REVIEW ARTICLE
Common and Uncommon Injuries in Ultra-endurance Sports
Louis C. Almekinders, MD and Charles R. Engle
Abstract: Ultra-endurance sports are associated with prolonged physical
exercise both during training and competition. Musculoskeletal injuries
are common as a result of the repetitive physical stresses. Stress fractures
in the weight-bearing bones should always be suspected when ultra-
endurance athletes present with pain over bony structures. Most stress
fractures can be treated with activity modifications but some such as
femoral neck and tibial shaft stress fractures may require operative fix-
ation. The knee seems to be the most frequent source of injuries in ultra-
Downloaded from http://journals.lww.com/sportsmedarthro by BhDMf5ePHKbH4TTImqenVH7iwJ14kTBOHN2ALq4cYjLrwzv/ZgYczDNnIXpxbX3C on 01/05/2019
endurance athletes. Patellofemoral symptoms from tendon injuries or
chondral problems are common injuries and can be challenging to treat.
Lower leg, ankle, and foot injuries also make up a significant portion of
the ultra-endurance injuries. Peritendinitis of the extensor tendons at the
extensor retinaculum of the anterior ankle or “ultramarathoner’s ankle”
seems to be a unique injury associated with ultramarathons. Other lower
leg injuries include medial tibial stress syndrome (MTSS) and chronic
exercise-induced compartment syndrome (CECS).
Key Words: Ultra-endurance sports injuries, stress fractures, patel-
lofemoral pain, ultramarathoner’s ankle, medial tibial stress syn-
drome, chronic exercise-induced compartment syndrome
(Sports Med Arthrosc Rev 2019;27:25–30)
A lthough the traditional sports like basketball, football, golf,
and baseball have been around for generally more than a
century and receive the majority of the attention in the public
media, in the United States participation in these sports have
not necessarily seen any recent, dramatic increases.1 In contrast,
sports like triathlon, road and off-road running events, obstacle
or adventure races, open water swimming, etc are relatively new
and receive on average little media attention. However, they
continue to see increasing participation rates in terms of number
of athletes with increasing number of events as well. One
common feature of these sports is the emphasis on aerobic
endurance and mental toughness rather than anaerobic strength
or skill. Initially standard running races and triathlons were
considered examples of endurance sports. But as their popu-
larity increased, they lost their label of “extreme” sports.
Looking for new ways to differentiate and challenge themselves
in endurance sports participants have moved to a special
subset of events that feature ultra-endurance distances.
Ultra-endurance events include foot races, both on the road and
off-road, beyond the marathon distance (26.2 miles), triathlons
with Ironman distance (2.4 mile swim, 112 mile bike, and 26.2
mile run) and beyond, multileg and often multiday obstacle and
adventure races as well as open water distance swims (6.2 miles
and beyond). It should be no surprise that musculoskeletal
injuries can be a common problem in these athletes. Both the
extended time spent preparing and training for these events as
well as the events themselves are obviously associated with
From the North Carolina Orthopaedic Clinic, Duke University Health
System, Durham, NC.
Disclosure: The authors declare no conflict of interest.
Reprints: Louis C. Almekinders, MD, North Carolina Orthopaedic
Clinic, 3906 Southwest Durham Drive, Durham, NC 27707.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Sports Med Arthrosc Rev  Volume 27, Number 1, March 2019
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
dramatic and prolonged physical stresses on the musculoskeletal
structures that can lead to breakdown and injury. Many of these
injuries can be seen in other sports. However, the frequency of
certain injuries as well the manner in which these athletes deal
with them can be dramatically different. In addition, there are
some unique injuries that are rarely seen in nonendurance
sports. This review article will give an overview of the common
and uncommon musculoskeletal injuries seen in these ultra-
endurance athletes and review the guidelines in terms of treat-
ment both during training as well as during competition.
EPIDEMIOLOGY
Accurate injury data can be difficult to ascertain in certain
sports. In order for injury data to be accurate and meaningful is
has to be controlled for exposure. In addition, an “injury” needs
to be carefully defined. In organized team sports, exposures are
often defined as practice and game sessions. Ultra-endurance
athletes are generally not part of an organized team and tend to
train and prepare on their own. Training and race sessions can
vary dramatically in terms of length, distance, and intensity. In
organized team sports, an “injury” is often defined and one or
more missed training or game session because of the problem.
Some level of musculoskeletal pain in a training or race session
is an accepted feature of the sport for the ultra-endurance ath-
lete. It seems common to “train and race through” suspected
injuries as many ultra-endurance athletes self-diagnose and self-
treat their aches and pains. As a result both exposure as well as
injury is more difficult to define in ultra-endurance sports.
Findings from the Ultrarunners Longitudinal Tracking
(ULTRA) study indicate a high incidence of injuries.2 In this
database of ultramarathon runners with self-reported injuries
almost 65% reported an exercise-related injury that resulted in
lost training days over the time span of 1 year. Injuries were
associated with younger and less experienced runners. The
knee was most commonly involved. There also was a 5.5%
incidence of stress fractures, nearly half of them involving the
foot, and they were more common in women than in men.
A similar high rate of injury has been reported in long-
distance triathletes. O’Toole et al3 originally reported that 91%
of the respondents of a survey of Hawaii Ironman competitors
acknowledged a soft tissue overuse injury in the preceding
year. Edgerman et al4 reported injuries in 74.8% of Ironman
triathletes based on a written questionnaire. Most injuries in
this study occurred from trauma during cycling training ses-
sions. Injuries were also associated with older athletes, high
performance athletes and large number of weekly training
hours. In addition, injury rates in long-distance triathletes are
correlated with the amount of intensive speed sessions done in
the time leading up to the injury.5
Injury rates during ultra-endurance competition events also
seem high. In multiday ultramarathon events injury rates ranging
from 56% to 85% have been reported.6,7 It should be noted that
a significant portion of these injuries includes skin-related dis-
orders such as blisters and chafing. The skin problems themselves
can seem minor but at the same time can lead to gait changes
www.sportsmedarthro.com | 25
Almekinders and Engle
that can put other structures at risks. In addition, longer and
multiday races may require the participants to carry their own
nutrition and hydration. This adds significant weight and pos-
sibly increases injury risk. It is also worth mentioning that only a
small portion of the reported injuries caused athletes
to abandon the race confirming the “race through the injury”
attitude of many of these athletes.
The exact contribution the various risk factors for
musculoskeletal injuries in ultra-endurance athletes can not
be determined from these few, mostly observational and
epidemiological studies. Many factors such as morphologic
characteristics, training regimens, running style, shoe wear,
etc have not been carefully studied. It seems likely that there
is a complex relationship between the various factors and
injury occurrence as suggested by Kienstra et al.8 However,
it seems also reasonable to assume that training volume and
intensity is a key variable. Particularly in stress fractures, sex
likely plays a role with women being at higher risk.
STRESS FRACTURES
For many health care providers of ultra-endurance
athletes a stress fracture represents the quintessential overuse
injury. Repeated physical stress on solid structure is known to
eventually cause mechanical failure of the structure with bone
not being an exception. It is important to recognize however
that the preinjury mechanical strength of the bone can be
variable and is dependent on several factors. Recognition
of these factors can be important in the prevention and
treatment of stress fractures. Lack of weight-bearing exercise
will lead to relatively decreased bone strength and possible
predisposition to stress fracture. As such, novice ultra-
endurance athletes with a rapidly increasing training volume
are likely at increased risk for stress fractures as evidenced by
the preliminary results of the ULTRA study. Nutritional
status also has been associated with bone quality. It is not
uncommon for ultra-endurance athletes to have fairly strict
dietary rules for themselves. Some of this can be grounded in
the fear of weight gain leading to decreased performance.
FIGURE 1. A, Acute, slightly displaced distal tibia fracture that occurred during competition in an endurance athlete with preexisting
symptoms of a stress fracture. B, Intramedullary fixation of the spiral distal tibial stress fracture to allow early weightbearing.
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Sports Med Arthrosc Rev  Volume 27, Number 1, March 2019
Others have different health concerns causing them so avoid
certain food items such as meats or other animal products.
These dietary restrictions can potentially lead to suboptimal
bone health. Finally hormonal factors especially in women
can lead to poor bone strength. The association of running,
amenorrhea and stress fractures has been well documented9
and should be considered in the treatment and prevention of
stress fractures. It may be important to aggressively pursue
the potential diagnosis of a stress fracture if suspected as an
undiagnosed and untreated stress fracture can progress to a
complete acute fracture potentially requiring emergency
surgery.10 This may not necessarily be an uncommon sce-
nario in ultra-endurance athletes who assume that a certain
level of physical discomfort and pain is a routine part of their
training and racing events (Fig. 1).
As previously mentioned the foot is reported to be the
most common area affected by stress fractures. Although any
bone can potentially sustain a stress fracture, the metatarsals
are by far the most likely affected. The bending stresses of the
running cycle seem to frequently exceed the strength of the
metatarsal.11 In particular the second and third metatarsal
bones are most commonly affected as opposed to the fifth
metatarsal seen in sports that require sudden cutting and
turning movements. Localized pain with running is generally
the initial sign of this problem. As the problem progresses,
localized swelling and even pain at rest can become evident.
Physical examination generally reveals a localized, dorsal
tenderness direct over the affected metatarsal. Radiographs
initially may be negative. Occasionally, the first radiographic
finding may be some callus forming as the actual fracture line
may be difficult to visualize. If neither is present but a stress
fracture is suspected, then MRI is generally used to confirm
the diagnosis. Treatment may simply be the cessation of
running for at least 3 to 4 weeks with gradually resumption
after that if the pain and tenderness has resolved. If the
fracture has progressed to a complete cortical break with pain
even on regular weight bearing such as walking or standing, a
walking boot or cast during the healing phase can be helpful
to minimize any bending stresses on the bone.
Sports Med Arthrosc Rev  Volume 27, Number 1, March 2019
Tibial stress fractures can occur in several locations.
Common locations are the distal medial side, anterior mid-
tibia and the proximal medial metaphysis. Similar to what
was described under metatarsal stress fractures, the localized
pain and tenderness that worsens with running are the
typical symptoms and findings. The radiographic diagnosis
can be challenging as the fracture line and any callus can be
difficult to ascertain. The signs and symptoms of a tibial
stress fracture can also be easily confused with other causes
of shin pain such as medial tibial stress syndrome or even
exercise-induced compartment syndrome. Again, MRI is
generally used to determine the presence of a stress fracture
if there is uncertainty. The more proximal and distal tibial
stress fractures being in cancellous bone have good healing
potential with cessation of running and jumping exercise.
However, cessation of running for at least 6 to 8 weeks is
frequently needed. A protective walking boot can be helpful
initially. The mid-tibia cortical stress fractures, frequently
called the dreaded black line because of their radiographic
appearance, have a relatively poor prognosis with regards to
spontaneous healing. Surgical treatment with internal fix-
ation is frequently recommended.12
The cause of pain in the hip and low back area in athletes
can pose significant diagnostic challenges. Although this can
indicate a stress fracture in the hip, pelvis, or sacrum, other
conditions such as femoro-acetabular impingement, adductor
strains, osteitis pubis, and abdominal wall pathology should be
considered. With regards to stress fractures, the majority of
these affect the femur as pelvis and sacral fractures account for
<3% of the stress fractures.2 Hip femoral neck stress fractures
can have disastrous consequences if not recognized and treated
appropriately. The main symptom is hip pain with weight-
bearing exercise, generally in the groin area. Physical exami-
nation is often normal as the femoral neck can not be assessed
for local tenderness because of its deep anatomic position.
Radiographs may show a subtle fracture line but MRI is
generally definitive. Inferior femoral neck fractures (the com-
pression side) are generally treated with conservative care
similar to other stress fractures. However, superior femoral
neck fractures (the tension side) have more of a tendency to
fracture through, displace and potentially injure the retinacular
blood vessels causing avascular necrosis of the femoral head.
Many authors advocate surgical fixation of this fracture type.13
KNEE INJURIES
Although knee injuries in epidemiological studies have
been often the most common site of injury, the exact nature of
the injury is often unclear. Several reports on injuries during
multiday running races classify the majority of knee pain as
patellofemoral or retropatellar pain.14,15 The patellofemoral
compartment is highly stressed during the running motion
cycle. At foot strike an eccentric contraction of the quadriceps
is needed to dampen the impact on the knee and prevent the
slightly bent knee from going into more flexion. Eccentric
contractions are associated with higher forces than concentric
contractions. This creates high tensile forces in the quadriceps
and patellar tendons which can lead to injury. Failure or
injury of the tendons tends to occurs at the bony insertion site
or enthesis. The lesion that develops may fail to heal and can
lead to a chronic tendon pain. As classic signs of inflammation
are generally absent, this injury is generally not called tendi-
nitis anymore. Most authors favor the term tendinopathy or
tendinosis as the tendons more likely show signs of a failed
healing response without inflammatory features. Both the
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Injuries in Ultra-endurance Sports
patellar and quadriceps tendon can develop these lesions and
consequently called patellar and quadriceps tendinopathy.
They tend to occur preferentially at the patellar insertion sites.
The athlete will have localized pain with high impact exercise
and localized tenderness at those sites as the main findings.
MRI can visualize these lesions but may not be needed as
clinical examination can generally yield the diagnosis. Initial
treatment is generally conservatively with relatively rest,
physical therapy concentrating on eccentric strengthening,
nonsteroidal anti-inflammatory medications (NSAID) and
lately platelet-rich plasma injection (PRP). However, it should
be recognized that the exact efficacy of some of these treat-
ment modalities has not been fully determined in controlled
studies. Corticosteroid injections in and around the tendons
are not recommend because of the potential for tendon rup-
ture. In chronic cases, surgical treatment with debridement of
the tendon lesion and possibly drilling of curetting the bony
insertion site has been advocated.16
The running motion and contraction of the quadriceps
also creates high compressive forces on the patellofemoral
chondral surfaces. Whether this can actually lead to chon-
dral damage is unclear. However, it is common to find
chondral damage in human knees either from a preexisting
condition or possibly as part of the aging process. The
repetitive compressive forces of the running motion can
create pain in knees with compromised chondral surfaces.
This can be complicated by preexisting malalignment of the
patellofemoral joint. Lateral tracking or even lateral sub-
luxation is not uncommon in human knees, especially in
women. This will tend to concentrate the compressive forces
on the lateral patellar facet and lateral trochlea resulting in
pain and possible accelerated wear and tear. It is not always
clear where the pain exactly originates in this condition.
There are high performance athletes with patellofemoral
chondral damage that seem to have little or no pain from
this condition (Fig. 2). The chondral surface itself has no
known sensory nerve ending and by itself does not seem to
be a cause of pain. It seems likely that the subchondral bone
can cause pain. This may be particularly the cause of pain in
patients who have developed bone edema on their MRI in
the area of their chondral loss. The surrounding synovium
FIGURE 2. MRI image of knee in an athlete competing in Iron-
man Triathlon World championships with advanced chondral loss
on both the lateral patellar facet as well as lateral trochlea.
www.sportsmedarthro.com | 27
Almekinders and Engle Sports Med Arthrosc Rev  Volume 27, Number 1, March 2019

and infrapatellar fat pad can seemingly react to the chondral
damage as well and has been implicated as a source of pain.
Most patients complain of a diffuse anterior knee pain.
Other than possibly an effusion, physical examination is
generally unremarkable. Signs of malalignment may be
important to note such as a high Q-angle or J-sign. Treat-
ment is invariably conservative at the onset.17 Relative rest
with avoidance of hill running, physical therapy, and pos-
sibly NSAIDs are frequently used. In resistant cases, injec-
tion can be considered. Corticosteroid injections may give
some relief of the pain from the reactive synovitis in the
surrounding synovium and fat pad. However, frequent
repeated injections are generally not recommended. Hyaluronic
acid injections may have a place in this condition as the chondral
loss could be considered a localized form of osteoarthritis.
However, the efficacy of this approach is controversial. Surgical
treatment of this condition is challenging.18 Isolated arthroscopic
chondroplasty tends to yield unpredictable outcomes. More
formal grafting procedures for full thickness cartilage lesion such
as osteochondral grafts or cell-based techniques like chondrocyte
implantation can be considered. However, this requires a pro-
longed recovery and rehab while the return-to-sports rates to
high intensity sports such as long distance running are unknown.
Isolated lateral releases seem only indicated in rare cases where
there is a tight lateral retinaculum both no gross malalignment.
Malalignment with marked lateral tracking or even lateral sub-
luxation may require a more formal realignment procedure.
Again, this requires a prolonged recovery and rehab while the
return-to-sports rates are largely unknown.
Finally, the incidence of lateral knee pain has been
reported as high as 15% in in ultra-endurance athletes.2 The
condition frequently is diagnosed as iliotibial band syn-
drome (ITBS) or iliotibial band friction syndrome. Rela-
tively little is known about the exact cause of the pain in this
condition, and the role of friction of the IT band over the
lateral femoral epicondyle has been questioned.19 Treatment
initially is through activity modification, IT band stretching
and hip abductor strengthening. Resistant cases can require
corticosteroid injection or even surgical release.
(CE) has seen and experienced that the tightness of the
material at the distal aspect of the sleeve can potentially create
excessive pressure and friction problems as well. Excessive foot
pronation, hard surface, overstriding, and the trauma from
repetitive eccentric load in these tendons may also play a role
in the etiology. This ankle problem frequently has been
reported during competition. It is not uncommon for it to lead
to a “DNF” (Did Not Finish) as there is no simple immediate
treatment known to resolve this. Relative rest, icing, cross
training, oral nonsteroidal anti-inflammatory medication
generally lead to complete resolution of the problem. How-
ever, it can be several weeks before unlimited, pain free
running can be resumed.
Similarly, on the posterior aspect of the ankle Achilles
tendon injuries can create painful problems for ultra-endurance
athletes. Achilles tendon problems can manifest themselves in
different ways. There seem to be 3 distinct forms of overuse
injuries in and around the Achilles tendon. The problem can
occur in the sheath or peritendinous tissues, in the midsubstance
of the tendon or at the insertion or enthesis. Peritendinous
Achilles pain and swelling is somewhat similar to the anterior
tendon problem, as it presents itself with diffuse pain and
swelling sometimes caused by friction of the shoe. During the
more acute phase swelling and crepitation can be noted as the
fibrnous exudate fills the tendon sheath. The midsubstance
problem tends to occur about once inch about the calcaneal
insertion and typically create a local pain and thickening of the
tendon (Fig. 3). This condition is often characterized by some
degenerative tissue in the tendon, and therefore often termed
tendinosis or tendinopathy. The examination reveal swelling
without crepitation and the tendinopathic tissue can only be
visualized by MRI or ultrasound imaging. Insertional tendon
problems at the calcaneus often are associated with bony reac-
tion created a hard, enlarged, and tendon bump on the posterior
calcaneus. When recognized, all forms of Achilles tendinopathy
are initially treated conservatively with relatively rest and

LOWER LEG, FOOT, AND ANKLE INJURIES

Following the knee, the foot, and ankle are the com-
mon source of injuries in ultra-endurance athletes. As dis-
cussed previously, a significant number of these will fall
under the stress fracture category. This section will focus on
soft tissue injuries. An ankle soft tissue injury that seems to
be relatively unique to the ultra marathoner is a tendon
injury to the foot and toe dorsiflexors at the level of the
anterior ankle, sometimes termed the “ultramarathoner’s
ankle.”20 It manifests itself by pain and possibly swelling
most commonly at the inferior extent of the extensor reti-
naculum of the ankle. Runners tend to adapt with a shorter
stride that is more of a shuffling gait in an attempt to
minimize the stress and motion in the affected tendons. The
injury is seemingly a peritendinitis likely associated with
repetitive friction as the dorsiflexors pass underneath the
anterior retinaculum. Tibialis anterior, extensor digitorum,
and hallucis longus tendons can be involved. It has been
postulated that excessive pressure from tightly laced running
shoes exacerbated by diffuse foot swelling that can occur in
ultra-endurance events are causative factors.14 Lately, it has
become common for ultra-endurance runners to wear com-
pressive calf sleeves as they are thought to promote circulation FIGURE 3. Swollen Achilles tendon proximal to the calcaneus
and enhance performance. Anecdotally, one of the authors because of midsubstance tendinopathy.

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Sports Med Arthrosc Rev  Volume 27, Number 1, March 2019
FIGURE 4. Compartment pressure testing of the anterior com-
partment of the lower leg.
activity modifications. It is unclear how effective NSAIDs are
with regards to the final outcome but simply may provide some
analgesia in the painful stages of this condition.21 Physical
therapy is frequently used and should focus on tendon flexibility
and eccentric strengthening. Many of these conditions resolve
with conservative treatment but it should be recognized that this
can take months in some athletes. Persistent cases can be
treatment with surgery but, again, it should be recognized that
postoperative recovery and rehabilitation generally takes many
months even in successful surgery. Many different surgical
approached have be proposed.22 For chronic and scarred peri-
tendinous problems, a release or excision of the affected sheath
can be sufficient although care should be taken not to damage
the anterior blood supply to the tendon. The midsubstance
tendinopathic tissue is generally treated with excision of the
lesion although simple longitudinal tenotomies have also been
described. Resistant insertional tendon problems often require
both the excision of diseased tendon tissue and impinging bone
or osteophytes. This may result in near-complete detachment
the tendon and necessitate a tendon transfer to reinforce the
affected area.
Lower leg pain is another relatively common complaint
in ultra-endurance athletes. There are several main causes that
will be briefly discussed here. Again, stress fractures especially
of the tibia should be included in the differential diagnosis of
this complaint, as discussed previously. Two other main causes
of lower leg pain are chronic exercise-induced compartment
syndrome (CECS) and medial tibial stress syndrome (MTSS).
CECS mostly commonly affects the anterior compart-
ment but can also occur in the lateral and deep posterior
compartments. It is still mostly considered to be a mismatch
of the volume that the compartment can accommodate and
the size of the muscle as they engorge and possibly swell
during exercise. This mismatch during exercise creates
increased tissue pressure that impedes muscle perfusion and
leads to pain. The condition is considered reversible as the
pressure subsides with rest. However is should be noted that
some athletes may be able to push themselves to into an
irreversible, acute stage as they are accustomed to a certain
level of pain especially during ultra-endurance competition
in remote areas under stressful conditions.23 Development
of acute, irreversible compartment syndrome without direct
muscle trauma is possible in this scenario and may also be
precipitated by rhabdomyolysis that can develop with pro-
longed intense exercise.24 Hallmarks of CECS are a feeling
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Injuries in Ultra-endurance Sports
of tightness and pain over the affected compartment that
starts relatively predictably at a certain amount of running
and subsides with rest. Other symptoms such as weakness
and numbness, tingling in the foot can occur as the con-
dition progresses. Physical examination at rest is generally
entirely normal. The gold standard for diagnosing CECS
remains invasive compartment pressure testing (Fig. 4).
Once diagnosed, surgical fasciotomy of the affected com-
partment is generally done in an attempt to alleviate
symptoms.25 It has been reported that running style mod-
ifications can alleviate symptoms in some runners.26
MTSS remains a poorly understood condition.27 It
manifests itself with chronic, slightly distal, posteromedial tibial
pain during and sometimes after running. Examination often
reveals a diffuse tenderness of the affected area of the poster-
omedial tibia. It is generally considered a diffuse bone reaction
possibly a local soft tissue problem as well. Advanced imaging
such as an MRI can distinguish it from a stress fracture which is
a more localized stress reaction. Treatment is conservative with
activity and shoe modifications, cross-training until the pain and
tenderness subside.
CONCLUSIONS
Ultra-endurance athletes can be affected by a wide
variety of injuries. Many injuries can be managed with rel-
atively simple, conservative means. However, careful
attention and a relatively high index of suspicion are needed
to recognize a few of the serious injuries that can have
dramatic consequences if left untreated.
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Sports Med Arthrosc Rev  Volume 27, Number 1, March 2019
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