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Cycling Injuries:  Prevention & Intervention

Here is what I've learned the hard way about coping with sports injuries and common, painful conditions as a cyclist. Disclaimer: I'm not a physician or licensed health care professional--this is what I do to take care of myself.

Read on if any of the issues below interest you:
    Bike Fit
    Feet (bunions, Morton's Neuroma, plantar fasciitis)
    Road Rash (skin abrasions)

Cycling Injuries:  Prevention

Good Bike Fit
    There is no substitute for a great fitting bike to increase your power and pleasure on the bike and decrease your risk of injury. Unfortunately, a good fitting bike is hard for many of us to come by.
    Local bike shops often have fit specialists but with wildly varying capabilities. Our best results came from buying very reasonably priced custom frames from Bernie Mikkelsen in Alameda, California (www.mikkelsenframes.com). Our second frames from him were noticeably better than our first, but our first were better than what we got from our local specialist tweaking a rack bike.
    I'm guessing that our second bikes from Bernie were better than the first because the first were an improvement over what we'd been riding--perhaps the better the fit on your existing frame, the better able you are to recognize changes he proposes that are improvements, not just differences.
    Going to a custom frame is a big step but what convinced us was our very non-standard body proportions and Bernie's specially designed fit bike. Unlike those stationery models used in bike shops, Bernie's fit bike is actually ridden on pavement so you feel the effect on your body as the bike tilts and turns. He changes the length of the tubes and the angles on the frame until you and he think it's right, and that's the frame he builds for you. The process is unnervingly brief, but Bernie knows his stuff and we couldn't go back to rack bikes now.
    I think the decision as to whether to gamble on a custom frame or not largely depends upon how closely your body matches the standards that bikes are built to. Lance Armstrong's body is a perfect match with rack bike proportions. And I knew a serious amateur rider who was advised against a custom frame by the builder as there was nothing to be gained--the rider's body fit the standard.
    In addition to enjoying the benefits of custom frames, Bill built-up our bikes with fully adjustable stems so we can change both the height and the angle of our handlebars at a whim on the road. These stems add weight to the bike but a touring bike is already so heavy, we were willing to bear the burden for the flexibility. Easy stem adjustment is a wonderful option if you develop a neck, shoulder, or back problem while touring. (And changing out the stem is one of the main tools bike shop fit specialists use to modify bike fit.)

Methodical Conditioning
    For any physical activity, especially those taken up as an adult, increasing intensity and duration gradually helps prevent injuries. With cyclo-touring, being incremental is more difficult because it's a big jump to go from doing training rides around town with little load to suddenly being on the road every day with a fully loaded bike.
    The simplest, most efficient way we have found to train for the rigors of cyclo-touring is to do our training rides at home on the steepest hills we can find.  Search out those 10%+ grades and work up to being able to do them with some dignity. And find sustained grades that accumulate 1000' in elevation gain and make the climb regularly. Nothing in our experience pays the training dividends that steep hill work delivers. But of course, condition for these challenges gradually. Vary your speed too, as you develop different attributes when you climb a hill as slowly as you can versus doing it as quickly as you can tolerate.
    At times, I even strapped a 10 lb weight lifter's disc onto my back rack for an easy, symmetrical way to create a little drag without having to fiddle with a pannier. And when doing training rides don't be a minimalist but load your bike down with plenty of extra clothes, water, food, and tools just to get accustomed to the extra load.

Sports Massage
     We are ardent believers and consumers of massage. Massage can help in dealing with injured tissues but more importantly, it can help prevent injuries. A skilled LMT (licensed massage therapist), especially one specializing in sports massage, can find accidents waiting to happen in your body and eliminate them. Knotted muscles, lumpy fascia (connective tissue), and asymmetries in your body can all collude to grind you to a halt when you are exerting. Cleaning house with regular massage for months (or years) can set you up for trouble-free cyclo-touring.
    Using the services of an excellent sports massage therapist on a regular basis for years has made the difference between me being a runner and then a cyclist and not. Abnormal foot dynamics, faulty knee geometry and other inherent anatomical variations made it a challenge for me to participate in endurance sports, but massage made them possible.
    A sports massage therapist can coach you to some degree on your conditioning process and will possibly have opinions about your bike fit based on changes in your muscles and connective tissue. And as you increase the intensity of your time on the bike, a massage therapist can help ease your body's adverse reactions to the strain. Remember that regular massage is important for injury prevention as well as injury intervention.
    I was such a believer in massage, I even took a number of classes at a local massage school. Developing some confidence to do self-massage and to trade massage with my cyclo-touring partner has been a huge help in staying relatively pain and injury free in our years on the road.

Routine Stretching
    Like massage, making regular stretching a part of my life was essential to being both a runner and a cyclist. Endurance sports press your body to the limit in many ways and your edge is closer in for some aspects of your body mechanics than others. Stretching and massage both help to elevate your overall capability in sports by finding and modifying the limitations.
    In addition to logging years of receiving massage, years of yoga also primed our bodies for the challenges of cyclo-touring. Like massage, yoga can help clean out old injuries, old patterns of tightness, and imbalances in the body that can increase your risk of injury.  Having a regular stretching routine before you begin cyclo-touring both gets you in the best possible condition and adds to your personal tool box for on-the-road repairs.
    My basic stretching routine for cycling covers the calves, hamstrings, quads, psoas, hip external rotators, and back. Though it's best to have a teacher, effective stretches for most of these areas can be self-taught from good books, except for the psoas ("so-as"). The psoas muscle is huge and attaches on the inner thigh bone, crosses the hip and dives posteriorly to attach to the spine. It gets tight in most people, but especially cyclists, and resists stretching. Ask for the help of a yoga instructor, personal trainer, physical therapist, or massage therapist to learn how to effectively stretch your psoas and master the technique. It is such a big, pesky muscle, I think it is next to impossible to learn how to stretch it without help.
    A regular yoga practice was how I developed the stretching wisdom I needed for my activities. I learned what the patterns of tightness were in my body and how best to intervene, both for prevention and treatment of injuries. Now, knee or back discomfort is a signal for us to immediately get off the bike and spend a few minutes doing 1 or 2 of a short list of stretches known to be general elixirs for the area.

Cycling Injuries:  Intervention

The Classics: RICE & NSAIDs 

We follow the tried and true "RICE" prescription for raging injuries, which is "rest, ice, compression and elevation", as well as using NSAID's or "non-steroidal anti-inflammatory drugs". Anything you can do to minimize the swelling around an injury will decrease the risk of additional damage, especially to a joint, as the swelling itself can cause injury.

    R = rest, is good advice & never anyone's first choice of remedies (except our mother's)
    I  = ice, which isn't fun for anyone or easy for travelers, but works and we use it
   C = compression, as in wrapping with an Ace bandage for support and stabilization of a joint
   E = elevation, which is also tedious, to reduce the swelling,  
Resting is a hard choice for active people to make, but it does help injured tissues heal. It reduces the risk of additional injury to the already vulnerable area and gives the time needed to mend. Sports medicine specialists recognize the challenge and have a term "relative rest" which is easier for athletes to abide by. For cyclo-tourists, relative rest might be shorter days, taking more breaks, off-loading some weight to a traveling companion or pedaling more strongly with the uninjured leg (which of course increases the risk of injury to the good leg.) 

Bed rest & icing a knee injury for 5 days in England in 2004.

Icing is the remedy with which I've had the most obvious success. I ice the injured area and surrounding tissue for 10-20 minutes at a time but no more than once every 2 hours. If I can, I do it 4 times a day to get the swelling under control. Icing with a bag of frozen vegetables before dinner is a favorite trick of ours on the road. One can rarely buy ice in European markets but restaurants or bars will sometimes fill your bag with ice for free or a small charge.
    Ankles injuries respond especially well to RICE. Rather than ice however, we usually submerge the whole foot in a bucket of cold water. Cold water is easier to come by than ice and the cooling effect of the immersion is more thorough. We of course don't carry a bucket with us, but often can rig up something that will work, whether its a water tight plastic bag, a hotel room wastebasket, a bathtub, a sink or even a waterproof pannier. Experiment with the temperature however as suddenly chilling that much tissue in a person can reveal a hidden heart problem and have serious consequences.
    When bathtubs with handheld shower heads are available and ice isn't, I do a modified icing routine that helps with my minor but chronic knee irritation.
After getting washed up, I make the tub water as hot as I can tolerate, then draw the lowest volume of ice cold water through the shower head as is possible. I alternately hold the shower head on each knee for about 20 seconds, switching back and forth between knees. I keep my knees bent and above the water line and the rest of my body as submerged as possible to keep me warm. After a minute or 2, I begin slowly letting the tub water drain out to keep from cooling off too quickly. I can usually get at least 5 minutes of knee 'icing' in using this technique and it rapidly chills my knees down to diminish the inflammation. Of course, if only 1 knee is irritated, focus all of the cold water on it.

: you'll have to experiment to determine if compression will be helpful for your specific injury. An elastic bandage or a pre-made elastic brace can make the difference between walking or not on a strained or sprained ankle and with some knee injuries. On injuries in other areas, I personally haven't found that it has anything to offer.

Elevation will help reduce the swelling and perhaps a little bit of the associated discomfort. Elevate the injured area higher than your heart for as long as you can tolerate it. It can often easily be combined with icing and resting.

    NSAIDs or non-steroidal anti-inflammatory drugs aren't as straight forward as they used to be. From my early 20's until my late 30's, I poured in aspirin or ibuprofen around the clock for days or weeks at a time to manage inflammation in my misshapen knees. Now there is increasing concern about kidney damage from the life time cumulative effect of NSAIDs in addition to the long-standing concern about GI bleeding. And to further muddy the waters, some are questioning the benefit of taking them at all. Others are saying they are most effective when infrequently used. We've gone to reserving their use to the peskiest injuries, as when Bill essentially laid in bed for 5 days with a knee injury while touring overseas.
    One caution about NSAIDs still holds, which is it's best to use them when you are not exercising. The NSAIDs can blunt pain and thereby deprive you of information about injury to your body. So they are best used when you are laid up with an injury or at the end of your exercising day.
    Ask your health care professional their opinion on the proper use of NSAIDs for your injuries or do your own research to decide what's best for you.

Our Favorite Interventions: Massage & Yoga
    Learning how to do a little self massage or being able to swap some targeted massage with a traveling companion is a huge help for early intervention in injuries when touring. It is not uncommon for us to feel something a little off in a leg or knee while pedaling, stop for a few minutes and give the area a massage. It's amazing how often a brewing problem will melt away with a little attention at the first sign.
    If you aren't motivated or able to take some introductory massage classes, see if your massage therapist will teach you how to soften the knots in the muscle groups with which you have the most trouble. Knowing how and where to go after the usual culprits in your calves, thighs, buttocks, and neck can be invaluable.
    When cyclo-touring abroad, I nab a professional massage when I can conveniently, which is usually only a couple of times a year. The word is recognizable in many languages and if someone has a sign out near our lodging, I'll drop in to see if I can get a convenient appointment. However, I find the therapists less willing to tackle a troublesome area and more willing to do general work.
    We also actively use yoga stretches for dealing with our injury management, especially with brewing injuries. Knowing a few stretches to release tight muscles in the back, legs or buttocks can make a huge difference. And most of us have predictable patterns or vulnerabilities so having even a half dozen stretching tricks up your sleeve may be enough. Like with massage, we don't hesitate to stop on the road to do a targeted stretch if something feels amiss.

Cycling & Keeping Your Knees Going
Cycling & Knees In General
    Cycling is basically knee-friendly and many knee injury rehab regimes include pedaling. Regardless of the malady, many people's knee problems benefit from greater leg strength. Stronger leg muscles help stabilize the knee joint and make up for some deficiencies in other supporting soft tissue structures that may be damaged. Stronger leg muscles can be a non-specific but effective fix for many knee ailments.
    And cycling is a favored way to develop and maintain that extra leg strength because of the low risk of injury and greater compliance. Other sports like running or tennis are good for leg strength but can be too harsh on already compromised knees. And cycling, whether on the road or on a stationary bike, engenders more compliance than the physical therapist's mainstay of leg lifts because pedaling isn't as boring. Of course, cycling can cause knee problems from the repetitive use if the bike fit isn't correct.
My Challenges    
    It was after talking with several young cyclo-tourists half our age who had to stop riding because of new knee problems that we understood what had spared both of us from a similar fate: it was my bad knees.  The combination of my knees and feet is so ill-suited to cycling (and running) that a podiatrist once told me that people with feet like mine usually only swim for exercise. But never one to take "No" for an answer, I found a way to both cycle and run with poorly designed original equipment.
    My vulnerable knees forced me to explore the limits of what was available from an equipment and training stand point. And in being so aggressive about always having knee-friendly equipment and technique, my vulnerable knees have actually ensured my endurance in the sport (and Bill's) and ultimately given me sturdier knees because of constantly strong leg muscles.
    For those craving details, my knee challenges are "lateral compression of the patella" which means my knee caps are on lop-sided and consequentially are too close to the leg bones at the outside of the knee joints and additionally, I have roughness on the underside of the knee caps themselves. Both conditions can cause a lot of swelling and some pain. My flat feet over-pronate or collapse inwards at the rear foot and I have forefoot varus, which causes the front end of the foot to roll outwards--a combination that literally twists my feet and shoes with every step.
    Both of my knee problems benefit from the general knee remedy, which is strengthening the thigh muscles. For my maladies, the strategy is to bulk-up the quadriceps (thigh) muscles so they mechanically lift my knee caps up a tiny bit. That little lift then increases the clearance in my knee joints, vastly diminishing the symptoms of both the lateral compression and the roughness under the knee cap.
My Solutions
    I often feel that if I can do long distance, loading cyclo-touring with my knees, then anyone can. Of course, it's not true, but if you have knee challenges, push hard for solutions rather than ignoring the problems or giving up too soon. It took me years to work through all of the separate issues but I finally did.
    In the end, the most important elements for making cycling a knee-friendly sport for me were:
        -switching to Speedplay Frog mountain bike pedals with an awesome
26 of 'float' or rotation so a fixed foot position
             doesn't put strain on my knees when they are in a vulnerable position
        -excessively lubricating the pedals to maximize the float
        -using a cycling computer that registered cadence to learn how to always pedal with high RPMs (which transfers less
             force through the knee joint with each pedal stroke rather than mashing those low gears on the grades)
        -Bill always making sure I have super-low gears on my bike so I can pedal with a high cadence on sustained climbs
        -regular and heavy use of massage and yoga to help my tissues adapt to the ever-changing demands
    I had to use the RICE and NSAIDs regime for years to deal with the chronic swelling in my knees while I found these solutions and sufficiently bulked up my quads. But I finally "arrived" as for many years now, I've had persistently unswollen knees without the use of ice or drugs.
Simple Sources of Knee Pain
    Saddle height is the classical variable that professionals address for knee pain but I think my problems were so serious that saddle height hardly registered. But experiment with saddle height as even variations in height as small as 1/8" can make a difference with knee comfort. And remember that winter clothing or a new saddle or saddle cover will change the effective height of your saddle and may cause knee pain.
    An unexpected source of knee pain can be from the seemingly innocuous pressure long pants create on the kneecap when pedaling. I have roughness under the patella (kneecap) and wasn't particularly surprised by having to tend to this issue, but it caught Bill off guard. He was into his 3rd season with a pair of rain pants when he discovered that the little bit of pressure they created on his knee caps was the source of his discomfort. He now wears a length of waistband elastic like a rubber band just below each knee to make sure his rain pants 'blouse' enough to create the needed ease in the fabric so it doesn't bind his knee cap.
Under-Used Muscles
    Bill had been advised by our massage therapist when in Portland one winter to climb stairs or hills to develop the Vastus medialus, the inner most of the quad muscles of the front thigh. That's a muscle that is underdeveloped in cycling and that imbalance may have contributed to his 2004 knee injury that laid him up for days.
    In the process of using stair climbing for CV exercise and for this knee remedy, we discovered that doing "doubles" or 2 stairs at a time had some extra benefits. Doing doubles added variety, helping us to deal with the boredom, as well as encouraging strength and flexibility over a bigger range of motion. I don't have an explanation, but I also strongly believe that going down 2 stairs at a time does something very helpful for my knees. Though it stresses them and I must be careful in doing so, I can tell while doing the activity that it is good for my knees. It makes them more stable and less easily irritated by odd motions that arise during an active day.

Cycling & Feet

A Simple Solution for a Multitude of Foot Problems: Cycling Sandals
    We both only wear cycling sandals and never wear cycling shoes. We switched to wearing Shimano cycling sandals early in our biking careers because they solved a number of problems and we never went back. We wear Goretex socks over our other socks when it is cold or wet. And despite the myths spread around the bike shops, we've never hurt our toes in them, even when we've crashed.
    Sandals address a number of  my foot problems. I have wide feet and am terribly uncomfortable in cycling shoes. The compression of the shoes aggravates my bunions and neuromas, which I discuss below. And the twisting motion in my forefoot means that I have less pain in my feet when I don't have any shoe material over my big toes. And when I've needed to wear orthotics, I found I could do so with sandals. So, for me, sandals solve a multitude of problems without creating any new ones.
    Though not stated as compatible on the official inserts, our preferred Speedplay Frog pedals work with the Shimano sandals. The newest version of the Shimano sandals have an elastic mesh that crosses the top of the foot which made the sandal too constricting for my thick foot. A quick snip with the scissors was surgery better done on the sandal than on my foot and it eliminated the constriction. I also add length to the Velcro on the straps on both my Shimano and Teva sandals to allow plenty of room in the critical forefoot area, no matter how many pairs of socks I wear.
    Bunions are a painful swelling at the base of the big toe and the ball of the foot. The skin can become visibly red and the whole area can be wildly sensitive to pressure. Some inherit the tendency to get bunions and tight shoes make them worse.

It really is possible to interlace fingers & toes.

    I developed painful bunions in my 20's and effectively cured them in my 30's over the course of years by switching from wearing shoes to only wearing sandals: big, roomy, wide sandals like Birkenstocks. Flip-flops are even better for me as they don't put any lateral compression on the bunion area of the toe and I continue to either go barefoot or wear flip-flops for part of each day. And I wear both my cycling cycling and street sandals with the forefoot straps on the loose side just to prevent my bunions from flaring again.
    I felt that an obscure yet simple yoga technique also helped my bunions heal. You can do this by sitting comfortably and interlacing as many of the fingers of one hand between the toes of the opposite foot, orienting the palm towards the sole of the foot. This seemed to  help restore the proper space between the bones in my feet. I focused on using my forefinger as a spacer between the big toe and the adjacent toe, as that was the problem area until I could easily have all 4 fingers between 5 toes at the same time. There are some other yoga techniques that a teacher might be able to show you in person or email me if you are interested in more details.
    I've also used silicon spacers between my big toe and the adjacent toe when a new pair of Shimanos are too stiff and compress my forefoot. The spacers were an easy way to tip the balance in favor of my toes without causing any distress.

Morton's Neuroma
As if bunions weren't enough, I also developed a Morton's Neuroma in each foot, which is a benign mass of nerve tissue, usually between the 3rd and 4th toes. Usually just called "neuroma", it's often caused by an inflamed, pinched nerve. It is a common problem, especially among women who wear high-heeled shoes; people with flat feet; and those whose feet overpronate or roll inward when they walk. Numbness or a stinging sensation in the ball of the foot is the usual symptom pattern, both of which in my experience can be severe.
    Podiatrist's can easily diagnosis the condition by holding the 2 adjacent toes and rubbing them so as to feel the bump or bulge from the enlarged tissue. Neuromas can be treated surgically, but not always with a happy outcome. Metatarsal arch (ball of the foot) supports often help and have worked well for me.
    A podiatrist can make a custom orthotic with a neuroma lift built-in to relieve the pain. The theory is to push the ball of the foot up just a bit from underneath so the 2 bones that are pinching the nerve separate just a little as the foot drapes over the dome in the orthotic. After having one pair of orthotics which I wore inside my cycling sandals, I started making a similar shaped neuroma lift out of a little pile of leather scraps made into a dome and taped it to the shoe bed of my cycling sandals. They worked as well as the orthotics and gave me the pain relief I needed.
    I now am using inexpensive gel metatarsal supports that I customize into neuroma lifts. I buy a package with 2 pairs of supports for about $5 and trim 1 pair down to about half the original diameter.
I center this smaller piece under the other intact support and then place an even smaller disc of the gel--about the size of a quarter--under it.  I position this stack of 3 layers of gel supports (with the smallest piece on the bottom of the stack) in the ball of the foot area of the sandal to create a small lift. The gel has just enough tack that I don't need to tape them together or in place in the sandal if I am mindful of them. It's definitely a trial-and-error process of determining the right shape, size, and positioning of the pads but it's no more time consuming than visiting a doctor and far cheaper and more convenient. And of course it frees me of the hassles of using orthotics.
    Many shoes and certainly the Shimano cycling sandals are shaped exactly the opposite of what relieves neuroma pain, as the stiff-soled sandals are concave at the ball of the foot. What neuromas need is a little dome-shape under the ball of the foot, not a hollow. The hollow just makes neuromas worse. Some people have no symptoms with their neuromas until they start cycling as pedaling makes neuromas more painful: all of the force you generate with your legs goes through the neuroma area on the ball of your foot and into the pedal.
    Like the bunions, I'm sure my neuromas benefited from me giving up shoes altogether and only wearing sandals which allow foot bones to spread. When cycling, I take off my sandals at lunch and wiggle and spread my toes to give my neuromas some breathing space. And I think the 'fingers between the toes' technique I used for bunions helps my neuromas too as they have gradually improved.
    In 2007 I switched from wearing Teva sandals to Chacos for my off-the-bike sandal and believe that despite being heavier and more expensive, that they are the right sandal for me. Among other things, the Chacos have a forefoot arch which I believe provides a subtle form of neuroma lift. The Chaco forefoot arch support isn't visible on inspection but my overall foot comfort has slowly increased and I'm guessing its because of the Chacos foot bed.

Plantar Fasciitis
Plantar fasciitis is inflammation of the connective tissue of the sole of the foot and causes pain under the heel and the arch. It's considered an overuse injury that is classically triggered by a sudden change in exercise routine, like when a couch potato goes to Disneyland and does a lot of walking. It's quite painful and tends to leave people hobbling around and can recur if not successfully treated. Podiatrists can make orthotics to support the foot to help treat the condition.
    We've each had a bout of plantar fasciitis, though neither event was associated with a change in exercise routine. We both followed a demanding taping regime to support the foot while the tissues slowly healed. We each had a full recovery and have had no recurrences.
    The taping technique is a hassle but we swear by it. We'd re-tape the affected foot each morning after showering with the old tape on, never putting any weight on the foot without the support of the tape, for weeks. That prevented micro-trauma or reinjuring the healing tissue. We used the technique known as
"Longitudinal Arch Taping" as shown in the Illustrated Guide to Taping Techniques by Karin Austin, Kathryn Gwynn-Brett and Sarah Marshall, Mosby 1994. A sports medicine profession should be able to help you with the technique, though it takes being consistent with it for weeks for it to do its magic.
    Stretching of the Achilles tendon  below the calf and the plantar fascia of the foot can sometimes help prevent this nasty condition. An easy way to stretch the plantar fascia is to kneel on the floor with your toes turned under so the soles of your feet are roughly vertical. Work up to resting your buttocks on your heels if you can. Of course, to prevent the risk of injury, start gradually and don't push too hard. Take weeks to stretch the area out if it's tight and maintain the new release by doing the stretch a couple of times a week.

Road Rash
    "Road rash" is a euphemism for what must be the most common cycling injury: leaving some flesh on the pavement. If you are going to ride a bike, you are occasionally going to go down, and at least some of those 'downs' will result in scrapes and bruises. We've had surprisingly few bouts of road rash given the ten's of thousands of miles we've ridden, but we've had enough to have a routine for dealing with it.
Setting Up a Work Station
    When we are facing nothing more serious than a bruised ego and road rash, we will often ride 5 or 10 minutes farther from the scene to find a comfortable place to tend to the wounds. Usually the scrapes needing attention happen in the warm weather as generally the extra clothing of riding in the cold or the rain protects the skin from direct abrasion on the pavement. So, finding a place to pause usually means getting away from the noise and commotion of traffic, finding shade, and hopefully locating a source of clean water--more than just our drinking water. Finding a quiet place helps with the decision making that will need to be done. And having a good place to unpack a pannier in search of the first aid kit that has undoubtedly worked its way to the bottom also keeps from adding to the aggravation.
    What we are looking for will depend upon the country we are in and whether we are in an urban or rural setting. Public restrooms are a great resource for supplying the needed abundant water, as is a public drinking fountain or water spout. We haven't had to knock on a door, but we'd do that if we were low on water.
Washing the Wounds
    Road rash has quite the reputation for being painful as it is usually a large area of scraped skin, though often very superficial. We haven't found it to be particularly painful and are suspicious it is our aggressive cleansing process that keeps the infection level down that makes the difference.
    Our strategy for dealing with road rash is to aggressively cleanse the wounds as quickly as we can. Infection is the real hazard and it's all the little bits of grit coated with bacteria that are the culprits. The surge of natural pain killers released by the body at the time of the injury gives a window of an hour or more in which you can be pretty brutal with your cleaning process without adding much to the pain. Several hours later, barely touching the wound may be intolerable.
    I was at the limit of my capacity for sympathetic pain when Bill asked me to scrub out his shoulder wound with a toothbrush. He had a lot of little grit embedded in his skin from asphalt grime and by chance I had my toothbrush in my handlebar bag that day. Bill decided that the microbes from my mouth were probably less risky than leaving the road grunge in his torn flesh, so opted for wound cleansing with a used (but cleaned) toothbrush. The thought of using the bristles on the raw skin made my stomach churn, but I screwed up my courage and did it. It didn't bother him at all because of the protective effect his natural pain killers. Lots of soap, water, and scrubbing got the grit out and his superficial wound healed nicely with little pain.
    Another time, I had a large scraped patch on my forearm with several deep gashes. The fall was into dusty gravel so it didn't have the usual grit of a skid on asphalt. We were lucky as in pedaling off to find shade, we found a public toilet and so had access to a sink and running water. We cleaned the sink with the detergent we keep on Bill's bike frame, drew 3" of water, and Bill began rinsing the submerged wound and then directly slathering it with undiluted detergent.
    Again, cleaning the wound promptly paid big dividends. The almost dizzying flood of natural painkillers made me very tolerant of the vigorous cleaning that Bill did to skin I could barely see. Luckily, I had no embedded grit, but did have 2 worrisomely deep gashes. But repeated rounds of rinsing and flat-handed scrubbing got the bacteria count down to a level that gave me an infection-free healing course.
Dealing With The Ooze
    Road rash tends not to need a lot of bandaging to help the wounds heal but needs protection from picking up dirt and dirtying up the world around it. These wounds tend not to bleed much but ooze and they can ooze a little for days. The clear yellow serous ooze isn't worrisome in itself, but it is messy. One can leave an unattractive trail of stains on bedding, clothing, and anything else the wound contacts. A little bit of ooze can dry on clothing and result in tearing open the wound when you unwittingly pull the garment off. So, more for living with the wound than direct wound care, it's often helpful to cover up the road rash.
    Bandaging road rash can be tricky as it typically covers a big area and regular sized bandages tend to result in bits of adhesive being applied to the damaged skin. So, if you are going to carry a minimum of first aid supplies, consider big gauze patches and tape rather than a collection of band-aids. The over-the-counter, triple antibiotic ointment is also good for road rash, if it's not too oozy. We also find our pair of folding scissors handy for possibly cutting off little flaps of torn skin at the time of wound clean-up and for the tags of scabs that lift up as it heals.
    Of course, if you are actually using your first aid kit and not just wearing it out carrying it around, the more to choose from within the kit the better. We had some more professional-level supplies in our kit when I injured my forearm, which were very helpful. The large Tegaderm wound patches were more comfortable and secure than gauze and tape and the Steri-Strips nicely pulled together my 2 deep gashes that might have qualified for stitches.
    Whether you are covering your wounds or not, keep an eye out for infection. We usually scrutinize ours a couple of times a day for the first 4 or 5 days to watch for the red of infection distinguishing itself from the red of normal inflammation. If any infection doesn't quickly respond to the triple antibiotic ointment, then it's time to rush off for professional assistance.
    At night I sometimes draped a clean bandana over my forearm wound, tying it above the elbow and pinning it at the wrist. That kept any oozing that occurred around the bandage or from an uncovered wound off the bedding. During the day I was very grateful for the homemade, fuzzy-lined arm warmer I had with me. I carefully pulled the arm warmer on over the wound, which protected it from being repeatedly brushed by fabric. Some days I put a small piece of tissue against the wound so any dried ooze would only stick the tissue and not the entire garment; other days I put additional folded fabric inside the arm warmer to give the delicate area some welcome padding.  

Keeping Comfortable
    Bill recommended against icing my last road rash wounds as he felt that it might hinder the healing, but I did some icing anyway. I was careful to keep the wounds dry while icing and felt that both my banged and slightly scraped knee and deeply banged and scraped forearm benefited from a couple of rounds of icing. I waited about 24 hours before icing and felt that the increased comfort from reducing the swelling in both places was worth the possible setback.
    I found that applying hand lotion to the skin around the forearm wound was helpful after a couple of days. It seemed like the swelling had irritated the adjacent skin and the lotion was soothing. And once scabs started forming and the wound began drawing the skin in, the pulling on the surrounding skin was uncomfortable. At that point I also started putting lotion directly on the scabs to keep the edges pliable and less likely to catch on fabric
Being Prepared
    The most obvious way to be prepared for dealing with road rash is deciding what to carry in your first aid kit. Then be sure to carry it with you on your more remote day rides as well as when touring. And especially for touring abroad, consider updating your tetanus vaccination before departing.

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