Medical considerations in triathlon competition: recommendations for triathlon organisers, competitors and coaches

Competitors in triathlons experience a range of environmental conditions and physiological demands in excess of that found in individual sport events of comparable duration. Consequently, there is a broad range of possible medical problems and complications that must be taken into account when preparing for such races. For most competitors, an Olympic-distance triathlon typically takes between 2-4 hours to complete. This race begins with a swimming segment of 1500 m. Given the wide variety of race venues found around the world, these swims occur in an assortment of water temperatures (from warm to cold) and conditions (from ocean surf to lake calm). Swimmers often exit the water in a state of moderate dehydration and hypothermia and then immediately start the 40 km cycling leg. Many do so in their swimming attire. A wide variety of road surfaces, technically challenging topography, variable environmental conditions and dramatically changing velocities can be encountered on the cycle course. The race concludes with a 10 km running leg. Since it is the final leg, it is often completed in higher ambient temperatures than those encountered at the start, with the athlete possibly running in a significant state of dehydration and fatigue. Other medical problems commonly encountered in triathlon include: muscle cramping, heat illness, postural hypotension, excessive exposure to ultraviolet radiation, musculoskeletal injuries and trauma, gastrointestinal problems as well as post-race bacterial infection, immunosuppression, sympathetic nervous system and psychological exhaustion, and haemolysis. The rate of occurrence of such events and the severity of their potentially negative outcomes is a function of the methods used by both the race organisers and the competitors to prevent or respond to the conditions imposed by the race. Triathletes also commonly compete in both shorter 'sprint distance' events (in the range of a 0.75 km swim, 20 km cycle and 5 km run) and longer events including both one-half and full Ironman distances (2.5 and 3.8 km swim, 80 and 180 km cycle, 20 and 42 km run, respectively), as well as ultra-distance events that exceed the Ironman distance. In the longer events, the previously mentioned medical considerations are further magnified and additional considerations such as hyponatraemia can also occur. Reducing risk associated with these concerns is accomplished by: taking into account weather and water temperature/conditions data prior to event scheduling; effective swim, cycle and run course organisation and management; environmental monitoring prior to and during the event; the implementation of a water safety plan; provision of appropriate fluid replacement throughout the course; implementation of helmet use and non-drafting regulations in the cycling leg; and competitor knowledge regarding fluid replacement, biomechanical technique, physical preparation, safe equipment and course familiarity. Despite these concerns, triathlon participation appears to relatively safe for persons of all ages, assuming that high-risk adults undertake health screening.