Sports medicine enthusiasts initially thought that triathlon would be associated with less overuse injury due to more balanced stress distribution throughout the muscles and bones. Unfortunately, this theory has not held up.
It has been found that triathletes tend to train more hours per week compared to single sport athletes, which leads to a higher incidence of injury. Most recent studies on triathletes primarily focus on overuse or traumatic injuries -- including back pain -- and concern has been expressed by some authors that investigation of the long-term consequences is needed.
Studying neck and low-back pain in triathletes
As an avid triathlete and neurosurgeon in Boulder, Colorado, I recently completed an epidemiological study in order to identify risk factors associated with the occurrence of neck and back pain in triathletes and to establish the lifetime incidence of such disorders in multi-sport athletes.
An online questionnaire was developed to collect information about physical characteristics, training habits, athletic status, number of races completed and neck or low-back pain among triathletes. The study population consisted of triathletes who are living and training in the Boulder area.
A total of 87 athletes were involved in the study. The average age of all athletes was 36 years. There were six elite (6.9 percent), 65 intermediate (74.7 percent) and 16 beginner (18.4 percent) triathletes. The lifetime incidence of low-back pain was 62.8 percent and for neck pain was 47.5 percent.
The majority of triathletes in this study complained of pain that lasted less than seven days, suggesting mainly soft tissue and ligament involvement. However, 24 percent of triathletes with low-back pain and 21 percent of those with neck pain experienced frequent, longer term discomfort.
This suggests discogenic pain, which implies that one or more intervertebral discs are suspected as a pain source. These are the cushions between the spinal column bones that can be associated with various disease processes -- such as arthritis and traumatic or congenital abnormalities -- that lead to spinal instability.
Symptoms of pain radiating into the arms or legs were also very common. Of triathletes with neck pain, 64.3 percent reported experiencing such "radicular" symptoms. 33.6 percent of those with back pain reported the symptoms.
Triathletes predisposed to injury?
These recent study results align with the theory -- supported by sports medicine-related literature -- that back pain is most frequently caused by traumatic injuries and overuse in athletes.
Based on this data, triathletes at greatest risk for chronic neck and low-back pain included those with higher participation rates in competition (low-back pain), total years in sports (neck pain) and a history of previous sports injury (both neck and low-back pain).
In some ways this may seem counter intuitive. Participation in more events usually means greater fitness levels in an athlete, which can be associated with a lower incidence of such chronic pain disorders.
It may also be the case that participating in more events, regardless of fitness level, could result in a higher number of injuries due to overuse, leading to more pain. When left untreated, overuse injuries are thought to lead to cumulative overload and consequently to spinal discogenic pain.
It was demonstrated in one study that athletes who reported previous low-back injury were three times more likely to sustain a low-back injury in the following year. Previous neck trauma has also been shown to be predictive of neck pain.
This resultant self-perpetuating cycle could be specifically related to the demands of endurance sports in general -- or to the multi-sport issue (running, biking and swimming) -- that requires a higher number of weekly training hours.
Another risk factor for neck and back pain is related to the natural history of degenerative changes in the general population. Previous publications support the idea that such problems increase with age.
I have not been able to observe any significant correlations between age and back pain in the recent study group of triathletes, even though 30 percent of them were 40 years or older. This could be attributed to the fact that the major risk of back pain was related to the incidence of injury, which could occur at any age.
Sex, athletic status, body mass index and training duration were not predictive of back pain in this study. Thus, back pain appears to be rather equally distributed across the population of triathletes, with no single demographic factor being significantly more at risk than another.
Athlete vs. non-athlete
A lifetime incidence of low-back pain has been reported in up to 80 percent of this country's general population. While it is debatable as to the incidence of back pain being lesser or greater in athletes, it is clear the factors leading to such problems are there.
Even though spinal anatomy and physiology may be the same for the non-athlete as for the athlete, the forces placed on the spine in sports like triathlon are -- in theory -- much greater than that for the non-athlete. These forces, including training duration, may increase the strain and vulnerability that damages the spine or surrounding tissue.
Some of the triathletes in this study reported that their back pain was not sport-related, but overuse injuries and intense repetitive loads during training and competitions may as well exacerbate it. Early back pain symptoms should not be ignored, even if they last less than seven days and lead to spontaneous recovery.
How to counter the pain
Minimizing disability associated with spine pain may be equally important for the athlete and non-athlete. However, the most effective methods for doing so may be distinct for each group. This study should be assessed in order to change the cycle of overuse-associated injury.
A rehabilitation program tailored to the athlete should take into account their high level of activity and endurance, as well as the strong motivation to return to training and competition. This could effectively address early back-related problems and help prevent the long-term consequences. In addition, modifying training to include more time devoted to flexibility and muscular balance is recommended.
In summary, a different approach is needed when treating athletes due to their high levels of activity and expectations to return to sports. Fortunately, the majority of sports-related back problems resolve with conservative, non-surgical management.
While surgical intervention is sometimes the fastest route to get the patient back into active sports, it may not be the best solution and should be decided upon on an individual basis. Extensive conservative measures should be exhausted before considering surgery.
Alan Villavicencio, M.D. is a Board Certified Neurosurgeon and one of only a handful in the country with both neurosurgery and orthopedic spine training. He specializes in minimally invasive spinal surgery in athletes and spends his free time running marathons, bike racing and competing in triathlons, including 13 Ironman triathlons (three of which have been the Hawaii World Championships.) For more information, click here.