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How to avoid the medical tent at the Two Oceans Marathon

Sports physician Dr Lynelle Hoeks outlines the common medical issues seen at the Totalsports Two Oceans Marathon, and tells you how to prepare to ensure you cross the  finish line safely.

Chasing PBs and looking to meet personal challenges, after months of sacrifice and hard work, can lead to immense pressure on race day. From a runner to my fellow runners, I get it. But as chief medical officer of the Totalsports Two Oceans Marathon, I want to get you across that finish safely – without having to visit the medical tent!

Medical Tent at Running Event

Pre Race Screening

While your planning starts with a training schedule, ours starts with a medical screening.

You will know as seasoned runners that to enter any major event you need to fill out a medical questionnaire online. This is not to make your life difficult.

Pre-race screening is designed to pick up health issues that could put you at risk if you race, and so that if you do end up requiring medical assistance during the race, we have access to accurate medical information, know what medications you are taking, know your medical history, can contact your family and therefore give you the best treatment. By filling this in honestly we can go a long way to preventing serious incidents.

We are mainly screening for cardiovascular disease, other chronic illnesses and known injuries. Depending on your profile we can stratify you into very high risk, high risk, intermediate risk and low risk categories. This has been proven to help predict adverse events during a race and we see a significantly higher number of events in those seen as high risk.

If you have filled out your information and we recommend that you see your doctor to be cleared before running, please do so. Many people simply fill in the medical waiver, ignoring medical advice, and this can have catastrophic outcomes.

Half Marathon

Each of the races is different and as sports physicians we plan for the common issues arising

from each. You may be surprised to hear that the 21km brings with it the majority of our work load. There are many reasons why this is the case, but some modifiable factors include:

  • No qualification requirements for a 21km so the field consists of more undertrained runners.

  • Runners deciding last minute to run and taking a friend’s entry. They then run under someone else’s details which can cause problems for medical personnel should something go wrong.


  • The ‘sprint distance’ idea; thinking that it’s not that far, undertraining and overdoing it on the day. Because it’s a ‘short distance’ running even if you are not feeling 100%.

What we commonly see in the medical tent with the half marathon / 21km are:


  • Acute injuries, such as fractures, pulled muscles, contusions, lacerations. Cardiac events, for example acute myocardial infarction.


  • Collapses on the finish line. After running for a period of time your blood volume accumulates in the peripheries and your calves work as a pump to move the blood back to the heart while you are running. When you stop suddenly after crossing the finish line there can be a dramatic reduction in the venous return to the heart, there is a decreased cardiac output and you will feel dizzy/have black spots in front standing in the midst of mayhem, I look around our field of your eyes and may even faint. Keep walking for a while an after finishing and if you do feel dizzy lie down immediately and raise your legs above your head.

  • Cramps. Exercise-induced muscle cramps are common in short- and long-distance races. Causes may include electrolyte imbalances but more recent evidence suggests they are due to muscle fatigue and damage during and a er events.


  • Heatstroke. With high-intensity exercise, when runners are pushing themselves in the shorter distance runs, there is a risk of developing heatstroke. This is when there is a failure of thermoregulation. Producing more heat that you can get rid of results in a dangerously raised body temperature. Central nervous system symptoms develop such as confusion, disorientation, agitation, clumsiness and eventually a reduced level of consciousness.

Being unwell, for example with a cold or flu, can also affect your body’s ability to regulate its temperature. Heatstroke is a medical emergency.

The Ultra Marathon

With having to qualify (and think a bit harder before deciding to run 56km) our ultra marathon runners are usually well trained and prepared. We see a slightly different profile in the medical tent during this race:

  • Heatstroke. Particularly if the weather is hot and humid, and more common in runners taking over 4hrs to complete the race.   Renal issues, triggered by dehydration and possibly taking antiinflammatories for the niggles picked up over the months of training.

  • Hypothermia. On cold or rainy race days and with slower running speeds.

  • Dehydration. Oten this is mild and can be attributed to heat (increased sweat loss) and inexperienced runners not taking in adequate fluids.

  • Over hydration. This occurs more often in the slower runners – less sweat with slower running speed and more opportunity to take in fluids over a longer period of time.


  • Blisters and toenail trauma.

  • Nausea and vomiting. Delayed gastric emptying occurs with endurance exercise – blood is shied away from the GIT to the muscles and therefore absorption of ingested food/ fluids is delayed and can cause issues.

  • Cardiac events. Much of this can be prevented to a certain extent with good preparation, particularly in the week before the race.

  • Injuries If you have an injury, be mindful of the implications if you just run through it for the sake of finishing.

There is a temptation to take analgesics and anti-inflammatory medication pre and during the race to mask pain, and this can be incredibly dangerous. Anti-inflammatories on top of even slight dehydration can put you into acute renal failure and sometimes result in long-term damage.

Some narcotic analgesics such as Tramadol (which has received some airtime recently after being placed on the WADA prohibited substances list) can cause drowsiness, affect your co-ordination and put you at risk of tripping and falling, causing other injuries and masking current injuries.

Illness If you have any viral illness (including gastro), upper or lower respiratory tract infection in the weeks leading up to a big race you need to see your doctor before running. The effects on your heart muscle, skeletal muscle, fitness and body reserves can be significant and put you at risk of developing a myocarditis.

Signs that you may be coming down with something include an increase in your resting heart rate, a decreased heart rate variability and feeling more fatigued than usual.

The general rule is that if you have symptoms above the neck you should avoid exercise for at least three days OR until symptoms resolve. Once you are symptom free and not needing to take any medication to mask the symptoms you can return to your exercise slowly over 2-3 days.

If you experience any rebound of symptoms you should see your doctor. If you have symptoms below the neck, such as muscle aches, fatigue, fever then you should do no exercise while you have symptoms, and then for 7 days after they resolve.

  • Immune Function We know that exercise improves our immunity, but there is an inflection point. Repeated efforts of high intensity exercise over time can reduce immune function. We are also more susceptible to upper respiratory tract infections in the 72hrs after a heavy exercise bout (> 60min at >80% of our maximum exercise capacity), the so called “open window” hypothesis. This is because exercise induces a stress response with increased cortisol, increased body temperature and certain immune changes.

To avoid getting sick, you need to avoid overtraining, ensure you fuel correctly with sufficient carbohydrates during exercise, hand wash frequently, take Vitamin C 1000mg and 20mg zinc daily during training and tapering, and – one of the most important rules – get enough sleep.

  • Tapering. The ideal taper length will vary according to your race distance, your training load and individual variations. A 2-3 week taper on average for marathon distances is beneficial and with experience you will learn what your ideal is. The aim is to slowly reduce your load while maintaining your fitness, allowing muscles to recover and restore glycogen (fuel) levels for race day. This always causes some anxiety but is an essential part of pre-race preparation.

  • Weather. Take note of the weather conditions predicted for the day and make sure that you wear appropriate clothing and plan your fluid and fuel intake accordingly.

  • Chafe and Blisters. Do not wear new shoes! Vaseline is your friend – don’t be shy to lather between toes, under arms, on the nipples (yes this is for the guys!), between the thighs and in other nooks and crannies.

  • Cat's Eyes. These can be incredibly dangerous, especially towards the end of the race when you are fatigued – clipping one with your toe can end in road rash, broken bones, lost teeth and bruised egos.

  • Earphones & Music. Many of us love listening to our favourite playlist to get us up the hills and through the dark moments. In a race situation it can be very dangerous as you may not hear marshals, emergency vehicles or other runners. Pack them away and listen to the race vibes to get you through!

  • Mediation. DO NOT take anti-inflammatory medications before or during the run. On race day, listen to the marshals and watch out for cars. Be aware of your fellow runners and look out for things which might mean trouble for them: erratic movements, tripping up or stumbling, aggression, confusion.

Make use of the medical services on the route should you not be feeling well yourself, for example feeling light-headed, any chest pain, unusual shortness of breath, nausea, or excessive cramping. And of course, have FUN out there!


Dr Lynelle Hoeks has spent time in both government hospital emergency rooms and private practice, and specialised as a sports physician through UCT. An avid trail runner, road runner, yogi, horse-rider and surfer she feels incredibly lucky to be able to combine her lifestyle and work interests in the sports medicine field. Find her at Cape Sports Medicine.


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