They’re arguably the most vilified employees in professional cycling but, as I discovered, races like the Tour de France simply wouldn’t happen without the cycling team doctor…

Paint a mental picture of a cycling team doctor and, in all likelihood, the scheming, tanned, Bart Simpsonesque, Michele Ferrari comes to mind. The Italian, you may remember, received a lifetime ban from the world of cycling back in 2012 for a medicine-cabinet’s worth of anti-doping violations including possession, trafficking, administration and assisting of doping.

Clients of Ferrari reads like a Who’s Who of professional cycling: current Astana team manager Alexander Vinokourov; Thomas Dekker, who exposed the culture of doping in cycling in his book ‘The Descent’; and, of course, Mr Lance Armstrong.

Cycling’s past has long been scarred by the actions of nefarious doctors living in the shadows accompanied by needles, vials of illegal drugs (EPO, steroids, testosterone) and an almost psychopathic desire to push the human body's limits.

This image of the cycling doctor is fuelled by their rare public appearances, which are often related to some illegal act or scepticism, as recently illustrated by the case of Dr Richard Freeman at Team Sky, whose non-appearance at the House of Commons Select Committee examining how to combat doping in sport (aka "the Jiffy Bag farce") left numerous unanswered questions about the ethics of some of the British teams' practices.

Clearly cycling team doctors require a PR makeover (Gareth Southgate’s publicist, please...) but, after spending time with a number of them on many different teams, my impression is of a hard-working, generous and intelligent group of men and women who genuinely care about their riders and the sport.

The majority, like Dr Adrian Rotunno - Team Dimension Data’s doctor - combine a lifelong personal passion for cycling and medicine and take it into the professional sphere. 

I spent time with Rotunno just prior to this year’s Tour de France at the 2018 Science & Cycling Conference in Nantes and we talked supplements, the importance of technology in saving cyclists' lives and the life of a team doctor on the Tour…

Health is the first priority

‘Ultimately, my role on the team is to ensure the riders’ good health,’ Rotunno told me. ‘To achieve this requires a huge number of tasks that start at the first training camp of the season and roll onto races like here at the Tour de France.’

At that first training camp – usually in November – Rotunno and the team’s medical staff give riders like Mark Cavendish and Edvald Boasson-Hagen a comprehensive medical screening and assessment, which focuses on cardiology health, bone mass and density, as well as optometry. ‘We’ll also give them quarterly blood tests and monitor the riders’ supplement needs.’

This last one is a particularly sensitive area, with UK Anti-Doping suggesting that in 2012, ‘44% of positive tests were caused by prohibited substances contained in supplements’.

The seven positives at the 2014 Winter Olympics in Sochi were also down to contaminated supplements. It’s why teams will only use supplements and energy products that are flagged up as being batch tested by the respective nutrition manufacturer, though Rotunno says that the team will also randomly batch test products for added peace of mind.

For your own peace of mind, Precision Fuel & Hydration's products are all independently batch tested for a wide range of prohibited substances on the World Anti-Doping Agency (WADA) list and the all-natural range are further covered by Informed Sport (aka Informed Choice).

Rotunno and his contemporaries ensure the team is compliant with UCI medical monitoring too, and that includes the "biological passport". ‘Many of our riders don’t speak English, so it’s imperative we explain to them the importance of filling in the Whereabouts system and not missing anti-doping tests.’

Though no medication passes the Dimension Data riders’ lips without Rotunno’s permission, he recommends the website, which is a drug reference library where you input the potential medication to see if it’s on WADA’s banned list.

Maximising technology

‘We also monitor rider travel programmes and jetlag as that has a huge impact on performance,’ says Rotunno. ‘One useful tool I use is Jetlag Rooster, a very handy app. Just put in your travel requirements, and the app plans how much sleep you’ll need before you get there and between times so you’re fresher when you arrive.’

And that’s not the only app Rotunno utilises – hardly surprising on a team funded by a South African technology company! 

‘Every morning, whether it’s training or at races, the riders will fill in a health questionnaire on an app that we’ve designed. It’s similar to one that you might find on Training Peaks but it's more bespoke to our requirements.

It gives you a snapshot every day where you can monitor stress levels, impact of altitude training, sleep quality… It looks at how you were feeling: your mood and motivation levels. The rider will complete it on waking, the results come through to us and we’ll pick up on any areas of concern.’

It's importance, says Rotunno, can’t be overstated, not only for managing a rider’s performance and training load but for more severe health issues. ‘One of our riders crashed, leading to minor concussion. We gave him a CT scan and then managed him as per the concussion protocol. He returned to training after a couple of weeks, completed a couple of races and his performances were fine.

‘Six weeks down the line, however, his daily report came through flagging up a medical alert. He said his nose was blocked, head not great and he just wasn’t feeling himself. Immediately I phoned him up and he said he’d actually had headaches for the last five days.’

The alarm bells were ringing. Rotunno sent the rider for another scan that identified a subdural hematoma. The crash to the rider’s head damaged a blood vessel between the rider’s skull and brain, leading to a blood clot that grew larger over time. Left untreated, it can lead to death. ‘Thankfully, the app helped us to react quickly. We knew exactly what was going on and could execute a treatment plan. He had surgery and is completely fine now.’

The Tour's punishing schedule

At the conference, Rotunno also highlighted the work schedule of doctors at the Tour de France – so exhaustive it required two slides! Here’s a snapshot…

  • Early morning wake-up call and hopefully squeeze in a run.
  • 6.30am. Visited by UCI anti-doping testers two or three times a week.
  • 7.30am. Quickly shovel breakfast down.
  • 8am. Urine analysis of the riders and pre-breakfast weight check.
  • 9am. Morning ‘ward round’ and dressing changes. This is to check the riders are healthy, and clean and dress wounds.
  • 10am. Pack up hotel room, hop onto bus and drive to starting village.
  • 11.30am. Arrive at stage start. Team technical meeting to decide the day’s tactics and the key players of the day. Then do a second weight check of the day to check hydration levels are fine. If not, advise further drinks containing electrolytes. 
  • 12.30pm. Riders begin stage. I’ll hit a team car or the bus and head to the finish with hopefully little activity between.
  • 5pm. Stage finish – hopefully a podium and anti-doping control thereafter.
  • 5.15pm. Find the bus – our Spanish driver often parks in the most obscure places! Then quick rider check-up including post-stage weigh-in for hydration levels, followed by transfer to the hotel, which is anywhere from 15km to 400km. 
  • 7.30pm. Evening ‘ward round’ to check riders are okay.
  • 8.30pm. Pharmacy run aboard one of the team’s ‘Buffalo Bikes’ (the bikes the team raise funds for and donate to children back in Africa). This is to find the nearest open chemist – Google Maps is good here – to stock up on supplies.
  • 9pm. Another management tactical meeting.
  • 9.30pm. Dinner.
  • 10.30pm. Last-minute ‘ward round’.
  • 11.30pm. Bed followed by tossing and turning in a room lacking air-conditioning!

Those 18-hour days are common for every one of the 21 stages, and not only in an effort to keep the riders healthy but the support staff, too. ‘I’ve even stopped for a few collapsed spectators,’ he adds. But it’s the riders who absorb most of the good doctor’s time.

‘There’s something called the “open-window theory”,’ explains Rotunno. ‘The immune system is suppressed during intense exercise load and that “window” opens more as the Grand Tour progresses.’

It’s why the chances of infection and illness spreading through a team and their eight riders – reduced from nine this year in an effort to make the racing more exciting – are high, and also why a rider displaying symptoms like a cough and sniffling nose will end up being moved from sharing a room to being "quarantined" on his own. 

The omnipresence of the hand sanitiser

Prevention, of course, is always better than a cure, which is where hand sanitiser comes in. Rotunno espouses its benefits, though it’s Team Sky who were the early high-profile adopters of this very simple prevention strategy, something touched upon in Dr Richard Freeman’s new book ‘The Line – where medicine and sport collide…’ 

‘We cut down on infections such as these once we introduced the hand sanitiser,’ Freeman wrote. ‘You’re just as likely to get an upper respiratory tract infection or gastroenteritis from shaking hands with somebody who’s infected, as being sneezed on or eating food prepared by the person who’s infected.

Whenever I saw anybody who looked even slightly unwell, they were either asked to stay away or I gave them one of the small travel-sized bottles of sanitiser I used to carry around with me.’

Freeman’s focus on hygiene also saw him introduce a no-hand-shaking rule and a policy of always closing the toilet lid whenever anyone flushed the toilet. ‘If there’s infection in the toilet, which is highly likely, and you flush it with the lid open, you create an aerosol effect,’ wrote Freeman, ‘so even if you’ve exited the bathroom or cubicle by the time that happens, you risk getting it on your toothbrush, so the next time you brush your teeth, you can pick up an infection.’ Hands up who’ll continue to leave the lid open?!

As well as infection, road rash is a big problem, says Rotunno. ‘Just make sure you always clean it before infection sets in… and saddle sores are always a problem.’

Again, this is a subject touched upon (delicately, of course – you don’t want to mess with a rider’s perineum) by Freeman, who highlighted the lengths Team Sky went to in search of banishing this common problem, which included MRI scans and ultrasounds, all beneath the umbrella of ‘Project Ouch’.

I spent some time with Katusha-Alpecin at the 2017 Tour de France where, out of the nine riders in the team, three had saddle sores. Or they had "three guys with a third ball", as the team’s doctor, Dag Van Elsande, put it.

Van Elsande was an expert in saddle sores – a proud one at that – and had even created his own formula. He’d promised me a look at his cabinet of ‘nodule ripeners’ and duly unveiled a plethora of tubs, tubes and dressings aboard the team bus.

‘This is tar. I’m going to put it on your ass,’ he said. I felt cold. ‘I’m joking – here’s some for your finger. It ripens an abscess faster and includes cod liver oil, zinc, disinfectant, vitamin E.

We also have a local anaesthetic; a healing cream with zinc; Compeed, which acts as a second skin; Betadine soap that prevents your groin from picking up an infection.

And that’s just for the outside. If you have a nodule under your skin, it’s time to ask the osteopath why you have friction on this point. Maybe you’re twisted on the bike. All these creams don’t work if you have a mechanical problem.’

A mechanical problem would require a professional bike fit but, for now, Van Elsande advises angling your saddle slightly downward to relieve perineum pressure. 

Despite a doctor’s best efforts, saddles sores happen, leading to inferior performance that arguably derives from broken sleep. Research by the Australian Institute of Sport’s sleep expert Shona Halson has shown one or two nights of broken sleep can be absorbed, but persistent poor sleep of three nights or more leads to lower power output and hazy decision making. So do riders take sleep medication, I ask Rotunno?

‘It’s a taboo topic,’ he replies. ‘A three-week Grand Tour puts a rider under unimaginable stress, which can severely affect their ability to “switch off”. I have prescribed sleep medication, and always start with the lowest of the low and then progress up if needed. But every doctor and rider must be aware of potential addiction. It’s been known to happen in the past, for sure.’

In a sport scarred by medication, it’s a last resort. But this is the Tour de France – the toughest race in the world. A race that sees the world’s fittest, bravest athletes battling each other upon the world’s most gloriously brutal terrain. It all conspires to batter a rider’s health.

‘There’s no single variable that affects a rider,’ Rotunno concludes. ‘It could be an overuse injury, chronic fatigue or acute problems like road rash. It’s my job to manage these issues, as well as gaining the trust of the rider so we can both perform at our optimum.’

And with this year’s race racking up 3,351km in fewer than 90 hours, good luck to Rotunno and his contemporaries – a diligent, hard-working group forever working beneath the historic clouds of suspicion…