Medical guidance
Introduction
The Dragon’s Back Race® is a tough challenge – you will need to look after yourself to finish well (at the front or at the back of the pack), so we’re glad you’ve come here to read this.
We know from previous editions of the race that a large portion of participants will seek help from the medical team at some point during the event.
In 2017, 65% of participants sought medical help, similarly in 2019 and 2021. Approximately half of these visits concerned blisters with the rest concerning medical issues or musculoskeletal sprains and strains.
We have a strong and experienced medical team at the Dragon’s Back Race® including doctors, nurses and physiotherapists and we are there to offer support and advice, and treatment if necessary. Experience shows that the participants who arrive at the finish, and finish well, are definitely those who are self-reliant & who look after themselves best, so to help you with this we are summarising this useful advice for the more common complaints we see.
Some first aid kit is mandatory ©No Limits Photography
We are expecting you to help yourselves - and us - during the event by looking after yourselves first and foremost. There will be approximately 350 participants and you’ll have plenty of company around you, so do buddy up to look after each other, not only on the hill but in the camp too. Don’t be afraid to get down and dirty, and help each other look after your feet and bodies!
But remember you are not on your own - If you need us, we will support you. The medical tent will be within reach of the finish, and if you have something you cannot deal with yourself (e.g. can’t reach it, tentmates can’t help) or you want advice, and especially if you are unwell, come & find us there.
Much as you would experience in a hospital emergency department, expect a triage or assessment system if you visit the medical tent for assistance. This enables the team to deal with the most in need first, regardless of how long others may have already queued.
The person most in need will be seen first. This is important if you are under pressure to start your day - we’ll help where we can, but we won’t de-priortise someone else if your timing is a little off.
Foot care
Self-care is key, and prevention is better than cure with regards to feet issues. If you haven’t read it yet, don’t forget to read our guidance on foot care:
We will advise, but not generally tape or dress your feet for you. That said, we are there to support you if you are not sure about something. When you come to the medical tent seeking advice on blister treatment you must have your (mandatory) blister kit and clean feet! Similarly, bring your (mandatory) K tape if you’re seeking physiotherapy advice.
Medic helping with blister treatment, your own blister kit is mandatory! ©Guillem Casanova
NSAIDs (e.g. Ibuprofen or Naproxen)
We do not recommend the use of non-steroidal anti-inflammatory medications (NSAIDs) at the Dragon’s Back Race® (E.g. Ibuprofen, Naproxen, Aspirin, or Diclofenac [Voltarol]) as they are associated with an increased risk of kidney damage (renal failure). Participants at ultra-endurance events are often dehydrated, rather than over-hydrated, and the combination of this and NSAIDs can be dangerous.
We also know that strenuous exercise, including long distance running, can result in damage to skeletal muscle cells, known as exertional rhabdomyolysis, which usually resolves by itself. In some cases, where the damage is severe, muscle proteins can be released into the blood, which can move into the kidneys, causing acute renal (kidney) failure. Research shows that a high proportion of runners who develop this have taken NSAIDs.
The following advice should be taken:
Paracetamol should be taken as a first line analgesic where necessary
We advise strongly against taking NSAIDs; if you think you need them, we will happily discuss this with you & assess the risks and benefits
If you notice your urine is particularly dark and Coca-Cola-like, this could indicate rhabdomyolysis and therefore kidney damage, so please do seek medical advice immediately
This was one runners’ urine after finishing a hot ultra. They required admission to hospital for treatment
Dehydration
Dehydration is talked about (& worried about) a lot amongst athletes. Actually, if you are “drinking to thirst” (we’ll say this a lot) you won’t get significantly dehydrated & won’t compromise your performance.
When fluid loss (sweat, urine, vomiting, diarrhoea) exceeds fluid intake (what you drink), you will become dehydrated. This can occur rapidly or slowly depending on the context - how hard you are exercising, the weather conditions, and if you are vomiting or have diarrhoea. Hot weather significantly increases the risk. When you have lost around 2% of your body weight, you are significantly dehydrated, you will get symptoms, and your performance will decrease. But thirst will kick in before you reach 2% body weight loss, especially in an endurance event like the Dragon’s Back Race®.
Drink to thirst! In the UK, dehydration is unlikely to cause serious medical problems if you are otherwise fit & healthy, but it can make your day in the mountains unpleasant & possibly end your race. The advice is really clear - DRINK TO THIRST!
The risk of overhydration (hyponatraemia) is a far greater risk than dehydration (especially in the UK). The best way to avoid this? Drink to thirst!
Please don’t come to the Dragon’s Back Race® with a precise pre-planned, timed hydration strategy, but please do ensure you drink small amounts frequently as dictated by your thirst.
Shin splints and stress fractures
Many runners will have suffered from shin splints in the past and they are common in many high impact sports. Shin splints are the result of repetitive stress to the shin bone and surrounding connective tissues and present as an aching type pain with associated swelling and tenderness (hurts when you press it).
Some people are more prone than others to developing shin splints.
Risk factors
Certain foot types - such as over pronation (flat foot)
A sudden increase in training load (or racing: like competing in a multi-day ultra endurance race…)
Lack of recovery days
Worn or damaged running shoes
These risk factors are important to consider in the build up to the Montane Dragon’s Back Race®.
Please do address your personal risk factors:
In training
Rest (this won’t be something that you can power through and hope it will go away) - yes, this may mean the end of the race for you if this is exacerbated during the race
Ice the area
Adjust your training (low impact activities such as swimming or cycling during the recovery period)
Footwear (consider changing your footwear as shoes wear out, and don’t start the event in worn-out shoes!)
Consider seeing a physiotherapist and/or podiatrist for specialist advice
During the race
Rest (as much as possible at the overnight camps but be prepared that this injury might be the end of your race)
Ice (or sitting in a stream may be more practical mid-event!)
Try to reduce the impact as much as possible – maybe run less and walk more or wear your least-worn shoes. Aim for an event completion rather than a specific result or time
A more serious injury to the lower leg can result in a stress fracture, which is damage to the tibia bone (your shin) which runs down the front of your lower leg. At the 2017 Dragon’s Back Race®, at least two people received hospital treatment for a stress fracture and had to stop racing. Stress fractures are generally more serious than shin splints and are likely to mean the end of your race, but the risk factors and treatment principles are similar.
Anterior tibialis tendonitis
In all editions of the race a large proportion of runners have come to us with pain and redness on the front of their legs, just above the ankle. Although anterior tibialis tendonitis has been recognised in runners, the incidence at the Dragon’s Back Race® is unusual and is the result of running consecutive days over rough terrain with frequent ankle rotation.
The anterior tibialis tendonitis runs down the front on the shin and connects the shin bone (tibia) to the ankle. When this becomes inflamed from excessive stress, it results in tendonitis (inflammation of the tendon).
As with most musculoskeletal injuries, the mainstay of treatment is rest and ice. If you come to the medical team with symptoms suggesting of tendonitis, we will suggest rest (i.e. stopping running) and regular icing (generally in a local stream!). There is no quick fix solution for this, and whether you are able to continue is difficult to predict.
That said, sometimes taping can be a temporising measure, so do come and seek help if needed.
Anterior tibialis tendonitis is the result of running consecutive days over rough terrain with frequent ankle rotation ©Jimmy Hyland
Hypo/hyperthermia
In previous editions of our expedition races, the Dragon’s Back Race® and Cape Wrath Ultra®, we have experienced wide differences in ambient temperatures from low single figures to high twenty degrees centigrade! And this brings challenges to your bodies:
Hypothermia
Hypothermia occurs when the body’s temperature falls below 35 degrees centigrade and can result from low outside temperatures, precipitation and wind chill; usually a combination of these factors. We see people suffering from hypothermia to various degrees, in every race.
Avoiding hypothermia from starting in the first place is the most important mainstay of treatment with wicking base layers, insulated mid layers and waterproof clothing being mandatory. We will check this at the kit check before the race starts and during the race. You will be prevented from starting if we deem your clothing to be inadequate.
Hypothermia generally presents with the ‘umbles’ and recognising this in both yourself and your fellow runners is important:
Stumbles - Loss of control over movement
Mumbles - Slurred, slow or incoherent speech, sleepiness or confusion
Fumbles - Slow reaction time, dropping objects, poor coordination
Grumbles - Change in behaviours, expressing a negative attitude
Other signs of hypothermia include poor judgment, apathy (can’t be bothered attitude), increased rate of breathing and cool/pale skin. As the condition worsens, the person may develop shivering and an inability to walk. Severe hypothermia results in a halt to shivering and ultimately death.
If you detect any of the above symptoms in yourself or fellow runners, STOP and immediately put on more clothing and eat before you become unable to do so, then try to keep moving; if you completely stop you will only become colder. Eating something to replenish the body’s energy reserves will help. If symptoms worsen, call for help. If you do have to stop, get into your survival bag, insulate yourself from the ground, seek shelter, and stick together.
Adverse weather conditions on Cadair Idris on day three - and the potential for hypothermia ©No Limits Photography
Hyperthermia
Hyperthermia is the opposite of hypothermia and is the results of the body’s core temperature becoming too high. As with hypothermia there is a variety of symptoms and this usually occurs when the ambient temperature is high; something that was experienced at the Dragon’s Back Race® in 2022 and the Cape Wrath Ultra® in 2018. Hyperthermia can be life-threatening if untreated.
Heat exhaustion results in rapid breathing, a fast pulse and heavy sweating and can generally be managed with general cooling measures such as cold water, removing clothing, seeking shade and rehydration.
When things become more severe, heat stroke results when the body is unable to cool itself. This results in hot and dry skin, a change in consciousness level, severe nausea and a lack of sweating. This is a dangerous condition and immediate steps should be taken to cool the participant down as well seeking immediate medical attention.
The following should be considered by all participants in case of hot weather:
Wear a hat
Wear sensible clothing
Keep hydrated – obey your thirst - and think about salt replacement
Take regular breaks, ideally in shade and consider slowing your pace
Pour water on head and neck areas
Wear sun cream
Good head-wear and easy access to hydration works well to combat the heat ©No Limits Photography
Sunburn
Sunburn can also result from hot weather and can be easily prevented by the early application of sun cream. At every event with hot conditions we see people suffering as a result of sunburn and it can be an uncomfortable experience. Sun cream is mandatory kit (whatever the weather forecast!) but you need to ensure you actually stop to apply it before it’s too late! A pale coloured long sleeve top can also be effective in keeping you cool and preventing burning.
Sun cream is mandatory kit - Don’t forget to apply it before it is too late! ©Guillem Casanova
Electrolyte imbalances
Exercising in hot weather can also result in salt imbalances in the body, namely low salt levels, known as Exercise Associated Hyponatraemia (EAH).
This condition generally occurs during a race and can result in weakness, dizziness and a headache to more severe symptoms of low levels of consciousness and seizures. In athletes (as opposed to people with a specific medical condition causing it), it generally occurs when a person drinks too much water and this results in a hormone imbalance in the body, meaning this excess water cannot be cleared from the body which dilutes sodium levels in the blood. Symptoms are a manifestation of this sudden fall in sodium (salt) levels in the blood. It’s relatively easy to prevent – drink to thirst! In other words, drink whenever you feel you need to, but don’t drink just because you have to get through X amount per X hours).
EAH requires urgent medical attention; please do not hesitate to ask for help if you are concerned about yourself or another participant.
Ticks
Ticks are small parasites that usually live on deer and sheep. They are found in abundance in remote upland areas, e.g. Wales! Whilst in themselves they are not directly harmful, they can carry Lyme disease, treatable with antibiotics if recognised early, but with potentially serious consequences if not.
It is therefore vitally important that you check yourself (and you tent buddies!) for ticks, every night and remove them if found. We recommend removal with a specific designated tick removal device to reduce the risk of leaving any part behind and would strongly recommend bringing such a device in your camp bag.
An example of a 'Bulls-eye' rash from a tick bite
If you notice a “bull’s eye” rash, please see a member of the medical team; don’t wait until you get home. Many people who have tick bites will get an inflammatory reaction around the bite - this is not the bull's eye rash, and usually settles very quickly - but if you are in any doubt, please ask.
However, if you remove ticks quickly (the sooner you remove them, the lower the risk), your chances of getting Lyme disease are low, and especially low of developing evidence of Lyme disease during the event. The typical rash usually occurs 1-4 weeks after the tick bite. We won’t repeat the advice given elsewhere, but if you’ve had a tick bite, and are unwell, or develop the typical rash after the event, please do see your doctor and tell them that you have had a tick bite. If the rash is a typical rash, they will treat you with antibiotics; if it’s not a typical rash or you have no rash but feel unwell, they will start investigations.
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Communicable Disease
Some illnesses are defined as Communicable Diseases, including the common cold, influenza, COVID-19, and gastroenteritis (diarrhoea and/or vomiting). These diseases are highly infectious and have the potential to impact not just your race but your tent mates and other participants. These diseases are transmitted from one person to the next through direct contact, respiratory droplets, and from touching contaminated surfaces. It is no exaggeration to say these illnesses can be race-ending for some participants and threaten the overall integrity of the event. If you unfortunately become unwell with the symptoms associated with these diseases, you MUST inform an Event Medic as soon as possible.
Please don’t worry that you’ll be automatically excluded from the event. Our approach is to manage each unwell person on a case-by-case basis, and the majority of our participants who become unwell continue with their race. However, typically, we will immediately ‘isolate’ the unwell person into one of our individual isolation tents to limit the spread of the illness.
Our approach to managing communicable diseases at our event applies to any transport we provide at the beginning or end of the event. Please don’t get on a coach if you are unwell because you might ruin a busload of participants’ race or, more seriously, put at risk a vulnerable person that someone else is travelling home to.
If you're unsure if what you have could be communicable, please ask! The Medical team would rather be able to reassure people than miss potential issues. First and foremost, please think about the other participants at the event and seek advice from the event medical team at the earliest opportunity.
COVID-19
Whilst the significant restrictions from previous years regarding COVID-19 are no longer in place, and there is no legal requirement to isolate, we would encourage anyone who tests positive to COVID-19 prior to the race not to attend. In a race like this, it is not easy to isolate infected runners or crew, and you risk infecting a whole tent or vanload of people. Equally, the physical challenge of CWU is enough at the best of times. Racing when covid-positive puts a significant strain on your body, and increases your risk of cardiac complications and long-COVID. If you are anxious about the COVID risk please contact us - whether that's before the event or during it. We're happy to discuss your concerns.
Final word
As a medical team, we want you to complete the race and will try our very best to enable you to do this. On rare occasions, we may insist that you stop running because we believe you are placing yourself (and/or other people) at serious risk. This is not something we undertake lightly, and this decision will only be made after discussion with the senior doctor and race director. Please do not hesitate from seeking medical attention if you are concerned about yourself or another participant.