Sunday, December 4, 2016

Masters Triathlete with Asthma/ Ironman Athlete With Knee Pain

Ice Baths, Should You Use Them?

The answer, like so many seemingly simple questions in this sport, is not a yes or no. It depends on what your goals are.  If you have one competition and want to be ready for another as soon as the next day, as I understand the literature, an ice bath may help.  But if your goal is somewhere in the future, an ice bath today may ultimately be detrimental for you say 2-3 months down the road.  Therefore, it seems to me that in general, ice baths have a limited role in triathlon.

Athlete leaves now frozen bathing suit in car overnight in sub freezing weather. I 'm sure that more than one reader knows what it's like to don an ice cold suit like this.  Right?______________________________________________________________

Two recent athlete letters and responses:

The first, a letter to Joe Friel passed on to me. Masters Athlete with asthma

 Joe - I am a 74 year old Ironman triathlete. Awhile back was top 10 in world 70.3.  In the last 2 years have come down with asthma.  In your research have you found any information regarding building aerobic capacity as it relates to lung capacity in asthmatics?   I have your book "Fast After 50", and am following your training methods. I use an inhaler and try to warm up before starting my work out.   
Thanks for your help.
Best Regards,    Wayne

Wayne - HI, I'm John Post, MD the Medical Director of TrainingBible Coaching and Joe has sent your note to me.  Sorry to hear of your difficulties.  Of the the three of us, you and Father Time are the best of friends.  That's one of your problems.  As you likely already know, after our peak racing years, say our 20's, our aerobic capacity, expressed as VO2 max, begins to decrease.  In some this can be as much as a percent per year.  This is primarily due to a lowering of our max heart rate with age and diminished lung function, both the total capacity of the lungs as well as the rate at which you can exhale the air.
Given that, now add asthma on top of it, and it can be a real pickle.  Maximizing your lung function and the influences of the asthma medically is done between you and your physician.  Your part is to not smoke, avoid areas of air pollution, get your flu shot (as well as Pneumovax and Prevnar - both vaccines recommended for all three of us since we're over 65.  I've had all three.) and doing your best not to get some kind of infection.  Got grandkids??  Good oral hygeine and frequent hand washing?
Lastly, your interest in endurance athletics will be the best antidote to this decline. Keep training!
Hope that helps.

The second, an athlete with a long history of knee pain:

Hi Dr. Post- 

I'll make this brief, and if you would please take a moment to help me, I would truly and dearly appreciate an objective criticism of the condition that I have gotten myself into. 

40 y/o male. 
Frequent Ultra runner. 
IM Finisher 
Registered Nurse (humbly before you) 

Because of a clogged sweat gland on the bottom of my foot (took 3 yrs for me to see the right person to get it fixed), I altered my walking and running form and also my cleat position on my cycling shoes. 

Changing my active forms of movement caused me to develop hip pain that was unexplainable, undiagnosable, and was found negative after 2 standard MRIs and 1 MRI Arthrogram (a 1cm x 2cm cyst was found and that's why the arthrogram). 

Lumbar MRI was unremarkable and interpreted as not causative of my hip pain, nor the knee pain that sometimes flares-up. 

After the arthrogram and Lumbar MRIs were negative, I went back to my most natural feeling movement patterns and relocated my cleats---AND THEN after about 3 months the hip pain stopped. 

I have one remaining residual issue that I need to ask about to better understand what I need to discuss with my orthopedist. I get a tight/pinching feeling (probably inflammation) at the distal head of one of my medial hamstring tendons. 
I rarely take NSAIDS, but it does improve with 800mg Ibuprofen BID. However, without medication the medial hamstring tendon bothers me while sitting, squatting (to play with my children), and also if I sleep with my knee in flexion. 

The orthopedist said it wouldn't hurt to check my knee with imaging and the knee MRI says that I have a popliteal cyst and some horizontal signal intensity on the posterior horn of my medial meniscus that, in the presence of the cyst, might be indicative of a meniscal tear. 

I am at a loss about how to approach this. My sports medicine doctor says that orthopedist might want to take out the cyst, but that a meniscus repair is probably not warranted. 

Should I just chill out and check back with the orthopedist in another 4-8 weeks, or should I press on and have the cyst removed? It seems like it will resolve itself, but the sports medicine doctor is wanting to use ultrasound to inject the cyst with cortisone, but then tells me about how that the cortisone is caustic and that it might damage me and then require surgery. 

Financially I'm running on fumes, and I really need to concentrate on my family and my work, but I desperately want to return to the sports that I love for both my physical and mental health (which also help me to concentrate on my family and my work). 

Thank you Sir.

You didn't give me your name so I'll call you Steve. After reading your note, I have a few observations that may help. In no particular order, any doc with an active knee practice likely gives a couple thousand knee injections each year. If there were a significant downside, that number would likely be lower. Popliteal cysts themselves are rarely primary and rarely the source of the patient's symptoms. I'm surprised between the radiologist and the ortho guy they can't be more certain of the presence/absence of torn meniscus. That said, the situation where a meniscus is repairable occurs much less frequently than that where the torn piece is simply removed, something done every day in the operating room by many docs. Is there a mild degree of early arthritis present in this medial side of the joint on would wonder as well. 

Your doc, after your knee exam, must have some opinion as to which of these two is more likely the source of distress. My money would be on a torn meniscus. If the decision to scope the knee is made, doing something to the cyst would be unusual. The norm is arthroscopically address the problems inside the joint and leave the cyst alone. If indeed you have a medial meniscus tear, removing the torn portion is quite easy and you'll back on the roads quickly. 

Steve - it sounds like you have a Sports doc and an ortho guy. If so, two opinions may benefit you more than one! 

Good luck, John 

John H. Post, III, MD 
Medical Director, Training Bible Coaching 
[email protected] 

Below is the full text of our followup e-mail traffic if you might be interested.

Thanks Dr. Post. I'm Mark. 

I agree that the cyst is probably not primary. 

An analogous situation occurred with my hip MRI and the presence of a cyst there, but then the arthrogram showed no tear. For whatever reason, I seem to be forming cysts due to minor injuries and overuse (or poor ergonomics) because I also had a ganglion cyst on my wrist this year. 

I'm very apprehensive about general anesthesia especially because the cyst might spontaneously resolve. 

I'm further distressed about the fact that neither radiology, ortho, nor sports Med has a conclusive opinion. 

Isn't it possible that the popliteal cyst is from an injury to my distal hamstring tendon? 

Dear Mark (maybe Steve in a former life? Ha!) 

Re: I'm very apprehensive about general anesthesia especially because the cyst might spontaneously resolve. 

Nobody is pushing you so take your time. And if you don't want general anes, don't have it. I've had a couple procedures on my legs had either local or spinal. No GA.

I'm further distressed about the fact that neither radiology, ortho, nor sports Med has a conclusive opinion. That may be good. No one is forcing your hand...."well sir, your only way out is an operation.." You got over the hip pain without a trip to the OR. Here in VA there's a resource the athletes love. It's called the speed clinic. They examine you, look at your studies, put you on a treadmill and try to heal you with exercise. One of my group had butt pain for a year, two injections, but since going to the SC, is planing IM Chatannooga in the fall. I wrote it up for LAVA - yet to be published - but if you promise not to share it and send me an email add I'll send it to you. [email protected] 

Maybe there's one near you wherever you live. Google UVA Speed Clinic. 
Re: Isn't it possible that the popliteal cyst is from an injury to my distal hamstring tendon? 

I doubt it 


Mark has since read the Speed Clinic piece and offered:

Thx for allowing me to talk this through. I cannot tell you (succinctly) how much that this dialogue has helped me. 

I appreciate your email. I will consider the concepts of speed clinic and whether it might help me. 

Merry Christmas, and all the best in the new year. 

Thanks Mark, Happy Holidays to you and your family. 

Sunday, November 27, 2016

What's the Best Weight Loss Program?

Devoured by Sophie Egan on the term low fat. "But when looking so carefully at the removed fat, we overlook what replaces it.  When fat is taken out, sugar and salt are added to keep the product from tasting like garbage.  Or, at best, tasting like nothing at all.  In addition, a product might get packed with extra carbs and weird thickeners and additives.  All of these replacement ingredients are often worse for us than the apparent offender." 

From Racing Weight to South Beach to Betty Crocker

We're probably alike in many of the ways we approach food.  Triathletes are taught to think on many planes about that which is put in their mouths as fuel, nutrition, contributing to our power to weight ratio - oftentimes more to weight part of that phrase - to name just a couple. When do taste or satisfaction enter the equation?  Not often enough is likely your immediate answer. One wouldn't suggest you take your paycheck down to Krispy Kreme and buy a gross of

these mouth watering treasures but once in a while is fine. We're bombarded from all sides on what constitutes the best nutritional plan for us to keep the weight off and have the energy needed at training and racing time.  Your kitchen library probably looks like the photo above, maybe worse, and trying to separate fact from fiction, what's the take home message here? can be a challenge.  So let's turn to a level head in the nutrition world, one who publishes mostly science backed data without a lot of opinion added in.  If you haven't read Sports Nutrition by Asker Jeukendrup, it would be a good addition to your Christmas list along with the 4th edition of the The Triathletes Training Bible by Joe Friel which came out last month. I own the former and plan to purchase the latter.  Jerukendrup tried to clear the smoke in the diet world and published the info below.  Yes, I know that it's four, no wait, five full paragraphs, not the CliffsNotes version, but it's really well written and I believe you'll learn something valuable.

What’s the ‘best’ weight loss diet? Tough question right? I’ve been thinking a lot about this recently especially in light of some things I’ve read on twitter, blogs, Facebook, Tumblr… there are certainly a lot of opinions out there and everyone is convinced they’re right and that their diet is best/better/bestest! Trials have been conducted (lots), but personal anecdotes seem so compelling, some have even established foundations to ‘prove’ that their theories as to causes of all [sic] obesity and diabetes - (note the subtle difference between these two websites and foundations, but with completely different dietary philosophies), - there’s some big money (and big interest) behind this! There are also institutions who have their entire reputations at stake advocating for certain dietary approaches - - What is so interesting is that few of these approaches seem to resemble the Food Guides, My Plates, Food Guide Pyramids from the respective countries in which these foundations, approaches, advice, etc say is THE way to eat. I mean if the experts disagree then what chance do the ‘mere mortals’ have?

Ockham's (Occam) razor is basically an axiom that in a sea of competing ‘theories’ (in this case dietary approaches to good health) the one with the fewest assumptions should be selected. The case may be that all of the approaches make assumptions? There appears to be enough evidence, from basic mechanisms, clinical trials, to support high fat/high protein, low fat/high fibre, high plant/high fibre or a multitude of other assumptions. But what’s missing, why are there so many ways to advocate for weight loss and good health? Could it be that multiple approaches work? Or are we just seeing crafted stories – Dr. David Katz (and his unnamed colleague) think so, at least in some cases: It seems, however, after conducting an in-depth survey (OK, it was a pretty shallow twitter question), that everyone (yes there are still some doubters) agrees that to lose weight – be it fat or lean – requires (yes I said requires) a negative energy balance. I know, hold on, it’s crazy but it’s true.

Many will talk about the ‘type’ of weight that is lost and I can certainly agree that fat loss should most often be emphasized over lean loss and it appears pretty clear that high(er) protein and exercise (particularly resistance exercise) are effective in this regard: (apologies for a gratuitous citation of our own work, there are many fine pieces of work in this area). But the fundamental truism is that E balance has to be negative and when you do that, and can sustain your new weight (likely by following the same approach you used to lose it) then you achieve success! But as we know the success rate of weight loss is not good (yes that’s an understatement) and yet every dietary best seller and concept that comes out has a new theory as to what it is that causes weight/fat gain and how to reverse it “Forever” and to “Forget everything you’ve ever been told” or that “What you’ve heard is all wrong.” I don’t doubt that there’s a shred of truth in everyone’s approach, but Ockham’s razor would suggest that there’s a really simple truth behind all weight loss programs and it really has to be whether you can stick to staying in negative energy balance to lose the weight and then stick to your new energy intake, eating less, forever… which as we know is a long time! So stick to it is what wins? Well I think that’s a big part of it.

It is said that those who do not study history are doomed to repeat it. What then of the Paleo, the LCHF, the high fibre vegetarian, the Real Food, Wheat Belly… well here’s a (brief) list of their predecessors and well know their fates: Scarsdale, Ornish, Weight Watchers, Dr. Bernstein, Herbal Magic, Cabbage soup, Atkins, Zone, South Beach, Raw Food, Mediterranean Diet, DASH, Jenny Craig, Sugar Busters, Flexitarian, TLC, Fruitarian, Cookie diet, Kangatarian, Hacker’s diet, Stillman Diet, Nutrisystems diet… you get the point. All of the aforementioned were called breakthroughs, revolutionary, and THE answer to losing weight and… yup keeping it off. And people still follow, swear by, adhere to, and ‘know’ these diets work. And for the people who stick to them they undoubtedly do. We also know, from the National Weight Control Registry that there isn’t one specific formula that promotes lasting weight loss. The one thing that does appear to be true is that whatever the folks who lost weight did to lose it then they have to keep doing it! A point recently made by Dr. Mike Joyner ( is that in his opinion “… the key to successful long term weight loss appears to be related to developing the skills and behavioral strategies needed to effect long term changes in diet, exercise and overall physical activity.”

I couldn’t agree more frankly and we’ve perhaps forgotten the lesson of how important cardiorespiratory fitness is ( And thus, when considering the answer to the question of what diet works and works best, you have to take a step back and recall your history. All of the diets have a history of ‘success’ on an individual level and yet the number of people who are obese continues to rise. So, is your diet on this list and is it the best? If it works for you of course it is, but there’s not been any magic in any diet to date and I’m betting it’s going to stay that way. I do wish all of the folks who have started foundations to prove their diet is best, the best of luck (I actually hope they succeed). But I think they’re being a little na├»ve when they think they’re going to ‘cure’ obesity or type 2 diabetes with THE best diet, unless of course they’ve found that magic ‘stick to it’ juice? For the record, there’s no such thing as ‘stick to it’ juice!

Sunday, November 20, 2016

"You're Going to Need an Operation." What do You do Next?

                                           “He who will not risk will not win.”

                                                        John Paul Jones

To some, bamboo would be a frightening choice for bike construction. To others, it's a chance to be a little different. Pretty cool, though!

Gluten Sensitivity. Really?

A recently published study in the journal Digestion found that 86 percent of individuals who believed they were gluten sensitive could tolerate it. Individuals with celiac disease, a hereditary autoimmune condition that affects about 3 million Americans, or roughly 1 percent of the population, must avoid gluten. Those with extremely rare wheat allergies must also remove gluten from their diet. In addition, those with gluten sensitivity, a condition that affects 6 percent of the population (18 million individuals), should also avoid gluten.
That doesn't explain why an estimated 30 percent of shoppers are choosing "gluten-free" options, and 41 percent of U.S. adults believe "gluten-free" foods are beneficial for everyone, especially when many of those foods are often lower in nutrients and higher in sugars, sodium and fat than their gluten-free counterparts. And much of the growth in the category is coming from cookies, crackers, snack bars and chips.

Thanks in part to a lot of hype from gluten-free evangelists and celebrity wheat-bashing, many Americans are convinced they're "gluten-sensitive" and better off avoiding foods that contain it. "People want to believe that they are gluten intolerant because it's a way for them to avoid carbs, because they also think carbs make them fat," explains registered dietitian Vandana Sheth, a spokesperson for the Academy of Nutrition and Dietetics.

Volunteers registering Ironman athletes on the Big Island
You’re going to need an operation.  Now what?

    “And then he walked out of the room.”  If you’ve never had surgery, being told that the next step in your care involves a trip to the operating room can be a tad upsetting.  What’s going to happen to me? How long will it take to get over it?  Can I pay for it?  Are you sure there isn’t another way to get better?

These and a 1000 other questions run through the mind of the new patient as he/she’s been told, for example, that their shoulder will continue to dislocate unless something is done surgically to prevent it.  Although it seems difficult, maintaining control is important and having some idea of what questions you need the answers to helps.  In this setting, our shoulder dislocator will probably have a discussion with the surgeon about the procedure, basics of the reconstruction including risks, location of the incision, time in hospital if any, post op therapy and finally return to sport.

There will also be a discussion with the nurse/assistant covering the nitty gritty details like agreeing on a date for the operation, where and time, diet, what to wear, pre-op blood or lab work if needed, and all the little details that are so important to the patient.  In our office this often includes a video about the surgicenter, parking, and an example of someone else going through the same basic surgery to try to put them at ease.  Also at this stage is the first of several permits that you’ll be asked to sign, the permit for surgery.  In our exceptionally litigious society this is the first document that you’ll see explaining the basic nature of what will happen to you and the basic risks.  You’re giving the surgeon permission to do the operation understanding that positive results, while implied and hoped for, are not guaranteed.  If you have any doubts, want a second or even third opinion, now’s the time to do so!  You’re the one having the operation and need to feel not only is it right for you but this surgeon and medical team are also right for you.  It doesn’t bother the surgeon at all if you say you need to delay the procedure, ask around, and in fact some docs actually encourage it.  There are some operations that get better results early, however.

You’ll also probably talk with the insurance office.  On the day of surgery you’ll arrive at the hospital/surgicenter an hour or two early, change into one of funny gowns that opens in the back, meet the anesthesiologist  - another permit – and discuss the options for anesthesia, picking what’s right for you.  There may be an IV involved also.  And when your turn comes, off you go into a whole new world.

Good luck!

And remember, SUPPORT THE SPONSORS THAT SUPPORT YOUR RACE.   It wouldn’t be bad taste to also wear their logo.

Sunday, November 13, 2016

You Can Always Win the Transitions

“I always win the transitions!” says a patient of mine. And she does.  I think she feels that more important than the race results some times.  Positive feedback for effort expended. 

Sensors being placed on legs of local athlete who sets the pace.

Here’s how.  She makes things very simple. 1) only bring into the transition area what you absolutely need, 2) Practice, practice, it’s all in the set up, and 3) Keep it simple.

The day before the race, know the course cold.  It’s so easy to memorize. On race morning when you rack your bike and drop your stuff do a nice slow walk through from your bike to the mount line and from the swim exit to your bike.  Do it a couple times (not talking to your friends but to memorize it.)  it will also help you relax some.

Anyone can have a lightning quick wetsuit exit.  If you ever have the pleasure of volunteering at the transition area of a sprint tri, watching the comedies of wetsuit removal appearing not unlike Harry Houdini and his 1920 straight jacket act or the wrestling of an invisible opponent.  First, Training Bible Coach Jim Vance will tell you to cut off the bottom hands breadth of the legs of the suit. I guarantee you it will make no difference in your swim, you’ll just get your feet out faster. And PAM sprayed around the ankles will make this remarkably easier. (Just make sure you use regular PAM as the flavored types seem to attract hornets, as one triathlete found out the hard way.)  At water’s edge you’ve unzipped the suit – while moving, you’re always moving – and a shrug or two aids in getting the top down to your waist giving you the appearance of the so-called “headless monkey.” At your bike, a quick pull gets the suit to your knees and Coach Eric Sorenson of the Annapolis Striders would tell you to simply step on the suit and pull your foot out.  All this in under 10 seconds. Remember that pre-race practice stuff?  Your race number is on a belt under your wetsuit so it’s helmet, sunglasses and go!  Forget that toweling off and foot bath stuff – unless it’s part of a pedicure.  Really, you won’t blister in a sprint race.

Your bike shoes are already clicked in and fixed with rubber bands, left pedal forward assuming you mount from the left, is a given.  This has been shown time and again to be the quickest.  If, during your home transition practice before the race, you ride barefoot with your feet atop the shoes for 5 or 10 minutes you’ll see how easy it is giving you one more learned skill that may be important one day.  In the race, you’ll have a quick mount well away from the start line and other riders.*  The mount line has the highest potential for collisions and that might ruin your day.  When you return to T2, slip on those lace locked running shoes, grab your hat and you’re off.  Some cannot do this standing up and will duct tape a towel to the outside bottom of a plastic milk crate, place it right next to one’s front wheel, and use it as a quick seat to apply running shoes.  It also makes for a handy way to transport your gear in/out of the transition area.

Compare your transition times to those in your age group, and to your performance last year and YOU WILL BE THE QUICKEST!!

*A good number of triathletes are just not comfortable with this technique regardless of practice.  That's fine.  Donning one's bike shoes in T1 can be done quickly if you have a good place to sit. Unless the transition is packed super tight, put all your stuff in an old plastic milk crate to which you have padded the bottom. There's usually just enough space between your bike and your neighbor for said crate. Once your wetsuit is off, put it out of the way, sit on the crate putting on the bike shoes, and off you go. Just remember, running on cleats can prove a little slippery.  Be careful. 

Padded milk crate

Saturday, November 5, 2016

What Ironman Says About the Chip on Your Ankle to Athletes

"I've got too much time on my hands
It's hard to believe such a calamity
I've got too much time on my hands
And it's ticking away, ticking away from me."


Time.  Chip time.  Elapsed time.  Transition time.  Ultimately it's what this sport boils down to.  The technology to measure it has gone rapidly from hand held stop watches depending on the users attention level for accuracy to chip timing of various sorts today.  In some running events the chip can part of your disposable paper race number or intertwined in the laces of your shoe but we triathletes use the ankle strap for most events.  Uniformly reliable, accurate, and virtually invisible to the user.

There are isolated instances where competitors have "lost" their chip, either accidentally or intentionally. When the latter occurs, almost without exception, the system is smarter than the user and this form of rule breaking is ferreted out quickly.

Two quick reported examples from Hawaii would be an athlete a couple years ago who cut the run course short by 4 miles bypassing the NELH (Natural Energy Lab of Hawaii, an out and back loop late in the event) or a decade ago when one athlete took another athletes chip with him/her to the far reaches of the bike course in the small village of Hawi.  Both episodes were discovered.

The following is copied from the Ironman Athlete's Handbook and is an excellent starting place to understand the thinking from the top on triathlon chip use. 

The 2016 IRONMAN® World Championship is timed with Mylaps Pro Chip technology by Sportstats. Your responsibilities as an athlete include: 
1) As soon as you pick up your race packet and Mylaps Pro Chip, please go to the Chip Verification table during registration. Be sure that your correct name shows up on the computer screen. 

2) You must wear your Mylaps Pro Chip at all times during the race. Fasten it to your right ankle with the velcro strap before the swim and leave it on until after you finish the entire 140.6 mile course. You may apply Vaseline around your ankle; it will not affect the chip or timing. We recommend securing the Velcro strap using a safety pin since this is a non-wetsuit swim. Volunteers will help you remove the chip at the finish line. 

3) If you do not start the race on Saturday, October 8, you are still responsible for returning the chip to race management. Chips should be returned to the Drops Clerk.  Rest stops, transitions, etc. will be included in your total elapsed time. Splits will also be recorded for each segment of the race. 

4) In addition to the 17 hour overall cutoff time, there are cutoff times for each segment of the race.  Start time may vary based on water conditions. 

5) If you drop out of the race at any time, you must notify and return your timing chip.  Failure to do so may disqualify you from participating in future IRONMAN events. It is essential that we know where you are on the course at all times for your safety and our peace of mind. If you are transported to any IRONMAN medical station, the medical staff will take responsibility for your chip. 

6) By picking up your race number and chip, you are guaranteeing that you will return your loaned chip to race management, or you will be fined $75 for it's replacement.

7) If you lose your timing chip during the event, you are responsible for obtaining a replacement. Volunteers will have extra timing chips at the following locations: swim exit, bike exit and run exit. If you lose your timing chip on the run course, you must notify a timing official immediately after crossing the finish line. 

8) Do not intentionally cross the finish line as part of a group. Your finish placement may be jeopardized potentially resulting in loss of prizes or awards. Remember: NO CHIP = NO TIME Failure to wear your chip on race day, return your chip after the event or pay the chip replacement cost will disqualify you from future IRONMAN events. PRE-RACE INFORMATION

And, what Ironman says about cutoffs.

RACE TIMING AND CUT-OFFS The race will officially end 17 hours after your designated start time. Aid station stops, transitions, etc., will be included in your total elapsed time. Splits will be recorded for each segment of the race. The following cut-off times apply for each segment of the race: Swim Cut-Off 2 hours and 20 minutes after your designated start time. Bike Cut-Off 10 hours and 30 minutes after your designated start time. Run Cut-Off 17 hours after your designated start time. MyLaps Pro Chips will capture your splits (swim, T1, bike, T2, run) and overall finish time. IRONMAN reserves the right to remove an athlete from the course and DNF the athlete if our course staff determines there is no possibility of an athlete finishing the given discipline (swim, bike, run) before the posted cut-off times based on an athlete’s location, time and average speed up to that point.

This is the entire Athlete's Handbook from Kona and if you had a couple spare minutes it makes for interesting reading.

Sunday, October 30, 2016

What Makes the Big Island Bike Course Different From All the Rest?

I've been to the Big Island several times.  Although the bike course is not rated as difficult as some of the other Ironman courses, when you ask a finisher who's just battled the heat, humidity and terrific winds, they may differ with that assessment.  A lot.  The Kona Athlete Guide notes " 'Challenging' and 'inspiring' are terms often used to describe the IRONMAN World Championship presented bike course."

They also note "Kona’s highways are only two lanes, and drivers are not accustomed to large numbers of cyclists and runners on the roads. The IRONMAN World Championship has become famous for special care of athletes during the race. This “Aloha” is given freely by our 5,000 volunteers. When training, please be courteous and aware that those sharing the roads with you are the people you will count on during race day to fulfill your physical and emotional needs. Please ride single file."  Hmm, the athletes help the volunteers; turns out life really is a two way street.

With the swim behind him or her, the athlete heads north for Kawaihae and ultimately the turn around at the village of Hawi where they experience a great sense of relief knowing that in one sense, the race is half over. 

Their hair is drying, they're thinking about the first bike aid station, their fueling plan, not getting a drafting penalty, stuff like that when right by the roadside, living in the lava so to speak, they get a glimpse of something they've not seen before.

A solitary cross on the Kona bike route

And they don't ride more than a couple more miles when they spy:

If they were to come back after the race, stop and carefully examine these, about 35 of these lava memorials are found on the Queen Ka'ahumanu Highway north of Kailua-Kona. Many are anonymous but some have elaborate poems, contents that likely belonged to what you can only assume is a lost loved one.  There are basketballs, base ball gloves, necklaces and hats.  You learn that many of these are for children.  Children who used to play with that basketball or those beads.

 This 112 mile bike is unlike any other.  The whole Hawaiian experience, Kona is so much more than just another race.