Injuries in triathletes: profiles and perspectives of risk and safety during competition

Triathlon is an endurance sport that combines the individual disciplines of swimming, cycling and running into a single event. The popularity of triathlon has increased since its inception in 1974. Training volumes, the intensity of competition and variable environmental conditions have all been reported as leaving the athlete susceptible to injury. This thesis aimed to provide an understanding of the incidence and aetiology of injuries sustained during triathlon competition, the perceptions of end-users towards injury risk and safety, and to provide an evidence-base for informing the development of prevention strategies to reduce triathlon competition related injuries. Competition injury surveillance, studies of triathlon stakeholders’ perceptions to injury and an observational study of risk factors were used to address the thesis aims. Injury surveillance for triathlon has primarily focused on counting, identifying and describing the profile of injuries. Many of these studies have used retrospective designs, which introduces the issue of recall bias. In addition, these previous studies used non-standard definitions, limiting comparability, and failed to report exposure data, preventing injury incidence reporting. Very little information about triathlon injuries occurring during competition is available for distances other than Ironman® events. The initial step of any prevention strategy is to identify the incidence and profile of injuries with appropriate measures of athlete exposure. This research programme developed and implemented an injury surveillance system, and the results were used to describe the profile of injuries in shorter distance triathlon competition. The results of this injury surveillance study demonstrated that the injury rate for shorter distance events was relatively low. However, injury rates warranting further investigation were presented for young competitors (12-19 years), running, bicycle mounting and dismounting, and race distance. The surveillance system was also useful for recording the occurrence of heat related casualties as a result of unusual environmental conditions, and the subsequent impact of changes to the organisations’ hot weather policy and athlete acclimatisation on heat injury cases. Injury epidemiology studies in most sports have primarily focused on the collection of data from athletes, however this has almost been exclusively so in the case of triathlon. Although coaches play an important role in the preparation of athletes for competition, identification of injuries and management of the injured athlete, they are used infrequently. Health professionals, whose knowledge extends from the treatment of triathletes, provide a perspective of common injury presentations. Coaches’ and health professionals’ perspectives of injury risk were similar. Key perceived injury risk factors included biomechanics, training load, and demographic factors. The preparation of the triathlete, training regimens and health monitoring were factor groupings deemed important for the prevention of injury. The risk factors, identified by these stakeholders, should be targeted for future investigation. Understanding stakeholder or ‘end-user’ perspectives, to ensure prevention strategies are more likely to be adopted, is an important stage of the injury prevention pathway. Triathletes perceived that although there are behavioural and environmental factors that increase injury risk, they are generally accepting of those risks when they compete. Triathlon competitors identified behavioural issues including experience, skill level and feelings of vulnerability as contributing to increased injury risk. Important environmental factors including athlete crowding, specific race sections (mount/dismount, cornering) and factors such as weather and water conditions were perceived as contributing to injury risk or decreased safety during competition. The triathlete perceived behaviour and environmental factors identified in this thesis are all potentially modifiable risks. The bicycle mount and dismount during competition was the race section where an increase in the injury rate was noted across the injury surveillance periods. The findings were supported by triathlon competitors who perceived there was an injury risk and vulnerability whilst performing this skill. Identification of risk factors is needed prior to the implementation of injury prevention strategies. The factors contributing to crashes and falls during the bicycle mount and dismount were generally related to triathlete behaviour, rather than specific environmental conditions. Experienced competitors who use moving mount strategies with their cycle shoes clipped into their pedals were at greater odds of crashes and falls than other competitors. However, during the dismount, behaviours including wearing cycling shoes during moving dismounts more often associated with crashes and falls. Triathlon is a sport with relatively low competition injury rates. This thesis has improved the knowledge about injuries sustained during competition, key stakeholders’ perceptions of injury risk, perceptions of safety during competition and aetiological factors contributing to crashes and falls. This knowledge provides an important basis for the development, implementation and testing of injury prevention strategies for the sport of triathlon.