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Overuse Injuries in Cycling:How, Why, Treatment and

PreventionDrew A. Lansdown, MD

Assistant Professor in Residence

Sports Medicine & Shoulder Surgery

UCSF Department of Orthopaedic Surgery

Disclosures

No relevant financial disclosures for this presenation.

Additional Disclosures:

• Research/Educational Support from:

‒ Arthrex, Inc.

‒ Smith & Nephew

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Cycling in San Francisco

128,000 trips made by bicycle daily

16% of San Francisco residents identify as “frequent cyclists”

Unfortunately, Injuries Are Common

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Overview

Injury patterns for professional and recreational cyclists

Factors that contribute to overuse injuries in cyclists

Etiology, treatment, and prevention of specific common overuse injuries

What Is Overuse?

Tissue damage from repetitive submaximal loading

Inadequate recovery time for microtrauma to bone, joint, and soft tissue

Cycling is repetitive1,2

• Professional cyclists ride 25,000-35,000 km/year

• Recreational cyclists report >7000 km/year

• 5,000 pedal revolutions per 1 hour of cycling

Histology of Tendinosis

Image: https://www.dovepress.com/cr_data/article_fulltext/s76000/76325/img/fig3.jpg

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Interviewed 109 cyclists of 7 professional teams in training camps

Inquired about injuries over the past 1 year

94 total injuries registered

• Low back and knee injuries are most common• Knee injuries responsible for most time missed

• Back pain prevalence constant across season

• Knee pain most common in preseason

• Possibly due to initial strength/coordination

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Cross-sectional Study of 518 Recreational Cyclists

85% reported at least 1 non-

traumatic injury over 1 year period

48% Cervical Spine

30.3% Thoracolumbar Spine

41.7% Knee

Affected Joint Severity

31% Required Medical Treatment

2.7% Quit Cycling

11.5% Stopped Cycling, Mean 42.8 Days

Cyclist Anatomy• Quadriceps Angle• Patellar Tracking• Spinal Alignment• Foot Alignment

Cyclist Anatomy• Quadriceps Angle• Patellar Tracking• Spinal Alignment• Foot Alignment

Bicycle Fit• Seat Height

• Seat Position• Handlebar Height

• Foot Position• Crank Length

Bicycle Fit• Seat Height

• Seat Position• Handlebar Height

• Foot Position• Crank Length

Training Factors• Strength• Flexibility• Cadence

• Resistance• Inclines

• Recovery Time

Training Factors• Strength• Flexibility• Cadence

• Resistance• Inclines

• Recovery Time

Potential for Overuse Injury

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Seat HeightInfluences knee/hip load and

oxygen consumption

Seat PositionInfluences tibial

alignment over feet

Handlebar Height & ReachLower height = greater

aerodynamics

Crank LengthLonger crank = greater mechanical advantage though more hip/knee

range of motion

FIT

Seat Height Methods4

Method Description

Hamley and Thomas5

• Height set at 109% of inseam leg measurement

• Produce longer time to exhaustion

TrochantericLength6

• 100% of length of greater trochanter to floor• Cycling economy better at 96% of 100%

relative to 104%

Ischial Tuberosity8

• 113% of length of ischial tuberosity to the floor

LeMond7 • 88.3% of distance from top of saddle and center of bottom bracket

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Seat Height Methods4

Method Description

Heel7 • When seated on saddle, knee fully straight with heel on pedal

Holmes9 • Knee flexion angle at 6 o’clock set to 25-30 degrees

• 25 degrees has lower VO2 compared to 35 degrees or 109% inseam

Howard7 • Knee flexion angle at 6 o’clock of 30 degrees with neutral foot

Common Overuse Injuries

Knee

Hip

Foot/ankle

Back

Neck/Shoulder

Wrist/Hand

Image: https://decaironmantraining.files.wordpress.com/2014/02/cycling-suffering-pain-barrier.jpg?w=600&h=516

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Patellofemoral Syndrome

Common cause of anterior knee pain

• >50% of knee pain was around patella during recreational event11

Presents as pain behind patella during or after activity

Due to:

• Increased pressure across PF joint10

• Patellar maltracking

Bony Alignment Can Contribute to Patellofemoral Syndrome

Q angle

• Clinical measurement of patellar tracking

Lateral tibial tubercle position

External rotation of the tibia

Foot alignment in pronation

Increased femoral anteversion

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Cyclist Factors Contributing to PF Syndrome

Rely on quadriceps strength and balance

Patellofemoral pain may be due to:

• Lateral tracking of patella

• Weakness or dysplasia of vastus medialisobliquis muscle

• Tight hamstrings

Image: http://morphopedics.wdfiles.com/local--files/osteoarthritis-of-the-knee/anatomypic.png

Evaluated knee joint loads during ergometric cycling

6 healthy men

Compressive forces can be decreased by:

• Reduction in work load

• Increase in saddle height

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Evaluated 17 cyclists:

• 10 without patellofemoral pain

• 7 with patellofemoral pain

PF pain group had:

• Earlier deactivation of vastus medialis

• Earlier biceps femoris contraction than semitendinosus

• Decreased activation of semitendinosus

Bicycle Fit Factors Contributing to PF Syndrome Low seat position

• Adjust so knee is in more extended position with pedal at 6 o’clock

• Aim for 25 degrees of knee flexion

Cleat position in pronation

• Adjust so hindfoot is neutral

Overly high resistance

• Low resistance training to maintain 80-90 rpm cadence

• Avoidance of hills while recovering

Images: https://www.goride.co.nz/wp-content/uploads/http://davesbikeblog.squarespace.com/

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Strategies to Treat PF Syndrome

Quadriceps strengthening

• Especially focus on VMO

Stretching

• Quadriceps

• Hamstrings

• Gastrocnemius-soleus

Patellofemoral brace or McConnell taping

Foot orthoses to adjust foot pronation and hindfoot alignment

Image: https://www.physioadvisor.com.au/wp-content/uploads/20193256300x300.jpg

Patellar Tendinitis

Patellar tendon connects patella to tibial tubercle

Repetitive microtrauma at tendon with insufficient time to allow for normal healing

Pain at the front of the knee, along the patellar tendon

Image: https://upload.orthobullets.com/topic/3015/images/mri2.jpg

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Patellar Tendinitis Treatment

Treat with stretching quads/hamstring/IT band

• Ice

• NSAIDs

Eccentric strengthening of quadriceps

Reduce training intensity until resolved

Some interest in PRP/biologic injections

Surgical treatment if refractory to all other treatment

Image: http://cdn.fix-knee-pain.com/blog/wp-content/uploads/2013/09/squat_on_flex_n_go_board-copy.jpg

Pes Anserine Bursitis

Pes anserine is insertion of three hamstring tendons on medial aspect of tibia

Bursa is a fluid-filled sac that allows for gliding of these tendons

Pain over medial proximal tibia

Treatment:

• Hamstring stretching

• Oral NSAIDs or topical NSAIDs

• Corticosteroid injection locally

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Iliotibial Band Syndrome

Pain at the lateral aspect of the knee

Iliotibial band (ITB) glides over lateral femoral condyle with knee flexion/extension

Causes:

• Higher seat position results in greater knee extension and may provoke this more

• Increased cadence = greater friction

• Tightness in ITB, gluteals, tensor fascia lata

Iliotibial Band Syndrome

Treatment:

• Higher resistance, lower cadence

• Lowering seat height

• ITB stretching

• Foam rolling

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Trochanteric Bursitis

Pain over the lateral aspect of the hip

May be caused/worsened with seat being too high

Treatment:

• ITB stretching

• Ice

• NSAIDs

• Corticoteroid injection

Iliopsoas Tendinitis

Psoas muscle

• Originates from lumbar spine

• Inserts at lesser trochanter

• Tightness can contribute to low back pain/core issues

Can manifest as hip/groin pain

Treatment:

• Lowering seat

• Stretching hip flexors

• Core strengthening

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Achilles Tendinitis

Pain at posterior aspect of calf/heel

May be caused by:

• Low seat position

‒ Knee flexion limits ability of gastrocnemius to contribute to calf power during pedaling

• Foot positioned posterior to center of pedal axle

‒ Increased motion at the ankle and stress at Achilles tendon

• Tight gastrocnemius/soleus complex

Achilles Tendinitis

Treatment:

• Correct fit problems

• Eccentric strengthening exercises, dorsiflexion stretching

• NSAIDs/ice

• Rest/reduction in training

Images: http://www.sportsinjuryclinic.net/images/stretches/eccentric-heel180a.jpghttp://www.sportsinjuryclinic.net/images/stretches/Calf-stretch-on-step.jpg

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Low Back Pain

30% prevalence over 1 year period between men and women in California3

• 75% of this was low back pain

Bicycle fit can contribute to malalignment of spine

• A long top tube extends lordoticlumbar posture

• Low handlebars exaggerate lordosis

Multiple small muscles contribute to stabilization of spine

Image: https://static1.squarespace.com/static/551476f6e4b0403810771cd7/t/55f8f2c3e4b0f3e154bd3e05/1442378962894/?format=1000w

Compared spinal kinematics and trunk muscle activity in cyclists with (N=9) and without (N=9) low back pain

Cyclists with pain trended towards:

• Increased lower lumbar flexion

• Loss of co-contraction of lower lumbar multifidus muscle

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Subjects with low back pain showed:

• Fatigue in arm muscles and postural spine musculature

• Reduced abdominal and back muscle thickness at rest and during contraction

• Greater lumbopelvic flexion

Position and pain may be improved with biofeedback training

40 cyclists

Lowered tip of saddle 10-15 degrees from horizontal in group with low back pain

72% reported no back pain

20% reported major reduction in occurrence/magnitude of pain

7% reported no change

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Treatment Recommendations for Low Back PainCore strengthening exercises

Biofeedback training for positioning of spine/pelvis

Consider changing saddle tilt

Neck/Shoulder Pain

Recreational cyclists:11

• 66% of riders had mild neck/shoulder injury

• 20% reported really uncomfortable neck/shoulder or had to change riding style or stop

Neck/shoulder problems more common towards the end of a tour-type event17

Image: https://www.exevalleyosteopathy.co.uk/single-post/2016/09/09/Neck-pain-in-road-cyclists---Why-and-what-can-you-do

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Neck/Shoulder Pain

Horizontal position

More trunk flexion –more aerodynamic

To compensate, neck hyperextends to allow horizontal gaze

Image: https://www.exevalleyosteopathy.co.uk/single-post/2016/09/09/Neck-pain-in-road-cyclists---Why-and-what-can-you-do

Treatment Strategies for Neck/Shoulder PainBicycle fit adjustments:

• Raise handlebars

• Shorten reach

Stretching:

• Neck

• Thoracic spine

• Paraspinal muscles of cervical spine

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Nerve CompressionCommon compression sites:

• Hand:

‒ Ulnar nerve at Guyon’s canal

‒ Median nerve at carpal tunnel

• Foot:

‒ Lateral branch of deep peroneal nerve at dorsum of foot18

Treatment:

• Padded gloves

• Adjust hand position

• Address shoe fit

Image: http://www.shoulderelbowhand.org/carpal-tunnel-syndrome.html

Prevention

Evaluation of bicycle fit

Cross-training and maintenance of strength during off-season

• Cycling relies on core strength but does not really build it

• Stretching/flexibility - Visit sportsrehab.ucsf.edu!

Gradual increase in training duration/intensity when returning to cycling

Complete rehabilitation after traumatic injuries

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Conclusions

Overuse injuries unfortunately common in cycling

Treatment and prevention strategies often involve:

• Evaluation of bicycle fit

• Adjustments for specific cyclist anatomy

• Appropriate training regimen

Thank you!

Drew Lansdown, MDdrew.lansdown@ucsf.edu

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