An hour on the trainer at base-building pace went very well this evening. No signs of cramping or claudication, no detectable difference in sensation from one leg to another.
However, after more than four months off the bike, the ol' chamois was feeling pretty thin and the saddle pretty hard...
Tuesday, January 5, 2010
The All Clear
Today I got the go ahead from Dr. Blecha to resume exercise. I'll be on my trainer this evening, pedaling for the first time in four and a half months. Never have I so looked forward to riding in place.
In the three months since my surgery, my incision area has presented no problems whatsoever. Although I haven't done any more exercising than simple walking, there have been no signs of claudication (the medical term for the lactate-type fatigue that I was experiencing). However, I have battled some unexpected post-surgical complications that have not involved my incision, but that have put me under the care of a urologist and made me feel rather old and vulnerable. I'm hoping that over time these will fade away.
In the three months since my surgery, my incision area has presented no problems whatsoever. Although I haven't done any more exercising than simple walking, there have been no signs of claudication (the medical term for the lactate-type fatigue that I was experiencing). However, I have battled some unexpected post-surgical complications that have not involved my incision, but that have put me under the care of a urologist and made me feel rather old and vulnerable. I'm hoping that over time these will fade away.
Tuesday, October 20, 2009
The Surgery: A Gore-Tex Jumper
The photo shows a sample of the Gore-Tex prosthetic that was put in place of my damaged external iliac artery. The sample has a length of about 19 cm, but the actual length used in my case was only a couple centimeters.
My operation took about three hours and left me with a scar about 10 cm long tracing an angle roughly the same as the southern California coastline down my stomach to just below my belt line. There were no external stitches, so my bandages were largely removed before I left the hospital. Nothing open or oozing and surprisingly little discomfort.
The surgery was conducted under general anesthesia. I was in intensive care the first night and up and walking the next day. I was discharged a couple days later, with instructions to avoid exercise, but otherwise to go on about my normal life. No cycling until after the first of the year!
Saturday, October 17, 2009
The Beginning of My Story
On August 16, 2009 I was on one of my regular group rides in northern Chicagoland - the "Old School Route" to those familiar with the area - when I began to experience the fatiguing sensation in my right leg usually associated with extended effort "above threshold." In other words, my leg had the feeling commonly referred to as "lactate build-up."
My first thought was that I had a bike fit problem: I was only three weeks into a new road bike, so I was still fiddling to optimize my position. I made it through the ride and then over the next couple of days, tried in vain to adjust the fit and eliminate the discomfort. Despite everything I tried - including switching back to my old bike - the fatigue would appear within a few minutes of pedaling, even at extremely moderate efforts. I concluded the problem was not with the bike, but with me.
I took a few days off, reluctantly. I've been a passionate roadie for four years, logging nearly 23,500 miles. I was at the top of my game and although I've only raced on a few isolated occasions, I was enjoying my status as one of the stronger riders in my circle of fellow aficionados. A month shy of my 47th birthday, I had a lean 147 pounds on my five-eight frame and was feeling like I was 20 again.
My hiatus from the bike didn't change anything, so I decided to get myself checked out. As it happened, I had had discussions with a couple friends earlier in the season about the vascular problem known as endofibrosis of the external iliac artery. Oddly, I had been experiencing some occasional tightening in my left thigh at that time and one of my buddies, a physical therapist by trade and a long-time CAT 2, was aware of the condition and of course, of the case of Ryan Cox.
I went first to my primary physician, who checked my pulse in various points and listened to my blood flow with his stethoscope. He detected diminished flow in my right leg, ordered a Doppler sonogram, and referred me to a cardiologist and a vascular surgeon.
Standard test protocol for the Doppler has the patient lying at rest on a table, so it was no big surprise to me that the results did not show any significant difference in blood flow from one leg to another. My symptoms (at least in that "early" period following their onset) only appeared when I exercised. I could induce them by cycling, but also by working out on my rowing machine, leading me to think that they were somehow related to hip flexion. In any case, I felt fine at rest and even when walking around, although that would later change.
The next stop was to the cardiologist, which, as I had expected, proved fruitless. Nothing was wrong with my heart and the subtlety of my condition was outside the scope of cardiology. As the doctor told me, cardiologists sometimes get involved with peripheral vascular issues, but usually only when they are so acute that the patient is in danger of losing a limb.
Finally, more than a month after I started experiencing the symptoms and stopped cycling, I was able to see a vascular surgeon, Dr. Matthew Blecha, who works out of St. Joseph Hospital in Chicago. Dr. Blecha was familiar with external iliac endofibrosis and seemed to share my suspicion that this condition matched my symptoms, so he ordered another Doppler sonogram and a CT angiogram. This time, however, he instructed that the Doppler be done both pre- and post-exercise.
I went back to the lab for the second Doppler and was attended to by the same lab technician who performed the original test. She was becoming intrigued by my case, having talked directly to Dr. Blecha about the post-exercise portion of his orders. She repeated the original protocol and was then going to have me jog up and down the hallway, but I suggested that I could probably produce the symptoms simply by running in place. I did so vigorously for about a minute, then hopped back onto the examining table. I could feel the lactate sensation and was pleased to get her confirmation that yes, indeed, blood flow in my right leg was diminished, dropping to 30% of its rest rate!
Now it was necessary to see where the blockage was occurring and for this, the CT angiogram was the key. I returned to the lab for this test about a week later. A CT angiogram provides the equivalent of a 3D X-ray - in my case, allowing the experts to get a clear image of my artery. When I visited Dr. Blecha a few days later, he had the unambiguous results: To my surprise, I did not have endofibrosis, but rather a dissection of the external iliac artery.
In a dissection, the inner wall of the artery tears, producing a flap that obstructs flow. Moreover, blood flows behind the flap pushing into the middle layer of the artery, a condition which can eventually produce an aneurysm. A dissection differs from endofibrosis, which is a narrowing of the artery that occurs as a result of a lesion. The fact that my artery was dissected explained why I experienced the lactate-type fatigue at very moderate levels of exercise whereas those with endofibrosis tend to notice fatigue only at much higher levels of exertion. It also explained why my symptoms appeared all of a sudden and why they became more pronounced over time (by the time I was officially diagnosed, my leg was fatiguing simply from walking around my living room).
Dr. Blecha advised surgery as the only viable long-term option. I consented immediately and underwent the knife on October 8.
My first thought was that I had a bike fit problem: I was only three weeks into a new road bike, so I was still fiddling to optimize my position. I made it through the ride and then over the next couple of days, tried in vain to adjust the fit and eliminate the discomfort. Despite everything I tried - including switching back to my old bike - the fatigue would appear within a few minutes of pedaling, even at extremely moderate efforts. I concluded the problem was not with the bike, but with me.
I took a few days off, reluctantly. I've been a passionate roadie for four years, logging nearly 23,500 miles. I was at the top of my game and although I've only raced on a few isolated occasions, I was enjoying my status as one of the stronger riders in my circle of fellow aficionados. A month shy of my 47th birthday, I had a lean 147 pounds on my five-eight frame and was feeling like I was 20 again.
My hiatus from the bike didn't change anything, so I decided to get myself checked out. As it happened, I had had discussions with a couple friends earlier in the season about the vascular problem known as endofibrosis of the external iliac artery. Oddly, I had been experiencing some occasional tightening in my left thigh at that time and one of my buddies, a physical therapist by trade and a long-time CAT 2, was aware of the condition and of course, of the case of Ryan Cox.
I went first to my primary physician, who checked my pulse in various points and listened to my blood flow with his stethoscope. He detected diminished flow in my right leg, ordered a Doppler sonogram, and referred me to a cardiologist and a vascular surgeon.
Standard test protocol for the Doppler has the patient lying at rest on a table, so it was no big surprise to me that the results did not show any significant difference in blood flow from one leg to another. My symptoms (at least in that "early" period following their onset) only appeared when I exercised. I could induce them by cycling, but also by working out on my rowing machine, leading me to think that they were somehow related to hip flexion. In any case, I felt fine at rest and even when walking around, although that would later change.
The next stop was to the cardiologist, which, as I had expected, proved fruitless. Nothing was wrong with my heart and the subtlety of my condition was outside the scope of cardiology. As the doctor told me, cardiologists sometimes get involved with peripheral vascular issues, but usually only when they are so acute that the patient is in danger of losing a limb.
Finally, more than a month after I started experiencing the symptoms and stopped cycling, I was able to see a vascular surgeon, Dr. Matthew Blecha, who works out of St. Joseph Hospital in Chicago. Dr. Blecha was familiar with external iliac endofibrosis and seemed to share my suspicion that this condition matched my symptoms, so he ordered another Doppler sonogram and a CT angiogram. This time, however, he instructed that the Doppler be done both pre- and post-exercise.
I went back to the lab for the second Doppler and was attended to by the same lab technician who performed the original test. She was becoming intrigued by my case, having talked directly to Dr. Blecha about the post-exercise portion of his orders. She repeated the original protocol and was then going to have me jog up and down the hallway, but I suggested that I could probably produce the symptoms simply by running in place. I did so vigorously for about a minute, then hopped back onto the examining table. I could feel the lactate sensation and was pleased to get her confirmation that yes, indeed, blood flow in my right leg was diminished, dropping to 30% of its rest rate!
Now it was necessary to see where the blockage was occurring and for this, the CT angiogram was the key. I returned to the lab for this test about a week later. A CT angiogram provides the equivalent of a 3D X-ray - in my case, allowing the experts to get a clear image of my artery. When I visited Dr. Blecha a few days later, he had the unambiguous results: To my surprise, I did not have endofibrosis, but rather a dissection of the external iliac artery.
In a dissection, the inner wall of the artery tears, producing a flap that obstructs flow. Moreover, blood flows behind the flap pushing into the middle layer of the artery, a condition which can eventually produce an aneurysm. A dissection differs from endofibrosis, which is a narrowing of the artery that occurs as a result of a lesion. The fact that my artery was dissected explained why I experienced the lactate-type fatigue at very moderate levels of exercise whereas those with endofibrosis tend to notice fatigue only at much higher levels of exertion. It also explained why my symptoms appeared all of a sudden and why they became more pronounced over time (by the time I was officially diagnosed, my leg was fatiguing simply from walking around my living room).
Dr. Blecha advised surgery as the only viable long-term option. I consented immediately and underwent the knife on October 8.
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