Nate Koch, experienced physiotherapist, founder of Endurance Rehab, and author of the two chapters on injury prevention and recovery in the book Triathlon Science joins us to discuss injury prevention and recovery from injuries in triathlon. 

• The best injury prevention methods. 
• How to find the right practitioner for you if you do get injured. 
• Training through injury or complete rest? 
• Core training for injury prevention and triathlon performance. 
• Stretching, foam rolling, massage, acupuncture, taping, orthotics, and other tools in the injury prevention and recovery toolbox. 

00:45 - 

• Nate is an experienced physical therapist, and he knows triathlon and endurance sports particularly well.
• Nate wrote two chapters on injury prevention and recovery in the book 'Triathlon Science'.
• Nate founded Endurance Rehab in Arizona in 2003.
• The clinic have been nationally recognised for their work with every day recreational athletes, as well as professional cyclists, triathletes and others.
• Nate is a contributor to magazine such as Lava magazine and Triathlete magazine.
• He also works as a consultant for the Trek-Segafredo professional cycling team.

4:21 -

• We typically see a lot of knee pain which can be related to patellofemoral pain or a patellofemoral tracking issues.
• It can be pain around the knee cap, or more lateral pain around the knee.
• Lateral pain is typically seen in IT-band syndrome.
• Worst case scenario we see an overuse, or degenerative cartilage tear in the knee.
• This is less common and happens more in the 40+ age group.
• Plantar fasciitis, achilles tendinitis or tendinopathies are all common.
• We also see a lot of lower back pain, sciatica and hip impingement.
• I don't have the most recent epidemiological study, but around 20% of triathletes will get injured in one year.
• I would say most triathletes will be injured at some point during their career. It's pretty much guaranteed.
• The best tool for injury prevention is doing a yearly performance evaluation.
• This is like going to the dentist when you don't have anything wrong with your teeth, but you go for a checkup.
• It involves a full body assessment that goes through flexibility, mobility, strength and injury history.
• Find things that might become a problem as you increase training intensity and volume
• Following from this, you can address some of the issues that you find.
• E.g. lack of mobility or excessive mobility.
• It may be more related to weakness, or a specific posture.
• There are a number of factors that go into it and it can be quite different across individuals.
• If I had to be pinned down, I would say the most common problem is a multi-planar weakness.
• In swimming, cycling and running we tend to work in one plane of motion, called the sagittal plane of motion.
• We don't do anything lateral or rotational, and missing those movements means they're usually weak in triathletes.
• This can be improved using any movement that involves resistance when you're moving laterally or rotating.
• E.g. russian twist on a medicine ball, side steps, monster walks.
• Nordic or skate skiing are great ways to cross train to build different muscles.

9:47 - 

• The first thing we do is ensure our triathletes, runners and cyclists would be including proper warm up before training.
  • Include dynamic mobility exercises or 'movement prep'.
  • You need to stretch with movement - don't hold a stretch because you want to prepare your body for the workout.
  • E.g. Lay on your back with your leg crossed over and reach as high as you can, then go to the opposite site and repeat it back and forth.
    • You're not holding the stretch, you're constantly moving to release the lower back and hamstrings.
  • You could then move on to skipping, or high knees, or hip openers, or walking lunges etc.
    • These will prepare your legs, joints, muscles and tendons for movement,
  • This is critical before an intense workout such as a track workout.
• Just as critical is a cool down.
  • This involves static/passive stretches which you hold for longer to re-lengthen muscles.
  • This is very important after cycling when you've been in a flexed position for a long time.
    • Do opposite movements, e.g. opening up the hip and the spine.
• This is also important to follow if you sit in a chair all day at work and then attempt a workout.
  • You need to open yourself up before exercise as you sit in a contracted position.
• Rest is just as important, and so is sleep.
  • More studies are coming out and suggesting sleep may be the most important thing for recovery and injury prevention.

• There's frequent debate on massage versus compression boots/socks and ice baths.
  • The research is not consistent on any of these methods for recovery and injury prevention.
  • We coach our athletes to use what feels good and helps them to recover better.
  • Experiment a little and pay close attention to how your body feels.
• I'm a big believer in compression boots and socks for recovery, as well as massage.
• In our clinic we use Astym tools which is a method of breaking up adhesions that may eventually cause injury.

14:27 - 

• Don't wait too long to see someone!
  • A lot of athletes will try to work around it, or google their symptoms.
  • Waiting to be seen will just extend your time to recovery.
• It's important to see a physiotherapist or a physician who understands your sport and will listen to you and knows what your training is like.
• Get a proper assessment of what is happening.
  • Not only the injury and it's symptoms, but the cause of the injury.
  • There's a lot of different ways to treat the symptoms but understanding the cause is the most important for coming back to sport.
• The most important thing is seeing someone who has good experience in the sport.
  • Understanding the biomechanics of the movements is key.
  • This could be a physio, a chiropractor or an MD.
• Getting a proper diagnosis is important, both of what the injury is and the cause.
• The next phase in identifying the cause can be a biomechanical assessment, and taking a full history.
  • This requires experience of working with athletes.
• In our case, we use video and pressure analysis for running.
• We also use bike fits to assess what is happening on the bike.
• You need to target the cause of the pain. If you just treat symptoms you'll be back at the clinic in 3 months with the same injury.
• When you're looking for someone to see, ask around!
  • In most areas there's usually a go-to person who works with the triathlon club.
• Once you've found someone, go and check out the facility - does it look like somewhere that treats athletes?
• Once you've seen them for the first time, remember you're not fully committed if it doesn't feel right to you.
  • If you feel rushed or not listened to, try somewhere else.
• The title of the person is less relevant than them having experience of working with athletes, and you having the confidence that they can treat you.

19:47 - 

• Some things will obviously depend on your injury, and on the individual.
• There is a process of healing, so listening to your clinician is very important.
• This process changes based on which tissue is injured (tendon, joint, muscle).
• You need to respect the healing process.
• Take note of how much time you need to take off, and whether or not you can continue light training.
• The good thing about triathlon is you can usually focus on one of the other disciplines while you are recovering.
• Your clinician should slowly get you back into your training plan.
• If you have a coach, it's important that they work with your clinician to develop a return to sport plan.
• If you don't have a coach, it's the clinicians job to communicate to you a gradual plan to return to sport with the injury in mind.
• The load on the injury should be gradually and slowly increased with time.
• It should also mimic the demands of the sport.
• E.g. if you're running, and you have a patella tendon injury, you need to get the tendon to load again properly under high force.
• At some stage in your programme, you'll be doing plyometric training to get it ready and strong for your running.
• One example of an injury you can train through is plantar fasciitis.
• While it may not heal as fast, you can't do a lot more damage by training.
• One example of an injury you can't train through would be a stress fracture from running.
• You could continue to bike and swim, but you can't run with a stress fracture.
• I know some athletes who have a hip impingement, and when it's acute and painful you can't run or ride a bike until it improves.
• It's important to listen to your body and not experience pain.
• As you progress through your rehab programme, if you have pain you're not ready to return to sport.
• Particularly pain with loading or with activity that mimics your sport.
• When you find limitations, particularly on one side of the body only, you may need to hold back until you're back in sync.
• E.g. Hip impingement restricting the right hip by 20 degrees or hip flexion or internal rotation.

25:10 - 

• One aspect of core training is for injury prevention, and this is multi-planar.
  • This involves doing core strengthening exercises that require you to rotate or move laterally.
  • E.g. Russian twists on the ball - shoulders on a ball and feet on the ground, then twist your upper body.
  • E.g. Lateral exercises could be side step monster walking with a band around your ankles. This would engage your gluteus medius and hip muscles.
• A second aspect of core training is for the specific demands of the prime movers in your sport.
  • E.g. Your calf and your gastrocsoleus need to be worked eccentrically as that's how they work when you're running to provide injury prevention and improve performance.
    • This can be done while engaging your core at the same time.
  • Core doesn't just mean abdominals, it includes your back and scapula muscles, your hips, and your glutes.
• Your core has to be strong to stabilise your extremities in running.
• I'm a big fan of Joe Friel and his 'Triathlete Training Bible' and there are good basic ideas of strengthening for the sport in there. 

28:29 - 

• What are your thoughts on stretching, including static and dynamic stretching?
• There's a place for both: dynamic before activity, static after activity.
• As we get older we all need a lot more of both!
• What are your thoughts on foam rolling?
• It is important for recovery. Done correctly it can help prevent injury and help you get the most out of your workout.
• What are your thoughts on massages?
• It's the same as foam rolling but it's more expensive and requires an appointment, so foam rolling is a bit easier!
• What are your thoughts on acupuncture?
• I'm not an expert on acupuncture at all but we do dry needling in our clinics and I'm a huge proponent for that. It can help recovery and go a little deeper than massage and foam rolling.
• What are your thoughts on Astym and Graston devices?
• They're similar, but there's more research around Astym tools. It's a similar principle of increasing blood flow and the body's natural healing response.
• We use Astym in a prevention way to look for potential injuries that could come up, much like you would use a massage.
• What are your thoughts on taping?
• We use kinesio taping. There are some blood flow changes but we don't know how much really.
• We generally only use it for injuries to help the muscles to fire better and take some pressure off joints.
• What are your thoughts on orthotics?
• It depends. In cycling, there's probably a 99% success rate of people feeling an improvement because cycling shoes generally don't offer much support.
• In running it's very dependent. We're very cautious in using them.
• We probably only use them 25-33% of the time.
• We're trying to get them strong first. It we can't get them strong enough and they have foot and ankle faults, we might use them.

31:45 - 

• What is your favourite book, blog or resource related to triathlon or your field of expertise?
• I have a few guys I rely on: Joe Friel, Jonathan Hall, Bobby McGee. They're experienced coaches who have taught me a lot about triathlon and sport.
• What is your favourite piece of gear or equipment?
• My Trek Top Fuel mountain bike, then my Normatec recovery boots.
• What's a personal habit that has helped you achieve success?
• Listening and learning. Really listening to people, athletes. Recognising there are people smarter than me and listening to them. Also paying attention to the research.

Links and resources mentioned

• Dysfunctional movement patterns, injuries and reduced performance with James Dunne | EP#45
• Sleep, recovery, and performance with Shona Halson | EP#52
• Individual coaching by Mikael - how it works
• "Should your hydration strategy change as you get older?" - Article by Andy on Precision Hydration

Connect with Nate Koch

• On the Endurance Rehab website
• On Twitter: @endurancerehab
• By email: nate(at)endurancerehab.com
• On Facebook: Endurance Rehab

Connect with host Mikael Eriksson

Hi! I'm your host Mikael,

I am a full-time triathlon coach and an ambitious age-group triathlete. My goal is podium at the Finnish national championships within the next few years.

I first started the website Scientific Triathlon in autumn 2015 as a passion project to share my learnings with a larger triathlon audience. Later on, in early 2017 I started the podcast That Triathlon Show. 

I sincerely want you to contact me to

• Send me feedback
• Give constructive critic​ism 
• Request topics and guests for the podcast
• Send me your triathlon-related questions 
• Tell me that you've rated and reviewed That Triathlon Show so I can give you a shout-out on the show and tell you how much it means to me!