Muscle cramping in endurance races.

I am a 54-year-old male runner and triathlete. Despite what I believe has been adequate training, hydration and sodium intake I still get severe cramping during my races. I rarely get the cramps during training. Yesterday I did a half-Ironman race in Cambridge, MD. The weather was perfect. It was overcast and not very warm. I stayed with my race plan to keep my cadence on the bike at 90 to 105, with my heart rate at 70 to 80 percent of maximum. I was comfortable until mile 38, and then suddenly my medial vastas and adductors started to cramp. This slowed my pace.

When I got off the bike as I dismounted I got severe cramps in both hamstring and adductors. I walked the best that I could and after two miles I was able to run the rest of the race. I did walk through the water stops for 10 to 20 seconds. My medical quads were painful through the whole run. This is a typical experience that I have. I have been doing all distances of triathlon as well as marathons for 17 years. It seems that during the longer races I have the most trouble.I am not sure if my training is incorrect, my salt intake too low or my calories insufficient. I am just not sure where to go from here. I have been reluctant to use salt tablets during these events. I have had my bike fitted. I have calculated out my calorie requirement and my hydration needs. Please help.

Dzielak, DO

Scranton, PA

This is a tough but common problem. You are correct in re-evaluating all aspects of your training and racing. Hydration and electrolytes are always potential sources of cramping, especially in longer events. Although dehydration is a concern, hyponatremia is commonly seen in Ironman events. (I have not seen data on half-Ironman races.) It is easy to take in excess fluids while on the bike. Weighing yourself prior to and following workouts can give you a good ballpark of your fluid intake. Obviously, this will vary depending on the weather conditions.

Another big issue is the exercise intensity during a race. Do you ride at the same intensity during training, especially after swimming? Many athletes perform short and fast, and then long and slow, workouts but never workout at race pace. Incorporating workouts at race pace may be helpful.

What is your caloric intake during a race? By the time you get off of the bike, you have been exercising for hours and your glycogen stores will be low unless you have ingested adequate calories while on the bike.

Although training for a triathlon is time intensive, you may consider adding in core and leg strengthening exercises. Each of the activities involves a limited motion of the hips; strength deficits are fairly common. Weakness causes the muscles to fatigue, leading to cramping with continued exercise.

Lastly, don't be hesitant to supplement electrolytes during a race (certainly after testing this during training). There are a number of capsules available that are easy to tolerate (I've used them during 100-mile runs). There is a new electrolyte strip called Endurolyte that dissolves in your mouth--you may want to try it.

Cathy Fieseler, MD

Tyler, TX

Recurrent cramping tends to be a phenomenon that is a bit perplexing and probably multifactorial. There is much debate about the role of sodium and other electrolytes but sodium loss in sweat/inadequate sodium intake is most likely part of the puzzle. Muscle fatigue with an aberrant spinal cord reflex preventing activation of golgi tendon organs in the muscle also leads to hyper-stimulation without down regulation. Other things to consider: whether you taking a statin drug; metabolic or mitochondrial myopathies (maybe some genetic variant of one of these); sickle cell trait; thyroid disease?

I recommend training and racing with Gatorlytes or Endurolytes as directed by manufacturers. Maintain your hydration and review your nutritional intake with a sports nutritionist. Stretch at the first warning sign of cramping. If this persists consider thyroid testing. Consider muscle biopsy by a specialist who knows the proper laboratory tests for these myopathies.

Fred H. Brennan, Jr., DO, FAOASM, FAAFP 

My thought on cramping is that it is primarily due to muscle overuse and/or fatigue. There also may be a component just related to the mental stress of racing. I know we always talk about and look for electrolyte problems and dehydration, and these issues can certainly cause cramping to occur, but it is usually obvious when these occur. It certainly does not sound like these were issues for you. Even so, I wouldn't hesitate to experiment with taking some electrolyte replacement tablets during your next long event (try them a couple of times in training first, to make sure you tolerate them okay), and see if that helps.

My first suggestion would be to look at your training (and I assume you have already done this); especially at race-specific training. Have you done bricks at race intensity, with shorter duration? I have found that doing workouts like bike-run-bike-run-bike-run-bike, where each bike segment is 5 to 10 miles, and each run 1 to 2 miles, both at race pace or even faster, to be highly effective. Or if the cramps are mainly in longer races perhaps you would benefit from longer bricks, such as 15 to 20 miles bike, 3 to 5 miles run; repeated 2 to 3 times. Tough workouts, but I have found that one or two of these workouts leading up to a race are worth the effort.

Another thought: was the course hillier than you are accustomed to? Perhaps this could be additional stress on you muscles that would lead to overuse and cramping. One other suggestion would be to work on specific training for the areas affected by the cramps, and try to improve strength and flexibility in these areas. So, specific adductor and vastas medialis resistance training for improved strength may help reduce cramping. I also wonder why the cramps occurred in your adductors and medialis, as these are not the typical muscles I would expect to be overworked.

My totally anecdotal comment is that I have occasionally experienced cramping in these areas in triathlons, even as I exit the water and start the bike. My conclusion has been that somehow wearing a wetsuit makes these muscles work more during the swim, thereby leading to fatigue. I'm not sure what the solution for this is; probably working on specific muscle conditioning as I mentioned above. Hopefully this will help you figure out what is causing the cramps and enable you to race cramp-free!

Mark Elderbrock, MD

Ashland, OH