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Saturday, July 14, 2018

Mountain Biking the Swiss Alps - The Trails

With MTBVerbier taking care of logistics, what was left was mountain biking and more mountain biking, on one of the most beautiful trails I have ever been fortunate to ride on!

The first day we started with a short 6km warm-up route to the lifts in Le Chable that took us from about 200m to about 830m where we caught our first glimpse of the magnificent mountain range. Verbier is a ski-resort and that means it is equipped with ski lifts that take skiers to the top of the mountain in winter. The lifts are designed to carry skis on the side and it so happens, mountain bikes must also fit the same hooks. But as a non-skier, it took me a bit of time to get the hang of how to quickly hook the bike and enter the lift safely! A few lifts we used throughout the three days were big enough to accommodate us and our bikes.

My bike fitting comfortably next to the door of the lift

The first 5km of the trail was flat and this was an opportunity to have a proper view on the mountain before getting into single tracks. This was followed by a fairly long downhill past the La Tzoumas (another ski resort) and lunch before hitting the only serious climb of the day, a long 5km climb on gravel, averaging 7% gradient over the distance. The trail took us into and out of villages where we were able to sit down for refreshments, and in total, it was a 60km ride that took us 7 hours (moving time 4 hours) to complete. It was really fantastic riding and breadth-taking views – sheer mountain biking pleasure.

Going up the lifts from Le Chable


Day 2 was just as fantastic, with great single tracks and wonderful views from the top. On the ride towards Siviez we came across a calm herd of cattle that seem to not mind our presence, some donning their signature Swiss bells, and so we had great fun riding amongst them. The highlight of the day, which easily I could call the highlight of the 3-day trip, was the Descente Col Des Gentianes (on Tour De Mont Fort) along what looked like a glacier. The views were absolutely amazing but the downhill was long and exhilarating. The downhill ended on the most amazing single tracks amongst really beautiful vegetation – all shades of green with blooming flowers of different colours. The distance covered on this day was 55km and similar to the day before, it took most of the day (about 7 hours) including all the pit stops and rides in the lifts.





We started Day 3 at Lac du Champex, about 30 min drive from the guesthouse, and as expected, there were great views and the rides through the villages were interesting. This ride had a fairly steep 1.5km climb which, thankfully, ended at a beautiful restaurant up the woods and this meant a well-deserved rest at the perfect time. This is the day we spent a lot of time riding on forest single tracks and this type of terrain is one of my favourite.






Riding the Swiss Alps is an experience that mountain bikers should really consider. If you have time, a self-guided trip is possible and I have come across a few sites that offer the basic information that you may need. I found that riding with a knowledgeable guide contributed significantly to the great experience and beautiful memories. I joined three other riders on the trip and to this day I still have contact with them and will hopefully ride with them again at some point in the future.

Sunday, July 8, 2018

Mountain Biking the Swiss Alps -Logistics


I like mountain sports and I will take as many opportunities as I can to experience a mountain by either running, hiking (climbing) or riding it. Mountain biking tends to be my default, if terrain allows, because I find that opportunities to run and hike are many more. Mountain biking, however, takes a lot more effort to plan. It is not only a matter of carrying the bike but in most cases you need to carry spare parts, tools, consumables such as lubricant and bike-specific clothing including the cycling pants, helmet, glasses and gloves. Then considering items such as action cameras or other specialized photographic equipment together with their batteries, the planning gets that much more complex.
At the airport - luggage for the week looking like I am emigrating



If the plan is to bike outside of your region or outside of your country, the planning must be much more elaborate. For example, taking a bike on a flight might ultimately influence your choice of airline(s) depending on how sports equipment is treated or whether they charge for it or not. You can easily pay 120 USD per leg for the bike (as an extra bag) and so it is worthwhile doing some homework before you even book your flights.

When I decided to visit my friend in Zurich, Switzerland in 2015, I wanted to spend a few days on the Swiss Alps  and after carefully considering all factors relevant to me, I settled on mountain biking.  If I was fortunate enough to have no limit on time and on luggage, I would have added an extra bag for gear and equipment to climb the Mont Blanc!

There is a variety of bike carriers in the market to transport a bike, but my trusted Evoc bag has never disappointed me. Depending on the weight of the bike, it is unlikely that you can fit anything more than a bike helmet and a few tools into the bike bag itself.  

Flying from Johannesburg to Zurich via London was fairly uneventful - the only discomfort is the size of the bike bag (had to be removed from the trolley occasionally as most escalators are narrower) and as “special luggage” it needs to be collected from special collection points at just about every airport I have been to.

I spent a few days with my friend before taking a train to Verbier, near Le Chable in the Alps. It was a very scenic and comfortable 180km ride (and a bit expensive, I must add) that took close to 4 hours from Zurich on Swissrail. The train ride from Geneva airport is much shorter, so anyone going directly to the Alps will find flying to Geneva the best option.

Because I had limited time to spend on the Alps, I eventually decided to use a mountain biking specialist in the region called MTbverbier (http://www.mtbverbier.com/) and this turned out to be a really good decision. Although I had already worked out my own plan to ride the alps (thanks to a few good websites that showcase the MTB route network across the whole of Switzerland), I soon found out that it would have been harder for me navigate on my own. The service at MTBVerbier was amazing and their knowledge of the mountain biking trails is extensive. They tend to take small groups and have their own comfortable guest house (complete with a bike workshop) where they serve all the meals. This ensures maximum time on the bike and therefore maximum fun on the trails!

View from the balcony of the MTBVerbier gueshouse

Great Service - All catering included


Saturday, June 23, 2018

When legs simply do not show up 9 – “The Fix 2”


Considering my physiology, the extent of the endofibrosis and the need to use my own vein as patch, my highly skilled surgeon worked out in detail how he will conduct the procedure to maximize our chances of a successful operation.
My lay understanding of the process was this:
  • Open the top of the upper limb and remove a spare vein that will be used as patch
  • Make an incision and cut through my abdominal muscles to access the inguinal ligament to release it (I have blogged about studies showing a tight inguinal ligament is often cited as a possible the culprit)
  • Open the groin area to access the external iliac artery, cut it open and conduct an endarterectomy (i.e. remove the endofibrosis from the lining of the artery)
  • Close the artery by patching it with the vein that was harvested from my upper limb
  • Close up and staple the skin together
Evidence?

Two gashes on the right side of my body making up 77 stitches overall as shown below.  This was obviously a major operation that requires time to recover - the best I can do is take it day by day.


"The evidence"

Saturday, June 16, 2018

When legs simply do not show up 8 - The Fix


I found the pre-operation procedure at hospital to be rather hectic. Once you are allocated a bed, you get surrounded by a whole host of healthcare professionals who ask you questions on your previous medical history, do final physical checks, draw blood, attach drips and also make you sign consent forms! I did not mind the buzz, it sort of got me too busy to think about what was ahead of me, and what felt like no time at all, I was given a magic pill to put me to sleep so I can be wheeled off to theatre.

Just checked in - anxiously waiting for the signal to get ready


The next I knew I was woken up and there was this massive pain on my stomach…. As if I my entire torso was on fire and the area felt so tight that I could not even talk.  Then my doctor checked whether I could hear him and then gave me the summary – the four-hour operation went very well, the vein that was removed from my leg to patch the artery was competent enough and was able to cover the wide area. He was very happy. There was no need to kick the Plan B that would have meant the use of artificial material – that made me very happy too.

But the pain was unbearable, at least for a few while - and then got better. The first night I did not sleep much – I kept on asking for more pain medication and I was getting only marginal relief. Because of this, I had to literally keep still but every time I dozed off, I was startled by the massive pain, because I kept on trying to change my position in my sleep. On Day 2, I was not psychologically ready to try and get out of bed – I was still traumatized from the pain but by mid-day it was under control. The odd thing is around the same time at midday I started to develop some “airlock” in my gastric system that was causing so much discomfort that I could not eat. It got worse overnight and so for the second night in a row I could not sleep because this airlock was causing extreme discomfort.

On the morning of Day 3, still heavily medicated, on liquid diet in high care, my physiotherapist came to help me get out of bed to do a few steps. I have heard a few people talk about how painful this process is but still I was not prepared for what I went through. She assured me the same afternoon we will try again and it will be better – and I thought those were only kind words of encouragement, nothing more. She could sense the horror and mostly the despair in my voice at the first attempt. That same afternoon she came and I was amazed by the great improvement and so literally 24 hours later, with more baby steps and effort, I was able to get on and off the bed on my own and was able to walk to the hospital coffee shop!

First steps after operation

I am walking very slowly with a severe limp – still on pain medication and still connected to machines that monitor me closely, but I think the worst is over, at least for this time around. My focus right now is on healing the right side and making sure that I am physically and mentally prepared for the next procedure. 

Monday, June 11, 2018

When legs simply do not show up 7 - "Help is coming"


I returned from the Netherlands armed with a diagnosis and two options to consider – to go back to the Netherlands to do the operations or to find a vascular surgeon in South Africa who could also do the procedure. I strongly believed even then, that there are vascular surgeons in South African that have come across my condition and that have assisted athletes with similar issues to mine. The procedure is pretty standard but the diagnosis IS the king. My first choice was a South African vascular surgeon because that meant the operation will be local and I would not have to fight a losing battle with medical insurance to get them to cover my costs. The other issue is that I would not be allowed to fly back home for about 3 weeks post operation – and that meant that I would be staying overseas without access to my close family at my most vulnerable time, not forgetting the high living costs that I will have to incur.

So my first task when I returned was to find a South African Vascular surgeon and my search had barely started when I came across one with the necessary knowledge and experience. It was by pure luck that I was referred to him; nothing I have read or come across online would have pointed me to him. He certainly was not amongst the doctors that received my last desperate appeal for assistance early in January.

The surgeon confirmed the diagnosis of external iliac artery endofibrosis using pre- and post-exercise Doppler and as part of his process, he wanted to do a catheter angiogram to help him plan the operations in detail. I had totally misunderstood what this particular angiogram actually entailed and it turns out I had to be under anaesthesia for the procedure. The angiogram did not tell me anything new, except to show that my endofibrosis was getting worse and that it would have reached occlusion in no time.

While I was at the hospital I met a lady that had just done the exact procedure as mine by the same doctor 2 days earlier and I was able to chat to her about her experience. We shared some common past experiences, for example, how we eventually got our proper diagnoses, the calf injuries that had impacted our sporting activities, etc. More importantly, chatting to her straight out of the operating room by the same doctor gave me a tangible reference for my own  confidence.

On 13 June 2018 I am checking into hospital for the first of the two external iliac artery operations and I am very nervous. The procedure is endarterectomy with vein patch - I am optimistic and I hope and pray that everything goes well. Help is coming and I am looking forward to getting my old life back.

Sunday, June 3, 2018

When legs simply do not show up 6 - The Breakthrough


I completed the admission process at Maxima Medisch Centrum in Veldhoven, Netherlands without any hiccups. SportsMax, the Sports Medicine Unit of the hospital was on the other side of the building but I made it right on time for the appointment with Dr Schep, the Sports Medic at the unit. As he appeared from his office, he needed no introduction because I right away recognized him from a few online photographs. I involuntarily called his name out loudly, in a way taking away the ice-breaker duty from him, and of course creating a tiny awkward moment right there. After short introductions, he asked us to wait for him while he completed another task. I took the time to look at the murals on the walls – admiring the painted images of athletes participating in various sporting codes and taking a picture or two in the process.

At the Sportmax Maxima Medisch Centrum, Veldhoven, The Netherlands
The consultation was kicked off with a detailed discussion around my sporting history and intensity as well as my symptoms and affected areas of my body. This was followed by physical examination to rule out, I suspected, nerve and spinal issues as possible causes of my complaints. Thereafter we proceeded to pre- and post-exercise Doppler and almost immediately he was able to pick up flow limitations and he was able to estimate the restriction. The Doppler was done with my body flat on the bed and in a crouched position similar to how road cyclists and time trialists ride.

We did not discuss the outcome in detail but I went to the waiting room for the next set of tests. These were the ECG (with Ankle Branchial Index) and having gone through similar maximal tests (towards your absolute limit), I was secretly pleased it was on the bike and not on the treadmill.  I know that without a 45 min warm up, I was going to reach my limit pretty soon and so I decided I was not going to back off before I reach 150W – and this is close to nothing – but if you have severe blood flow restrictions on both legs, this is really on the side of maximum. As soon as I reached a point where I could not stand the pain any longer, I got Blood Pressure meters attached to my arms and legs (with my legs raised) and my pulses were measured. Again, not much discussion after this as I sent to another unit to do the MRI scans.


Some of the testing at Spormax
These scans were becoming very routine to me and so I did not need much coaching and did not have questions to ask. The odd thing is that I did the exact same scan in Pretoria and so I wondered how different the new image was going to be. After the scan I was able to sit down to have some lunch while the report was being compiled for Dr. Schep and thereafter it was back to the Sports Medicine Unit to hear the verdict.

As suspected, the diagnosis of External Iliac Artery Endofibrosis was confirmed, stenosis of about 50% across almost the entire lengths of both arteries; and no kinking. At that moment it was like an entire load was taken off my shoulder.  I was overcome by emotion, for all those times when I insisted I had a major problem but could not get medical technology to corroborate. For the many morning when I returned from a run or ride and felt emotionally defeated and physically drained. For the many hours studying not only flow limitation amongst athletes but also trying to determine the best combination of training effort and supplements to slow down the speed at which I was accumulating fatique. This was the breakthrough I needed.

The next day we met Dr. Bender, the Vascular Surgeon, to discuss the options that were available. He made sure that I understood the risks associated with surgery and that doing nothing about the endofibrosis is also an option, especially for non-professional athletes. But that would mean that I opt for extremely low levels of activity and hope that it never gets worse. We spent most of the time discussing in great detail the surgical procedure (endarterectory with vein patch) and by the time we left, I was pretty sure that surgery was the only option for me.

I would not have gone as far as making the necessary sacrifices to get to a specialist unit for a diagnosis if I felt I could “live” with the problem. I am an endurance athlete and I almost feel like I am trapped in a body that no longer recognises this. I know that many people will not understand what I am trying to say, but perhaps many others will. I am grateful that we know what is causing my symptoms and that there is a “cure”; things could be worse.

Friday, May 25, 2018

When legs simply do not show up 5 - Drastic Measures


The more I read about External Iliac Artery Endofibrosis (EIAE) the more I was convinced that there are many others like me out there, especially in South Africa where the county literally punches a little above its weight in terms of participation in endurance sports. My out-of-hospital medical aid funds had ran out by the time I reached a dead end (around July 2017) and so I took the time to plan my next attack. I was certainly not going to do the same things I did the first time around and hope for a different outcome! I needed to think things through and did not have as much "trial and error" wiggle room as before.

So this was the plan:

-  Write an elaborate document that details as much information that I can remember regarding my activity levels over time, races, performance, injuries, supplements, scans and tests I had completed up to that point. I titled the document “On tired legs”
-  Take the document and send it to South African Sports Medics and Vascular Surgeons and with a bit of luck I will get a response from one of them that can assist me or knows someone that can. In the document I was even offering myself as a “case” for postgraduate students to consider. I was a bit ambitious there I must admit.

I only really completed the document in January and by February 2018 I was already sending emails. I did not get any positive responses from anyone and with my condition getting worse, I was running out of patience. I then decided that if I am not making progress in South Africa, I will have look for assistance elsewhere. Through reading articles and journals on EIAE, I got to know the names of the few doctors that were world leaders in the diagnosis and resolution of my condition and so my next focus was on finding out from them whether they know of South African doctors that can assist. I sent an email to Dr. Goof Schep in the Netherlands and in less than 2 days, he had read my document and told me I had 70% chance that I had EIAE and that the only way to confirm that was for me to come through to their specialist medical centre for testing. He personally did not know of any doctor in South Africa that he could refer me to.

My immediate question was whether I would afford the cost, not only of flying and staying there for a few days, but more importantly, the medical procedures and scans that are required for the diagnosis. The pleasant surprise was that the cost of the all the tests (including MRA and Doppler) together with his time and that of the vascular surgeon would cost less than what I had paid in total in South Africa in 2017. Notwithstanding the fact that I had nothing to show for the money that was spent on all the investigation that I did in South Africa. I must stress, this is typical across the world - the condition is not widely known. I am still lucky that it took less than two years to get a diagnosis.

I wrote an elaborate document to my medical insurance, trying to convince them that for a fraction of the original cost, they could pay for my tests in the Netherlands and that we were at the least guaranteed a diagnosis. I would pay for the travel and accommodation but the answer was NO….my benefit does not include overseas medical care, even if it is cheaper.

I was desperate and I thought I was left with no choice but to go to Maxima Medisch Centrum in the Netherlands in order to proceed to a post-diagnosis stage. I was convinced that after completing this key milestone, I should be able to find a vascular surgeon in the country that can do the surgery.


At a train station in Amsterdam - en route to Eindhoven
And so on the 20th of March 2018 my fiancé and I left Johannesburg for Eindhoven in the Netherlands to spend a day and a half with Dr. Goof Schep and Dr. Mart Bender (Vascular Surgeon), convinced that we are going to come back with either a confirmation that I have EIAE or that I do not have it. That would be a giant leap forward for us, either way!


Coming out of the taxi at the Maxima Medisch Centrum, Veldhoven








Friday, May 18, 2018

When legs simply don't show up 4 - What I learned About External Iliac Artery Endofibrosis


Between July 2017 when my diagnosis process reached a dead end and January 2018, I did not stop training and most importantly I did not stop looking for answers. I spent many hours studying vascular surgery journals looking, initially, for any information that would point me towards a different condition to External Iliac Artery Endofibrosis. Then later my focus shifted towards alternative therapies to surgery because I had, with a high degree of conviction, self-diagnosed External Iliac Artery Endofibrosis (EIAE) and had no hope of getting surgery, certainly not on the basis of an amateur self-diagnosis.
During the period, this is what I have learned about EIAE (for symptoms, see my previous blog "...looking for answers"):
  • The condition affects the external iliac arteries, as the name says, where a layer of tissue grows inside the wall of the arteries.
  • It is not known exactly why the layer of tissue starts growing but in many instances I have read that it has something to do with the velocity of blood hitting the artery wall and causing an irritation. This is during extended periods of training or racing. The body then responds by forming a layer of protection inside the artery because it cannot afford to have a leaking artery. Once the layer starts forming, there is no stopping the vicious cycle because the reduced radius of the artery continues to cause an increased velocity of the blood as it leaves the affected area
  • The endofibrosis can grow to a point of total occlusion (where the artery is completely blocked) but by then atheletes cannot ignore the impact anymore.
  • In some instances, the athletes (especially cyclists) have what is called kinking. The EIAE in that case is said to be caused by the cyclists’ bending position when they ride for long periods. This position  causes the continuous rubbing of the (enlarged) psoas muscle against the artery, again compelling the body to protect the artery. MRI scans and angiograms for such cyclists clearly show the bend in the artery.
  • The condition has been reported mostly in road cyclist and in some publications, the condition is even called the cyclist’s external iliac endofibrosis. I have seen more reports of the condition reported amongst recreational endurance athletes including runners, duathletes and triathletes.
  • There is also reports that the endofibrosis is triggered by the tightening of the inguinal ligament that runs across the external iliac arteries, causing the initial narrowing that sets in motion the downward spiral towards limited blood flow. The diagram below (credit: https://musculoskeletalkey.com/hip-and-pelvis/) shows the external iliac arteries as well as the inguinal ligament that crosses them.


https://musculoskeletalkey.com/hip-and-pelvis/


  • The majority of exclusive cyclists are not only unilateral (one artery affected) but also have endofibrosis on the left artery. No one is able to say exactly why this is the case.
  • A small number of athletes are bilateral (endofibrosis is on both arteries) and unfortunately under that circumstance, they require 2 operations to remedy. The most common feedback amongst those that have done the operation is that it is very painful and so imagine having to go through the process twice. Furthermore, athletes that are bilateral have no “strong” leg and so they are the most likely to quit the sport altogether. I have read blogs of unilateral athletes whose drops in performance did not warrant them quitting altogether. Actually one athlete was a podium finisher who declared that he continued to finish on the podium, but obviously through great pain, grit and bucket loads of determination and certainly on borrowed time.
  • This condition is said to be rare but I think it is just under-diagnosed. I believe that many athletes, especially those that are not professional, have less incentive to keep doing the sport and they simply just give up and move on. I am an endurance recreational athlete and I simply refused to accept that the rest of my life will be a semi-sedentary existence.
  • Many sports medics and vascular surgeons are not familiar with this condition. There are very few vascular surgeons and sports medics that know about the condition and even very few that have developed mechanisms to diagnose it. Moreover there are also very few that have mastered the specific solutions that are effective for athletes. For example, while balloon angioplasty works for people that are barely active, it offers only temporary relief to athletes. The more I read about the condition, the more I came across many scenarios of “trial and error” and re-operations that athletes had to endure.
  • It is estimated that athletes take on average 4 years before they start perceiving the effects of the endofibrosis and then it takes an average of another 3 years before they get to see a medical practitioner that can assist them. I think this period is getting smaller, thanks to sufferers who continuously raise awareness. Unfortunately in the 3 years, the sufferers are subjected to endless blood tests, excessive resting, multiple scans, alternative medicine, dry needling, physiotherapy, back operations etc. before they get to an accurate diagnosis. I came across an athlete who was forced to leave professional level cycling prematurely many years ago and is deeply aggrieved by this.
  • There is very little that can be done about the enfofibrosis, especially if an athlete has reached a point where even going up a flight of stairs triggers the symptons of fatigue and sharp pain.
  • In the future I will write about how I managed to keep training and what mechanisms I used to make sure that I maintained the little that was left of my fitness. Nevertheless, what I have learned is that the endofibrosis reaches a point where aspirin and vasodilators do not assist. The impact of an hour of training is probably equivalent to 3 hours under normal circumstances and that the extent of fatigue that you accumulate from a short session means that you can only do a few sessions a week.
There are many more lessons I have learned and I hope that some of these will come through as I relate my story.  Through this process I came across many positive stories of athletes who not only got fixed but have not been back at the operating table since. That kept me going. 

Saturday, May 12, 2018

When legs simply don't show up 3 - Looking for answers


I walked into a GPs room early in March 2017 knowing that I was there only to get a referral to a medical specialist – but at the time I thought I would probably be referred to an endocrinologist. I had over a few weeks, already ruled out many possibilities…. Mostly I believed very strongly that I was not injured, had no fatigue (nothing in my training history pointed to excessive training) and I was still reasonably fit. What I suspected was that my body had lost its ability to produce hormones that should prepare it for rigorous efforts. The fact that I developed symptoms only during training was a vital clue. After listening to my story (one that I would relate many times over), the doctor referred me to a Sports Medic.

The length of time between my perception of “the symptoms” and the Cape Town tipping point was more than sufficient for me to be very articulate about what I felt was wrong. I was able to clearly explain to the doctors that:
I have problems maintaining a heart rate of about 150bpm for up to 3 minutes
- After about 3 minutes above 150 bpm, I am forced to stop as I develop extreme fatigue that leads to pain on the calves;
- The fatigue later gets to the quads and hamstrings;
- In some instances, I reach a point where my feet get numb – especially when I am on the treadmill and on the stepper when I spent about 1,5 hours training;
- The symptoms are greater at the start when I have not warmed up and get better after about 30 min of exercise. The pace gets slightly higher and I can manage the climbs a little better but after about an hour and a half, my performance declines again;
- On the bike, I can barely keep up on climbs with the most under-trained people I know. On flats it is much better when I have not fatigued. On the bike, the quads take the most strain;
- I have gone from an FTP greater that 200W to below 100W. In recent times my best power output is 85W average over 1 hour,  at an average heart rate of about 125 BPM;
- I find cycling easier; Running presents the most struggle and I feel the effects (fatigue) many hours after the run – even under conditions where I was taking periodic rests.

Painful needling for my tight calves - 5 needles on each leg

After going through my sporting and medical history with my Sports Medic, the first tests I was prescribed were “bloods”. While I waited for the blood test results, I was also referred to a physiotherapist to assist with the tight calves and to rule out any possibility that they could be the cause. He was shocked at how hard they had become and so a very painful course of dry-needling followed.

The blood tests were all “negative” except one test which was of concern - CK-MB (Creatine Kinase MB) that was high. I was asked to take aspirin and immediately I noticed the next day that I was able to complete a 1 hour indoor cycling session without stopping. I did not perceive any improvement in the running though. Because of the high CKMB dosage, I went for an ECG Scan. I could not complete the scan and the highest heart rate I was able to reach was around 155bpm. We had to abandon the test as my calves were too painful.

I was then referred to a Cardiologist who conducted another ECG (even though I had one already), additional bloods and an Echo (Echocardiograph) – once again I could not reach heart rates higher than 155bpm on the ECG.  He also checked pulses from my arms down to the legs – but at rest, they turned out identical.
Next I did a Doppler Ultrasound, at rest, and after many attempts, unfortunately the doctor could not pick up restricted blood flow. The doctor also spent a lot more time trying to see whether she could pick up Popliteal Artery Entrapment Syndrome (she had a patient that had the syndrome) and again the results were negative.

I was then referred to a Vascular Surgeon and after considering all my history, prescribed a CT Scan, and again this did not provide any leads. The investigation then proceeded to an MRI scan and this time around I persuaded the radiologist to allow me to run up and down the stairs until I induce the symptoms. Again the scans did not reveal anything actionable.
We had sort of reached a dead-end and the advice I got from the Surgeon was that I continue with my training regime and wait for the problem to get worse, hopefully in another 6 months, we could start with another series of tests, starting with the Doppler.

Monday, May 7, 2018

When legs simply do not show up 2 - The Writing on the Wall


My weekly training plan used to include at least one interval training session on a Wattbike and each session started with about 15 minutes of warm up. The Virgin Active Groenkloof where I did most of my training at the time had 4 Wattbikes on the ground floor – thank goodness for that – and on this particular morning the bikes were not busy at all. I climbed onto the one bike with the soft saddle, as usual started my warm up while I paired my Garmin watch with the bike and set up the music. About 5 minutes into the ride I felt like I was on high resistance and so I turned the dial down and removed all resistance. A few moments later I looked at the power output and the reading was around 50W – close to nothing, and very odd. But my legs felt like I was riding up a steep hill at 200W power and so the stationary bike was clearly out of order.

I quickly stopped and moved onto the next Wattbike – I would have hated to put in a whole hour of training and then end up underestimating the amount of effort I put it and obviously the level of fatigue accumulated too. As I was going through the same motions of setting up, I noticed someone getting onto the faulty Wattbike and I quickly remarked to him that the bike was out of order. But just as I was settling down on the new bike, I looked again at the power output and got the shock of my life. Resistance was low, output was around 50W but again my legs were very hard at work. I could not believe what I saw. That was around August 2016.

For many weeks after that, my legs, especially the right one, became lazier and eventually I started to even take rests on the stationary bike. Post-workout stats indicated that I did not actually have a fitness problem, but rather a power problem. My output matched my heart rate but I could not understand why I was not able to engage higher heart rates. Around the same time I realized on my runs that I needed to take constant rests during a 10km morning run, something that had never happened before. But for many weeks I believed that this was a passing phase and that I will eventually get my fitness back.

I did the 3 Towers MTB Stage race in late September – literally finishing at the back and in many instances, getting a push from my partner on steep climbs because I was too slow. A week before the 94.7 Cycle Challenge I did an afternoon run and the intervals at which I had to stop were a lot more frequent than before and worst of all, a walk was no  longer sufficient to recover. I literally had to get to a complete stop to calm my calves and Achilles down. At the 94.7 Cycle Challenge I started a little after 7am – I had a fairly good seeding from MTB races the previous year – but cyclists would ride past me and then pass nasty comments about my legs not having showed up. It was humiliating but also physically painful. Nevertheless I managed to pick up some pace and completed 4:44, average heart rate of 136bpm - I hardly raced. On the surface this does not look like gross underperformance but for the effort that I put in, it was very discouraging.

Since my performance was noticeable only at high BPMs, I thought an expedition up Mount Aconcagua in Argentina would be ok. But even at the time. The first hour of the climb was always the hardest – and although the biggest factor for not reaching the summit was weather, I think I would have had a better chance to withstand the impact of the weather if I was at top form in terms of output from the legs.

Then in February 2017 I participated in a trail run in Grabouw, Cape Town that saw me ending the race in tears because for the first time I admitted that something was awfully wrong and that the problem was not only persistent, but it was getting worse. After that run I saw the writing on the wall, in big bold letters, and I could not ignore it anymore. That same week, in early March 2017, I made an appointment with a Sports Medic, marking the start of my long mission to get to the bottom of my leg problem.

Thursday, May 3, 2018

When legs simply do not show up - The Intro


The last time I had a really good run was in July 2016 in Tershelling Island, The Netherlands. I recall most of that run - it was on a flat terrain, sea level, barely off-road, fresh island air and beautiful surroundings – really fantastic setting. I did the 20 kilometres without much effort in 01H55 and this was not really surprising. Weeks prior to that, I had been consistent and focused in my training as I had set my goals to running Comrades 2017 in under 10H30.

The training ahead of that has been going so well that I recorded on the morning of the 30th April 2016 a personal best pace of 5.08 min/km over 10km. My hard work was paying off and it was really great. For the first time in a while I was feeling like my sweat was actually yielding results, unlike in the past where the link between hard work and results was often a huge blur. I had accepted some time ago that my level of talent as an endurance athlete requires me to train a lot harder than others only to just make the cut into the back end of the field. It was a fact of life that I had no issue accepting.

In hindsight, with my level of training, especially in early 2016, I should have been showing a lot more decent performances. In essence, my training was for some time, sufficient to just beat by a small margin, the effects of a condition that was brewing in my arteries.
   
For many years I had no reason to believe that there could be a much more profound explanation for my “slight” underperformances. For starters, I could still enter ultra-distance races and complete them. In February 2016 I entered the 7 stage TransCape MTB and finished, but right at the back of the field and taking maximum stage time almost every day. At the beginning of every stage, I always noticed how everyone seemed to be riding fast; yet I would catch up with the last groups and sometimes even drop them before halfway.
 
It turns out that I have been suffering from a condition called External Iliac Artery Endofibrosis and unlike many athletes that developed the condition, it took me about a year to get diagnosed. Others took as many as 5 years and many professionals were forced to abandon their careers just as they were taking off – serious matters of full potential never reached; dreams forsaken – but I think the worst is not knowing what is wrong and being forced to abandon your aspirations under those circumstances.
   
My story is not at all unique – I and many others share identical stories of a long, difficult road of misdiagnosis, painful physiotherapy sessions, dry needling, expensive scans, endless blood tests and referrals to a wide range of medical specialists. What we also have in common are stories of DNFs, despair as performances drastically deteriorate and the gloom every time we reach a dead end. But the most common thread is that out of desperation we’ve all had to spend many hours doing our own research to get to the answers. I have come across many stories of athletes that took piles of journal articles to their sports medics to shed some light; and yet many others who were still told “Impossible!”

This is because a fit athlete is not supposed to have symptoms associated with what is called Intermittent Claudication. This is a vascular condition more common in the elderly, people that smoke, people that are overweight and those that have high cholesterol. The least understood cases of intermittent claudication are those that appear amongst fit athletes that train for and participate in endurance events such as ultra-marathons, long distance cycling and triathlons. The condition is often described as rare, but I think it is a matter of serious under-diagnosis, especially amongst recreational athletes. I think that athletes that are not professional simply choose to move on given that the stakes associated with giving up on endurance are not high.  

I still fantasize about my return to my normal self; I cannot wait to go on long runs and rides across the mountains, on rocky single tracks, in the forests, crossing the rivers and up the steep hills. I would like to take a second shot at climbing Aconcagua and then move on to conquer climbs over 7000 metres . My Comrades Marathon medal counter came to a scratching halt at number 7 in 2015 – I would like to get my green number and now that I have been diagnosed, I am optimistic and upbeat. But in the mean time I would like to share my story in the next few blogs – with the hope that many other athletes learn from it and that no one has to go through the trial and error that many like me have experienced.

Tuesday, April 24, 2018

Comrades Marathon on shoe string mileage - Part 2


In one of my previous blog posts I asked: “Anyone ever wondered how far cross training mileage (on a bike) could reasonably take a multisport endurance athlete to a comfortable ultra-distance marathon finish?”
In that blog I related my running and cycling activity levels in the run up to Comrades, including the taper, but did not reveal the ultimate outcome. The running mileage was low but the question was whether the cycling mileage and the overall fitness would more than make up make up for the deficit.  Weeks after the 2015 race, this is what I shared….
"A few weeks ago I nervously decided to go into uncharted waters by taking a shot at completing the Comrades Marathon on low mileage, relying almost completely on the endurance that I developed cross training in cycling. 
Fast forward to this day, I stand proudly with a bronze medal around my neck after surviving groin and hip issues from early on into the race and fighting to stay on course like a warrior. As an endurance athlete like many others, I have learned to accept the trials that come with this territory and used the mantra “pain is temporary, glory forever” to keep me going.  
The issues were not new - I had the exact hip and groin challenge during the second half of the 2014 Two Oceans Marathon – and finished just in time to make the bronze medal cut-off. The concern I had at Comrades 2015 was that the onset was too early into the race (before the 15km mark), the terrain more testing and the distance much longer. My prayers were answered when I met my seconds at around 22km into the race and they had remembered to bring my massage stick. This stick, together with the foam roller, is the most important item in my ultra-distance running tool box. The stick instantaneously relaxed my tight groin muscles and although my right hip grew increasingly cranky from around 30km into the race, it was only after half way that it began to threaten my ability to complete the race. 
After half way, I prepared myself mentally to put up a big fight. I conceptually divided the course into two half marathons, took a very deep breath, set my sights towards Pietermaritzburg and got on with the programme. The sub-11 bus caught up with me at around 25km to go and left me a bit disheartened because I simply could not keep up. I knew that I was on track to finish but it took me a while before I checked my watch to estimate my finish time because I was preoccupied with the hip – massaging it with my right thumb, left thumb and right palm as I ran, and all the time making sure that I keep my normal running gait. Eventually at 17km to go, I looked at my average pace and how much time I had left to finish and was pleasantly shocked that I had more than three hours. I calculated that to get to the top of Polly Shortts at 10:00 was safely within reach - and so I had renewed energy. Up to that point, my fixation with the hip pain made me grossly underestimate my pace and lose focus on everything else. I reached Polly Shortts at 9:58 – content, under the circumstances, that I was only about 28 min off my original race plan. Because the pain was becoming hugely unbearable, I slowed down after that but kept a close eye on the time to make sure I was not cutting a sub-11 finish too fine.  
There is something special about the Comrades Marathon finish. When you enter the stadium and go through the narrow passages, all aches and pains literally disappear. You start feeling like you are floating on air and you are on an out-of-body experience trip. You see this mass of happy people, making huge noise, some calling your name; and you also see the huge flood lights that brighten the area and project some bit of dust in the air to complete the glow. The real magic, though, is at the end of the narrow passage when the finish area widens up, almost swallowing you as you complete your last turn. Ahead of you is the clock that continues to tick in large red numbers and as you get closer, there are no words to describe the sense of accomplishment. Those few moments towards the finish line wrap up all the long runs, morning runs, afternoon runs, gym sessions, massage sessions, speed sessions, hill sessions, tempo runs and qualifiers, in just a few, triumphant steps. 
You are home! 
I completed in 10:54, hugely relieved and thankful that I have managed to reach the finish line in one piece. I did not feel hugely fatigued at any point during the race and after the run, my quads, hamstrings and calves felt a lot fresher than ever before. 
And so the verdict is ..... Spending more time on my mountain bike and less on my legs is not bad for Comrades at all. I completed within the top 50% of the entire field that started and I believe that I could have done better if I did not have serious niggles. The other good thing is that, unlike before, I do not feel at this stage of the season that I’ve “had enough” of running and I need a huge break. This implies that I will be able to participate in trail runs – the trail season is exciting and starts gaining momentum around this time.  
The only thing I will do differently next year is to never stop running completely when I increase my cycling mileage. This will minimise the time, effort and frustration to get the joints and mechanics back on form to be able to absorb the high impact associated with running. I am confident that my hip problem was resolved and would not have surfaced if I had maintained my runs between December and March. Completing the Comrades Marathon 2015 is an exciting breakthrough for me as it removes a lot of the anxiety I had about going full multisport endurance."

Friday, April 20, 2018

Comrades Marathon on shoe string running mileage

Anyone ever wondered how far cross training mileage (on a bike) could reasonably take a multi sport endurance athlete to a comfortable ultra-distance marathon finish? This knowledge is particularly useful when running is temporarily out of the question due to injury but the heart is stuck at the Comrades starting line. I toiled with this question for many weeks some time ago when I was faced with an overwhelming sense to run the Comrades Marathon even though running was not part of my training for most of the 6 months preceding the race. Unfortunately I do not have the answer but I can relate my story. I have come across this piece that I wrote a few years ago and that I thought would be great to share..…. Enjoy.
"For the first time this year I will be towing the line at Comrades with low running mileage. And so the verdict is out there whether this will work or not; if it does, then I would have cracked a personal multisport training plan that will allow me to take part in mountain biking endurance events without sacrificing my Comrades green number ambitions. If it does not work out, well I still would have learned a lot and would be confident to preach “what not to do”. The Comrades training plan I have used before is my own – optimised for my personal/professional circumstances – and has consistently delivered expected results across all my 6 previous finishes. It starts in earnest on the 1st of December each year and gives me exactly 6 months (or 24 weeks) to train. In contrast, my current plan is 9 week long and crunches the entire build up, peak and taper in 2 months.

Before you start shooting this down as completely insane let me also provide perspective on the mountain biking training I did from December to February: 
-  Averaged 13 hours a week on the bike (indoor and outdoor) per week;  
-  Peaked at 17 hour a week, twice; and 
- Climbed over 35 000 m of altitude on outdoor riding.  
Running is a lot less forgiving but to loosely compare, I peaked at 8 hours a week on my Comrades training and averaged about 6.5 hours a week. The point I am making here is that I was not sitting around twiddling my thumbs over the first 3 months while Comrades runners were hard at work. Nervous and anxious as I am, I feel that at this stage a few factors still make my Comrades attempt this year a bit promising: I have ran my fastest 10km in a long while at pace 5:08 (51 minutes) a week ago and have ran a qualifying time of 4:15 at conservative pace 4 weeks into Comrades training. But the verdict still remains out there and we will know on May 31st for sure. I have ran close to 350km so far and have started tapering. The plan is to run the remaining 150km as safely as possible while ironing out a few niggles, especially around my hip area. "
Look out for the update!

Wednesday, April 18, 2018

Small World! – A Comrades Marathon Story


Every Comrades runner has an interesting story to tell – some tales more bizarre than others, but for a 90km race with more than 20 000 runners and thousands of nervous and tense supporters on the route, it is not difficult to understand why.

I have many stories but the one I like relating is about my lost cellular phone. It was a 2010 double down – an odd run because 2009 was also a down run. I was not particularly battling, I took the first half of the race really easy but as expected, the last 20 kilometers are always testing. At about 15km to go, just after passing a very busy water point, I looked up and suddenly this hill came into my view – literally out of nowhere. I do not know why it took me by surprise – it was Cowies after all – but at that point I immediately decided to find a bush and take a pit stop – use the break to regain my composure, I guess. I tackled the hill and after a few minutes, as I started descending the other side, I realised my pouch was open and my phone was missing. I was not in the habit of carrying a phone during runs, but for Comrades I used to because it made seconding easier.

It is widely understood that under extreme physical exertion such as in ultra-distance running, when resources get scarce, the body tends to give lower priority to the brain function. I tend to believe that. Under normal circumstances I would have just kept going, forgot about the phone and tested my luck. But on this day, I decided to turn back all the way down to the base of the hill where I took a pit stop to find the phone. In my limited thinking capacity I thought no one was ever going to find the phone and I could not imagine my seconds worried sick, trying to reach me. That I was left with only 15km to run was obviously not a factor that immediately came to mind. As I was running down, everyone was shouting at me, trying to get me to face the right direction because stories of runners found going the wrong direction by mistake are plenty.

I got to the pit stop and did not find the phone. My heart sank as I started climbing Cowies again. At the other side of the hill I started asking runners for a phone so I could call my sister who was manning the “nerve centre” from home, as I called it. I made a call and that calmed me down completely.  To cut the long story short – the phone was picked up by a fellow runner half way through Cowies hill, he put it in his pouch, ignored it as it rang many times, and only picked it up after he had completed the race. At the finish another fellow runner kindly allowed me to use his phone, I called my sister who then directed me to where the runner was waiting for me. I could not thank him enough!

I boarded my return flight to Johannesburg the next day and this particular cabin was unusually lively and happy – I suspect it was because it had quite a few foreign runners. Stories were related and I remember I was still standing up and facing everyone when someone else started relating a familiar story: “Did you hear about this one lady who ran Cowies twice. Apparently she lost a cell phone, ran down Cowies looking for it and we are told she still made it to the finish, can you imagine!”
I could not believe my ears! I got the phone out of my bag quickly and flashed it around: ”Oh that was me!” I exclaimed, smiling broadly, embarrassed and in complete shock!
Small world!!

That year I finished 11h26 and I still remember these events like they took place yesterday! The runners that assisted me in getting reunited with my phone demonstrate the real spirit of the race. What is your story, Comrade?

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