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An epidemiological investigation of training and injury

patterns in triathletes
ab b a a
Stefan Zwingenberger , Roberto D. Valladares , Achim Walther , Heidrun Beck , Maik
a a c a
Stiehler , Stephan Kirschner , Martin Engelhardt & Philip Kasten
a
University Hospital Carl Gustav Carus at Technical University Dresden, Dresden, Germany
b
Stanford University Medical Center, Stanford, USA
c
Klinikum Osnabrück, Osnabrück, Germany
Published online: 09 Oct 2013.

To cite this article: Stefan Zwingenberger, Roberto D. Valladares, Achim Walther, Heidrun Beck, Maik Stiehler, Stephan
Kirschner, Martin Engelhardt & Philip Kasten , Journal of Sports Sciences (2013): An epidemiological investigation of training
and injury patterns in triathletes, Journal of Sports Sciences, DOI: 10.1080/02640414.2013.843018

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 Journal of Sports Sciences, 2013
http://dx.doi.org/10.1080/02640414.2013.843018

An epidemiological investigation of training and injury patterns

in triathletes

STEFAN ZWINGENBERGER1,2, ROBERTO D. VALLADARES2, ACHIM WALTHER1,

HEIDRUN BECK1, MAIK STIEHLER1, STEPHAN KIRSCHNER1,
MARTIN ENGELHARDT3, & PHILIP KASTEN1
1
University Hospital Carl Gustav Carus at Technical University Dresden, Dresden, Germany, 2Stanford University Medical
Center, Stanford, USA, and 3Klinikum Osnabrück, Osnabrück, Germany
Downloaded by [Moskow State Univ Bibliote] at 20:21 02 December 2013

(Accepted 6 September 2013)

Abstract
Associated with the trend towards increased health consciousness and fitness, triathlon has established itself as a sport for
masses. The goals of this study were to evaluate injury risk factors of non-professional triathletes and to compare prospective
and retrospective evaluation methods. Using an online survey, 212 triathletes retrospectively answered a questionnaire about
their training habits and injuries during the past 12 months. Forty-nine of these triathletes participated in a 12-month
prospective trial. Injuries were classified with regard to the anatomical location, type of injury, incidence and associated risk
factors. Most injuries occurred during running (50%) followed by cycling (43%) and swimming (7%). Fifty-four per cent
(retrospective) and 22% (prospective) of the injuries were contusions and abrasions, 38% (retrospective) and 46% (pro-
spective) were ligament and capsular injuries, 7% (retrospective) and 32% (prospective) were muscle and tendon injuries
and 1% (retrospective) and 0% (prospective) were fractures. The incidence of an injury per 1000 training hours was 0.69
(retrospective) and 1.39 (prospective) during training and 9.24 (retrospective) and 18.45 (prospective) during competition.
The main risk factor for injury in non-professional triathlon is participation in a competitive triathlon event. A retrospective
design may underestimate the rate of overuse injuries.

Keywords: triathlon, injury, risk factors, training

Introduction professional, semi-professional and “weekend war-

rior” athletes.
Although competitions in which athletes perform in
When Jan Frodeno became the first German
several disciplines have been popular since ancient
Olympic Triathlon Champion in 2008, there were
times, the modern triathlon, a multidisciplinary
around 200,000 German athletes active in triathlon
event composed of swimming, cycling and running,
or duathlon (Deutsche Triathlon Union, 2013).
is still a comparatively young sport. The first triath-
Currently, almost 1000 triathlon or duathlon com-
lon competition, as we know it today, took place in
petitions are carried out annually in Germany
1974 in San Diego, California and was called the
(Deutsche Triathlon Union, 2013). There is also a
“Mission Bay Triathlon”. During the 1980s and
growing interest in triathlon in the United States. In
1990s, the triathlon captured the public eye with its
2011, about 500,000 athletes participated in 4334
images of exhausted athletes and came to be consid-
events (USA Triathlon, 2012). The International
ered as an extreme sport. The first “Ironman” took
Triathlon Union distinguishes between 4 different
place in Hawaii and had only 15 participants. The
distance categories: Sprint, Olympic, Medium and
decision of the International Olympic Committee
Long (Ironman) (Table I, Egermann, Brocai, Lill, &
(IOC) in 1994 to add the Olympic distance triathlon
Schmitt, 2003). The Ironman distance is mostly
as an official Olympic discipline in conjunction with
done by professional triathletes; there are an increas-
the trend towards increased fitness and health con-
ing number of amateur athletes taking part in the
sciousness helped establish it as a sport for masses of
shorter distances (USA Triathlon, 2012).

Correspondence: Stefan Zwingenberger, Department of Orthopaedics, University Hospital Carl Gustav Carus at Technical University Dresden, Fetscherstraße
74, Dresden, 01307, Germany, and Department of Orthopaedic Surgery, Stanford University Medical Center, 300 Pasteur Drive, Edwards Building, R-116,
Stanford, CA 94305-5341, USA. E-mail: stefan.zwingenberger@uniklinikum-dresden.de

© 2013 Taylor & Francis

 2 S. Zwingenberger et al.
Table I. Distance categories of the International Triathlon Union
(Egermann et al., 2003).
Swimming (km) Cycling (km) Running (km)
Sprint 0.75 20 5
Olympic 1.5 40 10
Medium 2 80 20
Long (Ironman) 3.8 180 42.2
Overall there is a limited number of investigations
focusing on triathlon-related injuries and the studies
that do exist are mainly focused on professional
triathletes (Egermann et al., 2003; Korkia, Tunstall-
Pedoe, & Maffulli, 1994; Main, Landers, Grove,
Dawson, & Goodman, 2010) with few focused on
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the rapidly growing number of amateur triathlon par-
ticipants (Rimmer & Coniglione, 2012). Therefore,
the primary objective of the current study was to
determine, by carrying out a retrospective and an
ensuing prospective investigation, the training regi-
mens and injury patterns of non-professional triath-
letes. Our secondary objective was to compare the
results of the prospective and retrospective investiga-
tion techniques. The decision to complete both a
retrospective and a prospective trial and compare
the data was based on the reality that most studies
in this field are retrospective; while prospective data
have been found to be more valuable when investigat-
ing sports injuries (Wallace, 2010). Our hypothesis
was that the incidence of an injury would be higher
using the prospective method compared with the ret-
rospective investigation technique.
Methods
Study design
During the last 2 weeks of the registration period for
the “Moritzburger Schlosstriathlon”, Germany, in
June 2009, participants were asked by the event
organiser to complete a retrospective online survey.
A total of 212 athletes were participating in the var-
ious distance categories of the International Triathlon
Union (Tables I and II), such as Sprint, Olympic,
Half-Ironman and Ironman, were included. After the
competition, 49 triathletes took part in a 1-year pro-
spective study. All data were anonymised prior to
analysis. All activities were carried out in accordance
with the local ethical committee.
Surveys
A total of 1048 triathletes were asked via email by the
organising committee to participate in an online sur-
vey containing both open-ended and multiple choice
questions with regard to their training habits, injuries
and anthropometric data. We received 212 (20.2%)
complete submissions (43 women, 169 men). Forty-
nine athletes (9 women, 40 men) proceeded with a
monthly online report of their injuries after the com-
petition. Training duration was asked in all surveys.
Injuries
Athletes described their injuries with regard to their
cause, anatomical location and recovery timeline.
We classified the injuries as described by Egermann
et al. (2003), to one of the following 4 groups: (1)
contusion/skin abrasion, (2) muscle/tendon injury,
(3) ligament/capsule injury and (4) fracture. Both
overuse and trauma injuries were included. Athletes
provided us with the number of training days that
their injury caused them to miss and the type of
treatment that they underwent for their injury: (1)
hospital stay, (2) outpatient care and (3) no profes-
sional treatment. The location of the injury was
matched to one of the following regions: shoulder,
upper arm, lower arm, wrist, hand (upper extre-
mity), hip, upper leg, knee, lower leg, ankle, foot,
(lower extremity) spine, pelvic, trunk and head.
Data analysis
All data were collected in Microsoft Excel® 10.0
(Microsoft Corporation, Redmond, WA, USA) and
anonymised. Statistical analysis was done using SPSS
19.0® (IBM Corporation, Armonk, NY, USA).
Description of the results was affected by median, quar-
tiles, minima and maxima as data often did not follow a
Gaussian distribution. Significance between unpaired
groups was tested using the Mann–Whitney test and
the Wilcoxon matched pairs test was applied for paired
groups. To determine the influence of risk factors on the
presence of injuries, the following 6 groups were formed:
age (<35 or ≥35), gender (female or male), performance
level at the “Moritzburger Schlosstriathlon” (finisher in
the first half or second half), weekly training duration
(<10 h or ≥10 h), coach (yes or no); preventive sports
medical care in 2007–2009 (yes or no). Significance was
tested using Pearson’s chi-square test. For all tests, the
significance level was set to 5%.
Results
Training patterns
The anthropometric characteristics and other perti-
nent data of the retrospective and prospective trial
participants are shown in Table II.
At the bike check-in for the competition, each bike
and helmet were checked for safety. While a helmet
is required for competition, only 93% of the athletes
reported using a helmet for training. Common rea-
sons to postpone training were reported as being due
to rhinitis (37%), cough (53%), sore throat (55%),
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Table II. Anthropometric characteristics, personal data and durations for training and competition of the retrospective and the prospective trial. Data are presented as the median with first (Q1) and
third (Q3) quartile as well as minimum (Min) and maximum (Max).

Retrospective analysis Prospective analysis

Distance Sprint Olympic Medium Long All distances All distances

(n = 77, ♀20, ♂57) (n = 57, ♀13, ♂44) (n = 56, ♀7, ♂49) (n = 22, ♀3, ♂19) (n = 212, ♂43, ♂169) (n = 49, ♀9, ♂40)
Age (years) 37 35 40 42 40.3 39
Q1 30, Q3 44 Q1 28.5, Q3 42.5 Q1 33.25, Q3 45 Q1 34, Q3 48 Q1 30, Q3 44 Q1 31, Q3 44
Min 18, Max 64 Min 20, Max 55 Min 21, Max 62 Min 20, Max 50 Min 18, Max 64 Min 21, Max 63
Height (cm) ♀ 169 ♀ 164 ♀ 172 ♀ 168 ♀ 168 ♀ 169
Q1 163, Q3 171 Q1 161, Q3 172 Q1 167, Q3 174 Q1 162, Q3 168 Q1 163, Q3 172 Q1 168, Q3 172
Min 153, Max 176 Min 160, Max 184 Min 165, Max 182 Min 162, Max 168 Min 153, Max 184 Min 164, Max 184
♂ 183 ♂ 181.5 ♂ 180 ♂ 183 ♂ 182 ♂ 183
Q1 179, Q3 187 Q1 178, Q3 186 Q1 174, Q3 186 Q1 178, Q3 185 Q1 178, Q3 186 Q1 178, Q3 187
Min 160, Max 200 Min 172, Max 192 Min 165, Max 192 Min 169, Max 193 Min 160, Max 200 Min 160, Max 197
Weight (kg) ♀ 60.5 ♀ 61 ♀ 66 ♀ 55 ♀ 61 ♀ 59
Q1 52.25, Q3 66.5 Q1 57.5, Q3 68 Q1 60, Q3 72 Q1 50, Q3 65 Q1 56, Q3 67 Q1 56, Q3 62
Min 48, Max 75 Min 55, Max 75 Min 56, Max 73 Min 50, Max 65 Min 48, Max 75 Min 50, Max 76
♂ 80 ♂ 77 ♂ 75 ♂ 78 ♂ 77 ♂ 78
Q1 72, Q3 85.5 Q1 72, Q3 82.75 Q1 71, Q3 81.5 Q1 72, Q3 85 Q1 72, Q3 84 Q1 72, Q3 85
Min 59, Max 108 Min 49, Max 100 Min 60, Max 108 Min 57, Max 91 Min 49, Max 108 Min 66, Max 100
Years of triathlon activity 2 3 4.5 5 3 3
Q1 1, Q3 4 Q1, 75, Q3 5 Q1 2, Q3 8.75 Q1 3.75, Q3 8.5 Q1 2, Q3 5 Q1 1, Q3 5
Min 0, Max 23 Min 0, Max 19 Min 0, Max 24 Min 1, Max 23 Min 0, Max 24 Min 0.5, Max 24
Weekly training hours swimming 1 2 2 2 1.5 2.06
Q1 0.5, Q3 2 Q1 1, Q3 3 Q1 1, Q3 2.75 Q1 1, Q3 3 Q1 1, Q3 2 Q1 1.30, Q3 3.11
Min 0, Max 5 Min 0, Max 8 Min 0, Max 10 Min 0, Max 12 Min 0, Max 12 Min 0, Max 9.33
Weekly training hours cycling 3 3 5 5 4 4.33
Q1 2, Q3 5 Q1 2, Q3 6.5 Q1 4, Q3 6 Q1 4.38, Q3 8.25 Q1 3, Q3 6 Q1 2.23, Q3 6.41
Min 0, Max 12 Min 0, Max 11 Min 1, Max 12 Min 1, Max 15 Min 0, Max 15 Min 0, Max 17.33
Weekly training hours running 2 3 3 3.75 3 3.25
Q1 1, Q3 3.25 Q1 2, Q3 4 Q1 2.5, Q3 4 Q1 3, Q3 5.25 Q1 2, Q3 4 Q1 2.52, Q3 5.29
Min 0, Max 7 Min 0, Max 8 Min 1, Max 10 Min 2, Max 10 Min 0, Max 10 Min 1.5, Max 10
Yearly training hours 338 442 520 637 442 503
Q1 260, Q3 520 Q1 325, Q3 715 Q1 416, Q3 676 Q1 457, Q3 874 Q1 312, Q3 650 Q1 392, Q3 795
Min 104, Max 780 Min 104, Max 1144 Min 208, Max 1300 Min 312, Max 1924 Min 104, Max 1924 Min 153, Max 1664
Training and injury patterns in triathletes

(continued )
3
 4 S. Zwingenberger et al.

diarrhoea (59%), feeling “unwell” (60%), dizziness

Prospective analysis
(76%) and fever >38°C (90%).

Min 1, Max 60
The duration of training and competition is shown

Q1 6, Q3 25
in Tables II and III.

22.4
10.2
10.2

40.8
26.5

85.7
16
Injuries of the prospective and retrospective trial
The anatomical locations of the reported injuries are
Min 0, Max 100
presented in Table IV. The lower extremities were
significantly more often injured than the upper
Q1 4, Q3 20

extremities, trunk or head (P < 0.001 retrospective

and prospective). Knee and lower leg injuries were
20.2

11.3

36.8
41.0

88.7
especially common.
6.6
10

The incidence of injuries (Table V) was found be

higher (13.4-fold retrospective, and 13.3-fold pro-
spective) during competitive events in comparison
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Min 0, Max 70

to training (P = 0.020 retrospective and P = 0.027

Q1 9, Q3 30

prospective). On average, 2.1 times more injuries per

1000 h of training per competition were found
18.2

59.1
63.6
90.9

during the prospective trial in comparison with the

4.5
9.1
16

retrospective trial (P = 0.030).

Retrospective analysis

Within the time period of 12 months prior to the

survey, athletes reported an average of 2.01 (Sprint
Q1 7.25, Q3 30
Min 0, Max 55

3.61, Olympic 1.38, Medium 1.78, Long 0.56)

cycling falls per 1000 h and an average of 0.91
(Sprint 1.10, Olympic 1.09, Medium 0.76, Long
50.0

91.1
19.6

46.4
7.1
8.9

0.41) running falls per 1000 h.

18

There were 101 injuries reported in the retrospec-

tive study. The injuries were classified as contusions
Min 0, Max 100

and abrasions (54%), muscle or tendon injuries

Q1 4.25, Q3 19

(38%) and capsule or ligament injuries (7%), and

only 1% was due to a fracture. The causes of injuries
were overwhelmingly found to be overuse (29%) and
87.7
31.6

15.8
35.1
35.1
8.8
10

trauma (71%).
During the prospective trial, 54 injuries were
reported. Again the injuries were due to contusions
Q1 1.75, Q3 13.5

and abrasions (22%), muscle or tendon injuries (46%),

Min 0, Max 70

and capsule or ligament injuries (32%), and there were

no fractures. The cause of injuries was similarly found to
be overuse (70%) and acute trauma (30%).
13.0

10.4
33.8

87.0
23.4
5.2
5.5

The retrospective data demonstrated that swim-

ming contributed to fewer injuries (7%) in comparison
Sport medical check-up within the last 5 years (%)

with cycling (43%) and running (50%). The severity of

the injuries was also decreased in swimming in com-
parison to cycling and running as evidenced by a med-
ian of 0 days (interquartile range 0–10) of recovery
needed to start training again compared to 7 days
Help of a trainer for swimming (%)

Help of a trainer for running (%)

(interquartile range 2–28.5) for cycling and 10 days

Help of a trainer for cycling (%)

10 (interquartile range 0–30) for running. The most

Use of a training plan (%)

serious injury happened due to cycling, as there was 1

Yearly competition hours

cervical spine fracture reported. Injuries from swim-

Table II. (Continued).

In employment (%)

ming were treated in 86% of athletes without profes-

sional treatment, 14% by outpatient treatment and no
hospital care was necessary. For cycling and running,
44% and 45% of the patients needed no professional
treatment, 32% and 53%, treated as outpatients and
23% and 2%, needed hospital care, respectively.
 Training and injury patterns in triathletes 5

Table III. Season-related training hours of the triathletes during the prospective trial. Data are presented as the median with first (Q1), and
third (Q3) quartile as well as minimum (Min) and maximum (Max).

Prospective analysis (all distances, n = 49, ♀9, ♂40)

Swimming Cycling Running

Weekly training hours spring 1 5.7 3

Q1 1, Q3 2.85 Q1 3.35, Q3 9.38 Q1 2, Q3 4.2
Min 0, Max 14 Min 1, Max 25 Min 1, Max 10
Weekly training hours summer 1.62 4 3
Q1 0.81, Q3 2.78 Q1 3, Q3 7.93 Q1 1.5, Q3 4
Min 0, Max 6 Min 0, Max 14 Min 0, Max 7.5
Weekly training hours fall 1.13 2.88 2.5
Q1 0, Q3 2.63 Q1 1.25, Q3 5.75 Q1 1.5, Q3 4.37
Min 0, Max 8 Min 0, Max 30 Min 0, Max 12
Weekly training hours winter 3 2.85 3.4
Q1 1.47, Q3 6 Q1 0, Q3 6.4 Q1 2, Q3 8.25
Min 0, Max 14 Min 0, Max 31.5 Min 0, Max 20
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Table IV. Anatomic location of the triathlon-related injuries in the trends as no risk factor led to a statistically significant
retrospective and prospective trial analysis. increase or decrease in injuries. Athletes <35 years
old had slightly less injuries (22.0%) than athletes
Anatomic Retrospective Prospective Retrospective Prospective
site (%) (%) (%) (%) ≥35 years old (24.6%, P = 0.656). Female athletes
had fewer injuries (16.3%) than males (25.5%,
Shoulder 6.00 1.85 Upper limb Upper limb P = 0.206). Athletes who finished within the first
Upper arm 4.00 0.00 25.00 5.55
Elbow 3.00 0.00
half of the field in the Moritzburger Schlosstriathlon
Lower arm 7.00 0.00 had slightly more (24.3%) injuries than athletes who
Wrist 0.00 0.00 finished within the last half of the field (20.7%,
Hand 5.00 3.70
P = 0.562). A strong trend between injuries and train-
Hip 1.00 0.00 Lower limb Lower limb
Upper leg 10.00 7.41 65.00 84.25 ing hours was seen as athletes with ≥10 training hours
Knee 20.00 33.33 per week (28.7%) had a higher absolute number of
Lower leg 21.00 24.07 injuries than athletes with less than 10 training hours
Ankle 4.00 9.26
per week (19.5%, P = 0.116).
Foot 9.00 11.11
Spine 1.00 5.56 Trunk 8.00 Trunk 9.26 No relationship was found between injuries that
Pelvic 3.00 0.00 occurred in athletes who train with a personal trainer
Rest trunk 4.00 3.70 (24.1%) and those training without a trainer (23.4%,
Head 2.00 0.00 Head 2.00 Head 0.00
P = 0.922). No relationship was found between
injuries and the athlete having had a sports medicine
physical therapy within the last 2 years (24.5%) or
Four athletes reported an overuse fracture that not (23.3%, P = 0.865).
occurred before the start of the observation period
in the 12-month retrospective survey. Two of these
Discussion
fractures were located at the foot, one at the tibia and
one at the fibula. The main finding of this study was that the only
significant risk factor for injury in non-professional
triathletes is participation in a competitive triathlon
Risk factors for injuries
event. Injuries of the lower extremities happened
Several risk factors were tested for the association significantly more often than injuries of the upper
with injuries. Overall, we were only able to discern extremities, trunk or head. More injuries (2.1 times)

Table V. Injury incidence per 1000 h of training per competition resulting from the retrospective and prospective trial analysis.

Retrospective analysis Prospective analysis

Sprint Olympic Medium Long Average Average

Competition 4.06 6.50 10.02 20.56 9.24 18.45

Training 1.23 0.53 0.50 0.32 0.69 1.39
Average 1.30 0.68 0.82 0.88 0.92 1.91
 6 S. Zwingenberger et al.
were reported during the prospective survey. Our
prospective study data demonstrated an overuse
injury rate 2.4 times higher than the retrospective
data. The prospective data also demonstrated a
trauma-related injury rate 2.4 times lower in com-
parison to the retrospective study data.
Compared with other investigations (Collins,
Wagner, Peterson, & Storey, 1989; Egermann
et al., 2003; Korkia et al., 1994; Manninen &
Kallinen, 1996; Shaw, Howat, Trainor, &
Maycock, 2004), we had a relatively low response
rate of 20.2% for our retrospective questionnaires. A
possible explanation could be that participation in
this study was by the athlete’s own choice.
Furthermore, we informed the athletes with only
one email. Since spam emails and sales promotions
Downloaded by [Moskow State Univ Bibliote] at 20:21 02 December 2013
via email have increased during the last years, some
athletes might have missed the information about
our study (Sheehan, 2001).
No data were found in the literature to compare
the weekly training durations of recreational Sprint-,
Olympic- and Medium-distance athletes. However,
the Long-distance athletes we investigated had
slightly lower median weekly training hours with
12.3 (2 swimming, 5 cycling, 3.75 running),
compared with Knechtle et al. (2010) who found
mean hours of 13.9 (2.4 swimming, 7.5 cycling,
4.0 running) for women and 14.8 (2.5 swimming,
8.0 cycling, 4.0 running) for men. Also, Gulbin and
Gaffney (1999) found higher mean weekly hours of
training with 15.6 (2.7 swimming, 8.5 cycling, 4.4
running). The ratio between swimming, cycling and
running hours of our study was comparable with
those presented by Knechtle et al. (2010) and
Gulbin and Gaffney (1999) A reason for the fewer
training hours in our group can be a higher number
of non-professional athletes in our study.
Furthermore, the median we used for statistical ana-
lysis is less affected by outliers than the mean
Knechtle et al. (2010) and Gulbin and Gaffney
(1999) applied in their studies.
Triathletes, even though they have a high number
of training hours per year, have a relatively low risk for
injuries. Ristolainen et al. (2010) asked athletes of
different disciplines similar questions as we did in
our study 12-month retrospectively for the presence
of acute or overuse injuries. The athletes had compar-
able training and competition hours to the cohort
presented in this study, but these athletes only
participated in a single discipline and not in multiple
disciplines as in triathlon. It was reported that Cross
Country skiers had a 2.2 times (females 2.33 and
males 1.77 injuries per 1000 h), Swimmers had a
2.8 times (females 1.94 and males 3.25 injuries per
1000 h), Long Distance Runners had a 3.0 times
(females 2.45 and males 3.15 injuries per 1000 h)
and Soccer Players had a 3.3 times higher injury rate
(females 3.25 and males 2.89 injuries per 1000 h)
than the triathletes we observed with 0.92 injuries
per 1000 h during the 12-month retrospective obser-
vation. An explanation for the low injury incidence of
multiple sports athletes like triathletes is that intense
training in a single sport discipline increases the risk
of overuse injuries and depression compared to per-
forming multiple sports (Most injuries during the
retrospective (65%) and the prospective (84%) period
occurred in the lower extremities which agrees with
the results of other investigations, where the injuries
of the lower extremities varied between 60% and 92%
(Burns, Keenan, & Redmond, 2003; Cipriani,
Swartz, & Hodgson, 1998; Collins et al., 1989;
Korkia et al., 1994; Manninen & Kallinen, 1996;
Shaw et al., 2004). Injuries of the upper extremities
(Bales, Bales, Baugh, & Tokish, 2012) and the trunk
are seldom and injuries of the head are rarely seen. As
we found during the retrospective survey, 47% of the
injuries needed no professional medical treatment,
42% required outpatient treatment and 10% required
hospital care. The rates for “no visit to a medical
doctor” and “outpatient care” in the study of Korkia
et al. (1994) were 49% and 36%, respectively, only
slightly different than our results. In contrast, Korkia
et al. (1994) reported that 1% of the injuries in their
study required hospital care, while 10% of the injuries
in our study required hospital care. This high rate of
hospital admissions was mainly caused by bike
accidents.
We found, that the main risk factor for injuries
was taking part in an organised competition. An
explanation could be that athletes in competition
have a highly activated sympathetic nervous system
which makes them more prone to ignore their
body’s response to pain and exerting themselves at
a higher level than they do in training (Binder et al.,
2004). No relevant influence of age, presence of a
trainer or sports medicine physical therapy was
found on the incidence of triathlon-related injuries.
A trend towards a higher rate of injuries was found
for males compared to females, athletes with a
higher performance level and training hours of
>10 per week. Similarly Collins et al. found no
influence of age, mileage per week and the presence
of a trainer. Although these authors did not observe
significant influences of sex, mileage per week and
performance level, overall their trends agreed with
those found in our study. Rimmer and Coniglione
(2012) reported recently that non-elite Ironman
athletes may experience a higher rate of injuries
than elite Ironman athletes. In addition to the pre-
viously stated risk factors, it appears that minor life
stress events are associated with an increased num-
ber of injuries during triathlon training and compe-
tition (Fawkner, McMurrary, & Summers, 1999;
Main et al., 2010).

Gabbe, Finch, Bennell, and Wajswelner (2003)
demonstrated that a 12-month injury history recall
has limited accuracy as injuries are forgotten and lay
people have difficulty in adequately describing an
injury. To address this issue, we added a 12-month
prospective period to our study and found an injury
rate 2.1 times higher than in the retrospective period.
There were much higher reports of overuse injuries
in the prospective period (70%) in comparison to the
retrospective period (29%). Thus, it seems that over-
use injuries are forgotten in a shorter time span than
as occurs with acute traumas. To reduce the number
of overuse injuries, it is important for athletes to
develop proper techniques in swimming, cycling
and running and to avoid rapidly increasing the
duration and intensity of their training (Migliorini,
Downloaded by [Moskow State Univ Bibliote] at 20:21 02 December 2013
2011). A confounding bias that could have occurred
in our study is that athletes with recurrent medical
issues may have had greater interest in taking part in
the study than athletes without prior medical issues.
The triathlon discipline with the lowest rates of
injuries and the lowest number of days of rest after
injury was swimming. However, interestingly, this
also seems to be the discipline with the highest death
rate. Harris et al. analysed triathlon competitions in
the United States between 2006 and 2008 (Harris,
Henry, Rohman, Haas, & Maron, 2010). A total of
959,214 participants were reported. Thirteen out of
14 deaths were reported to occur during swimming
and only 1 during cycling (Harris et al., 2010).
Injuries related to running did not lead to any death.
Risk factors for sudden death during swimming were
found to be cardiac abnormalities and a high number
of participants taking part in the competition (Harris
et al., 2010). To prevent sudden deaths during swim-
ming, a preventive cardiological screening is advisa-
ble. As most triathlons traditionally begin with a mass
swim, start limiting the number of competitors or
staging the starts could prevent the chaotic mass
swim starts have now become common.
The main limitation of this investigation is the rela-
tively low number of participants with the conse-
quence being that our results are not as reliable as
they would have been with a higher number of parti-
cipants. We, therefore, had parts of our results which
showed clinical relevant differences, though we only
presented them as trends as they did not show statis-
tical significance. However in this field of sports
medical investigations, our number of participants at
the retrospective trial is within the range of other stu-
dies presented (Collins et al., 1989; Egermann et al.,
2003; Korkia et al., 1994). We had only 49 athletes for
the prospective trial. With respect to this known
limitation, as always, conclusions must be seen with
caution. Our data remain valuable as until now there
are no direct comparisons between restrospective and
prospective trials in the triathlon literature.
Training and injury patterns in triathletes 7
For future epidemiological investigations of injury
patterns in triathletes, the results of professional
sports medical examinations should be included.
This will help address the specific anatomic location,
injury mechanism and risk factors more accurately in
order to improve our strategies to avoid trauma and
overuse injuries in triathletes. Furthermore, larger
sample sizes are needed to find statistically signifi-
cant risk factors for injuries in this specific popula-
tion of athletes.
Conclusion
The main risk factor for injury in non-professional
triathlon is participation in a competitive triathlon
event. Using a retrospective design may underesti-
mate the rate of overuse injuries.
Acknowledgments
We are grateful to Uta Schwanebeck for statistical
assistance and to Frank Heyne for programming the
online questionnaire used in this study.
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