The Tour de France is all about speed, and that goes for the doctors too.
The 101st edition of cycling’s biggest race ends tomorrow in Paris, where Italy’s Vincezo Nibali is expected to win. Former champions Chris Froome and Alberto Contador crashed out during the 3,664-kilometer (2,276-mile) ride, with other riders completing the course with broken bones and shoulder separations. Doctors don’t have long to diagnosis and treat athletes after a pile-up before race leaders are out of sight.
“If you wait for 2 minutes they are already a mile ahead of you,” Max Testa, medical director for BMC Racing Team, said in a telephone interview.
The drive to finish all 21 grueling stages despite crashes during the three-week event makes cycling different from many sports. In football and basketball, play can be stopped while an injury is evaluated and the player can be benched. In cycling, the race goes on.
There are only moments to check the rider’s condition and symptoms of a concussion might not be immediate, so the medical team will stay next to the rider and talk with him for a few kilometers, Testa said.
BMC’s American rider Tejay Van Garderen continued on but lost a minute on the leaders after a crash in stage 7, the same day teammate John Darwin Atapuma withdrew with a broken leg.
Tinkoff-Saxo’s Contador dropped out with a fractured tibia during stage 10, while last year’s champion Froome of Team Sky didn’t finish stage 5 after breaking his left wrist and right hand. Omega Pharma-Quick Step sprinter Mark Cavendish tore shoulder ligaments during the opening stage.
Even with the pain, Cavendish wanted to continue, team doctor Helge Riepenhof said.
“It was quite obvious to everyone right from the beginning but it was important for Mark to understand,” Riepenhof said in a phone interview from the Tour.
The focus on persevering, lack of definitive guidelines and difficulty of immediately diagnosing concussions could put athletes at risk, sports medicine experts say.
The decision on whether an athlete can continue is made by the rider, the team physician and the race doctor. Cavendish, who’s won 25 individual stages of the Tour over the past six years, crashed in the last straightaway in Harrogate, England. Riepenhof waited at the finish line.
The race doctor checked Cavendish for a head injury, and the rider got back on his bike to finish, cradling his arm against his side.
Follow That Rider
A standard neurological exam is performed for head injuries, race doctor Florence Pommerie said by phone. The medical team includes 10 physicians with emergency training and five nurses, with three ambulances and two cars to follow the race, and more ambulances and an X-ray and ultrasound van waiting at the finish line.
“Most of the head injuries are nothing,” she said, saying there’s more concern if the rider lost consciousness or if they were going at high speeds. In those cases, the ambulance will follow closely and a race or team doctor will typically keep talking with the rider as he continues, she said. If there are signs of a brain injury, a scan will be done, she said.
Testa said awareness of the risk of concussions, which can lead to long-term brain damage and have been linked to neurological disorders, has increased over the 20 years he’s been involved. The Union Cycliste Internationale, cycling’s governing body, made helmets mandatory in 2003.
“We’re much more aware of the risk of a second concussion so definitely we do more prevention,” Testa said. “We know more now about how we can push the envelope with some types of injuries rather than others.”
The UCI endorsed general guidelines on head injuries in sports in 2011. There are no sport-specific recommendations at the international level and race and team doctors make their own decisions on how to evaluate concussions and when to stop an athlete from continuing.
“In a race like the Tour De France that’s so deeply rooted in tradition, they’re going to handle it how they see fit,” said Jason Brayley, who helped develop guidelines for USA Cycling, which oversees the sport in the country. “Unless there’s someone who’s completely unconscious or obviously has a broken bone, there’s going to be an emphasis on leeway to allow the rider to continue.”
Specific guidelines would be better, said Riepenhof, who uses the Sports Concussion Assessment Tool. He’s had to stop riders based on their inability to focus and answer some questions, he said.
The test includes a series of symptoms, cognitive questions and balance tests. It also recommends that an athlete with a suspected concussion be removed from play.
With any injury, staying in the race is the rider’s goal. More than 30 of the 219 riders who entered the race have withdrawn. BMC’s Marcus Burghardt is continuing after a crash that left him with a separated shoulder and just a 50 percent chance to start stage 7, Testa said.
Burghardt kept riding because it wasn’t a mountain stage and he was able to handle pressure on his taped shoulder, Testa said.
“At home I would never have one of my patients go on the bike the next day with” that serious of an injury, he said. “You have to keep the balance. When you realize there is a risk for the athlete like the shoulder is worsening or he’s having trouble handling the bike, you stop him.”