Caring for and Counseling the Ultramarathoner


Ultramarathon races represent any foot race longer than 42 km and can occur over single or multiple days. As the popularity of ultramarathon racing continues to grow throughout the world, there are an increasing number of races and participants, with estimates of 70,000 runners participating annually. Most races are continuous single-stage, point-to-point races that occur over a specific time period (i.e., 24–48 hours). Multistage races are less common and are point-to-point races that occur over 3–7 days. These regularly occur in extreme environments with variations in terrain (snow, mountains, sand dunes, river crossings, etc.). Ultramarathoners routinely require different equipment than marathon runners and multiday racers frequently carry all of their gear (food, water, protective clothing, etc.) throughout the course of the race.

The unique aspects of variable distance, duration, terrain, and environmental factors of ultramarathon racing require advanced training, preparation, and equipment. Ill-prepared athletes and care providers place the athlete at risk for injury, illness, and decreased performance. The goal of this chapter is to provide education and care guidance on musculoskeletal, integumentary, medical, and environmental illnesses to enhance safe and successful completion with ultramarathon participation.

Musculoskeletal Injury

Musculoskeletal injuries are common in running sports. As research has expanded, we have seen variable injury patterns among different running distances. Musculoskeletal injury rates have been reported from 19% to 75% in marathons, 2%–32.8% in continuous ultramarathons, and 19%–22% in staged multiday ultramarathons. A prospective study demonstrated that within a staged multiday ultramarathon event, 95% of injuries were minor and 18.2% were musculoskeletal in etiology that were more likely to occur on days 3 and 4 of the multiday event (see Table 23.1 ).

Table 23.1
Injury Illness Rates Among Ultramarathon Runners (2005–06).
Data from: Krabak B, Waite B, Schiff M, Study of injury and illness rates in multiday ultramarathon runners. Med & Sci Sports & Exerc. 2011; 43(12):2314–2320.
Type of Illness or Injury n Rate per 1000 Runners (95% CI) Rate per 1000 h (95% CI)
All 1173 3871.3 (3652.9–4049.3) 65.0 (61.4–68.7)
Medical (major) 36 118.8 (83.2–164.4) 2.0 (1.4–2.8)
Medical (minor) 82 270.6 (251.2–355.9) 4.5 (3.6–5.6)
MSK (major) 14 46.2 (25.2–77.5) 0.8 (0.4–1.3)
MSK (minor) 203 670.0 (581.0–768.7) 11.2 (9.8–12.9)
Skin (major) 12 39.6 (20.4–69.2) 0.7 (0.3–1.1)
Skin (minor) 826 2726.1 (2543.3–2918.5) 45.8 (42.8–48.9)

Musculoskeletal injuries in runners predominantly involve the lower limb with incidences ranging from 19.4% to 79.3%. A review of incidence and prevalence of running-related musculoskeletal injuries found the most common to be medial tibial stress syndrome (incidence 13.6%–20%, prevalence 9.5%), Achilles tendinopathy (incidence 9.1%–10.9%, prevalence 6.2%–9.5%), and plantar fasciitis (incidence 4.5%–10%, prevalence 5.2%–17.5%). Ultramarathon musculoskeletal injuries were greatest for Achilles tendinopathy (prevalence 2.0%–18.5%) and patellofemoral syndrome (prevalence 7.4%–15.6%). Given the prevalence and performance impact of musculoskeletal injury on ultramarathon athletes, this section will highlight the unique and common musculoskeletal injuries for ultramarathon runners.

Table 23.2 describes common ultramarathon nontraumatic soft tissue overuse injuries that will not be reviewed in the following text due to space limitations. Treatment for these entities in the acute race setting includes icing and/or cold compress for 15–20 minutes (repeated several times when not running) and stretching of the involved site. Topical antiinflammatory creams can be used anytime if the overlying skin is intact(see below for nonsteroidal antiinflammatory drug (NSAID) guidelines). Anecdotal cases of using an abundance of topical cream at the injury site with an occlusive dressing overnight have worked well in multistage races but should be used with care and attention to possible skin reaction or allergy. Oral analgesics such as acetaminophen can be used to help decrease pain. Current guidelines recommend that oral NSAIDs be used only at the end of the day/race session after ensuring that the runner is adequately hydrated to prevent acute kidney injury associated with NSAID use.

Table 23.2
Common Ultramarathon Soft Tissue Overuse Injuries.
Injury Entity Incidence Symptoms Physical Exam Findings
Anterior tibialis tendinopathy
“Ultramarathoner's ankle”
19% Anterior ankle pain Swelling or fullness at the tendon, pain during palpation, resisted ankle dorsiflexion, and passive manual stretch of tendon
Plantar fasciopathy 10% Pain on the plantar foot Tenderness to palpation along the plantar fascia, pain with manual passive dorsiflexion, resisted toe flexion, and/or ankle plantar flexion
Achilles tendinopathy 10% Posterior heel or ankle pain Pain on palpation of the tendon, pain with passive stretch and/or with repeated single-leg toe raises
Distal iliotibial band 15.8% Lateral knee pain Pain with noble compression testing (palpation of the ITB over the lateral femoral condyle) in addition to Ober testing (stretch of the ITB)

For a comprehensive review of musculoskeletal running-related injuries, including in the non-race setting, please refer to Chapters 17 (“Hip, Pelvis and Thigh Injuries in the Runner”), 18 (“Knee Injuries in the Runner”), 19 (“Exertional Leg Pain in Runners”), and 20 (“Ankle and Foot Injuries in Runners”) in Clinical Care of the Runner .

Patellofemoral pain

Reported incidences have varied from 7.2% to 24.3% for patellofemoral pain (PFP) in runners and 24% for general knee issues in ultramarathoners. Studies have shown a prevalence of 7.4%–15.6% in ultramarathoners. PFP generally is chronic but may present acutely with ultramarathon racing. Runners endorse anterior knee pain. Physical exam demonstrates pain with palpation of the patellar facets, pain with single-leg or double-leg squatting as well as with resisted knee extension. Acute treatment includes the previously discussed regimens of icing and medications. A patellar tracking knee brace, patellar taping, or band strap may help decrease pain with running.

Ankle Sprain

Ankle sprain incidence in ultramarathons has been found at 10.8%. Most commonly, the mechanism of injury is an inversion moment to the ankle on uneven terrain causing stress to the anterolateral ankle ligaments. Runners present with anterior or lateral ankle pain and may have swelling and/or ecchymosis. Some athletes may be unable to fully bear weight. Physical exam will reveal tenderness over the anterolateral ankle ligaments. If tenderness is noted over bony landmarks, this may indicate fracture. An anterior drawer (anterior stress to ankle) or inversion stress test (inversion stress to ankle) may show laxity and pain. Runners with frank instability, ecchymosis, and/or high suspicion of fracture should be removed from competition. Treatments of icing and oral medications coincide with the previous recommendations in combination with compression and elevation when resting. Those with suspected fractures should be non-weight-bearing until radiographic evaluation is completed. Medial-lateral stability ankle braces or athletic taping should be used for injuries with instability and ability to bear weight. Runners who can walk without a limp and do not have instability can use the aforementioned bracing or taping with continued competition.

Muscle Strains

The most common muscle strains involve the calf (incidence 13.1%) and hamstring (incidence 11.8%). The mechanism of injury frequently is an eccentric contraction or quick burst movement that injures muscle fibers. Examination shows pain with palpation of the injured muscle and pain with passive stretch or active contraction of the muscle. Initial treatment consists of rest, ice, compression, and elevation after the day's competition is finished. Oral medications coincide with recommendations as discussed in previous sections. Inability to walk or run without a limp or altered gait should be cause to remove an athlete from competition for risk of further injury. If a complete muscle tear is suspected, the runner should be removed from the race and sent immediately for further medical evaluation.

Lumbar Injuries

This incidence has been reported at 12.4%. Mechanism of injury is variable from acute muscle strain or discogenic injury to degenerative changes within the lumbar spine. Runners present with axial low back pain. Those without trauma may be treated per routine strain recommendations with the previously reviewed ice, medication, and rest recommendations. If presentation involves radiating pain into the lower limb or neuropathic symptoms such as numbness or tingling, the athlete should be removed from competition and may be treated with NSAIDs, per prior discussion, and referred for further nonemergent medical evaluation. Any presentation with notable weakness, numbness, or tingling in the groin/genital/rectal area or loss of bowel or bladder control should be treated as a spinal emergency with transportation of the athlete to a hospital for immediate evaluation and treatment.

Bone Stress Injuries

Ultramarathon stress fractures have been reported at 0.5% for hip/femur, 1.9% for tibia/fibula, and 3.4% for the foot. Foot stress fractures were at a higher proportion in ultramarathoners than shorter distance runners. Bone stress injury (BSI) represents the inability of bone to withstand repetitive loading, which results in structural fatigue and localized bone pain and tenderness. A BSI occurs along a pathology continuum that begins with a stress reaction, which can progress to a stress fracture and then a complete bone fracture. A BSI is thought to result from disruption of the homeostasis between microdamage formation and its removal. Runners present with localized pain to the affected area and may have acute or chronic symptoms. Physical exam reveals bony tenderness in superficial structures (tibia). Pain may be elicited in deeper structures with bone loading tests such as fulcrum testing (torque applied to femur) to induce groin/thigh pain for femur injuries or one-legged extension loading (lumbar spine extended) to induce low back pain for pars interarticularis injuries. BSIs are cause for discontinuation of running until further medical evaluation completed. The treatment of BSI varies per low-risk (posteromedial tibia) or high-risk (femoral neck) anatomical site regarding weight-bearing modifications or surgical treatments. Athletes may be treated with ice, modified to non-weight-bearing (per anatomical site) and acetaminophen for pain until further medical evaluation. The unique physical challenges required for successful participation in the sport of ultramarathon provide a variety of opportunities to cause a disruption in the homeostasis of injury (high mileage, variable terrain) and repair (increased nutritional needs).

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