Triathlon injuries can be hard to fathom. We all have the odd twinge, but how do we know if it’s something or nothing?

Runners Knee

Illustration: Peter Greenwood

Anyone who has ever squirmed into a wetsuit, sat on a bike or pulled on a pair of trainers is likely to have had the odd injury or illness. But if you put the three together, the chances of a healthy year seem non-existent. So we put up with an assortment of generically described niggles, from a sniffle to the vague, runner’s knee, and get on with training and competing.

There is a chance, though, that your sore knee is not what it first seems and you could have picked up a condition that is more unusual than your hard-pushed GP had a chance to diagnose at first examination.

“Many of the problems athletes turn up with are outside what most GPs usually come across,” says Professor Greg Whyte, Head of Sports and Exercise Medicine and Performance at 76 Harley Street and a former physiologist to the UK triathlon squad. “And they are less serious than some of the other problems people come in with.”

Dr Courtney Kipps, Medical Director of the London Triathlon and Consultant in Sports Medicine at the Institute of Sport, Exercise and Health at UCL and ProActive Sports Medicine, London, agrees: “GPs see a lot of musculoskeletal injuries but they only have a few minutes to look at them, and they know most injuries get better.”

But sometimes the condition will not get better by itself, and can seriously limit your ability to participate. Here are four often hidden conditions triathletes can suffer from and would be well advised to get sorted out.

1. Runner’s Knee or Bipartite Patella

If you go to your GP and say your knee hurts and that you like running, the chances are he’ll send you away with a diagnosis of runner’s knee and a prescription of RICE (Rest, Ice, Compression and Elevation). But what if this makes no difference?

Experts estimate that one in 100 people have a bipartite patellar, where the kneecap is formed of two separate bones, fused together by a cartilage-type tissue. Most people never feel any symptoms but if you experience trauma – like a crash – the two pieces of bone can be shaken apart. Micro-trauma can also cause this and years of pounding the streets can weaken the join, and the rest of the knee structure can be pulled out of place as a result.

Because it usually leads to no symptoms, it’s rarely seen by GPs and is easily missed. “A patient of mine had a bipartite patella and ended up having surgery on it,” says Rachel Saligari, a Chartered Musculoskeletal Physiotherapist at Active Health Solutions in Holywood, Northern Ireland. “He’d had a load of treatment before having any X-rays or scans. Even then it can be missed or doctors think it’s a fracture rather than the way the patient was born.”

But finding out you have a bipartite patella may not help you find any answers. “Bipartite patellas frequently cause patella tendonopathy but all too frequently we pick it up on X-ray and it’s not related to the knee pain at all because it all depends how strong the fibrous tissues between the bits of bone are,” says Dr Kipps. It is only when the fibrous tissue becomes inflamed that in itself causes pain.

“There are other factors such as the pull of the muscles around the knee. So, rather than fixing the bipartite patella it requires rehab of the muscles so the pull is in a biomechanically normal direction rather than pulling it apart.” So a course of physio, rather than a surgical intervention, may be the best bet, but the right diagnosis is an essential start.

2. Muscle Strain or Cardiac Disease

Most twinges in the left arm are nothing more than just that. But just because you are fit, your ticker is not necessarily in good shape – there is even a chance that some long-term endurance athletes are at a slightly increased risk of heart problems. For the majority of people, the benefits of regular exercise outweigh any danger. However, a study in the British Journal of Sports Medicine published in 2012 suggested “lifelong” participation in endurance sport can cause the heart muscle to thicken, increasing the chance of a malfunction.

A study in The Journal of American Medical Association in 2010 counted 14 deaths in triathlons in the US from 2006-08, which equated to a reassuringly low 1.5 in 100,000. Of those, 13 were in the swim leg; probably because a heart attack victim in the water is much less likely to be reached in time than one on dry land.

The rarity of heart problems and the apparent fitness of most triathletes can be misleading at first when you go to the doctor complaining of pain in the neck, chest, back or left arm. Cardiac disease is “not common and at first glance it’s much more likely to be diagnosed as something musculoskeletal,” says Whyte. “Treatment would be removal of exercise, non-steroidal anti-inflammatories and painkillers to try to deal with something that actually could be masking a potentially fatal underlying cardiovascular condition.”

Kipps urges caution, particularly where the symptoms go beyond anything that could be mistaken for muscular pain. “In apparently healthy athletes, if the symptoms of cardiac disease are mild or unusual they can be missed. Chest pains, breathlessness, or collapse during exercise should be checked out with your doctor anyway.” Again, it is unlikely, but if those pains in the chest, neck, back or left arm persist, do not think it couldn’t happen to you.

3. Frequent Minor Infections or Unexplained Under Performance Syndrome

I see many athletes with a generalised increase in upper-respiratory tract infections – repetitive illness, a reduction in performance, poor sleep quality, possibly weight loss,” says Whyte. Unexplained underperformance syndrome is – like chronic fatigue syndrome – hard to pin down but experts agree it is an objectively measurable loss of performance without a medical cause, despite two weeks’ rest. Up to 20% of endurance athletes will have it.

“Part of the problem is that triathletes expect to feel tired after a period of hard training,” says Kipps. “But when their performance starts tailing off, that may be a sign that they are overtraining. It is important for the athlete to understand the cause and effect.” Those sniffles your GP thinks are the reason for your fatigue, stiff muscles and difficulty sleeping may be a symptom of a more general condition. “The critical first step is to exclude a disease that is causing the problem. When you get to the point where there are no obvious known diseases the question is ‘how do we treat it’ and it’s really only specialist centres that have the necessary expertise, experience and background in dealing with those areas.”

Treatment would involve a multidisciplinary approach of psychologist, nutritionist, physiologist and physician guiding a patient’s rest and recovery, and rebuilding their training to competition levels without causing a relapse, often using careful observation of heart-rate data.