Advertisement

Sports Medicine

, Volume 44, Issue 8, pp 1055–1069 | Cite as

Medical Services at Ultra-Endurance Foot Races in Remote Environments: Medical Issues and Consensus Guidelines

  • Martin D. HoffmanEmail author
  • Andy Pasternak
  • Ian R. Rogers
  • Morteza Khodaee
  • John C. Hill
  • David A. Townes
  • Bernd Volker Scheer
  • Brian J. Krabak
  • Patrick Basset
  • Grant S. Lipman
Review Article

Abstract

An increasing participation in ultra-endurance foot races is cause for greater need to ensure the presence of appropriate medical care at these events. Unique medical challenges result from the extreme physical demands these events place on participants, the often remote settings spanning broad geographical areas, and the potential for extremes in weather conditions and various environmental hazards. Medical issues in these events can adversely affect race performance, and there is the potential for the presentation of life-threatening issues such as exercise-associated hyponatremia, severe altitude illnesses, and major trauma from falls or animal attacks. Organization of a medical support system for ultra-endurance foot races starts with a determination of the level of medical support that is appropriate and feasible for the event. Once that is defined, various legal considerations and organizational issues must be addressed, and medical guidelines and protocols should be developed. While there is no specific or universal standard of medical care for ultra-endurance foot races since a variety of factors determine the level and type of medical services that are appropriate and feasible, the minimum level of services that each event should have in place is a plan for emergency transport of injured or ill participants, pacers, spectators and event personnel to local medical facilities.

Keywords

Acute Kidney Injury Acute Mountain Sickness Automate External Defibrillator Medical Guideline Emergency Transport 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

The authors have no potential conflicts of interest that are directly relevant to the content of this article, but acknowledge being Director of Research for the Western States Endurance Run (MDH), and Medical Directors of the Tahoe Rim Endurance Races (AP), Leadville 100 Race Series (MK, JCH), Remote Medical International (DAT), Al Andalus Ultimate Trail (BVS), Racing The Planet (BJK, GSL) and Dokever (PB). Each has also provided medical coverage at a variety of other endurance events, and most are experienced endurance athletes. We thank our ultramarathon running buddies who offered constructive comments on the work, including race directors Dr. David Horton and Craig Thornley, and Western States Endurance Run Board member Attorney Charles Savage. This material is the result of work supported with resources and the use of facilities at the VA Northern California Health Care System. The contents reported here do not represent the views of the Department of Veterans Affairs or the United States Government.

References

  1. 1.
    Hoffman MD, Ong JC, Wang G. Historical analysis of participation in 161 km ultramarathons in North America. Int J Hist Sport. 2010;27:1877–91.PubMedCrossRefGoogle Scholar
  2. 2.
    Ultrarunning (2013). The year in review. UltraRunning. Jan/Feb 2014:30–47.Google Scholar
  3. 3.
    Hoffman MD, Fogard K. Factors related to successful completion of a 161-km ultramarathon. Int J Sports Physiol Perform. 2011;6:25–37.PubMedGoogle Scholar
  4. 4.
    Krabak BJ, Waite B, Lipman G. Injury and illnesses prevention for ultramarathoners. Curr Sports Med Rep. 2013;12:183–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Krabak BJ, Waite B, Schiff MA. Study of injury and illness rates in multiday ultramarathon runners. Med Sci Sports Exerc. 2011;43:2314–20.PubMedCrossRefGoogle Scholar
  6. 6.
    Lipman G, Krabak BJ. Foot problems and care. In: Auerbach PS, editor. Wilderness Medicine. 6th ed. Philadelphia: Elsevier; 2012. p. 580–93.Google Scholar
  7. 7.
    Scheer BV, Murray A. Al Andalus Ultra Trail: an observation of medical interventions during a 219-km, 5-day ultramarathon stage race. Clin J Sport Med. 2011;21:444–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Sawka MN, Burke LM, Eichner ER, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39:377–90.PubMedCrossRefGoogle Scholar
  9. 9.
    Bennett BL, Hew-Butler T, Hoffman MD, et al. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia. Wilderness Environ Med. 2013;24:228–40.PubMedCrossRefGoogle Scholar
  10. 10.
    Hew-Butler T, Almond C, Ayus JC, et al. Consensus statement of the 1st International Exercise-Associated Hyponatremia Consensus Development Conference, Cape Town, South Africa 2005. Clin J Sport Med. 2005;15:208–13.PubMedCrossRefGoogle Scholar
  11. 11.
    Hew-Butler T, Ayus JC, Kipps C, et al. Statement of the Second International Exercise-Associated Hyponatremia Consensus Development Conference, New Zealand, 2007. Clin J Sport Med. 2008;18:111–21Google Scholar
  12. 12.
    Hoffman MD, Hew-Butler T, Stuempfle KJ. Exercise-associated hyponatremia and hydration status in 161-km ultramarathons. Med Sci Sports Exerc. 2013;45:784–91.PubMedCrossRefGoogle Scholar
  13. 13.
    Lebus DK, Casazza GA, Hoffman MD, et al. Can changes in body mass and total body water accurately predict hyponatremia after a 161-km running race? Clin J Sports Med. 2010;20:193–9.CrossRefGoogle Scholar
  14. 14.
    Stuempfle KJ, Lehmann DR, Case HS, et al. Hyponatremia in a cold weather ultraendurance race. Alaska Med. 2002;44:51–5.PubMedGoogle Scholar
  15. 15.
    Ayus JC, Varon J, Arieff AI. Hyponatremia, cerebral edema, and noncardiogenic pulmonary edema in marathon runners. Ann Intern Med. 2000;132:711–4.PubMedCrossRefGoogle Scholar
  16. 16.
    Kipps C, Sharma S, Tunstall PD. The incidence of exercise-associated hyponatraemia in the London Marathon. Br J Sports Med. 2011;45:14–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Noakes T. Waterlogged: the serious problem of overhydration in endurance sports. Champaign: Human Kinetics; 2012.Google Scholar
  18. 18.
    Siegel AJ, Verbalis JG, Clement S et al. Hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion. Am J Med. 2007;120:461.e11–7.Google Scholar
  19. 19.
    Winger J, Hoffman MD, Hew-Butler T, et al. The effect of physiology and hydration beliefs on race behavior and postrace sodium in 161-km ultramarathon finishers. Int J Sports Physiol Perform. 2013;8:536–41.PubMedGoogle Scholar
  20. 20.
    Hoffman MD, Stuempfle KJ. Hydration strategies, weight change and performance in a 161-km ultramarathon. Res Sports Med. In press.Google Scholar
  21. 21.
    Noakes TD, Sharwood K, Speedy D, et al. Three independent biological mechanisms cause exercise-associated hyponatremia: evidence from 2,135 weighed competitive athletic performances. Proc Natl Acad Sci U S A. 2005;102:18550–5.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Rüst CA, Knechtle B, Knechtle P, et al. Body mass change and ultraendurance performance: a decrease in body mass is associated with an increased running speed in male 100-km ultramarathoners. J Strength Cond Res. 2012;26:1505–16.PubMedCrossRefGoogle Scholar
  23. 23.
    Kenefick RW, O’Moore KM, Mahood NV, et al. Rapid IV versus oral rehydration: responses to subsequent exercise heat stress. Med Sci Sports Exerc. 2006;38:2125–31.PubMedCrossRefGoogle Scholar
  24. 24.
    van Rosendal SP, Osborne MA, Fassett RG, et al. Intravenous versus oral rehydration in athletes. Sports Med. 2010;40:327–46.PubMedCrossRefGoogle Scholar
  25. 25.
    McGarvey J, Thompson J, Hanna C, et al. Sensitivity and specificity of clinical signs for assessment of dehydration in endurance athletes. Br J Sports Med. 2010;44:716–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Owen BE, Rogers IR, Hoffman MD, et al. Efficacy of oral vs. intravenous hypertonic saline in runners with hyponatremia. J Sci Med Sport. Epub 18 Sep 2013.Google Scholar
  27. 27.
    Rogers IR, Hook G, Stuempfle KJ, et al. An intervention study of oral versus intravenous hypertonic saline administration in ultramarathon runners with exercise-associated hyponatremia: a preliminary randomized trial. Clin J Sports Med. 2011;21:200–3.CrossRefGoogle Scholar
  28. 28.
    Elsaesser TF, Pang PS, Malik S, Chiampas GT. Large-volume hypertonic saline therapy in endurance athlete with exercise-associated hyponatremic encephalopathy. J Emerg Med. 2013;44(6):1132–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Cuddy J, Slivka D, Hailes W, et al. Total energy expenditure, body water turnover, hydration status, and blood composition during the Western States 100. Med Sci Sports Exerc. 2009;41:S336–7.CrossRefGoogle Scholar
  30. 30.
    Davies CT, Thompson MW. Estimated aerobic performance and energy cost of severe exercise of 24 h duration. Ergonomics. 1979;22:1249–55.PubMedCrossRefGoogle Scholar
  31. 31.
    Glace B, Murphy C, McHugh M. Food and fluid intake and disturbances in gastrointestinal and mental function during an ultramarathon. Int J Sport Nutr Exerc Metab. 2002;12:414–27.PubMedGoogle Scholar
  32. 32.
    Stuempfle KJ, Hoffman MD, Hew-Butler T. Association of gastrointestinal distress in ultramarathoners with race diet. Int J Sport Nutr Exerc Metab. 2013;23:103–9.PubMedGoogle Scholar
  33. 33.
    Stuempfle KJ, Hoffman MD, Weschler LB, et al. Race diet of finishers and non-finishers in a 100 mile (161 km) mountain footrace. J Am Coll Nutr. 2011;30:529–35.PubMedCrossRefGoogle Scholar
  34. 34.
    Baska RS, Moses FM, Graeber G, et al. Gastrointestinal bleeding during an ultramarathon. Dig Dis Sci. 1990;35:276–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Rehrer NJ, Brouns F, Beckers EJ, et al. Physiological changes and gastro-intestinal symptoms as a result of ultra-endurance running. Eur J Appl Physiol. 1992;64:1–8.CrossRefGoogle Scholar
  36. 36.
    Hoffman MD, Ingwerson JL, Rogers IR, et al. Increasing creatine phosphokinase concentrations at the 161-km Western States Endurance Run. Wilderness Environ Med. 2012;23:56–60.PubMedCrossRefGoogle Scholar
  37. 37.
    Skenderi KP, Kavouras SA, Anastasiou CA, et al. Exertional rhabdomyolysis during a 246-km continuous running race. Med Sci Sports Exerc. 2006;38:1054–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Hoffman MD, Stuempfle KJ, Rogers IR, et al. Hyponatremia in the 2009 161-km Western States Endurance Run. Int J Sports Physiol Perform. 2012;7:6–10.PubMedGoogle Scholar
  39. 39.
    Hoffman MD, Stuempfle KJ, Fogard K, et al. Urine dipstick analysis for identification of runners susceptible to acute kidney injury following an ultramarathon. J Sports Sci. 2013;31:20–31.PubMedCrossRefGoogle Scholar
  40. 40.
    Lipman GS, Krabak BJ, Waite BL, Logan SB, Menon A, Chan GK. A prospective cohort study of acute kidney injury in multi-stage ultramarathon runners: the Biochemistry in Endurance Runner Study (BIERS). Res Sports Med. 2014;22(2):185–92.Google Scholar
  41. 41.
    Bruso JR, Hoffman MD, Rogers IR, et al. Rhabdomyolysis and hyponatremia: a cluster of five cases at the 161-km 2009 Western States Endurance Run. Wilderness Environ Med. 2010;21:303–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Clarkson PM. Exertional rhabdomyolysis and acute renal failure in marathon runners. Sports Med. 2007;37:361–3.PubMedCrossRefGoogle Scholar
  43. 43.
    Patel DR, Gyamfi R, Torres A. Exertional rhabdomyolysis and acute kidney injury. Phys Sportsmed. 2009;37:71–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Asplund CA, O’Connor FG, Noakes TD. Exercise-associated collapse: an evidence-based review and primer for clinicians. Br J Sports Med. 2011;45:1157–62.PubMedCrossRefGoogle Scholar
  45. 45.
    Holtzhausen LM, Noakes TD. Collapsed ultraendurance athlete: proposed mechanisms and an approach to management. Clin J Sport Med. 1997;7:292–301.PubMedCrossRefGoogle Scholar
  46. 46.
    Scheer V, Murray A. Endurance and adventure sports injuries: ultra-marathon running injuries (musculoskletal injuries and other health related problems). In: Doral MN, Karlsson J, editors. Sports injuries: prevention, diagnosis, treatment and rehabilitation. 2nd ed. [published online ahead of print 12 Sep 2013]. Berlin, Heidelberg: Springer. http://www.springerreference.com/docs/html/chapterdbid/363908.html. Accessed 12 Sept 2013.
  47. 47.
    Speedy DB, Noakes TD, Holtzhausen LM. Exercise-associated collapse: postural hypotension, or something deadlier? Phys Sportsmed. 2003;31:23–9.PubMedGoogle Scholar
  48. 48.
    Childress MA, O’Connor FG, Levine BD. Exertional collapse in the runner: evaluation and management in fieldside and office-based settings. Clin Sports Med. 2010;29:459–76.PubMedCrossRefGoogle Scholar
  49. 49.
    Holtzhausen LM, Noakes TD. The prevalence and significance of post-exercise (postural) hypotension in ultramarathon runners. Med Sci Sports Exerc. 1995;27:1595–601.PubMedCrossRefGoogle Scholar
  50. 50.
    Holtzhausen LM, Noakes TD, Kroning B, et al. Clinical and biochemical characteristics of collapsed ultra-marathon runners. Med Sci Sports Exerc. 1994;26:1095–101.PubMedCrossRefGoogle Scholar
  51. 51.
    Anley C, Noakes T, Collins M, et al. A comparison of two treatment protocols in the management of exercise-associated postural hypotension: a randomised clinical trial. Br J Sports Med. 2011;45:1113–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Brennan FH, O’Connor FG. Emergency triage of collapsed endurance athletes: a stepwise approach to on-site treatment. Phys Sportsmed. 2005;33:28–35.PubMedCrossRefGoogle Scholar
  53. 53.
    Noakes TD. Exercise in the heat: old ideas, new dogmas. Int Sportmed J. 2006;7:58–74.Google Scholar
  54. 54.
    Noakes TD. Reduced peripheral resistance and other factors in marathon collapse. Sports Med. 2007;37:382–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Noakes TD. Dehydration during exercise: what are the real dangers? Clin J Sport Med. 1995;5:123–8.PubMedCrossRefGoogle Scholar
  56. 56.
    Noakes TD, Sharwood K, Collins M, et al. The dipsomania of great distance: water intoxication in an Ironman triathlete. Br J Sports Med. 2004;38:E16.PubMedCentralPubMedCrossRefGoogle Scholar
  57. 57.
    Privett SE, George KP, Whyte GP, et al. The effectiveness of compression garments and lower limb exercise on post-exercise blood pressure regulation in orthostatically intolerant athletes. Clin J Sport Med. 2010;20:362–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Wilson TE, Cui J, Zhang R, et al. Skin cooling maintains cerebral blood flow velocity and orthostatic tolerance during tilting in heated humans. J Appl Physiol. 2002;93:85–91.PubMedGoogle Scholar
  59. 59.
    Kim JH, Malhotra R, Chiampas G, et al. Cardiac arrest during long-distance running races. New Engl J Med. 2012;366:130–40.PubMedCrossRefGoogle Scholar
  60. 60.
    Webner D, DuPrey KM, Drezner JA, et al. Sudden cardiac arrest and death in United States marathons. Med Sci Sports Exerc. 2012;44:1843–5.PubMedCrossRefGoogle Scholar
  61. 61.
    Harris KM, Henry JT, Rohman E, et al. Sudden death during the triathlon. JAMA. 2010;303:1255–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Resuscitation Council (UK). Resuscitation guidelines 2010. http://www.resus.org.uk/pages/guide.htm. Accessed 30 Aug 2013.
  63. 63.
    Howe AS, Boden BP. Heat-related illness in athletes. Am J Sports Med. 2007;35:1384–95.PubMedCrossRefGoogle Scholar
  64. 64.
    Khodaee M, Ansari M. Common ultramarathon injuries and illnesses: race day management. Curr Sports Med Rep. 2012;11:290–7.PubMedCrossRefGoogle Scholar
  65. 65.
    Seto CK, Way D, O’Connor N. Environmental illness in athletes. Clin Sports Med. 2005;24:695–718.PubMedCrossRefGoogle Scholar
  66. 66.
    Casa DJ, Armstrong LE, Kenny GP, O’Connor FG, Huggins RA. Exertional heat stroke: new concepts regarding cause and care. Curr Sports Med Rep. 2012;11:115–23.PubMedCrossRefGoogle Scholar
  67. 67.
    Bishop GW, Fallon KE. Musculoskeletal injuries in a six-day track race: ultramarathoner’s ankle. Clin J Sport Med. 1999;9:216–20.PubMedCrossRefGoogle Scholar
  68. 68.
    Fallon KE. Musculoskeletal injuries in the ultramarathon: the 1990 Westfield Sydney to Melbourne run. Br J Sports Med. 1996;30:319–23.PubMedCentralPubMedCrossRefGoogle Scholar
  69. 69.
    Lopes AD, Hespanhol Junior LC, Yeung SS, et al. What are the main running-related musculoskeletal injuries? A systematic review. Sports Med. 2012;42:891–905.Google Scholar
  70. 70.
    Bloch KE, Turk AJ, Maggiorini M, et al. Effect of ascent protocol on acute mountain sickness and success at Muztagh Ata, 7546 m. High Alt Med Biol. 2009;10:25–32.PubMedCrossRefGoogle Scholar
  71. 71.
    Beidleman BA, Fulco CS, Muza SR, et al. Effect of six days of staging on physiologic adjustments and acute mountain sickness during ascent to 4300 meters. High Alt Med Biol. 2009;10:253–60.PubMedCrossRefGoogle Scholar
  72. 72.
    Honigman B, Theis MK, Koziol-McLain J, et al. Acute mountain sickness in a general tourist population at moderate altitudes. Ann Intern Med. 1993;118:587–92.PubMedCrossRefGoogle Scholar
  73. 73.
    Roach RC, Maes D, Sandoval D, et al. Exercise exacerbates acute mountain sickness at simulated high altitude. J Appl Physiol. 2000;88:581–5.PubMedGoogle Scholar
  74. 74.
    Luks AM, McIntosh SE, Grissom CK, et al. Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness. Wilderness Environ Med. 2010;21:146–55.PubMedCrossRefGoogle Scholar
  75. 75.
    Elers J, Pedersen L, Backer V. Asthma in elite athletes. Expert Rev Respir Med. 2011;5:343–51.PubMedCrossRefGoogle Scholar
  76. 76.
    Hoffman MD, Krishnan E. Health and exercise-related medical issues among 1,212 ultramarathon runners: baseline findings from the Ultrarunners Longitudinal TRAcking (ULTRA) Study. PLoS One. 2014;9(1):e83867. doi: 10.1371/journal.pone.0083867.PubMedCentralPubMedCrossRefGoogle Scholar
  77. 77.
    Robson-Ansley P, Howatson G, Tallent J, et al. Prevalence of allergy and upper respiratory tract symptoms in runners of the London marathon. Med Sci Sports Exerc. 2012;44:999–1004.PubMedCrossRefGoogle Scholar
  78. 78.
    Mahler DA, Loke J. Pulmonary dysfunction in ultramarathon runners. Yale J Biol Med. 1981;54:243–8.PubMedCentralPubMedGoogle Scholar
  79. 79.
    Rogers IR, Inglis S, Speedy D, et al. Changes in respiratory function during a wilderness multisport endurance competition. Wilderness Environ Med. 2001;12:13–6.PubMedCrossRefGoogle Scholar
  80. 80.
    Talbot TS, Townes DA, Wedmore IS. To air is human: altitude illness during an expedition length adventure race. Wilderness Environ Med. 2004;15:90–4.PubMedCrossRefGoogle Scholar
  81. 81.
    Parise C, Hoffman MD. Influence of temperature and performance level on pacing a 161-km trail ultramarathon. Int J Sports Physiol Perform. 2011;6:243–51.PubMedGoogle Scholar
  82. 82.
    Costa RJ, Oliver SJ, Laing SJ, et al. Influence of timing of postexercise carbohydrate-protein ingestion on selected immune indices. Int J Sport Nutr Exerc Metab. 2009;19:366–84.PubMedGoogle Scholar
  83. 83.
    Costa RJS, Walters R, Bilzon JLJ, et al. Effects of immediate postexercise carbohydrate ingestion with and without protein on neutrophil degranulation. Int J Sport Nutr Exerc Metab. 2011;21:205–13.Google Scholar
  84. 84.
    Peters EM, Bateman ED. Ultramarathon running and upper respiratory tract infections: an epidemiological survey. S Afr Med J. 1983;64:582–4.PubMedGoogle Scholar
  85. 85.
    Walsh NP, Gleeson M, Shephard RJ, et al. Position statement. Part one: immune function and exercise. Exerc Immunol Rev. 2011;17:6–63.PubMedGoogle Scholar
  86. 86.
    Costa RJ, Teixeira A, Rama L, et al. Water and sodium intake habits and status of ultra-endurance runners during a multi-stage ultra-marathon conducted in a hot ambient environment: an observational field based study. Nutr J. 2013;12:13. doi: 10.1186/1475-2891-12-13.PubMedCentralPubMedCrossRefGoogle Scholar
  87. 87.
    Costa RJS, Swancott A, Gill S, et al. Compromised energy and macronutrient intake of ultra-endurance runners during a multi-stage ultra-marathon conducted in a hot ambient environment. Int J Sports Sci. 2013;3:51–62.Google Scholar
  88. 88.
    Lipman GS, Constance BB, Ladbrook M. Possible unilateral ultraviolet keratoconjunctivitis during an expedition-length desert race. Wilderness Environ Med. 2010;21:171–2.PubMedCrossRefGoogle Scholar
  89. 89.
    Committee on Trauma, American College of Surgeons. Advanced trauma life support for doctors. 9th ed. Chicago (IL): American College of Surgeons; 2012.Google Scholar
  90. 90.
    Harris T, Thomas GO, Brohi K. Early fluid resuscitation in severe trauma. BMJ. 2012;11(345):e5752.CrossRefGoogle Scholar
  91. 91.
    Vaillancourt C, Stiell IG, Beaudoin et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med. 2010;54:663–71.Google Scholar
  92. 92.
    Ross DS, Ferguson A, Herbert DL. Action in the event tent! Medical legal issues facing the volunteer event physician. Sports Health. 2013;5:340–5.PubMedCentralPubMedCrossRefGoogle Scholar
  93. 93.
    Centers for Medicare & Medicaid Services (CSM), HHS. Health insurance reform: security standards. Final rule. Fed Regist. 2003;68:8334–81.Google Scholar
  94. 94.
    Schwellnus M, Derman W. Overmedicalising-again! S Afr Med J. 2013;103:131–2.PubMedCrossRefGoogle Scholar
  95. 95.
    Sharwood KA, Collins M, Goedecke JH, et al. Weight changes, medical complications, and performance during an Ironman triathlon. Br J Sports Med. 2004;38:718–24.PubMedCentralPubMedCrossRefGoogle Scholar
  96. 96.
    Wharam PC, Speedy DB, Noakes TD, et al. NSAID use increases the risk of developing hyponatremia during an Ironman triathlon. Med Sci Sports Exerc. 2006;38:618–22.PubMedCrossRefGoogle Scholar
  97. 97.
    Zouhal H, Groussard C, Minter G, et al. Inverse relationship between percentage body weight change and finishing time in 643 forty-two-kilometre marathon runners. Br J Sports Med. 2011;45:1101–5.PubMedCrossRefGoogle Scholar
  98. 98.
    Hoffman MD, Stuempfle KJ, Sullivan K, Weiss RH. Exercise-associated hyponatremia with exertional rhabdomyolysis: importance of proper treatment. Clin Nephrol. In press.Google Scholar
  99. 99.
    Freund W, Weber F, Billich C, et al. Ultra-marathon runners are different: investigations into pain tolerance and personality traits of participants of the TransEurope FootRace 2009. Pain Pract. 2013;13:524–32.PubMedCrossRefGoogle Scholar
  100. 100.
    Hughes S, Case S, Stuempfle K, et al. Personality profiles of Iditasport ultramarathon participants. J Appl Sport Psychol. 2003;15:258–63.CrossRefGoogle Scholar
  101. 101.
    Wortley G, Islas AA. The problem with ultra-endurance athletes. Br J Sports Med. 2011;45:1085.PubMedCrossRefGoogle Scholar
  102. 102.
    Millet GY. Can neuromuscular fatigue explain running strategies and performance in ultra-marathons? The flush model. Sports Med. 2011;41:489–506.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland (outside the USA) 2014

Authors and Affiliations

  • Martin D. Hoffman
    • 1
    • 12
    Email author
  • Andy Pasternak
    • 2
  • Ian R. Rogers
    • 3
    • 4
  • Morteza Khodaee
    • 5
  • John C. Hill
    • 5
  • David A. Townes
    • 6
  • Bernd Volker Scheer
    • 7
    • 8
  • Brian J. Krabak
    • 9
  • Patrick Basset
    • 10
  • Grant S. Lipman
    • 11
  1. 1.Department of Physical Medicine & Rehabilitation (117), Department of Veterans AffairsNorthern California Health Care SystemSacramentoUSA
  2. 2.Silver Sage Sport Performance and Silver Sage Center for Family MedicineRenoUSA
  3. 3.St. John of God Murdoch HospitalMurdochAustralia
  4. 4.University of Notre DameMurdochAustralia
  5. 5.Department of Family MedicineUniversity of Colorado School of MedicineDenverUSA
  6. 6.Department of Medicine, Division of Emergency Medicine and Department of Global HealthUniversity of Washington School of MedicineSeattleUSA
  7. 7.Borders General HospitalMelroseUK
  8. 8.Team AxarsportAlicanteSpain
  9. 9.Department of Rehabilitation, Orthopaedics and Sports MedicineUniversity of Washington and Seattle Children’s Sports MedicineSeattleUSA
  10. 10.DokeverPierre-BéniteFrance
  11. 11.Division of Emergency Medicine, Department of SurgeryStanford University School of MedicineStanfordUSA
  12. 12.Department of Physical Medicine & RehabilitationUniversity of California Davis Medical CenterSacramentoUSA

Personalised recommendations