Cycling and Blood Clots?
Cycling and blood clots are generally not topics that enter the same conversation. Cycling brings to mind sport, physical fitness, and a healthy lifestyle, where blood clots bring to mind cardiovascular disease, stroke, and generally poor health. Recently though, cycling and blood clots have been used in my conversations together every day.
My right leg has been a mystery to me ever since I began racing. Even though it is my dominant leg, and I tore the anterior cruciate ligament in my left knee, my right leg was always the weak one. It would always fail before my left leg would even feel an effort on the bike, and be weaker when beginning strength training in the off-season. My right leg would fill up with this incredible burning pain, far worse than the normal lactic acid burn, in time trials and on long climbs, where my left leg would be fine.
Year after year, I would ask every doctor I had access to for input on this problem. Most of them said I just had a cramping problem or did not warm up enough. The others said they were stumped and really had no explanation. This includes the very cycling knowledgeable physicians I had access to when with the National Team and now have with the Mercury Cycling Team. While the problem worsened each year, I assumed that my right leg was just my weak link. I have learned to manage my cycling to accommodate it. I have gotten extremely good at governing my efforts, knowing how much pain I can tolerate in my right leg, and focusing on my left leg. When races forced me past the limit, my right leg fills with pain and becomes useless. Unless there is a rest quickly, I have to stop pedaling and click out for a few minutes. This all changed May 12th.
I had rested after fighting through the Tour of the Gila, and went out that day to start a block of endurance/tempo rides to prepare for the six-hour duration of the First Union USPRO Championships. About five-and-a-half hours into the ride, the usual burning pain began to build in my right leg at tempo pace. By the time I got home, at six-and-a-half-hours, I had the burning symptoms warming down. The next day, I couldn’t even pedal or walk for more than thirty seconds without the pain. My leg also had a strange background ache. I figured that I had just really over-done it the day before, since it was the highest average heart rate for the duration ride I had ever done. I tried to ride again the next day, but nothing changed. I figured another big rest day was in order, and then on to Arlington, Virginia for the Clarendon Cup and some help from our team’s therapist. There was no change as I lasted one lap. I returned home that night and went straight to a doctor the next morning.
I described my symptoms to the doctor and, after talking for a bit, he tried to find a pulse in my right leg. He found none! There was no pulse in my foot, behind my knee, or in my groin where on my left side I could see it through my skin. He immediately set up an appointment with a vascular surgeon for further investigation. I reported to the surgeon, and he scheduled me for an ultrasound and an arteriolegram study that afternoon.
An arteriolegram is an interior vascular study where a catheter is inserted into a blood vessel and a guide-wire is maneuvered through the vessel to the area of investigation. A contrasting substance is released up-stream, and then x-ray pictures are taken of the blood flow. It shows exactly where there are any obstructions or defects. It took about two seconds for my problem to be identified. I had a complete occlusion of my right iliac artery. In other words, I had a big-old clot plugging up the main pipe that goes into my right leg. I also had quite a bit of collateral development around the clot keeping my leg infused with enough blood to keep it alive. The extent of the collateral development made it evident that I have had a clot and obstruction there for many years. They also found five more clots throughout my leg. The next thing I knew, I was in a midnight ambulance headed for the Oregon Health Sciences University Hospital (OHSU) in Portland to start intravenous anti-coagulant medication and to be worked on by the nationally renowned vascular surgery team headed by Dr. Taylor.
Bright and early, they did another arteriolegram on me, and then later went into the artery again to attempt to break-up the clots. Most of the time, with clots of this magnitude and age, they are not successful in dissolving them. It was time I had some luck though. They were able to break up all but one clot down in my calf, which would not be a long-term problem. They were also able to identify why I had clotting to begin with. This is when I first heard the sport of cycling and the term blood clot used in the same sentence.
Over the next seven days at OHSU, I learned a lot about the rare connection between cycling and blood clots. My personal anatomy and the bent over cycling position caused the clotting. The constant bent-at-the-waist position, in conjunction with the action of some of the muscles that stabilize the rotation of my right leg, have been pinching and twisting my iliac artery against my inguinal ligament. That ligament, for the most part, is the crease in your groin. For whatever reason, my right side is just different than the left and not compatible with the amount and intensity of cycling I was doing. When I am on the bike, my artery is pinched off a bit. At the top of my pedal stroke it is nearly completely pinched off by the inguinal ligament. After a few years of riding and racing, probably in the late ‘80’s, clotting began to form near the obstructed area. Gradually, and in spurts, the clot grew until it plugged the whole artery. The infamous “leg lock”, as my Mercury teammates named it a couple of years ago, is a personal, cycling related biomechanical problem that has been with me my whole life. Although a most uncomfortable and frustrating experience, I finally had an explanation for “leg lock” and a cure.
Dr. Taylor and his team sent me home, on anti-coagulant medication and a cycling ban, for six weeks of recuperation before surgery to fix my artery. They at least needed to clear out some scar tissue surrounding the artery, and eliminate the pinching and twisting of the artery caused by the interaction between it, the inguinal ligament, and stabilizing muscles. The arteriolegram did show some damage inside of the artery, after the clot was dissolved, so they also thought that an artificial bypass might be needed. On June 30, I checked into OHSU hospital to be repaired.
My second hospital stay started off extremely well. They did another arteriolegram to assess the interior damage and found a clean, smooth tube. The internal vascular damage they suspected turned out to be just clotting that had dissolved. No Gore-Tex tubes for me! When they went in, they relieved the pinching and twisting of my artery by making an incision in my inguinal ligament, clearing out some scar and connective tissue, and in general making an obstruction-free path for my artery.
Believe it or not, I am one of the luckier people to have this problem. Most people require a bypass and/or have the problem on both sides. Although rare, it is not unheard of in cyclists. It is extremely hard to diagnose before major clotting. Most undiagnosed riders with the vascular problem decide right away that cycling is just too painful, and quit due to the symptoms. Cycling can be painful at times, but let me tell you, a good lactic acid burn is nothing compared to the pain this problem brings when pushed. What would most doctors say when you tell them that you feel a building and extended, excruciating, burning pain when you go hard on the bike? They would probably say, “Why don’t you just slow down” and not “Hmmm, I bet you have an obstructed artery.”
There are several cases in European riders, and in a growing number of Americans riders as well, who have gone through the same ordeal as myself. Ironically, while I warmed up for this year’s Redlands time trial stage, an ex-teammate of mine, Harm Jansen from Holland, suggested that my decline in time trial performance may be due to a vascular problem in my groin. The possibility was familiar to him from Europe.
I’ll be back on the bike in August, and when I get off the anti-coagulant, be able to start racing locally a few weeks later in preparation for next year. After all, I have some new equipment to try out!