B: REDUCING THE RISK OF MUSCULOSKELETAL (MSK) INJURIES
The most common injuries sustained in training for the Comrades Ultra-Marathon are musculoskeletal injuries. These include but are not limited to muscle strains, ligament sprains, tendon inflammatory conditions (tendonitis, tenosynovitis), tendon degenerative conditions (tendinopathies), bone stress injuries (bone oedema, stress fractures).
The most common reason for race-related injury is because of previous or new onset injuries that are not diagnosed and managed appropriately prior to race-day.
Prevention is better than cure:
Musculoskeletal (MSK) pain during Comrades:
C: REDUCING THE RISK OF EXERCISE-ASSOCIATED MUSCLE CRAMPING (EAMC)
Exercise associated muscle cramping (EAMC) are constant and uncontrolled muscular contractions (spasms) that can occur during or after physical activity. In runners, EAMC usually affects the lower limb muscles such as the calves, hamstrings, quadriceps, or feet.
Despite a general perception, EAMC is NOT associated with magnesium, sodium, or potassium losses.
EAMC is most commonly caused by common progressive muscle fatigue during. Therefore, EAMC is more likely in runners who are not properly trained and prepared for a race, runners that run at too fast a pace or run for a distance that is longer than what they trained for.
Other risk factors for EAMC are Individual (genetic) predisposition, an underlying muscle injury, use of certain medications, not tapering sufficiently before a race, and severe dehydration or other causes of fatigue, such as energy depletion, during the race.
Prevention is better than cure:
EAMC during Comrades:
D: REDUCING THE RISK OF COLLAPSE and / or FAINTING AT DISTANCE RUNNING EVENTS
A history of previous collapse or fainting is a risk factor for a medical complication during a race. Please consider the following important medical information related to collapse and / or fainting in distance runners (training and / or racing).
Collapse in a runner can be defined as “a runner who is unable to stand or walk / run unaided when training or at a distance running race.” There are many causes of collapse in runners, and these can vary from conditions that are less serious to conditions that are very serious.
When a runner collapses or has a history of previous collapse, the most important consideration is:
If you have ever collapsed, then please consider the following important medical information related to collapse in runners, either during running and / or after completion of a training session or a race.
COLLAPSE / FAINTING THAT OCCURS AFTER COMPLETION OF A RUN (a training session or a race)
Collapse (unable to stand, walk, or run unaided) after completion of a training session or a race is quite common. One of the most common conditions that present and require medical attention after a race in the medical tent on Comrades race-day is known as Exercise-Associated Collapse (EAC), or more accurately as Exercise-Associated Postural Hypotension (EAPH). EAC / EAPH can affect any participant.
EAC / EAPH that occurs after a race typically occurs as you suddenly slow down or stop physical activity because the regular contraction or your lower leg muscles (for example, your calf muscles) no longer assists in the return of blood to your heart. This can cause a significant drop in blood pressure (hypotension), which then makes a runner feel dizzy and can cause fainting / collapse.
This occurs more frequently in hot and humid conditions when your peripheral blood vessels are dilated to assist with thermoregulation (heat loss).
What are the other possible causes of collapse that occurs after completion of a run (training / racing)?
As mentioned, one of the most common causes of collapse that occurs after completion of a run is EAC / EAPH. However, there are other less common, but more serious causes of collapse after completion of a run. These other causes are exhaustion, moderate dehydration, exercise-associated muscle cramping (EAMC), low blood sugar (mild hypoglycaemia), exertional heat stroke, cardiac (heart) abnormalities and electrolyte abnormalities in your blood. Some of these conditions are serious and require urgent medical care.
What are the risk factors associated with collapse that occurs after completion of a run (training / racing)?
As mentioned EAC / EAPH is one of the most common reasons for admission into the medical tent at endurance events. Research has shown that EAC / EAPH is more common in females compared to males and is associated with longer race distances, slower running pace, and less running experience. Other risk factors are dehydration, unfavourable hot / humid and humid weather conditions, pre-race alcohol consumption, and a history of previous collapse after runs.
Less common but more serious causes of collapse or fainting after a race can be associated with a history of underlying chronic health disorders (for example, heart or blood vessel disease, lung disease), an acute pre-race infection, other acute pre-race illness, and certain types of medication including use of medication during a race that can affect kidney function and electrolytes in the blood.
What are the measures to reduce the risk of collapse that occurs after completion of a run (training / racing)?
Prevention is better than cure: the easiest way to avoid EAC / EAPH is to gradually slow down and to keep walking (despite your fatigue) at the end of a training session or a race and NOT to stop immediately after crossing the finish line.
This will allow the calf muscle to still contract and return blood back to the heart for a few minutes. It allows the body to gradually adjust after a long session of exercise. This is especially important when the physical activity has been prolonged, has been of high intensity, and when it has taken place in hot and humid environmental conditions. As dehydration can increase the risk of EAC / EAPH, it is important to stay hydrated during your run.
Measures to prevent other more serious causes of collapse after completion of a run are discussed in the section below on collapse / fainting whilst running. In cases of collapse / fainting on race day, medical attention will be available at the medical facility at the end of the Comrades ultramarathon.
Principles of treatment of collapse that occurs after completion of a run (training / racing) would include a complete assessment by one of the attending medical physicians in the medical tent before allowing for safe discharge.
COLLAPSE / FAINTING THAT OCCURS WHILST RUNNING (during a training session or a race)
Collapse (unable to stand, walk, or run unaided) during a training session or a race is quite rare, but can usually be more serious, specifically if it NOT related to accidentally tripping and falling.
What are the possible causes of collapse / fainting that occurs during a run (training / racing)?
As mentioned, collapse / fainting that occurs during running (a training session or a race), is usually more serious in nature. Causes can include exertional heatstroke, acute cardiac (heart) disease which can be related to a history of underlying chronic health disorders (for example, heart or blood vessel disease), acute lung conditions (for example, asthma), complications of an acute pre-race infection or other acute pre-race illness, certain types of medication including use of medication during a race that affect kidney function and electrolytes in the blood, muscle breakdown (known as rhabdomyolysis), serious blood electrolyte disturbances (for example, hyponatraemia), and even rare kidney or gastrointestinal disorders.
Participants that suffer collapse / fainting during a race may have a history of underlying acute pre-race conditions or chronic health disorders especially those that are cardiovascular in nature.
These are emergency situations that require runners to stop and seek immediate medical attention.
What are the risk factors associated with collapse that occurs during a run (training / racing)?
The main risk factors associated with collapse / fainting that occurs during running (a training session or a race) include the following: a past history of collapse during exercise, underlying chronic medical conditions (especially heart or blood vessel disease, lung disease, hormonal disease such as diabetes mellitus (DM), kidney disease, as well as other chronic diseases), a history of recent acute infection or other acute illness, regular use of certain types of medication for chronic illnesses, as well as use of medication during a training session or a race.
What are the measures to reduce the risk of serious causes of collapse / fainting during a run?
Known or previous chronic diseases such as cardiovascular disease (heart or blood vessel disease) is an important potential cause of collapse during running. We would like to share some important information with regards to exercising with known or previous acute illness or chronic diseases such as heart or blood vessel disease.
Please note that this is NOT to prevent you from participating but to provide you with information for safer training and participation. Consistent exercise is an important component in the treatment of many chronic diseases. However, if you currently have or have had previously suffered from a chronic disease, particularly heart or blood vessel disease, you may also have an increased risk of developing a serious and even life-threatening complication during physical activity.
The following are known risk factors of heart or blood vessel disease that we ask you to attempt to reduce as possible, so your risk of complications can also be reduced: elevated cholesterol levels, obesity, hypertension / high blood pressure, smoking (including vaping), diabetes mellitus (sugar sickness), excessive stress, as well as physical inactivity.
The following are suggested to help reduce your risk of collapse / fainting during exercise and we suggest that you consult with your medical doctor before running (race or training) if you:The consultation with your doctor may:
Please be aware of the development of any of the following symptoms during exercise (or even at rest): STOP immediately and seek urgent medical attention if they occur: chest pain or pressure or heaviness (at rest or with mild exercise), prolonged discomfort or pain in the jaw or left arm (or even your right arm) that is not otherwise explainable, dizziness or feeling faint, palpitations (an awareness or an abnormal sensation of your heartbeat or heart rate, shortness of breath greater than normal for you (at rest or with mild exercise), sudden nausea or vomiting or any other unexplainable symptoms
E: REDUCING THE RISK OF GASTRO-INTESTINAL TRACT (GIT) ILLNESS
Running and Gastro-intestinal Tract (GIT) Illness:
If you have any of the following GIT symptoms, it is recommended that you do NOT take part in exercise:
To emphasise this again, if you have any of the above-mentioned symptoms, it is recommended that you do NOT participate in physical activity.
Make an appointment for a complete medical evaluation, specific advice, and management by a qualified medical doctor. This consultation should include a complete history, a comprehensive physical examination, as well as screening for any medical complications.
In some mild cases where symptoms are isolated without any generalised symptoms, your medical doctor may allow for you to participate in low intensity physical activity. If at any point you feel unwell, it is advised that the physical activity is stopped immediately.
Return-to-sport (RTP) following a GIT illness or infection is only advised when all symptoms have disappeared and when you are feeling well again. If there is any uncertainty, an appointment for a complete medical evaluation by a qualified medical doctor is advised before RTP.
Do NOT attempt new routines on Comrades race-day i.e. avoid any new food and hydration changes that you have not tested before. Stay with what worked for you beforehand during your training, use bottled water, adhere to strict hygiene measures).
F: REDUCING THE RISK of ACUTE RESPIRATORY TRACT ILLNESS
An acute illness (respiratory, gastro-intestinal, bladder, or even skin infections) can occur at any time.
However, they can be more common at times of peak training or just before races. If you unfortunately have an acute illness, it may interfere with your performance but most importantly, it could lead to serious medical complications when participating in physical activity with an acute illness onboard.
We would like to share some important information with regards to exercise and acute respiratory tract illnesses. Please note that this is NOT to prevent you from participating but to provide you with information for safer training and participation.
Running and Upper and / or Lower Respiratory Tract Illness: URTI and / or LRTI respectively:
Respiratory tract illnesses are the most common acute infection that affects athletes and are most commonly viral in origin.
Some presentations can be non-infectious such as common allergies. Comrades race-day happens during the end of Autumn and the beginning of Winter in South Africa, which sees a general increase in respiratory tract infections over that period.
Travel (travel fatigue and time zone changes for overseas participants) also are associated with this increased risk of respiratory infections.
An URTI mainly effects the nose, sinuses and throat and presents with a blocked or runny nose, blocked or painful sinuses, or a sore throat. Although URTI do not usually result in symptoms affecting the whole body (fever, muscle pain, joint pain, general fatigue), there are instances when they do as in “flu-like” illlness.
A LRTI mainly involves the lower airways and lungs and presents with a couch (sputum productive or non-productive), chest pain, shortness of breath. LRTI can result in symptoms affecting the whole body (fever, muscle pain, joint pain, general fatigue).
Physical activity with an acute illness can be detrimental and can lead to serious medical complications. For example, some viruses that cause respiratory infections can affect heart muscle (myocarditis), which can lead to damage to cardiac tissue and in some instances, sudden cardiac arrest and death.
There are strict international guidelines to assist you when you have symptoms of a respiratory tract illness and to help prevent these serious complications from occurring:
To emphasise this recommendation again, if you have any of the above-mentioned symptoms, do NOT participate in physical activity.
In some mild cases where symptoms are solely isolated as an URTI without any generalised symptoms, your medical doctor may allow for you to participate in low intensity physical activity. If at any point you feel unwell, it is advised that the physical activity is stopped immediately.
Return-to-sport (RTP) following a respiratory tract illness is only advised when all symptoms have disappeared and when you are feeling well again. If there is any uncertainty, an appointment for a complete medical evaluation by a qualified medical doctor is advised before RTP.
G: RACE DAY CONSIDERATIONS
The Comrades ultramarathon is run every year during the winter season in South Africa. From a medical perspective, this assists with running in cooler weather conditions. However, there have been instances where the weather conditions are warmer and / or more humid than predicted.
If overly hot and humid conditions are unexpectedly present on race-day, please be careful of heat related illnesses, especially signs and symptoms of heatstroke. Hotter environments combined with activity causes the body to increase internal heat production, and if coupled with more humid conditions, this can limit an individual’s ability to sweat. The rise in internal heat production and reduced heat loss through sweating can present with a condition known as heatstroke.
Heatstroke presents as an elevated internal body temperature that can affect the central nervous system and can present with extreme thirst, headaches, dizziness, nausea and vomiting, confusion, slurred speech, fainting, and a loss of consciousness.
If the weather conditions are hotter and more humid than expected, use the designated water stations and the spray tunnels to cool down whilst on the race-route.
Determine your nutritional and fluid intake requirements in the build-up to race-day so that you do experience hypoglycaemia (low blood sugar) and are not under- or over-hydrated as these can affect your performance as well as your well-being on race-day.
Do not attempt any new routines on Comrades-race-day. Nutritional conditioning or pre-race testing of dietary and / or supplement use as well as planned nutritional strategies can assist in the avoidance of hypoglycaemia, and can ensure the absorption of required nutrients and fluids during training, recovery, and importantly on race-day.
Hypoglycaemia can present with dizziness, shaking, heart palpitations, confusion, and fatigue.
Overhydration and dehydration can result in medical complications especially to your renal (kidneys) and central nervous system.
Overhydration can result in blood electrolyte change that can present with vomiting, seizures, or collapse and a loss of consciousness. Dehydration can present as fatigue, little to no urine, an elevated heart rate and low blood pressure.
If your urine is dark red or brown and you experience severe muscle aching, muscle weakness, or muscle stiffness, please seek medical attention urgently as this may indicate muscle breakdown (rhabdomyolysis) and can have detrimental effects on your kidneys.
Do not use over-the-counter pain or anti-inflammatory medication to relieve pain during running as those can also have detrimental effects on your kidneys and make the developing condition worse.
Finally, please also be aware of the following important symptoms during exercise (or even at rest) as they can indicate a serious medical complication: chest pain, pressure or heaviness in the chest, prolonged discomfort or pain in the jaw or left arm that is not otherwise explainable (or even your right arm), dizziness, fainting episodes, palpitations (an awareness or a sensation of an abnormal heart beat or rate), shortness of breath greater than normal for you, sudden nausea or vomiting or any other unexplainable symptoms.
If any of the above symptoms develop during or immediately after exercise, please seek urgent medical attention.
Prescribed medication use should only be changed by your medical doctor.
We urge you to take careful note of these guidelines and if you are at all concerned about anything that has been mentioned, we strongly advise that you seek medical attention on race-day as needed.
