Common injuries in cycling: Prevention, diagnosis and management

Abstract

Cycling is a healthy recreational activity, although it can result in acute and chronic injuries. Acute injuries are usually the result of accidents, and preventative measures can be taken to avoid them. The most important measure for preventing serious acute injury is to wear a hard-shell cycling helmet. Chronic overuse injuries are usually the result of training errors and a poor bicycle-cyclist "fit". The key components of preventing chronic injuries are to ensure that the cyclist and the bicycle are appropriately matched, and that training follows well-established scientific principles.

Full text

SA Fam Pract 2005;47(7)
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Introduction
The health benefits of participating in
regular physical activity are well
established, and prescribing exercise
to prevent and treat chronic disease
is becoming more frequent. In
addition, medical insurers and
medical schemes use various
incentive schemes to encourage their
members to engage in regular
physical activity. Recreational cycling,
as one of the options for regular
exercise, is therefore also increasing
in popularity. In South Africa, mass
participation in recreational and
competitive cycling events is growing.
It is therefore not surprising that
patients presenting with injuries
related to cycling have also increased.
As a result, the family practitioner is
likely to be consulted more frequently
to deal with these injuries. The
purpose of this article is to briefly
discuss a clinical approach to the
more common acute and chronic
injuries that cyclists may experience.
Acute injuries suffered by
cyclists
Cyclists usually suffer acute injuries
during accidents. The causes of
accidents vary, from a collision with
a motor vehicle (> 50% of cases) ,
road surface damage and obstacles,
to mechanical problems with the
bicycle (12-24%). Risk factors for
more serious, acute traumatic injuries
in cyclists are collision with a motor
vehicle (4.6 times higher than other
mechanisms of injury), increased
cycling speed > 28km.hr, and age
(younger age – < 6 years, and older
age – > 39 years) . Acute cycling
injuries can cause damage to any
anatomical area, including the head,
neck, face, eye, upper and lower
limbs (most common), spine,
abdomen and skin (see Figure 1).
The various types of acute cycling
injuries are depicted in Figure 2. The
majority of these injuries are superficial
abrasions, lacerations and contusions.
More severe injuries, such as
fractures, dislocations, head injuries
and injuries to internal organs,
account for 5-25% of all acute cycling
injuries.
“Off-road” cycling has also been
increasing in popularity. It has been
documented that the injury risk and
the overall pattern of the anatomical
location of injuries are similar in
conventional cyclists and “off-road”
cyclists, but that the severity of injuries
in “off-road” cyclists is lower. This
reduction in severity has been
attributed to a reduced average
cycling speed, and the observation
that “off-road” cyclists use cycling
helmets more readily.
The more serious acute injuries in
cyclists that can result in fatalities are
related to trauma to the head and
neck and deserve further discussion.
Common injuries in cycling:
Prevention, diagnosis and
management
M P Schwellnus, MBBCh, MSc (Med), MD, FACSM
E W Derman, MBChB, PhD, FACSM
UCT/MRC Research Unit for Exercise Science and Sports Medicine,
Department of Human Biology, Faculty of Health Sciences,
University of Cape Town, South Africa
Correspondence: Prof. Martin Schwellnus UCT/MRC Research Unit for Exercise Science and Sports Medicine,
Department of Human Biology, Faculty of Health Sciences, University of Cape Town,
Sports Science Institute of South Africa, Boundary Road, Newlands 7700, South Africa
Tel: 27 21 650 4562, Fax: 27 21 686 6213, E-mail: mschwell@sports.uct.ac.za
(SA Fam Pract 2005;47(7): 14-20)
Figure 1: Anatomical site of acute injuries in cyclists (expressed as a percentage
of all the acutely injured cyclists – some cyclists were injured in more than one
area)6

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Acute head, neck and facial
injuries suffered by cyclists
Acute head and neck injuries are by
far the most serious injuries suffered
by cyclists and account for most of
the fatalities caused by cycling. The
scientific evidence that bicycle
helmets protect the head, brain and
face from more serious injuries is
now well established. It has been
shown that the use of cycling helmets
can reduce the risk of head injury by
85%, brain injury by 88%, and severe
brain injury by more than 75%. In a
recent study, the type of cycling hel-
met and the subsequent reduction in
head injury risk were investigated. It
was shown that the hard-shell helmet
type reduces the risk of head injury
by 64%, compared with a 17% reduc-
tion in risk when a foam helmet is used.
Practical recommendations to
reduce the risk of acute
injuries suffered by cyclists
Health professionals can make the
following practical recommendations
to reduce the risk of acute injuries in
cyclists:
•Encourage the use of designated
cycling areas (lanes) to avoid
sharing roads with motor vehicles
•Cycle on appropriate road
surfaces free from damage or
obstacles
•Younger and older cyclists are at
higher risk of injury
•Encourage the use of cycling
helmets (particularly the hard-shell
type)
•Educate younger cyclists on the
need to wear cycling helmets
•Encourage the use of front and
rear lights or reflectors on bicycles
•Encourage the wearing of high-
visibility clothing
•Discourage the use of alcohol
before and during cycling
Chronic injuries suffered by
cyclists
Chronic injuries, also known as
overuse injuries, are also frequent in
cyclists. They are generally less
severe, but can be the source of great
frustration to the cyclist and the
medical practitioner who is consulted
to solve the clinical problem. In one
survey among 294 male and 224
female recreational cyclists, 85% of
cyclists reported one or more overuse
injury, with 36% of these injuries being
reported as severe enough to warrant
medical attention. The most common
anatomical sites for overuse injuries
are the neck (48.8%), knee (41.7%),
groin/buttock area (36.1%), hands
(31.1%), and lower back (30.3%).
In this review article, common
injuries occurring in these anatomical
sites will be discussed. A detailed
review of each injury is beyond the
scope of this article, but principles of
diagnosis and management will be
highlighted.
The principles of management of
these injuries rely on firstly establishing
a precise anatomical and pathological
diagnosis of the injury and, secondly,
identifying the underlying intrinsic
(related to the cyclist) and extrinsic
(related to the bicycle and the
environment) risk factors associated
with the injury. Treatment generally
follows two phases. The first phase
involves the treatment of the
symptoms, and the second phase the
countering of the underlying causes.
Chronic neck pain suffered by
cyclists
Neck pain in cyclists is thought to
occur as a result of muscle spasm
(particularly the levator scapulae and
the trapezius muscles), perhaps in
response to constant hyperextension
of the neck during cycling.
Predisposing factors would therefore
include poorly conditioned upper
back musculature, “dropped”
handlebars, raised saddle, and a
“heavy” cycling helmet to which the
rider is not accustomed.
The management and prevention
of neck pain in cyclists will include
treatment of the muscle spasm in the
first phase. The treatment of the
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Figure 2: The type of acute injuries in cyclists (expressed as a percentage of all
the acutely injured cyclists – some cyclists were injured in more than one area)6

SA Fam Pract 2005;47(7)
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underlying cause of the injury may
include altering the cycle/rider
mechanics (shortened handlebars,
raised handlebars, reduced saddle
height), conditioning the upper back
muscles, and perhaps reducing the
weight of the cycling helmet.
Persistent pain should be investi-
gated further and cervical
radiculopathy and degenerative
arthritis should be excluded,
particularly in older cyclists.
Chronic knee pain suffered by
cyclists
Chronic knee pain is a very common
injury in cyclists. Although there may
be many causes for chronic knee
pain, only anterior and lateral knee
pain will be discussed in this article,
as they are reported most frequently.
Chronic anterior knee pain
suffered by cyclists
The most common cause for
chronic anterior knee pain in cyclists
is patellofemoral pain syndrome (PFP).
This is a condition where repetitive
flexion/extension of the knee results
in peri-patellar pain. During cycling,
the force generated by quadriceps
muscle contraction during the
downstroke (knee extension) is
translated to the patellofemoral joint.
This patellofemoral joint reaction force
is thought to injure the peri-patellar
structures, resulting in injury.
Predisposing factors to PFP in
cyclists include training errors (rapid
increases in training volume, incorrect
use of bicycle gearing, increased hill
training), incorrect pedal/foot interface
(type of cycling shoes and cleats
used), incorrect bicycle set-up
(incorrect frame size, saddle height
too high or low, incorrect saddle
position – usually too far forward),
muscle imbalances (quadriceps and
jip stabiliser muscles), and anatomical
abnormalities in the cyclist (small
mobile patella, hypoplasia of the
lateral femoral condyle, patella alta).
In recent years, biomechanical
studies using two-dimensional video
analysis conducted at the Sports
Medicine Unit of the University of
Cape have shown that cyclists with
PFP exhibit an abnormal nonlinear
pattern of knee movement during the
downstroke of cycling. Once this
abnormal pattern is corrected (by
using custom-made orthoses, altering
the cleats, or by altering saddle
height), PFP can be treated effectively.
The principles of management of
PFP in cyclists are to treat the pain,
followed by altering training and
correcting other predisposing factors.
The bicycle set-up, as well as
biomechanical analysis of the
downstroke, may be required to
reduce the loads on the patellofemoral
joint.
Iliotibial band friction syndrome
The most common cause of chronic
lateral knee pain in cyclists is iliotibial
band (ITB) friction syndrome. This
injury is thought to occur as a result
of repetitive mechanical friction
between the iliotibial band and the
lateral femoral condyle. The diagnosis
is made by careful clinical
examination. Pain can be reproduced
by repetitive knee flexion and
extension while applying pressure
over the lateral femoral condyle.
Classically, pain is maximal at 30o
knee flexion – the angle at which the
ITB crosses over the femoral condyle
(known as the ITB impingement
angle).
Specific predisposing factors for
this injury in cyclists have not been
well studied. In a recently published
study, researchers showed that the
minimum knee flexion angle during
cycling (at the bottom of the
downstroke) is close to the ITB
impingement angle. Therefore, apart
from correcting training errors and
conditioning the hip stabiliser
muscles, the adjustment of saddle
height is probably the most effective
management of ITB friction syndrome
in cyclists.
Chronic groin/buttock pain
suffered by cyclists
Chronic buttock and groin pain is a
common complaint of cyclists. This
pain is caused by the pressure of the
saddle during prolonged sitting and
can result in injury to several
anatomical areas. These injuries can
include saddle (pressure) sores,
perineal folliculitis and furuncles,
callosities, subcutaneous fibrosis, and
subcutaneous perineal cystic
nodules. Male cyclists can develop
pudendal neuropathy, resulting in
numbness or tingling in the scrotum
or the penis. Prolonged compression
of the pudendal nerve, usually
following repeated and multi-day rides
and resulting in transient impotence
in male cyclists, has been
documented. Traumatic urethritis and
torsion of the testis have also been
described. Female cyclists may
experience a variety of vulval trauma,
including superficial abrasions,
lacerations, contusions and
haematomas.
The management of these injuries
involves the treatment of the acute
phase by means of antiseptic creams
or powders, as well as corticosteroid
creams or antibiotics if required.
However, the most important advice
for cyclists is to prevent these injuries
by observing the following principles:
•Use a modern, anatomically
designed saddle (different for male
and female cyclists)
•Use padded cycling shorts that
are cleaned daily (multiple day-
rides)
•Consider shaving the perineal area
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SA Fam Pract 2005;47(7) 19
to avoid traction on hair follicles
•Adjust the seat position (height,
anteroposterior tilt) to distribute
the pressure evenly while seated
Chronic hand pain suffered by
cyclists
Cyclists participating in multi-day
events can present with chronic
numbness and tingling, with
associated weakness of the muscles
of the hand. In a recent study among
cyclists participating in a 600 km
multistage event, 92% of the cyclists
experienced motor or sensory
symptoms of the hand. The most
common injury is ulnar nerve
compression, causing symptoms in
the ulnar nerve distribution (ring and
little finger). The median nerve is
involved less commonly. The cause
of this injury is related to constant
pressure and vibration, with the wrist
in prolonged wrist hyperextension and
abduction. Treatment involves
refraining from cycling until the
symptoms resolve. Prevention entails
wearing cycling gloves, adjusting the
handlebar position, applying padding
to the handlebars, frequently altering
hand position during cycling, and
reducing body weight on to the
handlebars.
Chronic lower back pain
suffered by cyclists
Chronic lower back pain in cyclists is
usually the result of the prolonged
flexed position. Causes can be related
to intervertebral disc compression,
traction on the facet joint capsules,
and traction resulting in muscle strain
or ligamentous sprain. Recently, it has
been suggested that a variant of
chronic compartment syndrome may
develop in the back extensor muscle
groups in some cyclists. All cyclists
with lower back pain must be
evaluated for other causes by means
of an appropriate clinical examination
and special investigations, as
required.
The prevention of lower back pain
is related mainly to proper bicycle
set-up. Adjusting the saddle angle
appears to be particularly effective in
reducing back pain during cycling.
Adjustments to saddle height,
handlebar height, handlebar position
and handlebar length may also be
required. Attention should also be
paid to lower abdominal and core
muscle and flexibility.
Other injuries suffered by
cyclists
Other injuries that cyclists can suffer
include foot parasthesias (usually from
toe clips and shoes that are too tight),
metatarsalgia, and Achilles tendon
injuries. The effects of sun damage
must also be considered.
Summary and conclusion
Cycling is a healthy recreational
activity, although it can result in acute
and chronic injuries. Acute injuries
are usually the result of accidents,
and preventative measures can be
taken to avoid them. The most
important measure for preventing
serious acute injury is to wear a hard-
shell cycling helmet. Chronic overuse
injuries are usually the result of training
errors and a poor bicycle-cyclist “fit”.
The key components of preventing
chronic injuries are to ensure that the
cyclist and the bicycle are
appropriately matched, and that
training follows well-established
scientific principles.
See CPD Questionnaire, page ??
References
1. See LC, Lo SK. Cycling injuries among junior
high school children in Taiwan. J Formos Med
Assoc 1997;96:641-8.
2. Rivara FP, Thompson DC, Thompson RS.
Epidemiology of bicycle injuries and risk factors
for serious injury. Inj Prev 1997;3:110-4.
3. Mellion MB. Common cycling injuries.
Management and prevention. Sports Med
1991;11:52-70.
4. Stone M, Broughton J. Getting off your bike:
cycling accidents in Great Britain in 1990-
1999. Accid Anal Prev 2003;35:549-56.
5. Powell EC, Tanz RR. Cycling injuries treated
in emergency departments: need for bicycle
helmets among preschoolers. Arch Pediatr
Adolesc Med 2000;154:1096-100.
6. Rivara FP, Thompson DC, Thompson RS,
Rebolledo V. Injuries involving off-road cycling.
J Fam Pract 1997;44:481-5.
7. Pfeiffer RP, Kronisch RL. Off-road cycling
injuries. An overview. Sports Med 1995;19:311-
25.
8. Chow TK, Bracker MD, Patrick K. Acute injuries
from mountain biking. West J Med
1993;159:145-8.
9. Thompson DC, Patterson MQ. Cycle helmets
and the prevention of injuries.
Recommendations for competitive sport.
Sports Med 1998;25:213-9.
10. Robinson DL. Head injuries and bicycle helmet
laws. Accid Anal Prev 1996;28:463-75.
11. Hansen KS, Engesaeter LB, Viste A. Protective
effect of different types of bicycle helmets.
Traffic Inj Prev 2003;4:285-90.
12. McGuire L, Smith N. Cycling safety: injury
prevention in Oxford cyclists. Inj Prev
2000;6:285-7.
13. Rosenkranz KM, Sheridan RL. Trauma to adult
bicyclists: a growing problem in the urban
environment. Injury 2003;34:825-9.
14. Bishai D, Qureshi A, Cantu N, Parks C.
Contracting with children and helmet
distribution in the emergency department to
improve bicycle helmet use. Acad Emerg Med
2003;10:1371-7.
15. Frank E, Frankel P, Mullins RJ, Taylor N. Injuries
resulting from bicycle collisions. Acad Emerg
Med 1995;2:200-3.
16. Wilber CA, Holland GJ, Madison RE, Loy SF.
An epidemiological analysis of overuse injuries
among recreational cyclists. Int J Sports Med
1995;16:201-6.
17. Holmes JC, Pruitt AL, Whalen NJ. Lower
extremity overuse in bicycling. Clin Sports
Med 1994;13:187-205.
18. Gregor RJ, Wheeler JB. Biomechanical factors
associated with shoe/pedal interfaces.
Implications for injury. Sports Med
1994;17:117-31.
19. Van Zyl E, Schwellnus MP, Noakes TD. A review
of the etiology, biomechanics, diagnosis and
management of patellofemoral pain in cyclists.
ISMJ 2001;2.
20. Bailey MP, Maillardet FJ, Messenger N.
Kinematics of cycling in relation to anterior
knee pain and patellar tendinitis. J Sports Sci
2003;21:649-57.
21. Farrell KC, Reisinger KD, Tillman MD. Force
and repetition in cycling: possible implications
for iliotibial band friction syndrome. Knee
2003;10:103-9.
22. Andersen KV, Bovim G. Impotence and nerve
entrapment in long distance amateur cyclists.
Acta Neurol Scand 1997;95:233-40.
23. Spears IR, Cummins NK, Brenchley Z,
Donohue C, Turnbull C, Burton S, et al. The
effect of saddle design on stresses in the
perineum during cycling. Med Sci Sports Exerc
2003;35:1620-5.
24. Keytel LR, Noakes TD. Effects of a novel
bicycle saddle on symptoms and comfort in
cyclists. S Afr Med J 2002;92:295-8.
25. Patterson JM, Jaggars MM, Boyer MI. Ulnar
and median nerve palsy in long-distance
cyclists. A prospective study. Am J Sports
Med 2003;31:585-9.
26. Sanner WH, O'Halloran WD. The
biomechanics, etiology, and treatment of
cycling injuries. J Am Podiatr Med Assoc
2000;90:354-76.
27. Salai M, Brosh T, Blankstein A, Oran A, Chechik
A. Effect of changing the saddle angle on the
incidence of low back pain in recreational
bicyclists. Br J Sports Med 1999;33:398-400.
28. Helzer-Julin M. Sun, heat, and cold injuries in
cyclists. Clin Sports Med 1994;13:219-34.
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