Cycling Injuries

Through our unique 3-Step Integrated Bikefit-Package we have become specialists in treating cycling injuries. The vast majority of overuse injuries are caused by an improper riding position (Bikefit) and/or anatomical and biomechanical deficits associated with the rider. Our philosophy is to establish cause(s) and thereafter eradicate through our scientific approach.

We are specialists in resolving cycling-related overuse injuries

Based in the North West of England, many of our clients (cyclists and triathletes) come from Manchester, Merseyside, Leeds, Cumbria and beyond. We specialise in dealing with long standing cycling injuries e.g. knee and low-back. We are proud of our scientific approach to all aspects of cycling e.g.cycling biomechanics, cycling injuries, and cycle fitting. 

The vast majority of overuse injuries are caused by an improper riding position (Bikefit) and/or anatomical and biomechanical issues associated with the rider. Through our unique 3-step Bikefit-Package we are specialists in establishing cause(s) and resolving problems.

Common Overuse Injuries

Research shows that the most common sites of overuse injury are the knee, lower back, perineum (the region between the coccyx and the pubic bone), hand and foot1. The knee is the most common site2, affecting an estimated 40% to 60% of all regular recreational and elite cyclists, both on and off the road3.

Cause of injury

An improper body position (cycle set-up) is a frequent cause of overuse injury4,5,6. The most common factors that contribute to overuse injury include pedal systems7, issues at the shoe/pedal interface8,9, saddle height10, saddle tilt11, saddle design and trunk angle12, handlebar position13and improper biomechanics linked to misalignment of the foot or leg14.

Patellofemoral pain syndrome

The most commonly reported overuse knee problem in cyclists is patellofemoral (pa-tell-oh-FEE-mor-al) joint pain, often labelled‘cyclists knee’ 15. The condition is characterised by pain or discomfort behind or around the Patella (kneecap). Cycling typically involves a piston like, symmetrical motion of the legs for power generation and requires a smooth rolling transition between the contact points of the joint surfaces. Abnormal movement or ‘tracking’ of the patella can affect this transition and result in wear on the posterior (back) surface of the patella4 – see image on the right. Causes of abnormal tracking include improper saddle height i.e. too low16, saddle position that’s too far forward17 and problems at the shoe/pedal interface1. This includes pronation (rolling inward of the foot) and improper foot position8 linked with misalignment of the foot or leg14.

ITB syndrome (Iliotibial band)

ITB syndrome is arguably the second most frequently reported knee problem4 in cyclists. ITB stands for iliotibial band, which can also be known as the iliotibial tract. ITB syndrome is an inflammatory condition which develops when the band repeatedly rubs over the lateral condyle (outside) of the knee during repeated flexion and extension of the knee joint during pedalling. The pain occurs on the outside of the knee and is often represented by a sharp or stabbing pain17.

The ITB 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 the knee attaching at the outside of the lower knee. Similar to most overuse injuries, successful treatment of ITB problems requires an understanding of its cause(s), which can be multifactorial. Common causes include improper saddle height i.e. too high; saddle too far back18, 19, improper cleat position17, and excessive pronation linked with leg and foot alignment problems14.

Lower Back Pain

Lower back pain (LBP) appears to be common in cycling, yet few scientific studies exist  that try to explain the cause and risk factors6. The prevalence of LBP in cyclists has been reported as up to 50% in recreational cyclists20 and 22% in professional cyclists5. Contributing factors to the development of LBP have been linked  to increased training loads20, improper cycle set-up i.e. low handlebars provoking increased trunk flexion20, and improper saddle level/tilt21Generally, the conventional saddle (with nose) should be set horizontally ‘level’, or with a slight tilt (±3º), using a spirit level18. Women often prefer the front to be angled slightly downwards to reduce pressure on the perineal area13 and in some cases of LBP21. Cyclists adopting the classic aero position, with a highly flexed trunk, often prefer a more drastic forward tilt (≤10º), or prefer to use a ‘no-nose’ saddle22. Cyclists that adopt an upright trunk position, typically mountain-bike and recreational cyclists often prefer a level saddle or tilted slightly backwards18. This position can also help alleviate pressure on the ulnar nerve by redistributing the body weight1

Perineum

Research shows that cyclists are more likely to suffer from urogenital symptoms than their sedentary counterparts23,24. For men, typical symptoms include temporary groin numbness, pain, tingling sensations, erectile dysfunction, and frequent need to urinate. For women, typical symptoms include frequent bladder infections and painful skin irritations. 

The problem lies with the vulnerable perineum, the area between the genitals and the anus that is a mass of soft tissue, nerves and blood vessels. When we sit on a saddle for prolonged periods we compress the delicate structures (nerves and blood vessels) which can lead to the aforementioned urogenital symptoms and conditions. Complaints associated with increased perineum saddle pressures are common in male24 and female cyclists13. A recent review of research studies reported complaints in 50-91% of cyclists25. The main reasons for perineum pain and urogenital symptoms include prolonged saddle pressure26, more specifically, excessive body weight and saddle design27, saddle level/tilt21 and improper handlebar position12,13, most of which can be alleviated by a proper discipline-specific Bikefit.

When we look closely at the anatomy of our sit bones, they are wide at the back and gradually become narrower at the front. This anatomical feature has implications on riding position – meaning the contact point with the saddle moves depending on riding position. Riders that use an upright riding position sit towards the back part of their sit bones, thus require a wider saddle. When we bend forward as in an aero position (triathlete) our body weight (contact point) moves forwards on to the narrower frontal part of the sit bone, thus necessitates a narrow saddle. On average, the pelvic (sit bone) width is 118mm for males and 130mm for females. Many modern saddles have a partial or complete cut-out designed to decrease pressure on the perineum. Some saddles are nose-less – designed to leave the perineum totally unloaded. In a recent study involving USA police officers, traditional saddles were replaced with a nose-less variety. Although the nose-less saddle requires some getting used to, the majority of officers found the transition fairly straightforward. 

After a six month trial the number of men reporting improvements in genital sensation increased dramatically. Men reporting lack of genital numbness increased from 27% to 82% after using nose-less saddle. Moreover, around 97% of officers continued to use the nose-less saddle after the trial had finished27. In summary, perineum pain and urogenital problems are common in both male and female cyclists. Although saddle design is down to personal choice, proper riding-position (Bikefit), pelvic-width and saddle-tilt are critical factors in minimising urogenital problems and achieving cycling comfort.

Foot

‘Hot foot’ or the medical term ‘Metatarsalgia’ is arguably the most common problem affecting cyclists.   It is a condition where the nerves and tissues close to the ball of your foot are repeatedly squeezed and aggravated by the long metatarsal bones. The symptoms represent throbbing, burning pain and tenderness on the sole of the foot, usually over the 3rd and 4th metatarsophalangeal (toe) joints, with pain radiating along corresponding toes32.

The cause can simply be shoes that are too tight leading to compression of the nerves32, or more frequently the cause is related to either under-pronation (pes cavus) or over-pronation of the foot, which in turn, places extra loading on the forefoot33. Although there are no robust research studies on cause and subsequent treatment of metatarsalgia in cycling, anecdotally the use of appropriate shoe inserts to support the relevant arch(s) and forefoot wedges appear to help.

Hand

The most common overuse hand injury is chronic ulnar nerve compression, a condition termed ‘Cyclist’s Palsy’28; the median nerve is less commonly involved1. Ulnar and median nerve compression is common in experienced and inexperienced cyclists28, in long distance cyclists29 and mountain bikers30. Symptoms of ulna nerve compression typically present as numbness and/or paresthesia in the fourth and fifth finger as a result of sustained pressure on the hypothenar eminence (fatty part of the palm of your hand below the little finger). As it would appear, the simple solution is to reduce pressure on the hypothenar eminence. Often, this can be achieved by simple adjustments to body position, designed to unload hand pressure on the handlebars31, by regular changes in hand position28, or by wearing padded gloves. A nose down saddle (forward tilt) tends to redistribute the body-weight, moving it forwards, as a result this can lead to increased pressure on the hands and hypothenar eminence. Likewise, hand pressures tend to increase when the handlebars are lower than the saddle31

References

  1. Schwellnus, MP., &  Derman, E.W. (2005) Common injuries in cycling: Prevention, diagnosis and management, South African Family Practice, 47(7):14-19
  2. Silberman, MR. (2012) Bicycling injuries, Current Sports Medicine Reports, 12(5):337-345
  3. Wanich, T., Hodgkins, C., Columbier, J.A., et al., (2007) Cycling injuries of the lower extremity, Journal of the American Academy of Orthopaedic Surgeons, 15:748-756
  4. Callaghan, MJ. (2005) Lower body problems and injury in cycling, Journal of Bodywork and Movement Therapies, 9:226-236
  5. Clarsen, B., Krosshaug, T., & Bahr, R. (2010) Overuse Injuries in Professional Road Cyclists, American Journal of Sports Medicine 38(12):2494-2501
  6. Marsden, M. (2010 Lower back pain in cyclists: a review of epidemiology, pathomechanics and risk factors: review article, International SportsMed Journal11(1):216-225
  7. Wheeler, JB., Gregor, RJ., & Broker, JP. (1995) The effect of clipless float design on shoe-pedal interface kinetics and overuse knee injuries during cycling, Journal of Applied Biomechanics, 11:119-141
  8. Berry, A., Phillips, N., & V. Sparkes, V. (2012) Effect of inversion and eversion of the foot at the shoe-pedal interface on quadriceps muscle activity, knee angle and knee displacement in cycling, Journal of Bone and Joint Surgery, British Volume 94.SUPP XXXVI: 61-61
  9. Dinsdale, N.J. (2012) Musculoskeletal Screening of Competitive Cyclists prior to Cycle set-up, Conference presentation – unpublished. 40th Annual Pedal Power Conference, Association British Cycling Coaches, Coventry, 2012
  10. Peveler, W., & Green, J. (2011) Effects of saddle height on economy and anaerobic power in well trained cyclists, Journal of Strength and Conditioning Research,25(3):629-633
  11. Sommer, F., Goldstein, I., & Korda, J. (2010) Bicycle Riding and Erectile Dysfunction: A Review, The Journal of Sexual Medicine, 7(7):2346-2358
  12. Carpes, F., Dagnese, F., Kleinpaul, J., et al., (2009) Bicycle saddle pressure: Effects of trunk position and saddle design on healthy subjects, Urologi  Internationalis, 82:8-11
  13. Partin, S., Connell, K., Schrader, S., LaCombe, J., et al., (2012) The bar sinister: Does handlebar level damage the pelvic floor in female cyclists? Journal of Sexual Medicine,9:1367–1373
  14. Dinsdale, N.J., & Dinsdale, N.J. (Miss) (2014) Modern-day Bikefitting can offer proactive therapists new opportunities, sportEX dynamics, 39:25-32
  15. Sanner, WH., & O’Halloran, WD. (2000) The biomechanics, etiology, and treatment of cycling injuries, Journal of the American Podiatric Medical Association, 90(7):354-376
  16. Bini, R., Hume, P., & Croft, J. (2011) Effects of bicycle saddle height on knee injury risk and cycling performance, Sports Medicine, 41(6)463-476
  17. Asplund, MD., & St Pierre, P. (2004) Knee pain and bicycling, The Physician and Sports Medicine, 32:23-30
  18. Burke, E., & Pruitt, A. (2003) Body positioning for cycling, in E. Burke (ed.) High-Tech Cycling, USA: Human Kinetics, pp. 69-92
  19. Farrell, C., Reisinger, K., & Tillman, M. (2003) Force and repetition in cycling: possible implications for iliotibial band friction syndrome, The Knee, 10:103-109
  20. Schulz, S., & Gordon, S. (2010) Recreational cyclists: The relationship between low back pain and training characteristics, International Journal of Exercise Science, 3(3):79-85
  21. Bressel, E., & Larson, B. (2003) Bicycle seat designs and their effect on pelvic angle, trunk angle, and comfort, Journal of Medicine and Science in Sports and Medicine, 35(2):327-332
  22. Dinsdale, N.J., & Dinsdale, N.J. (Miss) (2011) The benefits of anatomical and biomechanical screening of competitive cyclists, sportEX dynamics, 28:17-20
  23. Carpes, F., Dagnese, F., Kleinpaul, J., et al., (2009) Bicycle saddle pressure: Effects of trunk position and saddle design on healthy subjects, Urologi  Internationalis, 82:8-11
  24. Sommer, F., Goldstein, I., & Korda, J. (2010) Bicycle Riding and Erectile Dysfunction: A Review, The Journal of Sexual Medicine, 7(7):2346-2358
  25. Leibovitch, I. & Mor, Y. (2005) The vicious cycling: bicycling related urogenital disorders,European Urology, 47(3):277-286
  26. Bressel, E., Nash, D., & Dolny, D. (2010) Association between attributes of a cyclist and bicycle seat pressure, Journal of Sexual Medicine, 7:3424–3433
  27. Schrader, S., Breitenstein, M., & Lowe, B. (2008) Cutting off the nose to save the penis,Journal of Sexual Medicine, 5(8):1932-1940
  28. Slane, J., Timmerman, M., Ploeg, H., et al., (2011) The influence of glove and hand position on pressure over the ulnar nerve during cycling, Clinical Biomechanics,26(6):642-648
  29. Akuthota, V., Plastaras, C., Lindberg, K., et al., (2005) The effect of long-distance bicycling on ulnar and median nerves: an electrophysiologic evaluation of cyclist palsy,American Journal of Sports Medicine, 33(8):1224-1230
  30. Sabeti, M., Serek, M., Geisler, M., et al., (2010) Overuse Injuries Correlated to the Mountain Bike’s Adjustment:  The Open Sports Sciences Journal, 3:1-6
  31. Patterson, J., Jaggars, M., & Boyer, M. (2003) Ulnar and median nerve palsy in long-distance cyclists:  American Journal of Sports Medicine, 31(4):585–589
  32. Hasouna, H., & Singh, D (2005) Morton’s metatarsalgia: Pathogenesis, aetiology and current management. Act Orthop, Belg. 71: 646-65
  33. Cornwall, M.W. (2000). Common pathomechanics of the foot. Journal of Athletic Therapy Today. 5,10-16.