Cycling injuries

We specialise in cycling related overuse injuries, which incorporates aspects of prevention, diagnosis, treatment and rehabilitation. Crucially, we investigate both the Cyclist and the Cycle fit for pre-disposing causative factors. We treat competitive cyclists from Lancashire, Cumbria, Manchester, Leeds, Merseyside and beyond.

Our approach considers:

• The Cyclist (anatomical and biomechanical problems, muscle weakness and imbalance)

• Bike Fitting issues (bike positioning e.g. saddle and handlebar position & rider prescription for foot/pedal interface)

Introduction

Knee injuries as a result of overuse, are the most common injury in cyclists, followed by low-back pain, then wrist and hand problems. Although cycling is low impact, the repetitive motion of pedalling can lead to a variety of overuse knee injuries. The majority of cycling injuries are indeed caused by overuse, usually exacerbated by anatomical and biomechanical problems of the foot / lower-limb, which leads to cumulative tissue microtrauma and consequent symptoms.

Cycling knee injuries

Knee pain is the most common overuse problem in cyclists (1-9), affecting an estimated 40% to 60% of riders (10). Most knee problems result from overuse repetitive pedal movement and/or improper biomechanics linked to the leg or foot. Most knee injuries occur anteriorly (front), usually involving the patellofemoral joint (11), and can be sustained by elite and recreational cyclists - road and off-road. The aetiology (cause) of overuse injuries are often multifactorial and diverse (12) but the majority of research appertaining to overuse knee injuries in cyclists, focus on the anatomical structural variations of bones in the lower-limb and foot.

Cyclists knee

Considerations when evaluating knee injuries

The most common overuse knee problems in cyclists include; patellofemoral joint (syndrome), quadriceps tendinitis, patella tendinitis, iliotibial band syndrome, medial plica problems, patella bursitis, hamstring tendinitis and pes-anserinus bursitis. In addition to the above conditions, routine musculoskeletal screening for other problems such as muscle imbalance, swelling, ligamentous injuries, degenerative changes of  joints is important. The image on the right shows quadricep muscle imbalance established during our screening process.

Muscle imbalance

When evaluating knee pain it is very important to consider the many pedisposing factors. These include; cyclist, anatomical factors (foot and limb alignment), shoe choice, shoe insert, cleat style and position and pedal system, bike position, seasonal variations (early cycling season), training distance and intensity, and numerous human anatomical factors such as inflexibility, muscle imbalance, patellofemoral malalignment, leg-length discrepancy etc. Differentiation between actual (true) leg-length and apparent (functional) leg-length is paramount.

Patellofemoral pain syndrome 

Sometimes called "anterior knee pain" or "runner's knee" or "cyclists knee"( 3, 4, 13), patellofemoral (pa-tell-oh-FEE-mor-al) pain syndrome (PFPS) is a condition that causes pain behind or around the kneecap. Cyclists with patellofemoral pain syndrome have anterior knee pain that typically occurs when cycling and often worsens when they are descending steps or hills. It can also be triggered by prolonged sitting. If not addressed, it can lead to fraying (wear) and damage to the underlying patellar cartilage (see image below), sometimes referred to as chondromalacia. Reasons for the high incidence of PFPS include; high forces generated on joint surfaces during knee flexion (1,2), abnormal patella / knee tracking caused by structural variations of the lower-limb and foot (14-16), exacerbated by high training loads (17) and/or lack of pedal float (18,19). Davis and Hull (20) found forces applied to the pedal can reach three times body weight during the downstroke.

Cyclists knee

Fraying of cartilage

Foot and cleat positions must be thoroughly evaluated in cyclists presenting with anterior knee pain. Excessive foot pronation, for whatever reason, increases the quadriceps angle (Q angle), which leads to muscle imbalance and abnormal tracking of the patella within the femoral groove. Cycling typically involves a piston like, symmetrical motion of the legs for power generation and smooth rolling transition between the contact points of the PFJ. Abnormal tracking of the patella can result in wear on the posterior surface of the patella (6, 14) - see image left. The main reason for the predominance of PFP problems in cycling is the force that the riders generate at the PFJ surface. These forces can be exacerbated due to abnormal biomechanics and abnormal knee tracking. Abnormal biomechanics result from; incorrect saddle position, usually too low and/or too far back (aft), quadriceps muscle imbalance or alterations in muscle pattern activities e.g. weak vastus medialis. However, addressing abnormal tracking of the patella (knee) due to lower-limb and/or foot misalignment is usually one of the key areas for a successful outcome.

Iliotibial Band Syndrome

ITB stands for ilio tibial band, it can also be known as the iliotibial tract. It is not a muscle, it’s a band of strong connective tissue (fascia) that runs the entire length of the thigh, from the top of the hip to knee attaching at the outside of the lower knee, the knee joint capsule and the patella (kneecap). Many authors consider ITB problem to be the second most frequent knee injury in cycling. ITB syndrome is an inflammatory condition which develops when the ITB repeatedly rubs over the lateral condyle of the knee during repeated flexion and extension of the knee joint. The pain occurs on the outside of the knee and is often represented by a sharp or stabbing pain. The area may become warm / hot due to inflammation of the fibrous tissues which make-up the ITB. The ITB tissue becomes irritated due to friction, typically when the knee is approximately at 30° of full extension. The literature suggests the main causative factors include; anatomical abnormalities which cause excessive foot pronation, varus and valgus knee positions, leg-length differences, incorrect cleat positioning, saddle too high, saddle too far back (aft), high training loads, muscle imbalance e.g. tight gluteus maximus and tensor fascia lata (TFL) muscle (1, 5, 10, 21).

Femoral area of friction

Similar to most overuse injuries, successful treatment of ITB problems requires an understanding of its cause(s), which can be multifactorial. Saddles that are too far back cause excessive forward reach for the pedal, stretching the ITB. Increased tension or tightness on the ITB may be caused by tight muscles, namely the gluteus maximus and TFL. In these cases, a musculoskeletal rehabilitation programme designed to stretch the offending muscles, allied with appropriate manual therapy can help release tension. Studies have shown that weakness in the gluteus medius (often observed in cyclists) can also overload the TFL, and the ITB into which in inserts. Therefore, core and pelvic stability / strengthening may prove beneficial. The femoral area of friction (see image) has been described as the 'impingement zone’, this represents approximately when the knee is at 30 degrees of extension. Therefore, lowering the saddle below the impingement zone to somewhere between 35 and 40 degrees will release tension within the ITB, thereby help the tissue to settle down. Both excessive varus and valgus knee positions have been reported to cause ITB problems. Correcting any excessive malalignment problems at the foot/pedal interface can often prove beneficial.

Medial plica problems

Although approximately 30% of the general population is born with a medial plica – the plica does not necessarily cause any problems unless repeatedly traumatised or irritated. Medial plica irritation is a very common source of anterior knee pain in cyclists due to repetitive irritation associated with overuse and anatomical / biomechanical alignment problems. If the condition is ignored, the plica can become thickened, fibrotic and painful (10).

Symptoms

The main complaint is an intermittent, dull aching pain in the area medial to the patella above the joint line (22). Some cyclists complain of crepitation (popping sensation), catching, and locking events (23). Pain increases with activity, especially during cycling when the knee is repeatedly flexing and extending (10). Pain has been reported upon arising from a prolonged sitting position, and pain when going up and/or down stairs.

From: www.Kneeguru.co.uk

From: www.Kneeguru.co.uk

Physical examination   

On examination, the cyclist typically has tenderness over the medial aspect of the knee near the joint line. In some cases, a thickened plica can be palpated by rolling the fingers along the tissue between the medial femoral epicondyle and the medial border of the patella. Refer to image.  

Causes

It has been reported that poor quadriceps muscle tone and/or tight hamstring muscles are often associated medial plica problems. Anatomical / biomechanical malignment problems such as valgus knee alignment, internal tibia (knee) rotation and excessive foot pronation (adversely impacting on the foot/pedal interface) increase the pressure on the medial plica resulting in pain during cycling (10).

Location of medial plica

Treatment

Initial treatment involves physiotherapy approach, applying ice, reducing activity and if necessary rest. When acute symptoms have been resolved a rehabilitation program should be used to address musculoskeletal imbalances. It is important to address any anatomical / biomechanical alignment problems at the foot/pedal interface. In cases that fail to respond, corticosteroid injections may be given. In chronic cases, failing to respond to the above, surgical treatment using arthroscopy is usually appropriate (22, 23).

Pelvic instability

Strength and balance in the muscles situated in and around the pelvis and core is prerequisite to symmetry and paramount for efficient cycling, whether this involves road, track or mountain biking (6, 24). Excessive foot pronation is responsible for transmitting deleterious forces up the kinetic-chain generating excessive pelvic motion primarily in the frontal plane and transverse plane (see below). Excessive pelvic motion can be very disruptive – creating pelvic and core instability, pelvic muscle imbalance, sacro-iliac joint dysfunction (rotated innominate - functional leg-length difference), and lower back pain.

The consequences of pelvic instability are loss in pedalling symmetry, which can lead to power loss and increased injury risk. Pelvic instability arising from excessive pronation usually presents with function leg-length differences. The rider appears twisted while sat on the saddle and sits to one side. The saddle often shows signs of uneven wear.

                               Excessive pelvic motion - frontal plane

                           Excessive pelvic motion - transverse plane

Leg-length differences (LLD)

It is paramount that competitive cyclists are checked for leg-length difference (LLD), however without the use of radiographs (x-rays), leg-length differences (LLD) are difficult to reliably diagnose. LLD can be classified by two main categories, anatomical and functional. Great care is required when attempting to diagnose LLD and when differentiating between the two categories i.e. anatomical and functional. Anatomic LLD is often mistaken for functional LLD; inadvertently compensatory packing shims are fitted to the cycling shoe unnecessarily, further exacerbating the problem. This issue alone highlights the importance of a comprehensive musculoskeletal screening.

Anatomical differences, which are true LLDs, result from an actual anatomic shortening of one or more of the bones of the lower extremity. Whereas, functional LLD is not a true leg-length difference, it usually occurs as a result of muscular weakness or inflexibility at the pelvis or foot and ankle complex. These include pelvic obliquity, adduction or flexion contractures of the hip, foot disorders including excessive pronation. In the absence of x-rays, and since there is not one reliable test to determine LLD, it is recommended that a variety of tests be used in the clinic to arrive at a reliable hypothesis (26-31). Ideally, the therapist / clinician should use a battery of LLD tests taken with the patient weightbearing and non-weightbearing, prone and supine – combined with palpatory and visual skills.

LLD check standing

LLD check prone

Metatarsalgia (hot-foot)

The transverse arch, sometimes known as the metatarsal arch, stretches from the big-toe across to the little-toe. This arch can be subjected to extreme plantar pressures (forefoot pressures) during intense cycling efforts. If the arch collapses, the cyclists will suffer from a condition commonly known amongst cyclists as 'hot-foot'. The medical term is metatarsalgia and is often described as a burning or aching sensation under the metatarsophalangeal joints (balls of your toes) shown as red in image. The above symptoms may be accompanied by shooting pains, tingling or numbness in the toes. Conventional treatment for this condition usually involves fitting a firm metatarsal pad / button to support the transverse arch.

The primary reason why the transverse arch collapses is due to excessive pronation (forefoot tilt). First and foremost, the foot should be supported by appropriate varus wedges and a longitudinal arch support, and then if necessary, a metatarsal pad. This approach assumes the problem is not down to tight cycling shoes.

References

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