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Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries
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I put down some fairly heavy mileage on the bike, and I'm starting to worry about overuse injuries since I heard about Phil Southerland, manager/founder of Team Type 1.

Some background info for those not familiar:
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"This damage, or arteriopathy appears to cause the arteries to stretch, narrow or kink in such a way that during high-intensity exercise the athlete experiences decreased blood flow due to the constriction or obstruction of the artery in the affected leg. This lack of blood flow, or ischemia, causes pain, burning, weakness, and powerlessness during exercise."
http://sportsmedicine.about.com/...s/a/Arteriopathy.htm

For running, I roll my IT band and stretch my calves to prevent patella tracking issues... there must be something I can do to prevent this from happening on the bike.
Thoughts?


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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [amclean] [ In reply to ]
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Can't really prevent it. I know, I had surgery for it about a year and a half ago up at UVA (Dr. Cherry - same surgeon who worked on Phil). I started having issues while during triathlons over 6 six years ago and then just raced on the road and track (cycling) for about 4 years (putting in tons of bike miles) and the issue got progressively worse. A large part of it depends on your anatomy. My issue was my inguinal ligament was compressing the artery, which caused the damage and resulted in the lack of blood flow to my left leg. This is found in most cases. Another friend of mine just had surgery last month for this and her issue seemed to be more of a kink in the artery (artery can be "too long" and kink) and compression from the ligament. It's a combination of bad luck in the anatomy department, being in the cycling position, and increased blood flow during exercise. Even my surgeon said he can't predict who will have the issue and who will respond well to surgery.

Working on your IT band, calves or patella tracking are completely unrelated to your iliac artery. Actually, there isn't any stretch or exercise that can help as far as prevention. The iliac artery is in your lower abdomen/groin area. Also, remember that it is fairly rare as far as injuries go so your likelyhood of having this issue is NOT super high.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [little red] [ In reply to ]
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Oh man, sorry to hear about the trouble you've had. Did the surgery make much of a difference?
I'm concerned because I've noticed a loss of sensation in my left foot, as well as some terrible cramping in the same leg on long rides... I'm hoping its something else.

--Alan
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [amclean] [ In reply to ]
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Without being a fancy pants, I'll direct you to this thread:

http://forum.slowtwitch.com/...m%20demerly;#3171408


Tom Demerly
The Tri Shop.com
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [Tom Demerly] [ In reply to ]
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Fair enough. Thanks Tom.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [amclean] [ In reply to ]
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Hopefully it's like being hit by lightning...rare enough that no action is called for in regard to prevention.

But I would guess that less time on the bike would be helpful. I would also guess that the more open your hip angle, the better in this regard.

Anyway, your symptoms can also come from many other more common things. So considering the Iliac artery is premature.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [jyeager] [ In reply to ]
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Yeah, it wasn't my intention to come off as a hypochondriac... Tom's point is well taken.


What I was trying to get to though, were ways to prevent overuse injuries in cycling, something that until recently, I hadn't even considered was possible. Sure, there are the usual suspects like a tight ITB... but I wasn't aware of overuse conditions that were specifically attributed to the cycling position. Of course, with running, I am very much aware of it. I roll my ITB twice a day, doing VMO strengthening exercises, go to the physio... etc etc.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [amclean] [ In reply to ]
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I know you've already been directed to another thread... but yes, surgery made 100% difference for me and I am pretty much back to normal. All my tests post surgery have come back normal as well. I had the issue for so long before diagnosis and surgery that I've had a lot of muscle imbalance issues to correct but that stuff is relatively easy to work on.

If you think you may have this issue it may be worth getting checked out for iliac artery endofribosis BUT you will most likely have a hard time finding a doctor or ortho, or in some cases, even a vascular surgeon, willing to consider a vascular issue in an athlete. Very few doctors, including vascular surgeons, are familar with this issue in cyclists. Vascular surgeons typically deal with old, overweight, sedentary and very unhealthy people - not athletes. Actually, many vascular surgery labs aren't even equipt to test athletes. An athlete needs to test on a bike or treadmill and often typical vascular patients with peripheral artery issues can give a positive test just doing toe raises. So if you seriously think you may have this condition do some more research on it and the best doctor to contact is Dr. Cherry at UVA in Charlottesville, VA. Your symptoms could be this or something completely different. Feel free to PM me if you want more info.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [amclean] [ In reply to ]
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Well, in that light I'll just throw out some cycling overuse injuries that come to mind:

- saddle sores
- knee pain
- low back pain
- neck pain
- perineal nerve damage
- ulnar neuropathy (arm or hand numbness/pain)

Biggest factors in reducing these?
- decreased bike time (but who wants that!?!?)
- proper bike position
- mixing it up...on a road bike, you can stand, sit, move your hands, get off every hour to pee...
- mix up your bike training: make use of tri bike, road bike, mtn bike.
- proper cleat placement and adjustment
- seat selection
- I personally am of the opinion that strength and flexibility training can help to prevent the back and perhaps neck pain
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [jyeager] [ In reply to ]
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jyeager wrote:
Hopefully it's like being hit by lightning...rare enough that no action is called for in regard to prevention.
e.


I would have thought so, but myself and two other athletes I have come across through my team have (or had) the same condition. I don't know a super-large number of athletes, and I have been surprised that I've met two others in a fairly small pool.

Not that we should all be riding with more open hip angles or lining up bovine artery grafts ... It's just caused me to think this affliction might be more common than we assume.

Interesting that one of the articles highlights the aerodynamic position of cyclists as a culprit. remedy: sit straight up in tt's.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [amclean] [ In reply to ]
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check for pelvic malaignment
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [amclean] [ In reply to ]
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I'm looking for recovery advice.

After three years of symptoms and two years of seeking diagnosis, evaluations and dead ends I finally obtained a positive diagnosis and surgical remediation of iliac artery compression from the excellent vascular team at Mass General Hospital in Boston, Dr. Michael Watkins and his surgical Fellow, Dr. Sean English. In the hunt I saw a ridiculous number of specialist's (need to go back and do a precise count) and pursued various treatments (ineffective hip and spine injection; dry needling; structural manipulations and PT to relieve pelvic and sacral misalignment which helped but ultimately were ineffective). I had said from the start of this medical odyssey that it just doesn't feel like I get enough oxygen in my leg but for some reason the case was managed in such a way that vascular was the last stop. I was considered medically important to find the source of the pain, otherwise I might have given up although I couldn't imagine giving up cycling and there did not seem to be a middle ground.

Last Friday they performed surgery to release the left femoral ligament (causing the restriction on the iliac artery) and patch angioplasty of the left external & common femoral arteries (was about a 3 inch incision in the artery and a Dacron patch). It went well and they are confident of a good outcome. It took two hours and was done with an epidural. It's about a three inch vertical incision in the groin.

I am looking for advice from athletes who have undergone this surgery in terms of how they approached reconditioning. I am 58 but still very competitive and hoping to get myself back in shape to go for my age group record on Mt. Washington this year. It's been a wipe-out of a season because I also tore my meniscus and popliteal muscle in June (kite boarding...) and had my knee scoped in August. So very little quality time on the bike this season and no racing but I believe I can climb back. I only race uphill. I am not a triathlete and no longer run marathons because the knees can't take it. I started racing Nordic last year and would like to continue and get more competitive skiing. I experienced some pain and weakness in my leg while racing but not nearly at the same intensity. I do regular core and strength training and am constantly stretching and doing yoga moves - all critical to my competitiveness and injury avoidance.

I'd would like to raise awareness of this condition in the cycling community. I wasted a LOT of time and money chasing a solution even though my symptoms were classic. They were: Pain and loss of power in my left thigh when riding but essentially no problems at rest. At higher power levels the pain would increase to the point of failure of the leg. Pain radiated generally from my hip joint and throughout my thigh, seeming to concentrate on my quads and wrap around the front of the leg. But it varied in intensity and location. It was very non specific. Sometimes it radiated into my lower leg. I had some numbness in my toes and foot but also have that on the right side so am not assuming it is connected. Sometimes it would be painful the moment I climbed on my bike and it always felt like too much lactic acid. I experienced breakthroughs while riding where there would occasionally (rarely) be temporary relief. But maybe that was just my brain overcoming the leg. It would not respond to rest and there was no stretch or strengthening which made any difference. It didn't stop me from riding it just made it terribly hard. It did rob me of power. And of course it is not fun to work harder and harder but be dropping off the back of the pack you used to lead. :-)

Regarding the subject line of this forum, I don't think I could have done anything to avoid this other than never having cycled at a high level. I have excellent form and really good, well-fitted equipment. I did do a lot of mileage and some very extreme events but I suspect that simply being at a competitive level, with the intensity that requires, would have triggered this condition even if I hadn't done the endurance stuff.

I have a great coach, Marti Shea, and I'm sure we will come up with a good plan, but input from athletes who have been through this would be very welcome. Thanks!
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [trishkarter] [ In reply to ]
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Sorry--didn't see this post earlier. Look at this thread for general iliac artery endofibrosis info and advice on reconditioning post-surgery. The summary: take it slow and don't overdo it.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [HeidiC] [ In reply to ]
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Thanks so much Heidi. I saw a general discussion about the condition but no discussion of recovery from the surgery. Am I in the wrong place?
Questions: How slow is slow? Metrics? What should I be looking for to indicate I'm going too fast? When others first get back on the bike do they still feel some mild pain/weakness in the thigh? Does the incision area hurt at all? How to distinguish between the atrophy and the underlying condition? Have you seen any cycling coaches write about their experience with their athletes? Evaluating different methods of rebuilding while cautiously watching for trouble?
Thanks!
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [trishkarter] [ In reply to ]
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I'm sure recovery varies from person to person and depending on what needed to be done. I had my inguinal ligament released and both my femoral and iliac artery patched about 5-6 years ago. I was allowed to start easy swimming as soon as the incisions were healed, which was just under 2 weeks for me. I started swimming really easy with a pull buoy and no flip turns. By the 4th week I was able to start swimming part of the masters workout and by 6 weeks I was swimming full masters workouts. It was probably closer to 4 weeks before I was able to start on the elliptical and easy spinning on the indoor trainer (sitting up - definitely not in the aerobars). Around 6-7 weeks I was able to start running and ease back in regular cycling. I did have a lot of muscle imbalances because it was many years from the start of my symptoms to diagnosis, so I had to do a lot of strengthening to balance my right and left leg, but I wouldn't say I had a noticeable atrophy with my left leg. Your surgeon is really the best to guide you as far as your recovery, I can only speak to my experience. Dr. Cherry performed my surgery at UVA.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [trishkarter] [ In reply to ]
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Sorry, I thought the other thread had more of a discussion on recovery. As little red said, there will be some individual variation in recovery. I had iliofemoral bypasses on both legs at the same time (not patches because it was too blocked and I also have a DVT history), so I had one center (abdominal) incision and one groin incision in each leg. The center incision hurt for a couple of months, which is normal. My surgeon was very specific about not swimming for six weeks, mostly because my abdominals had been cut open, and then I was only allowed about 1000 yards/workout for a few more weeks. I started riding the trainer for ~20 minutes after about 6 weeks, rode outside at about 8 weeks. Before I started riding, I saw a good bike fitter (Phil Casanta at Hypercat Racing) -- told him my situation, he researched it, and gave me a position that opened up my hip angle as much as possible, to about 110 degrees on my road bike. I still had pain the first couple of weeks of outside riding but that did go away. I rode a 5:20ish century 5 months after surgery. I think I started running after about 8 weeks as well, but just a couple of miles at a time.

The bane of vascular surgery is intimal hyperplasia, which, simply put, is the formation of scar tissue inside the repaired artery. It's a normal healing process, but if it's significant enough, it will block the artery again. Most of that is largely out of your control, but avoiding any additional injury to the intervention site can only be helpful. You really want to do all you can to prevent additional stress there before it's all healed. Taking a slow return is important to that healing process.

I also had a lot of muscular imbalances related to 25+ years of having this issue. I worked with (and am still working with) a very good MAT (Muscle Activation Technique) guy (Blair Ferguson, Ventura, CA) to get things firing correctly again. That has been a lifesaver for me.
Last edited by: HeidiC: Dec 15, 14 9:14
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [HeidiC] [ In reply to ]
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Very Helpful Heidi. Thanks! I need reasons to hold back. It's hard to take it slow. That's a big one. Much appreciated.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [trishkarter] [ In reply to ]
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It's December -- let yourself heal; you have plenty of time to get back into shape. Repeated stress on the intervention site from cycling is ultimately going to do more harm than good. Go for a walk instead, although not on slippery ground if you're somewhere where there's snow. Google Ryan Cox (pro cyclist) for additional reasons why it's important to let things heal.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [HeidiC] [ In reply to ]
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I would like to know how you are doing and if you still have symptoms. I have also had this surgery 5 months ago.

Tammy
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [tammy] [ In reply to ]
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I know this reply wasn't to me, but I had the surgery in 2009 and have not had any issues since. I've had some other injuries since ... but nothing related to IAE. :)
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [little red] [ In reply to ]
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I wish I could say the same. When I run track or run faster then 7min pace I will feel that burning pain in my right quad a little. It is not as bad as it use to be before surgery but I hope I goes away over time. It is on and off and some days I do not feel it at all with a hard workout. It has been 6 months since I had surgery.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [tammy] [ In reply to ]
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I'm still doing well. I seem to have a little bit of intimal hyperplasia, which is similar to scar tissue and is the bane of vascular surgery, which has taken my function down a tiny bit in one leg (I had both done), but not so significantly that I notice it. A weird thing: I was taking niacin for a while and when I stopped it I noticed that it had really contributed to pain in that one leg and of course led to panic. If you're taking anything like that, or a statin, and can safely stop taking it, that might be something to consider. I found Muscle Activation Technique to be really helpful in getting my muscles working again, as they had been without appropriate blood flow for a very long time, so if you have an MAT person in your area that might be helpful -- but expensive and not covered by insurance. I think it's still possible for yours to recover more, but, on the other hand, I do know people whose surgery was not 100% effective. Sorry, I know that's not comforting. Give it a little more time before you go into full-blown panic, and stay in touch with your surgeon. Good luck! It's stressful, I know.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [HeidiC] [ In reply to ]
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What is a MAT person? Sorry I do not know
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [tammy] [ In reply to ]
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 A Muscle Activation Technique person.

Edited to add a link explaining MAT: http://wgntv.com/...nd-through-exercise/. It's been enormously helpful for me.
Last edited by: HeidiC: Jan 14, 15 10:40
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [tammy] [ In reply to ]
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If you haven't already, you may also want to see someone to have a functional assessment to see if you have any muscle imbalances that could be causing issues. I did have some problems with my leg for a year or so after surgery but the issues were because of all the muscle imbalances from running/cycling for years without adequate blood flow to my left leg. Once I figured out those imbalances and started specific strength training the problems went away. It's very likely you have some areas of weakness and tightness and it's possible that is where the pain you are feeling is coming from.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [HeidiC] [ In reply to ]
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HeidiC-thanks for your valuabel input to this forum and the other forum about IAE. Can I ask, what sort of imbalances did you experience? I have an appointment with Dr. Jason Lee at Stanford next month to get an ABI test. I had R side transverse and lower ab weakness for years that I struggled to correct and could not. I have a trainer at the gym who is amazed at how imbalanced I am. I think the psoas on the R side tried to compensate and contributed to IAE. This is all my theory until I get the ABI test since when I first stopped cycling, I happened to have buldges and ruptures in my back and one ortho says my problems are still my back, and two other orthos say my back is fine. All 6 cortisone/nerve blocks to the disc did not help. A muscle therapist says it's all in my head. I started to cycle on flat land since I totally lose all power on climbs (even though I was a climber). My normalized power on rides are going down on the R side no matter what I do even though my "back is fine" and "it's all in my head". I feel like the coordination in my R leg is decreasing. All my symptoms are what were discussed in the other forum exactly. I just wondered if you could expand on your imbalances and how they are progressed after surgery to now.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [MicheleM] [ In reply to ]
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Hi Michele: Yes, transverse abdominis, internal and external obliques, and some of my spinal muscles have been significant issues for me for years. I've also had issues in my hips and legs, with muscles picking up the slack for other muscles which were weaker or not firing at all. But keep in mind that my blood flow was restricted/missing for 25+ years, so the problems were extreme and the compensations pretty well set in. Interesting about orthos attributing your issues to your back. I may have said this already in one of these threads, but I did rupture a disc a few years after the leg problems started. The ruptured disc caused nerve issues and more acute leg dysfunction (foot drop, etc), which was corrected with a discectomy. When my legs never got fully better, we assumed it was still a residual back/nerve issue but, as it turned out, it wasn't at all; it was the endofibrosis. Your ABI test will be critical to figuring out which way to go. And certainly don't let anyone tell you it's all in your head. I spent 25+ years thinking I was a total head case, when in fact my symptoms were related to a real physical issue -- which doesn't necessarily rule out me being a head case :-).

With respect to ongoing progress in addressing my muscle imbalances, I was hit by a car on my bike a couple of years ago -- not horrible, but enough to mess up my knee and shoulder -- which has limited my forward progress since then. I've had both knee and shoulder surgery so I just can't comment on how the imbalances have worked themselves out more recently. Pretty much, I'm a mess, but it does not seem to be related to the blood flow issues. Prior to the run-in with the car, I was making good progress and finally starting to feel balanced and strong.
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [HeidiC] [ In reply to ]
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Thanks again Heidi for you additions to this thread and the other. My leg problems started years before my rupture as well. The docs said my back should have been better in Oct so I thought it was merely waiting the time out for the disc to heal. I requested an MRI just so I would know whether I was going crazy, and in Dec I still had a "high intensity zone" on my MRI. I would also need a discectomy to take out that high intensity zone but I'm not sure that's the problem since two nerve blocks into that disc area in Jan at the same time did nothing (as did the 4 other shots). My power has been dropping since then, so the waiting is not working. I have imbalances with the R glute med and glute min overuse tendinitis and L (nonaffected side) QL compensation that I cannot seem to balance out more. I will look into your MAT suggestion. I'm sorry to hear about the accident - hate to hear about that especially after you've gone through so much. Hopefully the resolution to your knee/shoulder will be many times faster and more straightforward than the IAE was!
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Re: Preventing Iliac Artery Endofibrosis - Cycling Overuse Injuries [little red] [ In reply to ]
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I also have external iliac endofibrosis on the right side. I’m having surgery with Dr. Cherry this month...he says I will most likely need a bypass due to extensive fibrosis.

Did your surgery go well? Any pointers for recovery and transitioning back into training?
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