Personally, working at the Ironman Races has been one of the greatest highlights of my career as a physical therapist and ART instructor and provider. I was fortunate to volunteer at the Hawaii World Championship in 1997. This was my first race and the memories are still vivid. I have worked a number of races over the years and try to attend at least one Ironman Race every year or two. To be around these athletes is incredibly inspiring. Their dedication, hard work, and athleticism as an endurance athlete at the pinnacle of their career and as the world’s best has absolutely no comparison. To know that at the end of the day you made a difference is an extremely rewarding experience. It is a place that challenges your clinical skills, where you have to think quickly, and on your feet with focus.
These athletes are in top form, but some have had the misfortune to have an injury pop up a week before the race through the cumulative injury cycle. Other athletes commonly may have had another misfortune like a fall off of their bike or being struck by a car. I have witnessed fractures of the clavicle to bones in the wrist or foot from a fall or a long standing injury that’s just blown up. Regardless of their physical issues, they are here to compete. You also have the opportunity to work with challenged athletes –amputees, paraplegics. They have trained years to get here –dropping out at this point is just not an option. The anxiety runs high with the possibility that the dream of a lifetime could end in a horrific nightmare without starting the race or not competing well. It’s amazing how fine-tuned these athletes’ bodies are- fit, chiseled, sinewy and strong!
Because they are so fit, they respond to ART very quickly. Their bodies have ramped up thousands of miles of running, swimming and biking.
Working at the Ironman races enables you to become an expert at Active Release Techniques. Here is where you get to put it all together. This experience increases the doctor’s confidence and ability in the musculoskeletal management of soft tissue injuries. This includes your precise evaluation, accurate diagnosis, applying biomechanics, and treatment with excellent results.
This is also where you get to meet wonderful clinicians from all over the world and people who make a difference with world class athletes. These are lifetime memories that can change you in what you thought was possible for yourself and for others. Working with these “repetitive motion” athletes is like a lab class for ART and is considered the “final exam” in your training as an ART provider.
These are some of the cumulative trauma common conditions seen at the Ironman:
Case #1: Low Back Pain- facet dysfunction. This individual had severe low back pain with cycling or running. We then watched the athlete run. The athlete exhibited loss of hip extension and poor thoracic rotation/extension. Posture and mobility testing indicated a thoracic hyperkyphosis with anterior chest shortening and poor pelvic rotation. There was positive restricted muscle length test in the hip flexors. We treated the iliacus, psoas, gluteals and T/L multifidi. Treatment consisted of ten minutes of those structures, mobilization of the joint restrictions with rotational mobility exercises also prescribed. After two visits, the athlete was running pain free and was amazed at the results.
Case #2: Achilles and calf pain. The athlete exhibited localized tenderness of the Achilles, poor hamstring flexibility, weakness of the gluteus medias, poor hip extension, poor hamstring length, posterior tilt of the pelvis when running, poor knee extension with mid stance and weight acceptance. Treatment: sacrotuberous ligament, medial hamstrings gluteals and the posterior side of the achilles. After one treatment– resolved.
Case #3: Shoulder Impingement. The athlete presented shoulder pain with impingement signs with overhead motion and pulling through the water. The athlete exhibited restrictions in the latissmus dorsi, subscapularis, triceps, and posterior rotator cuff. After two visits, full range of motion, no pain, full function– resolved.
Case #4: A runner with foot pain presented symptoms similar to plantar fasciitis with localized pain at the bottom of the foot and along the attachment at the calcaneus. This was determined not to be plantar fasciitis at all. The athlete exhibited positive muscle adhesions and restrictions of the foot intrinsics. This athlete exhibited poor talocrual dorsiflexion upon evaluation of running gait. This was due to a restricted soleus. It was found that this area was overloaded due to a tight iliacus and psoas groups bilaterally. It was hypothesized that there was decreased muscle activation of the gluteus maximus due to the tight antagonists overloading the foot and ankle. After one visit, the athlete was running pain free the next day—resolved!
Case #5: Anterior knee pain; this athlete exhibited very poor trunk rotation. Restricted, tight oblique and transversospinalis group in the T/L spine. There was gluteus medius tightness, illiotibial band tightness, vastus lateralis and hamstring shortening. The athlete was running with a shortened stride and flexed knees loading the patella-femoral joints. After working the structures, the athlete also utilized self- management such as icing the knees and mobility exercises. The client was able to finish the race and run pain free throughout the marathon.
Case #6: Neck pain with radiation into the entire arm. This is a classic case of many miles in the aerobar position. Restrictions were found in the levator scapula, rhomboids, scalene, cervico-thoracic erector spinae. Pain was experienced with rotation and extension. There were restrictions/adhesions found in the above structures. Posture showed a moderate head forward position, tight pectoral fascia and hyperkyphosis of the thoracic spine. The athlete got significant increases in range of motion in the cervical spine after 3 treatments and was able to compete without the impairment. –resolved.
These results are typical and expected. You see great results day after day and witness some real miracles. During the treatment week, we treat over 400 to 600 athletes combined with 30 Ironman doctors treating at the race tent. The ART Doc uses their knowledge of biomechanics, and their ability to target the aggravating factors and then determines why the specific tissue is being overloaded. We then apply ART for its specificity and effectiveness to fully resolve the athlete’s pain and dysfunction.
You begin to see similar patterns with these athletes. You begin to see the muscle imbalances and syndromes of the entire lower extremity kinetic chain, spine and the connections of the opposite upper extremity in action. If the doctor can diagnose specifically, finding out what area is being overloaded or symptomatic, then trace it back by identifying what areas of the body may not have adequate mobility or stability, there is clinical success. The next step is implementing corrective, very specific exercises related to resolving the dysfunction and educating the athlete to enable self-management.
You gain an appreciation for the superb fitness of these athletes, their motivation, ability, and their race car-like bodies. I like to think of Ironman athletes as race cars that can go the distance. A little treatment goes a long way. These are small tune-ups to a highly fine tuned body. You get really good at taking an accurate history, discovering the aggravating factors, doing functional tests and then re-testing, having them reproduce the activity that causes the pain. Then you know how much you “fixed the problem.” By really asking the athlete good questions, they can usually accurately describe what activity is bothering them and locate the precise location of their symptoms.
I can recall the many smiles and the sweaty hugs at the end of the race from athletes who were so happy to accomplish their goals…this feels so wonderful to know you really helped them accomplish what they came to do! There is no barrier or fear to express the joy and the emotion. You may witness a few tears of joy and some amazing feats of drive and determination. All the way up until the last finisher comes in- at midnight, just the most incredible high to witness and participate!
For more information on the partnership between ART and Ironman, click here.
Please note: Volunteers are accepted…if you want to participate, just ask me!
This is me finishing my 4th Ironman in Kona 2004.
Tammara Moore, DPT, ART Provider and Instructor
