Staying Out of the Medical Tent
By Rich Strauss

Whether you're preparing for your first sprint triathlon or an Ironman veteran, there are several tips that can help keep you healthy through the race and keep you out of the medical tent. I'll go over some of the more common problems that present to the medical tent at Ironman and discuss some ways to avoid meeting your friendly volunteer race medical staff.

Proper training is important to get you to the starting line of the triathlon. However, what you do in the days leading up to the big race can have a huge effect on your race day results. One of the more common problems we see at the Hawaii Ironman in Kona is the triathlete that sustains a bad sunburn the week before the race. A serious sunburn (such as a second degree burn with blisters) can have a detrimental effect on how the body is able to regulate body temperature and sweat loss during exercise. This decrease ability to control body temperature and sweating can have a negative impact on the race outcome. Extra caution such as sunscreen before and during training and racing or wearing protective clothing can reduce the risk of developing sunburns. A water-proof sunblock of SPF 30 will provide the best protection for about 2 to 4 hours, so remember to reapply the sunblock on longer workouts and races.

Other problems we commonly see before the races tend to be overuse injuries, such as tendonitis or muscle strains, and viral upper respiratory tract infections. Allowing your body to properly recover from the stress of training is important in avoiding or limiting these conditions. Generally, endurance athletes experience a higher incidence of viral infections because high intensity exercise has a short-term (2 to 24 hours) depressive effect of the body's immune system. Tendons and muscles also need adequate time to recover from increases in training to prevent chronic injuries. I'll cover specific overuse injuries in future articles.

Sport Specific Issues

Each individual leg of the triathlon presents a unique set of injuries or medical problems on race day. With the longer races typically beginning with a mass start, injuries from close contact are common. The usual injuries from the swim tend to be corneal abrasions (a scratch on the surface of the eye) after a pair of goggles are knocked off, and other injuries to the head, such as bruises and even mild concussion. Additionally, Ironman Utah unfortunately demonstrated that the swim can have serious consequences.

Placing yourself based on swimming ability and attempting to avoid the pack at the beginning of the swim start can help lower your risk of these injuries.

The bike portion of the race results in the majority of traumatic injuries that are seen. Broken clavicles (collarbones), shoulder injuries and road rash are some of the more common injuries, all caused from falls. Being comfortable and aware of what other cyclists and traffic around you are doing is important in avoiding preventable accidents. Remember to follow the rules as outlined by the race director and bike course marshals. Passing on the bike should always be to the left, and don't expect that the athlete that you are overtaking is aware that you are passing.

The most common injury complaints from the run are muscle cramps and blisters. While there are a lot of theories on the causes of muscle cramps in athletes, there haven't been any good studies that can prove or disprove that muscle cramps are a result of dehydration or electrolyte imbalances. The cause of exercise-induced muscle cramps is probably multifactorial. There are case reports of athletes known to have high sodium sweat rates that resolve their muscle cramps after drinking a sodium electrolyte drink (1). Another current theory for exercise-induced cramps is that the cramping is due to muscle fatigue and acts as a protective mechanism designed to prevent further damage to the muscles (2). I'll write more on muscle cramps and prevention in a future article.

Blisters can develop due to increased friction and pressure upon the skin, and the discomfort can impair running performance. Prevention is paramount, and includes keeping the skin dry (3), using proper fitting running shoes and synthetic socks (4).

Other Medical Issues

One serious medical condition that has recently been on the decline, but can still have a serious outcome is hyponatremia (low sodium levels in the blood). This condition tends to be the result of drinking too much water, thus diluting the sodium level in the blood. Symptoms in mild cases can include nausea, vomiting and edema of the hands and legs. More serious cases may present with confusion, coma, or seizures. The prevention of hyponatremia is simply limiting the amount of water ingested during the race, and using an electrolyte sports drink such as Gatorade or Accelerade instead. (5)

Most of the competitors that end up in the medical tent arrive from after the finish line. Once across the finish line, they finally stop running, and many triathletes suffer "exercise-associated collapse" (6). This collapse isn't usually due to dehydration, but a sudden drop in systemic blood pressure. During the run, the muscles of the legs act as secondary pumps, helping to return blood back to the heart. After the athlete stops, there is a slight delay until the body's cardiovascular system can compensate for the sudden lack of pumping action from the leg muscles. The cure for this condition isn't necessarily IV fluids, but simply laying the triathlete down with the legs slightly elevated above the level of the heart and gradual oral hydration.

At bigger races, such as Ironman in Hawaii, the medical staff exceeds over 200 volunteer doctors, nurses, lab techs and other medical providers such as physician assistants. This number doesn't include the numerous volunteer massage therapists that also donate their time to these events. The medical tent can get quite busy, with 10 to 20% of competitors receiving medical care throughout the day. It's a long day – starting well before the race, and usually ending sometime well after midnight, once all the triathletes have finished.

References:

1. Bergeron, M.F. (1996). Heat cramps during tennis: a case report. Int. J. Sport Nutr. 6: 62-68.
2. Schwellnus, M.P., E.W. Derman, and T.D.Noakes (1997). Aetiology of skeletal muscle 'cramps' during exercise: a novel hypothesis. J. Sports Sci. 15: 277-285.
3. Knapik JJ, Reynolds K, Barson J. Influence of an antiperspirant on foot blister incidence during cross-country hiking. J Am Acad Dermatol. 1998 Aug;39(2 Pt 1):202-6.
4. Herring KM, Richie DH Jr. Friction blisters and sock fiber composition. A double-blind study. J Am Podiatr Med Assoc. 1990 Feb;80(2):63-71.
5. Speedy DB, Rogers IR, Noakes TD, Wright S, Thompson JM, Campbell R, Hellemans I, Kimber NE, Boswell DR, Kuttner JA, Safih S. Exercise-induced hyponatremia in ultradistance triathletes is caused by inappropriate fluid retention. Clin J Sport Med. 2000 Oct;10(4):272-8.
6. Holtzhausen LM, Noakes TD. Collapsed ultraendurance athlete: proposed mechanisms and an approach to management. Clin J Sport Med. 1997 Oct;7(4):292-301. Review.

* John Martinez, M.D. is a family and primary care sports medicine physician with Kaiser Permanente in Fontana, CA. He has been on the volunteer medical staff for 5 Ironman triathlons, as well as Wildflower, the NORBA National Mountain Bike Championships and the Redlands Bicycle Classic. He is also a triathlete and mountain biker. He can usually be found training, eating or sleeping.

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