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Rod Cedaro knee painText by Rod Cedaro (M. App. Sc.) Consultant Sports Physiologist

ACC Accredited Level III Triathlon Coach

The three disciplines of triathlon place different demands on triathletes: Technically speaking, swimming is the most demanding, from a time efficiency perspective cycling is the most costly, while running, physically, is the most demanding on the body. With this in mind I thought we’d focus on the duress the running places through probably the most susceptible joint in the body – the knee.

First up, you need to identify what “sort” of knee pain your experiencing before you can hope to remedy it.

Here following is a quick checklist of problems and some suggested ways of alleviating them.


a. Your knee “aches.” Q: Does your knee feel stiff through the front and/or medial (inner) side of your kneecap? Is it worse after sitting or kneeling? Does it hurt more walking down steps? Does the pain go away after you warm up? If you’ve answered “yes” to most of these questions chances are your suffering “Patellofemoral pain”, see 1 below for suggested cure.

b. The outside section of your knee aches.

Q: Are you doing track sessions and or putting in some big training volume – during your long training sessions the knee aches and then the pain dissipates shortly thereafter.

You’re probably suffering from “Iliotibial band syndrome” (ITBS), see 2 below.

c. The front of your knee aches and it seems to get worse the more you run Q: Is the pain in the front of the knee just below patella (kneecap)? Have you recently added more training volume in on the run? If you’ve answered yes to these questions, you’re probably suffering from “Patellar tendinitis”, see 3 below.

d. You’ve been running a lot of late and you’ve got knee pain that seems to be “under” knee cap. Q: Is your knee swollen? Have you run a lot of kms in the same shoes?

If this is the case, you may have Osteoarthritis, see 4 below.

Some suggested cures:

1. Patellofemoral pain is often caused by alignment problems which in turn can damage the articulating surface of the kneecap (what is slides on), cause excessive pronation and/or muscle/tendon weakness or tightness. Often times you can “run through” this sort of pain, but you’re going to need to back off volume, hills and intensity. Some strength training, wearing a knee brace, taping your arches or wearing an orthotic, and replacing worn shoes or wearing motion-control shoes can help to realign your knee and alleviate this problem.

2. (ITBS) occurs when the IT band, which runs from the hip down and across the knee becomes tight and inflamed. Athletes that over-pronation and/or are bow-legged often suffer from this problem. If you get on to it quickly you can recover in one to four weeks. Take anti-inflammatories one to two hours before you run, stretch your ITB’s pre and post run and ice the distal part of your ITB post-run. In the short term you may need to decrease of your training volume and intensity and stay out of the hills. If you’re doing track sessions mix them up – do half the session clockwise and the other half anti-clockwise. If the problem persists you may need taping or or orthotics.

3. Patellar tendinitis is an inflammation of one patella tendon. Tendinitis occurs when tissue breakdown outpaces re-growth. It is often caused by a sudden increase in training volume, adding in more hill work and/or quality work. If you try to “run through” this sort of an injury it’ll only get worse. It is an “overuse” injury in the true sense of the term. You need to give you knee time to recover. If treated early, it can heal in a few weeks. Focus on your swimming and cycling while the knee is healing, take some anti-inflammatories (under doctor’s direction), ice the knee, try wearing a patella strap to lift the knee cap, stretch and strengthen your quads – straight leg lifts with the leg fully extended and the foot weighted can be helpful here.

Rod Cedaro osteoarthritus4 Osteoarthritis occurs from wear and tear of cartilage. It can flare up on a run or even when you’re out for a leisurely walk depending on how bad it is and how old you are. The good news is, if you keep your run training to a moderate level you should be okay. Simply manipulate your training volume/intensity around the symptoms. Change your running shoes over regularly – you’ll generally get about 400-700km out of a pair of shoes max – if you’re suffering from osteoarthritis turn your shoes over after 400km max. Make sure you’ve got a good strength training program that focuses on the supportive muscles of the knee joint to lessen the load on it (i.e. Hamstrings, quads, shins, and gluteals). You might also consider a knee brace and taking nutritional supplements of chondroitin and glucosamine.

Speaking of chondroitin and glucosamine – normally I don’t recommend supplements, but I must say from having read the research and personal experience glucosamine and chondroitin appear to be the real deal. A recent internet poll on the popular Runner’s World website found that 79.8 percent of those that have used this supplement reported that their symptoms had either “somewhat improved” or “greatly improved” after taking glucosamine and/or chondroitin. Less than one percent reported that “things got worse” after taking the supplements. Glucosamine and chondroitin both occur naturally in the body. Most commercial glucosamine comes from the exo-skeleton of shellfish, and most commercial chondroitin from cow or shark cartilage. Both have relatively low rates of absorption from the intestines, and yet both are said to promote healing of the articular cartilage in joints. It’s the wearing away of this cartilage that causes the pain and inflammation of osteoarthritis. It is the trauma of running over extended periods of time that wears away on these articulating surfaces and the knees and hips of older athletes are particularly at risk simply because of the volume of training that has been done. Having said that, there are no actual studies that conclusively show that running “causes” (or for that matter, doesn’t cause) osteoarthritis.

The problem: All existing studies are cross-sectional in nature. As such they can only provide a snapshot of a given group of runners at a given time. They don’t account for injured runners who might have stopped running before the study was conducted and why they stopped. What is needed is a comprehensive prospective study – looking at the same athletes over extended periods of time – such research is more likely to prove/disprove the running-osteoarthritis connection.

The medical literature in support of glucosamine/chondroitin is however cautiously positive. Although some scepticism persists as many of these studies have been funded by supplement manufacturers with vested interests. A recent meta-analysis of studies (i.e. Where the results of a number of studies are tallied and reviewed) demonstrated on the whole positive outcomes. The paper concluded that glucosamine and chondroitin were “effective” treating several outcomes measures of osteoarthritis. While several other meta-analyses studies have reached similar conclusions, most in the scientific community believe that the jury is still out.

Personal experience on both myself and some of the older runners and triathletes I work with, would suggest it is money well spent!




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Text by Rod Cedaro (M. App. Sc.)

Consultant Exercise Physiologist ACC Accredited Level III Triathlon Coach

Pieta Cedaro (APD) Consultant Dietitian

It never fails to surprise me just how much misinformation still exists around the athletic training circles. My wife works on a consultancy basis as a dietician with many of the athletes we coach. One of the services she provides is a complete dietary review whereby the athletes provide her with a comprehensive 3-day diet review of everything that goes into their mouths. She then provides them with feedback as to how to optimally modify their diets to optimise their recovery, performance, etc. Time and time again what comes across is the incredible amounts of money triathletes are spending seemingly adhoc on nutritional supplementation and one of the most exploited myths is that of creatine. With this in mind I thought it timely to consider just what you are potentially doing to your performance – running in particular because of its weight bearing nature – if you are creatine supplementing on a daily basis.

So let’s look at the physiology behind creatine. When athletes consume creatine be it from meat and fish or in supplementary form, some of the creatine will be absorbed from the blood into the muscles. Once there, creatine can be combined with phosphate to form phosphocreatine, a vital—but very limited—source of energy for brief, high-power activities such as sprinting and resistance training. It follows that creatine users should have more phosphocreatine energy available to perform these kinds of activities, leading to improved performance – at least in sprint and power events – already distance running off the bike associated with triathlon isn’t looking to benefit too much from this form of supplementation now is it!?

This rationale sounds great, and a whole industry has been built upon it with many millions of dollars worth of creatine supplements sold every year. But even after the completion of several hundred scientific investigations, many questions remain about the value of creatine supplementation for performance of various sports and about how much and when to use creatine—if it should be used at all. Here is some of what we now know from the current research:

* Supplementing the diet with 20 grams of creatine daily (four X 5-gram doses) for 4-5 days (i.e., “creatine loading”) will increase muscle levels of creatine in some, but not all, individuals. When consumed in amounts greater than 20 grams per day the balance is excreted via the urine.


*2 grams of creatine ingested daily for 30 days is just as effective as the aforementioned loading regimen in regards to the concentrations found in muscle at the end of the loading phase.

* Consuming carbohydrate with creatine increases creatine uptake by muscles marginally.

* Creatine ingestion generally results in weight gain by a couple of kilograms, some of which will be extra muscle and the rest extra water. This additional weight is likely to be detrimental to your running performance.

* Most lab studies of high-power tests lasting 30 seconds and/or repeated high power tests show slight (but signficant) improvements in performance in creatine users.

* Lab testing between 30 and 90 seconds duration suggest some positive performance with creatine supplementation. As test durations exceed 90 seconds, creatine users show little or no change in performance compared to non-users.


TABLE 1. Evidence for and against the use of creatine in different events. Type of Testing Ergogenic (Performance Enhancing) Effect or not?
Intense Brief Exercise (e.g. Laboratory tests; <30 seconds e.g. Sprint cycling – the shorter the better) Established performance benefits.
Intense exercise in lab setting for exercise bouts of 30-90 seconds to 3 minutes duration (e.g. Rowing ergo). Established performance benefits.
Intermittent style intense exercise bouts in the lab of 30 seconds to 3 minutes duration (e.g. Laboratory tests simulating mountain biking – stop-go-stop-go style intermittent efforts.) Supported by “some” research.
Intense exercise of longer than 3 minutes duration (Lab and field studies – e.g. Endurance based activities such as distance running.) No supportive evidence available for the use of creatine.



* When consumed in moderate doses, there doesn’t appear to be any adverse health effects with the supplementation of creatine in healthy adults.

* There have been no studies reviewing the effects of creatine supplementation on growing children so it would be prudent NOT TO use this supplement with athletes under the age of 18.

* Since the manufacture of supplements isn’t tightly regulated there is no guarantee that what is stated on the bottle is what is actually in the product. As was the case with the Bek Keat issue there have been incidents where supplements are “spiked” with stimulants or prohormones that are banned by sport governing bodies – so ensure that the product you are using is from a reliable source.

* Endurance athletes such as triathletes have little if anything to gain (and particularly during the run leg, much to lose) using creatine because of the associated weight gain due to increased muscle mass and fluid retention.

* Dietary supplements won’t make you a champion! The key to great performances is dedicated intelligent training over time coupled with a genetic predisposition to endurance sports, recovery and sensible dietary habits. Get all of these ingredients in place and them search for the 1%ers to give you that edge – creatine for the triathlete doesn’t fall into this category.