By: Dr. Richard DeFalco, DPT, OCS, CSCS, CWcHP, Cert. DN
When I drive to work early in the morning I see the same group of cyclists getting together to put in some serious miles. They appear to be riding very nice high-end bikes, wearing sport specific uniforms as well as aerodynamic helmets. Groups like these really have made an investment in the equipment they use to perform at a higher level and gain an advantage towards peak performance. I would hope they take the same time and effort to invest in maintaining their bodies to allow for continued performance and training. So many times we spend so much time and money on the equipment to perform a specific sports activity, that we easily overlook the most important piece of equipment, our own body. If your body breaks down, then all of that other impressive equipment does not matter.
Cycling injuries result in 500,000 physician visits per year and these visits are most commonly due to overuse injuries and to lesser extent, traumatic events. Overuse injuries can be due to improper training, muscular weakness/imbalances, and improper bike fit. This article is not meant to cover an in-depth lesson in the biomechanics of cycling, but rather to provide a general overview of common injuries that are associated with cycling and suggestions to mitigate them.
There are two main phases of the pedal cycle, which are the power phase and recovery phase, in which the joints of the lower extremities go through a restricted range of motion due to relatively fixed buttock and foot positions. During the power phase, forces are being applied to the pedal to propel the bike forward, and it is in this phase where we see the greatest muscular activity. The recovery phase is where we see the realignment of the foot and leg for the next power phase, and subsequently less muscular activity. These restricted positions combined with repetitive muscular patterning, muscle imbalances, and training errors can cause the overuse injuries that are commonly seen.
The areas of common overuse are the knee, hip, back, and neck. The areas can vary depending on the cyclists' riding position. To begin, cyclists can develop knee pain in the front of the knee, possibly due to patellar tendonitis (an inflammation of the patellar tendon) or patellofemoral pain (a tracking problem of the knee cap). As the knee flexes or bends more during the recovery phase of cycling there are excessive compressive forces between the kneecap and the thigh bone (femur). This can be caused by muscular imbalances (i.e., tight quadriceps), a seat that that is too low, and excessive riding in too high a gear.
One can also develop lateral knee pain, or pain on the outside of the knee that can be due to iliotibial band (ITB) syndrome. Pain usually begins around the outside aspect of the thigh as well as the outside aspect of the knee. This is typically due to irritation/friction where the iliotibial band passes over the outside aspect of the thigh bone (femoral condyle). Again, muscular imbalances, leg alignment, improper seat position, and training errors can be causative factors.
Cyclists also can experience pain on the inside aspect of the knee. This can be due to muscular imbalances, specifically weakness of the hip abductors (the muscles that keep the pelvis level when we walk or perform single leg tasks), as well as excessive hill riding, which can cause increased angulation at the knee. Women are usually more susceptible to this due to anatomical differences and subsequently greater angulation at the knee. This increased angle, known as the Q angle, creates a sort of bowstring effect on the inner knee, leading to pain, inflammation, and degeneration. Strengthening of your gluteal muscles as well as orthotics to correct foot position can mitigate this.
Cyclists may also encounter various forms of hip and thigh pain when riding. A common injury may be a simple hamstring strain or impingement of the tissues of the front of the thigh due to being in a flexed position for prolonged positions, to the not so common, hamstring syndrome, which is an entrapment of the sciatic nerve (which is usually preceded by a hamstring strain). The treatment of which is entirely different than that of a hamstring strain.
Just as with knee and hip pain, neck and back pain can develop from muscular imbalances and improper bike set-up. Impaired core strength, a seat that is too high are too far back, handlebars that are too low causing maladaptive neck postures, decreased spinal mobility, can all be causes of neck and back pain.
Research has demonstrated that on average the optimal seat height should be between 103-104% of the cyclist's inseam leg length. This is important, as knee pain is often the most common complaint of cyclists, and having too low of a seat height is highly correlated with that complaint. Just as important is the pedal position. The most efficient pedal position is with the ball of the foot on the pedal, rather than the heel. This helps to decrease the stress at the knee as well place your lower leg muscles in the optimal position for turning the crank.
Some general guidelines to consider when cycling and mitigating your risk of injury include maintaining muscular balance, which entails addressing lower extremity flexibility deficits especially of the hip flexors, quadriceps, and hamstrings. Include lower extremity strength training as an adjunct to your program, with specific attention to the gluteals, hamstrings, and quadriceps. Try to include exercises that focus on co-contraction of the leg muscles, as this is a sport specific demand to the pedal cycle. Functional movement patterns (squatting, lunging) that utilize multiple large muscle groups at once are preferred over isolation exercises (leg extension, leg curl) for improving motor skills/learning that are associated with cycling. Also seek out the consultation of a local bike shop to ensure that your bike is properly set up for your body.
If you are living (and cycling) with any type of musculoskeletal pain, a thorough physical therapy examination by a physical therapist that is board certified in orthopedics should be able to detect the root cause(s) of your problem, devise a treatment plan to return you to the road, and keep you there with corrective movements to be included as part of your training regimen. Many of the chronic issues that cyclists and other active people endure can be successfully treated with physical therapy measures in just a few treatments.
At Professional Rehabilitation Services we pride ourselves in distinction, and one of our Board Certified Orthopedic Physical Therapists will pursue an individualized treatment approach to your needs. Less than 5% of physical therapists in South Carolina are board certified in orthopedics. All physical therapists at Professional Rehabilitation Services are board certified. So if you or someone you know is having musculoskeletal pain from cycling or any other cause, seek the consultation of a physical therapist at one of our three locations or see your physician for a referral to one of our facilities.
At Professional Rehabilitation Services, we treat a wide variety of musculoskeletal conditions using the latest in evidence based therapies provided by highly credentialed physical therapists. In addition to being licensed physical therapists, our providers have additional specialty certifications in orthopedics, manual therapy, sports, strength and conditioning, and vestibular treatment. Professional Rehabilitation Services now has three locations, with the newest office located at 1301 48th Ave North, Myrtle Beach, SC. For further information on this or other related topics you can contact Richard DeFalco, DPT, OCS, CSCS, CWcHP, Cert. DN at Professional Rehabilitation Services (Myrtle Beach) (843) 839-1300, Brian P. Kinmartin PT, DPT, MTC, OCS, STC, CWcHP, Cert. DN, (Pawleys Island) (843) 235-0200, or Richard A. Owens, PT, MS, OCS, Cert. SHT, CWcHP, Cert DN (Surfside) (843) 831-0163, or visit our website at www.prsrehabservices.com where you can learn more about the company and even download a referral form for you physician to fill out. You can also call and schedule a free 15-minute consultation!