Episode Transcript
[00:00:15] Speaker A: Welcome to Shitco Talks, the no Nonsense cycling podcast.
Welcome to yet another episode of Shitco Talks. Today we're going to talk about a very particular syndrome that affects mainly endurance athletes, specifically those who participate in sports that are characterized by repeated hip flexions.
And our guest for today is Jim Arnold, Canada based physiotherapist, who is very well versed on this topic and who's actually doing his PhD on this topic. So I think that's he's the perfect person to talk about this particular syndrome. Many thanks, Jim, for accepting my invitation.
[00:01:20] Speaker B: Yeah. So an invitation to. Come on, Sebastian. I think it'll be interesting to talk about this. Of course, it's always good to put out more information for athletes and patients who might be out there and clinicians as well.
[00:01:32] Speaker A: Yeah. Talking about athletes and patients, I think that this is the kind of episode that will be watched by not many people. But the ones who are watching it I think will be very interested on what you are going to say here. So let's start with some very basic questions.
First of all, how will you define the iliac artery syndrome or specifically the iliac artery endofibrosis, the technical term. And why would you say that the people who are mainly affected by this are endurance athletes such as cyclists or runners?
[00:02:12] Speaker B: Yeah, so that's probably the first thing to kind of talk about is what is this condition called? Because it goes by a few different names. I tend to call it flow limitations in the iliac arteries or FLIA as kind of the nice abbreviation, but it's also called endofibrosis, as you said. Or it can be called cyclist Iliac syndrome. There's a few different names, but it kind of all refers to the same thing. And it's this condition that does primarily or predominantly affect cyclists, where blood flow is limited during exercise through the iliac artery. You know, we'll get into the details, but the iliac artery is the main artery that feeds blood and oxygen to our working muscles and the legs. The iliac artery becomes the femoral artery. So obviously it's quite important when we're talking about endurance sport, why it affects cyclists or, or it's. The first reason is, and, and this is kind of the major component of this condition is it's, it's a mechanical compression, it's a mechanical condition. And so it's related to the body position that cyclists are in, that, that forward hip flexed position, that aggressive aerodynamic position. And so we can think of other sports like speed skaters as well, are in a similar position and they can also show signs of this. But it's basically when we're in that hip flexed, compressed position.
Again, we're thinking about the iliac artery in the pelvic space. So we're not even down into the legs yet. We're still kind of up in the pelvis.
And every time we take a pedal stroke or a stride, we're contracting muscles and we're kind of compressing structures in that area. So that's why it tends to be more often seen in cyclists. That's why we sometimes call it cyclists Iliac syndrome. But it can be observed. It has been observed in runners, you know, well, relatively often simply because, of course, there's so many runners at a high level, at an elite level. So the, the just kind of the number of athletes plays a role here. It's been seen less often in other sports as well, even, even field sports, rugby players.
So it does exist in other areas because again, all of these athletes are still striding and they're still contracting muscle. And so we're going to get kind of a, a cyclic, a repeated contraction and compression on the iliac artery in that space. But it really has to do with that kind of aerodynamic position.
[00:04:50] Speaker A: Okay. And imagine that I'm a cyclist who has noticed during the last weeks to months that lower power output during his training, pain during the pelar stroke, et cetera. How will you differentiate between this syndrome and the vast array of muscular or tendinous injuries that may happen in the sacrist body?
[00:05:19] Speaker B: Yeah, unfortunately, is one of the difficulties in this condition. It is difficult to differentiate. So maybe to back up, and you summarize the symptoms quite well, um, the characteristic symptoms of this condition. Let, let me back up a little bit further. So again, it's, it's a blood flow limitation in the iliac artery getting to the working muscles during exercise. And it's all about this supply demand relationship of the higher our exercise intensity, the higher our demand is for energy. Uh, and, and our body is going to supply oxygen through blood flow to try to meet that energetic demand. So as long as we're able to increase our supply, then there's no problem. And we're easily able to match that workload in these athletes because of this kind of structural compression and limitation that I've talked about. There's a, there's a premature limitation in the supply side and how much blood flow and oxygen they can actually get through. So we're left with this mismatch, which then means the muscles, the working muscles which are doing all the work and consuming all of that oxygen are left in this deoxygenated state. And that's where we get these symptoms of kind of, you know, burning, heaviness, tightness, fatigue, all of these kind of characteristic sensations which sound fairly similar to just what all of us experience at high intensity all the time. Right. So it's, it's, that's one of the difficulties here is it's more a matter of severity rather than a completely different difference in the symptoms. And as well, right, if, yeah, if a patient, if an athlete comes to see me in the clinic and says, oh, I have, you know, pain and tightness and heaviness in my leg when I'm cycling really hard, well, that could be anything. That could be any number of musculoskeletal injuries, as you say, uh, it could be training load, you know, management issues, it could be over training or fatigue conditions. So it could be so many different things. And it's quite hard to, to attribute those symptoms directly, you know, immediately to a vascular condition. And so the, the, the, the detection process or the diag. Or the investigation process, let's say, you know, really starts with kind of a, a history taking and understanding where the patient is coming from. Very often, unfortunately, the patient will have had symptoms that are kind of gradually getting worse over a period of time and they've probably sought out other treatment, other clinical treatment, other other interventions to try to manage it. And maybe they just haven't responded as the clinician, as a. And as the patient would expect. And so it's, it's, it's lingering or it's, it's, you know, it's resolving and then it's coming back. And that's maybe where we start to suspect, is there something else going on? Is there something in addition going on? So that's where we might start to investigate a vascular cause. So, so, you know, understanding kind of the medical history and the sports injury history is an important part of this.
And it's, it's maybe worth bringing up. This is a rare condition. This is, this is not nearly as common as some of these other musculoskeletal sports injuries. So it's absolutely correct if we have pain in the leg to investigate those conditions first and to try to address, you know, whatever it is we see on that side before we start suspecting a flow limitation. So, you know, this, this condition is kind of gaining more awareness in the news. A Lots of, unfortunately a, lots of household athletes, right, professional athletes have, have talked about their diagnosis with this and, and often talked About a long period of investigation or of questions and, you know, not being satisfied with their performance before this is diagnosed.
But that's kind of part of the process is ruling out all of those more common features, those, those more common possibilities for before we get to this, this condition, if that makes sense.
[00:09:28] Speaker A: Yeah. Is the, is the usual presentation bilateral or. We are talking normally about one single limb affected?
[00:09:35] Speaker B: Yeah, this sheets unilateral. It's usually in one leg, often in the left leg. We don't exactly know why that is. Have some ideas but, but yeah, it's more often in one leg which, which does, you know, that is a characteristic feature of this. So it means if an athlete is coming in with a very clear and obvious asymmetry and they're complaining about symptoms exclusively in one leg, that can be one of these features that help us kind of, you know, obviously it helps us know where we're looking for and it means when we are diagnosing an athlete and we can get into what the diagnostic process looks like, it means we can compare one leg, you know, usually their affected leg to their unaffected leg. So we have that normal control built in when we're assessing these athletes.
[00:10:24] Speaker A: Yeah, for me it's quite curious that you will have a greater compression on the non dominant side. No, it's, it's.
[00:10:33] Speaker B: It doesn't seem to be related to leg dominance, at least not, not 100%. So. Yeah. Why, why is it the left leg more often? We're not exactly sure. Of course there's always asymmetries, kind of anatomical asymmetries. We all have that and, and we all have, you know, just individual variation and how stretchy our arteries are or how long they are through that area or how, you know, what the, what the course the artery takes around all of those other tissues around it. So there's a lot of kind of, in my opinion, I think it's, it's, it's not necessary or, sorry, it's not sufficient that an athlete is just in an aggressive racing position all the time and they'll definitely get flea. That's, that's not the case. There has to be some other maybe predisposing risk factors involved. Right. Because two athletes on the same team, on the same bike, they're training the same volume, one develops flea and one does not. So, so why is that? Right. There must be just some unlucky anatomical quirk in one of the athletes that makes them more predisposed to this. And again, this is a rare condition. So not every athlete is at risk of this, but we really are trying to understand what are some of those risk factors and what are some of the presentations that we can identify earlier in the process so we can detect it, diagnosis, and treat it.
[00:12:02] Speaker A: Okay, so let's go to the next step. Once the athlete seeks medical attention, what will be the diagnostic procedures here?
[00:12:14] Speaker B: Yeah, so what I, what I do as a physiotherapist in my clinic and with my PhD work, um, I kind of do some of the screening test for this. And, and again, in Vancouver in Canada, it's mostly amateur athletes, but I've worked in the Netherlands with some of the, the real experts in this at Maxima Medical center in the Netherlands, and, and lots of collaboration with other vascular specialists, vascular surgeons in the UK and Spain and in North America and the US as well. Um, and, and there's a pretty clear diagnostic criteria or an algorithm that we use. And it actually comes from my, my late supervisor, Dr. Hof Shap in the Netherlands, who, who developed this in his PhD, you know, 20 years ago.
It starts, as I said, with a history taking, understanding where the patient is coming from and their kind of existing injuries and medical history.
Again, this tends to be a condition that worsens over time. So we're usually expecting to see this in someone with a longer training history and someone who's at a higher fitness level, because again, of this kind of mismatch that I talked about, you know, you have to be at a very high fitness level even to approach the limit of the vascular's capacity to deliver blood for that to be the limiting factor. So that's quite important. Part of this is, is the history taking, of course, and then the, the, the next, I think most important part is a provocative exercise test. So we basically have to see, okay, you get symptoms when you're riding for five minutes at 300 watts. We're going to make you, you know, do an incremental test or a graded exercise test, just like you would do in a laboratory. And we're going to see what does it look like at lower intensity before symptoms arise and then as a function of increasing intensity, what does it look like when, when symptoms appear, when symptoms become the limiting factor. And of course, at maximal tolerance, at maximal provocation, and, and of course, the, the test has to be specific to where the patient is getting symptoms. So if it's a, if it's a mountain biker, for example, who, you know, they're getting symptoms with the much more kind of repeated sprint efforts or repeated punchy efforts, we might do a Test that looks more like that versus a road athletes or a time trialist who's kind of in a steady state, but in that position, we'll put them in that position and we'll, you know, we'll make them do whatever they need to do to elicit symptoms. Um, we're looking at a few things during that provocative test. One thing is muscle oxygenation or muscle near, near infrared spectroscopy is, is. We've, we've just recently again with my colleagues in the Netherlands, kind of started to understand how this can help diagnosis where these are non invasive little optical sensors you stick on the muscle. And it gives us a sense because again, we have this asymmetry between one leg and another. It can kind of show us what does it look like in the muscle itself in both legs, right. The affected versus the unaffected leg. When they're, when they're, when they're getting symptoms, right before they have symptoms and when they get symptoms. So nearest muscle oxygenation is part of that. And then we're taking blood pressures usually after exercise at the ankles. So the, so if we think about, right, if we think about, we have a, you know, pipes or tubes going down both of our legs and one of the legs, we've constricted that pipe and so we're not letting blood flow get through that segment. And so the downstream of that pipe will be at a lower flow and a lower pressure. And so we're taking blood pressures at both ankles and then we can compare that. And again, we have some diagnostic criteria that we look at. So that's kind of the gold standard measurement.
And then the next step would probably be imaging. We've, the athlete would get ultrasound first of all, right. Kind of imaging of the, of the artery structure, you know, in different positions.
And then it kind of depends, you know, it maybe depends on what the treatment options are. If it's, if it's a surgery that we're thinking or if it's conservative treatment. But anyways, if we think there's more suspicion, then we would do more advanced imaging, mra, magnetic resonance angiogram or CT scan to really get a sense of what the structure of the artery looks like. And of course that would help direct us, direct the surgeons to, to repairing some of the, or to seeing which structures need to be repaired. So that's kind of the process. You know, it's, it's again, most of it can be done kind of in a single session. And that's why what I do, I call screening tests. And then if I feel the athletes need the more advanced imaging, then they'd be referred onto to that. So that's kind of the process.
[00:16:55] Speaker A: Okay. And once you have been diagnosed, you have said that you have basically two, two treatment options which are surgery or, or conservative treatment. Could you elaborate a little bit on, on those two?
[00:17:09] Speaker B: Yeah. So the kind of, I would say the definitive treatment for this condition is surgery is, is surgical reconstruction of the artery. It's, it's quite a major surgery, especially when there's endofibrosis. We haven't talked about it, but endofibrosis is kind of, you know, the, the chronic stage or the chronic progression of this condition where this compression during any one single bout of exercise that repeatedly over time, over months and over years can cause pathological remodeling of the artery wall. So endo, meaning within the artery, fibrosis, meaning thickening of that artery wall, which then narrows the artery further and restricts blood flow even more. So once you have that endofibrosis, that, that structural change in the artery, then surgery really is the definitive treatment.
And again, what we're trying to, what I'm trying to do as a physio certainly is, I'm not a surgeon, you know, that's not my expertise. But absolutely, during the investigation process before we get to the stage of surgery, you. Conservative treatment, I think is a very important part here. And even more so after surgery when the athletes are coming back and returning to sport, returning to the world tour, returning to professional sport, then it's absolutely critical and there's really not a lot of systematic information available out there. So we recently reviewed the literature on this condition and provided kind of a summary of the conservative movement non operative management options that we have and propose some guidelines for return to sport after surgery. So maybe I'll get to that in a moment. But some of those conservative management, again, we can kind of implement some very easy tools early in the process. So as soon as we start to suspect, oh, maybe there is flea happen, maybe there's a flow limitation, we can start to apply some very simple things. Bike fit is basically the first start. Right. So we talked about the positional aspect of this condition. It basically means, okay, if we're getting symptoms when we're in our time trial, our racing position, can we kind of modify that position, you know, kind of get our body into a bit of more of an upright training position and we'll do it during training. We don't necessarily have to change the racing position yet, but we can do it during training where most of our volume is accumulated to try to minimize or reduce some of those compressive forces on the artery. So bike fit is number one. It's very easy. Right. And that, of course, right. If we have pain in a, in a, in a cycling position, we should of course, try to modify our bike fit. I, I think bike fit is, it's always a moving target. Right.
In, in my opinion, you know, some people will maintain the same fit for a long period of time. Others will constantly be kind of tweaking and playing around. And I think that's totally fine either way.
So in general, again, we're just trying to get into a more upright position that starts with right handlebars up, maybe a shorter stem to reduce, reduce the reach.
Those are pretty universal. They're not very fun changes to make because it doesn't look as racy, it doesn't look as aggressive. But, you know, maybe it's in the winter when we're on our turbo trainer at home, right. We can, we don't need to be in an aerodynamic position. We can raise ourselves right. Right up.
When we start to think about saddle position, it's much more individual. So it's really hard to give universal guidelines. But of course, just playing with that position of forward, backwards, up and down and the angle, the tilt of the saddle to try to find a comfortable position, it's kind of. There's an interesting trade off. And we're still trying to kind of understand this. I'm, you know, I'm not an expert in biomechanics, but just that saddle position will tend to change the muscle recruitment. You know, between the quadriceps and the glutes and the hip extensors. And then of course, it will change the hip angle as well. Right. So a forward saddle will tend to bring you upright by, by reducing the reach. A backward saddle will tend to increase the reach and bring your torso down. So all of these factors come into play. And then the fun one, the popular one these days, is talking about crank length. Uh, in, in my opinion, I think a short crank length is very often beneficial in this condition because what are we doing with a shorter crank when, when, when our foot and our leg is at the pedal, at the top of the pedal stroke, we have more space between our, you know, our knee and our torso. We have opened up that hip. Hip angle just changing nothing else just with a shorter crank. So that can be a.
It's not a, it's not a fix. It's not a cure. It doesn't, it doesn't cure anything. But It's a management method. So it may reduce symptoms that we have and then just quickly we can talk about training modifications as well. So what are we doing in our training? How are we training to manage our symptoms? One of the things I think is really important for us to realize in this condition in particular is we've said, right, this is a condition that mostly affects one leg. So we kind of have one leg that, that's, that's, that's limiting everything else, right? One leg becomes the limiting symptomatic factor before, you know, before our whole body can really kind of get to its full capacity. So all of our training targets and our, and our thresholds and our FTP and our critical power really have to respect the onset of symptoms and respect that local limitation. We are no longer limited systemically in a nice kind of whole body balance. We're being limited by a single limb, by a, by more of a local system, part of the system.
So I think we really have to respect the onset of symptoms when we're training. And that probably means, yeah, going easier, right. The symptoms only tend to arise at higher intensity. So it probably means reducing the volume of high intensity work that we do.
It doesn't have to be zero. You know, we're not looking for zero symptoms, but we're looking to reduce the symptoms because I don't think, you know, smashing ourselves into a brick wall of pain every time we go riding, whether it's a flow limitation or any other injury, or if we're sick, if we're ill with a bug and we're just continuing to smash, I don't think that's a productive way to train.
You know, our body is trying to devote resources to whatever the injury or the illness is and now we're just kind of taking it away from that. So anyways, that's a philosophical question, but I think we training has to respect the onset of symptoms. So we can do something more like intermittent intervals. Instead of a 5 minute VO2 max interval, we split that up into shorter intervals with brief rests. Maybe we do the five minute interval, but we take much longer rests like we do. You know, instead of everything back to back, we kind of do shorter intervals within a longer session just to allow us to kind of recover a little bit between those intervals.
Or my favorite is probably when we are doing high intensity, do it in a standing position, I think a standing, you know, standing climbing, right. Find a local hill. If we have that and, and, and do the 3 minute or 4 minute or 5 minute interval out of the saddle the whole time. It's less efficient, it costs more energy, but it tends to, in this condition, it tends to reduce the symptoms, reduce the symptom limitation so that it allows us to kind of get more whole body cardiac output, whole body VO2 max right. Going. And, and in my opinion, I think there's reason to think that it, it preserves and it allows us to kind of maximize the, you know, the stimulus on our heart and lungs. Right. And that's kind of the main factor that drives endurance performance. So standing intervals is kind of my, my favorite little tweak that we can make if that works for the individual. So those are kind of some of the management. Right. Very.
Nothing crazy, right? Nothing, nothing kind of unusual.
So easy steps that we can implement and if something doesn't work, then we, then we go back, right? We change the bike fit back, we change our training back to how it was. So that's kind of the, where we start.
[00:25:28] Speaker A: Anyway, I may be wrong here, but given all these limitations you have commented here, I think that this will explain why most of the pro elite cyclists end up getting the surgery. Because in the end, if you are as limited as you're pointing out, you know, in your training, then you're, you're, you're getting nowhere.
[00:25:49] Speaker B: No, yeah, yeah, unfortunately, that's right.
There's only so much that we can do on the conservative side. Again, in my opinion, as far as we know right now, there, there is nothing that will stop or cure or. Right. Like stop the progression of the condition other than stop causing ourselves pain. Right. Avoid the activity. And, and that's not possible for professional athletes who have that, that obligation.
And so yeah, that's why surgery is.
Oh well, I don't actually know if it's more common, but certainly that's why we hear of the professional athletes having surgery because they've probably tried all of the other options.
Right. They, you know, it's nice when you have a full team of clinicians and support staff around you. You can make these changes and investigate this. And certainly, yeah, if the decision is made that, you know, this athlete, number one, wants to keep competing.
Number two, we've kind of tried all of the low hanging fruit, all of the possibilities and the athlete is still having symptoms, then surgery is absolutely important. And, and it's, and it's an option that we have.
It's a major surgery. There's a few different options of what the surgery might be. But, but we're talking about vascular surgery, we're talking about surgery on a major artery in the body. So of course it's a, it's a major surgery.
The success rates and the satisfaction rates by patients who come out of surgery is quite high. Again, my colleagues in the Netherlands have reviewed this recently. So again, the success is quite good.
What we're trying to develop now is kind of okay, how do we really improve the return to sport process after that surgery? Because the athlete who wants to return to the World Tour number one, that's a very high demand, right, to, to get back to number two, the time frame is set. You know, again, the, the, the obligations of sport means that the time frame that they expect to come back might be quite, quite tight, quite compressed. And so we have to do as much as we can to really support that process. And so that's something we're kind of working on right now with again, colleagues in, in Europe, in Spain and the UK and you know, clinicians who are over there working with these World Tour athletes.
[00:28:14] Speaker A: So that was my, my next point. Imagine that I got the surgery which will be your recommendations for the return to sport? No, for the return to. Not necessarily for pro athletes, but maybe even amateur athletes who want to return to their cycling or other activity.
[00:28:37] Speaker B: Of course it's going to depend on the athlete because it depends what the surgery looked like and what the findings were in that surgery. So again, we have a review article just published at the end of 2024 proposing some very general guidelines. And we have, you know, a table with the different phases of return to sport. And the safest thing to say is, you know, the first six weeks or so is going to look pretty much the same for everyone. And that is no cycling, really, no exercise, gradual progression back to walking and back to just activities of daily living, of course, during that timeframe. But that first six weeks is really just about the vascular healing process.
So if we think about it, that six weeks of no training, right. It's even if there wasn't a surgery before that, and even if there wasn't an injury for potentially years before that, it requires some time to get back into our full training and our full fitness. So, you know, unfortunately, again, historically, often the athlete will get advice out to that six week mark of, you know, here's what you can do in week one and week two to three out to week six. And then, because at that point the surgeon, the medical team is satisfied that the artery is as, is fully healed and fully ready to, you know, take the higher blood pressures during exercise. Usually it's kind of the athlete is unrestricted at that point. But if we jump immediately back into our full training load that we had before, maybe that doesn't end very well. And it, and it, you know, again, just like jumping back into your full training load after an off season. So, so we've started to talk about what should the, the phases look like from week six to week 12 to week 16 and beyond. And again, there's nothing crazy here. There's nothing unusual if, you know, knowing nothing else. If we think about what would we do when we're restarting a training plan after the winter, after the holidays, we've taken some time off. It's January as we're speaking, people are starting to ramp up their, their training volume. It's basically the same thing.
Maybe something that we add is a consideration of the position. Right. We talked about the sensitivity of this condition to position. So if we can start, restart our training in a really more upright position, again this is probably going to be on a stationary trainer. It might be out on the road as well.
We're starting at maybe 30 minutes at a time. So very short training loads and we're starting at low intensity, zone two, aerobic training, whatever we want to call it.
Because again, we have to kind of gradually increase our intensity, gradually increase our blood pressure to allow this artery that we've just repaired to kind of re. Accommodate and to allow the, the rest of our body, right, the tissues that have to be cut through. It's a, it's an abdominal incision. Not to go into too much detail, but if we say right, the abdomen, the core muscles are kind of important during cycling. So we have to make sure that those muscles are rehabilitated and repaired and ready to take on the demands of sport. So a very slow process of building up the training volume, first the frequency and then the intensity over kind of again that maybe 12 to week, week 12 to week 16 and that kind of phase.
And again, not to give any universal timeframe by any means, but we would say by, you know, somewhere around that week 16 mark or somewhere around that, I think it phase six in our, in our program, that's where we can start to introduce return to competition. So we've, we've been training consistently for eight to 10 weeks.
We've increased our training volume and our training intensity. So we're doing some higher intensity efforts. Now we can start to think about a return to competition, whether that's professional or amateur. And that will depend when in the season of course, and what races or what are the target events. But I, I, well Let, let me say this.
I haven't personally, anecdotally, I haven't spoken with an athlete who says they wish they returned faster. You know, it's, it's usually the answer is I could have taken longer. Right. I could have gone a little bit slower. Not that there's anything catastrophic, right. By, by increasing our training a little bit too fast. But I think it's when we're recovering from a major surgery and a period of time, of, of an injury before that, the body really has to take time to recover. And it's not just the tissue that's been injured acutely during surgery, but it's all of those kind of compensations or adaptations that we've, that we've, we've had during the injury itself. Right. While we were limited, while we were getting pain, our body is going to change how it's moving to try to avoid pain. And so undoing some of those compensations, it takes time. So it can be common. This is probably important to say it, it can be common to have symptoms still after the surgery as we're returning to training.
That can be quite scary. Right. Like, I just went through this whole process and I'm still having symptoms. Hopefully it's not as bad. Hopefully there's none at all. But it is possible and we would say no problem. That's expected. Keep training, you know. Right. Let, let's, let's maybe slow things down, make sure we're not pushing too hard, but slowly, gradually, over time, the tissue kind of resolves and repairs.
[00:34:18] Speaker A: You have commented before that there are some genetic predisposing factors for this syndrome that we don't know about yet. But one of the main factors seems to be the training load. Given that mostly pro athletes are getting this syndrome. Given this, what recommendations would you give to the general athletic population if they want to reduce the, the risk of getting this syndrome, given that, you know, they want to train as much as possible?
[00:34:54] Speaker B: Yes.
Yeah. The first thing there it again, I think that we can say not every athlete is at risk of developing flia, because there do. There does seem to be some combination of risk factors. So I think that's important to say, you know, not all of us have to take precautions or, or, or change our behavior to try to avoid flea, because it's, it's a rare condition. It's not going to affect everyone. And so in the absence of any symptoms or any perceived issue, you know, I do what you want, do, do, do, do whatever kind of you enjoy.
If there is a, if there's an, an asymmetry or, or just a suspicion by the athlete that, that there's something happening or if there's a concern about flea or about, you know, maybe just other kind of vascular conditions. Right. Maybe there's a family history of vascular conditions. Whatever the case is, then, yeah, there, there are kind of a few things that we can do, and we've talked about them already, really, and it starts with the bike fit and the position that we're putting ourselves into. And again, I, I really think it's, it's. It's quite nice because I think there's an obvious and immediate feedback is if we change our, our bike position and if it feels better, great. Like, let's, let's keep it, let's, you know, stay in that position. If it feels better, we're probably going to be stronger and more sustainable in our training in that position. If it, if, if we make the change and it feels worse, well, I, I don't think there's any reason that we have to really hold. Hold ourselves in there and, you know, just tolerate it for six months and then we'll, you know, we'll get it. We'll get used to it.
Maybe for professional athletes, again, professional professionals have obligation if they have to get into the fastest time for opposition possible, that that's what they have to do. For all of us amateurs, we, we probably don't need to hold ourselves in that really uncomfortable position. And we're probably going to be more benefited by having a comfortable position, in my opinion.
And then if you change a position and there's no change, there's no, there's no perceived change. There's no difference.
Do whatever you want, Change it more, change it back, you know, not a big deal. So there's that instant feedback of is this going to feel good or not?
Some other things that we can talk about again, you know, bike position, crank length, I think is a good one. And, you know, that's the trend these days anyway, so let's go all. All in six, five cranks. Just, you know, make all the Shimano happy by selling those cranks. Anyway, for, for training, what we, what we can think about is not, not so much recently, but more kind of, I don't know, 10, 15 years ago or longer. There is a big push. There's a big meme about, you know, pedaling circles and all of the, the kind of the pedaling metrics that we get from our, our power meters can show us, you know, how effective we, we are at pedaling. Circles.
The, the research on this is pretty clear that we, we don't see any difference in terms of the actual performance outcomes whether an athlete is pedaling perfect circles or whether they're not. And, and, and often, again, this is one of those things of, if we're trying, if we're, if we're intentionally thinking about pedaling circles, often we make ourselves less efficient and we limit, reduce our performance in that sense.
I say that because that's the performance side here. But the clinical side is if we're pedaling circles, meaning we're kind of, you know, pulling around the bottom of the pedal stroke and especially pulling up the top, the back of the pedal stroke, we're going to be using more of the muscles around our hips and pelvis.
And we think potentially that overusing those muscles, and I'm thinking about the hip flexor, the psoas muscle and the iliac artery actually basically runs right kind of in front door just, just beside the psoas muscle. So the more we think we use that psoas muscle, maybe the more compression we put on the artery. So one of the recommendations is don't worry about pedaling circles. Just stomp the pedals down harder, just push down. Just worry about that part of the pedal stroke. So again, from a performance side and from a symptom management or a, or a, you know, reducing risk factor side, that's something that we think is, you know, totally fine. Just don't worry about pedaling efficiency or pedaling technique. Just be a stomper and that seems to be totally fine.
Any other kind of restrictions?
[00:39:36] Speaker A: Just out of curiosity, have you seen any case of someone who got flirty and got it solved by making biomechanical modifications.
[00:39:49] Speaker B: Potential? But it's always hard to say because if, if we haven't kind of invasively investigated, then we don't know for sure whether it's flea or whether it's maybe something else. But what. Certainly, you know, I've worked with athletes who have just had conservative treatment and who have been able to manage their symptoms. Again, the other clinicians I work with closely with, Kat Steen is, is a physiotherapist in Girona, and she works with a lot of the World Tour athletes on the male and female side. And I know she's working with athletes there, managing their condition, whatever, whatever the injury, whatever the presentation is, managing it conservatively. And, and the athletes are still competing in the World Tour. So if at that level, again, whatever the condition is, whether there's a combination of the Vascular and musculoskeletal.
There do seem to be cases that are, that are able to be managed conservatively. So it's almost kind of that reporting bias of the athletes who, you know, end up having surgery are almost by definition. Right. The worst of the worst. That's of course how it is. And we maybe don't hear about as much some of the athletes who have, who are less symptomatic and who are then able to manage it conservatively.
With my colleague in the Netherlands, Dr. Martijn von Hof, we're just about to start looking at some of the data from their hospital, looking at patients who did have conservative treatment. So it's something hopefully we'll have better data on and better answers on in the next few years. And of course, how do we manage these athletes? What is the best thing that we can do? But yeah, we don't have those answers yet.
[00:41:32] Speaker A: Okay, one last question. And it is related to doping because I have seen several times on social media people who are attempting to relate athletes who retired due to FLIA with their potential doping, infection, etc. And for me at least there, there is this, there is a point in that, given that as long as we have commented in this episode that superior training loads expose you to the greater risk. No. And given that, I don't know if you're getting EPO or something like that, that in the end will make you train harder and longer.
It at least potentially it could predispose you to flee and all. And I would like to know your take on this and whether you think there could be a potential link.
[00:42:32] Speaker B: Yeah, I think that's an important question.
Of course I've seen as well, comments on social media.
I have to say though, it's not our first concern in, in the clinical conversation, you know, again with, with my colleagues, which, which it's, it's not something that we think is like very closely involved or associated and I think that's important.
So maybe the first thing to say is I'd agree doping would increase the. Either increase the risk or, you know, aggravate the condition. And, and very simply, that's a theoretical statement, right? I, I have no data on this. I can talk about the data. I think there are two reports in the literature that, that talk about doping. Even so there's really not a lot of information out or data available. But from a theoretical perspective, and I wasn't even thinking about, as you just said, of, of, you know, yeah, someone who's, who's taking performance enhancing drugs is Going to increase their training volume and their training intensity. But just from a direct, you know, what are these, uh, what are these drugs doing? Epo blood doping, of course. Right. We're increasing our blood volume and our blood viscosity, our thickness. And so if we're. Then, you know, if we're doing that. But now we have this limitation and we're driving even higher forces through that local limitation. Yeah. That could tend to cause more of an issue.
So. So in my clinical opinion, doping is bad.
Not a, Not a shocking revelation here, but I think it's important to, you know, again, consider, like, why don't we think this is a major concern and maybe we can talk about is.
I touched on it earlier in terms of, you know, it seems to be that there are multiple risk factors or multiple factors that are necessary for FLIA to develop. It is. It is not sufficient for just an aggressive, aerodynamic position for FLEA to develop. It is not sufficient just for an athlete to maybe have, again, some anatomical quirk if they're never a cyclist in the first place. Right. It's both together are necessary. And so it can. We. We can think about is doping either sufficient on its own to cause flea, or is doping necessary for flea to develop? And in both cases, I'm quite confident to say no. I. I don't think it is. So I don't think it's sufficient because, again, because of these other factors, if an athlete is. Is.
Yeah, if an athlete is doping but they don't have the. Whatever the genetic or the anatomical predisposition, they're probably not going to develop flea. And we know lots of dopers who do not have flea. Right. So at least we can say not all dopers will develop flea. The other side is, is doping necessary? Is doping required for FLIA to develop? And again, I'm very confident to say no.
It's. It's hard to prove. I can't prove that every athlete I've ever worked with has not been doping or, you know, you can't prove a negative. But I'm very confident because it doesn't just affect the top athletes, affects amateurs. It affects all kinds of athletes. It affects all kinds of other sports. We see it in, in, in other populations and in individuals who just have no reason to be doping. And, and again, it, you know, my confidence is a hundred percent.
You, the listeners, your confidence should not be a hundred percent. It never is because of the sport, because of the history of our sport. But I, I don't think that we need to say that dope that doping will necessarily lead to flia. So we have to consider this kind of the harms of this association. And this is what I think really strongly about is if we falsely associate this condition with doping, there's a potential for harm to the athletes who have this condition. Right. The athlete who has symptoms might not want to come forward, might not want to pursue clinical treatment because there's this false association with doping. Oh, people are going to think I'm right, and I think that's very harmful.
Again, historically, from the data in the literature and from kind of clinical experience. And this is mostly me speaking with other clinicians who have, you know, worked in this area for 20 plus years.
It just doesn't seem to be a concern. Like, I'm sure there are athletes who have doped, who have had flea, but I don't think it's a major driving factor here. And I say, I think we really have to argue against an association. I don't think there is any association.
You know, it's something that we have to consider. And again, I do think that doping would make this condition worse. So it's something. Yeah. If we're speaking with a professional athlete, maybe we do have to raise that and say, like, hey, for so many reasons, this is a bad idea. But, yeah, to me it's, It's. To me, there is no association. And I think it's harmful if we start to falsely convict, you know, athletes simply based on their medical presentation. So unfortunately. But of course, you know, social media will sometimes do that.
[00:47:59] Speaker A: I'm trying to think about a nice summary for this chapter. I think we can say that if you are not getting any symptoms of flia, you shouldn't worry. If you do get symptoms, you should seek medical attention. Try first biomechanical and training modifications. If that doesn't work and you want to keep training and cycling, you may get a surgery. And if you end up getting the surgery, you still need a lot of patience, you know, because it is a very major surgery and, you know, it takes quite a few months. That would be a summary I don't know if you agree with.
[00:48:42] Speaker B: Absolutely. Write that down after. Put that into line. Yeah, that's exactly right. It's. It's. If there's. If there's no indication of an issue, let's not go looking for an issue. If there is a suspicion of an issue, we have to rule out all of the more common causes. Sports injury, musculoskeletal, biomechanical, fatigue and training load management. Right. Energy deficiencies that's all hugely important.
And, you know, along the way, even if there is a vascular component, we might be able to manage and address the issues. And if we can't, and if we have evidence of endofibrosis, then surgery is absolutely an available option. And yes, we have to be very patient and very gradual in our return to sport. And that goes for, you know, team managers and coaches and staff as well, thinking about these athletes. We really can't put pressure on these athletes to return, you know, three months after they've just had a major surgery and return to the world to where we really have to give these athletes time from a, you know, a health standpoint.
And yeah, just like the surgery, you know, as a physiotherapist with manual therapy and exercise therapy, if there's endofibrosis, I can't do anything about that. We can manage, but we can't fix. Surgery can fix the artery structure, but we still need. But it can't address all of the functional aspects that led to that structural pathology in the first place. And so, of course, we need both together. We need the rehabilitation conservative side and we need the surgical side. And so we have those tools available and we're just trying to make sure that we have more information to make those tools available to the athletes who need it earlier, before this condition really gets, you know, to a severe stage. That, that's the whole kind of goal of my PhD work and clinical work.
[00:50:39] Speaker A: I hope to see, to see it published soon. I think that it will be very interesting material. So that's a perfect summary. Jim, many thanks again for, for this conversation. I think that would really quite useful for those affected and practitioners and clinicians and for those of you who are watching us. See you in the next sheetcotors episode. Goodbye, all. Many thanks, Jem.
