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Breaking The Cycle of Injury

By Dr Grahame Brown, Dip.Sp.Med.

Cycling holds a low risk of injury compared to many other sports but there are a number of risk factors unique to cycling.

Unique risk factors

  • Single-plane movement pattern in the saggital plane
  • The repetitive action of cycling - cyclists average 5,000 revolutions per hour. A slight biomechanical flaw through one revolution is insignificant by multiplied by 5,000 for just one hour and the smallest point of weakness or misalignment can lead to dysfunction, impaired performance and pain.
  • Limited range of movement of the hips, knee and ankle. When cycling the hip never moves into extension and utilises less than 50% of its available range during a full pedal revolution.
  • Prolonged static fixed posture with the spine in flexion.
  • Trauma - fractures and dislocations to the upper limbs and shoulder complex are commonplace. There are limits to what can be done to prevent trauma with the possible exception of wearing a helmet (1).

Overuse injuries

These are by far the most common type of injury in cyclists and this article will concentrate on how to prevent and manage these injuries. Initially the aim must be to prevent any injury by sticking to the basic guiding principles common to all sports. Give your body sufficient time to adapt to training overload and increase your activities gradually following the general rule of no more than 10% increase in the quantity of exercise per week.

Allow your body time to recover from training and competition with rest, or undertake lighter periods of training built into daily, weekly, monthly and annual schedules. General conditioning and flexibility work is important paying particular attention to spinal posture and stability. Warming-up and warming-down, before and after cycling, is particularly important for track riders and ensure your equipment is well maintained to reduce the risk of trauma.

Secondary prevention

Once you do have an injury there are a few basic principles of management that you should follow:

  • Adjust activity to allow healing. This is usually preferable to complete rest
  • Reduce inflammation. Ice, oral non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, physical therapy modalities such as ultrasound and interferential are common ways to reduce inflammation
  • Correct any biomechanical stresses or training errors. Check and modify bicycle fit and cleat placement as necessary (see bicycle set up article p25)

Common injuries specific to cyclists

Knee pain
This is the most common reason why a cyclist seeks medical attention. It can result in decreased performance, participation and enjoyment for cyclists at any Level.

Anterior knee pain (patellofemoral pain syndrome)
This is the most common cyclists' complaint. It is thought to be due to maltracking of the kneecap (patella) in the femoral groove, between the femoral condyles. In advanced cases there may be damage to the cartilage surface of the patella which is diagnosed at knee arthroscopy surgery and referred to as chondromalacia patellae.

What causes it?
Excessive force pushing the patella on the surface of the femur creates stress and shearing forces. Excessive hill climbing and too high gears are the usual causes and the saddle may be too low. A wide pelvis and 'knock knees' (valgus knee) will make this more likely and muscle imbalance creating a relative weakness of the inside thigh muscle (vastus medians) is known to be a cause. If the problem affects only one knee check for Leg length discrepancy. Weight training and running off the bike are also causes.

What can help?

  1. On the bike A relatively high-in-the-saddle position helps. With the shoe in the cleat and at bottom dead centre, the knee should not be flexed more than 25°. Gears should be low to spin more - at least 85rpm. Avoid hills and Long cranks until the condition settles. Check your cleat position, cleats with more float, a spacer between the pedal and crank, more offset cranks or a wider bottom bracket axle may all eliminate the problem. If leg length discrepancy is detected, fit cycle to the longer leg and place shim under cleat of shorter leg.
  2. Off the bike Quadriceps strengthening with terminal extension and isometric exercises helps. Limit the knee to 20 degrees of flexion. For example, place a pillow under the knee with a weight on the ankle, straighten the knee and hold for a few seconds and lower slowly. Working at about 20 repetitions maximum and do three to five sets daily. Increase the resistance gradually. Stretch the quadriceps in between sets. Hamstring and iliotibial band muscles should also be stretched. Avoid running, deep squats and weight training activities that load the patella-femoral joint such as Leg presses and squats.

Medical tips
Ice the knee for periods up to 20 minutes, followed by stretching quadriceps and strengthening exercises. Rule out hip problems as a cause. A short course of non-steroidal anti-inflammatory drugs (NSAIDs) can help. Taping and knee supports are not very useful in cyclists and cortisone is not used in this disorder. Surgery is as an absolute last resort.

Patella tendinopathy
This gives anterior knee pain. Tenderness is well localised at the inferior pole of the patella. Early recognition of this is vital. If the disorder becomes chronic then a very prolonged period of recovery may be required. (2,3)

What causes it?
All the possible causes of anterior pain above and it is often related to a sudden increase in mileage or hill work. Excess angular traction on the tendon while pedalling may also be responsible.

What can help?

  1. On the bike The same recommendations apply as for anterior knee pain. If active foot pronation (see p31, SportEX Health 8) is present during pedalling then rigid orthotics (inserts inside the shoe) can be used.
  2. Off the bike There is evidence to support the use of eccentric loading of the quadriceps during strength training. This is lowering the ankle slowly under load and following the same repetition maximum and progression principles as above. The rehabilitation of chronic tendinopathies (over three months duration) may require up to twelve months and riders need to be made aware that recovery can be slow.

Medical tips
The use of cortisone injection in this condition is the subject of much debate. It can be used effectively as a one-off treatment, which may then allow rehabilitation to progress. However, injections are not a substitute for the hard work needed for rehabilitation.

Medial knee pain
The most common diagnosis is anserine tendonitis and/or bursitis. The anserine tendon attaches to the upper inside (medial) aspect of the tibia. It is the result of three muscles coming together: the semitendinosus, gracilis and sartorius. The tendon or its bursa underneath is inflamed. At worst, medial joint line pain may indicate early degenerative osteoarthritis in the knee.

What causes it?

Increased pressure on the medial aspect of the knee. This may be due to having the toes pointed outwards or the knees too far apart when cycling. 'Exiting clipless pedals' that have too much tension often stress the medial knee. Those with turned-in tibias, foot pronation and 'bow legs' (varus knee) are more vulnerable.

What can help?

  1. On the bike If fixed cleats are used adjust them so that the toes point more inward. If floating cleats are used, limit float to 5°. Reduce the tension of the pedal release mechanism. Check saddle position as for anterior knee pain. Reduce mileage and spin a lower gear. Sometimes a media[ wedge between the cleat and shoe is necessary if there is significant biomechanical misalignment.
  2. Off the bike Avoid running. Skiing may also aggravate.

Medical tips
Use ice to reduce swelling and NSAIDs may help. Cortisone injection is useful in this area and orthotics may help. For internal knee disorders you should seek medical advice.

Lateral knee pain
Usually abrupt onset of localised pain, often rhythmical, with pedalling. Known as iliotibial band syndrome, it is due to irritation from repetitive friction of the iliotibial band (ITB) across the lateral femoral condyle.

What causes it?
Too much pull on the lateral knee. Badly adjusted cleat with foot pointing is the most common cause. Narrow bottom bracket, low saddle, over gearing, excessive hill work may also precipitate the condition. This is an area commonly affected in a fall so trauma may be a cause. A wide pelvis, 'bow-legs'(varus knee) and tight glutei muscles may contribute.

What helps?

  1. On the bike Adjust cleats to allow toe out a little. Switch from fixed to float cleats, but limit to 5°. Increase distance between the feet by widening the bottom bracket axle, offsetting the cranks or a spacer between the crank and pedal. Elevate saddle height and check for leg length discrepancy. Avoid hills and reduce mileage.
  2. Off the bike Stretch ITB, avoid running and weight training.

Medical tips
Ice the area and NSAIDs may help in the early stages. Cortisone injection is useful in this condition. Surgery should only be a last resort.

Posterior knee pain
The most Likely disorder is biceps tendonitis. This is inflammation of the tendon of biceps femoris, one of the hamstring muscles, where it attaches to the fibular head. Low back disorders commonly refer pain into the back of the thigh and must be considered.

What causes it?
High saddle position, sitting too far back, poor hamstring flexibility, dropping the heel when pedalling and too high gears can all be factors. Excessive cleat float is sometimes related because the hamstrings help to stabilise the leg while pedalling. Muscle imbalance between quadriceps and hamstrings is also a cause.

What helps?

  1. On the bike Sit further forward and lower the saddle. Avoid dropping the heel when pushing big gears or during hill work. Limit cleat float to 5 degrees. Stretch the hamstring regularly on the bike. Check for leg length discrepancy.
  2. Off the bike Stretching and strengthening the hamstrings and lumbar spine are most important.

Medical tips
Ice and stretch. Acupuncture and or osteopathy can help. Orthotics and cortisone injections are not useful in this disorder.

Swollen knee
In cyclists this is most likely to occur following trauma and consequently must be medically examined. A swelling on the posterior of the knee, known as a Baker's cyst can occur spontaneously. It may give pain or rupture to give a swelling in the calf. It is a benign condition that occasionally will need surgery. In some circumstances, a very inflamed patellofemoral joint will give rise to a small effusion (water on the knee). Swelling of the knee, in the absence of any trauma must be examined by a medical practitioner.

Neck and back pain
These are very common in cyclists. The vast majority of disorders are self-limiting. However a significant number of cyclists of all abilities need to actively manage the problem (4).

Neck pain

What causes it?

Extra tension develops in the muscles of the shoulder, neck and upper spine to keep the neck in the hyper-extended position for long periods of time. The jarring caused by rough road surfaces, or riding off road aggravates the problem. Myofascial pain is by far the most common clinical disorder accounting for this type of neck pain.

Another common problem is the thoracic outlet syndrome where the nerve/vessel bundle is under tension (not trapped) near the base of the neck. The cause is mostly poor posture. The condition gives postural related aching into the arm with a variety of disordered sensations including coldness in the affected arm. These symptoms may only manifest themselves during or after cycling. Aching felt between the shoulder blades is usually due to stiffness and dysfunction in the upper dorsal spine.

What helps?

  1. On the bike Consider raising the bars or change the bars to those with a shallow drop, shorten the bar extension. While riding, consciously relax the upper body. Look around and take opportunities to stretch the neck. Ride with the hands on the hoods and tops and not on the drops all the time. Bar extensions ('tri-bars') can be relaxing for the upper body but are not allowed in road races.
  2. Off the bike Do regular spinal stretching exercises that include not just the neck but the dorsal and lumbar spine. Neck pain is usually associated with mid and upper dorsal spine stiffness and dysfunction. The whole spinal posture needs to be improved. Ice and stretch painful muscles or try manipulation or acupuncture. Spine mobilisation and manipulation can be very helpful. Surgery is only for the rare nerve root pain with associated muscle weakness.

For some people, learning relaxation exercises can be very helpful and yoga, Alexander technique and Pilates are all examples of good exercise programmes for these problems.

Low back pain

The problem for the human spine is that it is constantly being compressed while upright and sitting, with maximum pressure at the bottom of the spine. Most of what we do in modern lifestyles involves sitting and slumping forwards, which includes cycling. Given correct and active management, low back pain need not affect performance on the bike or the enjoyment of cycling or any other activity, except in rare cases.

What helps?

  1. On the bike Adjust saddle height, (usually down slightly), reach and bar height. Adjusting the saddle so that it is nose down slightly, approximately 10 degrees from the horizontal can be very helpful. Check carefully for leg length discrepancy and adjust fit to the longer leg. Stretch and change position on the bike frequently. Use lower gears, especially on long climbs.
  2. Off the bike Practice regular spinal stretching exercises to activate, co-ordinate and strengthen transverses abdominus and multifidus muscles. These are known as the stabilising muscles and the process as 'core stability.

Pilates is an excellent example of this type of exercise programme to manage and prevent lumbar spine disorders. Mellion (4) gives a good account of a similar programme designed for cyclists.

Medical tips

NSAIDs and muscle relaxants are helpful during an acute episode to control pain and allow early active management. Bed rest should be ruled out. Manipulation can be very effective especially in the first few months. Trigger point acupuncture can help in relieving stubborn muscle tension that is preventing recovery.

Injections have an important role to play in some cases where pain is persistent and preventing active treatment, for example epidural steroid, trigger point injections and sclerosant ligament injections (prolotherapy). Surgery is an absolute last resort for back pain. However, it may be required urgently in 5% of all cases of sciatica.

The onset of back pain with difficulty holding urine, flatus or with numbness in the crotch, or with pain to the foot and inability to walk on heels or toes is a potential surgical emergency and must be urgently examined by a specialist spinal surgeon.

Hand problems

Handlebar problems affecting the hand divide readily into compression syndromes and overuse conditions. Of the compression syndromes, ulnar nerve lesions are by far the most reported, median nerve lesions are a distant second.

De Quervain's tenosynovitis affecting the thumb tendons is the most common overuse problem (5). Ulnar nerve compression producing sensory symptoms or muscular weakness has been recognised in cyclists for over 100 years and it has come to be known as cyclist's palsy.

What helps?

  1. On the bike Take the pressure off the medial (thumb) side of the hand by altering the bar position or its height. Changing the style of bars, thicker bar tape or padded mitts can all help. Suspension forks may help road riders but can be essential for offroad riders. Tenosynovitis of the thumb tendons is most likely be due to gear shifting. Changing the shifter solves the problem.
  2. Off the bike The main treatment is to take the pressure off the hand. NSAIDs or cortisone injection may be necessary in resistant cases. Surgery is a last resort.

Saddle sores and crotch problems
These are problems experienced by all cyclists at some time.

What causes it?

A rapid increase in mileage, saddle position and type, poor hygiene, seams in shorts chaffing and insufficient padding are the commonly reported causes. Mountain bike riders may be at increased risk of scrotal problems due to microtrauma (6).

What helps?
Attention to good hygiene and riding position are the main issues. The anecdotal list of potions, cures and remedies is huge. Novices must pay attention to correct and well made cycling shorts, correct position and avoiding too much riding too soon.

There are a great variety of saddle designs on the market; it comes down to trial and error and personal preference. Suspension systems for regular off-road riders is a sensible development.

Usual causes of overuse injuries

Mileage and intensity

For example, too much too soon in training or normal exercise - too many mites, excessive hill or speed work
Bicycle fit - knee pain is the most common problem, this may be due to numerous factors such as the saddle is too high or low, cranks too long or too close together (see article on cycle position page 25)

Anatomical variations
A few examples include a wide pelvis that places the knees further apart and stresses the outside of the knee, leg length discrepancy of as little as 5mm may be significant in a performance or long distance rider, excessive foot pronation is associated with inside (medial) knee pain.

What happens off the bike
For example, activities such as running can place huge stresses on the knee especially hill work, weight training has many benefits but full squats, leg extensions and lunges are particularly loading on the knee.

Common overuse injuries

Tendons - Inflammatory reaction causes much of the pain in the early stages of injury to these structures when it is known as tendonitis. Swelling and sometimes a crackling (crepitus) due to fluid accumulation can be detected.

Myofascial - (muscle and fascia). These are conditions of neuromuscular dysfunction. The affected muscles harbour painful trigger points which can refer pain some distance (7).

Bursitis - Bursae are cystic structures that form between surfaces that move over each other, either tendon, bone or muscle. Bursitis is irritation or inflammation of the bursa. Bursae adjacent to tendons will present with symptoms and signs similar to tendonitis, for example iliotibiat band syndrome and Achilles tendonitis.

Compression neuropathy - This is a disorder of peripheral nerve function. In cyclists the common problems of this nature include utnar nerve in the hand due to pressure on the inside of the wrist on the handlebar, and the pudendal nerve giving a numb penis.

Bone stress fracture - These are much more common in high impact sports such as running. They are rarely due to cycling, but may occur in a cyclist who has been cross training by running.


  1. Rivara F.P., Thompson D.C., Thompson R.S. Bicycle Helmets: it's time to use them BMJ 2000: 321;1035
  2. Khan K.M., Cook J.L., Taunton J.E., Bonar F. Overuse Tendinosis, Not Tendinitis: A new Paradigm for a Difficult Clinical Problem. The Physician and Sports Medicine 2000:28;5
  3. Cook J.L., Khan K.M., Maffulli N., Pudam C.; Overuse Tendinosis, Not Tendinitis: A new approach to Patella Tendinopathy. The Physician and Sports Medicine 2000:28;6
  4. Mellion M.B. Neck and Back Pain in Cycling. Clinics in Sports Medicine; Jan 1994
  5. Richmond D.R. Handlebar Problems in Bicycling. Clinics in Sports Medicine; Jan 1994
  6. Frauscher F., Klauser A., Hobisch A., Pallwein L., Stenzi A. Subclinical microtraumatisation of the scrotal contents in extreme mountain biking The Lancet 2000: 356; 1414
  7. Simons D.G., Travel[ J.G., Simons L.S. Myofascia[ Pain and Dysfunction The Trigger Point Manual vol 1: Upper Half of Body. Williams & Wilkins Baltimore 2nd edition 1999

Dr Grahame Brown is a physician in orthopaedics and sports medicine at the Royal Orthopaedic Hospital in Birmingham. He has been a regular cyclist for over 35 years an d he uses his bike daily for work, for recreation, holidays and sport. He has competed as a first category amateur in road racing and time trailing.



Title Breaking the cycle of injury.
Author Brown, G.
Source SportEX health (Wimbledon, England)
Publisher Centor Publishing Ltd.
Issue 9
Date July 2001
SIRC Article # S-785529


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