Elite athletes often undertake altitude training to improve sea-level athletic performance, yet the optimal methodology has not been established. A combined approach of live high/train low plus train high (LH/TL+TH) may provide an additional training stimulus to enhance performance gains. Seventeen male and female middle-distance runners with maximal aerobic power (VO2max) of 65.5 +/- 7.3 mL kg(-1) min(-1) (mean +/- SD) trained on a treadmill in normobaric hypoxia for 3 weeks (2,200 m, 4 week(-1)). During this period, the train high (TH) group (n = 9) resided near sea-level (approximately 600 m) while the LH/TL+TH group (n = 8) stayed in normobaric hypoxia (3,000 m) for 14 hours day(-1). Changes in 3-km time trial performance and physiological measures including VO2max, running economy and haemoglobin mass (Hb(mass)) were assessed. The LH/TL+TH group substantially improved VO2max (4.8%; +/-2.8%, mean; +/-90% CL), Hb(mass) (3.6%; +/-2.4%) and 3-km time trial performance (-1.1%; +/-1.0%) immediately post-altitude. There was no substantial improvement in time trial performance 2 weeks later. The TH group substantially improved VO2max (2.2%; +/-1.8%), but had only trivial changes in Hb(mass) and 3-km time-trial performance. Compared with TH, combined LH/TL+TH substantially improved VO2max (2.6%; +/-3.2%), Hb(mass) (4.3%; +/-3.2%), and time trial performance (-0.9%; +/-1.4%) immediately post-altitude. LH/TL+TH elicited greater enhancements in physiological capacities compared with TH, however, the transfer of benefits to time-trial performance was more variable.