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Care of the multisport athlete: lessons from Goldilocks
  1. David Scott Marr
  1. Correspondence to Dr D Scott Marr, Department of Sports Medicine, OA Centers for Orthopaedics, Portland, ME 04102, USA; smarr{at}

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Once upon a time, a young triathlete named Goldilocks visited three sports medicine doctors. She was experiencing Achilles tendon pain and was concerned about her ability to train and compete. The first doctor told her she was training too much and simply needed complete rest; the second doctor told her she could bike and swim but could not run; the third doctor told her she could continue to train but prescribed a course of physical therapy. Goldilocks was confused and did not know what treatment was just right.

The Goldilocks Principle states that something must fall within certain margins, as opposed to reaching extremes. In the care of multisport athletes, we often apply this principle to define the appropriate balance of training volume, intensity and recovery to avoid and treat injury. This principle may work for a girl in the forest looking for a warm meal and a proper sized bed to sleep in, but anyone who has ever watched the video footage of triathlete Julie Moss stumbling, staggering and eventually crawling across the finish line in Kona at the 1982 World Championship understands that ‘extreme’ is what many multisport endurance triathletes do. The remarkable force of mental and physical will that defines many of these athletes is also the Achilles heel that exposes them to injury. Overuse injury risk has been reported to be higher during the competitive race season as opposed to preseason training,1 likely because of the strong competitive drive of these athletes. After hours and hours of training, these athletes are focused on accomplishing their competitive goals first and dealing with injury later.

It is not always the competition, however, that forces an athlete to the sideline, but sometimes their preparation. Several studies have demonstrated the correlation among overuse injury and training time and frequency of training sessions.2 3 Experienced endurance multisport athletes are a group that is often walking a fine line between performance and overtraining. More (training) is better and less (rest) means failure. But do all multisport athletes suffer from, what I call, obsessive compulsive training disorder? There is an interesting U-shaped association pattern among triathlete injuries and training volume.4 Although athletes who train at high volumes tend to have higher injury risk, those who train at low levels also seem to have a higher injury risk. There clearly seems to be two ends of the athlete spectrum that are at risk for injury – the overtrained and the undertrained.

The many faces of Goldilocks

Clearly, not all multisport athletes are like Julie Moss. Many multisport athletes are new to the sport, simply enjoy the social connections or look at the sport as a way to maintain fitness. The remarkable growth of triathlon among all ages and varying levels of fitness has presented unique challenges to sports medicine professionals. At the end of 1999, USA Triathlon annual membership stood at 19 060. As of June 2010, membership totals reached 134 942.5 The greatest growth has occurred in the 35–39 and 40–44 age groups – individuals who are at particular risk for overuse injuries.3

This surge in popularity has put the sports medicine community on a fast learning curve as it tries to address the injury problem. Overuse injuries such as stress fractures, ligament/joint capsule injuries and muscle/tendon injuries predominate, but fatigue, psychological disorders and nutritional imbalances are also common. New multisport athletes are particularly injury prone. The high demands of training, cumulative effects of cross-training and varying levels of fitness create an environment ripe for musculoskeletal injury. Paradoxically, many athletes who have been former single-sport athletes, such as runners or swimmers, choose triathlon for the perceived benefit of cross-training with swimming, biking and running to reduce overuse injuries. Unfortunately, most of these athletes simply add volume and intensity to their training regimen through additional disciplines without subtracting any workouts. This is often a recipe for injury.

The care challenge in treating Goldilocks

Once an athlete is injured, applying the Goldilocks Principle to define a modified training schedule as part of the treatment plan becomes difficult. Pre-existing characteristics such as fitness level, experience, mechanical efficiency, strength, flexibility and nutritional health that will define their tolerable, injury-free training volume and intensity is highly individualised. An athlete's psychological state of mind will affect his or her adherence to a treatment plan. Thus, it is imperative to identify the type of athlete you are treating and negotiate a treatment plan that (1) the athlete will adhere to and (2) identifies and rectifies the factors that contributed to the athlete's injury. With this in mind, optimal multisport athlete care would clearly include a multidisciplinary approach with the physician, physical therapist, nutritionist, biomechanist, coach and physiologist all working together to provide a structured framework for the athlete's recovery from injury. Unfortunately, this level of resources is not available to most injured multisport athletes.

Sports medicine professionals are often faced with the challenge of providing complicated athlete care with limited time and resources. The accomplished, experienced multisport athlete who may walk a fine line between obsession and dedication may demand a different level of care than a beginner multisport athlete with little grasp of the concept of graduated training volume and even less grasp of his or her current fitness. In either case, there are remarkable demands placed on healthcare providers to find a ‘quick cure’. One can fall into the trap of feeding unrealistic treatment and recovery expectations given the overwhelming pressure from the athlete to continue training and not stray from their season's race goals. The challenge is getting an athlete to ‘be sold’ on the treatment plan. Unfortunately, we often have little evidence that our recommended care is (1) necessary to resolve the injury or (2) known to prevent future injury.

The future for Goldilocks

It would seem that to provide optimal care for multisport athletes, we need to have a better understanding on how individual athlete characteristics affect their risk for injury. Let us say that the injured Goldilocks decided to visit a fourth doctor and he reviewed her entire training diary, did a thorough physical examination, assessed strength and flexibility, performed a gait assessment, reviewed her bike fit and took a nutritional history. He set a treatment plan in place that included a focused physical therapy regimen to address biomechanical issues, detailed a modified training load, prescribed orthotics and scheduled her for gait retraining. Will this get Goldilocks back to racing more quickly than the recommendations of the first three doctors?

In the journal Nature in 2004, Harvard anthropologist Daniel Lieberman put forth the hypothesis that humans gained their dominance from an ability to run.6 The ability to run well and remain injury free depends on the stable spring-like arch in our foot, the tendons in our legs that act like springs, and a strong gluteus maximus to help stabilise the trunk on the pelvis and allow for proper foot strike. Any break in this remarkable kinetic chain, such as gluteal weakness, may lead to lower extremity overuse injuries. But do we know that getting a triathlete to do strength training will lower injury risk or allow him or her to train injury free at a greater load or intensity?

Sports medicine providers usually do not see a multisport athlete until after they have been injured and rarely have a chance to evaluate an athlete for injury prevention. I believe that this is where using the Goldilocks Principle to define an individualised training load falls short. Although helpful in treatment, the injured athlete has already chosen the wrong ‘fit’ for his or her training. Why was this the wrong ‘fit’ and could anything have been done differently to prevent injury? Unfortunately, our knowledge is a bit behind the growth of multisport athletes. As Gosling et al7 point out in their review article from 2008, there seems to be a paucity of information regarding multisport athlete injuries, including (1) incidence of injury, (2) profile of sustained injuries and (3) evidence for prevention. The studies that have been done are limited by retrospective design, an inconsistency in defining injury exposure and poor outcome measurements such as unvalidated recall. With the remarkable growth in multisport athletes and their associated injuries, the challenge to the sports medicine community is to drive research that leads to a better understanding of the complex environmental, biomechanical, nutritional and psychological risk factors that play a role in multisport athlete injury. This could help define a framework for preparticipation evaluation and injury prevention to help our multisport athletes reach their participation and performance goals injury free.


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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.