By Jacqueline Godbe, MD, Ph.D.
Elite cyclist, physician, and scientist Jaqueline Godbe’s life-threatening experience with Deep Vein Thrombosis
I’ll start with good news and bad news. The good news is that I can use my MD for this article! The bad news is, well, I was recently diagnosed with Deep Vein Thrombosis (DVT). As I’ve been dealing with the condition, management, and navigating my return to sport (health first!), I wanted to share personal and professional insight into the condition to help others. A cautionary tale of Deep Vein Thrombosis and cycling.
Healthy but Not Invincible
The first thing to know about Deep Vein Thrombosis (DVTs) is that they can and do affect young and otherwise healthy individuals. As athletes, we often consider our athleticism as protection against many common conditions like high blood pressure, diabetes, and heart disease. And while that is true, it doesn’t mean we are invincible.
It’s why we wear helmets. Get vaccines. And, even if nothing is wrong now, see a doctor regularly to ensure that we stay healthy for that big coffee ride we’re planning.
How to Recognize a Deep Vein Thrombosis—Warning Signs
Briefly speaking, a DVT is a clot that forms in the body’s deep veins (the ones you can’t see on the surface of your skin). This clot can cause the blood to back up inside the vein, causing pain and swelling (often in the legs—a cyclist’s favorite body part). More dangerously, pieces of this clot can also embolize—meaning that small parts can break off and head to other parts of the body to cause problems.
Pulmonary emboli can kill! They do kill about 100,000 Americans per year.
The most common site of problems is the lungs (a cyclist’s second favorite body part). It is because the lungs are where the blood vessels suddenly go from very big (vena cava, pulmonary arteries) to very small to maximize surface area and, therefore, oxygenation. When this happens, it’s called a pulmonary embolus (PE).
Like a DVT, it can be exquisitely painful. Depending on how large of a clot it is, it can prevent your blood from exchanging oxygen and put immense strain on the heart.
Clinical Symptoms and a DIY Home Test for DVT
Cyclists get aches and pains in their legs. It’s a cost of doing business that most ignore and embrace if you’re like me. However, if you experience calf pain that you can’t explain, you must make some further diagnosis.
Ask yourself these questions:
- Is your calf swollen and more than 3 cm larger (circumference—girth measurement) than the other?
- Is your calf hot and red?
- Is your calf tender and painful with movement and to the touch?
- Are the veins in your calf popping out?
- If you poke your finger into the calf’s swollen part, does the imprint stay there (pitting edema)?
To narrow it down, you can also perform a ” test ” at home. It’s called the Homan’s Sign. Your physician will perform this quick test to get an impression, and you can try it at home. Here’s how:
- Sit with your leg straight out in front of you.
- Ask a friend to lift your leg a few inches while you keep your knee extended.
- Then have your assistant push your foot back (dorsiflex) as they squeeze your calf with their other hand.
- Deep calf pain and tenderness is a positive Homan’s Sign and the chance you may have a DVT.
If you answer “yes” to these questions, notify your healthcare provider immediately. They may want to do a Doppler Ultrasound to get a better look.
Risk Factors For Deep Vein Thrombosis
I’m not here to cite depressing statistics or scare you straight. I’m here to share information with the hopes that someone who reads this article learns something that will make a difference in their life or their biking buddies.
We’re not invincible. In fact, some of the things we do put us at greater risk.
Sitting down—not sitting biking but remaining sedentary for long periods like on an airplane (or a radiology desk job #guilty) means that blood has a chance to pool in our veins and form clots.
Hormone treatments—testosterone OR estrogen can increase the risk of clots. So anabolic steroids, estrogen-containing contraceptive methods, pregnancy (They really get you coming and going. Ugh!), and hormone therapy puts you at higher risk.
Crashing—direct trauma and breaking bones. Clotting blood SAVES OUR LIVES in the acute setting here. We want our blood to clot so it stays inside us and doesn’t end up on the road. However, for the few weeks after a crash, our body can remain shifted towards wanting to clot more even if we go back to sitting at our blood-pooling desk job. Like a desk job, a tumble off my bike likely also contributed to my DVT.
Dehydration—this one is easy. Less water in our bodies means our blood is more concentrated. Have you ever made double-concentration Jell-O? Know how fast that gels? It’s the same concept here.
Family history—Several known gene mutations can cause an increased risk of bleeding. One of the most common (and the one that I have) is Factor V Leyden. While this isn’t something you can change, it is something you can get tested for so that you and your doctor can make decisions about how to approach issues like hormone therapy.
Treatment For Deep Vein Thrombosis and the Return to Cycling
Currently, Serena Williams is my role model for returning to sports. If she could dominate tennis after not one but TWO devastating clots, I know there can be a path forward for me too. So this doesn’t necessarily mean the end of cycling. But it may mean that you have to be careful for a while.
Medications and Lifestyle Changes
After my DVT, my doctor put me on Apixiban (Eliquis), a blood-thinning medication to prevent any more clots from forming while my body broke down the one I already had. Unfortunately, it put me at a higher risk of bleeding from a crash, so the doctor made me promise not to bike (outside) for a while. It probably didn’t help that I still had big ol’ scabs on both knees from my last crash.
I also had to dial back my training. While we were pretty sure that the clot hadn’t gone to my lungs yet, we didn’t want to risk dislodging a chunk with an ego sprint. I may be a doctor and a scientist, but I’m not immune to sprinting solely to boost my ego. Whether it’s because I want a jersey on Zwift or can’t stand to let THAT person beat me.
There was also the distinct and likely possibility that overtraining had contributed to my body wanting to form extra clots. However, that didn’t mean I had to STOP entirely. Remember when I said earlier that sitting still increased the risk of blood clots?
Studies show that early mobilization in DVTs like mine helps the recovery process, so there were a lot of long easy rides to help mobilize the blood in my clotted vein. It worked too. Virtual rides were one of the best things to reduce swelling in my leg (and catch up on my shows).
So, discussing with my doctors, myself, and my coach, I put together a program that integrated my medical risks as they evolved (bleeding, clotting, and anxiety), my goals for the season, and meaningful milestones to keep me on track (Figure 3). Anxiety is a very real risk for me and many others. Just because I can’t see it on a CT scan doesn’t make it any less important!
Because bicycle racing has traditionally been a sport that is an absolute no-go for athletes on blood thinners, there wasn’t a lot of literature. While there were a few case series of return to sport, there was no consensus or set of guidelines from a reputable professional society.
Return to Sport
My guidelines are as follows:
In the week after my diagnosis, I was at the highest risk of my clot getting dislodged and going to my lungs. I was also at the highest risk for bleeding since I had to take a double dose of Eliquis for a week. My leg was swollen and painful.
To minimize my risk of bleeding, I had to refrain from my regular bike commute. I also refrained from things that could raise my blood pressure really high and cause micro-bleeds (sprints, etc.) because I didn’t know how my body would handle Eliquis yet. Unfortunately, that meant withdrawing from the Zwift Continental Qualifiers.
To minimize the risk of my clot dislodging from my leg, I refrained from high-velocity movements like sprinting or weightlifting. I even dialed back my running since that can cause much microvascular damage. It was a second reason to withdraw from the Zwift Qualifiers. It sucked!
To minimize my pain, I always wore my compression stockings and wrapped my leg on top of it because I have relatively skinny ankles compared to my cyclist’s calves and needed extra help there. My swelling was noticeably less after my evening walks/easy bike rides. So I was very motivated here!
While my clot was still at a higher risk of getting dislodged, I got to decrease my dose of Eliquis this week, which meant that I was at a lower risk of bleeding. My leg swelling was also getting better.
Knowing that the opening race of the RGT Echelon Racing League was at the end of this week, I began to experiment carefully with slightly higher powers to see if my body would tolerate it.
Due to the risk of clotting, I tried to keep my cadences low and predictable. I also kept a close eye on my heart rate, which would be the first indicator that I was pushing my body beyond what was advisable.
(A reminder that a resting HR > 100 bpm can indicate a blood clot in the lungs)
Because I was cautious and methodical and didn’t encounter any red flags this week, my coach and doctor agreed that I could participate in the Echelon Racing League Race as long as I respected my limits and had a low threshold to stop if something happened.
Fortunately, I had my husband John there to keep me honest. Also, fortunately, the rest from the previous two weeks set me up for an early breakaway! It turns out that following medical advice can be good. Who knew?
With the race’s sound “test” result, I continued to progress in my training. At this point, I knew that the clot in my leg was starting to scar over and get fixed in place (like a scab versus a scar on your skin), so there was less risk of it moving around.
I also knew that my body was handling Eliquis quite well, so as long as I exercised appropriate caution, I could safely progress from week to week. I started running again. I started lifting again. I integrated harder and more challenging intervals into my workouts.
During this period, I still had a lot of safeguards in place. I still observed my heart rate. I continued to mask appropriately (COVID and other viruses can make you more likely to clot). I was still seeing my doctor and discussing how my diagnosis impacted other areas of my health and what else I needed to know. I was limiting my overall training stress and not racing as frequently as before so that overtraining didn’t contribute to a pro-inflammatory/hypercoagulable state.
Here is where I am now! Aka, the “don’t be stupid” phase. I’m still on Eliquis, so I’m at a higher bleeding risk than the average person. My clot is still present but mostly scarred down (according to my hematologist, 50% of clots are still present at one year, so that may not change much in the future).
Progress and Prognosis
Fortunately (and not to jinx it), my recovery process has gone well so far. There have been a few bumps in the road, like navigating the headache of insurance prescription coverage. Even with an MD, navigating the medical system is HARD. I had to ask my mom for help!
I’ve been able to get my prescriptions and schedule appointments with my doctors. But, my body has tolerated Eliquis well. I haven’t had any complications related to bleeding, like terrible nosebleeds or periods from Hell.
The clot in my leg has gotten a lot smaller and less painful. However, if I don’t wear my compression socks religiously, I will still get significant leg swelling and heaviness.
While IRL racing is on hold as long as I’m on blood thinners, I have been able to return to (a more limited schedule) of racing. More good news, I recently accepted a nomination to Team USA for Worlds in February 2023!
Conclusion—Not Invincible, but Smart
Overall, I’ve been extremely lucky, thanks to having a doctor for a husband who kicked my butt to go into the Emergency Department when my clot first developed to the supportive coaches and friends. I want to acknowledge my frustration while knowing my story could have taken much scarier turns.
I also want to acknowledge that my story is still ongoing and will continue to evolve as I meet with specialists and ramp up my racing! So I want to use that privileged position to remind you all that while cycling and sport help keep us healthy in general, we are not invincible.
If you or a loved one experiences signs or symptoms of a DVT, please go to the hospital ASAP! While it’s frightening to admit that we are vulnerable, the most important thing we can do is empower ourselves with the knowledge to do something about it.
Fortunately, as virtual cyclists, we are already part of a supportive community to help us take the next steps after that. And rock silly compression socks together.
Semi-retired as owner and director of his private Orthopedic Physical Therapy practice after over 20 years, Chris is blessed with the freedom to pursue his passion for virtual cycling and writing. On a continual quest to give back to his bike for all the rewarding experiences and relationships it has provided him, he created a non-profit. Chris is committed to helping others with his bike through its work and the pages of his site.
In the summer of 2022, he rode 3,900 miles from San Francisco to New York to support the charity he founded, TheDIRTDadFund. His “Gain Cave” resides on the North Fork of Long Island, where he lives with his beautiful wife and is proud of his two independent children.
You will read him promoting his passion on the pages of Cycling Weekly, Cycling News, road.cc, Zwift Insider, Endurance.biz, and Bicycling. Chris is co-host of The Virtual Velo Podcast, too!