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I have to declare an interest when refereeing this paper. The circumstances and the athlete involved are well known to me as I was the medical officer to the GB cycling team at these Olympic Games.
The severity of symptoms and their close proximity to the Games were such that, had the cyclist taken part without treatment, it would have amounted to participation rather than to competition. Some clinicians may object to this operative intervention on a short term basis, but most sports doctors would support the view that it can be justified on the “once in a lifetime” opportunity it gave the athlete.
It is only within the last five years that any level of awareness of external iliac artery syndrome has reached the wider sports medicine community—all this in spite of the earliest reference cited dating back to 1986 and a previous British Journal of Sports Medicine paper that described the surgical treatment of the first case that I am aware of in the United Kingdom. I was originally alerted to the condition by a sports journalist who had noted that a number of European professionals had undergone vascular surgery and was wondering whether this constituted some as yet unbanned surgical doping technique!
The mechanism of external iliac artery syndrome is as yet unknown and theories are little more than speculation. Trauma has been suggested as a cause; however, there can be no elite cyclist who is unable to provide a history of previous significant crashes. The aerodynamic crouched positions now adopted by cyclists have also been cited, and I should mention here that many of such positions have now been banned by the UCI on the grounds that they are too aerodynamic. In attempting to define the cause, it may be more constructive to think in terms of the athlete's position on the cycle, the repetitive flexion/extension movement at the thigh, and the vast number of hours spent in training and competition by elite cyclists. Given that this elite group will be cycling with a cadence of about 100 revolutions/minute for an average of four hours a day, six days a week for 50 weeks of the year, it follows that flexion/extension at the thigh is occurring in excess of 7 million times a year. Add to this a “compressed” position on the cycle and an otherwise inconsequential anomaly of the external iliac vessels, and the syndrome may just be produced.
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