Recovery Methods and Medical Issues during the TransAlpineRun 2023: A Prospective Observational Study

This study systematically investigates recovery methods and medical issues among participants of the TransAlpineRun 2023, a challenging multi-day trail running competition in the Alpine region. To evaluate the effectiveness of recovery strategies and identifycommon medical issues in this setting, this study analyzed the physical, mental and nutritional recovery methods employed by athletes. Despite the increasing popularity of such events, data on the physiological and psychological impacts remain limited. Over seven days, 464 questionnaires were analyzed to evaluate recovery strategies, including sleep patterns, nutrition and physical and mental regeneration. The findings highlight traditional recovery methods, such as stretching and foam rolling, as the most utilized. Mental recovery techniques, though less common, were associated with significant positive effects on overall well-being (r = 0.15-0.17). Common medical issues included overuse symptoms like joint pain and muscular imbalances (prevalence on Day 1: 85%; Day 7: 64.3%). Optimized nutrition and sleep (average 5.37–6.93 hours) emerged as critical factors for preventing overuse complaints and supporting recovery. This study underscores the need for personalized recovery strategies and further research to enhance safety and performance in multi-day trail running events.

Key Words: Ultramarathon, Recovery Strategies, Sports Injuries, Athlete‘s Nutrition, Prevention

Multi-day trail running events such as the TransAlpineRun, pose unique physical and psychological challenges to athletes. Despite their growing popularity, research on the effectiveness of recovery strategies and associated medical complications is scarce (1). Recovery, encompassing physical, mental, and nutritional aspects, plays a pivotal role in maintaining performance and minimizing injury risks (7, 8). This study aims to provide insights into the recovery practices employed by participants of the TransAlpineRun 2023 and their effectiveness. Particular attention is given to sleep behavior, nutrition and the prevalence of injuries and medical issues, contributing to evidence-based guidelines for future multi-day endurance events.

Study Population
A convenience sample of up to 600 athletes from the TransAlpineRun 2023 formed the basis of this study. This cohort included 400 participants in 200 two-person teams and 200 solo starters. Additionally, the RUN2 event during the first two days hosted a maximum of 300 athletes. Over the seven-day event, a total of 464 completed questionnaires were collected: 140 on Day 1, 94 on Day 2, 61 on Day 3, 52 on Day 4, 38 on Day 5, 37 on Day 6, and 42 on Day 7. The participant group comprised 57.76% male (n=268) and 42.24% female (n=196), with no individuals identifying as non-binary. The mean age of the participants was 44.77 years (±1.28), ranging from 21 to 67 years. The average trail running experience reported was 8.96 years (±7.76), with a range spanning beginners to those with 55 years of experience. On average, participants had competed in the TransAlpineRun 1.65 times (±0.30), ranging from first-time participants to those with 11 previous participations. Preparatory training mileage averaged 73.07 kilometers per week (±1.46), with individual values ranging between 30 and 150 kilometers. The cohort also reported participation in an average of 26.71 trail running events (±1.68), spanning experience from one to 200 competitions. No gender-specific analyses were conducted, as this was beyond the primary scope of this observational study.

Data Collection
Data were collected through a 49-question online questionnaire designed for daily completion following each race day. The questionnaire consisted primarily of multiple-choice questions, some of which allowed multiple answers. Conditional questions required further responses depending on previous answers, e.g., when injuries or sleep disturbances were reported. Slider scales were used to assess subjective well-being. To facilitate accessibility, no registration was required, and a direct link to the questionnaire was provided. This ensured higher participation rates but precluded linking individual responses across different days, treating each questionnaire as an independent data point for analysis. All responses were anonymous and no personal identifiers were collected. The questionnaire remained accessible from 09/09/2023, to 10/04/2023, allowing retrospective completion. Initial sections gathered demographic data, running experience and training volume. Subsequent sections addressed physical recovery methods, nutrition, mental recovery, sleep, injuries and subjective evaluations of recovery strategies. Sleep quality was assessed via a visual analogue scale from 0 (very poor) to 10 (excellent), subjectively rated daily by the participants.

Ethical Considerations
The study adhered to ethical standards, with informed consent obtained from all participants via the questionnaire platform. Since data collection was anonymous and non-interventional, Institutional Review Board (IRB) approval was not required. A statement clarifying this has been included in the manuscript.

Statistical Analysis
Descriptive and exploratory statistical analyses were conducted using REDCap and Microsoft Excel. Spearman’s rank correlation coefficient was used to assess associations between recovery methods and outcome variables.

Physical Recovery Methods
During the TransAlpineRun week, 12.4% (n=59) of participants utilized physiotherapy, with 69.49% (n=41) of these sessions lasting 15–30 minutes. Stretching was used by 60.1% of participants, peaking at 68.85% (n=42) on Day 3 and decreasing to 46.34% (n=19) by Day 7. The majority of stretching sessions were brief, with 52.7% lasting under 10 minutes and 36.0% lasting 10–15 minutes. Foam rolling was reported by 40% (n=165), with usage decreasing from 44.2% (n=61) on Day 1 to 20% (n=8) on Day 7. Most foam rolling sessions lasted under 10 minutes (49.1%, n=81). Fascia pistols were used by 21.8% (n=100), with a decline from 26.1% (n=36) on Day 1 to 9.8% (n=4) on Day 7. The most frequently treated areas included the calves (14.62%) and quadriceps (14.36%) (figure 1).

Statistical analysis showed significant correlations between recovery methods and outcomes. Cold-water immersion showed a significant correlation with injury prevention (r=0.26, p<0.01). Stretching (r=0.16, p<0.01) and physiotherapy (r=0.14, p<0.01) also correlated positively with injury minimization. Sauna use (r=-0.14, p<0.01) and compression clothing (r=-0.10, p=0.03) showed negative correlations. With respect to performance, positive correlations were observed for physiotherapy (r=0.23, p<0.01), foam rolling (r=0.21, p<0.01), and recovery boots (r=0.15, p<0.01) (figure 2).

Mental Recovery Methods
Mental recovery strategies were reported by 14.0% (n=65) of participants. The highest usage was on Day 1 (19.4%, n=27) and the lowest on Day 7 (7.1%, n=3). Techniques included progressive muscle relaxation (2.8%, n=13), autogenic training (2.4%, n=11), and meditation (5.9%, n=27). Mental recovery was correlated with physical well-being (r=0.19, p=0.016). Meditation (r=0.0003, p=0.006) and autogenic training (r=0.07, p=0.021) showed positive associations. A negative correlation was observed between meditation and performance (r=-0.14, p=0.004). Correlations with reduced injury prevalence were also found (r=0.18, p<0.01) (figure 3).

Sleep Patterns
Average sleep duration ranged from 5.37 hours (Day 1) to 6.93 hours (Day 7), with significant variation across days (F=5.65, p<0.00001). Sleep duration declined from Day 1 to Day 4 and increased again toward Day 7. Reported strategies to enhance sleep included earplugs (17.9%, n=83), motivation from achievement (10.6%, n=49), and melatonin (7.1%, n=33). Sleep quality ratings were significantly improved by earplugs (p=0.012), weighted blankets (p=0.014), melatonin (p=0.010), and guided sleep meditation (p<0.001). Sleep quality was correlated with physical (r=0.44), mental (r=0.41), and overall well-being (r=0.50). No significant correlation with performance or injury prevention was observed (figure 4).

Medical Issues
The prevalence of overuse symptoms, such as joint pain and muscular imbalances, decreased from 85% on Day 1 to 64.3% on Day 7. The most frequently reported joint issue was knee pain (13.1%, n=61), followed by ankle pain (4.3%, n=20) and hip pain (3.1%, n=14). Muscle soreness was most commonly reported in the thighs (31.7%, n=147) and calves (14.0%, n=65); 62.7% of participants reported no muscle soreness.
Muscle cramps affected 11.6% of participants, particularly in the thighs (6.5%, n=30) and calves (4.3%, n=20). Skin-related issues included abrasions (5.0%, n=23), hematomas (4.6%, n=10), and blisters (26.3%). Blisters were most common on the toes (6.0%, n=28), balls of the feet (3.4%, n=16), and heels (5.4%, n=25). Less than 1% reported skin irritation.

Tendon pain affected 13.4%, with the Achilles tendon most commonly affected (6.0%, n=28), followed by plantar fascia and patellar tendons (each ~3%). Other general complaints included fatigue (6.4%, n=30), headaches (7.3%, n=34), and nausea (4.1%, n=19). No fractures were reported. A significant decrease in reported complaints was observed after Day 4. Recovery strategies such as stretching, foam rolling, and compression were significantly associated with reduced injury prevalence (p<0.01) (figure 5).

Nutrition
Participants’ diets were primarily omnivorous (65.9%), followed by vegetarian (26.8%) and vegan (5.4%) diets. Fluid intake varied, with 49.7% consuming 3–4 liters/day and 37.1% consuming 5–6 liters/day. Changes in nutritional habits included increased use of energy bars (p=0.01), on-course nutrition (p<0.01), and carbohydrate-rich drinks (p<0.01). Magnesium (r=0.258, p<0.01) and vitamin B (r=0.112, p=0.02) showed positive correlations with recovery and reduced injury incidence. Participants who did not use supplements reported worse outcomes.

Self-Assessment and Recovery
Subjective ratings of well-being fluctuated over the event week, reaching the lowest point on Day 4. Positive correlations were observed between well-being and physiotherapy (r=0.17), stretching (r=0.14), and sleep quality (r=0.21). Recovery method effectiveness varied significantly between individuals (p=0.04).

While this study explored associations between recovery strategies and self-reported outcomes, the primary aim was to provide a descriptive overview of the methods employed during a multi-stage ultramarathon. All statistical analyses were exploratory in nature, and the observed associations must be interpreted with caution due to small effect sizes and the non-interventional design of the study.

Physical Recovery
Recovery methods such as physiotherapy, stretching, and electrical muscle stimulation (EMS) were consistently used across race days, highlighting their routine integration in athletes’ recovery behaviors. The positive correlation between stretching and injury prevention (r=0.16, p<0.01) supports its role in maintaining flexibility and reducing muscle tension (10), though the small effect size suggests limited clinical relevance. Similarly, physiotherapy showed a modest correlation with injury minimization (r=0.14, p<0.01) and performance enhancement (r=0.23, p<0.01), indicating a perceived benefit.
Cold-water immersion demonstrated the strongest association with injury prevention (r=0.26, p<0.01) and may support recovery through reduced inflammation and improved circulation (8). However, the correlation remains weak and should not be overinterpreted. Foam rolling (r=0.21, p<0.01) and recovery boots (r=0.15, p<0.01) also showed positive associations with performance. These observations may reflect adaptive use of recovery tools based on perceived physical demands rather than proven effectiveness.
Conversely, sauna use was negatively correlated with performance (r=-0.14, p=0.0035) and injury prevention (r=-0.16, p=0.00075), possibly due to dehydration or thermal strain post-exercise (16). Compression clothing also showed a weak negative correlation with injury prevention (r=-0.10, p=0.03). These findings underline the importance of context-specific application of recovery strategies and further highlight the variability in individual responses.

Although athletes appeared to increase their use of specific methods on days perceived as more physically demanding, no objective measure of workload was collected. As such, changes in usage patterns may reflect subjective perception rather than actual physiological need.

Mental Recovery
Mental recovery strategies were reported by 14.0% (n=65) of participants and included meditation, autogenic training, and progressive muscle relaxation. While these methods were underutilized, they demonstrated positive correlations with physical well-being (r=0.19, p=0.016) and reduced injury prevalence (r=0.18, p<0.01). Autogenic training (r=0.07, p=0.021) and meditation (r=0.0003, p=0.006) were specifically associated with improved well-being, aligning with their known stress-reducing effects (17).

However, meditation also showed a negative correlation with performance (r=-0.14, p=0.004), which may reflect competing priorities between relaxation and physical arousal. These findings support the potential role of psychological recovery but also highlight the need for further exploration regarding their influence on performance (15).

Nutrition and Supplementation
Participants displayed diverse nutritional profiles, with omnivorous (65.9%), vegetarian (26.8%), and vegan (5.4%) diets (10). Supplement use revealed small but significant associations: magnesium supplementation correlated with recovery and reduced injury incidence (r=0.258, p<0.01), and vitamin B with improved outcomes (r=0.112, p=0.02). These findings support previous evidence on micronutrient roles in muscle function and metabolic recovery (1). However, dosage, timing, and compliance were not standardized, limiting the interpretability of these associations.

Hydration strategies also showed stage-dependent variation, particularly on Day 5, and underline the logistical and environmental challenges of fluid intake during prolonged competition (2) (figure 6).

Sleep
Sleep duration ranged from 5.37 to 6.93 hours per night, remaining below recommended thresholds for athletic recovery. A significant day-to-day variation was observed (F=5.65, p<0.00001), with the lowest values mid-race and a slight increase toward Day 7. Sleep quality, assessed via a visual analogue scale, showed moderate positive correlations with physical (r=0.44), mental (r=0.41), and overall well-being (r=0.50) (6, 12).

Sleep-enhancing interventions such as melatonin (p=0.010), earplugs (p=0.012), weighted blankets (p=0.014), and guided sleep meditation (p<0.001) were reported to improve subjective sleep quality (3). While promising, these findings remain subjective and should be confirmed using objective sleep assessments in future studies (figure 7).

Injuries and Medical Issues
The prevalence of overuse complaints, particularly joint pain (knee: 13.1%, ankle: 4.3%, hip: 3.1%) and muscle soreness (thighs: 31.7%, calves: 14.0%), declined over the course of the event (9). Muscle cramps were most frequently reported in the thighs (6.5%) and calves (4.3%). Other issues included abrasions (5.0%), hematomas (4.6%), and blisters (26.3%).

Stretching and foam rolling were significantly associated with reduced injury prevalence (p<0.01), consistent with previous literature on overuse injury prevention (7). However, these findings are based on self-report and may be influenced by confounding variables such as athlete experience, pain tolerance, or training background.

The reduction in injury rates over time may also reflect adaptation processes or increasing use of recovery strategies as the race progressed (11,13). No serious injuries (e.g., fractures) were reported.

Self-Assessment
Subjective well-being showed significant day-to-day variation, with the lowest ratings on Day 4. Positive correlations were found between well-being and the use of physiotherapy (r=0.17), stretching (r=0.14), and sleep quality (r=0.21) (18). Perceived performance improvements were reported by 55.92% of participants, yet only 13.38% noted objectively measurable gains. This discrepancy underscores the multifaceted nature of recovery and the importance of individualized approaches.
The significant variation in perceived strategy effectiveness (p=0.03841) further highlights that recovery is a highly personal process, shaped by subjective experience, physical condition, and individual expectations (5, 14).

This study has several limitations. First, due to the anonymous and voluntary nature of data collection, participant self-selection may have introduced bias, particularly favoring more motivated or health-conscious individuals. Second, the inability to match daily responses across timepoints precluded longitudinal tracking of individual recovery patterns. Each questionnaire was treated as an independent data point, limiting insights into intra-individual changes. Third, all data were self-reported and thus susceptible to recall bias, social desirability bias, and subjective interpretation. No objective physiological or performance metrics were collected to corroborate self-reported outcomes. Furthermore, the small effect sizes observed in statistical analyses (r<0.3) limit the clinical relevance of many associations, emphasizing the exploratory nature of the study. Lastly, no gender-specific or subgroup analyses were conducted, which may mask important variations between different athlete populations. Future studies should consider longitudinal designs, biomarker integration, and stratified analyses to strengthen the evidence base. Importantly, this study does not aim to establish causal relationships but rather offers an exploratory, descriptive overview of recovery behaviors and experiences during a multiday endurance event. The findings serve as a starting point for further research and underscore the need for personalized, evidence-informed recovery strategies.

This observational study provides a descriptive overview of the recovery strategies employed by participants in a multi-day ultramarathon. While associations between specific recovery methods and outcomes such as injury prevention, perceived performance, and well-being were identified, effect sizes were generally small and should be interpreted cautiously.

Physical Recovery
Recovery modalities such as physiotherapy, stretching, and cold-water immersion were commonly used and showed modest associations with injury prevention and subjective well-being. The negative correlations observed for sauna use suggest potential drawbacks under certain conditions, possibly due to dehydration or thermal strain. These findings underscore the importance of context-specific recovery planning but should not be generalized without further controlled research.

Mental Recovery
Despite limited adoption, mental recovery techniques (e.g., meditation, autogenic training) were positively associated with subjective well-being. These results highlight a potentially underutilized area in endurance sports that merits greater attention and athlete education.

Nutrition and Supplementation
Dietary patterns varied widely among participants. Supplement use, particularly magnesium and vitamin B, showed positive associations with recovery and reduced injury prevalence, although causal conclusions cannot be drawn due to the observational nature of the study.

Sleep
Sleep emerged as a critical but often insufficiently addressed component of recovery, with average durations below recommended thresholds. Positive correlations between sleep quality and well-being suggest that individualized sleep strategies may offer meaningful benefits during high-demand events.

Medical Issues and Self-Assessment
Participants reported a range of medical complaints, with a decline over time that may reflect adaptation and increasing use of recovery measures. However, subjective performance gains often diverged from objective outcomes, underscoring the complexity of recovery perception and the need for individualized approaches.

Outlook
Overall, this study offers exploratory insights rather than definitive conclusions. The observed associations are hypothesis-generating and highlight the need for longitudinal, biomarker-based studies with controlled designs to evaluate the efficacy of recovery strategies in endurance athletes. Tailored, evidence-informed recovery practices integrating physical, mental, nutritional, and sleep-related components remain a promising avenue for supporting athlete health and performance in multi-day events.

Conflict of Interest
The authors have no conflict of interest.

Ethical Approval
The study adhered to ethical standards, with informed consent obtained from all participants via the questionnaire platform. Since data collection was anonymous and non-interventional, Institutional Review Board (IRB) approval was not required. A statement clarifying this has been included in the manuscript.

What is known about this topic? Recovery methods are essential for endurance athletes to maintain performance and reduce injury risks.

What does this study add? This study highlights the importance of personalized recovery strategies and identifies critical factors such as sleep and nutrition in multiday trail running events.