaerobic threshold is the exertion level between aerobic
and anaerobic exercise where the body needs to switch from aerobic to anaerobic
metabolism. This is needed when exercise intensity increased, and the aerobic sys-
tem can no longer keep up with the body’s energy demand. During aerobic metabo-
lism , the body creates energy through burning carbohydrates and fats in the pres-
ence of oxygen. Carbondioxid is produced and water as by-products because of
breathing and sweating. Anaerobic metabolism leads to burn stored sugars by the
body to successfully perform the exercise. Lactic and acid is produced faster than it
can be metabolized. The results are muscle pain, burning and fatigue, therefore aer-
obic energy expenditure is hard to hold for longer than a few minutes.
Moving the anaerobic threshold works through compound modifications in muscle
metabolism. Mitochondrial density and oxidative enzymes have to increase But also
an transfer in muscle fibre type and an enhanced capillarization of muscle fibers are
involved.
The muscle needs to be maintained
To perform aerobic training it’s necessary to posses over a good adaption between
respiratory and cardiovascular systems. Both provide the muscles with the requisite
2 MUSTERAUTOR: Kurztitel
supply of energy which gets metabolized into mechanical work. (stimmt
das?metabolized? Orginales wort: transformed).
1.2 Physiological Characteristics
Achievement in sports is regulated to sports technical and conditional factors. After

strength, endurance is the second best trainable basic motor property.
It’s Scientifically proven, that triathlon is physical and psychologically lass demanding
on the human body compared to a marathon. Equally, hormonal stress and metabolic
stress are low. Nevertheless, no other endurance sport is as extensive for the mus-
culature, metabolism and cardiovascular system as the triathlon. ( Sportverleztungen
Buch). In general, triathletes spend – hours of training per weeks, what leads to high
demands on the locomotor system (Engelhard et al.).
1.3 Characterization of Triathlon Disciplines
1.3.1 Swimming
Swimming is in Triathlon the most difficult leg. A good performance given in swim-
ming depends mainly on biomechanical factors like the leverage and coordination of
arms and legs. Those stable factors show the differences between the performance
in different swimmers. Interindividual performance in one athlete is given by unstable
power assets (Leistungsvermögen) which depends on the intensity and the scope
of the trainings period. That’s why a good triathlon should come from the swimming
sports (Szögy et al, 1986).
The discipline of swimming in triathlon takes place in an open water area like lakes
and the ocean with no lanes are given to separate the swimmers. The profile of re-
quirements of the triathlete while swimming can be divided into two phases. One is
the time at the competition till the start of the swimming. The swimmer needs to have
good assertiveness (Durchsezuungsvermögen) to find a good starting position (in
order to get a profitable field position and to get an optimum way to the first buoy)
and to increase attention ability and ability to concentrate. The other phase takes

place from the start signal till the swim exit. The athlete needs to get into an initial
speed to find a position with the frontrunners. An average velocity needs to be hold.
Physical and mental assertiveness are required, as well as an optimized orientation
capability. (Wolfgang Rentschler, Schwimmen im Triathlon-Anforderungsprofil,
Training, Systematisierung.Anforderungsprofil Triathlon (s82). The goal of triathlon
swimming is to the safe energy for the following disciplines in cycling and running
(How to get). Middle-distance swimming is a combination of both aerobic capacity
and exercise efficiency (Costill et al., 1985). But there are several parameters for
factors associated with the swimming performance (Toussaint et al, 1994). To gen-
erate a maximum propulsion which is needed to increase pace while swimming, fol-
lowing points influence the maximum propulsion: speed of the body segment (with
respect to the water), surface area of the body segment, shape of the body segment,
orientation of the body segment, direction of the force and duration of the force. It’s
also important to minimize resistance to increase pace with continuity of movement,
resting muscles during recovery, using appropriate joint angles and levers and using
the large muscles of the body. While swimming the speed increases and decreases
with the swimming stroke. From a biomechanical view this is called the intra-cycle
velocity. More energy is required if the variations are big and a consistent swimming
speed should be performed (Barbosa et al, 2005). It’s necessary to find a swim tech-
nique which helps to use the same amount of energy while having the aspect of
keeping the intra-cycle velocity as small as possible to generate a smooth and con-
stant movement (Cala et al., 2011). For swimming crawl, the muscles on one body
side are contracting and shortening with the other body side relaxing, lengthening
and storing energy (Tureski, 1997). While crawling, the main muscles involved are
the latissimus dorsi, m.teres major, m.pectoralis, m. triceps brachii and m. deltoideus
(pars anterior) (s71hottentott). WELCHE GELENKE??!
1.3.2 Cycling
Cyclic sports is less demanding for the athletes with the view on sports technological
execution. In Cycling sports there is a hierarchy for the difficulty of technical design.
Muscular Activity in cycling:
There are plenty of forces that effect the biomechanics of cycling. Forces produced
by cyclists are generated through the muscles and transmitted by the skeletal system
to the pedals. Pedaling forces are affected by external forces of drag, weight and
rolling together with forced appropriated to the saddle and the handlebars (Bini et
al.,). To ensure propulsion while cycling following muscles are required: m.tibialis
anterior for dorsalflexion of the foot, the two articulated m. Gastrocnemius for plantar
flexion of the feet and flexion in knee joint., knee extensor m vastus laterals and
vastus medialis, hip flexor and knie joint extensor rectus femoris, hip extensor and
knee flexor m. biceps femoris, m semimenbranosus and semitendinosus hip extensor
gluteus maximus and hip flexor m. Iliopsoas. The Muscles unequal long activated
while pedaling rhythm. While sitting and with a low pedaling resistance (120W), the
rectus femurs is with 64% of the cycle time longer activated compared to other mus-
cles. With an higher pedaling resistance (240 W) the active time of the m.tibialis an-
terior and the ischiocrural muscles stay longer activated (hottentorr). The require-
ments for cycling are for example an increased tactical knowledge about driving
behavior. More, the athletes need to stand a short-term maximum stress with almost
lactation and tolerance and to keep a high speed level after short-term maximum load
(Rentschler, 2004/ 2005).
Aerodynamics and power output of the required muscles must be maxim-
ized..(WOHER?!) and can be achieved by forward of the saddle to the bottom bracket
(Ricard, et al., 2006). To reduce frontal area, the upper body should be flexed with
the help of aerobars. This helps to support arms and hands and closer the knees to
the bicycle frame (Burke and Pruitt, 2003).
1.3.2 Running
While the running, he athlete has to run his own body mass. That’s why running
counts to the most strenuous sports and causes a high energy consumption
(Stromme und Ingjer, 1982).

An (almost) maximum initial speed is required after the change from cycling to run-
ning. But also a short burst of speed is needed under the conditional and tactical
aspects. To success in the end, the final spurt must be fast even if the preload was
really high. (Muskelaktivität laufen!) (Rentschler, 2014/15) The running cycle includes
a stance phase and a swing phase. From the kinematical view the first contact with
the ground is the start of the cycle for the leg (Anderson, 1996) where the muscles
need to contract eccentrically in order to occlude forces while landing, resulting
through a transition to concentric contraction and force generation. This is called the
“mid-stance”. The last movement in the stance phase Is where the last instant foot is
in contact with the ground. With changing running velocity and change of the ground
slope, there muscle activation pattern changes too. The main muscles to generate
force stay the same. While the second part of swing phase and stance phase the hip
extensors including XX work. While stance phase the knee extensors, ankle plantar
flexors, and hip abductors . The leg get pushed by the hip flexors to the front after
the take-off. Gluteus maximus, minimus and medius and the hamstrings drag the
athlete forward. Quadriceps femoris and ankle plantar flexors cause an upward force.
The muscles and the tendons lengthen need to absorb appearing forces while land-
ing (Koznic and Sarabon, 2017). Because of the elastic characteristics of the ten-
dons, they return up to 95% of the energy located in the amortization phase (No-
vacheck, 1998). Most of the work while propulsion is made through the plantar flexors
(Hammers, Seth & Delp, 2010).
1.3.4
The transition is the progression from one discipline to the next and can be described
as the forth discipline in triathlon (Murphy, 2009). Margarits et al, remarks that „the
physiological conditions in which the first transition is made can limit the performance
in the two following events“. This also counts for the second transition where the
athletes have to switch from cycle to run (Margaritis, 1996). A fast run is needed to
the changing position from swimming to cycling and from cycling to the run. The tran-
sitions area is a limited section. For the second transition the athletes need to dis-
mount their cycles and to run barefoot or with their cycling shoes on, to a holding
piece to a defined location. After this they need to take off their helmed, get into the
running shoes and leave the transition area to start the last phase with the run
(Rentschler 2014/15).
If an athlete wants to achieve high athletic performance in triathlon he needs to have

an optimum state of health. Good Sports-technical skills in all the three disciplines,
the willingness to have a high training workload and a continuous capability which is
known as the aerobic capacity. (Buch sported profil)
Aerobic Capactiy is „the maximum amount of physiological work that an individual
can do as measured by oxygen consumption. It is determined by a combination of
aging and cardiovascular conditioning and is associated with the efficiency of oxygen
extraction from the tissue“ (https://medical-dictionary.thefreedictionary.com/aero-
bic+capacity).
Aerobic Capacity is the ability to perform submaximal load with optimal 02 usage for
a long time. Morphological factors like a high amount of slow-twice fibers and func-
tional factors like the 02 Transport-System (including breathing, cardiovascular sys-
tem and gas exchange) and factory of metabolism (retain of glycogen, free fatty acids
and enzymes) influence the oxidative energy supply. A well-trained triathlete needs
to dispose about a high 02 provision and a high usage of the 02 in the working muscle
(Szögy et al., 1986).
Endurance is also generated through the adaption to extensive and faster gas ex-
change at the level of the lungs. This is possible because by increasing the number
of functional pulmonary alveoli and by increasing of pulmonary hemostasis. This form
of appearance continues after the effort. Even after anaerobic effort, being phrased
by the rapid regaining of the body values at the rest (Dudley et al., 1982). Effort in
endurance is mostly provided by slow-twice (ST) fibers (Kindermann et al, 1979). The
significance of the aerobic-anaerobic transition for the determination of work load
intensities during endurance training (Kindermann, et al., 1979.). They have more

myoglobin with the heme group related to them, which allows the storage of oxygen.
Also an increased oxidative potential is given while being recruited during endurance
efforts with an higher amount, compared to rapid-twitch fibers, with a significant gly-
colytic potential (Casile et al., 2014) An Improvement in endurance is remarkably
correlated with an higher amount of mitochondria and an higher oxidative capacity of
the muscles (Counsilman, 1977).
(-> Lactate Threshold and functional utilization of Vo2Max

„ The fastest pace an athlete can sustain during an endurance event is strongly re-
lated to the rate of aerobic energy production approximating the threshold of blood
lactate accumulation (LT), or the onset of hyperventilation (ventilatory threshold, VT).
{…}. Both LT and VT have been have been termed the aerobic threshold, based on
a common misunderstanding, that the onset of lactic acid production in the muscle,
and hence appearance in the blood, is caused by insufficient oxygen in the contract-
ing muscle. The LT and VT appear closely linked but may not be physiologically cou-
pled. Regardless of physiology or terminology, exercise above LT and VT cannot be
maintained indefinitely due the factors related to accelerated glycogen depletion,
reduced fat oxidation, and metabolic acidosis. The ventilatory and lactate thresholds
reported in triathletes are similar slightly lower than those reported in elite single-
sport athletes. Average LT expressed as a percentage of sport-specific VO2max ap-
pears to be greater during running than cycling. In recreational and subelite triath-
letes, VT occurred at 72% to 75% of swim VO2max, 63% to 82% of cycle VO2max,
and 74% to 75% of run VO2max. Similarly, LT (defined at 4 mmol/L) was reported to
occur at 72% to 88% of bike VO2max and 80% to 85% of run VO2max. Energy output
at VT or LT would appear to be the lowest in swimming followed by cycling and run-
ning.
In a group of international-caliber short-course triathletes, relative run VT was low-
ered
Characterization of Triathlons Equipment
For the swimming leg in Triathlon, the Athletes might wear a wetsuit. As the water
temperature is not controllable in open water swimming, compared to regular swim-
ming in a pool, in standard-distance races wetsuits can be worn when the water tem-
perature is below 16°C, to avoid hypothermia. If the water temperature rises over
20°C, it’s forbidden to wear a wetsuit (Bentley et al., 2002). A rule was implemented,
limiting the wetsuits fabrics thickness to 5 mm according to set a limit to the buoyancy
provided threw wearing a thick wetsuit (Chatard et al., 1995). Sporting good manu-
factures produce many different types of wetsuits, differing in lengths or as one piece
or in two pieces. The biggest advantage of using a wetsuit is to increase velocity
because buoyancy and hydrostatic lift (Bentley et al., 2002). To minimize the direct
contact with the head and the water to reduce water resistance, caps can be used
for gliding (Hue et al.,). Googles provide a better view underwater.
Cycling:
For success in Triathlon there must be a connection between physical and mechan-
ical parts. Biomechanics helps to build a bike which maximizes power output for the
given muscles input and minimize strain on the working muscles, even noting that
propulsion in cycling only works with the cyclist’s legs. Triathlon Bikes often have
aerodynamic rims, tyres and handlebars (aerobars) and a light, aerodynamic frame
(Jeukendrup et al., 2001). Aerobars help to reduce frontal projected area and im-
prove the cyclist’s aerodynamics. The changed upper body position caused by the
use of aerobars also provides a reduced activation of the biceps brachii and the up-
per trapezius compared to the cyclists riding in the “Superman” position. ( Changing
upper body position has a consistent effect in activation of upper and lower body
muscles [105]. Triathletes and time trialists use aerobars to reduce frontal projected
area and improve aerodynamics. This practice reduces activation o biceps brachii
and upper trapezius compared to the Superman position, when cyclists pedal with
their arms fully extended lying on a support longer than aerobars used by triathletes
[127]. ) (Wurnitsch et al., 2010). The bike’s saddle is compared to a regular road-
bike’s saddle usually projected forward through change the seat tube angle or
changing the position of the saddle more forward (Bini et al., 2014).

cycling shoes relieve power transfer from the foot through the shoe to the cleat and
pedal because of a stiff sole. Metal or plastic cleats provide hold of the shoe and
the pedal. Cycling pedals can be divided into three groups: flat pedals, clip pedals
and cleat pedals (clipless pedals) with different benefits. The shoe for cycling must
support the foot and generate comfort but also provide an effective transmission of
force while the shoe should be stiff enough to distribute pressure and flexible enough
for a natural foot motion (Neumann et al.,2004).
Athletes Heart
The „athletes heart“ shows changes in the electrocardiogram (ECG). Abnormalities

are seen by 40% of the athletes in their ECG (Maron et al., 2006). Depending on the
sport and the intensity of training different changes can be found in the ECG. Blabla
at al found different changes like extended QRS-complexes and diffuse modifications
in T-waves. (Pelliccia 2013)
3.1 Injuries
The modern triathlon was evolved by runners who wanted to provide a multitude
cross-training to reduce overuse injuries due to running. Further, more variety in their
workouts was given trough swimming and cycling (Strock et al., 2006). In the begin-
ning of triathlon’s history, many believed that training in triathlon with the three disci-
plines would lead to less injuries compared to athletes training in a single sport but
several studies found the different outcomes (Tuite, 2010).
This systematic review compares outcomes of studies about acute and overuse in-
juries among triathletes. While an acute injury “refers to the first 24-48 h after an
injury due to a traumatic episode, such as one sustained during a sporting activity.”
(https://medical-dictionary.thefreedictionary.com/acute+injury) the overuse-injury
can be described following: “A sports- or occupation-related injury that involve repet-
itive submaximal loading of a particular musculoskeletal unit, resulting in changes
due to fatigue of tendons or inflammation of surrounding tissues; (..) (eckige klam-
mer) syndrome. (overuse injury. (n.d.) McGraw-Hill Concise Dictionary of Modern
Medicine. (2002). Retrieved July 19 2018 from https://medical-dictionary.thefreedic-
tionary.com/overuse+injury).
Medical Considerations:
Although this review focuses only on acute and overuse injuries among triathlon,
Athletes can suffer from many different medical problems while competition or train-
ing. Not only muscoskeletal injuries can stop Athletes from finishing training or com-
petition. There are several medical problems Athletes can suffer from. SA et al, de-
scribes in his study medical treatments while South African Ironman 2014.
Most of the medical treatments have to be done because of the exertion of the ath-
letes (64%). Including exercise-associated collapse (EAC)/hypotension (34%) and
exhaustion (5,2%), hypothermia (5,2%), exercise-associated muscle-cramps (5,2%),
hyponatremia (2,8%), hypoglycemia (2,4%) and hypothermia (<1%). Medical help in
the field of the gastrointestinal system is required (13,7%). Nausea with or without
vomiting (7,6%), epigastric pain (2,8%) and diarrhoea (2,8%) and heartburn (<1%).
Skin abrasions (4,7%), blisters (3,3%), bee stings (<1%), erythema (<1%) and sun-
burn (<1%) count to the dermatological field where help was required and account
for 9,9% of the injuries. Dehydration (9,4%) can occour because of sweating and
participating under heat and sun. Additionally especially Cardiorespiratory diagnoses
(2,4%) can be serious, including pulmonary embolism, atrial fibrillation, asthma, bron-
chospasm, and sore throat with coughing. More findings are heat stoke, postural hy-
potension, excessive exposure to ultraviolet radiation, bacterial infection from expo-
sure to contaminated water, a variety of gastrointestinal problems, post-race immu-
nosuppression, sympathetic nervous system exhaustion and hemolysis.
Acute and Overuse Injuries
Swimming

Suffering from an acute injury in swimming is uncommon (Seafair). While swimming
the athletes can digging by wetsuit (armpits, neck). Muscle injuries can occur in the
shoulder, the eyelid can get injured (while getting hit or a step on the goggles), or
skin burns because of inadequate using of sun protection. Most of the injuries in
swimming occur on the competition route. This can be explained because of fights
about a good position or swimming to the buoy. Most of the injuries while swimming
occurs because of position fights and the combats of the athletes at the beginning
and at the buoys (Sportverletzungen buch). Lower limb muscle strains or foot lacer-
ations can occur while exit water or beach exit in the swim leg (Migliorini 2011). 1/3
of acute injuries while swimming in open water and the transition areas occur be-
cause of objects like iron nails or glass fragments. Lacerations and cuts are 50% of
injuries while open water swimming and 20% are bruises and abrasions (Thies et al,
1986). More acute but uncommon injuries are liaisons with sharks, jelly fish and net-
tles, or medical problems in lakes or rivers with possible high bacterial contaminant
concentrations and submerged debris (USA Triathlon. Event sanctioning require-
ments (online). Available from URL: http://www.active.com/usat/forms/requrired.cfm)
(Accessed 2018)
Overuse injuries in swimming involve especially the shoulder. Suffering from an over-
use injury in swimming is less common compared to injuries from cycling or running.
Because of the repetitive abduction, flexion, and extension while freestyle stroke
(which is used by most of the triathletes) the motion against resistance can result to
an overuse injury (de Villers et al., 2016). This is especially seen by swimming in the
front-crawl, which is the most swimming stroke used in triathlon.
Injuries:
While cycling, most of the acute injuries occur because of falling from the bike,
caused because the aerodynamic cycling position leads to an reduction of instability
and control of the bike. Additionally, when big groups of riders cycle together with a
high speed, crashes are possible (McHardy et al., 2006). Approximate 1/3 of triath-
letes fall from their bike each year, during competition even 1 out of 250 Athletes fall
from their bike (Imaging of Triathlon INjuires, 1127). Abrasion’s, bruises, Clavicular
fracture, Acromioclavicular joint disruption, forearm fracture, traumatic brain injury
and torn muscle fiber in lower extremities can be found. (buch?).
Reasons why overuse injuries occur in cycling are similar to them in running. Two
more reasons can be overtraining, and muscle imbalance and flexibility. This can be
explained because of stressing the musculoskeletal system with a too high burden
for the musculature and soft tissue. Muscle imbalance can lead from an unfamiliarity
about the demands of the cycling sport and because of general muscle weakness.
The missing of flexibility can be explained because tight muscles don’t respond ac-
curate (well) of the cycling stress. (Cycling Injuries). To find an explanation why over-
use injuries in cycling exists, the biomechanical demands on muscles, bones, liga-
ments and joints need to be considered. The incidence of overuse injuries in the
ankle/foot complex can mostly result from the interface between foot and pedal. De-
pending on how the food is secured to the pedal is also related to the type of injuries
found. Cleat design and toe-strap influence the compression on the digital nerves of
the foot and can lead to numbness and temporary paresthesia. For example, cleat
designs with a smaller shoe pedal contact surface area put high pressure concentra-
tion on the plantar surface of the foot and can result in metatarsalgia. (S365). The
combination of an excessive dorsiflexion connected to a low seat height can result in
an Achilles tendinitis and plantar fasciitis. (Mellion 1991). Pain in the knee can occur
because of the improper mechanics and the accumulative insult of repetitive loading.
Both together are the reason for most of the overuse problems in cyclists. The cy-
clist’s anthropometrics and the construction of bike have to fit together, otherwise
there could be a negative influence on the knee joint dynamics and subsequent tissue
strain. To this counts shoe-cleat alignment on the pedal, seat height, and force-aft
adjustment, and various aerodynamic positions. Second important factors to note are
individual pedaling technique, structural variations of the athletes, and anatomic
asymmetries of the athlete (386 Athletic injuries and reha, Biomechanics of cycling,
Robert J. Gregor, Eileen Fowler).

Running:
Etiological factors related to overuse injuries in runners are abnormalities in the ana-
tomic alignment of the lower extremity and foot and limitations in the soft tissue mo-
bility (McPoil et al, 1996). “root et al identified several structural abnormalities in the
lower extremity as factors extrinsic to the foot that were compensated for by abnormal
foot pronation” (Root et al 1977) To the extrinsic factors count tibial varus, internal
and external tibial or malleolar torsion, internal and external femoral torsion, and dif-
ferent long legs ( leg length descripancies). Also a lower degree in flexibility of the
calf, hamstring, and iliopsoas muscles can lead to an abnormal lower extremity align-
ment during activity. Excessive stress to the patellofemoral joint can also emerge
because of an excessive pronation in the foot. An excessive pronation of the foot can
force the lower leg to stay in a prolonged period of internal rotation. Patellar tracking
patterns while running and walking can be changed because of this internal rotation.
Several authors reported a connection between knee pain and excessive subtalar
joint pronation. For example Heil showed that various extrinsic factors like genu
varum and genu valgum or coaxa vara and coaxa valga or an abnormal internal and
external rotation of tibia and femur can result in an excessive pronation. This is
caused because abnormal lining of the foot and the lower extremities (Heil, 1992).
There are several Common Triathlon Injuries described by sports medical literature.
Following described are some of the more common injuries related to XX XX
(Bücher).
Upper extremity
Overuse injuries in the upper extremities involve the shoulder, the arm, the forearm,
the elbow, the wrist and the hand.
The pain the athletes feel related to shoulder impingement can be compounded
while cycling with the use of aerobars. The position leads to higher compression of
the humeral head against the already inflamed supraspinatus tendon and subacro-
mial bursa. (imaging of triathlon injuries). While freestyle stroke in swimming, a re-
petitive abduction, flexion and extension motion against resistance can also lead to
the shoulder impingement (Imagining S 558). Another injury leading from this move-
ment are the rotator cuff tendinopathy or bursopathy (Tuite, 2010). Bursae are
fibrous fluid-filled sacs with an inner synovial-like fluid in the inside. The bursa pre-
vents musculotendinous structures to become deteriorated from continuous friction
against bony surfaces. Buch!. While the athlete do shoulder abduction and flexion,
the subacromial bursa keeps the glenohumeral joint capsule from the inferior aspect
of the acromion away (hutson and speed, 2011). The rotator cuff includes the su-
praspinatus superiorly, subscalpularis anteriorly, infraspinatus and teres minor pos-
teriorly. Most affected are the supraspinatus and the biceps tendon by tendinopathy
(Imaging) including tendinitis and tendinosis. Tendinitis is described as an inflam-
mation of the tendon. Occurring because of micro-tears happening while musculoten-
dinous unit is overloaded with too heavy or sudden tensile force (Boyer et al., 1999).
Tendinosis is the response of a chronic overuse, as a degeneration of tendon’s col-
lagen. Especially because of insufficient recovery time, the overuse is continued and
tendinosis can occour. (Bass, 2012). While movements of swimming, the rotator cuff
and the biceps tendon have to pass under the coracoacromial arch and can get dam-
aged because of the rapidly movement (Imaging). Both damaged tendons (Biceps
and rotator cuff) can result because of an enlargement from hypertrophy or inflam-
mation. This make it harder for the structures to pass under the arch while moves in
swimming (Imaging).The swimmers shoulder is a combination of rotator cuff tendi-
nitis, impingement, and laxity, due to overstretching of the anterior glenohumeral lig-
ament (Rupp et al., 1995). A Glenohumeral instability (mutlidirectional instability)
can result in high shoulder pain in swimmers.
Acromioclavicular ostoarthritis:
Osteolysis of the distal clavicle can be count a complication of the Acromivclavicular

joint synovitis (Bales et al., 2012).

De Quervain tenosynovitis is an inflammation of two tendons which control move-
ments in the thumb and their tendon sheat. Athletes feel pain of the wrists outside
(https://orthoinfo.aaos.org/en/diseases--conditions/de-quervains-tendinosis/). It oc-
curs because of shearing stress injury of the first exentsor compartment tendons
along the radial styloid and counts to the most common tendinopathy (ja) of the wrist
in athletes. Repeated motion in the wrist with radial or ulnar deviation and flexion or
extension can lead tenosynovitis. In the worst case the tendons of the extensor poli-
cies brevis and abductor policies longus can be teared of (Bancroft et al, 2013).
The Paget- Schrotter Syndrome which is Also called „thoraric inlet syndrome“ or
„effort-induced thrombosis“ is a subtype of the venous thoracic outlet syndrome.
it occurs mainly as an overhead arm activity. Reasons are compression of the sub-
clavian vein at the costoclavicular (ja) junction which leads to venous damage and
possible venous thrombosis( Eliahou et al., 2012) and is related to triathlon (Tao et
al., 2010) because athletes have to maintain the anaerobic posture on their bike for
a long time, leading to a mechanical conflict with the upper extremity veins. While
elbows and shoulders are flexed to bike with the use of handlebars, the risk of suf-
fering from the Paget-Schroetter disease is increased (Sancho-Gozálet et al, 2006).
Elbow and Wrist:
Using traditional handlebars while cycling can lead to compressive forces on the wrist
and an extended position which can result in ulnar nerve compression and a con-
dition similar to carpal tunnel syndrome. Also common are motor and sensory
deficits in the ulnar (Deakon et al, 2012). One type of the intersection syndrome
is caused as an overuse injury because of repetitive microtraumata. In literature the
name oarsmen’s wirst, squeaker’s wrist, or crossover syndrome can be found (Ban-
croft et al, 2013). The first and second extensor compartment tendons suffer from
peritendinous edema in the distal forearm while they cross each other (560 Imaging).
Lower extremity:
The lower extremities include the shin, the lower leg, the femur (thigh), patella, plan-
tar, sural (calf, backside of lower legs), the tarsal (ankle), the hip and buttocks.
Excessive running and cycling can lead to injuries in the knee. (Sanner et al., 2000),
which is the most popular region for injuries in runners with 25-30% (Clemens et al,
1999). Running can be seen as the most stressful of all the disciplines, that would
explain the high incidence rate (Vleck et al, 1998).
Injuries at the patellar, including patellar tendinosis and the patellofemoral stress
syndrome can come from running. For cycling, anterior knee pain results mostly
from Patellar tendinosis and is caused because of high extension forces while down
stroke in pedaling (Bailey et al., 2003).In Running it may be caused because a fast
increasement in running mileage. (1131 imaging). Patellofemoral stress syndrome
which is also called “biker’s knee” for cyclists and “runners knee” for runners, has a
higher incidence rate for females (females tend to have a greater Q angle what leads
to an lateral displacement forces on the patella) and is caused from the repetitive
loading of the patellofemoral joint while cycling. An abnormal patellar position (patal-
lar tracking on physical examination tests?) like an positive “j” sign leads to an lateral
deviation of the patella while full knee extension. Athletes with the “biker’s knee” may
have a patella alta, lateral subluxation, or a shallow trochlear groove (Imaging 1129).
Achilles tendinopathy is the most common ankle injury and account for 5% of inju-
ries in Triathletes (Seafair). It can result from running or cycling. In cycling it’s caused
because of the repetitive plantar flexion against resistance while down stroke (Cohen,
1993). The Achilles tendinosis can be divided into two groups with a hypoxic type
showing an focal thickening of the Achilles tendon. The other one is the mucoid type,
with an painful focal thickening of the tendon and a higher risk of progressing a tear.
It can be helpful for cyclist to raise the seat height in order to reduce ankle dorsiflex-
ion. Also stretching of the ligament is recommended. (1130, tuite).
Meniscal tears can result from repetitive impact forces while running with the poste-
rior horn of the medial meniscus being the most affected.
Stress-fracture:is defined as partial or complete breaks in bones. Reasons why ath-

letes suffer are mostly ascribed because of overuse and furthermore excessive com-
pressive or torsional loading. Moreover to this releated, if insufficient recovery and

thus the absence of required modeling process if given, those also called micro or
fatigue fractures can occur. Repeated mechanical loads can trigger micro-damage
and deformation to bones. After some times, the accumulation of those factors can
lead in partial or complete fractures and can be vulnerable to displacement (Ward et
al,. 2016). Especially Metastarsalia, Tibia, Fibula, Calcaneus, Femur and Pelvis can
be affected by stress fractures. Metastarsal stress fractures can occur because of
overpronation and hypermobility if the first ray which can influence higher stress to
the three central metatarsals. But also an unusual lengths of metatarsal bones con-
juncted in repetitive loading activities can be higher the susceptibility of athletes for
an higher stress fracture risk. (Ward et al., 2016). Stress fractures in tibia can be
explained because of overloading the bone by consistent muscle contractions which
can happen in running. The stress distribution in the bone changes because of not
stopping running, even when the muscles are particularly fatigued. The muscles can’t
handle with the stress, so the bones have to compensate. But also changes in the
running surface can higher the risk of suffering. (http://www.sportsinju-
ryclinic.net/sport-injuries/ankle-achilles-shin-pain/tibia-stress-fracture) fibula: „the
main function of the fibula bone is as a point of attachment for many of the muscles
of the lower leg. The tibia is the weight bearing bone of the two whereas the fibula
has much of its surface for muscle attachment. This results in traction and twisting
forces placed on the bone from the surrounding muscles which over time cause a
stress fracture. Athletes with excessive pronation or rolling in of the feet when running
are more susceptible because the peroneal muscles must work harder for longer
during toe off in the running gait cycle.“ !!!!!(http://www.sportsinjuryclinic.net/sport-
injuries/ankle-achilles-shin-pain/fibua-stress-fracture) Calcaneus: calcaneal
(schreibt man so!) stress fracture can be caused because of antagonistic pull of
achilles tendon towards that of the plantar tendons. Another reason are activities like
jumping and continuous standing because the gastrocnemius muscle gets eccentric
and concentric contracted and can higher the risk for an calcaneal stress fracture.
(stress fractures of the foot and ankle)
Iliotibial band Syndrome (IBTS)The ilitibial band syndrome is the main reason for
lateral knee pain in runners and causes for 15% of overuse injuries in cyclists (Ellis
et al,. 2007). IBTS occurs because repeated compressive stress between the IBT
and lateral epicondyle of the femur while the knee is in flexion (Puniello 1993). When
the knee gets into a flexion over 30° the IBT gets posteriorly positioned on the epi-
condyle. Under a position of 30° like in running, where knee angles around 21° at
foot strike are common, the force are higher and lead to proximate inflammation of
the band or its underlying bursa (Bell et al., 2016). Enhanced subtler pronation, genu
(riight) varus, excessive tibial torson (right) and tightness of the ITB can also increase
the chances of getting the IBTS (Engebretsen et al., 2003). Lateral knee pain wors-
ened during being active, especially while running is described by patients (Bell et al,
2016). IBTS can get worse because of a too high seat or if the seat is too far back
(Farrell et al, 2003)
sinding-larsen syndrome: is a traction tendinitis of the distal pole of the patella. It

arises because of repeated microtraumata and is a common reason for adolescent
anterior knee pain. Presenting signs is pain at the inferior patellar area. This can be
caused because of running and jumping.
retropatellare chondropathy (richtig so?),
shin splits - Also called medial tibial stress syndrome or periostitis. An incidence
of 35% is given in active populations to suffer from shin splits (Yates and White,
2014), while 12-18% of runners suffered from it (Harrast and Colonno, 2010). A focal
tenderness along mid- to distal portions of tibial crest’s posteromedial border is de-
cried by patients. The risk to injure increases through excessive tensile and compres-
sive forces from loading, tensile and compressive loading from myofascial forces and
shear stress from torsional bone forces (Harradine, 2013). Additionally because of
footwear and running style (Ward et al, 2016) the injury risk and increase.
Piriformis Syndrome: Can be described as an irritation of the sciatic nerve because

of the piriformis muscle and leads to local and referred posterior leg pain (Ward et
al., 2016). Neural pain can occur because of the sciatic nerve passing through the
piriformis. This only occurs in around 16% of people but an contraction or shortening

of the muscle can lead to pain. (Smoll, 2010). The nerve passes through the pirifirmos
muscle or the greater sciatic notch and can get damaged (Fishman et al., 2002).
Osteitis Pubis : is defined as an chronic inflammatory condition of the symphysial

joint. Osteitis Pubis is mainly found in athletes participating in soccer, tennis, cycling
and running- sports with an high rate of twisting and cutting. Reasons can be overuse
and micro traumata of the muscles used while running an kicking. Another etiological
factor can be the instability of the SI joint, repetitive adductor pull at origins of the
pubic rami, excessive motions (frontal or up-and-down) of the pelvic and because of
limitations of the hip joint movement (Flynn et al, 2009)
Cyclist’s nodule
plantar fasciitis; athletes with pain of insidious onset located on the heel on the
plantar surface of the food may suffer from plantar fasciitis, also called plantar fasci-
opathy. The pathology describes it as an degeneration and fragmentation of the
plantar fascia ( Lemont et al., 2003). The Plantar fascia includes three bands, the
medial band which is the thickest one and the most implicated (Ward et al., 2016).
But also the tight achilles tendon can be described as responsible for an plantar
fasciitis (Kibler et al., 1991). Athletes describe an insidious onset located on the heel
on the plantar surface of the foot. Risk factors are among other things an reduced
ankle dorsiflexion because of weak dorsiflex muscles and short plantarflexor (richtig)
muscles. , adiposity, increases in load-bearing actives like standing, walking and
running, biomechanical and overpronation. Additionally, pes clavus and cavus (richtig
so!), improper footwear and training on hard surface (Ward et al., 2016) can higher
the risk.
Metatarsalgia occurs with pain over the metatarsal heads and includes a large num-
ber of injuries like tendinitis, metatarsophalangeal joint synovitis/capsulitis, metatar-
sal stress reaction, metatarsal stress fractures, sesamoiditis (ja), and Morton neu-
roma (Tuite 2010)
Insertion tendinopathy (Knee/ spinal column/ foot)
Back pain
Lower back pain and neck are is possible during cycling. Xx of athletes had experi-
enced back pain. Lumbar pain in cycling may be partly explained because holding
the trunk while being in an aerodynamic flexed position for a long period. The origin
of back pain can lead from the muscles or ligaments, Villavicencia et al, found that
three-fourths of athletes had an amelioration of the pain after a few weeks. Backpain
holding loner than for 3 months may be explained because of an abnormality like an
faced disease or unrecognized spondylosis (Imaging 1130). Neck pain is seen in xx
% of triathletes and may be caused trough the hyper lordosis of the neck while cycling
in the aerodynamic position with a low trunk and an forward looking head. Same
accounting for lower back pain, having neck pain for longer than 3 months might be
caused because of an abnormality in a cervical disk disease (Imaging 1131)
Running:
muscle injury, capsule-band injury on , upper jump joint, soft tissue hematoma
Overuse Injuries:
Tenosynovitis and ENDOTENOITIS (keine übersetzung??) , the tenosynovitis (or

tenovaginitis) is an „inflammation of a tendon and its sheath“ (Dorland et al, 1988).
myotendinosis of the superficial pes anserinus ,
muscle imbalance lumbar vertebra
Thoracic Outlet Syndrome:
The thoracic outlet syndrome is an neuromuscular syndrome. Compression of the

brachial plexus and subclavian vasculature in the region of the thoracic outlet can
lead to it. There are several types found, like the arterial, venous, and neurogenic
types. Compression of the brachial plexus is the most popular and occur in 95%

cases (Elliahou et al, 2012). Compressing syndromes in athletes (in this case of tri-
athletes) are related with muscular hypertrophy through swimming. Anatomic vari-
ants or deformity guilty to past trauma like first rib fractures or clavicular (Elliagou et
al., 2012).
Lower Back and Neck pain:
Lumbar pain appears mostly while a prolonged aerodynamic flexed position while
cycling. While three-quarters of the athletes sorrow from the pain because it’s mus-
cular or ligamentous in nature and temporary, a quarter of the athletes feel the pain
because of disk, facet, or undetected spondylosis (Tuite et al., 2010). Neck pain can
be found in approximately 45 % of triathletes. Normally it appears while prolonged
hyperextension while cycling but mostly its muscular by nature (Tuite et al., 2010).
Upper leg, hip and groin
„hip injuries in triathletes reportedly account for between 5 and 20% of all injuries.“
Injuries involving the hip are primary associated with running but cycling can also
account for or exacerbate some conditions (Spiker et al., 2012).
Hip bursopathy:
There are three major bursae in the hip region: the iliopsoas bursa, the greater tro-
chanter bursa, and the ischial bursa. The main defitintion is decribed in XX. The ilip-
soas bursa can result from excessive activity (and the pain appears in the inguinal
area and radiates across the femoral triangle.) Trochanteric bursitis can be found in
runners, cross country skiers and ballet dancers. Ischial bursitis can lead from a di-
rect bruise or trauma after falling (Sanders et al., 1996).
The snapping hip syndrome is also called “coxa saltans” and is a term to describe
a painful, palpable, or audible noise made while moving the hip joint. Athletes partic-
ipating a sport with an higher hip movement like running (Konczak and Ames, 2005)
show an higher incidence. The condition can be divided into three classifications:
intra-articular snapping hip, internal extra-articular snapping hip and external extra-
articular snapping hip (Frampton et al., 2016). The Intra-articular snapping hip involve
associated pathology like acetabular labral tears, cartilage defects or loose bodies or
fracture (Yamamoto et al, 2004). Catching, locking or a painful clicking or sharp
stabbing sensation are the symptoms (Yamamoto et al, 2004). Internal extra-articular
snapping hip occurs because of an abnormal movement of the iliopsoas over a bony
prominence (typically the femoral neck) (Frampton et al., 2016). But research
showed, that the iliacus muscle can be more responsible for this than the iliopsoas
tendon (Deslands et al., 2008). External extra-articular snapping hip: can occur be-
cause of an abnormal movement of the ITB over the greater trochanter (Pelsser et
al., 2001) while lateral rotation and flexion (Brattaglia et al., 2011). Unusual but pos-
sible is the involvement of the gluteus maximus (Brignall et al., 1993). (BIS YAMOTO
ALLE NORMAL; AB JETZT FRAMPTON?).
Delayed Onset Muscle Soreness (DOMS) is described by painful muscle stiffness.

And results mostly from unfamiliar exercise, for example when training with an unu-
sual intensity. Pain, stiffness, and swelling commonly affect a defined muscle group
with symptom lasting for up to 10 days (Cheung et al. 2003) LITERATUR NICHT
MEHR GEFUNDEN

Korkia et al describes in his study overuse injuries in 155 British triathletes during the
competitive season in 1990. All distances from sprint triathlon till full ironman could
be performed. Questionnaires were handled to athletes through investigators, club
secretaries, coaches at competition or triathlon clubs. The athletes had to fill up the
questionnaire with sell-classification as recreational, intermediate or elite and per-
sonal details and the background in triathlon. After that, the athletes had to write a
trainings dairy for 8 weeks to adhere details about injuries sustained while training or
competition. Information’s training and competition, activity, intensity , mileage, dura-
tion and type of surface where the training was done, had be to described. To under-
stand the relationships for the study, information’s about rest days, non-triathlon re-
lated injury and illness and other comments had to be written down, too. The last part
in the questionnaire was for self-reporting of injuries associated with triathlon training
or racing while the 8-week period with information’s about body parts injured, body
tissue involved, nature of injury and how it happened. Those information’s must be
viewed with caution because the athletes might be laypersons.
SA ironman 2014:
The aim of this retrospective, cross-sectional study was to record the medical history,
illness and injury of athletes receiving medical attention during the 2014 Ironman
South Africa, and to examine the temporal presentation of medical encounters. The
study population included all participants from the ironman. All triathletes using the
medical attention during the event were included in the study. The information’s used
in the study were maintained from the standard documentation of medical encounters
while being personal present at the event. At all IMSA events the medical and demo-
graphical information’s of the athletes which needed medical attention at the event
were documented. The staff on duty made the clinical diagnoses by means of history
and recorded them. The clinical examination included blood pressure, heart rate,
core temperature measurement, and special investigations if needed. If needed,
blood gases, glucose, urea and electrolyte measurement, urinalysis, spirometry and
ECG could be used, too. Compared to the other studys include in this review, this
study also considers internal aspects like gastro-intestinal or cardiorespiratory prob-
lems If the final diagnosis couldn’t be made, the main presenting symptoms treated
were reported. All participating athletes demographic data were included too. The
data were ingested by one author and analyzed be the Department of Biostatics,
Faculty of Health Sciences, University of Free State (UFS) using SAS version 9.3.
Following descriptive statistics were calculated: frequencies and percentages (cate-
gorial variables) and means, and standard deviations (SD) or percentiles (numerical
variables). Subgroups got compared via Fisher’s exact test or chi ^2 test with an level
of statistical significance set at 0,05.
Zwingenberger et al,
This study was made determine training regiments and injury patterns of non-profes-
sional triathletes. The second aim was to compare results of the retrospective und
prospective investigations techniques. Non-professional triathletes participating at
the “Moritzburger Schlosstriathlon” were requested to take part in an online survey
with filling up retrospective information’s about their training habits and injuries in the
past 12 months. In this survey injuries were classified by the athletes about their

anatomical location, type of injury, incidence and associated risk factors. The injuries
were classified into following groups: contusion/skin abrasion, muscle/tendon injury,
ligament/capsule injury and fractures. Overuse and trauma injuries were included,
too. Information’s about number of training days, that their injury caused them to miss
and type of treatment of the injuries (hospital stay, outpatient care or no professional
treatment). The anatomical location of the injuries was divided to following regions:
shoulder, upper arm, lower arm, wrist, hand (upper extremity), hip, upper leg, knee,
lower leg, ankle, foot, (lower extremity) spine, pelvic trunk and head. 49 of those
Athletes took part after the competition in another trial. There they had to report
monthly online about their injuries in training duration. Data were collected with Mi-
crosoft Excel 10.0 and statistical analyzed by SPSS 19.0. Most of the data didn’t
follow a Gaussian distribution, so results were affected by median, quartiles, minima
and maxima. The Mann-Whitney test was used to test the significance between un-
paired groups. The Wilcoxon matched pairs test was used for paired groups. (welche
risiken?). The find informations about the significance of risk factors and injuries
Pearson’s chi-square test was used. All tests were checked with an significance level
of 5%.
Table 1: Quality Checklist
Author/ Triathlon Qualification Study Design Number of Gen- Data Col- Di

Duration Subjects der lection and Inj
Year
Invited/ duration
Number of
feedback
Korkia Sprint- Self- assessment Prospective 155 29% M 124 8 weeks

Full Dis- of Athletes: overall re-
W 31
tance sponse
- 69% pro-
fes-
sional/sem-
iprofes-
sional
- 47% from
running
back-
ground
- 19% swim-
ming back-
ground
- 10% cy-
cling back-
ground
Holtzhausen Ironman Retrospective, 2331 M 1991 SA Triath- 9,6

Cross-sec- (82%) lon
tional
F 420
(18%)
Collins Olympic Retrospective 600/ 257 77% Feedback 49

and sprint male 1 year
 45%
re- 23%
turn female
French LD SD Retro 788/ 390 M: Feedback

49,4% 82,1% 1 year

W:
17,9%
Germany LD SD Retro and Pro 1048 M 169 1 year

(12%) 212 feedback 1
W 43
49 year
M 40
prospec-
W9 tive
Australia 10 197
Table 2: Results
Injury Definition % Group Af- Associations Found +

fected
Korkia Event that forces athlete - Years of com-

to (1) stop the current petitive Experi-
training session or race, ence + injury
and prevent return to the rate (i)
session and (2) rest the - Previous injury +
day after injury; or which injury incidence
caused any of following: (P<0.01) (i)
injury to the eye, teeth or -
nerve; fracture; or con-
cussion
Acute injury: an injury

which arose because the
integrity of the musculo-
skeletal system was bro-
ken by a single traumatic
event
Holtzhausen - 7,7 % medical - Significantly

help higher percent-
age of younger
76,8 medical
participants en-
events per 1000
countered medi-
starters
cal problems
17 musculo- (P= 0.04)
skeletal (8%) -> - 80,1% patients
4,7% overuse, occurred after
3,3% acute race
traumatic -
Collins Any muscoskeletal align- - Training in other

ment that caused the ath- sports + overuse
lete to stop training for at injury incindence
least 1 day, reduce mile- (P<0,05) (i)
age, take medicine, or -
seek medical care
French - - Injured athletes

reported devote
signi less time to
warm-up (13,7
vs 18 min;
p<0.01);

- strechting 8,3
min vs 10,6 min
p<0,01
- time warm up
and strechting ->
tendinopathies
- prevalence of
muscle injuries
sigi associated
with number of
training
hours/week
(p<0,05) and
weekly training
distances
(p<0,05)
Germany Event taking place during 101 injuries in - only risk factor
training or competition retro for injury in non-
which forced the athlete to professional tri-
Contusion/abra-
stop the current training athletes is par-
sions 54%
session or race ticipation in com-
Muscle or ten- petitive triathlon
don injuries event
38% - injury of lower
extremities more
Capsule or liga-
often
ment injuries
7%
1% fractures
Overuse: 29%
Trauma: 71%
Prospective:
54 injuries; con-
tusions/ abra-
sisons:22%
Muscle or ten-
don injuries
46%
Capsule or liga-
ment 32%
Overuse: 70%
Trauma: 30%
Australia Data collection from all

athletes seeking medical
assessment or treatment,
Reportable injury defined

as any injury or illness
presentation requreired
treatment and/or assess-
ment by medical staff
Korkia France Ger- Seafair AUS SA

man

An- 27 % Ankle: 4+ 23 % 29,1 Lower
kle/Foot 20,6 % 9,26 % Extremi-
Foot: 9 ties
3,3 % +11,11
Lower 16 % Tri- 21 + 13 % 11,4 11,4
Leg + ceps 24,07 %
Calf surae:
7% +
tibia
4,6%
Knee 19 % 18,3 % 20 + 25 % 5,4 %
33,33
Upper 20 % 15 % 10 + 15 % 5,4 %
Leg/ 7,41
Thigh
(incl. ili-
otibial
band)
Hip 1+0 4%
Total 68,8 %
Lower
Extremi-
ties
Spine Back: 1+ Trunk

14% 5,56
Pelvic 3+0
Rest 4+
Trunk 3,70
Shoulder 8,3 % 6+ 14 % Upper
1,85 Ex-
tremeties
Upper 4 +0
Arm
Elbow 3+0 6%
Lower 7+0
Arm
Wrist 0+0
Hand 5+
3,70
Total Up- 8,3 %
per Ex-
tremeties
Back 14 % 13,3 %
Table XX gives an overview about occurred injuries examined in the studies. Different
injury rates in the studies may be explained because of different lengths of the study
or the race distance. Some of the studies only include sprint and Olympic distance,
wherever one study only examines the ironman distance. To make the study’s com-
parable, it’s important consider the different definitions of injury. Hamilton et al,
showed, that changing the specification of an injury definition of an injury in a group
can lead to variational results for significant risk factors, what could explain different
findings on injury rates.
The etiology of triathlon injuries can be multifactorial (Cipriani et al., 1998). The risk
factors that play part in athletic injuries can be classified into two groups. They can
be extrinsic (independent of the athlete) or intrinsic (those are inherent in the athlete
in nature). Intrinsic factors related to lower leg injuries are for example cavus foot
with decreased pronation, an high impact running style, or hypermobility of the joints.
Extrinsic factors are factors which can’t be direcetly influenced by the athlete, for
example: cold, wind, rain, running surface or an insufficient care of the muscles (risk
factors and injury mechanism in triathlon).
Description of the population
The probands of the studies differ in their level, age and distance. Related to this, the
subjects also differ in terms of training time, number of training sessions, and back-
tracked distances. While in Korkia et al’s study the probands divided themselves into
a level, Galer et al., only requested elite athletes.(STIMMT DAS??) (NOCHMAL: IN-
JURY DEF UNTERSCHIEDLICH).
Injury rates
Incidence rates are the number of injuries divided by the number of athlete-expo-
sures. Based on the epidemiologic concept of person-time at risk (Knowles et al.,
2006), it differs from 37% (Korkia et al.,) during an 8-week period, 52,4% suffering

(Galera) during one season, In the study of Holtzhausen et al,. 8% of athletes suf-
fered from an muscuskeletal injury (this low percentage occurred because only the
competition day was evaluated). Zwingenberger et al., described the injury rate of
compared to Collins et al., with an injury rate of 49%
injured from a trauma, and overuse accounting for 61.7 to 75%. being injured during
past season (Galeria et al.,)..
Athletes who suffered from an injury were more probable to report another injury in
the study-time (P< 0.0001) (Korkia et al.,)
Men / Age Level of Height, Main Time partici- Stretch-

Woman compe- Weight, BMI dis- pating in Tri- ing?
tence tance athlon
Korkia 124 34(8.9) Elite 10 176.7 (17.7) 14 long 30% < 4
m cm years
Intermedi- 101
ate 99 71.6(10.2)kg short 19% 3-4
years
Recrea- 22.6(2.8)
tional 14 BMI 21 % 2-3
years
20 % 1-2
years
11 % > 1
year (no as-
sociation)
Korkia 31 32(7.3) Elite 3 166.5(6.3) 1 long
f cm
Intermedi- 27 short
ate 22 58.0 (5.9)kg
Recrea- 20.9(1.8)
tional 4 BMI
Galera 309 - - -
Zwing- 42 / No-profes- 168/ 169 cm Sprint:
enbger 40.3 sional 77
61/ 59 kg
Olym-
182/183 cm
pic: 57
77/ 78 kg
Me-
dium:
40
Long:
42
Colins 257/ 32 Elite: 11% BMI: 1 km
schwimmen,
77% Intermedi-
28 km
male , ate:
fahrrad, 10 k
23% fe- 127/257
laufen
male
Beginner
100/257

83.5% of injuries occurred during training vs. only 16.5% during competition.
Korkia: Using logistic regression analysis an association was still evident when expe-
riencewas adjustedforage andrunningdistance (kmweek-')(P= 0.04).
No evidene between m/f
Reasons for injurys:
while overuse was in 41% of cases the reason for the injury, 27% was classified as
“other” 12% of athletes reported they got injured because of twist and turn, 10 % got
injured while contact or Collison and 9% because of overstretching (Korkia )
Occurrence of Injuries
Environmental Location
To better understand injury mechanism in triathletes, the studies tried to find out in
which of the three Triathlon legs athletes report most of the injuries. To have a better
overview, table 4 presents the percentages of injuries attributed to each triathlon leg.
Running seems to be the discipline where most of the injuries are attributed to, fol-
lowed by cycling and swimming. Problematic is, that the sport consists of several
individual disciplines (Millet et al. 2009) and the lack of some incidence rates, make
horology hard to specify (Vleck, 2010). Running and cycling could lead to cumulative
stress (Massimino et al. 1988) which affects injury risk (Vleck). Korkia at al. observed
65% of injuries occurring while running, 16% in cycling and 12 % due swimming,
while in 9% cases no exact time could be figured out. Zwingenberger at al. examined
athletes participating at all distances and observed similar injury rates for cycling with
43% and running with 50 % compared to 7 % in swimming. In the French study, 39,9
(72,5%) in running, 12,4 /22,5 in cycling and 3,9 (7%) in swimming. Collins et al.,
distributed 70% of injuries due or partly due to running, including 8% of the injured
athletes suffering from an injury related to running and another sport. In the same
study 12,5 % injuries lead from cycling and 11% from swimming. Collins also exam-
ined the cumulation of various sports, showing that 7 of 167 injuries could be ex-
plained through running and cycling, and other combinations of sports leading to 6 of
167 injuries. According to Vleck et al., the cycle-run transition could also be described
as a risk period for lower back and knee injuries but to verify this association, more
data are required (Gosling et al., 2007).
Percentage of Injuries due to leg

80
70
60
50
40
30
20
10
0
Korkia et al. Zwingenberger et Collins et al. Galera et al. seafair SA
al.
Swimming Cycling Running
An overview in percent of the anatomical locations (related to the total number of

injuries) is shown in Table 3. Not omitted to the following explanations are the data
from the SA study because the duration of the study was too short, to make it com-
parable to the other results. According to the studies most of the injuries occur in the

lower extremities, including the ankle , foot , leg, thigh and the hip. The lower extrem-
ities are affected by 68,8% (French), 65% in the retrospective and 84,25% prospec-
tive (Zwingenberger et al.,) from injuries. Ankle and foot 27% (Korkia et al.,), 23,9%
(French), 13% and 20,37% (Zwingenberger),
Korkia et al., reports that the frequency of injuries were increased in runners while
spring and summer, related because this time of the year is the one with the most
intense training and competitions.
Gender:
Most of the authors found similar injury rated between female (48%, Collins) and
male (49%) athletes. A trend was only found by Zwingenberger at al, comparing in-
juries of females (16,3%) and males (25,5%, P= 0,206).
Even if the athletes had to classify themselves as elite and the group was slightly
younger (average age 29,8) with a lower rate (3 of 30) of females participating as
elite, the injury rate for was comparable with 60% of the non-elite group. There was
no significantly difference between elite and non-elite groups. The distribution of run-
ning injury was the same compared with the non-elite group. All injuries except from
one were related to running or to running and cycling. Three elite athletes suffered
from more than one injury , cycling injuries included only wrist and shoulder.
Age
Collins et al., differed for the injury incidence between the age groups older and
younger than 40 years. Athletes older than 40 years suffered in 52% compared to
48% of athletes younger than 40 from injuries, what doesn’t show any significant
difference, using chi square test (P> 0,05). Zwingenberger at al, recognized a trend,
but no association about younger Athletes (<35 years old) suffering less from inju-
ries (22,0%) compared to older athletes ( <_ 35 years old) (24,6%, P=0,656).
Numbers of Injuries
The numbers of injuries the Athletes received, differed between the study’s. Collins
et al., reported 169 injuries in 126 athletes, within 18% of athletes suffering from two
injuries and 7% of athletes suffering from 3 injuries. 13 of 32 suffered from only run-
ning injuries, while 18 reported the running injury with additional one or two injuries
related to cycling, swimming, or both. 7 of the 23 athletes with two injuries got one or
more injuries while cycling and 4 suffered from an injury while swimming. One athlete
reported only cycling injuries. From the 9 athletes with three injuries, 6 suffered from
one or more injuries while cycling and 4 suffered from injuries while swimming. Korkia
et al., reported that 47 / 155 suffered from one, 10/ 155 reported 2 1/155 reported
three injuries, noting that the injuries appeared in “clusters”, may be explained by
Biomechanical interdependency in the locomotor system can influence structures be-
low and above the injured site (Molnar et al, 1988), and structures of the contralateral
side, and leading to injuries in other areas when the training is still done, even injured.
36 acute injuries 34 gradually developing injuries. Galera et al.,: 17% of 52,4% sev-
eral times injured.
Severity
To measure the severity of injuries in sports is underlying to understand the impact

of injury on athlete’s health (van Mechelen, 1997). The severity of injuries is com-
monly estimated related to the days of sport time-loss and differs between the disci-
plines. Athletes injured while swimming needed between a median recovery of 0 days
(interquartile range 0-10) (Zwingenberger et al.,) and 5 days (Collins et al) till starting
training again. A little longer recovery period was found for cycling, with between 7
days (interquartile range 2-28,5) (Zwingenberger et al.,) and 5,1 days (Collins). Most
of the recovery time with 10 days (interquartile range 0-30) was found by Zwingen-
berger, compared to higher rates from Collins et al., with an average of up to 17,3
days. 35,5% of the running injuries, 38 of cycling injuries and 31,5% of swimming
injuries were treated with medical care and 26% running injuries, 42% cycling and
47% swimming injuries forced to athletes to the use of medication.
Treatment and severity

Treatment methods for injuries are only described by Korkia et al. He describes that
right after the injury, 9% of athletes had to get immediately help, 4% from Hospital,
accident and emergency, 4% from physiotherapist and 1% from general practitioners.
The “rest” was treated by nurses or manipulative therapists. Follow-up treatment was
required by 51%of all injured triathletes. Korkia et al., reports 84% of injuries as mi-
nor, 13% as moderate and 3% as serve, 16% had to stop all three disciplines. Related
to the disclipines, Injuries from swimming were threated in 86% (Zwingenberger et
al,) of athletes without professional treatment, 14% (Zwingenberger et al.,) had to be
treated by outpatient and no athlete hat to get hospital care. Collins et al., avoided
swimming for average of 5 days per injury and medical care for 31,5% and medica-
tion for 47%. 21 % of Korkia et al.’s athletes had to stop swimming 18% swimming
and running and 16% swimming and cycling. Similar findings are from Galera et al.,
study’s showing that 91% of injured athletes had to stop their training, 77% could still
participate in at least one discipline: 71% in swimming, 61,5% in cycling and 14,5%
in running.
Cycling Treatment
For Cycling, 44 % (Zwingenberger et al.,) needed no professional help, 32%(Zwing-

enberger et al.,) as outpatients and 23% (Zwingenberger et al.,) in Hospital. While
Collins et al., reported medical care for 38% and medication for 42%. Korkia: 37%
stopped cycling , 33% stopped cycling and running.
Running Treatment
For Running, 45% (Zwingenberger et al.,) no professional treatment, 53% (Zwingen-

berger et al.,) treated as outpatients and 2% (Zwingenberger et al.,) Hospital care.
Collins et al., medical care for 35,5% and medication for 26%. Korkia at al.: 78% of
injured athletes hat to stop running.
To better understand injury mechanism in triathlon it might be helpful to find factors
associated related to an higher injury rate. Another trend was found in in athletes
finishing within the first half of the field in the Triathlon with little more injuries (24,3%)
compared to athletes finishing within in the last half of the field (20,7%, P= 0,562)
(Zwingernberger). Another strong trend was found between injuries training trainings
hours with athletes spending >_ training hours per week (28,7%) and less injuries in
athletes spending less than 10 training hours per week (19,5%, P= 0,016).
Training:
The long-distance athletes in Zwingenberger et al., study spend median weekly train-
ing hours of 12,3 (2 swimming, 5 cycling, 3,75 running) for woman and 14,8 (2,5
swimming, 8,0 cycling and 4,0 running) for men. (NOCHMAL NACHLESEN; Grün
MARIKIERT). The ratio between the training time in the three legs was comparable
with the outcomes from XX An explanation for lower training hours may be explained
because of more non-professional athletes taking part in Zwingenberger at al,’s
study. “Furthermore, the median we used for statistical analysis is less affected by
outliers than the mean Knechtle et al. (2010) and Gulbin and Gaffney (1999) applied
in their studies“ . Collins et al., didn’t find any injury incidence in relation to weekly
running mileage by miles per week (P> 0,05) with an average mileage of 10 to 19
miles and 20 to 29 miles per week. Also there was no correlation with cycling or
swimming mileage (P> 0,05).
Galera et al., reported an a significantly association with training volume in swimming

and prevalence of injuries in swimming (8km vs 4,6km swimming/week; p<0,001),
also the prevalence of injuries in running seems to be associated with the volume of
training in running (28,6 vs 25,6 km/week; p= 0,06).
Galera et al., found a higher prevalence of muscle injuries due to total training volume
(p< 0.01) with an average of 10.1 hours training per week and 8.6 hours of training
per week for non-injured. Another trend between injuries and training hours was
found by Zwingenberger et. al, where athletes spending more than 10 hours of train-
ing per week had a higher number of injuries compared to athletes spending less

than 10 hours of training per week (28.7% vs 19.5%, P=0.116). The volume of train-
ing per leg was also significantly associated with the prevalence of muscle injuries
(p< 0,05) with an average of 5,6 km for injured and 4,4 km for non-injured per week
in swimming, compared to 141 km and 115,5 km cycling and 30,6 and 26 km per
week in running. No training relationship found between athletes training with a per-
sonal trainer (24,1%) and without a trainer (23,4%, P= 0,922) (DEUTSCH).
Regarding warm-up and cool down, most of the studys investigated stretching as a
possible risk factor. Galera et al., found out that the time spend stretching in the end
of the training was significantly associated with prevalence in a tendinopathies
(p<0,01) with injured athletes spending an average time of 7,4 minutes stretching
compared to non-injured spending an average time of 10 minutes stretching. Also
Galera et al found out, that injured athletes reported to spend with 12.5 min warming-
up less time compared to uninjured athletes with 16.7 min for warmin-up.
No relationship between athletes having sports medicine physical therapy in the past
2 years (24,5%) or no physical therapy (23,3%, P= 0,865). (Deutsch)
The main finding of the study from Zwingenberger at al,. was the only significant risk
factor for injury in non-professional athletes is the participation in a competitive triath-
lon event. Injuries of the lower extremities occurred more often than injuries of the
upper extremities, trunk or head. 2,1 times more injuries were registered in the pro-
spective survey compared to the retrospective with an overuse injury rate being 2,4
times higher than in the retrospective study. The trauma-related injury rate was 2,4
times lower in the prospective study. (Deutsch)
Training and Competition
It’s hard to differ if there is a severity of injuries or higher frequency, compared be-
tween training and competition. Zwingenberger et al., found an association between
non-elite triathletes having an higher incidence of injuries with 13.4.fold times and
13.3-fold times higher during competition compared to training (P =0.020 retrospec-
tive and P= 0.027 prospective)
Weekly Weekly km Weekly No of injuries

training per 1000h of
No trainings
hours training / com-
sessions
petition
Korkia 7 (3.4) Swimming: 4.2 7.9 (3.4) 5.4 injuries

(2.6) training (95%
confidence in-
Cycling: 100.2
terval 4.0-7.2)
(70.6)
17.4 per 1000h
Running: 23.4
of competition (
(15.2)
95% confidence
interval, 10.9-
27.9)
Galera 8.9 hours Swimming: 4.6
Cycling: 120.2
Running: 26.8
Zwingen- 12.3 hours
berger for females
(Swimming:
2 h; 5 cy-
cling h; 3.75
h running)

14.8 h
hours
males
(Swimming:
2.5 h; cy-
cling 8.0h;
4.0h run-
ning)
Colins 10-19 miles - - -
week / 20-
29 miles
Weekly Training hours
Level
Korkia et al., found an association between experience in triathlon and incidence of

injury (trend test, P= 0.02) resulting that the rate of injury increased with the amount
of time sport had been practiced. Athletes training for longer than 2 years sustained
in 45% at least one injury, compared to 22% training between 2-3 years and 14% of
those training for 1 year or less.
Injury Mechanism:
Korkia et al., 41% overuse, 27% “other”, 12% twist and turn, 10% contact collision ,
9% overstretching.
Falling while training or competition can lead to acute injuries. Zwingenberger et. al
probands reported an average of 2.01 falls (retrospective) and 0.91 falls (prospective)
falls per 1000h.
Experience in Triathlon
Korkia, showed that there is an association between Triathlon experience and inci-
dence of injury (trend test, P= 0,02), showing that injury rate increased with the
amount of time the athletes practiced for Triathlon. If trained for longer than 4 years,
45% of athletes had at least one injury in the 8-weeks study time. Compared to this,
while training between 2 and 3 years, incidence rate was at 33% and for 1 year or
less 14% to suffer from one or more injuries. The data were checked using logistic
regression analysis and still showed an evidence after adjusting age and running
distance ( km week ^-1) (P = 0,04) (Rein oder nicht?)
Conclusion:
This systematic-review showed some of the knowledge that exists in the published
literature to describe injury incidence of Triathletes and any possible correlations be-
tween risk factors. In the following Conclusion are possible prevention possibilities
described, which may lower the risk of getting injured when participating in Triathlon,
for training and for competition.
Before Training, it’s common for athletes to stretch their muscles. Like above de-
scribed there is no scientific proof for a positive injury prevention related to stretching.
Indeed, there are a few studies showing a positive effect for risk-reducing. Harting et
al showed that the overuse injuries in the lower extremity was significantly lower in
the intervention group (29%) than in the control group (17%) (P=0,02) (RR=0,63,
95% Cl 0,41-0,99) with hamstring stretching in addition to the regular training (Hart-
ing, & Henderson, 1999) (700). In the same study a statistically significant difference
(P < 0,001) of changes in the hamstring flexibility was found between intervention
and control group. On the other hand in the study from Arnason et al. where also an
cohort study was done, there was no significant difference for the incidence of ham-

string strains between the groups (RR: 1,53, 95% Cl 0,76-3,08) with hamstring flexi-
bility training. “This study further found no difference in the incidence of hamstring
strains between the intervention teams and all the teams the previous year (RR: 1.03,
95% CI 0.59-1.79) or between the two seasons for the intervention group only (RR:
0.89, 95% CI 0.42-1.85).” There is another study from Liu at al showing an positive
effect on risk-reducing for leg injuries. The study was done with 122 participants with
static stretching of the m. gastrocnemius 4 times daily for 30 seconds vs once daily
5 times 30 seconds over 12 weeks. RR shows an result of RR 0,47 95%-Kl 0,23-
0,96) (Liu et al., 2008) Cool-Down has the effect to smooth the muscles, reduce a
high muscle tone and start the physical relaxation. The regeneration force should be
hold short after an intense trainings load and shouldn’t be longer than 20-30min to
avoid the lost of energy (493 Hottentott)
Focusing on acute injuries there are several possibilities how to avoid suffering from
an acute injury. While swimming, the athletes could use Vaseline or milking grease
to avoid acute injuries like abrasions. But also, a training for faster swimming while
starting to avoid contact related injuries. The cycling leg of triathlon points several
medical risk management concerns. Environmental factors, the cycling course, draft-
ing, dehydration and hyperthermia have to be considered. An cold water temperature
(5-15°C) can be a risk for hypothermia (Trappe et al., 1995) which can influence the
riders balance and coordination early in the cycling part (Triathlon Canada. Triathlon
medical manual. 1st ed. 2000 Jul (online). Available URL: http://triathlon.mb.ca/sanc-
tion_triathloncanada_medicalmanual.pdf).
According that contact with other swimmers or other subjects is the highest risk of
getting suffered from acute injuries, a floating technique related to the buoys can help
to reduce the risk about contact injuries with the buoys. The same accounts for the
mass starts. Organizers of the Triathlon could to change the rule about mass starts
by lowering the number of starters at the same time. This already happened in sev-
eral competitions by introducing XX XX but athletes are still complaining about too
many people starting at the same time. While competition medical help should be
provided the whole time and for amateur events there should be three doctors, nine
nurses and support staff per 100 participants for the latter stages of triathlon (Rimmer
et al., 2012).
While cycling the first rule is to wear a helmet, even in training. According to Zwing-
enberger et al., only 93% of Athletes wear a helmet while training, even when wearing
a helmet is required by the International Triathlon Rules. “Helmets have to be ap-
proved by a national accredited testing authority recognized by a National Federation
affiliated with ITU”. They have have to be worn in all official activities while riding the
bike, in competition and training. Falling from bikes or crashing into another vehicle
can result in head, neck and brain injuries (Thompson et al., 2004). Several authors
showed that wearing a helmet lowers the risk between 63% and 88% of getting in-
jured while cycling (Thompson et al., 2004). Higher risks of falling or collisions, which
is in Korkia et al.’s study 10% liable to injuries, can be on wet roads or while drafting.
While drafting, cyclists ride behind another cyclist in an area with reduced air pres-
sure created by the leading cyclist. The aim of drafting is to spend less energy while
cycling with a higher speed. General Guidelines for drafting doesn’t allow Elite Ath-
letes to draft in middle and long distance and in the age group not in standard dis-
tance and middle and long distance. In Those events it’s not legal to draft off another
athlete or motor vehicle. In Middle and long distance races the drafting zone is 12
meters long, for standard and shorter distance 10 meters, starting from the leading
edge of the front wheel. Crashes from drafting could be reduced. Accidental collisions
or falls are possible but rare (Canada link), but when falling, injuries can be serious.
It Is helpful for the athletes to get proper information’s about the driving route and
possible dangerous passages to lower the risk by unexpected changes of the street.
Muscule Imbalance and Shape deviations (divation?) in physique and load capacitiy
Muscle Imbalances can be described as a modification of strength balance between

agonist and antagonist muscles. From the biomechanical view the agonist muscle

group can do a concentrically contraction to cause limb motion. The Agonist muscle
group evolves an eccentric exertion to slow down and protect the involved joint. (mus-
cular imbalance and acute lower extremety.). Skeletal muscles show in peace a basic
tension which is called muscle tone and which increases while cycling and running
(583 großes buch von triathlon weiter!!????) A high muscle tone Wagner at all count
up muscular imbalances as an increased muscule shortening and muscle weakening
influencing unfavorable loads on joint structures. This can lead to muscle tension,
distortions, overloading the tendon and muscular dysfunction and coordination disor-
ders or the premature abrasion of articular cartilage (Engelhardt 2006). Muscular Im-
balance can decrease the load capacity of the locomtor system and lower the physi-
cal performance of an athlete. (A.Wagner S 145, Krafttraining im Radsport). An ac-
curate diagnosis about statics of the lower extremities can contribute for athletes to
find fitting running shoes or get orthopedic insoles. To move the swimmer trough the
water, upper body force is needed. This propulsive force comes mostly from adduc-
tion and internal rotation of the shoulder and drives to an agonist-antagonist imbal-
ance (300) and is caused by the shoulder adductors (m. pectoralis major, m. coraco-
brachialis, m. latissimus dorsi, m teres major, m. triceps brachii (caput longum and
caput breve) and the internal rotators (m. deltoideus (pars clavicularis, m. pectoralis
major, m. subscalpular, m.latissimus dorsi, m. teres major). If the anterior shoulder
muscles are strength imbalanced, shoulders getting pulled forward, leading to a pro-
tracted posture. The two characteristics of the shoulder in an forward position and
the protracted scapula can be related with pain in the shoulder while swimming.
(301). In elite athletes an adaption of an higher difference between agonist and an-
tagonist muscle where found. But not only within the upper extremity’s, also for the
lower extremity’s the differences where found. (302). This phenomenon can be ob-
served in the body position of swimmers, with an (forward neues wort) head and
round shoulders (303) and can may be explained because of the stronger internal
rotator and adductor muscles pulling the clavicula and scapula more to the front (for-
ward..) above the weaker external rotator and abductor muscles. (304) Another ex-
ample can be demonstrated by patients with shoulder impingement. A reduced pos-
terior tilting of the scapula while elevating the humerus can be find, what decreases
subacromial space. (305) This could be explained because of the stronger anterior
muscles , (particulary) the pectoralis minor . (Effect of stretching)
Deviations limit (because of accidents or born ones) lower the exercise capacity of
performancing triathlon. Examples are scoliosis, kyphosis, spondylolisthesis, devia-
tions in the leg axle (genu varum, genu valgum) or the flat foot. (großes buch vom
triathlon). Another suggestion is the get therapeutic treatment from physiotherapists,
chiropracts or osteopathics to work with complaints and imbalances of the movement
system including the joints, muscles and neural tissues.
Following Table gives an overview about muscles getting strained while performing
the triathlon.
Muscle Discipline
m. pectoralis major Swimming, Cycling
m. teres major Swimming, Cycling
m. biceps brachii Swimming, Cycling
m. trapezius Swimming
m. flexor carpi radialis et ulnaris Swimming
m. rectus femoris Swimming, Cycling, Running
m. iliopsoas Swimming, Cycling, Running
mm. ischiocrurales Swimming, Cycling, Running
mm. adductors Swimming, Cycling, Running
m. triceps surae Swimming (Chest), Cycling, Running

m. triceps spinae Swimming, Cycling
Muscle Shortening of 195 professional Athletes

80
70
60
50
40
30
20
10
0
m. rectus m. triceps m. erector m. m. iliopsoas m. tensor m. pectoralis
femoris surae spinae ischiocrurales fasciae latae major
Muscle Shortening in % Spalte1 Spalte2
Previous history of old injury’s can influence future injury’s. (307, factors associated).
The cause of the old injury might still be there or the injury leads to weaknesses in
other soft tissues or bones and reasons a new injury. (factors associated). Another
reason which is common in all type of sports may be the relation to an inadequate
warm up or cool down. Several authors mentioned that inadequate warm up and cool
down can be a risk factor for sports injury. (308). This influence of warm up and cool
down is discussed in the field of sports science and many scientist have different
opinions if the risk is higher to get injured or have if benefits are given.
Warm-up can increase the joint range of motion and decreased stiffness of connec-
tive tissue what leads to greater force and length of stretch required before musculo-
skeletal damage appears. Cooling down may lower muscle soreness and stiffness
what also can lead to injury’s in (subsequent) training. (309) Inadequate preparation
for the incoming load like the warm-up, strechting or hypothermia are the reason for
around 20% of injuries and incorrect loading while cycling or running (großes triathlon
buch 585).
In training and in competition athletes should listen to their body and not ignore pain.
Overuse injuries can lead to macro traumata and the process of healing of the injury
can increase from weeks to months. Especially while competition, athletes might ig-
nore pain because of being ambitious to finish the race. Holtzhausen et al., descibred
in his study (moment) that especially younger athletes tend to have a little more inju-
ries compared to older athletes, what might be explained because of older Athletes
being more focused on participation than winning and recognizing and treating inju-
ries before they escalate (Krabak et al., hat Studie gemacht oder Holtzhausen??).
The higher injury risk while competition may be explained because athletes taking
part in competition have an highly activated sympathetic nervous system. This leads
to them more prone to ignore the body’s pain response and let them perform in a
higher level compared to training Binder et al, 2004).
To explain which forces the athletes have to conquer, it’s necessary to have a look
at the performance the athletes bring up. For example, the professional Austrian Iron-
man Athlete Michi Weiss, swims with an average pace of 4,25 km/h which are 14,72
minutes per km. He cycles with an average power of 300 watt and an average pace
of 38,16 km/h what makes a time of 1,34 minutes per kilometer. The final run was
done with an average time of 14,15 km/h and an time of 4,14 minutes per km
(http://www.wiki-miki.com/news-156-fpid-331-srm-analyse-ironman-stgeorge) at the
ironman in Utah, USA. The extremities are exposed to very high loads to deal with
the requirements.
Some overuse injuries related to cycling can be explained because athletes contact
while cycling with the pedals, seat and the handlebars. Poor biomechanics and poor
ergonomics factors can influence and lead to overuse. Regarding that most of the
guidelines for proper bike configurations in the published literature were only done
for road cyclists (brini 49), it’s difficult to suggest fittings for injury prevention. Alt-

hough Triathletes had a greater anterior knee position and smaller frontal area com-
pared to competitive road cyclists. Another difference was found with a larger pelvic
angle at the 6 o’clock crank position and less frontal area.
Pain in the patellafemoris (Patellofemoral) pain is the reason for many of knee prob-
lems. To regard is compressive force on the patellofemoral joint while knee flexion
and extension. (Cycling Injuries) . The Patellofemoral contact reaches his maximum
at 90° of flexion in the knee and decreases when the knee is getting extended (Lead-
better and Schneider). The high prevalence of knee injuries caused in cycling is the
result of the relationship between knee joint forces and kinematics (Bressel, 2001).
Athletes have the possibility to Holmes et al. method to reduce the risk of knee inju-
ries and reduce the risk for lower limb injuries. An range between 25°-30° of knee
flexion was suggested to reduce knee injury risk and minimize VO2 (Bini et al., 2011).
If the seat is too high, posterior knee pain or tight hamstrings can occur. A too low
seat can lead to the patellofemoral syndrome, patellar tendonitis, or iliotibial band
syndrome (Baker, 2000). Aerobars and long distances cycling may lead to back pain
and can be counteracted by stretching of the low back and hamstrings but also with
core strengthening (Gregory et al, 2006 P 557).
. An injury can be defined as a musculoskeletal symptom triggering an unplanned

stop in training or failure to compete a race, or leads the individual to seek medical
care (Burns et al, 2003).
Several authors argue that overuse injuries among triathletes are more frequent than
injuries in athletes participating in a single-sport (Burns at al, 2003). One argument
is, that the triathletes training hours are way higher compared to most of the single-
sport athletes. Triathletes train in average 10 to 14 hours per week (Shaw et al, 2004).
(HIER NORMAL ÜBERLEITUNG OB IRGENDEIN AUTHOR DAS IN STUDIE
BESTÄTIGT HAT). Another explanation could be, that triathletes may have poorer
technique or equipment compared to dedicated single-sport athletes (War das
BURNS ET AL., 2003?). Wrong running shoes or a poor bike fitting can result in
damages. An addition of multiple competitions might lead to fatigue and loss of con-
centration with following higher possible risk to injure. Also there are not too many
triathlon clubs and connected to that there not many athletes training under medical
(Sportverletzungen beim Triathleten, E.Thies et el, grünes buch 86) and professional
control.
The locomotor system is under high burdens while running. Requirements are a good
fitting with space in the toe area, a solid shoe sole with an treaded sole, a soft midsole
for a good damping system, a stable heels part which braces the athlete in the stance
phase, stable marginal heels part for prophylaxis to avoid irritation of the Achilles
tendon, a soft upper material which adapts the foot shape, a skin-friendly material
and an good quality and durability of the shoe. (139 Sportverletzungen-
sportschäden).
For training there are several approaches how injury risk might be lowered. A
thoughtfully training helps to improve performance and reduce injury mechanisms.
Enke and Gallas (2012) mentioned that individualized programs should be formed
for the athletes, which are adapted to the individual risk factors the athletes are ex-
posed. Clansey et al., developed an idea how to reduce injury risk while running.
They used a real-time feedback method to give information’s about peak tibial accel-
eration to athletes running on a treadmill. To lower ground reaction forces, the ath-
letes were leaded to correct their running technique. 6 times with 20 minutes session
in three weeks helped to decrease peak tibial acceleration, average and instantane-
ous vertical force loading rates were significantly decreased.
Core stability with exercising is an common prevention possibility. “..core stability

comprises the lumbopelvic-hip complex and is the capacity to maintain equilibrium
of the vertebral column within its physiologic limits by reducing displacement from
perturbations and maintaining structural integrity.” The core works as the base of
the kinetic chain for an easier transfer of the torque and momentum related to the
upper and lower extremities. Movements influenced are especially in sports and ex-
ercise (Kiesel et al., 2007).

It can be helpful to learn good warm-up techniques to avoid damaging warm-up tech-
niques. This can be done with the increasingly well-known idea of movement preps.
Mark Verstegen found with the movement preparation, an idea how to improve long-
term mobility and flexibility of the muscles. First the need to become muscle lengthen
(active elongation) to a new range of motion with following contraction of the muscle.
By strengthening in a new range of motion, the tiny muscles around joints which help
to hold joints together get stabilized, what helps to improve posture and performance
and help to decrease the potential for injury.
Some swimmers use paddles to improve their performance. Several Analysis of com-
petitive swimmers identified the use of paddles while swimming training could be a
risk factor for shoulder injuries (200). This may be explained because of a growth of
the hand surface with the paddle. The bigger surface increases resistance while
catch and pull phase of the stroke leading to more strain on the shoulder. It’s recom-
mended to avoid paddles in training, especially when there are already shoulder com-
plaints (Tovin, 2006).
Methods:
Systematic Literature search
A first search was performed in May 2018 and final search in August 2018. Follow-
ing Databases were used: PubMed, Researchgate, Sciencedirect (and Web of Sci-
ence ?). Studies were accounted with the use of the database search and the
screening articles reference lists. The search terms “overuse”, “injury” , “triathlon” ,
“triathlete” , “ironman” and “prevention” were used in different combinations (MeSH
terms and free text). (An additional citation search of reference lists of the retrieved
articles was performed. No restrictions were placed on date of publication and no
attempts were made to search the grey literature soll das rein? Wenn ja um-
schrieben!!) Two authors were contacted for more informations about the outcome
data. Only studies in the languages of English, German, French and Portuguese
were considered.
Inclusion Criteria
A search of the items revealed 6120, 760, 1940, articles. Only 8 articles were in-
cluded for this review. According to the high amount of papers, the literature was
collected and sorted based on following criteria:
I used the Preferred Reporting Items for Systematic reviews and Meta-Analysis
(PRISMA) guidelines in this review. First the inclusion criteria were applied to the
title and abstract of the articles from the literature research. The next step was the
full-text screening to generate relevant articles for this review. Inclusion criteria
were 1) Type of studies: only retrospective or prospective or cross-sectional study
designs were used. 2) Types of participants: at least 20% (oder mehr?) participants
in the whole study population should be female. The study population should at
least consist of 2/3 participants over 18 years. To generate this, the age range and
the mean age with standard deviation was for the study population was checked. 3)
a clear state about either if the injurie came from overuse or acute/ traumatic 4)
sample size greater than XX.
Data extraction:
I made three descriptive checklists, one quality checklist, one table of results and
one table of location of injuries. Table 1 includes information’s of the Authors, year
of publication, Triathlon level, number of subjects invited, number and age of partic-
ipants, duration and method of data-collection, and a description of information col-
lection and who diagnosed the injury.
Table 2 includes information’s about the results, including injury definition, % of

group affected by injury divided into to overuse and traumatic/acute and possible
risk factor associations.
Table 3 includes an % overview about injuries location.
Bias:

Risk of Bias during Research Process
Systematic reviews got popular in the area of health. Compared to a traditional nar-
rative review, systematic reviews can minimize bias through locating, selecting,
coding, and aggregating individual studies (Schlosser, 2007). Nevertheless there
might be bias distort the study results. There are possible selection bias while
search strategy are by the definition of the title and the keywords. Only Papers in-
vestigating overuse and acute injuries in general in triathletes were included. By us-
ing different keywords, some articles couldn’t be included. By limitation of the lan-
guages of English, German, French and Portuguese, some studies couldn’t be con-
sidered. Another possible Bia could appear because only peer reviewed articles
were considered.
Risk of Bias in the Study’s
While reviewing the studies data, methodological issues should be considered. The
response rate which is described in table XX should be evaluated because this can
be count as a subject of contemplation for the representation of the data collection of
the population. An higher response rate shows a more representative data of the
population (Barcley et al, 2002). The response rate of the studies differed from x – x
%. Retrospective studies examine already existing data while prospective studies
examine data what could happened in a defined period (Greenberg et al., 2001).
Prospective studies are more expensive, taking more time and have a higher rate of
dropouts but those studies produce stronger conclusions (Dawson et al., 2001). Most
of the studies are retrospective studies and ask about already sustained injuries what
can lead to recall bias. Recall Bias appear when outcomes of treatments can change
subject’s recollections close or while treatment. Athletes might have forgot about mi-
nor injuries or note injuries to sever injuries than they are. A 12-month retrospective
study where patients have to recall is limited in the accuracy. Injuries could be for-
gotten because of self-reporting and lay persons might not adequately describe their
injuries (Gabbe et al., 2003). Prospective studies could reduce recall bias but there
is just a little amount of studies found in the literature about triathlon injuries. Pre-trial
bias can occur because of the study-design and patient recruitment. The faults can’t
be compensated while data analysis. In this case Zwingenberger et al., didn’t recruit
all athletes, he just recruited those, which sign in to last two weeks before the com-
petition. This can result in bias because some Athletes might be already injured. An-
other pre-trial Bia can be made because of the way patients got recruited. Via e-mail
contact might include that the athletes didn’t see
One limitation of the study’s Is the sampling method. Athlete’s which already suffered
from an injury might be more interested and might be more likely to give information’s
about their training habits and injury’s. This might lead to possible selection bias. The
other way around healthy Athletes might perceive the questionnaires as unneces-
sary. Interviewer Bias depend on how information’s are solicited, recorded or inter-
preted (Hennekens, 1987). As already described above it would be helpful to better
compare the studies if injury definition and grouping would be standardized. The
small sample sizes in some studies, especially to make comparable findings for ex-
ample between female and males, leads to not be as representative as compared
with a bigger sample size.
Additionally, many athletes keep on training even feeling pain and discomfort (Bahr
2009).
To compare data between the studies might be limited. Rules changes and perfor-
mance changes between the years from X to X might be done, leading to a change
in injury patterns and injury risk (Vleck et al. 2008).

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Physiologie Endurance Sport

Endurance in Sports is generalized trough repeated isotonic contraptions by large

1.2 Physiological Characteristics

Achievement in sports is regulated to sports technical and conditional factors. After

1.3 Characterization of Triathlon Disciplines

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If an athlete wants to achieve high athletic performance in triathlon he needs to have

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(-> Lactate Threshold and functional utilization of Vo2Max

Characterization of Triathlons Equipment

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The „athletes heart“ shows changes in the electrocardiogram (ECG). Abnormalities

Acute and Overuse Injuries

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Osteolysis of the distal clavicle can be count a complication of the Acromivclavicular

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Elbow and Wrist:

Stress-fracture:is defined as partial or complete breaks in bones. Reasons why ath-

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sinding-larsen syndrome: is a traction tendinitis of the distal pole of the patella. It

retropatellare chondropathy (richtig so?),

Piriformis Syndrome: Can be described as an irritation of the sciatic nerve because

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Osteitis Pubis : is defined as an chronic inflammatory condition of the symphysial

Insertion tendinopathy (Knee/ spinal column/ foot)

Tenosynovitis and ENDOTENOITIS (keine übersetzung??) , the tenosynovitis (or

myotendinosis of the superficial pes anserinus ,

muscle imbalance lumbar vertebra

Thoracic Outlet Syndrome:

The thoracic outlet syndrome is an neuromuscular syndrome. Compression of the

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Lower Back and Neck pain:

Upper leg, hip and groin

Delayed Onset Muscle Soreness (DOMS) is described by painful muscle stiffness.

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Table 1: Quality Checklist

Author/ Triathlon Qualification Study Design Number of Gen- Data Col- Di

Korkia Sprint- Self- assessment Prospective 155 29% M 124 8 weeks

Holtzhausen Ironman Retrospective, 2331 M 1991 SA Triath- 9,6

Collins Olympic Retrospective 600/ 257 77% Feedback 49

French LD SD Retro 788/ 390 M: Feedback

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Germany LD SD Retro and Pro 1048 M 169 1 year

Injury Definition % Group Af- Associations Found +

Korkia Event that forces athlete - Years of com-

Acute injury: an injury

Holtzhausen - 7,7 % medical - Significantly

Collins Any muscoskeletal align- - Training in other

French - - Injured athletes

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Australia Data collection from all

Reportable injury defined

Korkia France Ger- Seafair AUS SA

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Spine Back: 1+ Trunk

Description of the population

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Men / Age Level of Height, Main Time partici- Stretch-