Returning to the bike after an injury, whether a traumatic crash or a non-traumatic ailment—something like an overuse injury—can be a lengthy process. Not only is there a physical cost, the mental aspect of both dealing with the injury and the slow progress you might face can be challenging for endurance athletes.
With the help of our director of sports medicine, Dr. Andy Pruitt, someone with a 40-year career built upon helping athletes get the most from their sport, we discuss the different types of injuries one can face and the various paths one can take to return to the bike.
We also dive into the critical mental aspects of returning to cycling, regaining confidence, finding your way in the pack, and much more.
We’ll also hear from Dr. Kevin Sprouse, head of medicine for the EF Education-Nippo WorldTour team, who runs Podium Sports Medicine in Knoxville, Tennessee.
We hear from Petr Vakoc of Alpecin-Fenix, who suffered a catastrophic back injury when he was hit by a vehicle in training in 2018. Petr talks about his long road to recovery, and the long-lasting impact this has had on his professional career.
Finally, we hear from Bruce Bird, an elite amateur cyclist who also suffered devastating injuries and has made his way back to the elite ranks.
For more on avoiding injuries, listen to Fast Talk episode 59: Preventing Cycling’s Most Common Injuries, with Dr. Andy Pruitt.
Episode Transcript
Chris Case 00:12
Hey everyone, welcome to another episode of Fast Talk your source for the science of endurance performance. I’m your host Chris Case.
Chris Case 00:20
Returning to the bike after an injury, whether that’s a traumatic crash or a non-traumatic ailment, something like an overuse injury can be a very lengthy process, and I emphasize the word process. Not only is there a physical cost, but the mental aspect of both dealing with the injury itself and the slow progress you might face can also be very challenging, particularly for endurance athletes. With the help of our Director of Sports Medicine, Dr. Andy Pruitt, someone with a 40-year career built upon helping athletes get the most from their sport and get back to that sport, we discussed the different types of injuries one can face, and the various paths one can take to return to the bike. We also dive into the critical mental aspects of returning to cycling, things like regaining confidence, finding your way in the pack, and much more. We’ll also hear today from Dr. Kevin Sprouse, he is the head of medicine for the EF Education Nippo World Tour team, and he also runs Podium Sports Medicine in Knoxville, Tennessee. We’ll also hear today from Petr Vakoc, of Alpecin–Fenix. You may remember he suffered a catastrophic back injury when he was hit by a vehicle in training in 2018, Petr shares his story about his long road to recovery, and the long-lasting impact this has had on his professional career. Finally, we hear from Bruce Bird, an elite amateur cyclist who also suffered devastating injuries and has made his way back to the elite ranks. All that and much more today on Fast Talk. Let’s make you fast.
Colby Pearce 02:02
Hello there listeners of the Fast Talk Labs podcast. My name is Colby Pearce, you might know me from my own podcast, Cycling in Alignment. I would like to invite you to join me and come and listen to my show. For those of you who are listeners of my show in the past, I’m going to have to ask you to re-subscribe, as we made some technical changes, some behind-the-scenes server jumps, everything will look exactly the same. The title of my podcast is Cycling in Alignment, just as it has been in the past. If you want to continue to listen to my show, please re-subscribe. If you want to join my show as a new listener, welcome. Some of my episodes are extremely dorky, and technical, and others are a bit more esoteric and philosophical. I like to dig into things from a wide perspective, and I also take a really deep dive on some subjects. My objective is to help people understand what I’ve learned in my 35 years of bike racing in four disciplines. Hope to have you join my show and take part of the discussion or simply learn from it, up to you. Thanks for listening, pedal fast.
Chris Case 03:26
Welcome, everybody to another episode of Fast Talk. We’ve got Dr. Andy Pruitt in the studio with us today. He is our Director of Sports Medicine here at Fast Talk Laboratories, you’ve possibly seen him on our recent release of the knee health pathway, we’re really excited to have you on board with us, your perfect guest for today’s episode of returning safely and effectively returning to sport and specifically in this case, cycling after injury or after illness. There’s a lot of different types of things you might have prevented you from being on the bike, traumatic stuff, non-traumatic stuff, simple stuff, complicated stuff. So, we want to talk a lot about all of those things today.
Trevor Connor 04:12
Really what we’re focusing on this episode is returning successfully from injury and illness. So we’ve talked in the past, we did that episode 59 that was really focused on the prevention, this is what to do when you are coming back and it’s important, I’m going to give you an example of poor recovery.
Chris Case 04:33
Is this an example of yourself?
Story of a Career-Ending Injury
Trevor Connor 04:36
Well, that’s me every week. Too many stories about myself. No, this is, unfortunately, watching a friend who was a teammate for a little bit, he was at Canadian Nationals in 2003, and there was a super fast descent and he crashed on that descent got really injured, and really banged up his knee. So, it was a while before he came back, the rehab, unfortunately, the people who were helping him didn’t do the best job. When he finally got back on the bike, he rode for a couple of months, and then his knee started hurting again, it was in his head about this crash. So as soon as his knee hurt, he just couldn’t ride. So, he got off the bike, took six months off, got back on the bike, did a few more months of training, the knee started to hurt, and then he quit again, and he did this two, three, four, times, I think? Then finally just quit cycling altogether, and it was unfortunate because he’s a really talented cyclist who was going somewhere, but that pain, and the memory of the crash, and just inappropriate rehab that didn’t get him back to a good place basically ended his career. So, this is an episode about how to avoid that sort of scenario.
Chris Case 05:52
Right. Right.
Dr. Andy Pruitt 05:53
So, let me just jump in there for a second. The only time his knee hurt is when he returned to the bike, which tells me that it’s the bike. There’s something about that motion that was inadequately addressed, either something in his position needed to be supported post-injury, or something in the injury that was inadequately rehabbed, that was directly connected to the bike. So, the missing piece to get that back, get that guy back going again, not only beyond the mental aspect of it, was to address what was going on in his biomechanics to relieve that knee pain.
Mistakes Made in the Recovery Process
Trevor Connor 06:33
Yeah, that’s exactly it. We’re going to talk about this, I’m actually gonna bring in the whole, was it Einstein who said, the definition of insanity is doing what you’ve always done and expect something different? That was exactly the approach he took, he could have gone and seen a proper medical fitter, maybe that would have solved it. He should have gone to a proper PT that could have helped him with the recovery from the injury, his solution I think his doctor was recommended to this to him was simply rest. Take six months off, get back on the bike, and it’d be fine. Well of course, it’s not going to be fine he’s going right back to what was hurting them before. So why would it be different?
Tissue Re-Education
Dr. Andy Pruitt 07:11
Which I would insert here, my philosophy about return post-injury is that we want tissues to do in recovery, what you want them to do post-recovery. So, I think that’s what your friend was missing was that tissue re-education.
Trevor Connor 07:27
Yes. This is something I tell my athletes, I think you’re gonna agree with this completely, the way your body repairs from injury and the mechanism that your body uses for adaptation from training, remember, training is basically doing injury to your bodies. It’s basically the same mechanism, and your body is remarkably good at adapting and repairing to whatever you throw at it. So, if you are sitting on the couch doing nothing after an injury, that’s what your body is adapting to.
SAID Principle
Dr. Andy Pruitt 07:59
The whole concept of return to sport, and training, as you say, are very similar. I always refer to the SAID principle, specific adaptations to implied demand, it is the same for recovery as it is for training. Absolutely, 100%.
Trevor Connor 08:18
Petr Vakoc, a professional cyclists with Alpecin–Fenix, was hit by a truck while on a training ride in 2018 and put in the hospital. He shared with us his experience recovering from his injuries.
Petr Vakoc: Recovery After Accident in 2018
Petr Vakoc 08:29
The whole rehab after the crash was very long, it took me six weeks just to get out of the hospital, and more than three months before I was actually able to move my back and start at least walking without the chest brace or to start riding then on the indoor trainer, so I was pretty much almost four months out before doing proper rehabilitation. Before that was just very basic exercise, I could already start riding in like lying down position with a special setup of my of my bike. The biggest part of the rehabilitation was starting just under four months after the accident, and it took me another eight months to be in a state where I was competitive again, it took me just two months to be riding on the bike in pretty decent shape, but another six months then afterwards to really be back to full health and have the green light to the race again.
Chris Case 09:40
Yeah, an incredibly long road back to what you, you know, in a flash you went from elite athlete to somebody stuck in a bed and having to go through this process. I wonder if we could dive a little deeper into that. What do you think was key to the success for you coming back? What made you a good patient? Was it all about just doing exactly what the doctors were telling you to do? Or was it something that you brought to the table that made your rehabilitation go in the direction it needed to?
Key to Recovery
10:21
Yeah, it was a lot from my side, I was really pushing the doctors and the physios to give me more. They were kind of like having fun of me because some of the doctors were also cycling fans, and they said, “We heard that cyclists are healing twice as fast as normal people, and we will see.” I kind of show them that, okay, maybe the bones they still grow as fast as other people, but I can put more energy into the rehab. Good thing was that I had really good physios to work with, and together we made it challenging, but also fun, the rehab, but what really helped me was really focusing on how I’m getting better, rather than what instead I am and how I how far do I need to get. So, it was necessary for me to constantly remind myself like which progress I did since the last week or so, and this, of course, went progressively more difficult because at the beginning, the gains were really, really visible, and later on, there was just a very small, small improvements. There were many moments where I was typing to get better, but having the vision to come back to racing and doing everything for that was really something that helped me to do all the exercises, and do it enthusiastically, always trying to do more than I was told.
Chris Case 11:52
Why don’t we start focusing a bit on specific types of injury categories, if you’d like to, returning from overuse injuries is a common one. I suppose we should start with a definition here. What constitutes an overuse injury? What are some of the common forms? I’ll turn that over to you, Andy?
Overuse Injuries
Dr. Andy Pruitt 12:13
So, I think there are two kinds of overuse injuries. There are extrinsic and intrinsic. Extrinsic overuse injury is training error or bad bike fit, that kind of thing. And intrinsic is basically a biomechanical malalignment or symmetry that is unaddressed. You can get an overuse injury and be a biomechanical ten, which we’ve talked about in the knee pathways, both are absolutely common. One of the keys I tell people is that a pain that goes away when you stop is probably the pain of exertion. The pain that doesn’t go away when you stop is an injury, now, delayed onset muscle soreness, is probably the exception to that rule, right? I’m one of those guys that 36 hours after that hard workout I thought I’d avoided it, boom.
Chris Case 13:09
Right.
Dr. Andy Pruitt 13:09
So, that is not an injury that is purely the specific adaptation occurring. Alright. So extrinsic and intrinsic injuries, both are overuse, overuse injuries, but I think it’s that pain that doesn’t go away. So, I get off the bike, I’ve got a frontal knee pain, I get off my bike, good it’s not there, then I climb the stairs and it’s still there, right? So that pain was still there after I got off the bike, even though maybe it didn’t recognize it immediately. It was the stair that brought it out or getting out of the car after seated position, called the positive theater sign sometimes for knees, that you’ve had a hard workout and the knees were a little tender, and you get up, okay, I dodged that bullet, and then you sit in the theater with your knees bent, and then you get up after a two-hour movie and you creak up the incline, right? So, that pain after stopping doesn’t have to be immediate, it can be recognized in some activity of daily living.
Chris Case 14:07
Can you create an overuse injury that leads to permanent damage or permanent pain?
Permanent Damage
Dr. Andy Pruitt 14:13
What a great question. You betcha. So, let’s think about either a tendon or a musculotendinous unit, right? So, the muscle is the motor and the tendon is the transmission, the tendon hooks to the bone and actually moves the joint, right? The weakest tissues are where the muscle and the tendon intersect, two different kinds of tissues blending together like to paintbrushes coming together and becoming one, and that is the weakest link. The second weakest link is where the tendon inserts into the bone, again, two different kinds of tissue trying to marry each other in a specific place. So, those are the places where an overuse injury can occur, a chronic overuse injury can occur.
Tendinitis vs. Tendinosis
Dr. Andy Pruitt 14:52
So, I guess this is a good place to talk about tendinitis versus tendinosis. So, tendinitis is an overuse injury of the tendon that will heal if given the opportunity to. Tendinosis is an overused, chronic situation where there’s been tissue damaged, tissue death, or fiber tearing that has scarred, so that’s tendinosis, right? Those are two very different things that happen in the same place, and symptom-wise, they’re very, very similar, right? So, you go to your family practice doctor, and he tells you, you’ve got patella tendinitis, if you’ve had it for two years, you got patella tendinosis, right? And an MRI would identify that, and the treatment of the two are very, very, very different.
Trevor Connor 15:39
So, Ryan, let’s throw this to you. I’m sure you’ve had experiences with athletes who have had overuse injuries. How do you work with them? What do you tell them when you encounter that?
Ryan Kohler 15:51
Yeah, I have, when this happens, then I try to get them to now step back, and we look at their whole plan differently, and we say this is not a time to continue this focus on the overload perhaps, that we’re working on. We need to take a step back and allow the body to recover. So it goes from this perspective of having this focus on overload and improving fitness to knowing that, okay, fitness might have to take a backseat while we just focus on allowing the body to recover itself and get back to baseline.
Trevor Connor 16:21
So, what do you do when an athlete is resistant? Let’s say you tell an athlete, “We need to back down”, They say, “No, I’m not going to, I’m going to keep training.”
Athlete Resistance and Prolonged Recovery
Ryan Kohler 16:28
Stubborn. Well, one, I mean, I don’t support it, under no circumstances. So, I would try to again, keep explaining to them why we’re doing this and tell them that really, they’re not going to see the benefits and the main message that I try to get across, and it helps having a wife who is a physical therapist that deals with this on an almost daily basis, is that we’re looking at prolonging the recovery. I think that’s the big negative is, yeah, you can go out and push yourself and continue to push through the pain, but you risk prolonging the recovery, and actually, I was just messaging with a buddy who I ski with a couple days ago, and I asked him if he wanted to go up into the Indian Peaks and make some turns in the next few weeks. He wrote back and said he messed up his PCL a couple of weeks ago snowboarding, and of course, this is not chronic, but similar vein here, but he messed up his PCL, and he went out and decided to do a hard road ride and time trial at Flagstaff the other day, and he went too far, and now he said, he’s out for weeks now, and there’s no way he’s gonna be getting back on skis, anytime soon. So this is that effect of doing too much, and then now we’ve prolonged the recovery. So, I was trying to advise against that, and that’s really the consequence that we’re looking at.
Trevor Connor 17:44
Something I’ll bring up here, that’s really important when you’re talking about overuse, and this is something I find interesting, where there’s this strange contradiction in very high-level cyclists. If you’re just riding your bike four hours a week, you can have bad fit, a whole bunch of things going wrong, and you’re just not on the bike enough to really cause an overuse injury, so you’re probably going to be fine. The more volume you do, the more of these little issues are going to quickly show up. So, this is the contradiction, you take somebody who’s training 25 hours a week, they’re remarkably tough athletes, they have huge amount of stamina, but they’re also in this strange way a little more fragile. If their positions a little bit off, if their saddles a little bit wrong, it’s going to show up, and if they don’t do something about it’s going to show up in really bad ways.
Chris Case 18:34
Yeah, the volume amplifies the small issue into a big issue.
Trevor Connor 18:38
So, really important for any of our listeners who are thinking I really want to up my volume, when an athlete comes to me and says, “Well, I’ve been training six, seven hours a week, I want to take it up to eleven, twelve, what do I need to do?” And they’re expecting me to give them a training plan, my answer is, go get a medical fit. You know, all that core work that you told me you were doing but you really weren’t doing?
Chris Case 19:00
Start doing it.
Trevor Connor 19:01
Now you have to do it, and you up all these things so that you can actually handle the higher volume, and when I see an athlete up their volume and not take care of all these things first, they end up often shortchanging their season because they get all these overuse injuries.
Chris Case 19:18
Yeah, you need to modify the structure and systems around the engine, again, always using these car analogies, but otherwise the supporting system isn’t there and things start to break down.
Dr. Andy Pruitt 19:32
A millimeter of maladjusted cleat can translate to a centimeter at the knee, because of the length of the tibial shaft in between, it gets magnified, right? So, if you’ve got a cleat that’s a millimeter maladjusted that’s resulting in excessive medial-lateral knee travel of a centimeter at 90 revolutions a minute do the math, right? If you’re going to go from four hours a week to 12 hours a week, the number of times that knee is done that unusual movement, because that one-millimeter cleat maladjustment gets totally magnified. That’s how that extrinsic overuse injury occurs. The intrinsic overuse injury, so your biomechanical 10, right? Your Tom Boonen, right? Why does Tom Boonen get patella tendonitis? Because he can push 1500 watts for an extended period of time over the cobbles, you’ve got the roughness, the vibration, the magnitude of the cobbles, magnified by his power output, plus time, right? So he gets that micro bleeding at the insertion of the patellar tendon into the tibial tubercle on the shin bone, it swells, it gets this little, it gets this little gnome-like, it’s like a little gnome’s nose sticking out at the tibial tubercle, where that injury actually is occurred. So, that is an acute overuse injury that occurred, I hope people see the difference in the kind of overuse injuries that can occur, and one is either driver error or bad position, the other is, is just something inside yourself, and a biomechanical 10 gets it from being just so powerful.
Overuse Injury Rule of Thumb
Chris Case 21:09
I don’t think we have the time to walk through every scenario one would face as an athlete or that you’ve faced in your career, Andy, but are there general rules of thumb here for you know, the question of the day is, how do I return from this effectively, safely? Maybe even better than I was before this overuse injury?
Dr. Andy Pruitt 21:31
Specific adaptations from implied demand. If Tom takes the time to let that tendinitis heal, it will be stronger as a result of that injury, and it will be less apt to happen again until he gets even stronger or holds that longer. But so yes, if you allow an overuse injury to heal, and rehab appropriately, using the SAID principle, right, it should be stronger, just like your VO2max can go up, your lactate threshold, all those other training metrics can go up, so can that muscle-tendon unit be stronger? Absolutely.
Chris Case 22:10
Again, one of these very broad questions that might be impossible to answer, but how long does someone have to sit out? Or get off the bike, if they have an overuse injury? What’s the rule of thumb there?
Dr. Andy Pruitt 22:26
There isn’t one. It’s really gonna depend on whether it’s a knee, or Achilles, an IT band, it really does depend on the blood supply to the area, is it a motion that occurs with every pedal stroke? So, there can be rest by changing the position for a time being, right? You can take pressure off wrists and backs by changing the front end of the bike and use a rehab position and they still keep riding. So, you can still do your base miles, you can do a lot of quality, if you’re not worried about being aero, right?
Chris Case 23:00
Sure.
Dr. Andy Pruitt 23:00
So, I believe in active recovery, active rehabilitation, recreating the motion that you want those tissues to do after they’re healed, absolutely. So, there’s no formula for that, but, you know, ice, you know, the old RICE, rest, ice, compression, elevation, those are you know, for court sports and football kind of injuries, but they do apply to cycling as well, and coming home you know, you get sore into to your knees, first big spring ride, yes, I would put ice on them. Yes, I would go through passive range of motion the next morning. Yes, I’d get right back on the bike and do cycling as my active recovery to help those knees acclimate, right?
Chris Case 23:46
Yeah, I suppose there are certain situations where you start to feel a certain pain, hasn’t been there before, you’ve upped your volume, okay, this is maybe an overuse injury. However, I’m not going to take any time off I’m going to make adjustments and it might take a little while, but I’m gonna have to ride through some pain.
Dr. Andy Pruitt 24:05
Absolutely.
Chris Case 24:05
But I’m on the right path because I’ve made these changes.
Dr. Andy Pruitt 24:09
So, I’ve got a recent story for you. So, everybody knows Chloe Dygert, everybody knows about her big crash, everyone knows about her 80% transected quadriceps and her compound femur fracture. It’s a potentially career-ending injury, right? So, we fit her, she’s doing well, she’s rebuilding well, powers 50/50, you know, it’s one of those like, what a great gene pool, right? To be able to do this, and mistakenly, she gets on a new team bike, changes teams in the middle of all this, gets on a new team bike, and there were transcribing errors in position. She gets on her new bike, and goes to camp, train, train, train. Wow, my back and knee are killing me.
Chris Case 24:58
That’s unfortunate that a little numerical error leads to this.
Dr. Andy Pruitt 25:02
It is so common.
Chris Case 25:05
Oh.
Dr. Andy Pruitt 25:05
Even at the highest level, one mechanic measures one way, the next mechanic measures the other way, they send the bike home with the athlete, they unpack it.
Chris Case 25:14
Mm hmm.
Dr. Andy Pruitt 25:14
Yeah, you trust an athlete with a tape measure?
Physical Therapy and Bike Fit Need To Work Together
Chris Case 25:18
Some of them, not all of them.
Dr. Andy Pruitt 25:20
Bottom line is, so we know her tissues acclimating really, really well, and I bring her back to the lab spent last Friday with her, get her back in the right position, which I know is going to be the right position for her because it was successful before, but her backs already sore. So, she’s got to let that back resolve, and so she gets the therapy for that. The knee, one little muscle in that injury, the vastus medialis, is not quite recovered yet right where her scar goes through her quad, wasn’t firing quite right. So, I put a little wedge in her cleat to basically support what the vastus medialis wasn’t doing for her knee. The first day back on the road, she says, “My back’s way better. My knee is still sore.” Second day, “My back’s way better, my knees half a sore.” Third day, “Nothing hurts,” right? So, we let her make those changes. Now, I supported the lack of VMO strength, the physical therapist next door would say you shouldn’t do that, you should strengthen the vastus medialis, and you won’t need that wedge in her shoe. Well, you’re talking about Chloe Dygert here, how many weeks are we from the Olympics, right? So my point is no, we need the wedge now, let’s strengthen her VMO, and maybe the wedge with come out.
Chris Case 26:54
Two things simultaneously.
Dr. Andy Pruitt 26:55
Exactly. Exactly. So, bike fit is not a one and done, PT is not a one and done. So, I think that she’s a really good example of how a bike fit can be used supportively, and then the physical therapy and bike that need to work together.
Trevor Connor 27:13
So, I gotta make a really bold statement here before we move on to traumatic and non-traumatic injury, and please, Dr. Pruitt, want to hear if you go, Yep, agree with you, or no, Trevor, you’re so wrong. I’m just going to make a bold general statement of when it comes to overuse injuries, I do believe that if you take care of yourself, so you get that proper fit and make sure that your fit is checked regularly, if you’re doing you’re off the bike work, if you are doing all the things that you should be doing, overuse injuries are avoidable.
Dr. Andy Pruitt 27:50
They are avoidable, but the trouble is sometimes we don’t know what we need to avoid until they happen, right? Until they identify themselves. But yes, I think if you, in a perfect world, you do all that base work, you do all that core work, you’re doing all your functional strengthening, the overuse injury probably is less likely to happen. Is that? Yeah, yeah.
Chris Case 28:12
Yeah, yep.
Dr. Andy Pruitt 28:13
But you know, so Chloe’s original injury was traumatic, very much so. But what we were treating the other day was not, it was bad fit and overuse.
Trevor Connor 28:24
So let me rephrase that, and I think kind of my early take home here on the overuse injuries is if you do get an overuse injury, this is that that quote of the definition of insanity is doing what you’ve always done and think you’re gonna get a different outcome if you have an overuse injury, you need to figure out what was causing that and address that if you keep getting that overuse injury, you are at that point neglecting something,
Chris Case 28:51
Or it’s just been misidentified as the cause.
Dr. Andy Pruitt 28:55
It hasn’t identified itself correctly. Yeah, yes, exactly. I always talk about pain-free time, and distance, right? Oh, and intensity. So the guy says, you know, my knee doesn’t hurt until an hour and a half. Well, so you want to do all the base work, you want to do the PT, you want to do the right fit, but then you want to keep him underneath his pain-free distance or his pain-free intensity. My knee doesn’t hurt unless I’m over 250 watts. Great. So, there are ways to train under those pain-free ceilings while you’re recovering from an overuse injury.
Trevor Connor 29:34
Bruce Bird, a fellow Canadian Master’s rider, a multi-time World Granfondo Champion, had a severe crash back in 2016. He talked to us about the impact of such an injury not only in his racing, but his family and job.
Trevor Connor 29:47
I actually saw your crash, we were at Calabogie, there’s a car racetrack and there’s a concrete wall there. So at the finish line, even though it was right beside it, all you can see is really the tops of people’s helmets. So we’re trying to see what’s going on with the finish, and then all of a sudden, we just saw this rider go in the air, a bike go in a completely different direction, and it was one of those, like, did he die? It looked that bad, and we all ran to the course to see what was going on. I’ve got to say, I’ve seen a lot of crashes, that was one of the worst I’ve seen. So tell us a bit about it. Tell us about a bit about what you went through.
Bruce Bird: Traumatic Crash and Recovery
Bruce Bird 30:28
So, as soon as this happened, my wife found out and drove with the kids to Ottawa, to just be there with me, and I was in the hospital, and waiting for an operation to fix the clavicle. They also had a drain put in to drain the lung, and I wasn’t allowed to leave the hospital till that was fully drained, till it stopped draining. It becomes real evident, like the whole idea about risk getting back to work on Monday. Now, the people at my work, I tell them, look, I’m in the hospital, I don’t know when I can come back to work. I’m a consultant, I’m a contract worker, I don’t show up to work, I’m not getting paid, there are so many people in our workforce that are like that. So not only like, what was I risking? Now, I’m in the hospital, I’ve, you know, my I’m worried, you know, my health, I’m putting a big stress on my family, I don’t, I know, now I’m worried about getting back to work so that I can continue my contract, you know, contracting, continue getting paid. That becomes the number one priority. So, like, it’s a real sort of shifted maturing process that I went through, and it’s a big cost, like, obviously could have been a lot worse. At that moment, you don’t know how you’re going to land and what damage is going to happen in just a second. In cycling, where you know, you got two wheels, you’re not moving, you’re falling over unless you’re propping yourself up, we know, we love the feel of the air, the wind, the feeling of riding the bike, but inherently there’s danger. So, what can you do to reduce that danger and still enjoy it? So, that’s the kind of looking at looking at what I love about cycling what I want to do in the future with cycling, that is a little bit of soul searching I had to do.
Trevor Connor 32:20
I actually think you came back a stronger rider after than you were before, and you were a strong rider before. Tell us a bit about your recovery and how you got back to full strength.
Coming Back as a Stronger Rider
Bruce Bird 32:31
Yeah, thanks for asking. So, one of the benefits about, you know how I crashed, it’s not the cycling motion, like the way you pedal, your legs are moving, your core is working, and I didn’t injure that. So, I could still spin, so I talked to, I had to learn to sleep sitting up for three months, you know that there’s a bunch of things like basic life, things are change when you get injured. I asked the doctor like, “Okay, how do I speed up my healing, I want to heal, I want to do everything I can to heal.” Like, obviously, I gotta sleep, I got to learn to sleep sitting up, you know, I’ve got to eat well, but I need to exercise, this is the only thing it’s going to, you know, to speed up your healing is blood flow, and because all the bones you broke are on the exterior, it’s not a lot of blood flow to those areas, but I encourage you to you know, get your blood flow up. This is perfect, I’m just gonna spin, I’m gonna spin easy, and I’m gonna look at my heart rate, and I was always training in the basement.
Consequences of Injury
Bruce Bird 33:46
So I just got a got on that again, it’s like mental health, I’m just, I’m doing something I’m participating in my healing, and just waiting to heal, so what can I do to help that? And then finding that balance of you know, can I put a bit more load on, I could hardly walk, I was limping around, you know, getting myself to doctor’s appointments so that I could get clearance to get back into work, and in fact, they didn’t renew my contract I had to find another job. Like it was some serious life stuff. So, I guess yeah, I guess I ended up you know, with a great group of people now I’m working with at Scotiabank, and I’m, you know, real thankful, and it’s, yeah, those are the kind of things I kind of get thrown a little bit when I think about it because it’s really some serious stuff. You know, we put ourselves in a spot and I’ve seen some other people and good friends get injured and you don’t, you know, some of them can’t recover all the way and they got to make the best of what they have, and it’s can be devastating.
Chris Case 34:54
Let’s turn our attention to the discussion of this traumatic versus non-traumatic injuries. Simple, simple definitions here for these two categories, Andy.
Traumatic vs. Non-Traumatic Injuries
Dr. Andy Pruitt 35:04
Well, traumatic you hit the ground, or something hit you and it is a sudden onset event, right? You were hit by a car, you crashed in a race, you broke something, that’s a traumatic event. Non-traumatic is kind of what we’ve been talking about, right? I mean, the overuse, either extrinsic or intrinsic injury is that is that non-traumatic.
Chris Case 35:30
And concussion would fall into the traumatic category, even though there doesn’t have to be, you know, we’ll hear from an expert later in the show, you did a scan of somebody’s brain, it’s not going to show anything for a concussion.
Dr. Andy Pruitt 35:46
Correct.
Chris Case 35:48
It’s not going to show up on that MRI. However, you can take it to the next level, you can have a TBI, traumatic brain injury, where there would be some bleeding or some fracturing and things like that, but all of those I would consider in the traumatic category.
Concussions
Dr. Andy Pruitt 36:03
Absolutely. So, there are levels of concussion, there are levels of traumatic brain injury, and at the lowest level, one of our rules for head injuries, if there’s any damage to the helmet, the athlete needs to stop. We know now that the well we always have known that the outer layer of the helmet is meant to dent easily to absorb that energy, but that doesn’t matter. I think if they’re not getting a paycheck, they’re an amateur rider, there’s a dent in the helmet, their party’s over. But even if they were to scan that afternoon, you can get a contrecoup or slosh of the brain that does not cause any kind of bruising or bleeding, that still will leave them with a concussion set of symptoms. You betcha.
Trevor Connor 36:46
That’s actually a really important thing to bring up about the helmet to his modern helmets, they are designed to cave, it’s rather the helmet break than your head break. So, you have to think of your helmet a little bit as a one and done, you crash hard and you crack it, that helmets done. You need a new helmet.
Dr. Andy Pruitt 37:05
And many companies have a crash replacement policy, a relatively inexpensive way to get a new helmet, doesn’t mean you go out and hit your helmet with a hammer to get a new one, but there is usually a crash, you know, kind of return discount for new helmets.
Chris Case 37:22
So Ryan, I want to get your thoughts here on the concussion, and returning from a concussion from a coach’s perspective, what are your thoughts?
Ryan Kohler 37:31
Yeah, I guess I can turn it into a bit of a story for an athlete, where I was coaching a team, and we had an athlete that crashed, had a concussion, and it was interesting, now as a coach, I had information and access to physiological testing for this athlete, it was a completely different experience. This athlete was going through the return to sport process, and it was at a point in that where he was expecting to start feeling better, like he can get back on the bike and things were going to return to normal. Luckily, we had baseline physiological data on him, we had lactate testing data available, and when we did a follow-up test, I forget how many weeks out this was, but it was at, like I said, a point where he felt like things would be getting back to normal, he’s gonna start getting back to training. We tested him again, and we found out it was completely wrong, it wasn’t happening. His physiological response to the same exercise loads that we had for his baseline, were way off. His lactate levels were still elevated, that his heart rate response was elevated, everything was different, and that was explaining why he wasn’t feeling great coming back into this. So as a coach, I was able to take this, and work with him to say, “Okay, we need to keep things light and just really look at this long term.” So, we continued to do some consistent testing down the road, and ultimately, it took about six months before he was really back, and we saw those physiological values return to somewhat near baseline, and that timed really well when, with the point where he said, “Yep, I feel better now, things feel back to normal.” So, being able to connect those two of the athlete’s feedback with the physiological data was crucial for him to just really not start pushing too hard too soon.
Chris Case 39:22
In that first, or I guess, subsequent test after a concussion, what was your estimate there, two months after the injury or something like that? Just to give people a reference point.
Ryan Kohler 39:34
Yeah, it was somewhere in that. Yeah, six, eight weeks, roughly. Yeah.
Chris Case 39:38
But it took a full six months for you to see data that looked somewhat equal to what you saw pre-concussion?
Ryan Kohler 39:46
Right. Right. And for the athlete too, it was surprising because he saw the data and he realized, “Oh, wow, I need to back off and just let the body heal and take my time with it.”
Dr. Andy Pruitt 39:58
You know, there’s unseen energy being spent with regardless of the injury.
Chris Case 40:05
The healing process.
Dr. Andy Pruitt 40:06
You betcha. We talk about crutch walking, for example, being 30%, more caloric expensive, and that’s something we can see. The athlete, “I’m so hungry, but I don’t deserve to eat.” No, you do deserve to eat, you’re crutch walking, it’s 30% more caloric expensive. The concussion, you can’t see that, that energy is being spent. So I think what you’re saying is right on the money.
Diet Building Blocks
Trevor Connor 40:32
As much as I’m not a big fan of talking about macronutrient ratios, a lot of endurance athletes are very carbohydrate-focused, and you don’t need that stocked-up glycogen when you are trying to recover from an injury. What you need is your building blocks, and protein is one of the key building blocks, especially as your immune systems wrapping up, so is fat, because the whole lipid bilayer of your cells is made from lipids fat. So, you need to make sure you’re consuming enough of that, you’re eating a high nutrient density diet to help your body with its rebuilding. The other thing I’ll bring up, and this is a longer conversation, but eating a more anti-inflammatory diet. So, as strange as it sounds, the immune system is responsible for all this repair, and it’s going to create inflammation, and that’s good inflammation. When they talk about an inflammatory diet, that’s where you have systemic inflammation, that’s inappropriate, and that will actually hinder your immune system’s ability to focus on what it needs to focus on. So, you need to make sure that you are eating an anti-inflammatory diet.
Anti-Inflammatory Diet
Dr. Andy Pruitt 41:43
Which brings me to something even more curious, in that there’s usually a weight change or body on the scale, the scale number is going to change, and the athlete is always freaking out if it’s going up, right? But there might be, Ryan, a weight change based on what’s going on, right? That may be containing or holding more water, as athletes, we’re chronically dehydrated, so we can kind of manipulate that morning number, right? But suddenly, you’re not sweating as much. So, I think they need to be informed that number may change a little bit while they’re not as active in changing these diets. I don’t know.
Ryan Kohler 42:22
Yeah, I mean, that’s a regular conversation that I have with athletes that don’t have concussions is understanding that throughout the year, there should be these normal fluctuations in body weight, body composition, and I think at a time like that, when there’s a concussion and you’re recovering from it, I mean, wait, let’s just shift it off the table, don’t even worry about it. Let’s focus on the things that we talked about, the high nutrient density, the energy intake, get yourself back-to-back to good health and performance, and then worry about weight.
Trevor Connor 42:51
Perfect.
Trevor Connor 42:55
Let’s hear from Dr. Kevin Sprouse, the head of medicine for World Tour team EF Education Nippo, about what to do if you think you, a teammate, or a loved one has suffered a concussion.
Dr. Andy Pruitt 43:05
The reason I thought about you for this particular podcast was the concussion. We all remember Tom Skujin crashing in the Tour of California, and being put back on his bike under questionable, you know, circumstances and swirling down the road.
Dr. Kevin Sprouse 43:22
There’s nothing questionable about it, Andy.
Dr. Andy Pruitt 43:25
Right. Right. Okay.
Dr. Andy Pruitt 43:28
So tell us about the current concussion protocol in the pro tour? How can an amateur rider take from that protocol and maybe use it on himself or his teammates, if they crash?
Dr. Kevin Sprouse: Concussion Protocol in the Pro Tour
Dr. Kevin Sprouse 43:42
Yeah, so I think it was a really important advance this year that Dr. Bogaard with the UCI and a small panel put together this cycling-specific concussion. It’s not really a protocol, because nothing in it is required, it’s kind of an educational document, but it’s a great place to start, and it does have wide applicability in cycling, you know, not just at the World Tour, but all the way down to your Tuesday night world really. I think, you know, so our team implemented a concussion, or kind of a head injury protocol, maybe six or eight years ago at this point, maybe longer, that really just served as what we did was pre-testing. So, we had an idea of the athlete’s baseline cognitive status, what were they normally able to do? And then there were some protocols around educating the staff to recognize a concussion, and then what do we do in follow-up in terms of diagnosis of concussion, and then return to play? And that’s a lot of what the UCI addressed in here is, first and foremost, how do we identify a concussed athlete? Cycling has some pretty unique hurdles in this, because, you know, if you’re playing football or soccer or whatever other sport, you pull the athlete over to the side, the sideline, and you have time to evaluate them, in cycling, you know, if it’s gonna take more than 20 or 30 seconds the race is gone, it’s, it’s kind of, you know, you might as well just pull them out, and you don’t want to pull someone who doesn’t have a concussion, but you always want to error on the side of the safety of the athlete and pull them if you have any concerns, but that requires a bit of an evaluation. So, the nice thing that they did here, you reference Tom’s crash is they kind of, in the document, they empower team staff to step up and say, you know, if you’re a mechanic or a swan, you’re who’s handing bottles, or a director, and there’s not a doctor in the car like if something looks off, take the initiative to either raise it to a medical person nearby or pull the rider yourself. Because ultimately, we’re most concerned about their safety, health, and well-being. That I think, is a big part of this document, because any of us that have raced have seen crashes, and many of us that have seen crashes, recognize that there are people that get back into the race that shouldn’t, for a number, not just head injuries, but for a number of reasons. I think we all have a general idea of a Gestalt when we look at someone, you know, we, when we all looked at Tom’s trying to get back on the bike on TV, we all knew that he should not get back on that bike, and it took us time to track him down and get him off, and it worked. It worked out well in the end for him, thank goodness. But anybody along that route, anybody involved with the race, should feel empowered to take that step.
Dr. Andy Pruitt 46:53
So, what are the most obvious signs? I mean, one of the things I tell people if the helmet is cracked, take them out of the race. If there’s a dent in the helmet, you got to remove them, regardless of what, so what else can our folks look for? What can that wife look for when her husband comes stumbling home after a crit crash?
Signs of a Concussion
Dr. Kevin Sprouse 47:15
Yeah. So I think it’s important to recognize that the symptoms of concussion evolve, they are not just suddenly present, you know, you break a bone it broken as soon as you break it, but a concussion, sometimes you don’t have symptoms for hours later, even that night or the next morning. So, you have to look at it as a constant reevaluation, the most common symptoms that you’ll see, you know, if somebody is unconscious, they’re stumbling, you know, they have difficulty with balance and getting back on the bike, those are all pretty obvious, right? The ones that are a little more, probably more common and a bit more a cult and harder to pick up, sleep disturbances, maybe changes in mood, or just kind of how the person generally is in a given scenario, headache, which they may or may not report, nausea, which they may or may not report. So, the symptoms can be kind of wide-reaching, often, they just feel off, they have a hard time putting their finger on it. When we do testing and we look at things like balance and cognitive function, we’re able to delineate that with when we give them certain tests, but if not, given those tests, it just kind of manifests as this, I don’t know, I just don’t feel great. So, having a high suspicion that there might be a concussion is the first step for somebody who’s either hit their head or is kind of helping someone who has hit their head, and that’s a good time to not brush it off, but seek out proper diagnostic care.
Dr. Andy Pruitt 49:03
So, let’s think about an American crit situation, right? Where they might get a free lap. So you might have 30 to 60 seconds, right? Do making a vow before you throw them back into it, so got any quick, you know, what steps?
Knowing When To Pull Out of a Race
Dr. Kevin Sprouse 49:24
Yeah, for sure. So, you know, assuming they weren’t unconscious, they aren’t vomiting anything like that you’re not concerned about a worse injury, a neck injury, and you can’t just brush those off because those things happen too. But assuming they get back up and they’re a little dazed and you’re trying to figure out are they just isn’t an adrenaline rush from the crash or maybe your concussion? One, look at their helmet like you said Andy, I think it can be a little tricky because with the way helmets are designed now, the outer shell dents pretty easily, and you can certainly have visible damage without a concussion, but for non-professional athletes, in particular, someone who’s not getting a paycheck, Why risk it? If there’s visible damage just step out of the race. If there’s no damage to the helmet, you can actually get a concussion without hitting your head, just the whiplash of going down. So, there may be no damage to the helmet, and you can still have a concussion. An easy thing to do on the sideline, or the side of the road in this scenario, is ask some basic questions. What day is it? What race is it? What lap are they on? How much time is left? Who’s leading the race? Some things that any racer would know and see if they can answer those appropriately. That can take 10 seconds, 15 seconds. The other thing you can do is balance, the riders are wearing cleats, which make it uniquely difficult to balance, and that’s something you want to test, you can do a one-legged balance. Often what we’ll do in the in the world tour is if they clear those first hurdles, put them back on the bike, but there’ll be coming back often they’re even out of the cars, right? So, we’re way off the back, and we can watch them if they’re having trouble maintaining a line, you know, they’ve got a wide road at this point, and it’s closed. If they’re having trouble maintaining their balance in any way, you know, we’ll talk to him again, and then maybe pull them. So, the same things can hold true in this in this crit scenario, ask him some basic questions, look at their balance, and then recognize that symptoms are evolving, and if they get to laps in and they’ve got a pounding headache like you can pull the plug then, as an athlete don’t feel like just because you got back on your bike, and everything was fine, that you don’t have a concussion.
Dr. Andy Pruitt 51:44
What’s interesting is that Fast Talk did a whole podcast on concussions, so a lot of this is a review for some of the listeners. I think the real takeaway is that, that if the pro tour has empowered everybody in the caravan to take charge, you know, of somebody with a potential concussion, that outta trickle down, right? I mean that that is your teammates out of taking charge, your family, your so I think empowering other people at every level of racing to help take charges, I think that’s the takeaway for us here.
Trevor Connor 52:24
I think another important message here, you just talked about, be able to maintain balance. If you’re in a crit, that’s a technical race where you need to be at your best, so I know some athletes want to pull that, well, I’m tough, I can handle a type, mentality, I’m going to get back into the race. But it’s also important to consider you’re getting into a pack of maybe 100 riders, and if you aren’t there if you can’t maintain your balance, it’s not only you who’s going to go down again, but you’re going to take a whole bunch of riders with you. So, you have to do that assessment of, am I safe in this field? I’ll give you an example, I didn’t have a concussion, but I was at the Cascades, was suffering from really bad dehydration, and was having a problem holding my line and had to say the same thing, I’m like, I’m actually happy to tough through this because I’m an idiot, but I’m gonna, I’m gonna hurt somebody else, and had to pull out the race.
Dr. Kevin Sprouse 53:19
Yeah, I think that’s a great point. As you point out, it applies to really any injury or scenario you might come across in cycling, it’s often the threshold that we look at for, you know, hand injuries, shoulder issues, you know, it may be the kind of thing where it’s safe to continue. Now, it’s not safe to continue with a concussion, I’m not saying that but you may have an injury that you think you can push through, or you may just decide to push through a concussion, you know, in an ill-advised manner, but unless you can control the bike, in these very tight situations at high speeds, it is totally irresponsible to put the rest of your colleagues there at risk. That I think can be freeing to some people because we’re taught as endurance athletes to push through anything, but I think all of us can kind of sympathize with this idea that okay, I can push through this, but it’s just not responsible for me to do with respect to the safety of my fellow competitors.
Chris Case 54:30
So you know, this non-traumatic category is essentially what we’ve just been talking about the overuse injuries, we did an episode number 59, quite a while ago now with Dr. Pruitt, that gives a lot of background information on this type of common injury in cyclists, preventative measures, and that sort of thing. So yeah, anything else to add there, or should we move on to traumatic?
Dr. Andy Pruitt 54:56
So I think the one thing I might add there would be the low back disc injury that occurs over time, but there is a moment in time when this ruptures or more bulges, and that moment is traumatic, right? They didn’t fall off, they didn’t crash, they’re probably in a really aggressive position.
Chris Case 55:18
The dam broke.
Dr. Andy Pruitt 55:21
The dam broke, you didn’t fall off, but that moment at that, at those cells, that is a traumatic event in those cells, and the healing response is a traumatic one in that area. So that might be that, that one, new tendons rupture. I’ve got a patient with bilateral quad tendon ruptures that occurred a year apart all from cycling. There are moments when that chronic overuse injury, that tendinosis, has a traumatic event without an impact, right? So, are those I think, the tendinosis that ruptures or the disc that dramatically ruptures in the middle of a hard climb? Right? Those are those are borderline, maybe gray area between the two.
Trevor Connor 56:12
Yeah, and you keep looking at me?
Dr. Andy Pruitt 56:14
No.
Chris Case 56:17
You had a disk burst, you were probably brushing your teeth at the time.
Trevor Connor 56:22
Actually.
Chris Case 56:23
Flossing?
Trevor Connor 56:24
Dr. Pruitt was there.
Chris Case 56:25
Combing your hair?
Trevor Connor 56:26
I’ve had all these, yes. I got good, thick, lush hair.
Trevor Connor 56:35
No, I was at Tour of the Hilo, was it 2011? You were supporting our team. Second day, we were getting towards the top of the big climb, there had been a at attack, I actually think it was Laughlin who attacked and went with it, and was going, “Oh, this day is great.” Right as we’re getting to the top of the climb, we go around this sharp right where it also dips down really quickly off Camber, and I twisted with my body and the road took my bike the other way, and just got that extreme shooting pain in my back, dropped down onto my top two, I’m amazed I didn’t crash. Fortunately, momentum carried me over the hill, but then we hit one of the most technical descents in North American racing, and I’m, like hanging on to my handlebars, unable to move at all trying to go down this descent and I went from being in the breakaway to the last rider to the bottom of the hill, somehow managed to finish the stage. The time trial was the next day, I remember waking up, you’re were at our house, you took one look at me, like, “Trevor, come over here,” and gave me some sort of horse tranquilizer to get through the time trial.
Dr. Andy Pruitt 57:50
He was in his time trial position, even when he wasn’t on his bike.
Chris Case 57:53
Sure.
Dr. Andy Pruitt 57:54
Yeah, we had to lay his bike over and get his leg over, get him upright, and pushed him down the hill. So it’s one of those times, where the bike position actually was supportive of his low back, and that’s not uncommon, right? Because we have multi-point contact with the bike, so there are injuries, they’re actually supported in the cycling position. That would be in one of them.
Trevor Connor 58:21
The next day was the crit, I basically said, “Just get me on my bike.” Yeah, I was purely, I just survived this crit, and you did what I needed to survive, and that was about all I could do.
Chris Case 58:33
Well, well, that brings up a question in my mind, was this advisable behavior?
Dr. Andy Pruitt 58:38
Absolutely, not. Really not. But as the team Doc, he was in no danger, right? And he’s a good enough bike handler, I don’t think he was gonna endanger anybody else. I made a decision, right? To let him participate if it didn’t endanger himself, or anybody else wasn’t gonna make him worse.
Trevor Connor 58:55
I’ve remember some of our conversation, and the fact was, the next day was the time trial, which if I took the risk and crashed or whatever, I’m only hurting myself and not hurting anybody else. So we just and I knew I wasn’t going to do a good time trial, so it was just get through the time trial. So, we just made the decision, get through the time trial, and then we’ll see how you feel the next day and it was actually feeling much better by the time I got to the crit, so we made the decision to keep going, had the crit and the next day, we probably would have had a different conversation.
What Makes a Good Patient When It Comes to the Treatment of Traumatic Injuries?
Chris Case 59:27
Yeah. What makes a good patient, I guess in your mind, Dr. Pruitt when it comes to these traumatic type injuries? What do you want a person to do? What do you want to see them do?
Dr. Andy Pruitt 59:39
Athletes make terrible patients. One part of me says they make terrible patients, on the other hand, I say they make great patients because they’re so motivated, and most of us are pretty coachable as athletes. So, if the medical provider, the therapist, whatever sports medicine doctor, or whatever it is, you know, approaches that athlete correctly, right? And so okay, here’s how we’re gonna get you back on your bike, when we’re gonna get you back on your bike, blah, blah, blah, they’re going to be way more cooperative than if you use the rest technique. Rest is overrated as a recovery tool when it comes to injury, it really, you have to balance the energy spent in the healing process, with the energy spent with returning to sport and then the energy spent psychologically, that’s it’s a triangle of trying to get the athlete back healthy.
Loss of Skin in Cycling
Chris Case 1:00:34
Let’s talk about some other traumatic injuries here, loss of skin is a big one for cyclists. I don’t know any cyclist that hasn’t lost some skin at some point, and if you’re not familiar with Tegaderm, when you start riding, you become familiar with Tegaderm, and that brings up a Trevor story, Trevor? Tell us about Tegaderm, and your relationship with Tegaderm.
Trevor Connor 1:00:56
I have a long-standing and good relationship with Tegaderm.
Chris Case 1:01:00
You have stock in the company?
Tegaderm
Trevor Connor 1:01:02
I wish I did. So when I was racing with Rio, actually Dr. Pruitt gave us this big medical bag, we were an amateur team, but we had a better medical bag than any of the pro teams. We probably had $10,000 worth of Tegaderm, something crazy in this bag. I know I wasn’t the only one who experienced this, but I personally caught somebody sneaking into our van from another team trying to steal our Tegaderm. So, we had, we learned we had to lock down this bag and we had to keep an eye on it because everybody wanted our Tegaderm.
Dr. Andy Pruitt 1:01:41
So what is Tegaderm?
Trevor Connor 1:01:44
There’s a good question, I’m gonna give you a bad answer. The way I explain it to people,
Chris Case 1:01:49
It’s a magical thing.
Trevor Connor 1:01:51
So, before I experienced Tegaderm, I always used Neosporin, which is an antibiotic ointment, so you’d put that on the wound, and then you would cover the wound with a bandage. The issue with that is you have to constantly be replacing that bandage or it’s going to start sticking to the wound, and that’s what you don’t want, and the wound can dry out. Tegaderm is an antibiotic ointment with this plastic bandage or covering that actually comes off and goes on very easily. So, you can put it on, you can leave it on much longer, you can shower with it, and when you take it off, it’s not going to take the wound off with it.
Dr. Andy Pruitt 1:02:32
It’s basically a second skin if you will. Now, second skin is a trademark brand of a moisture-retaining dressing, but if I don’t, if I go into small letters like a second skin.
Chris Case 1:02:43
Sure.
Dr. Andy Pruitt 1:02:45
It has an adhesive boundary, right? Around the edge and you have the pieces big enough to cover your whole wound. The thing with your antibiotic ointment or cream is that they actually suffocate the wound, it doesn’t let the wound breathe. So, if you clean the wound appropriately, and then you can place a layer of Tegaderm over it and allow the tissue to do what it would normally do, it does create a fluid boundary in there, there’s debris from the healing wound, there are blood cells, there’s hopefully not puss, but it can be, but it creates a contained system where the tissue layers can heal from the ground up. So there are several layers of the dermis, right? There are several layers of skin, so it’s going to heal, it’s going to granulate, if you will, from the bottom to the top, and this Tegaderm second skin layer allows that to happen. You can buy it, it used to be really rare, and it was only your medical bag that I made for you that had it you can go into.
Chris Case 1:03:54
Yeah.
Dr. Andy Pruitt 1:03:55
The big supermarket, big drugstores now and buy it, and it’s crucial, but you can leave it on for days, you can bathe and shower with it, and you can actually drain it. If the fluid builds up under the Tegaderm significantly and stick a little insulin needle in there and draw off that excessive debris fluid and leave the Tegaderm intact. If it springs a leak then we just take it off and wash the wound again and replace, but Tegaderm good cleansing of the original wound and immediate dressing with Tegaderm, or there’s there are other brands now that the drugstores are making, but Tegaderm is the, it’s kind of become the Kleenex of sure second skin dressings.
Chris Case 1:04:37
Yes, right.
Trevor Connor 1:04:38
Tegaderm is amazing. The one big piece of advice I’m gonna give from having had lost a lot of skin over my career is do not let it dry out.
Chris Case 1:04:48
Yeah.
Dr. Andy Pruitt 1:04:49
That’s like any wound, if a wound is dry, you want it to be wet. If a wound is gooey, you want to dry it out. So, there’s that middle.
Chris Case 1:04:56
Happy medium.
Dr. Andy Pruitt 1:04:57
Exactly. Yeah, and it is a medium in the tissue itself.
Trevor Connor 1:05:02
But if it’s scabs over too quickly, it’s painful, extremely painful, I find it doesn’t heal as well, it can scar more. I like to keep it, they get the Tegaderm, keep it moist, let it heal without scabbing for a while.
Dr. Andy Pruitt 1:05:18
So, in the old days, you again, we used an ointment with a dressing and burn netting. That’s how we held things in place, it was it was a badge of honor. If you had burn netting on you, you know you, you were a warrior if you had burn netting on. Now, we don’t even have to see the wounds anymore. I mean, they’re really well hidden with Tegaderm, and these other second skin dressings and they work so much better. Yeah, so don’t let a wound, there’s nothing worse than crashing in Europe and getting on an airplane, and your clothes are all stuck to you, and you may be stuck to the seat when you land back hours later, I’ve had it happened. That sound like a personal experience?
Chris Case 1:05:57
Yes. Speaking of skin, we touched upon it in Episode 59. Do we want to just briefly mentioned saddle sores? Because a lot of people deal with them? What’s the best way to care for a saddle sore?
Best Way To Treat a Saddle Sore
Dr. Andy Pruitt 1:06:11
Well, there’s a couple of different kinds, right? So, there’s a frictional saddle sore that is occurring, because you probably have one spot where you interface with your saddle that is rotating or creating a friction patch. The hair is meant to be like little all ball bearings, right? That’s a friction reducer, but in modern grooming, there’s a lot of hair removal, so now we have stubble, in place of long hair, which acts as a little ball bearing, so friction is one of them. Now, in a rainy race, a lot of debris on the road, you get a lot of sand in your shammy, so you have a perfect bike fit and still get frictional saddle sores with debris, right? The other is is a is a pressure sore, and so we talk about an ischemia, the ischemia is when there’s no capillary blood flow is being pushed away from the tissue. So, if you take your pink palm and you press on it and makes a white spot that’s ischemia. So if I’m sitting on my saddle and I sit there long enough, and that ischemia lasts long enough, I’m actually going to get some cell death in that area, and it will ultimately, the tissue will die, and some kind of rupture might occur, and that’s, that’s that’s a pressure sore that needs to be that’s a fit issue, right? and then the last one is is a hair follicle, I guess it’s three different kinds, it’s a hair follicle that’s been sheared off and has become infected, the hairs probably grown around underneath the skin a little bit. They’re all basically wounds, Chris. They’re all basically different kinds of wounds. Some of them are addressed with permanent bike that changes, some of them are addressed with temporary shammy alterations to relieve the pressure in the area. The dirty shammy, the rainy the rainy-day issue can be devastating. I think about Tom Boonen story back in 2012 or 13, he’d won his fifth in April, and he was riding support in the Vuelta that Fall on a really rainy day and he’d been, you know, charged doing his job, going to the front and drilling people in this pouring rain in the sand. Tom developed a saddle sore in the nether regions, between his scrotum and his rectum, and he rode there so long, and it got numb that he actually wore a hole in his tissue the size of a dime, I have a picture on my phone, Chris.
Trevor Connor 1:08:54
Never been so happy that we are audio-only.
Dr. Andy Pruitt 1:08:58
But my point is that he was so tough, he just rode through it, I gotta do my job. I saw him 60 days later and still treating this saddle sore, so we combined our work with a dermatologist, and actually designed a saddle specifically for Tom’s saddle sore, and you know, the rest is history as they say. He came back, he thought it was a career-ending injury. He thought it was going to end his career.
Chris Case 1:09:29
That’s crazy. I guess I want to briefly mention the fact that you occasionally hear people having to undergo surgery to remove something down there. Can it happen such that you know, you ride a race your shammy gets dirty or whatever and it irritates something, and maybe just some like something grows down there, but over time it gets bigger and bigger and to the point where it has to be removed.
Dr. Andy Pruitt 1:09:57
Absolutely. So, you can get a cystic scar in the area that has to be treated, no doubt about it. There are some, there are some cysts that do occur in the perineum, regardless, whether you’re cyclists or not, so if you are unlucky enough to get a pilonidal cyst or something like that in your groin, and be cyclists, yes, it’s gonna be surgically addressed. Of course, labiaplasty, in female athletes is, is far more common than we ever thought, and so yes, there are labia reconstructions being done because of saddle sores.
Chris Case 1:10:37
Sure.
Trevor Connor 1:10:38
The only thing I’m going to bring up because I’ve seen this fairly often is cyclists will get regular saddle sores, you know, that’s pretty typical ones that we get, and go and see their GP, and their GP immediately recommends surgery. I think surgery is a last resort and be very careful about that.
Dr. Andy Pruitt 1:10:57
And even steroid injections. So, I remember Ron Kiefel, in the middle of the Tour de France, had a big old saddle sore, he rode a whole stage without ever sitting down. He was in the break, he did the whole stage without sitting down and came to the clinic that night and actually said, here’s the upside to Cortisone, here’s the bad side of Cortisone, and here’s your risk. We had like five days to go, and we just put a little low-dose steroid right into that cyst and it was shrunk down by the next day, and, you know, as they say, the rest is history. So, there are times when you can do an interventional medicine for a severe saddle sore, for sure, but surgery is absolutely the last resort for sure. Now, you’d mentioned the chronic reoccurring saddle sore. So, I one of my interview questions for somebody coming from medical bike fits is, do you get saddle sores? Are they always in the same place? And so that tells me that they’re pivoting on an issue tuberosity, which they may have a pelvic asymmetry where they’re pivoting on one area, or they’ve got an old scar there or whatever, that’s really a diagnostic clue is reoccurring saddle sores in the same place.
Trevor Connor 1:12:08
And a little trick, nobody ever believes me about until they try it and then say, this is the greatest thing in the world, why didn’t I do this years ago? If you’re doing a big training camp or a big block, double shammy.
Chris Case 1:12:20
I knew you were going to say that.
Dr. Andy Pruitt 1:12:22
So double Shammy, I’m gonna be devil’s advocate here, is actually raising your saddle, right? So, your effective saddle height goes up by those few millimeters, oh, it’s not that big a deal, a millimeter at the foot is a centimeter at the knee. If you’re on the borderline of a high saddle, you’re, you’re a guy that likes toe point and you ride a higher saddle, and you put on to shammies or chain saddles to a thicker pad on the shammy on the on the saddle to go to camp, you have affected your bike, so caution there. I would rather see you use a medicated petroleum jelly in your crotch, instead of the double shammy. So, petroleum jelly, Vaseline, Kleenex, I mean, you know, I mean, when I say the Kleenex thing, right? You nobody ever asked for facial tissue, right? You ask for a Kleenex, right? Probably get a Puffs, but you ask for Kleenex. So, Vaseline is the Kleenex, petroleum jelly.
Chris Case 1:13:15
Sure, there are other brands.
Dr. Andy Pruitt 1:13:17
There are other brands. I usually take an antibiotic ointment and mix it one to one with the petroleum jelly, and that is my friction-reducing saddle cream.
Chris Case 1:13:29
You’re not mentioning shammy cream.
Dr. Andy Pruitt 1:13:31
I am not.
Chris Case 1:13:32
Which I want you to explain why for people out there.
Dr. Andy Pruitt 1:13:40
They’re water-soluble. So, they’re going to be absorbed into the skin and disappear, they’re going to be sweat off or rained off in time. So, you end up reapplying Shammy creams multiple times during a day. How I see it, a big scoop of shammy cream, a lot up in the in the crouch, and that is probably another problem that needs to be addressed here. I’m not a fan of water-soluble shammy creams.
Chris Case 1:14:09
Yeah.
Dr. Andy Pruitt 1:14:09
But so the downside of petroleum jelly is that it does make your personal grooming and cleansing much harder, because you do clog up some pores. So, you really do have to get that alcohol astringent in there earlier, get out of your shammy get your crotch clean, right?
Chris Case 1:14:26
Yes. No lounging around at the cafe for hours.
Dr. Andy Pruitt 1:14:33
Get out of your shammy, grooming, cleaning, all those things are really important if you’re going to use the petroleum jelly, so I would prefer medicated petroleum jelly versus that second shammy.
Chris Case 1:14:44
So, let’s turn to that question of how much the body changes with some of these issues we’ve been talking about and whether, you know, you can come back from that as is or if things change so much that your body’s not the same, and you have to do things differently. Let’s let’s address that. That’s a big question, but how does an athlete understand the changes that may have taken place?
How the Body Changes After an Injury
Dr. Andy Pruitt 1:15:11
Obviously, depends on the injury. So, go back to Chloe Dygert had a femoral fracture with operative repair, right? So, there’s a really good chance that she might have a shortened femur, or lengthen femur, both can happen with surgical repair, so that any kind of operative repair clavicle, femur, tibia, forearm, all of those things are going to potentially result in a segmental length change that needs to be addressed on the bike. Short forearm is a different brake away placement, there’s lots of ways to address it. The less obvious is the significant crash with a knee sprain, right? So, there’s, there’s levels of return, and we talked about this earlier. One is range of motion, so if I get back on my bike, and I don’t have full extension, or I don’t have full flexion on my knee, that is going to show up either at the top or the bottom of the pedal stroke, which, you know, saddle sores are rarely, the cause is rarely at this at that at the saddle, it can be because my knee is either overstressed at the bottom or over flexed at the top, and I’m rocking on the saddle. So, return of range of motion is crucial. The Most Extreme thing I’ve ever seen was a guy that spent two tours in Vietnam unwounded, came home in L.A., got a stray bullet through the window on the freeway, shattered his elbow, and he just got a frozen elbow and like 30 degrees of flexion, and a short form, we actually built his bike with two separate stems and two half handlebars. So, his elbows and hands are two very different places, but his torso angle and everything was perfect once done. So, recognize these asymmetries, his is gross, right? That was painfully visibly obvious what we need to do for that guy. A gal like Chloe, that’s going to be millimeters hidden behind gigantic quads and an aggressive athlete. So those millimeters may or may not be important to recognize, but as she returned to the bike, it was all about range of motion at the knee first, then it was about strength, now we’re working on endurance. That’s how you come back from these traumatic, these traumatic injuries. Back, I mean, think about range of motion my back, yeah, hip hinging, forward flexion is crucial to coming back from a back injury on your on the bike. So recognizing them, either temporarily or permanently in bike positioning are crucial.
Chris Case 1:18:02
And Ryan, I want to have you jump in here. What are your thoughts on restoring function to an athlete that’s coming back from an injury like this, from a coach’s perspective?
Restoring Function on the Bike
Ryan Kohler 1:18:15
Yeah, I think as a coach we have, I mean we’re in communication with these athletes pretty consistently, we know we can help them, get in touch with the appropriate people. So, I’m always looking to try and figure out who can I get this person in touch with to help in a specific area? Is it like the sports psychology? Is it the PT? Is it medicine? What areas can we work with together to involve more experts to try and get that body back to being the same? So, it’s really, sort of look at the coaching as becoming this this connector sort of model.
Dr. Andy Pruitt 1:18:45
Ryan, are you in favor of one legged on bike exercise?
Ryan Kohler 1:18:52
Actually, after having an injury and coming back from it, I am now. Yeah, I had, I had, my left leg had to be straight for, I don’t know, four or five weeks after I tore open the skin right over the patella. I did a lot of single-leg paddling, and it was interesting coming back from that because the neuromuscular piece was really missing, and firing that quad was not happening. So, when I was on the bike, I was doing unilateral training on the good leg, the other leg was just hanging out there, but it was this gradual progression of doing very small leg raises with some weight on the on the affected leg and being diligent about that. And over time, that leg was gradually able to come back to pedaling again, but it’s still, it took weeks before that that neuromuscular function was back.
Dr. Andy Pruitt 1:19:44
I’m a big believer in the bilateral education, right? I mean, so if I’m firing all my quad muscles on a good leg, there is some neurological bilateral education occurring even in a casted, opposite leg. So, I am a believer, not everybody is a believer because you do develop some bad habits and saddle sores, in one-legged pedaling, but I am a big believer in unilateral training.
Getting Back on the Bike
Trevor Connor 1:20:10
So I think the last question that we need to ask is what happens if your departure from your sport has been quite long, so that there’s actually essentially some rust built up and muscle memory and race memory, and you have to start addressing that now that you’re coming back to your sport, I actually think this is somewhat relevant right now because we have a lot of people who, even though they weren’t injured, haven’t raced in over a year because of COVID, and are now getting back to racing.
Starting With the Fundamental Principles
Ryan Kohler 1:20:41
The thing that comes to mind is back to basics, we get this, we have this long break, and as you said, there’s rust, we need to get that off, and many times, I’ll go to teaching bike skills with people many times what I find is that as people are putting years and years into cycling, their speed starts to increase, and what happens is that speed masks some of those fundamental skills, when we take the time away from cycling or any sport. Well, now all that speed is gone, the fitness goes away with it, and now what we’re left with is the basics, those fundamental principles. So I think coming back and starting with those fundamental principles are really the key in my in my view to help start that process too, because it’s where we need to begin and that’s what’s going to help us build from there.
Dr. Andy Pruitt 1:21:25
The gyroscopic effect of wheels turning, and momentum are great maskers of our lack of bike handling skills, right? So slow riding is probably one of the first things that I would have somebody returned to, right? I mean, mountain biking, slow riding skills are way important, gravel in the middle there somewhere. But road cycling, the gyroscopic and momentum is such a huge one, look at me, I’m a great cyclist until they go into two-wheel slide and gravel the corner.
Ryan Kohler 1:22:01
Yeah, that’s the first thing is with doing bike skills with people, it’s always let’s slow down, let’s see, just how do you balance on your bike when we take you down to two miles an hour.
Dr. Andy Pruitt 1:22:11
What are you seeing from the lockdown, right? I mean, the people training indoors, and so they’re really, really fit one way but are they unfit in other ways?
Trevor Connor 1:22:22
Yes, yeah. Ryan, so you want to take this one? Go ahead, and I’ll just jump in.
COVID-19 and Differences in Training
Ryan Kohler 1:22:26
Okay, I think we just experienced this last week on Sunshine Canyon, when we’re riding together. I think you talked about it, and I mentioned it later in the ride as we were descending. We’ve been spending a lot of time on Zwift, and yes, the fitness is great to see, but then once we go outside, and going down Sunshine Canyon, the upper part is all dirt and it’s loose and it’s full of braking bumps, start leaning the bike over all of a sudden, you didn’t lean your bike for six months on your Zwift and on your trainer, so now that feels very awkward. So, it’s been hard, it’s kind of dangerous to just go and jump back into it.
Dr. Andy Pruitt 1:23:01
Even Peter Sagan even mentioned it, you know he was off because he had COVID, and all of a sudden, he’s back in the Peloton, and he he’s not the brave beater that we’ve seen in the past, right? He’s a bit more cautious, and he says, “no, I’m having to rebuild my skills.” So even at the highest level, the World’s best bike handler, saying, “Wow, I’m rusty.”
Trevor Connor 1:23:25
I have fully experienced this, I had a while that I was away from at least domestic Pro Cycling, and remember the first time I went back, so I went back to the Cascades in 2017. I was terrified, going, “Wait, I used to bring the team here, and show them how to race in a Peloton. I’m the guy at the back going, oh my god, this is scary.” It is critical to rebuild those skills, you can really lose them. And yes, I agree, If you’ve been injured or because of COVID you’ve been riding on Zwift, I think that’s great. It’s gonna keep your fitness but go find some friends who are willing to do this ride with some friends get used to riding with a group before you attempt to get into a race.
Ryan Kohler 1:24:11
Yeah, that confidence. You know, we have that comfort zone that we have shrinks down over time, so now we need to figure out how do we gradually push that, get into that that reach the zone where it’s a little bit scary but still controlled, and then we can start to build that confidence again.
Dr. Andy Pruitt 1:24:28
If we think about what now is called Cat5, back in my day they were Cat4. The Cat4 crashes were just planned, you just put a medical person in every corner but Cat4 crit. Because they had been training alone, most of them are new to the sport, and they had not gotten together with a group to do fast-paced line work and descending work in a group, there’s only one way to learn it and that’s why we put them all in the same category. So, there are all kinds of skills and there are all kinds of fitness, right? I mean that you can tune the motor, right? But man, the bike handling skills in a group they also need to be trained as part of this recovery process. Much overlooked, much overlooked.
Trevor Connor 1:25:15
The most dangerous rider is the rider with a giant engine and no pack skills. So make sure you’re not that rider, if you’ve been off for a bit, you get back to racing.
Trevor Connor 1:25:28
We don’t just change physically after a bad crash, it can also have an impact on us mentally, let’s get back to Petr, and what it was like for him mentally to return to professional racing.
Petr Vakoc: Mentally Recovering From a Traumatic Injury
Petr Vakoc 1:25:38
In my head, especially at the beginning really, really okay, because my accident was so bad that I was actually happy that I was alive, and that it seemed like there will be no or not any, like significant injuries that will be impossible to deal with or to cure. So already that I was like, okay, that’s, that seems like I can come back, so let’s do everything to come back, and I never had really doubt if I want to keep racing or if I had some doubts about like feeling down or, you know, not motivated to do the rehab, and everything didn’t last long, because I knew, okay, I want to come back to the state where I can race, and okay, then I can decide if actually, I want to keep racing or not. But first I want to be in that position. So actually, that was the moment when I had to start working with psychologists more closely was only at the moment when I was already healthy, but then was difficult to do the race again. I had to deal with the, with the stress to race and I had to be in the Peloton and decide if it’s something that I want to keep doing.
Chris Case 1:27:02
Could you take us a little bit inside what those conversations were like? How did you regain the confidence to be able to race side by side in a peloton like that going at high speeds, overcoming the fear that you probably had?
Petr Vakoc 1:27:19
It was a gradual development because, in the beginning, I was really scared. I came to the first race and I say, “Okay, I want to race,” and the first kilometers were really stressful. But then, yeah, my initial role was mainly to pull the levers and that was easy, but then came some moments when was like crosswind or whatever, and I had to fight for position. At the beginning, I was really not comfortable. But there was something that gradually improved, and I think it’s normal to have this fear right at the beginning, it’s natural, but you just get more comfortable in the position by getting there, by getting in this position again and again. Then it gradually gets easier, I think it’s important to know that you probably will have to deal with that if you have certain significant injury and that it will take time before you will get fully comfortable again, it’s just to accept it, and work on it step by step.
Chris Case 1:28:21
And I would assume that the same goes for the skills that you may have lost, the technical skills to get back in the bunch. It just takes time and experience to do it again, or did you go out and practice, you know, descending on your own or cornering on your own to be able to then jump back into a pro race?
Petr Vakoc 1:28:45
It wasn’t really such an issue I have to say because the skills that it went quite fast, for me the challenge was more psychological. I remember like coming back from other injuries like for example, just broken collarbone it was at the beginning was difficult because you are racing pretty fast again after a crash, and then before you get comfortable in the downside it also takes a while, so I think because it took me so long, so long time of training before I got back to racing my skills were back to where they needed to be, and I was I was comfortable on the bike. I just had to get used to again to the pressure of racing.
Chris Case 1:29:30
Is there anything else I didn’t ask you about that you think is an important aspect of coming back from an injury?
Petr Vakoc 1:29:38
I think it’s important to realize that when you are injured it’s normal to feel down and to be disappointed and have a lot of doubts. It’s good to really go through this phase relatively quickly, and then focus on where you are now instead, and how much progress you do instead of where he used to be before the injury, and this is really something that helped me to get through it. I think I had, on average, maybe one day a week during the whole year of coming back when I felt really down and like stuff that I didn’t do any progress or whatever, but the other six days, I was always focusing on how, how far did I get already since the injury. So, I mean, realizing that you will have a lot of doubts, and bad moments, and it’s normal, but you can always just let them go and focus most of the time on what you are achieving.
Trevor Connor 1:30:46
Okay, well, I get to start out the take-homes for this week. So Dr. Pruitt, why don’t we start with you? What is your one-minute take home from this episode?
Dr. Andy Pruitt Takeaway Message
Dr. Andy Pruitt 1:30:57
If they don’t recall or take away anything else, it would be to recognize the unseen energies that are needed to return from either injury or illness. There is a cost of cellular repair, that you will see in your diet and in your sleep, but it’s unseen, but needs to be recognized.
Chris Case Takeaway Message
Chris Case 1:31:23
Yeah, my take-home would be, you know it’s a process this returning to the bike, returning to your sport of choice after an injury is a process, takes a lot of patience, there can be a big physical toll, there can be a very big psychological toll. I would recommend people not cut corners, I’ve seen that in the past where somebody might say, for instance, they had a shoulder injury, they go to rehab, they start doing the things they’re supposed to do, they see the progress they want to see, they get to a point they say, “I am better,” They go to rehab, they see the progress they want to see, and they get to a point maybe it’s only halfway through what was originally slated to be the rehabilitation, and they say, “I’m fine, I’m done,” and they stop. But they stopped too soon, and slowly, but surely, the injury sort of maybe crawls back into their life and becomes an issue, and maybe they lose little range of motion, maybe something prevents them from going back to the therapist because they’ve lost that momentum, and it just leads to a long term issue. So don’t cut corners, be patient, and reach out to people that may have also had the same type of injuries as you, that helps you set expectations and figure out what the road ahead looks like.
Ryan Kohler Takeaway Message
Ryan Kohler 1:32:49
My takeaway is to take the long-term view, when you’re coming back, know that this will be a process, and it’s not just a quick hop back on the bike and start pedaling again. So take that viewpoint, understand that you’ve probably lost some things, there might be some mental blocks that need to be overcome and work with your coach or another expert or a couple experts that can help you figure out a plan to hit these milestones along the way so that you can get this nice feet forward effect and make the progress that you’re hoping to see.
Trevor Connor Takeaway Message
Trevor Connor 1:33:24
I actually think there’s a lot to take homes from this one, but I’m gonna focus on something that I brought up a few times, which is the definition of insanity is doing what you’ve always done and expect something different. If you’ve been injured, just saying I’m going to try to ignore this and go back to what I’m doing isn’t the best approach, you need to make sure that you can come back as effectively as possible, you might need to make some changes, If you’ve been injured like a broken bone, you might have to change your bike position. Make sure that you are coming back in a healthy manner and making the changes you need to make to not put yourself back to where you were.
Chris Case 1:34:06
That was another episode of Fast Talk. Subscribe to Fast Talk wherever you prefer to find your favorite podcast and be sure to leave us a rating and review. The thoughts and opinions expressed on Fast Talk are those of the individual, as always, we love your feedback. Join the conversation at forums.fasttalklabs.com to discuss each and every episode and become a member of Fast Talk Laboratories at fasttalklabs.com/join and become a part of our education and coaching community. For Dr. Andy Pruitt, Dr. Kevin Sprouse, Petr Vakoc, Bruce Bird, Ryan Kohler, and Trevor Connor. I’m Chris Case. Thanks for listening
