The sport of triathlon involves three different endurance sports: swimming, biking, and running. Cross-training allows the athlete to train for one sport while resting from another. The repetitive motions required for each sport may lead to overuse and injury. The purpose of this study was to examine musculoskeletal injury incidence in amateur triathletes to determine if these injuries caused lost time from training, racing, working, or daily functioning. Seventy two recipients responded to survey items that gathered information about demographics, sports participation, and musculoskeletal injury occurrence and interference with sports participation, work, and daily activities. Three-quarters sustained triathlon-related rnusculoskeletal injuries during training due to overuse. A majority experienced training interruption and interference with daily functioning and sought professional help for their injuries. Little information is available on the treatment of rnusculoskeletal injuries in triathletes. This survey raises important clinical implications for physical therapists. Further exploration of overuse injury incidence is warranted in this population.

The triathlon sport has brought attention to the idea of cross-training or exercising in more than one sport. The concept of cross-training is that sports-specific anatomical structures and systems are stressed and rested in an alternating fashion. This allows the athlete to train for one sport while resting or recovering from another. The repetitive motions that occur while the triathlete trains for increased endurance in each sport may lead to a musculoskeletal injury. A review of the literature reveals that triathletes sustain overuse musculoskeletal injuries (1-4). The purpose of this study was to survey a group of amateur triathletes to examine the incidence of musculoskeletal injury in this population and to ascertain if these injuries were severe enough to cause loss of time from training, racing, working, or daily f11nctioning.
The sport of triathlon is one where athletes participate in three distinct endurance sports in a consecutive order. The most common three endurance sports sequence is swim, bike, and run. Triathlon racing and training have steadily grown in popularity since the first swim/bike/run triathlons were held in San Diego's Mission Ray in 1974. In the United States, there are an estimated 200,000-300,000 active triathletes (5). Triathlon Federation/USA (Tri-Fed/USA) is the U.S. national governing body for the sport of triathlon, and it recognizes four different distance categories: the sprint, the Olympic, the long, and the ultra triathlon events (5.6). Listed in the order of shortest to longest total distances of the three sports events, each of the races is considered to be a full-fledged triathlon. Racing strategies and training regimes, however, may vary according to the distance of competition.

METHODS

Survey Sample

One-hundred-fifty members of the Tri-Miami Triathlon Division of the Miami Runners' club were identified as the largest group of amateur triathletes that was easily accessible. Therefore, this triathlon club was considered to be an appropriate population for the proposed survey. A survey was mailed to each member to solicit their participation. The prospective participants were notified that the survey results would he presented at a sports medicine symposium.

Survey Development

Twenty four survey items were designed to collect basic demographic data to describe the sample of amateur triathletes and to identify the incidence of musculoskeletal injury and its impact on training, rating, working, or daily activities. The first four items collected demographic information on age, sex, height, and weight. The next five items gathered information relating to triathlon sports participation: I) the length of time of' triathlon competition and events participated in over the last year; 2) the identification of and participation in other endurance sports besides swimming, biking, and running; and, 3) the incidence of triathlon- related musculoskeletal injury during training or racing. The last 15 survey items requested specific information correlating to the participants' triathlon-related injuries. These items collected information relating to the following: 1) had the triathlete been injured more than one time; 2) were the injuries incurred during training or competition; 3) had professional help been sought for the injury and, if so, what type of professional had given the treatment; 4) was the musculoskeletal in-jury a result of overuse or due to trauma; 5) did the in-jury cause an interruption in training or cause the triathlete to miss or not complete a scheduled triathlon or related competition; 6) did the injury hinder daily activity or cause an absence from work; 7) did the injury cause permanent loss of function or permanent impairment; and, 8) did the triathlete experience an injury that was not triathlon-related and did this injury prevent training or competing. For the purposes of this study, the survey participants were given a triathlon-related injury definition as follows: a triathlon-related injury is considered to be any in-jury that occurred while training for or racing in a triathlon or while training for or racing in an individual swimming, cycling, or running event. An example was given to help the participants’ identify the difference between a triathlon-related vs. a nontriathlon-related type injury. The survey participants were given the following examples to help them define a musculoskeletal injury due to overuse or due to trauma: I) a back injury from riding too long on a bike was considered to be an example of an overuse musculoskeletal injury; and 2) a triathlon injury due to a fall or collision during training or racing was considered to be an example of a traumatic musculoskeletal injury. Most of the demographic survey items required numeric responses. Two of the demographic items and most of the triathlete musculoskeletal injury items were developed in a closed-ended, fixed ves/no response format. In two of the musculoskeletal injury items, respondents were given an opportunity to list the other endurance sports in which they participated and to list specifically what other type of professional had given them treatment if it did not appear among those already listed in the survey.

Administration of the Survey

The triathlete survey was mailed to the 150 names listed on the Tri- Miami Club membership list. Each survey mailing contained a survey instrument and a cover letter. The cover letter explained the purpose of the study and included instructions for completing and returning the instrument. The instructions requested that the survey be completed and returned whether the respondent had or had not experienced an injury. A pre-addressed, stamped envelope was included in each mailing for returning the instrument. A p proximately 2 weeks after the mailing, a follow-up postcard was sent. The purposes of this postcard were to
thank respondents who had already completed and returned their survey and to encourage those who hadn't completed the survey to do so and return it as soon as possible. In addition, two verbal announcements were made regarding completion of the survey at two different Tri-Miami membership meetings.

Data Analysis

The data from the survey were coded and descriptive statistics were analyzed using Statistical Programs for the Social Sciences (Statistical Programs for the Social Sciences for Windows Package, Version 6.0, SPSS Inc., Chicago, IL). The numeric demographic data were evaluated for characterization of the study sample by value ranges, means, and standard deviations. Responses to two of the demographic items and all of the triathlete musculoskeletal injury data were analyzed as percentages of the total number of responses to each yes/no question item. For the survey item assessing types of professional help sought, each professional category that was marked was recorded as a "yes" response. Unmarked categories were recorded as a "no" response and percentages were calculated for each professional classification.

RESULTS

A total of 72 completed surveys were returned from a mailing to 150 triathlon members for a response rate of 48%. The survey data requesting participants to indicate any other endurance sports of participation in addition to swimming, biking, and running were not used. The responses given in the "other" category of the aln7ey item addressing types of professional help sought were not quantified according to any other specific groupings. These two survey items were felt to have an insignificant impact on the overall survey results due to the low frequency and randomness of the response.
The demographic survey results are shown in Table 1. Review of the raw data ranges for age, height, weight, years of triathlon competition, and number of triathlon races completed in the past year reveals the scope of the sample participants. The frequency of male/female respondents demonstrates a percentage of 56.9 male participants and 43.1 female participants. The rest of the survey results are shown in Tables 2 and 3 as the frequency of response and percentage of answers to the ves/no survey items. Respondents were found to sustain a musculoskeletal injury during training 75% of the time as compared with a 27.8% injury occurrence during a competition. Survey participants indicated that 78.9% of the musculoskeletal injuries were sustained according to the given definition of the term "overuse" vs. 33.3% of the participants that acquired their musculoskeletal injury due to trauma. These injuries interfered with training schedules (training interruption, 77.8%) more than scheduled racing participation (absence from scheduled triathlon competition, 33.3%, and related competition, 37.5%) or the ability to complete an event (inability to complete a competition, 20.8%). While the triathlon-related musculoskeletal in-juries were shown to hinder daily activities 63.9% of the time, they did not appear to cause permanent loss of function (4.2%) or significant absence from work (15.3%). Non-triathlon injuries were shown to prevent training or competition 45.8% of the time. A majority of the respondents (65.3%) did seek professional help for their in-juries, with physicians and physical therapists being the two most frequent type of assistance sought.

RESEARCH S T U D Y . . . - - -
-
X SD Range
Personal data
Age
Height (inches)
Weight (Ibs)
Athletic history
Number of years competing in triathlons
Number of triathlon races participated in
during the past year
Frequency O/O
Sex
Male
Female
Do you participate in other endurance sports?
Yes
No
TABLE 1. Results of demographic survey information.

Discussion

The triathlete sample surveyed in this study was considered to be representative of the triathlete population and similar to the biographic data of triathlete samples described in previous survey research (1-4). The 48% response rate was attributed to the verbal announcements that were made at two different triathlon club meetings, the return envelopes that were enclosed with the survey instrument, and the follow-up postcard mailing. Although the response rate was less than 50%, this rate of return was equivalent to, if not better than, other triathlete survey response rates found in the literature (1-4). In combination, the response rate and the characteristic sample were felt to strengthen the importance of the survey findings.

As indicated by several other studies (1-4), this survey confirmed that triathletes' musculoskeletal injuries are most commonly nontraumatic in nature, occurring during training due to overuse activity. Previous studies have used samples of triathletes that were professionals Micheli (2), these results demonstrated that the overuse injuries did interfere with training activities. O'Tool ct al (4) have indicated in their research that many triathletes appear to continue training in spite of having an in-jury present. While the triathlete respondents in the current study indicated that they had sustained nontriathlon-related injuries, these unrelated injuries were found to prevent training or participating in competition less than 50% of the time (45.8%). O'Toole et a1 (4) found that exceptions do occur, but in the majority of overuse syndromes in ultraendurance athletes, there was no permanent impairment in the ability to perform. The findings from this study are in agreement and showed that in the majority of respondents, triathlon-related musculoskeletal injuries did not seem to cause permanent loss of function or absence from work; however, more than half (63.9%) of the survey participants did experience triathlon-related in-juries that interfered with daily activities. As indicated by Ireland and Micheli (2), the results of this study also revealed that a majority (65.3%) of the triathletes surveyed did seek professional help for their injuries. While examining musculoskeletal issues that are of' particular interest to physical therapists, the present study also differentiated between physical therapy intervention and other specific types of professional services. Physicians were found to be the most frequent type of medical professional sought in both of these studies, while the present survey showed physical therapists were seen in the second-highest frequency.