Dr. Andy Pruitt literally wrote the book on endurance sports health. He founded the Boulder Center for Sports Medicine, and developed the Body Geometry System for Specialized, so he understands how to keep endurance athletes functioning and pain-free. We saved up your questions on pains and injuries to discuss with Dr. Pruitt. Today, we talk about resolving back, knee, and saddle pain as well as staying healthy while training increases.
A quick note on this episode. Coach Connor is back up in Canada and his audio quality isn’t great. Our apologies about that, he was probably being attacked by a polar bear in a snowstorm while eating poutine. Don’t worry, Trevor is very “sorey”.
Advice for a 40-Year-Old About “Exploding” Back Pain
“I’m a 40-year-old avid cyclist and have been seeing a lot of progress in my training, but recently I was struck by a big setback. I’ve had some nagging back pain for a, bit but a few months ago it “exploded.” I lost a lot of power in my left leg. It turns out I have an L4 herniation. PT helped a lot, but the pain is not fully gone. Guess that’s something I have to get used to at my age, but I don’t like.
I’ve been doing research on strength and conditioning work that I can do to improve my back’s health. I’ve been surprised to read multiple articles saying to avoid strength machines which isolate muscle and any sort of rotation in the back. What’s your feeling about this? And what is the best approach to strengthening my back and keeping it healthy?”
Knee Pain & Training Volume
“I’m a reasonably competitive category 3 rider. I’m trying to increase my training volume to get up to that category 2 or even category 1 level, but the last few years I’ve suffered knee issues whenever I’ve increased my volume.
I really want to make this my year, but I’m scared that my knees are going to keep preventing me from training the way I want. Is there anything I can do to protect my knees or strengthen them so that I don’t go down that same rabbit hole again?”
Knee Tracking & Hip Stability
This second question comes from Philip Darley on our Forum:
“Hi all, in Episode 68 the knee touching the top tube was touched upon. Knee tracking and hip stability were mentioned as reasons. Does anybody have resources for further information on how to address this? Thanks!”
Tingling, Burning Pain in the “Nether Regions”
This question comes from RCCO on our Forum:
“I’m a reasonably fast 50-year-old male recreational cyclist.
These last few months I’ve suffered with the Cyclists’ Syndrome: pudendal neuralgia. I have pretty much had to give up cycling, and sitting down in general, due to the constant tingling, burning and pain in my nether regions.
I’ve tried to go onto a low-inflammation diet, started taking CBD oil, spent time off the bike and bought a standing desk but it’s still with me all the time and it’s a literal pain in the ass.
Has anyone come across this before?”
Again, Dr. Pruitt to the rescue.
Can We Continue to Adapt with Age?
This question comes from Tom Maher on our Forum:
Just been listening to your podcast on adaptation and recovery. It prompted a possibly rambling thought in my mind, perhaps having just turned 40, but is adaptation possible throughout life? Or does adaptation mean adaptation that is perhaps just combatting the decline of age?
On a simplistic level, for example, is it possible to keep building one’s aerobic base over the years, increasing genuine FTP albeit at a slow rate? Or could everyone reach their ceiling regardless of age? And if there is a ceiling, then how do we improve? Is it to look for other areas to improve? What incentive is there other than to minimize loss of performance?
From a somewhat cynical viewpoint, could I drop my training for a year and then expect to be able to get back to where I would have been had I still been training in that year?
Just a few thoughts, I suppose querying whether we are just like hamsters on a wheel trying to keep it spinning but ultimately going nowhere, or whether it’s more like pushing a boulder up a hill….
Rob Pickels 00:04
Hello and welcome to Fast Talk, your source for the science of endurance performance! I’m your host Rob Pickels here with Trevor Connor and special guest Dr. Andy Pruitt.
Rob Pickels 00:14
Dr. Andy Pruitt “literally” wrote the book on endurance sports health. He founded the Boulder Center for Sports Medicine, and developed the Body Geometry System for Specialized, so he understands how to keep endurance athletes functioning and pain-free. We saved up your questions on pains and injuries to discuss with Dr. Pruitt. Today, we talk about resolving back, knee, and saddle pain as well as staying healthy while training increases.
Rob Pickels 00:41
A quick note on this episode. Coach Connor is back up in Canada and his audio quality isn’t great. Our apologies about that, he was probably being attacked by a polar bear in a snowstorm while eating poutine. Don’t worry, he is very sorey.
Trevor Connor 01:04
Preparing for a race, do an at home lactate testing, reviewing post race data. It’s important to understand how to test what the numbers mean and how to change your training based on your data. From training peaks to whoop sifting through your data can feel like it requires a master’s degree. Good news. We have those plus over 30 years of coaching and data analysis experience. You go race leave the data analysis to us book your data analysis session today at fast talk labs.com. Well, Doctor Pro, welcome to another episode of fast talk we haven’t had you on in a bit. So it’s a real pleasure to have you back with us.
Dr. Andy Pruitt 01:43
Well, thanks, Trevor. It’s always great to be here. I love this opportunity to chat with you guys and share what I may or may not know.
Rob Pickels 01:51
You know, here’s a fun fact for us to think about. Andy the last time you and I were on the podcast together was episode nine 211 episodes ago, we sat across from each other recording a podcast with Trevor and I just I thought that was incredible to think all the way back. We’re Oh geez.
Dr. Andy Pruitt 02:09
I am very OG but what was our topic that day? Oh, God. It
Rob Pickels 02:13
was it was a roundtable I think just on all things sort of bike fitting and sports science and physiology. Yeah. Yeah, it was a good one. Everybody should go back and listen to episode nine.
Trevor Connor 02:23
So that was episode nine. Yeah, that’s back when all I had was a recorder. I had no idea what I was doing. And basically, I was just reaching out to people I know saying please help me.
Rob Pickels 02:34
And because Andy and I were on it. It was one of your best episodes, even though he didn’t know what you’re doing. So there you go. There we go.
Trevor Connor 02:39
I actually do remember that because I have a black and white really nice photo that I use sometimes is my computer desktop from that episode. That’s scary.
Rob Pickels 02:50
So q&a episode today, guys.
Trevor Connor 02:54
So to underdone, how many episodes later? Yeah, we’re not any better.
Rob Pickels 02:58
Not any better.
Dr. Andy Pruitt 02:59
Yes. Yes, we
Trevor Connor 03:01
are. Alright, well,
Rob Pickels 03:02
hey, Dr. Pruitt, we’re here. We have a whole bunch of questions. A lot of them are about medical and bike fit. I think that you’re more than qualified to answer it. I think Trevor and I are hopefully going to keep up. But here’s our first question. It’s going to be from Ben Allen, and it’s going to be about back health. They’re looking for some advice on strength work. And the question is this. I’m a 40 year old avid cyclist and have been seeing a lot of progress in my training. But recently, I was struck by a big setback. I’ve had some nagging back pain for a bit, but a few months ago, it exploded in quotation marks. I lost a lot of power in my left leg. Turns out I have an L for herniation. PT helped a lot, but the pain is not fully gone. I guess that’s something I have to get used to at my age, but I don’t like it. I’ve been doing research on strength and conditioning work that I can do to improve my back’s health. I’ve been very surprised to read multiple articles saying to avoid strength machines, which isolate muscles and any sort of rotation in the back. What’s your feeling about this? And what is the best approach to strengthen my back and keep it healthy?
Dr. Andy Pruitt 04:08
Let’s talk about lumbar disc physiology at the cellular level first, right? So our discs are like jelly donuts that are hyper filled. So you’ve got a one square centimeter space with two square centimeters of jelly in it. So it’s hyper pressurized and that’s how the disk absorbs pressure and how to change his shape with spinal mobility. But as we age, the discs do become dehydrated, they may occur a split and if you do the wrong moment at that time, the split actually spills out some of the jelly and that’s a herniated disc 80% of these kinds of episodes will resolve themselves in time where the body basically goes in and and sucks up that extra material takes the pressure off the nerve which is the numbness and weakness in The left leg. So 80% of these episodes resolved themselves if given the time to do so. But 80% of those episodes will reoccur, because that’s become a weakened spot in that desk. So there are medical ways to expedite the healing of that desk, some people cauterize the herniation, some people need to go actually go in surgically and remove that material, all of which leave the the disc and itself scarred and weakened, and has less jelly in it now. So it does its job less well. So that’s, that’s the physiology and a layman’s way of thinking about how this works, right. So the spine has a really unique structure, and that it’s the only rigid structure we have in the abdominal kind of tube. The rest of it is all dynamic structure, which is muscular, and fascial. So the spine has to be supported with muscular strength, it has to be otherwise it’s going to do the job all by itself, and it will fail, such as your disc herniation. So strengthen is incredibly important. So physical therapists help to identify the weaknesses you have in your core system. So attacking those weaknesses, which you’ve acquired either through this injury or acquired over time, cyclists, we tend to be pretty static in our position. So we do acquire weaknesses in the core as a cyclist. So we really need to attack those weaknesses off the bike. So I’m a big believer in core strength, low back strength, and even isolation by machinery, if you’ve identified that a certain movement is a need you have, and there’s a machine that will isolate that movement and help you strengthen it, then use it. If it needs to be a floor exercise or a ball exercise, instead of a machine. That’s all well and good, too. So free weights are probably the most dangerous. But if you are around track cyclists, much you’ll know they live in the weight room, because they need that explosive, Box Jump deadlift, you know, all those kinds of things. So there is a place for the freeware world and there’s a place for the machine world. And there’s a place for for exercises. But first you have to identify the weakness that you have, and the need you have in strengthening those. Now, what about range of motion, right? So you splint yourself, if you’ve got this L for rupture, you’re going to self splint around that injury. And you can acquire some scar you can acquire loss of range of motion. So regaining normal function is the key to any kind of therapy and following this. So bike fit does play a role, not knowing what he looks like on his on his bike. But as we roll that lumbar spine forward, think about that jelly in that disc is going to get pushed back as the disc is going to become a wedge. And so the back portion of that disc is going to be pressurized by that jelly. And so an aggressive front end of a bike with a lumbar spine that lacks mobility is going to put more pressure on the posterior aspect of all the discs in the lumbar spine. So bike fit does play a role. Range of Motion plays a role. Strength plays a role
Rob Pickels 08:13
in it, I want to touch on something you brought up of identifying the weakness that he has an addressing that right because, you know, strength training, a ton of calf raises isn’t going to help his his lumbar disc issue, potentially not. Now, if somebody does have a known injury like this and L for disc injury, does that give us any insight into weaknesses they may have? Or is this really working with a knowledgeable individual who can assess this person in their movement patterns in their strength and their flexibility? Is that the way that listeners have to go about it?
Dr. Andy Pruitt 08:45
Well, let’s go back to the calf raises for a second. So with an L four or L five, you may acquire a calf weakness because of that pressure on the nerve. He may require a lot of downstream strengthening that occurred because of the of the pressure on the nerve. Yes, yeah, he may need to do a lot of calf raises. But working with someone to help you identify those self, you know, we talk in the medical profession, he He who has himself as a as a physician has a fool for a patient, right? So we have to be really careful about self care. So it does take some objective and subjective help from an outsider typically, to help identify the needs falling back injury.
Trevor Connor 09:27
That’s certainly something that I learned. So I have a an L for herniation. I’ve had a problem with it since I was 16 years old. And it got really bad back around 2015 2016 To the point that I missed out on a lot of the season for a couple years because my back was constantly in pain. And I know that this doesn’t go out that’s an expression but whatever is actually happening. That was happening to me multiple times a year. The solution for me ended Bing, I bought one of those back extension machines. And now every morning, I get up and get on that back extension machine for five to 10 minutes. And my back is not bugged me and yours because of that. But there are other people who would have an L four problem if they got an A back extension machine, it would put them in the hospital. So the one thing I’ve really learned out of my own experience is the solution is very individual, I don’t think there is a single solution that’s going to help everybody
Dr. Andy Pruitt 10:29
Absolutely, you keyed a couple things in my mind compensation. So you had a long term back injury, and we are great compensators. So part of compensation is to self splint against the injury, and to build other muscles to do what is not now being done because of the injury. So compensation over a long period of time is very difficult to reverse. So getting on top of it early on is really important. You self found your solution. And that sadly, that’s what a lot of us do, we wander into the forest looking for a tree that’s going to solve our particular issue, your right extension, if you’ve got a bulging posterior disc Extension helps kind of put that thing back into place. So a good therapist is going to prescribe extension exercises, once they know where that bulge is. But there are other people where extension would have maybe increased their issues. So self exploration, if you’re lucky, you might find a solution. I know a lot of people, including myself, and all three of us, we’ve self explored our own issues and self treated and some of the times we’ve been successful, sometimes we have it, Trevor, I remember having to lay your bike over and help you get on it in the middle of a multi day stage race. The other two are the line and you said to me, just get me on it, I’ll be okay. So it was getting on and off. That was the problem, not not pedaling, and we got you through it. So
Trevor Connor 11:58
one of the scariest moments I ever had on a bike was so it was a second stage a tour of the ILA I was having a great stage, I had just broken away with going up that first climb and was feeling really good. And there was this really sharp hairpin turn right near the top, went around that turn and just twisted slightly wrong. And just, you know, when people talk about hitting the ground, the pain is so bad. That hit me but I’m on a bike going full speed. So I kind of slumped down onto the top tube, but managed to keep myself up on the bike and then came over the top of the hill and had to do one of the more technical dissents in American racing with my back on fire and went from broken away to the last person to finish that
Dr. Andy Pruitt 12:45
you went from broken away to just broke
Rob Pickels 12:47
to just broken.
Dr. Andy Pruitt 12:50
Just tell the listeners what really is happening. So you had multiple episodes of your back giving out right. And that back giving out is typically a little more leaking through that wounded disc puts a little pressure out there. So you have the acuity of the disc itself being cracked, you have swelling in the area, you have spasm to protect it, it’s it resolves over time, it’s weakened, you didn’t really do much about it. And boom, five months later, you’ll have another one and another one and another one. So over time, that disk really just totally leaks becomes totally dehydrated as lost all of its jelly out of the donut. And it really becomes dysfunctional. So something else that has to happen. There’s going to be arthritic changes around that disc level to stabilize it. There’s just this cascade of events that occur at that level as that disc continues to leak, and then you’ve compensated quite well. So people say you had finally got better last year, it was bad for five years. But now it’s great. Well, it’s great because it has finally lost all of its material. And it’s settled down upon the vertebra above and below it. And it’s going to kind of self arthritic ly fuse. And people’s I used to have a lot of back pain. Now I’m just stiff, but it’s not painful anymore. So that’s kind of that cascade of events. So this poor guy with his l four, he needs to pursue a good therapeutic course. Whether that is invasive include injections or colorization, or surgery, and then off the bike PT. He needs to pursue all of those things, or he will have that continued cascade of events.
Rob Pickels 14:29
Yeah, I want to take this opportunity to back up a little bit and to broaden this because, you know, we all love to talk about ourselves. Here I am doing it. I’ve never had an L four. I’ve never had a disc issue. But I have had an SI joint issue that has plagued me since college. It actually was one of the things that prevented me from running, competing my senior year of college. For years, it would get out of whack. Right and it’d be painful. The muscle splinting was really a source of the protection and the pain there. And the big His thing that helped me was strength training, but not traditional strength training, like I was trying to do not the squats and everything else that I was doing to improve my performance, if anything that would put me in a place that I would just hurt my SI joint again. But seeing physical therapists learning about my body, learning about those weaknesses, and the thing that seems to have really helped was me working on hip stability, even though the muscles didn’t necessarily cross to my sacrum. By controlling my hip strength, I was able to control my leg movement and the jarring that was occurring on my SI joint when I ran or played with my kids or tried to lift. So, you know, strength training itself, I don’t think is necessarily a panacea for for fixing back problems, right? I don’t think that’s the message or saying, but the thing that I really want to take away from what Andy said before was identify your weaknesses and address those, because they really could be the key, you know, to improving how you’re feeling and how your body is functioning.
Dr. Andy Pruitt 15:55
We could talk backs all day, and I would love it. So SI pain, right? So SI dysfunction, or an SI joint sacroiliac joint, which is slightly out of place can mimic lumbar disease. And there have been a lot of MRIs taken in injections given etc for lumbar disease when it was really a slightly displaced SI joint. So make sure you got the diagnosis, right, number one, number two, you talk about oh, geez, I’m really the old G here, right. So when I was in undergraduate school as an anatomy major, we basically learned that the sacroiliac joint did not move and that therefore don’t worry about it. Unless there was a huge trauma like a car accident or some this SI joint did not move. And it wasn’t until I got out of school and began to practice and, and started working with athletic trainers and physical therapist that they finally convinced me that there is micro moving in the SI joint, I’ve taught my wife how to adjust mine. So please, out there and listeners that know that the SI joint can absolutely mimic and create radiating leg pain. So learning how to adjust, self adjust and stabilize your SI joint. And there are medical treatments for it. If it’s a hyper mobile, SI joint, you know, the SI joints are critical in pregnant women for childbirth and the SI joint doesn’t move then that baby’s not coming through the birth canal. So thank you for bringing that up the SI joint is crucial, as a rule out or confirm aspect of low back pain.
Rob Pickels 17:28
I think it’s really insightful that you brought up the misdiagnosis there because that’s exactly what happened to me in college describing all the symptoms, all the things I was going through, they kept looking at my low back my low back my low back and MRI said to your discs are fine, I don’t see any issues here. We don’t know what to treat. And so I went essentially untreated and I would fall into this thing of on Monday, I would feel good I would do a workout on the track on Tuesday, I couldn’t walk by the weekend, I could walk again on Monday, I would feel good on Tuesday, I couldn’t walk you know in like that, in I didn’t really get any resolution or a proper diagnosis. Until you know, Andy, you and I, our good friend, Tim Hildon, an extremely knowledgeable physical therapist said, Hey, I think I know what this is, you know, and then through his treatment, you know, ultimately really got my initial resolution there. But it has been a management thing ever since.
Trevor Connor 18:16
So one last thing I just want to throw in, you know, we’ve talked about some of the things you can do. Another thing to be very careful about is, for lack of a better word, your posture hygiene. So we talked about my experience at Hilo, that’s a good example. We are an amateur team, which meant we are cramming a whole bunch of people into a small house and I was sleeping on a really soft, awful couch. And I’m certain that’s what caused me in the middle of the race to fall apart. I have also learned over the years through through tough experience. If I’m traveling, I always travel with the sleep bags by going to a hotel or a house and there’s a soft bed there, I’m better off just sleeping on the floor. Likewise, if there’s a couch with no support I avoid sitting in these are the other things, you really have to be careful of
Dr. Andy Pruitt 19:05
sitting standing walking posture, there’s our athletic skills. And cyclists, we tend to acquire this hip flexor kyphotic, which is your upper back rolling forward to get that we kind of create this on bike posture that if we ride 1020 hours a week, it’s a lot of time spent in that position. So we kind of acquire this cyclists posture, I can pick a cyclist out of a crowd at the movie theater, right? Especially an old one. So we do need to think about off bike posture sitting standing walking. Absolutely.
Rob Pickels 19:37
Very nice. All right, guys. Well, man, we took that back question, you know, pretty broad. Let’s focus back down a little bit. The next two questions are actually about the knee. So I’m going to read both of them together. And then Trevor, let’s give you the first crack at it. So the first one is from Jen Carson. And it says fear of knee problems. I think this is something we might all relate to. I’m a reasonably competitive category three Ryder, I’m trying to increase my training volume to get up to the category two or even category one level. But the last few years I’ve suffered knee issues whenever I’ve increased my volume. I really want to make this my year but I’m scared that my knees are going to keep preventing me from training the way I want. Is there anything I can do to protect my knees or strengthen them so that I don’t go down the same rabbit hole again? And then as a second question, this one is from a Philip Darley. It’s about the knee touching the top tube. Hi, all in Episode 68, the knee touching the top tube was touched upon knee tracking and hip stability were mentioned as reasons. Does anybody have resources for further information on how to address this? So Trevor, I think with you, you know, in the coaching experience that you have, and people trying to increase their volume, especially as they’re trying to increase their level? Is this something that you’ve dealt with in the past? You know, how do we make sure that Jen’s knee doesn’t get in the way of her achieving her goals?
Trevor Connor 20:58
Yeah, I’m gonna start by saying, I mean, we have one of the top experts, if not the top expert in the world in the room when it comes to knee issues. So I’m not going to try to touch that except to just say, there’s many types of knee issues. This is also not a monolith. But what I will say as a coach is, this is something new you see a lot with athletes, particularly athletes that are trying to raise their level, everybody thinks it’s just a matter of increasing your volume, or finding that time to do more training. And I can’t tell you how many athletes I’ve seen get frustrated, because they make that time. And then because they haven’t been doing their support work, the bodies are basically falling apart, they start getting aches and pains and being fatigued and find that even though they now have that time, they can’t take advantage of it. And I have actually seen that discourage a lot of athletes and cause them to quit. And in particular, I’ve seen a lot of them, when they start putting in that volume, start getting knee pain, and it really does Mentally take them down a bit. And I always tell athletes before you raise your volume, you have to raise your support work, get your body ready to be able to handle that bigger volume. And I’ll leave my response there.
Dr. Andy Pruitt 22:12
Well, those are all good points during this for sure. I think there’s two questions, but they really go hand in hand, the fear of knee pain because she’s had it when she tries to increase her volume, which there’s two pieces to volume, right, there’s intensity and volume. And so I would ask her if I had the opportunities does increased intensity also bring this on, or is it purely time in the saddle that brings it on because they could be slightly separate thanks. Most female humans have a wider shallow pelvis a greater hip angle, which leads them to having more valgus knee a more not need alignment. So for her, I’m assuming that she falls into that 80 or 90% of female phenotypes that has a valgus knee. So as she increases her volume or intensity, the knee is going to then as the leg fatigues it was going to drift more toward in toward the top tube. So it’s gluteal work, it’s the abductors, all the muscles that would hold the knee out, but it’s also at the foot. So stance width plays a role here, as does orthotics or forefoot canting. So there’s two kinds of support we’re looking for to support the knee, the knee is the victim caught between the hip and the foot. So there’s two kinds of support one is dynamic, meaning that we’re going to accomplish this with strengthening of the glutes and other other abductors. And the other is structural support, which we accomplished by bike fit. And that’s stance with and in shoe support to make sure the foot is not contributing to that valgus inclination, which takes us to the knee hitting the top tube that can be a guy or or gal, either one that have that valgus alignment. If it’s only one knee hitting the top two, I question whether or not they’re square on the saddle. In other words, if they’ve turned, for some reason on the saddle, the saddle is the wrong saddle. And they’re trying to seek support, they might move their pelvis or their sit bones to a place on the on the saddle that makes their their sitting more comfortable. But that also leaves them turn to one side, which we’re putting one knee out away from the bike and drive the other knee in toward the bike. So you’ve got to solve the dynamic support with strengthening you got to solve the structural support with bike fit, which would include pedal choice and into structural support. And then you’ve got to make sure they’re sitting on their saddle squarely. And I would go back to what was your name Jen.
Rob Pickels 24:51
Jen was first and then Phillip was the knee touching the top two.
Dr. Andy Pruitt 24:54
I would go back to Jen for a second. And so if it’s only one knee, then it may be her saddle. Believe it not the answer to both of those questions is
Rob Pickels 25:02
the same. Yeah, you know, Andy, I think that that’s something that I’ve spent a lot of time watching you fit and sometimes helping every once in a while. Yeah, you know, and it is incredible how the knee is the victim, we all say, oh, knee pain, and you look at the knee, you go straight to the knee, and nine times out of 10 the knees probably not the problem, right? And I’ve always talked about that, and like a top down or bottom up sort of problem. Is it a hip issue? Is it a foot issue? Is there a way for the at home cyclists to tell the difference easily, maybe they don’t have somebody that can do a full eval on them and understand their forefoot varus or whatever else, is there a way to tell it apart, which one they should focus on from the shoe or from the hip?
Dr. Andy Pruitt 25:42
You know, I’ve had lots of guys send me videos of themselves from the front and the side attempting to find help, and no doubt. And occasionally I can identify it from a video for self care. So I don’t think you can fit yourself. I mean, so let’s say I’m a pretty good fitter. But I go get looked at once a year myself, because I cannot fit myself, although I can recognize whether I’m square on my saddle. And as a saddle developer, I have sat on every kind of saddle known to man, and I’ve created knee pain and back pain by being on the wrong saddle. This wasn’t part of your question, but I want to state it here, the saddle is the center of the universe. If you have hand pain, it can be the saddle. If you got back pain, it can be the side you have knee pain, it can be the saddle. So it is the center of the universe. So can a guy self diagnose if he lives in the upper up and there’s not a qualified fitter for miles? Wow, there are some good books out there. I’m not gonna blow my own horn. But there’s others? Yeah, I think finding that rural fitter is a tough, tough question. Well,
Rob Pickels 26:48
let’s not go too deep on that one. Because believe it or not, we have a question about that coming up. So let’s stick to this one. Trevor, did you have any more thoughts on the knee health,
Trevor Connor 26:57
not too much. I mean, the only thing I’m gonna continue with the two of you talked about as a coach, you know, I always encourage my athletes to get fit and to get fit regularly. And whenever I have an athlete who gets fit for the first time, they they call me up afterwards, and they just go, Oh, you won’t believe this. But I have a leg length discrepancy. And they had to do all these things with my shoes and describe it all to me. And my response is always you want to shock me tell me that your legs are exactly the same length, and they need to do no adjustment, because I’ve yet to hear that. And it’s just it’s word, none of us are made perfectly. And if you’re not taking care of that position on the bike, if you’re not getting fit and adjusted, that’s where you can start having issues. Because you’re not perfectly symmetrical. Your legs are not exactly the same length. Well, Trevor,
Rob Pickels 27:44
I was in fact made perfectly. But unfortunately, I broke my hips. So now I have a leg length discrepancy.
Trevor Connor 27:51
Well, you’ve been working with me for five months here thoroughly broken.
Dr. Andy Pruitt 27:55
Okay. So the body is not symmetrical as we would like to believe, right? There’s even a condition where the organs are swapped inside of some people, or they’re on the wrong side. So cycling should be a sport for life. I have a couple of elderly neighbors and they leave on their bike ride every morning, and she’s on our tricycle and he’s on a regular muscular two wheel bike. And off they go. And I was, you know, 30 miles from home the other day. And God, there’s my neighbor. So cycling should be kind to your body. But because of the number of revolutions per minute per hour, any mild a symmetry that we might have, whether it be a leg length inequality, foot being longer than the other, your pelvis isn’t perfectly symmetrical, she may have one set bone light slightly longer or wider than the other side. So with the revolutions required to be a cyclist, they get magnified by those revolutions. So finding a good reputable fitter, and having that fit evaluated, at least on an annual basis. If you’re writing more than twice a week, is the best advice I can give you for health as a cyclist.
Rob Pickels 29:09
Andy, I love that you brought that up because it was a great transition to a question I was going to ask. Cycling is a very repetitive sport. You literally locked in position doing the same motion over and over again. Could Jen or could anyone else like her who are trying to increase their volume? Could they get some relief from maybe splitting their volume up and riding different bikes, not just on your road bike for every mile, kind of like runners will maybe rotate shoes, you know, she spent some time on a gravel bike and a road bike and a mountain bike would that help alleviate some of the repetitive issues?
Dr. Andy Pruitt 29:41
You’re such a clever boy. One of the things I really always would tell you especially young riders, you need to share the stress. I manage the specialized junior team for several seasons and I made the boys do at least two different disciplines and they had to train all the different does disciplines, I really believe in shared stresses. So runners change shoes, I actually think cyclists can change shoes on a regular basis or change pedal systems, just as part of the sharing of stresses. And a lot of people are afraid of going, Oh my God, I’ve got to put new cleats on. I’m petrified. If your window of comfort is so small, that you probably require a little bit more float in your pedal system, for example. But I do believe in shared stresses. And I think coaches really need to take that into account and make sure that athletes are sharing stresses and not being in the same position doing the same workouts week after week after week.
Rob Pickels 30:40
I love it. That’s great. Anything else on this topic, guys, or should we move on to the next question?
Trevor Connor 30:46
I’ve been carrying this next one because this is not a topic I enjoy. So let’s move on and Dr. Pruitt take this one.
Rob Pickels 30:57
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Rob Pickels 31:27
Okay, so Andy is going to be the default person to answer the question about pain in the nether regions. This is just from an our CCO it came in across the forum. I’m going to call you Rocco. Hopefully that’s accurate. Probably not. Question is this. Hi, everyone. I’m a reasonably fast 50 year old male recreational cyclist. This last few months I’ve suffered with a cyclist syndrome pudendal neuralgia. I have pretty much had to give up cycling and sitting down in general due to the constant tingling, burning and pain in my nether regions. I’ve tried to go into a low inflammation diet started taking CBD oil spent time off the bike bought a standing desk, but it’s still with me all the time. And it’s a literal pain in the butt. Has anyone come across this before?
Dr. Andy Pruitt 32:17
Oh, gee, have we ever come across it right? So think about anatomy for a second. And this is you know, everybody thinks that and another reasons. Men and women are very, very different. In reality, they’re not very, very different. The blood supply the nerve supply, etc, are very similar. The organs in which they innovate and provide blood to are slightly different, but in all up realities, they’re fairly similar. They put down the nerve as the nerve that feeds the genitalia. And it is comes down from the pelvis into the genitalia split between right and left, it’s just inside of your sit bones are your ischial tuberosities. Normally, it’s very well protected in soft tissues, fat muscle, skin, gristle, all protective bundle nerve as well as the urethra that runs down through there and the premier artery and vein that run through the same regions. They’re all protected in soft tissues and are found inside of the set bone. So for this gentleman, the head to have suffered either a repetitive injury to it, or a one time injury to it. I had one patient that was a cowboy. And he was walking on top of a fence and slipped and straddled the rail.
Rob Pickels 33:43
And he everybody cringed.
Dr. Andy Pruitt 33:46
Well, we’ve all seen the crashes in the top tubes, we’ve all seen the supposedly funny
Rob Pickels 33:51
videos up to was break. I don’t know that fence rails did well,
Dr. Andy Pruitt 33:54
but He crushed his food, Donal nerve, and that was a long term, obviously, long term issue, but it’s that so this can be a one time drama or can be multi minor traumas. And that’s kind of what cycling does on a bad saddle. If you find yourself right on the nose of the saddle is going to work its way up in between the sit bones and irritate the pudendal nerve or nerves by repeated micro trauma. So the fact that this guy actually has diagnose pudendal nerve palsy means that it was a significant injury and I suspect he’s one of those individuals where his nerve either lies more superficial and wasn’t protected. Or he is a very lean, fit 50 year old I think you said he was so I would suspect that his saddle has been too narrow for a long period of time and he’s been micro traumatizing the pudendal nerves, nerves. We used to think really once gone were gone. But when now we do know they do regenerate. So in time he should get better. I don’t know whether the CBD oil is going to be concentrated on his growing And I’m a believer in CBT. But I’m not I don’t see that as playing a huge role here. There are therapies, I would suggest the Find a pelvic floor specialist, and it can be a urologist, it can be a neurologist, the nether regions, as they call them is kind of where orthopedics, urology and neurology all kind of come together in that region. So there’s usually a team approach to treating periodontal neurology, and that is usually a neurologist, a urologist and a physical therapist, the physical strengthening of the pelvic floor is crucial. So the fact that he has pain and just sitting, that’s beyond cyclists, palsy, that’s a whole nother thing. It’s a much broader, so he probably, I would guess, is a guy who is nervous, totally unprotected. So there are cushions that, you know, you travel with, you got them in your car, you got them in your dining room chair, you avoid hard chairs, all those things. So I’m not sure I’m going to help this guy’s therapy plan at the moment. But saddle choice gonna go back to the saddle is the center of the fit universe. So I would suspect that this guy has been on the wrong silo for a long time and created this issue. And he’s the need to stay all he needs to get off the bike until this resolves. And going back to the bike, it could be a noseless saddle, there’s lots of therapeutic ways to go back to the bike
Rob Pickels 36:26
into you said something that I thought was interesting. I’d love to dig into a bit more. And I understand we’re not diagnosing anything. Let’s throw that medical disclaimer out there right now. But do you feel like this is when people get to this level? Is this more of an issue where the nerve just needs to regenerate and grow? Or is it a lingering inflammation? What is actually causing all of this pain like it is things like a low inflammation diet, CBD oil are those just misaligned because it’s not an inflammation problem?
Dr. Andy Pruitt 36:55
I don’t think they’re misaligned. But I wouldn’t look for them to be miraculous time is going to be this guy’s best physician, the nerve is inflamed is damaged. So if you think about a nerve, like a garden hose, alright, so your garden hose is laying across your driveway, and as watering your garden, and as long as that water is flowing, just dandy, then the garden is going to flourish. If somebody steps on the garden hose, the water is going to get through there. You know, if somebody stomps on the garden hose repeatedly, it’s going to become damaged and the water flow is going to decrease. If my parks their car, on the garden hose, then the the flower garden is going to die. So this guy’s flower garden isn’t dying, somebody has been stomping on it. And the garden hose has to be, let alone long enough to return to its tubular functional size. And so it can conduct that water or neuropathways, whichever the case may be.
Rob Pickels 37:59
Trevor, any thoughts on this topic? I know you didn’t want to touch it before, but you want to touch it now.
Trevor Connor 38:03
You know, I’m just gonna say what I think is the message here and depraved you and I have been around long enough to remember the days of really bad saddles and shammies that you could barely call shammies. And how miserable that was, and how nice it is now with the saddles that are out in the shammies that are out and the message I’m getting from you, which I agree completely with is get a good saddle get the right saddle for you. And if you’re going to invest some money in something, invest in a decent Shami because these are going to make a big difference in your cycling experience and prevent issues like this.
Dr. Andy Pruitt 38:40
Before we go totally away. Let’s talk about the differences in men and women, right? There’s so many similarities, but there are differences. So the guy usually says, you know, I’m only numb for a few minutes after I get off my bike that tells me needs a bike fit or new saddle, the guy that says I’m numb for an hour I have true sexual dysfunction. Those are male related issues that have an obvious need to fix, right? The women have a different anatomy and their soft tissue takes a different kind of abuse as a cyclist, and it’s really labile compression or labile swelling that leads to scarring for women. So we studied for two years and finally designed a saddle to maybe we call it mimic to mimic the soft tissue pressures. And then we’ve suddenly found that 30% of those saddles were being bought by dudes, right and one of them was written at the parry Bay and then the Tour de France and all of a sudden, it was okay for men to to ride the saddle that was designed to mimic women’s genitalia and kind of caressing and support versus pressurized. So the women’s issue is far more labile and the men’s issue is more functional. So you want to go into a shop where you feel comfortable As a male or a female, to help guide yourself to the right saddle choice, there’s ways to measure pelvises at retail now, that helped really start a conversation or the right with saddle, which is crucial. The types of densities and a foam, I have improved immensely. So settled development is changing every day. And I encourage people to really search out and find the right saddle.
Rob Pickels 40:27
Now, Andy, I don’t know if you feel free to talk about this. But if you remember back years and years ago, when grip UCSF and we started a pilot study where we were looking at sensitivity of genitalia after writing, and listeners, it did involve electrodes and and clips and everything else that you can imagine. And, you know, if I remember correctly, was something that was seen during that was women actually had an increased sensitivity as opposed to men that have a numbness, women had increased sensitivity of soft tissue. And that just seems totally opposite from what we would expect. And maybe, because all we ever talked about is numbness. The message isn’t getting out there that hey, this is a problem, too.
Dr. Andy Pruitt 41:08
So yes, we did do a study where we placed electrodes that were meant to measure nerve conductivity and burn victims. And these were women’s subjects only looking for is there decreased sensation in the women’s genitalia after a two hour bike ride. And yes, you’re right, what we found was there was an excitation of tissues. I think, had we done that long term with a same subjects over a period of years, I think we would have seen, I know we would have seen a change in those tissues and scarring, there would be a loss of sensitivity in those tissues over time. So the edema and the loss of blood flow due to this compression of the labia over time. In fact, the woman that ran that original study for us was a subject of mine years later, for labile scarring. So it’s an ongoing area of study for cyclists, both men and women. No doubt. Finally, we’re talking about it right for years. You just didn’t talk about it’s part of cycling. Oh, yeah, I go numb for a while. That’s okay. As part of cycling and women. Yeah, it’s crushing myself. But my dad says I gotta be tough and suck it up. So it’s happening. Now finally, we’re talking about it. Talking about men’s erectile dysfunction. We’re talking about labile scarring. And it’s finally out there. Even at the retail level. I’m so pleased that I had a role in it.
Rob Pickels 42:39
Awesome. Glad to hear and I do want to move on. Because we have a great question from Tom Mayer, that’s about constant adaptation with age. This is a long question. So try to hang with me. Just been listening to your podcasts on adaptation and recovery. It prompted a possibly rambling thought in my mind, perhaps having just turned 40. But is adaptation possible throughout life? Or does adaptation mean adaptation that is perhaps just combating the decline of age? On a simplistic level? For example, is it possible to keep building one’s aerobic base over the years? Increasing genuine FTP but at a slow rate? Or could everyone reach their ceiling regardless of age? And if there is a ceiling then how do we improve? Is it to look for other areas to improve? what incentive is there other than to not minimize the loss of performance? First, a somewhat cynical viewpoint, could I dropped my training for a year and then expect to be able to get back to where I was? Had I still been training? Just a few thoughts, I suppose querying, whether we are just like hamsters on a wheel trying to wow, he’s getting off into the I do think that there’s a purpose to life and a purpose to trading, even when we get old. But um, you know, Trevor, you’ve you’ve definitely worked with a lot of athletes that are probably asking this, this same question. You know, what advice do you have here?
Trevor Connor 44:02
Well, the answer I give athletes who asked me this question, I’m getting older. So am I just trying to prevent the climb? I’m gonna give you kind of the flippin answer, which is a yeah, if you are somebody who is winning the Tour de France and you’re turning 40, you’re going downhill, there’s not much you can do about it. But that’s because that Tour de France winner got pretty darn close to their full genetic potential. And that potential is starting to decline and there’s not much you can do about it. Most of us don’t get anywhere close to our potential. So even when you’re in your 40s, and your potential is declining. There’s still a lot of room for you to improve and become a better endurance athlete. Before you you butt into that ceiling. So I don’t think people should look in and say I’ve now have 40 All I’m doing is declining and trying to reduce that decline. I, I’ve seen a lot of athletes who had their best years in their 50s. And even if you’ve seen their best years in their 60s,
Dr. Andy Pruitt 45:07
absolutely, there’s a couple pieces to this, can you take a year off and come back. So I think your years off, and your ability to come back are best served in your youth. I think if you take a year off as a 20 year old and go off to medical school, or whatever, and then come back, we’ve seen it right. We’ve seen men and women go away from the sport for educational purposes or military service, and come back and reach the absolute pinnacle of their sport. So in, in those certain age groups, I think it’s very much possible. As the Masters athlete, how old was this guy in the question? 5040, he just turned 40 just started. So he’s still got a lot of room, I think. So. I guess we’ve all used ourselves here at least once today. So I was a high level cyclist in my mid 30s, won a couple of World Championships, retired, started boulders number sports medicine worked like crazy for 20 plus years, I rode but I didn’t train got my butt kicked by guys much older than me that were not working as much. So I retire at 65 with a one goal to get really fit again. And I did it and I have surpassed my measured allotted lactate threshold. I’m riding today at 72 at a level that I did in my 30s cannot keep up with the 30 year old knows that other musculoskeletal declines as well. But as far as my capacity is concerned, so I would suggest your listener read Joe Freels book faster after 50. That book is full of stuff which I live by. So as we age, I think quality is much more important than quantity. I’ve been racing bikes for 40 years, think how much mileage I have built into my system. It doesn’t take me much to get ready for a century. Now I want to go fast for 20k or 40k. That’s much harder. So I think as we age, quality becomes an in YouTube physiologists can can speak up here, but I think quality becomes much more important than quantity. As we age, and there is huge potential to improve as we age.
Rob Pickels 47:24
Yeah, for me, it’s training smarter. You know, yeah, I know that I’m 40. Now this year, make that public to everybody, you know, and here’s the thing life, kids getting kids to soccer, getting kids to bike practice, sometimes when my kids are bike practice is the only time I get to ride my bike myself, right. And so we need to be smarter about how we train. I think if you’re 18, I’ve worked with a lot of youth cyclists, you can throw anything at them, and they’re going to adapt when you’re 40. Maybe that doesn’t happen anymore, at least not with a readiness to adapt there. But as Andy’s saying, if you’re smart about it, if you can put in the time, if you can do the other things, the strength training, the things to help you recover, so on and so forth, then yeah, you can definitely keep moving toward that potential. Like Trevor said, not many of us are actually reaching our true sporting potential. That’s let’s be honest, right. And that potential might be coming down a little bit, but we can certainly close that gap. With good smart training
Dr. Andy Pruitt 48:21
and recovery. You’re 40 I still couldn’t recover 50 Bad little less, but so net overrun good friend of mine, and as also as a sidebar in Joe’s book faster after 50. I asked Ned. Here he is in his 50s and 60s still winning elite races, said Now how are you doing this? He said I still do today the same thing I did when I was 20 and 30. I said really? He said yeah, a six week block now takes me 12 weeks. So he still does the same intervals, the same particular workouts that made him great. As a youth. He’s still doing them and taking twice as much rest to recover. I think quality and rest as we age, your 40 year old listener can absolutely improve. Absolutely. So
Trevor Connor 49:13
I’m going to throw out two bits of of what happens with our physiology as we age, it’s actually really going to back with both of you said, you know, one most people are aware of which is as we get older, our aerobic engine actually continues to improve for a long time. It’s our anaerobic strength or power that tends to decline. So as we get older, we become these pure aerobic animals. So going back to your point about it’s the quality, not the quantity, if when you were younger, you’ve done a fair amount of base training and you have a good aerobic engine. You don’t have to worry as much about losing that you still have to feed the beast but you know that’s that’s not what’s declining with age. It’s that anaerobic side that’s going to decline if you’re not I’ve spent a lot of time working on it. So that’s the, you need a little more quality work, you need to hit that top end more to prevent your body from losing that. You know, another thing that’s really interesting with age is and I have to explain a little bit of physiology here. But when we talk about muscle fibers, you actually talk about neuro muscular patterns or groupings. So basically, almost never in the body will a single nerve innervate, a single muscle fiber, normally have a single nerve that’s innervate in multiple muscle fibers. And so when that nerve fires, all those muscle fibers will fire. One thing they’ve shown with age when somebody doesn’t take care of themselves is you’ll actually see muscle fibers disconnect from a nerve and become isolated, and eventually another nerve will re innervate that fiber. But what you see is a decrease in the number of nerves. And you see the nerves that are left are innervating a lot more muscle fibers than they used to. And again, because it’s an on and off, switch a nerve fibers and all the fibers attached will then activate or contract. If you’ve got bigger groups, you have less motor control, less fine control of those muscles. And that’s going to affect your sports performance later, and they have showen if you’re doing strength work, if you’re doing neuro muscular work, if you’re doing that off the bike type work, you can prevent a lot of that the muscle fibers become an de innervated and then joining another group and that age effect is not something that’s inevitable. And I hope I explained that. Well, I’m trying to keep it simple.
Dr. Andy Pruitt 51:49
One of my dear friends that have written race bikes, 40 years tells me that he’s lost his motivation to train hard, he loves to ride his bike. He wants to ride at least every other day, if not two days on one off four hours. But when I tell him we’re gonna go do hill repeats are gonna ride in a paceline for three hours. He’s lost his motivation to do it. And I think what it tells me is that that the stuff we need to do as we age hurts, right, the kind of training that we need to do as we age is the stuff that hurts it spindles it Sprint’s it’s high intensity intervals, those suckers are uncomfortable, but that’s what we actually need. You know what medicine tastes bad. And that’s what we need to do as we age is more of that stuff. And my friends is I’ve just lost my motivation to hurt. But I’ve not lost my motivation to ride my bike.
Trevor Connor 52:44
Yep. But I have a friend who was a fantastic racer multiple time national champion. And in his mid 50s, he quit racing. And I asked him why and he just said, I couldn’t hurt myself the way I used to. And I knew I could win races anymore if I couldn’t hurt that much.
Dr. Andy Pruitt 52:59
I like that part of the training. I hate the long intervals and go home
Rob Pickels 53:06
India, you’ve been like that since the day I met you. So that’s not something that’s happened as you’ve age,
Dr. Andy Pruitt 53:12
because I was a sprinter as a kid, right? I mean, so anyway, I got it.
Trevor Connor 53:18
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Trevor Connor 53:36
All right, guys. Well, I think it’s time to wrap this one up. Even though we actually had a couple more questions. We’ll have to save that for another time. ardupilot real pleasure to have you on the show. Those are fantastic answers is we knew we would get from us so I really think the listeners are going to enjoy it and really appreciate your joining us.
Dr. Andy Pruitt 53:54
I enjoyed immensely. I hope they enjoyed and I hope you invite me back because I could sit here and talk like this all day.
Rob Pickels 54:00
Well, I think that episode 220 was at least as good as episode nine but everyone listened and let us know what you thought about it. And we’ll definitely do it again.
Rob Pickels 54:11
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Rob Pickels 54:11
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Rob Pickels 54:11
For Dr. Andy Pruitt and Trevor Connor, I’m Robert Pickels. Thanks for listening.