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Shoulder Health of Ironman Triathletes | Boddicker Performance

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Shoulder Health of Ironman Triathletes

by on Feb 20th, 2011

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Triathlon is a sport that requires long hours of training spanned across multiple disciplines ultimately leading to a single day race covering up to just over 140 miles in 9 hours at the elite level. Developing the work capacity to compete for 9 hours or more requires substantial dedication and, as you can imagine, carries a substantial risk for volume-related injury and illness (Gosling, 2008).

The shoulder sees a great deal of abuse in all events and is chronically loaded in 2 of the 3 disciplines. Obviously, swim training carries repetitive physiological impingement-rumored to be the leading cause of shoulder pain in swimmers-and may facilitate the development of Janda’s crossed syndrome(s). Cycling long periods in aerobars requires chronic compression of the shoulder joint and generalized facilitation of the hypertonic tissues in crossed syndromes.

Not surprisingly, then, protecting the shoulder is one of the chief concerns in the athletic development programming of a competitive triathlete. For the clinician, restoring shoulder health a primary concern in the injured athlete. Clinicians often utilize imaging studies to assist in diagnostics for the injured athlete and having an understanding of normal shoulder histology and mechanics are of critical concern for both parties.

The Study

Dr. Robert Reuter and colleagues sought to compare the shoulders of Ironman triathletes who were asymptomatic or symptomatic with shoulder pain and also to compare triathletes against an age matched non-triathlete to determine pathoanatomical occurrences. The asymptomatic group–G1–consisted of 7 finishers (5 male, 2 female) with an average age of 35 years old, and the symptomatic group–G2–included 16 subjects (11 male, 5 female) with the average age of 39. The third group–G3–consisted of 17 (9 female, 8 male) non-triathletes to serve as a control group. All subjects were screened by a competent orthopedic physician and met inclusion criteria.

The Process

Subjects consented and received an MRI on the shoulder either prior to or 48 hours after intensive training to reduce training-related influences on joint health. Images were assessed by two radiologists who were blinded of subject’s condition to determine the presence of rotator cuff tear (full and partial), tendinopathies, and AC joint marrow edema.

The Results

Group 1, the asymptomatic group, demonstrated that 29% had partial tears of the rotator cuff, 29% had tendinopathies, and 57% showed up with AC joint arthorsis. 71% of G1 also showed signal changes of marrow at the AC joint indicative of marrow edema. Group 2–the group experiencing pain–had 19% with partial tearing, 50% with evidence of tendinopathies, 31% with AC joint arthosis, and 62% with marrow signal changes. Comparing the two groups, there are no statistically significant occurrences of pathology, leading to the author’s conclusion that “there is no clinical correlate” between damage in imaging and disability. Interestingly, unlike other overhead athletes, the incidence of labral pathology was 0.

This has been demonstrated in a number of alternatives that imagining studies on athletes need to be utilized, but tempered with the understanding that damage is not always indicative of functional capacity (Hagerman, 2004; Jost, 2005; Wright, 2007).

If not anatomical changes, then what?

Dismissing imaging in its entirety may be a mistake (Strobel, 2003), but recognizing that tissue damage is not the entire picture is a huge first step to creating ideal programs for outcomes. The damaged tissue may be waiting to reach the threshold of threat and subsequent pain production at the central level, but something is keeping it at bay and should be exploited as best and reasonably as possible.

Movement quality may play a role in reducing tissue stress and delaying the development of threat, which can and should be enhanced in training. Psychosocial stress is also hugely important, and has been associated with the onset of pain from RSIs in shift workers time and time again. The sneaky aspect of stress is that most triathletes only log stress of training in time or volume, but fail to account for life stress. Utilizing HRV may offer a decided advantage in controlling training volumes to best fit the athlete THAT DAY.

What else could it be?

Carson Boddicker

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Leave a Comment »4 Comments
  • Allan Phillips February 20, 2011

    The typical Ironman age-group athlete already brings a lot of dysfunction to the game from lifestyle factors (i.e. white collar jobs, relative affluence, not always highly athletic before taking the Ironman plunge). Honestly, most Ironman age-groupers are rather poor swimmers in the grand scheme of aquatics. Think of it this way…we can have pathology that doesn’t manifest as pain in walking, but can become painful when running. Ironman swimming for age-group athletes compared to competitive pool swimming is often like comparing walking to running. The repetition can cause damage, but often not with enough intensity to cause pain.

    Endurance athletes often self select into a distance that simply doesn’t hurt. Going slow-to-moderate for a really long time allows certain people to stay competitive without provoking pain mechanisms. In terms of training programs, this creates a vicious cycle…unchecked movement problems leads to seeking out training that is non-provocative of pain, yet the only training that is non-provocative is really long and slow. As a result, we see all these one dimensional training programs and people simply decide to lengthen the event when they become less competitive at a shorter event! The only ways out of this cycle are 1) multidimensional training (But that hurts….!) or 2) get to the cause of the problem (often movement, managing life stress, etc). A similar phenomenon is the longtime old-school runner who turns to ultras simply because they don’t cause as much pain to his body. His hips and ankles may be as dysfunctional as ever, but he simply turns to an activity and venue that is less provocative of pain.

  • SnippetPhysTher February 21, 2011

    Pain is always interesting.

    Research is supporting the same kind of thing this study indicated about pathological findings. Basically, most people have pathology and they don’t even know it.

    More and more research leads to me being more confused. The power of our brain and what happens with expectations and perceptions is intriguing. There is probably a high likelihood that the individuals with both pathology and pain have a different outlook, different expectations, different perceptions and different belief systems than those without pain. By belief systems I mean self-efficacy and coping strategies.


  • SnippetPhysTher February 21, 2011

    This study is another good one to keep in mind with all the other studies indicating diagnostic testing results need to be correlated with a physical evaluation and a subjective history. Many individuals have pathology with no symptomology.

    Pain is always an interesting topic. More and more research in the pain arena leaves me with more and more confusion. It seems that a lot of research on pain points to the importance of an individual’s expectations, perceptions and beliefs. By beliefs I’m referring to coping strategies and self-efficacy beliefs. I would bet that there is a high likelihood that the individuals with pain symptomology are different than those with pathological findings in their outlook, perceptions, expectations and beliefs.


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