Medicine and Science in Ultra Endurance Sports – an update from the 2nd annual medical conference

The Medicine and Science in Ultra Endurance Sports conference is an event put on in conjunction with the Western States Endurance Race (WSER) and is geared towards the most recent literature in ultra endurance sports. As it is estimated that there were over 50,000 ultra finishers last year, and new races are frequently popping up all over the world, developing data driven approaches to these events is a necessity. It’s a great conference for anyone associated with ultra endurance sports, including medical directors/providers, race directors, volunteers, coaches, and athletes.

Much of the content revolved around observational data of symptoms experienced during ultra events. Not surprisingly, nausea, bloating, and vomiting were the most commonly reported symptoms during an ultra. These generic symptoms are generally termed “exercise associated gastroparesis”, which is presumptively caused by reduced perfusion to the splanchnic/mesenteric circulation from shunting of blood that leads to a decrease in peristalsis. This was also the number one reason for non-finishers to drop out in the cohorts studied. Musculoskeletal issues, blisters, respiratory complaints, and dehydration were generally the other most common reasons for competitors to seek medical care. Interestingly, in one study, 10% of those that sought medical care were non-competitors (volunteers, pacers, etc).

As expected, exercise associated hyponatremia was a big topic.  The risk primarily comes from two major factors: over hydration and SIADH. Consistent with the teaching over the past few years, managing dehydration by drinking according to thirst is still the top recommendation for avoiding both significant dehydration and dilutional hyponatremia. Electrolyte tablets don’t prevent cramps, nausea, or protect against hyponatremia, and can actually increase the thirst mechanism causing over hydration, so are now generally recommended against.

Acute Kidney Injury (AKI) in ultra runners is caused by three main mechanisms:  dehydration (most common), rhabdomyolysis (most serious), and NSAIDs (most dumb) as described by Dr. Weiss. The key points were to avoid NSAIDS, and treat rhabdo with fluids. Dehydration, even with significant weight loss during the event, was not tied to performance, and clinically insignificant AKI is not unexpected in ultra runners.

Interestingly, there were several presentations on psychology. Dolores Christianson is a PhD student in psychology that is doing her thesis on recognizing the psychological difference between finishers and non-finishers. Although there is a lot left to study, and the mindset of a runner during a race is difficult to assess outside of real time, it seems that those that focus more on the race and how they are feeling as opposed to abstract, unrelated topics is more characteristic of separating finishers from non-finishers. Also, the unhappy triad of pain, nausea, and worsening mood seem to lead to a downward spiral toward the DNF column. Lastly, 2 ultra runners gave personal accounts of their struggles with depression, which was very a powerful look into the struggles of recognizing, accepting, and coping with their mental illness.

Dr. Joslin gave two talks, the first on considerations for the medical screening of ultra-endurance athletes. See this article published in the Journal of Sports Medicine. The second talk was on the management of the seriously ill or injured ultra marathoner, including trauma, anaphylaxis, hyponatremia, and several other potentially fatal conditions. John Vonhof of Fixing Your Feet gave a fantastic lecture of blister care. Dr. Hoeg gave a presentation on Ultramarathoner’s Eye, which is a degradation of visual acuity thought to be related to corneal edema, although it is poorly studied or understood. See this article in Wilderness and Environmental Medicine. Dr. Badowski spoke on recovery after exercise, and the paradigm is shift from a RICE approach to CAM – compression, activity (low intensity), and massage. She is collecting data during this year’s WSER to help better understand the potential benefits of different modalities.

There was an interesting talk given by Dr. Kurland on acute respiratory issues in ultra marathoners. He focused on exercise induced bronchospasm and vocal cord dysfunction (VCD). VCD is much more common than recognized, and characterized by severe respiratory distress with stridor without wheezing. It is exacerbated by physical or emotional stress, and ceases in a sudden manner with relaxation. As opposed to most causes of respiratory distress, the oxygen saturation is normal, and there is often a history of previous episodes. Recognition of VCD is key, as these individuals are often (inappropriately) intubated because of the severity of their presentation.

Overtraining Syndrome – yes, it’s a real thing. Interestingly enough, this article from Outside Magazine was going around social media in the weeks leading up to the conference, and was highlighted in a case report and as part of a couple of other presentations. It is characterized by generalized fatigue and exercise intolerance lasting >4 weeks that cannot be attributed to another cause. More information can be found here.

Each day of the conference had exhibited small groups on medical kits (Joslin) and foot care (Vonhof), and Dr. Hoffman gave presentations on how to do research in a race setting and discussed some of the medico-legal aspects of performing medical care at ultra events. Unfortunately I wasn’t able to attend these groups, but I’m sure they were excellent.

Lastly, the conference was held at Squaw Valley Ski Resort, which is a beautiful area with great terrain for hiking, trail running, mountain biking, and only about 10 miles from Lake Tahoe (see pics below). The wildflowers were in bloom and the weather was beautiful.

Overall it was a great conference and one that I would recommend to anyone associated with the ultra community. There is still much to be learned about the physiological changes and injury patterns in ultra-endurance athletes, and with 50,000 runners per year, it behooves us a medical community to continue to study this population and keep them healthy both on the course and in their day-to-day life.