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INJURY PREVENTION AND TREATMENT

By Warren Hutson, MSc, DO

Cycling has been described as balancingthe body on an unstable system, whilesimultaneously providing motive forcescombined with speed and direction.

The two major components are themachine (cycle) and the human body, theformer is adjustable but not adaptable,while the latter is adaptable, but only tocompensate within certain limits. If onegoes outside those limits then injuries,traumatic or overuse, will almost certain-ly occur in the athlete's cycling career.

The human body makes contact with thebike at three points; hands (handlebars),pelvis (saddle) and the feet (pedals). Ifthese three points of contact are disre-garded and set up incorrectly then almostcertainly overuse and traumatic injurieswill occur. One can try to adjust the biketo the person but one cannot adjust theperson to the bike without a great deal ofdifficulty.

OVERUSE INJURIESThese type of injuries occur in most sport-ing activities and can be treated with similar treatment regimes, but whentreating cycling injuries one must takeinto consideration the forces applied to astructure over a period of time. In cyclingthis can apply to an increase in mileage orthe intensity of the training regime (hillwork or big gears), these are the mostcommon cause of overuse injury. Onceagain one has to look at the set up of thebike and its components ie. leg lengthdiscrepancy or misaligned cleats.

Overuse injuries can be graded accordingto pain or persistence of pain:Grade 1 Pain only after activityGrade 2 Pain starts during activityGrade 3 Pain persists the next dayGrade 4 Pain is constant

Treatment principlesCycling is no exception, applying generalprinciples which are common to mostsports should prevent overuse injuries.Allow the body sufficient time to adapt tothe increase in activity. Levels of activityshould be increased gradually withallowance for rest, heavy and light train-ing regimes, with time for a warm up, cooldown and with stretching incorporatedinto the training. Track cyclists tend to

spend more time in the above routinesthen their road or off-road colleagues.

General treatment principles Adjust activity to allow healing,

reduced activity maybe preferable tocomplete rest

Reduce any inflammation using ice,oral non-steroidal anti-inflammatorydrugs (NSAIDs), cortisone injectionsand manual (physical) therapy includ-ing ultrasound, contrast baths andmassage

Adjust if needed the biomechanicalstress or external factors in cycling.Check and alter the bike if needed,cleat position. The bike must fit therider not the other way round

General injury types Tendinitis - inflammation or irritation

of a tendon can be caused by differentreasons ie. ill-fitting shoe or cleat posi-tion. Falls may also cause bruising totendons and overuse or extra or suddenforces may cause strains. Pain can arisefrom nerve irritation within the tendonand must be taken as a warning thatsomething is wrong, the tendon maybeswollen or stretched or small tears may

have occurred. Many overuse injuriesaround the knee are overuse tendoninjuries.

Bursitis - irritation or inflammation ofthe fluid filled cystic structures foundbetween surfaces that facilitate move-ment over each other. When one ofthose surfaces is also tendon then it isdifficult to distinguish between ten-dinitis and bursitis. This is of little rel-evance because the treatment regimeis the same for both.

Compression neuropathy - an abnor-mality of nerve function often causedby pressure on a nerve or the bloodvessels that supply it. The commoncycling neuropathies are cyclist's palsy(ulnar nerve) and penile numbness, acommon problem related to the abnor-mal function of the pudendal nerve.

Stress fracture - an overuse injury ofbone which are relatively uncommon incycling.

SPECIFIC INJURIES Knee injuries The most common area for injuries incyclists is the knee, from possibleoveruse, trauma and the cycling position.Overuse injuries in and around the kneeare due to the repeated and constantstresses of riding a bike and represent themost common problem that cyclists seekmedical advice for. The common overuseinjuries are chondromalacia patellae,patellar, quadriceps, anserine, tibialisanterior tendinitis, and prepatellar bursi-tis, plica (patellofemoral ligament inflam-

CYCLINGINJURIES PREVENTION AND TREATMENT

Saddle up: Fitting Body to Bike- Article in sportEX health issue9 - detailed information on

how to achieve the correct biomechanical set up of a bike

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mation), iliotibial band syndrome andtight hamstrings.

Table 1 outlines the possiblecauses and possible solutionsthat can be made to thecyclist's position on the bike.

InterventionThere are many treatmentregimes for any of these problems but themost important thing is to check the rid-ing position and alter as suggested above.After this use RICE and appropriate treat-ments such as massage, stretching andstrengthening exercises.

Neck pain The biggest problem cyclists have in thisarea is related to the musculoskeletal painin the back of the neck, pain from this areausually travels upwards causing headaches.You must consider a neurological originand examination should take place onthose grounds especially if there are symp-toms associated with upper-extremitysymptoms such as pain and loss of sensa-tion or loss of power in the arms/hands. Ifthere is any pain in front of the neck or jawconsider urgent medical help as this maybe a symptom of cardiac origin.

CausesNeck pain can follow strain or overuse anda possible cause can be a fall or crash. Thearea may be at the back of the head butcould become more generalised. If nervesare involved, radiating pains may travel tothe upper extremities.

Possible causes include: Muscle strain or spasm Arthritis usually degenerative osteo-

arthritis. Strain on vertebral jointsfrom misalignment, usually secondaryto disc problems

Herniation or bulge of an intervertebraldisc, pain may radiate to the upperextremities.

InterventionThe older cyclist tends to have a combi-nation of muscle strain and degenerativechanges often associated with age. Inyounger cyclists neck pain is usuallycaused by muscle strains. Cycling neckstrains are often caused by long rides andover-exertion during racing. The positionon the bike can be a factor in helpingovercome this problem. The racing posi-

tion is usually more aerodynamic then thenormal training/riding position, thereforecyclists should be encouraged to ride atleast some of their trainingrides in racing posture.Stretching and flexibilityexercises are recommendedfor relieving this problem.

Scapular syndromeThe pain is usually situated inthe scapula/upper back area where it mayor may not be associated with neck,shoulder or arm symptoms. It is possiblethat it may not be cycling related and canoverlap the back pain areas.

Causes Extended riding time, longer training/racing rides giving more time for other

factors to develop caus-ing tension in the areaand rough terrain causingjarring especially in offroad cyclists are commoncauses. Another causemay be too much pres-sure due to abnormal

weight distribution, particularly moreweight on the upper arm and neck area,causing excessive use of upper back andneck musculature ie. during sprinting,climbing.

CYCLING INJURIES

TABLE 1: BIKE ADJUSTMENTS BASED ON LOCATION OF KNEE PAIN

Location Causes Solutions

Anterior Seat too low Raise seatSeat too far forward Move seat backClimbing too much Reduce climbing activityBig gears, low rpm Lower gears, more rpmCranks to long Shorten cranks

Medial Cleats - toes point out Modify cleat position - toes inFloating pedals Limit float to 50 or fixed cleatExiting clipless pedals Lower tensionFeet too far apart Modify cleat position move closer

Shorten bottom bracket axleUse cranks with more offsetShim pedal on crank 2mm

Lateral Cleats - toes point in Modify cleat - toe outConsider float pedals

Floating pedals Limit float to 50 or fixed cleatFeet too close Modify cleat position move apart

Longer bottom bracket axleUse cranks with more offsetShim pedals on crank 2mm

Posterior Seat too high Lower seatSeat too far back Move seat forwardFloating pedals Limit float to 50 or fixed cleat

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InterventionCheck bike position, make sure nothinghas caused a change to posture on thebike. Stop any upper body exercises(weights), which may cause increase insymptoms, RICE, strengthening of upperback/neck muscles, increase in ROM andflexibility.

Cyclists palsy (ulnar neuropathy) There can be a number of signs and symp-toms in relation to this condition whichcan sometimes be ignored when the symp-toms overlap with carpal tunnel-likesymptoms, but both can be related to thetwo nerves of the forearm (ulna and medi-al). In cyclists palsy (ulnar nerve) theheel of the hand along with the little andring (third) fingers are usually involved,causing pain, tingling, numbness andweakness, it is usually the hand that stayson the bars when drinking. The symptomsare worse whilst riding and for severalhours afterwards.

Causes Extended riding time, rough terrain,improper hand positions, too much pres-sure with weight distribution placed ontohands and wrists.

InterventionAlter the position to take pressure of thehands and wrists and use extra padding(mitts/gloves or handlebar tape). Reducethe time spent on the bike if really need-ed. Mobility of the carpal area will helpand massage to the forearm musculature,stretching and strengthening also helpsalong with NSAIDS.

Carpal tunnel syndromeThe pain pattern for this complaint con-sists of tingling, pain, numbness andweakness in the hand following the pathof the medial nerve. Symptoms usuallypresent in the thumb, index, middle andring fingers, with symptoms travellingabove the wrist, elbow or even to theshoulder and are often worse at night. Itis common amongst those who bend theirwrist at work ie. therapists and keyboardoperators.

CausesThe medial nerve is compressed at or in thewrist and inflammation caused by the com-pression can be present. Cycling-relatedcauses are once again extended time onthe bike, rough terrain, improper wristpositioning or too much weight bearing.

InterventionsTreatment on the bike is the same ascyclist's palsy. Off the bike try reducingrepetitive motions at work or at home.Use RICE, wrist braces or splints, and workon strengthening of the wrists, shouldersand arms reducing pressure on the carpalarea. Cortisone injections may be helpfulas may NSAIDS. Surgery should be a lastresort.

THE AUTHORWarren G. Hutson MSc DO gained his masters in sports injuries and therapy in2001 from Manchester MetropolitanUniversity and was the first osteopath todo so. He has over twenty five years experience in treating cyclists at every levelfrom club to elite riders. He has workedwith a number of professional teams aswell as the Great Britain Olympic teamssince 1982.

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