Journal of Human Sport and Exercise

Significant effusion in the joints of the lower extremity after running an ultramarathon in extreme conditions

Gino Steinmetz, Sebastian Höller, Jan Hubert, Thelonius Hawellek, Arndt Friedrich Schilling, Dominik Saul


Introduction: The “Brocken challenge” ultramarathon takes place in the cold of February over 80 km with 1,900 m of elevation change. The purpose of this study was to evaluate the effects of an ultramarathon under extreme conditions on the lower extremities. Methods: Out of the 182 starters, 44 athletes were included into the study (n = 44). We examined these athletes using a questionnaire, by measuring circumferences of their lower extremities and by standardized sonographic measurement of joint effusion of knee and ankle joints before and after the run. Results: After the run, the right leg and both feet significantly increased in circumference. Knee joints on both sides and the left ankle joint showed significantly more effusion after the run (right knee: 84%, right ankle: 43%; left knee: 80%, left ankle: 48%). Heavier and less trained athletes showed significantly more effusion in sonographic assessment of the knee and ankle. Neither swelling, nor effusion had a measurable influence on finishing time. Conclusions: Running an ultramarathon in the cold overloads the fluid draining capacity in the muscles and joints of the legs especially in heavier and less trained athletes without measurable immediate effect on performance.


Marathon; Physiology; Swelling; Effusion; Sonography


Aumüller, G. (2007). Anatomie: 208 Tabellen ; [mit CD-ROM zum Präp-Kurs]. Duale Reihe. Stuttgart: Thieme.

Bergeron, M. F. (2014). Heat stress and thermal strain challenges in running. The Journal of orthopaedic and sports physical therapy, 44(10), 831-838.

Bracher, A., Knechtle, B., Gnädinger, M., Bürge, J., Rüst, C. A., Knechtle, P., & Rosemann, T. (2012). Fluid intake and changes in limb volumes in male ultra-marathoners: Does fluid overload lead to peripheral oedema? European journal of applied physiology, 112(3), 991-1003.

Carmona, G., Roca, E., Guerrero, M., Cussó, R., Irurtia, A., Nescolarde, L., et al. (2015). Sarcomere Disruptions of Slow Fiber Resulting From Mountain Ultramarathon. International journal of sports physiology and performance, 10(8), 1041-1047.

Case, S., Evans, D., Tibbets, G., & Miller, D. (1995). Dietary intakes of participants in the IditaSport Human Powered Ultra-marathon. Alaska medicine, 37(1), 20-24.

Cejka, C., Knechtle, B., Knechtle, P., Rüst, C. A., & Rosemann, T. (2012). An increased fluid intake leads to feet swelling in 100-km ultra-marathoners - an observational field study. Journal of the International Society of Sports Nutrition, 9(1), 11.

Chávez-López, M. A., Hernández-Díaz, C., Moya, C., Pineda, C., Ventura-Ríos, L., Möller, I., et al. (2013). Inter- and intra-observer agreement of high-resolution ultrasonography and power Doppler in assessment of joint inflammation and bone erosions in patients with rheumatoid arthritis. Rheumatology international, 33(1), 173-177.

Christodoulou, A. G., Givissis, P., Antonarakos, P. D., Petsatodis, G. E., Hatzokos, I., & Pournaras, J. D. (2010). Knee joint effusion following ipsilateral hip surgery. Journal of orthopaedic surgery (Hong Kong), 18(3), 309-311.

Costa, R. J. S., Snipe, R., Camões-Costa, V., Scheer, V., & Murray, A. (2016). The Impact of Gastrointestinal Symptoms and Dermatological Injuries on Nutritional Intake and Hydration Status During Ultramarathon Events. Sports medicine - open, 2, 16.

Del Coso, J., González, C., Abian-Vicen, J., Salinero Martín, J. J., Soriano, L., Areces, F., et al. (2014). Relationship between physiological parameters and performance during a half-ironman triathlon in the heat. Journal of sports sciences, 32(18), 1680-1687.

Frey, W., Wassmer, P., Frey-Rindova, P., Braun, D., Schwarz, F., Arnold, M., et al. (1994). Muskelschmerzen und biochemische Veränderungen nach einem Ultramarathon in der Kälte--Beeinflussung durch Diclofenac [Muscle aches and biochemical changes following a ultra-marathon in the cold--modification by diclofenac]. Schweizerische Zeitschrift fur Medizin und Traumatologie = Revue suisse pour medecine et traumatologie. (2), 30-36.

Gaulrapp, H. Funktionelle sonografische Diagnostik bei fibularer Kapselbandläsion: Gaulrapp H. Functional sonography in lateral ankle joint sprains. Unpublished manuscript, OUP 2014, 3: 100-104.

Hartung, W., Kellner, H., Strunk, J., Sattler, H., Schmidt, W. A., Ehrenstein, B., et al. (2012). Development and evaluation of a novel ultrasound score for large joints in rheumatoid arthritis: One year of experience in daily clinical practice. Arthritis care & research, 64(5), 675-682.

Hoffman, M. D., Ong, J. C., & Wang, G. (2010). Historical analysis of participation in 161 km ultramarathons in North America. The International journal of the history of sport, 27(11), 1877-1891.

Hoffman, M. D., & Wegelin, J. A. (2009). The Western States 100-Mile Endurance Run: Participation and performance trends. Medicine and science in sports and exercise, 41(12), 2191-2198.

Hung, A., Sayre, E. C., Guermazi, A., Esdaile, J. M., Kopec, J. A., Thorne, A., et al. (2016). Association of Body Mass Index With Incidence and Progression of Knee Effusion on Magnetic Resonance Imaging and on Knee Examination. Arthritis care & research, 68(4), 511-516.

Ishikawa, M., Dousset, E., Avela, J., Kyröläinen, H., Kallio, J., Linnamo, V., et al. (2006). Changes in the soleus muscle architecture after exhausting stretch-shortening cycle exercise in humans. European journal of applied physiology, 97(3), 298-306.

Jacobson, J. A., Ruangchaijatuporn, T., Khoury, V., & Magerkurth, O. (2017). Ultrasound of the Knee: Common Pathology Excluding Extensor Mechanism. Seminars in musculoskeletal radiology, 21(2), 102-112.

Kane, D., Balint, P. V., & Sturrock, R. D. (2003). Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis. The Journal of rheumatology, 30(5), 966-971.

Kingston, A.-R., Toms, A. P., Ghosh-Ray, S., & Johnston-Downing, S. (2009). Does running cause metatarsophalangeal joint effusions? A comparison of synovial fluid volumes on MRI in athletes before and after running. Skeletal radiology, 38(5), 499-504.

Knechtle, B., Knechtle, P., & Lepers, R. (2011). Participation and performance trends in ultra-triathlons from 1985 to 2009. Scandinavian journal of medicine & science in sports, 21(6), e82-90.

Knechtle, B., Wirth, A., Knechtle, P., Zimmermann, K., & Kohler, G. (2009). Personal best marathon performance is associated with performance in a 24-h run and not anthropometry or training volume. British journal of sports medicine, 43(11), 836-839.

Krampla, W., Mayrhofer, R., Malcher, J., Kristen, K. H., Urban, M., & Hruby, W. (2001). MR imaging of the knee in marathon runners before and after competition. Skeletal radiology, 30(2), 72-76.

Kursunoglu-Brahme, S., Schwaighofer, B., Gundry, C., Ho, C., & Resnick, D. (1990). Jogging causes acute changes in the knee joint: An MR study in normal volunteers. AJR. American journal of roentgenology, 154(6), 1233-1235.

Lohman, M., Kivisaari, A., Vehmas, T., Kallio, P., Malmivaara, A., & Kivisaari, L. (2001). MRI abnormalities of foot and ankle in asymptomatic, physically active individuals. Skeletal radiology, 30(2), 61-66.

Magrini, D., Khodaee, M., San-Millán, I., Hew-Butler, T., & Provance, A. J. (2017). Serum creatine kinase elevations in ultramarathon runners at high altitude. The Physician and sportsmedicine, 45(2), 129-133.

Millet, G. Y., Banfi, J. C., Kerherve, H., Morin, J. B., Vincent, L., Estrade, C., et al. (2011). Physiological and biological factors associated with a 24 h treadmill ultra-marathon performance. Scandinavian journal of medicine & science in sports, 21(1), 54-61.

Millet, G. P., & Millet, G. Y. (2012). Ultramarathon is an outstanding model for the study of adaptive responses to extreme load and stress. BMC medicine, 10, 77.

Parise, C. A., & Hoffman, M. D. (2011). Influence of temperature and performance level on pacing a 161 km trail ultramarathon. International journal of sports physiology and performance, 6(2), 243-251.

Proft, F., Grunke, M., Reindl, C., Schramm, M. A., Mueller, F., Kriegmair, M., et al. (2016). The influence of long distance running on sonographic joint and tendon pathology: Results from a prospective study with marathon runners. BMC musculoskeletal disorders, 17, 272.

Rundfeldt, L. C., Maggioni, M. A., Coker, R. H., Gunga, H.-C., Riveros-Rivera, A., Schalt, A., & Steinach, M. (2018). Cardiac Autonomic Modulations and Psychological Correlates in the Yukon Arctic Ultra: The Longest and the Coldest Ultramarathon. Frontiers in physiology, 9, 35.

Salinero, J. J., Soriano, M. L., Lara, B., Gallo-Salazar, C., Areces, F., Ruiz-Vicente, D., et al. (2017). Predicting race time in male amateur marathon runners. The Journal of sports medicine and physical fitness, 57(9), 1169-1177.

Scheer, B. V., & Murray, A. (2011). Al Andalus Ultra Trail: An observation of medical interventions during a 219-km, 5-day ultramarathon stage race. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 21(5), 444-446.

Schmid, W., Knechtle, B., Knechtle, P., Barandun, U., Rüst, C. A., Rosemann, T., & Lepers, R. (2012). Predictor variables for marathon race time in recreational female runners. Asian journal of sports medicine, 3(2), 90-98.

Schueller-Weidekamm, C., Schueller, G., Uffmann, M., & Bader, T. R. (2006a). Does marathon running cause acute lesions of the knee? Evaluation with magnetic resonance imaging. European radiology, 16(10), 2179-2185.

Schueller-Weidekamm, C., Schueller, G., Uffmann, M., & Bader, T. (2006b). Incidence of chronic knee lesions in long-distance runners based on training level: Findings at MRI. European journal of radiology, 58(2), 286-293.

Schünke, M., Schulte, E., & Schumacher, U. (2015). Innere Organe (4., überarbeitete und erweiterte Auflage). Prometheus: LernAtlas der Anatomie / Michael Schünke, Erik Schulte, Udo Schumacher ; Illustrationen von Markus Voll, Karl Wesker. Stuttgart, New York: Georg Thieme Verlag.

Schütz, U. H. W., Ellermann, J., Schoss, D., Wiedelbach, H., Beer, M., & Billich, C. (2014). Biochemical cartilage alteration and unexpected signal recovery in T2* mapping observed in ankle joints with mobile MRI during a transcontinental multistage footrace over 4486 km. Osteoarthritis and cartilage, 22(11), 1840-1850.

Scrimgeour, A. G., Noakes, T. D., Adams, B., & Myburgh, K. (1986). The influence of weekly training distance on fractional utilization of maximum aerobic capacity in marathon and ultramarathon runners. European journal of applied physiology and occupational physiology, 55(2), 202-209.

Shellock, F. G., & Mink, J. H. (1991). Knees of trained long-distance runners: MR imaging before and after competition. Radiology, 179(3), 635-637.

Soderberg, G. L., Ballantyne, B. T., & Kestel, L. L. (1996). Reliability of lower extremity girth measurements after anterior cruciate ligament reconstruction. Physiotherapy research international : the journal for researchers and clinicians in physical therapy, 1(1), 7-16.

Stuempfle, K. J., Hoffman, M. D., & Hew-Butler, T. (2013). Association of gastrointestinal distress in ultramarathoners with race diet. International journal of sport nutrition and exercise metabolism, 23(2), 103-109.

Stuempfle, K. J., Lehmann, D. R., Case, H. S., Bailey, S., Hughes, S. L., McKenzie, J., & Evans, D. (2002). Hyponatremia in a cold weather ultraendurance race. Alaska medicine, 44(3), 51-55.

Stuempfle, K. J., Valentino, T., Hew-Butler, T., Hecht, F. M., & Hoffman, M. D. (2016). Nausea is associated with endotoxemia during a 161-km ultramarathon. Journal of sports sciences, 34(17), 1662-1668.

Stuempfle, K. J., & Hoffman, M. D. (2015). Gastrointestinal distress is common during a 161-km ultramarathon. Journal of sports sciences, 33(17), 1814-1821.

Tanda, G., & Knechtle, B. (2013). Marathon performance in relation to body fat percentage and training indices in recreational male runners. Open access journal of sports medicine, 4, 141-149.

Terslev, L., D'Agostino, M. A., Brossard, M., Aegerter, P., Balint, P., Backhaus, M., et al. (2012). Which knee and probe position determines the final diagnosis of knee inflammation by ultrasound? Results from a European multicenter study. Ultraschall in der Medizin (Stuttgart, Germany : 1980), 33(7), E173-8.

Theysohn, J. M., Kraff, O., Maderwald, S., Kokulinsky, P. C., Ladd, M. E., Barkhausen, J., & Ladd, S. C. (2013). MRI of the ankle joint in healthy non-athletes and in marathon runners: Image quality issues at 7.0 T compared to 1.5 T. Skeletal radiology, 42(2), 261-267.

Thijs, W., Rabe, K. F., Rosendaal, F. R., & Middeldorp, S. (2010). Predominance of left-sided deep vein thrombosis and body weight. Journal of thrombosis and haemostasis : JTH, 8(9), 2083-2084.

Vassalle, C., Masotti, S., Lubrano, V., Basta, G., Prontera, C., Di Cecco, P., et al. (2018). Traditional and new candidate cardiac biomarkers assessed before, early, and late after half marathon in trained subjects. European journal of applied physiology, 118(2), 411-417.

Vernillo, G., Rinaldo, N., Giorgi, A., Esposito, F., Trabucchi, P., Millet, G. P., & Schena, F. (2015a). Changes in lung function during an extreme mountain ultramarathon. Scandinavian journal of medicine & science in sports, 25(4), e374-80.

Vernillo, G., Schena, F., Berardelli, C., Rosa, G., Galvani, C., Maggioni, M., et al. (2013). Anthropometric characteristics of top-class Kenyan marathon runners. The Journal of sports medicine and physical fitness, 53(4), 403-408.

Vernillo, G., Millet, G. P., & Millet, G. Y. (2017). Does the Running Economy Really Increase after Ultra-Marathons? Frontiers in physiology, 8, 783.

Vernillo, G., Savoldelli, A., Skafidas, S., Zignoli, A., La Torre, A., Pellegrini, B., et al. (2016). An Extreme Mountain Ultra-Marathon Decreases the Cost of Uphill Walking and Running. Frontiers in physiology, 7, 530.

Vernillo, G., Savoldelli, A., Zignoli, A., Skafidas, S., Fornasiero, A., La Torre, A., et al. (2015b). Energy cost and kinematics of level, uphill and downhill running: Fatigue-induced changes after a mountain ultramarathon. Journal of sports sciences, 33(19), 1998-2005.

Virchow, R. (1851). Ueber die Erweiterung kleinerer Gefäfse. Archiv für Pathologische Anatomie und Physiologie und für Klinische Medicin, 3(3), 427-462.

Visconti, L., Capra, G., Carta, G., Forni, C., & Janin, D. (2015). Effect of massage on DOMS in ultramarathon runners: A pilot study. Journal of bodywork and movement therapies, 19(3), 458-463.

Vitiello, D., Degache, F., Saugy, J. J., Place, N., Schena, F., & Millet, G. P. (2015). The increase in hydric volume is associated to contractile impairment in the calf after the world's most extreme mountain ultra-marathon. Extreme physiology & medicine, 4, 18.

Vitiello, D., Rupp, T., Bussière, J.-L., Robach, P., Polge, A., Millet, G. Y., & Nottin, S. (2013). Myocardial damages and left and right ventricular strains after an extreme mountain ultra-long duration exercise. International journal of cardiology, 165(2), 391-392.

Warren, G. L., Cureton, K. J., & Sparling, P. B. (1989). Does lung function limit performance in a 24-hour ultramarathon? Respiration physiology, 78(2), 253-263.

Weltgesundheitsorganisation (1995). Physical status: the use and interpretation of anthropometry: Report of a WHO expert committee. Technical report series / World Health Organization: Vol. 854. Geneva.

Williams, E. S., Ward, M. P., Milledge, J. S., Withey, W. R., Older, M. W., & Forsling, M. L. (1979). Effect of the exercise of seven consecutive days hill-walking on fluid homeostasis. Clinical science (London, England : 1979), 56(4), 305-316.

World Health Organization (WHO) (2004). BMI classification. Retrieved April 13, 2018, from

Yang, X.-G., Wang, Y., Bao, D.-P., & Hu, Y. (2015). Anthropometric Characteristics of Chinese Professional Female Marathoners and Predicted Variables for Their Personal Bests. Collegium antropologicum, 39(4), 899-905.

Žákovská, A., Knechtle, B., Chlíbková, D., Miličková, M., Rosemann, T., & Nikolaidis, P. T. (2017). The Effect of a 100-km Ultra-Marathon under Freezing Conditions on Selected Immunological and Hematological Parameters. Frontiers in physiology, 8, 638.


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