Friday, January 22, 2016

The Eccentric Post- Injury update

The 2015 mountain bike racing season was a year of highs and lows for me.  Overall I had excellent fitness the entire year and had improved my bike handling skills another small notch.  The recipe was right for good results but a few events derailed my season temporarily and cost me a few more great results.  

This post is mostly about the aftermath of one of those crashes and the ensuing rehab, which I am still doing.  That is to say the Eccentric Exercise Protocol for Tendonopathy.

Most people as some point in their life have what they may refer to as tendonitis, and it may be a long term injury for them.  More accurately after they have had tendonitis for a while it becomes a tendonopathy.  The difference being a structural change in the tendon with the stands of tendon no longer oriented in a liner fashion.

I have been unfortunate enough to have this 3 times in my life now.  The first being with my Achilles tendon during my competitive running career, the second being in my shoulder or rotator cuff from splitting wood, and the third this year from cutting my knee at WORS Cup in July. 

My knee immediately after stitching
 The biggest issue was some tendonopathy in my left patellar tendon which developed after the initial injury had healed.

My knee now.  The thickened portion of the patellar tendon is visible as a bump below my knee cap
Most recently after I fell at WORS Cup I got my knee stitched up and finished out my mountain bike racing season.  However come October and cyclocross I was in constant pain pedaling the bike and running was almost out of the question.  It took a bit of prodding from the doctors but I eventually got an ultrasound image of my knee and it confirmed damage to approx 50% of the tendon fibers on my patellar tendon right under the scar from my stitches.

State CX was a snowy muddy affair and I was able to lean on my skills and equipment to compensate for fitness
When I got a similar diagnosis of my left Achilles tendon in 2008 most of the doctors told me this damage was irreversible and my running days were over.  It seemed to be the prevailing medical opinion at the time. 

Enter Hakan Alfredson and his eccentric heel drops for Achilles tendonopathy.  How he discovered the protocol is a good story.  Read about it here.

For Achilles Tendons the exercises look like this:
I stumbled across this emerging protocol in 2008 and struggled with it for almost a year before I got it right and eventually “cured” my Achilles tendonopathy.  The latter half of that year I was a participant in a study here at UW Health with Dr.John Wilson for PRP and was getting my Achilles examined by ultrasound every few weeks.  The structural changes were apparent here and I could see the progress with my own eyes on the ultrasound images.

Fast forward a few years after I became a cyclist.  I injured my shoulder/ rotator cuff splitting wood and dug back into more research.  Again I turned to eccentric exercises, I had to invent my own protocol, but the results were the same.  Success.

Back to November 2015 and my injured knee.  Patellar Tendonopathy already had a well establish and documented eccentric protocol and I adopted it immediately.

The exercises I've been doing look like this

The problem with the protocol was that it involved doing 3 sets of 15 squats twice per day or 315 squats per week.  My legs were fried for bike racing.  I managed to scrape together a somewhat respectable ride for the state championships but then decided to call it a season and focus on rehab.

Today I am again cycling pain free but still on the eccentric routine which I will continue through March.

It seems this past year a few people had asked me about the eccentric rehab program and I have sent out links to various studies and protocols as well as trying to explain in person.  It seems I have had a high success rate with eccentrics and I think it’s because I do a few key things.  If I could summarize things and make recommendations for someone dealing with a tendonopathy case I would say the following:

1.  Be your own advocate.

8 years ago it was rare for a doctor to be familiar with the eccentric protocol.  They were still recommending rest and ice mostly.  It’s much more widely accepted now but chances are still good your Dr or PT hasn’t heard of it or is skeptical. There is lots of good research to support it, tell whoever you are seeing it’s the protocol you want to try.

2.  Get an ultrasound to confirm. 

X-rays and MRI's don’t show tendon structure like an ultrasound does.  It’s cheaper and easier than either as well.

Typical tendon ultrasound image showing and area of tendonopathy
3.  Fully commit.

It’s going to get worse before it gets better.  It will hurt.  Read the Alfredson Protocol again.  Pain is necessary to healing.  Remember how/why he discovered the protocol?  When I first started this I thought it wasn’t working because the pain got worse and I backed off.  I had to work through it for at least 4 weeks before I turned the corner. 

The exception is if the pain becomes sharp or excruciating.

4. Go heavy weight

During my Achilles rehab I made it up to about 90# in a backpack then headed to the Smith Machine in the weight room where I had up to 175# on the squat bar.  I’ve heard stories of people having more than 400# on a squat bar. If you get to the point where you can do eccentrics pain free, add weight until it hurts.  That’s how you progress.  For perspective running generates more than 12 times body weight of force in the Achilles tendon with every stride.  For me that is 1620 pounds every stride so I don't worry about rupturing the tendon.

5.  Be a good patient

Part 2 of being your own advocate is following your advice.  I think doctors are reluctant to prescribe this because the protocol is really hard work and it takes commitment to see it though.  Generally people hate PT and don’t do it or stop as soon as they can start working out again.  Don’t quit half way.  13 weeks as a minimum.  Even once you are pain free.

6.  Avoid anti inflammatories

No ice, no elevation, no compression, no ibuprophen.  That stuff is for the acute phase of injuries, not chronic.  Plus NSAIDs are generally not good for ones health.  More research now is pointing towards anti inflamitories hindering the healing process, not helping it.  This article sums it up nicely. Eccentrics involve a lot of inflammation of the tendon.  The thought here is that more inflammation means more blood flow and more healing.  If you are going to push or pull do so with all your might.  Don’t push with one hand and pull with the other.

Beyond this I believe that eccentrics will one day be proven effective to healing almost all tendons in the body.  It just takes a long time for clinical trials to be done on each one and that information to get published and then adopted by the medical community.  There is also little $$$ incentive for more research. 

I have seen already it applied to tennis elbow here.

And hamstring tendonopathy here

Many times I feel a slight ache or pain coming on and turn to heavy weights as a remedy.  It’s somewhat counter intuitive but it has worked in almost all cases for me.  

I can say thus far my knee has been going in the right direction and hopefully I will be back at it full force by this spring. 

We all have bumps in the road but I believe those who do best in their pursuit of lifelong fitness are the ones who work through the bumps and find a way to persevere.

Monday, October 5, 2015

Bike Chequamegon

The roll out through Hayward is a sight to be hold

 I haven’t written too much lately about my bike tech or setup but thought I would take a little time to go over my Chequamegon ride and my F-si hardtail.  For those not familiar this race is more of a road race on mountain bikes than it is a single track shred session so the race often sees some unique setups.   While most of the year I chose my Cannondale Scalpel dual suspension bike as my race rig I had been putting in some good training miles on the new F-si hardtail and was waiting for the chance to race it.  While the components, carbon layups, and tech on this bike are all top notch it is really set apart by its unique geometry.  

XC Race weapon

Specifically what makes this bike unique is the combination of:
Short head tube (important for us shorter riders)
Super short chainstays
Slack head tube angle (for an XC bike) and
Large fork offset 

I won’t go over the exact numbers here but if you do some digging on the interwebs you can see that this combination is something really unique by Cannondale for this model and represents what I believe is the future in mountain bike geometry.  After riding the bike for a year I can see why this is a winning combination.  The acceleration is super snappy but what sets it apart is the ride stability on the rough trail or downhills.  In some cases it feels even more stable than my full suspension. 

It adds up to a perfect weapon for Chequamegon.

I put a good amount of thought and time into my setup, especially for an important race like Chequamegon.  The week prior to the race everything is cleaned, assembled, ridden, and re checked multiple times.  Tire pressures are dialed down to the 0.5 psi.  Bolts are torqued to the N-m.

These are the nitty gritty details of my build: 

Frame: Cannondale F-si Hi Mod size medium
Fork: Lefty 2.0.  85 psi.
Drivetrain: SRAM XX1
Crankset: Cannondale Hollogram Si XX1
Chainring: SRAM XX1 36t
Rim: NOX Composites- Skyline 29
Hubs: DT Swiss 240 rear, Lefty Front
Spokes: DT Swiss Revolution.  32 count, 3 cross
Rear Skewer: DT Swiss RWS
Brakes: SRAM XX1
Rotors: SRAM HSX- 160mm F&R.  Ti bolts all ‘round
Bars: Truvativ Noir T40.  680mm width.
Seatpost: Zipp Service Course SL carbon

Saddle: Fizik Tundra- carbon rails
Grips: ESI racer’s edge. Right side cut to ½ length for grip shift.
Stem: Cannondale OPI 100mm, -17 deg.  No spacers.
Pedals: Shimano XTR
Rear Tire: Schwalbe Thunder Burt 29x2.25- Snakeskin (18.0 psi)
Front Tire: Schwalbe Racing Ralph 29x2.25- Liteskin (16.5 psi)
Bottle cage (1): King Cage stainless
Bike weight as pictured: 19.20 lbs
Rider height: 5’-7”
Rider weight: 133 lbs

Leading the pack up Firetower Hillclimb

Tucking in behind Jordan for a nice draft
Podium Time!

Saturday, January 31, 2015

Year in review

Well, I am putting the finishing touches on the oaf-est period of my off season after Cyclocross nationals in Austin.  Since I left before the major rains came, I wasn’t fortunate enough to be part of the cancellation/non cancellation of the elite races.  I opted for the 35+ Masters race with the goal of going for a stars and stripes jersey.  In the end a poor start meant that I never made contact with the front group and I had to settle for 9th despite a great ride and some hot lap times.  One thing that race drove home was that I need to devote some specific attention to starts next year.

Here is a look back at 2014 in pictures:

Nothing great is achieved alone and I had a lot of great help along the way

Many miles were logged

Sometimes in sun
 sometimes in rain, sometimes in blowing snow 

Until I wore the tread off my tires

But always aboard some of the most sick and dialed bikes out there

 I rode in the woods

and on the road

and even sometimes indoors

And I raced

In old haunts 

and in new territory

 I raced a lot 

Sometimes I won

Sometimes I lost

I raced with some people I hadn’t yet met

and new friends were made

And sometimes we celebrated

 sometimes more than others 

This year I learned that sometimes it is just as satisfying to watch someone achieve their goal as it is to achieve my own

And I am one hell of a lucky guy

And at the end of the year I was ready for a little nap with the one I love

To be ready to do it all over again next year