First, let me be clear about two things: I’m not a medical professional, and if a reader thinks they might have a clot, they should bear themselves hence to a hospital as quickly as possible. I’m serious about both statements, but particularly the latter. A clot in a deep vein is serious, and time is not on your side.
I wasn’t a runner when I got sick. I took up running a bit over a year after I was hospitalized, but I learned that quite a few of my friends from my cycling days had also suffered from deep vein thrombosis (clots in the deep veins of the arms, legs, or abdomen) and emboli (clots in the arteries of the lungs), which surprised me. Athletes in general have a low risk of developing clots, but the fitness that lowers their risk can, ironically, work against them. Extensive travel, dehydration, and injuries increase the risk of developing clots, symptoms can be similar to muscle strains or allergies, and both athletes and medical professionals are disinclined to believe that physically-fit individuals, particularly young athletes, could develop clots.
Yet Chris Bosh, Serna Williams, and Steven Stampkos, all elite athletes, have suffered from clots. Runners, particularly endurance runners, may also be susceptible to developing DVTs, which can then travel to the arteries of the lungs to form potentially lethal pulmonary embolisms.
My Story
It started with a cramp in my left foot, though it would be accurate to say that the cramp was the first symptom that something was amiss. It happened early on a Sunday morning during SUNY Morrisville’s spring break in 2018. At first, there was nothing to indicate that this was anything more than a run-of-the-mill Charley horse except for the lingering soreness in my foot. That wasn’t normal for me.
But it also wasn’t alarming enough to raise any flags. Plenty of people experience tightness after cramps, so I lived with what I assumed to be an annoying but harmless remnant of the cramp.
Then I tried to stretch my leg that Wednesday. The pain multiplied tenfold and radiated up my calf. Every step hurt, navigating the stairs was a nightmare, and my calf felt like it was full of gravel.
I hardly slept that night, but the pain began to subside the next day. I still walked with a limp, and using the stairs, especially descending, was unpleasant, but the diminished pain convinced me that I’d merely pulled a muscle with an ill-advised stretch.
The pain continued to subside on Friday. Then it took a turn for the worse. The sandy, abrasive feeling in my calf returned; with it came an ache behind my knee. It felt like the ache one might feel after a hard workout, but it was sharper and more persistent.
My left ankle was swollen Sunday morning. Additionally, I noticed that I was out of breath when I climbed the stairs, but I’d also had some allergies or a minor cold a few days earlier, so I thought nothing of it.
I felt groggy Monday morning as I drove to teach my class at Morrisville. A cup of coffee seemed to clear my head, but it did nothing for my leg. The swelling in my ankle was worse; more alarmingly, my calf was visibly swollen, warm to the touch, and taut, like I was flexing my calf muscles.
I’d had enough. I called Traci, who drove me to Crouse Hospital. A doppler ultrasound scan revealed a clot in my Popliteal vein behind my knee that extended down into the veins of my calf.
Shortly afterward, a CT scan found an embolism. I was admitted to the hospital that night, put on a heparin drip, and confined to a bed until my levels improved.
I was released that Friday. If a patient isn’t in imminent danger, the treatment for DVTs and emboli is actually relatively simple: blood thinners and bedrest, the latter to keep clots in the extremities from breaking free and migrating to the lungs—or brain.
It could have been so much worse. I’ve read accounts where patients with smaller or fewer clots required surgery, clot busting drugs, and lengthy stays in the hospital, but I was hemodynamically stable—my blood flow was normal and there was little strain on my heart, which is what kept me out of intensive care.
I left the hospital with a prescription for Eliquis. In many cases, patients take blood thinners for a number of months after they’re released, but I’ll likely need them for the remainder of my life.
The first few weeks were rough; the hospital stay reduced the swelling, but standing motionless for more than a few minutes caused my ankle to swell and the back of my knee to ache. My calf ached, tingled or itched—sometimes internally—for weeks. Walking helped, but it was a month before I could comfortably walk at a faster pace for more than a mile or two. I had a mild cough and chest pain from the emboli for several months.
I still have occasional aches, tingling, or discomfort in my left leg, but running has done a great deal to reduce the symptoms. If I have any residual lung damage from the emboli, I haven’t noticed it.
How I escaped extensive lung damage or worse is beyond me. My patient report sums up my condition as follows:
Vessels: There are extensive bilateral pulmonary emboli including a saddle embolus stranding the main pulmonary artery trunk and extending through the pulmonary arteries of both lungs.
I think the saddle clot should be surrounded by commas. Either way, both of my lungs were full of clots, including a monster right above my heart.
I’ll say it again: I was lucky. I was very, very lucky.
Causes
I was diagnosed with an unprovoked DVT, meaning that there was no detectable cause for my clots. Because patients who are diagnosed with unprovoked clots have a much higher possibility of developing clots in the future, I will probably be on anticoagulants for the rest of my life.
I can think of several factors that possibly contributed to my DVT and emboli; I was over 40, I didn’t drink enough, I was overweight, and I have low blood pressure and a low resting heart rate. The combination of these factors likely played a role, but there was no smoking gun.
Approximately 70% of patient diagnosed with deep vein thrombosis have provoked clots.
There is also merging research suggesting that Covid-19 causes clots in some patients.
Causes include:
- Inherited clotting disorders
- Surgery
- Overweight/Obesity
- Smoking
- Cancer
- Family history
- Age
- Some hormonal birth control pills
- Injury
- Long trips
Symptoms
DVT symptoms can vary widely, with some patients showing no symptoms at all. Mine started with a Charley horse that never resolved, more intense pain in my calf that seemed to fade a bit, pain behind my knee, and swelling of my ankle and calf. These are some of the classic symptoms, and the swelling was a clear sign that I was facing a serious issue.
Other symptoms include warm spots, which I had to a limited degree, discoloration, and bulging veins. An unusually high resting heart rate is another symptom.
Emboli are extremely dangerous, annually killing as many Americans as breast cancer, AIDS, and car accidents combined. Those afflicted with emboli often have no symptoms, which adds to their deadliness: According to the CDC, death is the first symphony for a quarter of those afflicted with PEs. My symptoms were subtle and largely masked by a mild cold or allergies. Climbing the stairs left me gasping for breath, and I felt woozy the day I went to the hospital. Both symptoms were overshadowed by the DVT.
Shortness of breath, rapid heart rate, chest pain, and coughing are some of the symptoms of an embolism.
In retrospect, I should have gone for treatment several days before my ankle started to swell. The problem is that most of my symptoms were similar to problems I’ve had before. The leg pain wasn’t unlike an ankle injury I’d developed the previous summer after I walked long distances in a cheap pair of shoes. The pain also fluctuated and even diminished, if temporarily.
I also had no known family history of DVTs or emboli, and testing later revealed that I lacked any of the genes associated with inherited risk factors. The swelling was ultimately what tipped me off, and we caught my condition in time.
Treatment & Recovery
Treatment depends on the severity and location of the clots and the risk of an embolism damaging a lung or cutting off the flow of blood from the heart. As I related above, I had a large clot in my left leg, another large clot in my pulmonary trunk, and numerous clots throughout the arteries of my lungs, yet because there was little strain on my heart, my treatment was little different from that of a patient with fewer or smaller clots: heparin (an anticoagulant), and three days of bedrest. Upon release, I was put on Eliquis, a newer anticoagulant that doesn’t require extensive monitoring or dietary changes. Because of the high probably of recurrence in idiopathic patients, patients diagnosed with unprovoked clots are likely to be on anticoagulants for life.
Patients with more severe clots might receive thrombolytics, drugs that break down clots. In some cases, physicians may need to perform surgery to remove the embolism. Some clots in the leg or arm may also require surgical removal as well.
Long term treatment involves anticoagulants, compression stockings, and in some cases, surgical insertion of a filter in the afflicted vein to prevent emboli. Many patients will stop taking anticoagulants six months to a year after their clots, but patients with genetic risks, idiopathic diagnoses, or other conditions that increase their risk of future clots will likely take anticoagulants indefinitely.
Anticoagulants reduce the body’s ability to for clots, thus protecting patients from future DVTs and embolisms, though both are still possible even with treatment. Cumadin/Warfarin, a commonly-prescribed blood thinner, is inexpensive and readily available, but it requires testing and dietary restrictions to ensure effectiveness. Newer medications require less testing and fewer restrictions, but are pricier.
As anticoagulants compromise the body’s ability to clot, patients may face restrictions on some activities. Running, walking, swimming, and other sports with limited potential for physical impacts are generally fine, and even beneficial, as they can improve blood flow through recovering veins. While cycling falls into this category, I know of several athletes who abandoned the sport or restricted themselves to indoor training due to the risk of crashing. Head injuries are of particularly concern, again because of the body’s limited ability to form clots. Contact sports are, for obvious reasons, discouraged.
Patients recovering from DVTs often suffer from post-thrombotic syndrome, a consequence of vein damage from the clot and the healing process. Symptoms include soreness, swelling, tingling, discolorations, and in severe cases, sores and ulcers. These symptoms can last for weeks or months; for some patients, they can last a lifetime. Exercise can help with the symptoms. My symptoms include itching, a general discomfort that’s hard to explain, a feeling of swelling in my left ankle, and aches in my calf. None are debilitating, but standing still on hard surfaces occasionally cause aches, and the symptoms sometimes keep my awake at night. Walking helped, but these symptoms played a major role in my decision to take up running, and the various aches and itches have diminished noticeably since I started to run.
Though my emboli posed the greatest threat to my life, I noticed relatively few symptoms during my recovery compared to those of my DVT. I had sporadic chest pain and a persistent but mild cough for weeks after I left the hospital, but by July, I was pushing 15 minute miles on my walks without feeling winded or exhausted. Again, I can’t explain this. One PE survivor’s doctor told her that recovery from an embolism could take 1-2 years, so it’s possible that I had more damage than I realized, but aside from the symptoms I described before, I never had many of the long term issues commonly associated with emboli.
My theory is that since my clots, while large and extensive, never significantly interrupted my blood flow, I avoided some of the long term damage others have experienced.
Athletes and DVTs
Not everyone is so fortunate. I’ve read a number of accounts of athletes, people who were young and active, developing DVTs. One of the most tragic stories is that of Anna Frutiger, a 23 year-old dental student at the University of Pittsburgh. Anna was young and athletic; in other words, someone we wouldn’t associate with blood clots.
She developed symptoms similar to mine—cramps and pain behind her knee. A doctor suspected a clot, but a doppler ultrasound scan found nothing. Her symptoms diminished, and she was discharged.
Anna travelled extensively over spring break. Shortly after she returned home, she began to experience shortness of breath and fatigue—nothing out of the ordinary for a stressed-out dental student—until she collapsed suddenly. Doctors found and removed a foot long embolism from her arteries, but the damage was done.
She died four months after she developed the DVT, which was unfortunately undetected. A combination of birth control pills and extensive travel by plane and bus likely caused the DVT, which gradually broke apart, forming and feeding the massive saddle clot above her heart.
Marathoner Jenny Hadfield developed a small but deep clot in her leg during a long flight. She developed a second, more serious DVT after a second flight. I’ve read accounts of other athletes describing how seemingly common aches gradually developed into discolored legs or restricted breathing. Her symptoms, like mine, were reminiscent of regular sore muscles, allergies, or colds.
My symptoms developed over a week, though it’s likely that my DVT could have formed long before. The swelling was an unmistakable sign, the clot in my leg was so large it was almost impossible to miss, and the saddle clot in my pulmonary artery and smaller emboli spread throughout my lungs never disrupted my blood flow. Otherwise, my story would have ended much as Anna’s had.
Notably, a number of cycling friends responded to a lengthy post I shared on Facebook with stories of their own experiences with clots or accounts of others they had known who had suffered from DVTs or Emboli. We simply don’t associate a condition often linked to bedrest, old age, or surgery with the fittest and most active among us, and that works against athletes. Too many presume that the aches and pains are the price of hard exertions, and healthcare workers sometimes assume that athletes are too young and too fit to suffer from clots.
These assumptions can be, and often are, fatal.
Risks for Athletes:
Athletes have a low risk: for clots, but there are risks associated with exercise and travel, including.
- Hemoconcentration: reduction of plasma and increase of red blood cells resulting in thicker blood
- Dehydration: also thickens the blood.
- Long-distance travel to/from events: allows more blood to pool.
- Inflammation
- Injury
- Low blood pressure/resting heart rate Low blood pressure and a low resting heart rate could lead to more pooling of the blood. Note: an increased resting heart rate can be a sign of an embolism.
- Pain tolerance: This is speculation on my part, but an endurance athlete who can run, ski, or cycle for lengthy periods of time in the upper threshold of their heart rate is accustomed to suffering. They are also likely to associate symptoms such as arm and leg pain with muscle pulls or other common injuries.
Resources
- Clot Connect: Athletes and Clotting
- National Blood Clot Alliance: Athletes and Blood Clots
- UNC Health Talk: The Athlete Blood-Clot Connection
- Runner’s World: Runners and Blood Clots: What You Need to Know
- Econ Athletes: My September 2018 Blood Clot Injury
- AMSSM: Blood Clots and the Athlete: A Review of Deep Vein Thrombosis in Sports
- The Clot Buster racing to STOP THE CLOT
- NIH: Hypercoagulability in Athletes
- Women’s Running: How To Prevent Blood Clots After Destination Races
- American College of Cardiology: Athletes and Anticoagulation: Return to Play After DVT/PE
- Video: Extracting Massive Embolism (Graphic)
- NIH: Venous Thromboembolism
- Blood Clot Recovery Network: How Long Does it Take to Recover from a PE?
