Article Text


The foot in multistage ultra-marathon runners: experience in a cohort study of 22 participants of the Trans Europe Footrace Project with mobile MRI
  1. Wolfgang Freund1,
  2. Frank Weber2,
  3. Christian Billich1,
  4. Uwe H Schuetz1
  1. 1Department of Diagnostic and Interventional Radiology, University Hospitals, Ulm, Germany
  2. 2Department of Neurology, German Armed Forces Hospital, Ulm, Germany
  1. Correspondence to Dr Wolfgang Freund; freund-ulm{at}


Objectives 67 runners participated in the Trans Europe FootRace 2009 (TEFR09), a 4487 km (2789 mi) multistage ultra-marathon covering the south of Europe (Bari, Italy) to the North Cape. Reports on ultra-marathons are lacking, but the literature reports overuse injuries in athletes, especially to the Achilles tendon (AT), ankle or hind foot. Bone oedema may be related to exposure and is present in fatigue fractures. Therefore, the aim of this study was to determine prospectively if sustained maximal load during an ultra-marathon leads to damage to the foot.

Design and participants In a cohort study, repeated scanning of the 22 athletes participating in the study was performed before and during (approximately every 1000 km) the race. Using the obtained fat saturated inversion recovery sequence, two experienced readers blinded to the clinical data rated the images regarding foot lesions. Statistical analysis included regression analysis and computation of the inter-rater reliability.

Setting The TEFR09 course. MRI scanning was performed according to prearranged schedules for every participant, using a mobile 1.5 Tesla MRI unit on a trailer following the race.

Primary outcome measures MRI data such as AT diameter, bone or tendon lesions, subcutaneous, plantar fascia or intraosseous oedema.

Results The 22 study participants did not differ significantly from the total of the 67 TEFR09 runners regarding height, weight and age. The AT diameter increased significantly from 6.8 to 7.8 mm as did intraosseous signal, bone lesions and subcutaneous oedema. However, finishers differed only regarding plantar aponeurosis and subcutaneous oedema from participants aborting the TEFR09. Inter-rater reliability was 0.88–0.98.

Conclusion Under the extreme stress of the TEFR09, an increase of the AT diameter as well as bone signal are thought to be adaptive since only subcutaneous oedema and plantar fascia oedema were related to abortion of the race.

Trial registration number University of Ulm, Germany Ethics Committee Number 78/08-UBB/se.

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  • To cite: Freund W, Weber F, Billich C, et al. The foot in multistage ultra-marathon runners: experience in a cohort study of 22 participants of the Trans Europe Footrace Project with mobile MRI. BMJ Open 2012;2:e001118. doi:10.1136/bmjopen-2012-001118

  • Contributors WF designed the study, read the images and planned the statistical analysis. He wrote the manuscript and approved the final manuscript. UHS designed the study, acquired the MRI data, read the images and critically revised the manuscript and approved the final manuscript. FW designed and performed the statistical analysis. He wrote parts of the manuscript and approved the final manuscript. CB designed the study, acquired the MRI data and critically revised the manuscript and approved the final manuscript. Also, MRI scanning was performed by Heike Wiedelbach.

  • Funding This project was mainly supported by the German Research Association (DFG: ‘Deutsche Forschungsgemeinschaft’) under grants SCHU 2514/1-1 and SCHU 2514/1-2. Other non-public funds were received from Siemens Medical and the Medical Faculty of the University of Ulm. All funding was unrestricted. None of the funding bodies had any role in the study design, data collection, data analysis, data interpretation, manuscript preparation or decision to publish.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by ethics committee of the University of Ulm, Germany.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional are data available.

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