A 39-year-old Canadian semi-professional cyclist and former club level ice-hockey player, now living and working in the UK, was enjoying a fishing trip in Canada with his father-in-law in August 2002.
One day, as he was pushing their boat away from the rocks, he slipped badly, abducting his right hip strongly. He felt a sudden pain in his low back on the right side, and in his groin. Within hours, the pain had become very unpleasant.
He was seen in Canada by an orthopaedic specialist, who diagnosed groin strain and right-sided spinal joint strain of L3/4. No diagnostic tests were done at this point. The specialist recommended conservative treatment.
The cyclist (1.83m/6ft 1in and 90kg/198lb) returned from his holiday, and at the end of August went to see his GP, who directed him to me. He was still experiencing the right-sided low back and groin pain, and now also pain, parasthesia and anaesthesia (pins and needles and numbness) anterolaterally on his right thigh and on the lateral aspect of his right foot. I immediately referred him to a neurosurgeon for MRI and an opinion.
When the results came back three weeks later, all seemed straightforward. The MRI had revealed no sign of the suspected disc pathology at L3/4, and the neurosurgeon’s diagnosis was a traction injury to the right femoral nerve root, and groin-adductor strain. He recommended physical therapy – so it was back to me.
Over the next three months we proceeded with intermittent physical and electrotherapy. My patient was still aware of his pain, but it was less severe and less frequent. The main symptoms, including recurrence of numbness and pins and needles in the right thigh and on the lateral margin of the right foot, would appear during cycling, and especially competitive club rides. A continuous ride of more than one hour would reliably bring on pain and symptoms, which would subside within five minutes of stopping.
Five months after the injury, I referred the cyclist to a physiotherapist colleague, Tom Williams, for full isokinetic testing. This revealed weaknesses in the right adductor and quadricep muscles, which my colleague felt was the result of damage to the nerve root.
We put the patient on to a specific rehabilitation programme and over the next six months he responded with gradual improvements, mainly in the reduction of his low back and groin pain. Yet exercise – and specifically the long-duration bike rides – continued to generate the nerve symptoms and increased pain in the right thigh, calf and foot.
In July 2003, nearly a year after the accident, I decided to refer the cyclist to Balance Physiotherapy in London for a cycling ergonomics test, hoping to shed some more light on his continued injury problems. There, they observed that my patient’s right pelvic joint appeared anteriorly rotated during cycling, so I did some manipulation of the right sacroiliac joint, which further reduced the low back pain, but once more did nothing to alter the exercise-onset symptoms.
After a trip to France to take part in an Alpine cycling event, my client returned to Balance for some further tests. While he was there in August 2003 – a year on from his accident –the physiotherapist Paula Coates recommended he consult a vascular surgeon, to investigate the admittedly unlikely possibility that some kind of intermittent claudication was involved (the type of lower extremity vascular constriction you would rarely associate with an extremely fit 40 year old).
If Paula’s hypothesis was a long shot, what the CT scan, angiogram and vascular consultation finally revealed was even more unexpected: Type B aortic dissection to his descending aorta down to the right common iliac artery (see box). The cyclist had a tear in his main artery. The appearance of symptoms and pain only on prolonged exercise was because this was when his muscular need for oxygen and glucose exceeded the ability of his damaged blood vessels to deliver to his right leg.
He was instructed to cease all exercise immediately and booked in for major vascular surgery. At the end of October he was operated on to replace his descending aorta – and the aortic arch. He made a good recovery, was discharged from hospital after a week and put on to a gradual rehabilitation programme.
The cyclist is slowly returning to physical activity – and has recently returned to training levels not too far off his pre-surgery state. He is, however, keeping an open mind about his sporting ambitions – all too aware that he is rather lucky to be alive!
The big unanswered question was, why did the tear to his artery happen? One theory was that the cyclist was ‘borderline Marfan’s syndrome’ – a genetic connectivetissue disorder which predisposes carriers to aortic aneurism. But neither the genetic testing (which is not wholly reliable) nor the pattern of vascular damage bears out this possibility. There is no conclusion available on the diagnostic side – only a happy ending for the individual concerned.