QANDrA - Episode 4

I thought I could present this month’s episode as an interesting case study of four Kona-bound triathletes who come to see me at my clinical practice this year. These cases illustrate serious injuries, which have lead to the athletes either missing or continuing their dream of racing Kona in 2015.

POP QUIZ: who makes it to Kona?

a. Case 1: Stress fracture right shin (male, mid 30’s)

b. Case 2: Severe lumbar disc prolapse (female, early 50’s)

c. Case 3: Degenerative left hip (male, late 30’s)

d. Case 4: High speed crash (40km/h) onto guard rail (female, early 30’s)

e. None of the above

To preserve the anonymity (and dignity) of these athletes I’ve de-identified them, but I hope their cases are both of interest and utility to athletes trying to avoid the pitfalls of serious injury.

Case 1: Stress fracture right shin (male, mid 30’s)

A fascinating case, which saw this man come to me with multiple stress fractures in his right tibia (shinbone). Somewhat intuitively, stress fractures occur about 70% of the time in a dominant leg (Bennell et al 1996).  These types of tibial stress injuries do occur commonly in runners, but more frequently in females with menstrual cycle absence (or abnormality) and reduced calf musculature.

The fracture had reoccurred in the same limb as last year, despite the patient making every effort to strengthen and stretch the calves; as well as activate muscles around his pelvis (abdominals and gluteals). He wasn’t a slacker! He also described an odd way he relieved the pain of this injury when running: stopping and walking for a time made allowed him to run pain free for a significant time after the rest. If he was really had a fractured bone, why did the pain ‘go’ with rest?

Further questions revealed that whilst he did have two radiologically diagnosed stress fractures, he had the symptoms of endo arteriofibrosis. Aha I hear you say, what is endo arteriofibrosis?! It’s when a big blood vessel in the hip (the external iliac) get’s repetitively kinked during hip flexion and extension (running and especially cycling) causing the internal aspect of the vessel to thicken and narrow. This means less blood can pass through. When the leg is stressed with exercise (especially high intensity), not enough blood can supply the muscle with oxygen…leading to pain. The rest, followed by slower running, was allowing the blood to get to the leg more effectively.

Case 2: Severe lumbar disc prolapse (female, early 50’s)

This lady could barely get out of bed in the morning due to the pain running down the back of both her legs. She was sent to me for nutritional advice after losing about ten percent of her body weight in her Ironman debut (where she won her age and qualified for Kona). She had surgery on the back scheduled, but was trying every option to avoid the procedure before Kona. I’m not exaggerating, she had trouble walking with the pain each day after a long run. At times she needed to stop cycling to stretch her back because of numbness and pain. She was taking a suite of very strong pain killers and anti-inflammatories (including oral steroids) to stay away from the knife and on the track.

Case 3: Degenerative left hip (male, late 30’s)

A former footy player, this elite ager came to see me with nagging, niggling hip and back pain. Not a small lad, his weight fluctuates between high eighties and one hundred kilograms. It wasn’t long after assessing him that he was sent off for an MRI, which revealed a CAM lesion and a deteriorating hip joint that looked like it needed surgery to correct the problem.

The side of the injury, in relation to his sports history is a key part of his history. Kicking with your dominant leg (in this case his right leg) means you pivot and stress the left leg on the ground. So the non-dominant leg is more prone to injuries of the hip and knee joint. Weight is also a major factor when assessing the running athlete. Each additional kilogram above ‘winter weight’ causes a ground reaction force of at least five kilograms. So ten extra kilos loads the hip and knee with fifty plus kilograms when running. When you run for a couple of hours this stresses the joints in a way they are unable to cope with, leading to degenerative changes.

Case 4: High speed crash (40km/h) onto guard rail (female, early 30’s)

Gravel and high speed cycling can be a lethal mixture. This athlete came off and wrapped around a guard rail on a descent, where the shoulder had loose gravel. The three important aspects of this crash were: 1) the patient was wearing a helmet which saved her from a significant head injury; 2) the lower abdominal muscles had signs of trauma from either the handlebars or the railing; and 3) the hip was superficially damaged/bruised in the area of the big blood vessels (groin- femoral artery and vein).

Even though this athlete hadn’t broken any bones or been knocked unconscious, a trip to the emergency department was still indicated. Any high speed crash (30km/h or above) should be taken very seriously. Additionally, the abdominal and groin injuries could both prove lethal, if not cleared with ultrasound or a period of observation. A handlebar to the soft contents of the abdomen can cause serious injury to the bowel or a blood vessel.


Case 1: No Kona. Went on to have serious vascular surgery, grafting a new blood vessel onto the thickened one to allow better blood flow. He is now a long way down the track of rehabbing to qualify for 2016.

Case 2: Kona bound! The surgery was a success, and the very broad-minded surgeon has allowed this tough lady to book her tickets to Kona in October. She returned to running pain free only four weeks post surgery. Her main impediment to Kona greatness will be nutritional, not psychological.

Case 3: No Kona. Hip arthroscopy revealed damage to the hip that requires both corrective surgery and a series of injections over many months. Rehabilitation and weight management should see this athlete successfully return to his passion in 2016.

Case 4: Kona bound! After three days off to allow for the bruising and rash to begin to subside, this athlete returned to the track tentatively. With ten days of reduced training schedule, her campaign was back on track for 2015.



Bennell, K. L.; Malcolm, S. S.; Thomas, S. A.; Reid, S. J.; Brukner, P.; Ebeling, P. R.; Wark, J. D., Risk factors for stress fracture in track and field athletes: a twelve-month prospective study. American Journal of Sports Medicine24 1996, 6 (810-818).