Overuse Injuries in Professional Road Cyclists

Abstract

Little epidemiological information exists on overuse injuries in elite road cyclists. Anecdotal reports indicate anterior knee pain and lower back pain may be common problems.
This study was conducted to register overuse injuries among professional road cyclists with special focus on anterior knee and lower back pain.
Descriptive epidemiology study.
We attended training camps of 7 professional teams and interviewed 109 of 116 cyclists (94%) on overuse injuries they had experienced in the previous 12 months. Injuries that required attention from medical personnel or involved time loss from cycling were registered. Additional information on anterior knee pain and lower back pain was collected using specific questionnaires.
A total of 94 injuries were registered; 45% were in the lower back and 23% in the knee. Twenty-three time-loss injuries were registered-57% in the knee, 22% in the lower back, and 13% in the lower leg. Fifty-eight percent of all cyclists had experienced lower back pain in the previous 12 months, and 41% of all cyclists had sought medical attention for it. Thirty-six percent had experienced anterior knee pain and 19% had sought medical attention for it. Few cyclists had missed competitions because of pain in the lower back (6%) or anterior knee (9%).
Lower back pain and anterior knee pain were the most prevalent overuse injuries, with knee injuries most likely to cause time loss and lower back pain causing the highest rates of functional impairment and medical attention.
Future efforts to prevent overuse injuries in competitive cyclists should focus on lower back pain and anterior knee pain.

Full text

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Clarsen, B., Krosshaug, T., Bahr, R. (2010). Overuse injuries in professional
road cyclists. American Journal of Sports Medicine, 38, 2494-2501.
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OriginalArticle:1
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OveruseInjuriesinProfessionalRoadCyclists
Short Title: Overuse injuries in road cycling
Word Count: 5336 words

Abstract5
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Background: Little epidemiological information exists on overuse injuries in elite road
cyclists. Anecdotal reports indicate anterior knee pain and lower back pain may be
common problems.
Purpose: To register overuse injuries among professional road cyclists with special focus
on anterior knee and lower back pain.
Study Design: Descriptive epidemiology study
Methods: We attended training camps of seven professional teams and interviewed 109
of 116 cyclists (94%) on overuse injuries they had experienced in the previous 12
months. Injuries that required attention from medical personnel or time loss from cycling
were registered. Additional information on anterior knee pain and lower back pain was
collected using specific questionnaires.
Results: We registered 94 injuries; 45% were in the lower back and 23% in the knee. 23
time loss injuries were registered; 57% in the knee, 22% in the lower back, and 13% in
the lower leg. Fifty-eight percent of all cyclists had experienced lower back pain in the
previous 12 months, and 41% of all cyclists had sought medical attention for it. Thirty-six
percent had experienced anterior knee pain and 19% had sought medical attention for it.
Few cyclists had missed competitions due to pain in the lower back (6%) or anterior knee
(9%).
Conclusion: Lower back pain and anterior knee pain were the most prevalent overuse
injuries, with knee injuries most likely to cause time-loss and lower back pain causing the
highest rates of functional impairment and medical attention.
Clinical Relevance: Future efforts to prevent overuse injuries in competitive cyclists
should focus on lower back pain and anterior knee pain.

Introduction 29
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Road cycling has been a part of the Olympic Games since their inception in 1896, and the
sport’s annual centrepiece race, the Tour de France, is currently one of the world’s most
popular sporting events. Despite the history and popularity of the sport, surprisingly little
attention has been paid to the epidemiological study of overuse musculoskeletal injuries
among competitive cyclists, although anecdotal reports suggest that certain injuries such
as patellofemoral pain16-17, 25 and lower back pain24 may be prevalent.
Several studies have investigated overuse injuries among participants of non-competitive
recreational cycling events.11, 22, 29, 31 These investigations have unanimously found knee
injuries to be prevalent, affecting between 24% and 62% of subjects, whereas reports of
other injuries such as lower back pain and neck pain, are more variable, with prevalence
rates of 3-31% and 3-66%, respectively, for the two conditions. Whilst they may give a
general idea of the types of overuse injuries that cyclists experience, the results of these
studies may not be directly applicable to competitive cyclists, largely due to vast
differences in cycling exposure between non-competitive “recreational” cyclists, and elite
professionals. One study of recreational touring cyclists reported an average annual
training volume of 7114km, and an average participation rate of 2.9 non-competitive
events per year.31 Professional cyclists, on the other hand, have been reported to ride
between 25000 and 35000 km, and complete 50-110 days of intense racing each year.18, 26
It would therefore be reasonable to assume that the overuse injury load experienced by
these two cohorts may be substantially different.
There is only one in-depth report on overuse injuries in professional cyclists, a
retrospective review of the patient records of two professional teams over a 13-year
period.7 The likelihood that all injuries sustained by this study’s subjects were treated,
and thereby recorded, by their team medical staff may be questionable, given that
members of professional cycling teams are typically based over a very large geographical
area and riders tend to have their own local medical support, outside of the official team
structure. Although the validity of the results may be questioned, the results of this study

are of interest, especially given the paucity of research in this field. While knee injuries
were found to clearly be the most common problem, representing 62% of all overuse
injuries, few cases of lower back pain and no cases of neck pain were reported. This
contrasts significantly with the findings of a brief survey on overuse injuries among
members of the British national cycling team,10 which reported a lower back pain
prevalence of 60% and a neck pain prevalence of 19%. Unfortunately, a lack of detail in
this report prevents any analysis of the potential reasons for such differing results. The
need for further investigation of the general pattern of overuse injury among competitive
cyclists is therefore clear.
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There is also some evidence that competitive cyclists may be particularly predisposed to
a range of leg symptoms including pain, numbness and loss of power caused by flow
limitations of their external iliac arteries.1, 8 This has been referred to by several names in
the literature, including sports-related flow-limitations of the iliac arteries,8 exercise-
induced arterial endofibrosis,1 and cyclists’ iliac syndrome.30 While several high-profile
cyclists have undergone surgery for this condition, very little is known as to the
magnitude of the problem among elite cyclists.
The primary aim of the present cross-sectional study was to investigate the patterns of
overuse musculoskeletal injuries in a cohort of professional road cyclists. As lower back
pain and anterior knee pain may be particular problems in this cohort, the secondary aim
was to collect additional information on each of these problems through the use of
specific questionnaires. Finally, questions on iliac artery flow limitations were also
included in an attempt to improve knowledge of the prevalence of this condition in
professional cycling.

Materials and Methods 80
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Recruitment methods and data collection procedures
Eleven road cycling teams, certified to take part in international competitions by the
Union Cycliste Internationale (UCI), were invited to participate in this study. These
teams were targeted either because we had prior contact with members of the medical
staff or management, or because they were based in a convenient geographical location.
Seven teams responded positively and were included in the study (n=116). These were
based in Australia, Denmark, France, Norway and Switzerland, and included riders from
23 different nationalities. Two teams (n=49) were from the highest level of professional
cycling (one UCI Pro-Tour team and one UCI Pro-Continental team with wildcard
status), competing in all major races including the UCI World Tour and the Tour de
France, while the remaining five were UCI Continental-level teams, competing in the
UCI Europe tour (n=67).
We visited team training camps during the period between October 2008 and February
2009 and invited all cyclists in attendance to complete a 10-20 min interview on overuse
injuries. Attempts were then made to conduct interviews by telephone with all team
members who were not present at the camps (n=7), as well as all riders who were listed in
the 2008 team rosters and who retired from international competition during or following
the 2008 season for any reason (n=11). All cyclists were informed that participation in
the study was voluntary and the information they provided could not be traced back to
them or their team. The study was approved by the South-Eastern-Norway Regional
Committee for Research Ethics and the Norwegian Data Inspectorate, and all subjects
gave their informed consent prior to participation in the study.
Athlete Interviews
All athlete interviews were conducted by physical therapists with experience working
within professional cycling. The interviewer went through a standardised questionnaire
verbally with each subject, providing further explanation or translation of the questions

where necessary. All participating teams had an official language of either English or
French, and interviews were conducted in one of these languages. Written material was
also available in both languages. In two cases it was necessary to call upon a team staff
member to assist in translation of the interview questions into Spanish. The interview was
divided into the following sections:
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1.SubjectCharacteristics
Subjects were questioned about their age, height and weight, the number of years they
had been riding in a UCI registered team, the number of days of racing they had
completed in the 2008 season, and the number of hours of training they had completed in
the preceding twelve months. They were encouraged to use training records to assist in
estimation of training and racing exposure.
2.OveruseInjuryRegistration
Subjects were asked to give information about all overuse injuries they had experienced
in the preceding 12-month period. A schematic representation of the time period,
including all major competitions, was shown to the subjects to assist them to recall
injuries as best possible. Subjects were asked to link specific dates and races with any
periods of injury upon this form. The definition of an overuse injury was any pain or
discomfort that was not directly associated with a traumatic event and was different from
the normal aches and pains associated with competitive cycling. We elected to use this
broad definition in order to capture as many potential injuries as possible; however, only
injuries that required attention from qualified medical personnel were subsequently
recorded. They were further classified as “time-loss” injuries if they caused the subject to
miss one or more days of training or competition.
The anatomical location of the injury was recorded using the system proposed by Fuller
et al for injury surveillance studies in football (soccer).13 Two separate methods of
classifying injury severity were used; one for all registered injuries and another for those
leading to time loss. The severity of medical attention injuries was assessed by
classifying them into (a) injuries that did not disrupt normal training and racing

performance, (b) those during which the athlete could continue to train and compete, but
with either a reduced intensity or volume, and (c) those during which the subject could
not ride at all. Time-loss injury severity was assessed by using the absolute number of
days of time lost from training or competition, and grouped according to the UEFA
model,15 into slight (1-3 days), mild (4-7 days), moderate (8-28 days) or severe (>28
days).
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3.LowBackPainandAnteriorKneePainQuestionnaires
After the completion of the Overuse Injury Registration, the interviewer went through
two questionnaires specifically asking about lower back pain and anterior knee pain. All
questions and injury definitions were based on a questionnaire from a previous study
analysing lower back problems in cross-country skiing, rowing and orienteering5 that had
been developed and validated for the study of occupational injuries.3, 23 Lower back pain
was defined as “pain, ache or soreness in the low-back with or without radiating pain to
the gluteal area or lower extremities” and anterior knee pain was defined as “pain, ache or
soreness on the front of the knee.” We chose to use the broad term “anterior knee pain” as
the retrospective design made it difficult to distinguish between individual diagnoses. The
standard questions in each questionnaire included the following:
 Have you ever experienced low back/anterior knee pain?
 Have you experienced low back/anterior knee pain in the previous 12 months?
 How many days in total have you had low back/anterior knee pain over the past
12 months? (none, 1-7 days, 7-30 days, >30 days but not daily, daily)
 Have you been examined or treated for low back pain/anterior knee pain by a
physician, physical therapist, chiropractor or other medical personnel in the
previous 12 months? (not including regular post-race massages)
 Have you taken pain-killers or non-steroidal anti-inflammatory medications for
low-back/anterior knee pain in the past 12 months?

 Have you ever been hospitalised for low back/anterior knee pain? 161
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 Have you ever had surgery for low back/anterior knee pain?
 How many days of training have you missed due to low back/anterior knee pain
in the past 12 months? (none, 1-7, 8-30, >30 but not daily, daily)
 How many races have you missed due to low back/anterior knee pain in the past
12 months? (none, 1-3, 4-10, >10)
Subjects were also asked whether they had had low back or anterior knee pain symptoms
during each of four season periods; (a) the period in which they are not riding their
bicycle (off-season), (b) the period in which they are training on the bicycle but not yet
racing (pre-season), (c) the period in which they have commenced racing but not in peak
condition or competing in their most important races (early season), and (d) the period
during which they are in peak condition and during which they compete in their major
races of the season (peak season).
The low back pain questionnaire contained an additional question asking subjects to
indicate whether they had experienced pain radiating into their gluteal area, thigh, knee,
lower leg or foot. The knee pain questionnaire contained an additional question asking
whether riders used pedals that allowed a degree of rotation, commonly referred to as
“float,” or if they preferred completely fixed pedals.
4.Sports‐relatediliacarteryflowlimitations
Subjects were asked whether they had ever been assessed a vascular specialist for leg
pains related to bicycling, and if so whether they had subsequently received surgical
treatment for iliac artery flow limitations.
Data Analysis and Statistical Methods
It is unknown whether subject characteristics, cycling exposure or overuse injury
prevalence differs between riders in racing at the UCI World Tour/Tour de France level

and the UCI Europe Tour level and therefore all data were compared between groups.
Chi square tests (Pearson’s chi square and Fisher’s exact tests where appropriate) were
used to detect differences between non-parametric categorical variables and unpaired t-
tests were used to detect differences in parametric variables. Differences were considered
statistically significant if the p-value was less than 0.05.
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Results
Response Rate
The seven teams included in the study included 105 active cyclists, as well as eleven
former team members who had retired during or following the 2008 season. We were
able to complete questionnaires with 101 of the active riders and seven of the retired
riders, giving us a total response rate of 94%. Through interviews with team medical staff
we were able to confirm that the three retired riders whom we were unable to contact did
not end their careers due to overuse injuries. Similarly, we were able to confirm that the
four active riders whom we were unable to contact were not unavailable due to overuse
injury.
Subject Characteristics
Subject characteristics are shown in Table 1. Significant differences existed between the
World Tour level and the Europe Tour level riders in age (p<0.001), the number years
spent riding for UCI teams (p<0.001), the number of annual race days (p<0.001) and in
annual training hours (p<0.001). The proportion of riders able to give exact exposure
information based on their training records was 46% for the number of race days and
40% for the number of training hours, while the remainder provided an estimate. No
significant differences were found however, between accurate and estimated exposure
data.
(Table 1 near here)
Retrospective Injury Registration

No significant differences were observed between the World Tour and Europe Tour
riders for any injury data, therefore these data are presented as for a single cohort.
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During the athlete interview 63 subjects recorded a total of 94 overuse injuries for which
they had received medical attention, details of which are shown in Table 2. Thirty-nine
percent of medical attention injuries did not affect the subject’s ability to complete
normal training and racing, 36% led to a reduction in either racing performance or
training volume, and 24% caused the subject to miss one or more days of training or
competition. The most common medical attention injuries were lower back pain (46% of
all medical attention injuries), knee pain (23%) and neck pain (10%). Time-loss injuries
(Table 3) had a slightly different pattern, with knee pain the most common (57% of all
time loss injuries), followed by lower back pain (17%) and lower leg or Achilles tendon
injuries (13%). Seventeen percent of time-loss injuries were classified as slight, 17% as
mild, 43% as moderate, and 17% as severe, whilst one case of lower back pain was
sufficiently severe to end the competitive career of the subject. The average duration of
time loss was 13.5 days (SD 10.1), not including the career-ending injury.
(Table 2 near here)
(Table 3 near here)
Low Back Pain Questionnaire
No significant differences were observed between cyclists competing in the World Tour
and the Europe Tour in low back pain data and therefore these data are presented for a
single cohort. There was a high prevalence of low back pain (Table 4), with 58% of
subjects reporting symptoms in the past twelve months and 41% having sought outpatient
medical assistance; however, relatively few had missed racing due to pain (6%).
Symptoms were more prevalent during the pre-season preparation periods and
competitive season than the off-season (Fig 1).
Anterior Knee Pain Questionnaire

No significant differences were observed between cyclists competing in the World Tour
and the Europe Tour in anterior knee pain data and therefore these data are presented for
a single cohort. The 12-month prevalence of anterior knee pain (36%) was lower than
low back pain (Table 4). Fewer subjects sought medical assistance (19%) but more
missed training (27%) and competition (9%) due to knee pain. The prevalence of anterior
knee pain also fluctuated throughout the year, peaking during the pre-season (Fig 1).
Twenty-eight percent of subjects reported using fixed pedals, and 72% using floating
pedals.
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(Table 4 near here)
(Figure 1 near here)
Iliac artery flow limitations
Six subjects (5.5%) had been investigated by a vascular specialist at some stage during
their professional career for exercise-related leg pains. Two of these (1.8%) had been
diagnosed with unilateral sports-related flow-limitations of their external iliac artery and
had undergone surgery for the condition.
Discussion
We found that symptoms of both lower back pain and anterior knee pain were common
among elite cyclists, with an annual prevalence of 58% and 36%, respectively. More than
half of all time-loss injuries were located at the knee, whereas cyclists were unlikely to
miss training or competition due to lower back pain. Despite this, a large percentage
suffered from performance-limiting lower back pain symptoms and sought medical
attention for it. Other injuries previously reported to be common in recreational cyclists,
such as neck pain and hand numbness, were generally mild or non-existent in this group
with only four cases of neck pain affecting cycling performance and only one leading to
significant time-loss from cycling participation.

To our knowledge, this is only the second epidemiological study investigating overuse
injuries in elite competitive cyclists. While we consider this to be a methodological
improvement on the one existing study, it does have some limitations which much be
taken into consideration when interpreting the results. Instead of using a prospective
design, currently considered the gold standard in injury surveillance research,13 we
conducted a cross-sectional study with retrospective data collection. This was primarily
due to doubts over the quality of the data we were likely to be able to collect
prospectively from a large group of professional cyclists, each of whom compete in an
individualised and highly variable international race program. Recent evidence suggests
that in such logistically difficult situations, retrospective athlete interviews may capture a
greater amount of injury data than prospective collection based on team medical staff
reporting.9, 11 The main explanations for this are thought to be that minor injuries are not
always reported to and examined by team medical staff, and that team medical staff are
not always travelling with the athletes. This is particularly true for professional cycling
teams, where riders and support staff rotate to take part in the various competitive events
the team takes part in. However, the major problem with retrospective studies is that they
are subject to the threat of recall bias. Previous studies investigating the effects of recall
bias show a general under-reporting of injury occurrence, particularly for milder
injuries,19 and an over-estimation of exposure data.21 Interestingly, in this study no
significant differences were found between exposure estimates and data from accurate
training records when the data were subjected to statistical analysis, however it is
impossible to know for certain how accurate the estimates were. We attempted to
minimise recall bias during the general injury registration by presenting a graphical
representation of the previous competitive season and asking subjects to link specific
dates and races with any periods of injury. This technique has been used before in a study
of beach volleyball injuries with apparent success;4 however, the recall period of that
study was only eight weeks and the effect of using the same strategy over a one-year
period is uncertain. Despite this, it remains likely that there is an element of injury
underreporting in the current study due to recall bias. For example, while 27% of riders
reported having missed training due to knee pain in the anterior knee pain questionnaire,
only 13 time-loss knee injuries were identified during the retrospective injury
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registration. This discrepancy is most likely explained by a number of time-loss injuries
being forgotten during injury registration, and then recalled when subjects were prompted
by specific questions within the knee questionnaire. The question of whether location-
specific questionnaires may be more accurate than general retrospective injury
registration in dealing with recall bias could therefore be asked.
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The fact that data were collected through direct athlete interviews by medically trained
personnel allowed for a greater level of detail, and presumably accuracy, than for
example had they been collected through an internet-based survey. However this
introduced a risk that the opinions or expectations of the interviewers may have biased
the results. Interviewers were therefore instructed to remain as objective as possible and
not to attempt to influence the data given by each subject. Nevertheless, this source of
bias cannot be ruled out.
The lower back and knee pain surveys were included in this study as recent evidence
shows that questionnaires of this type may give additional information on overuse injury
problems that is not captured by normal injury registration methods.6 However, the
particular focus on these two injury areas introduces the potential for bias in the general
injury registration data. To eliminate this source of bias, the specific questionnaires were
conducted after the general registration was completed.
Cross-sectional studies are also subject to the threat of sampling bias, for example data
collected at a competitive event may underestimate true injury levels, as more seriously
injured subjects may be absent. We expected this to be a particular problem in
professional cycling, as only a small percentage of each team may be present at any given
race. For this reason we chose to collect data when entire teams were gathered together,
regardless of riders’ fitness or injury status, and made a substantial attempt to contact any
missing or recently retired riders by telephone. As we were able to include a high
percentage of targeted riders, and given the geographic diversity of this study’s sample,
there is good reason to believe that this study’s subjects are a representative sample of
road cyclists competing on an equivalent level.

The high prevalence of anterior knee pain in this study is consistent with previous
epidemiological investigations of professional7 and recreational cyclists,11, 22, 29, 31 and
appears to confirm anecdotal reports that knee pain is a common injury affecting
competitive cyclists.16-17, 25 If, in accordance with currently recommended sports
epidemiology methods,13-14, 20 time loss is used as the sole measurement of injury
severity, then it would seem that knee injuries are clearly the most significant problem
affecting professional cyclists. Lower back pain on the other hand, would according to
these methods seem to be a far milder complaint, given the comparatively low number of
time-loss injuries it caused. However, although time loss was a relatively rare
consequence, lower back pain was clearly the problem leading to the greatest amount of
medical attention. While some degree of lower back discomfort may be considered a
normal part of such a physically demanding sport, more than one in five riders reported
back pain causing reduced cycling performance. The injury load posed by the problem
should therefore not be so easily dismissed. A reduced capacity to train and race could in
itself be considered a serious injury outcome in a cohort such as this, for whom career
and financial success is so dependent on optimum physical performance. Furthermore, a
significantly greater percentage of cyclists reported long-term (>1 month) symptoms
from lower back pain than knee pain and one rider ended their professional cycling career
due to lower back pain. In fact, results from the low back pain questionnaire were highly
comparable with results from other sports where lower back pain is considered to be a
significant problem, such as cross-country skiing and rowing.5 Clearly, lower back pain
represents a significant injury load on competitive cyclists, yet current recommended
injury-surveillance methodology, developed primarily for the study of acute injuries, is
unequipped to adequately measure it. The development of novel methods to quantify
overuse injury problems, with focus on prospective measurement of functional
impairment and exercise exposure, is needed.6
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In analysing the prevalence of symptoms throughout the year, lower back pain is
relatively even during periods of racing or training, and markedly lower during the off-
season. This indicates a strong relationship between cycling and lower back pain. For
knee pain, symptoms were also lowest during the off-season and most prevalent during

the pre-season preparation period. This could perhaps be explained by rapid increases in
training load over this period, or perhaps other factors such as cold weather conditions, as
this season period occurs during winter for a vast majority of subjects. Prospective
investigations including risk factor analysis and accurate exposure measurement would
be necessary to ascertain this with more certainty.
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There was generally a low prevalence of upper-body complaints, and with the exception
of one serious case of neck pain, almost all those reported were without functional
consequence. This finding is in contrast to several studies of recreational cyclists, among
which neck pain prevalence has been reported to be as high as 66%.29 Parasthesia of the
ulnar nerve, sometimes known as “handlebar palsy” has also been reported to be highly
prevalent in cyclists,2, 22, 27 however no cases were recorded in this study. One
explanation for this, favoured by Barrios et al,7 is that to elite cyclists these conditions are
familiar and of such little consequence that they are regarded as a normal part of the
sport. Alternatively it could be speculated that these athletes have, by this stage in their
cycling career, either adjusted their bicycle position to minimise discomfort on upper
body structures, or physically adapted to the ergonomic demands of the sport.
Arterial claudication problems would perhaps not normally fall under the umbrella of
overuse sports injuries; however, we felt the inclusion of iliac artery flow limitations in
this study was indicated, as the condition has been linked to cycling exposure and has
frequently been reported to be a common problem in elite cyclists. Despite this, the only
information available on the magnitude of the problem among cyclists is a suggestion
that 20% of all top-level cyclists may suffer from the condition.8 However, as this was
based on a study by a group of surgeons that regularly treat the condition,28 it may be
subject to sampling bias. Having only identified two athletes who had received surgery
for flow limitations, our results suggest a far lower prevalence than this. Investigations
involving greater numbers of cyclists would be necessary before more definitive
conclusions could be made.
Conclusion

This article provides new information on the pattern of overuse injuries sustained by
professional road cyclists. Lower back pain and anterior knee pain were found to be the
most prevalent overuse injuries, with knee injuries most likely to cause time-loss from
cycling and lower back pain leading to the highest rates of functional impairment and
medical attention. Future efforts to prevent overuse injuries in competitive cyclists should
focus on these injuries.
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381
382
383
384
385

References 386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
(1) Abraham P, Bouye P, Quere I, Chevalier JM, Saumet JL. Past, present and future
of arterial endofibrosis in athletes: a point of view. Sports Med 2004;34(7):419-
425.
(2) Andersen KV, Bovim G. Impotence and nerve entrapment in long distance
amateur cyclists. Acta Neurol Scand 1997;95(4):233-240.
(3) Andersson G, Biering-Sorensen F, Hermansen L et al. [Scandinavian
questionnaires regarding occupational musculo-skeletal disorders]. Nord Med
1984;99(2):54-55.
(4) Bahr R, Reeser JC. Injuries among world-class professional beach volleyball
players. The Federation Internationale de Volleyball beach volleyball injury
study. Am J Sports Med 2003;31(1):119-125.
(5) Bahr R, Andersen SO, Loken S, Fossan B, Hansen T, Holme I. Low back pain
among endurance athletes with and without specific back loading--a cross-
sectional survey of cross-country skiers, rowers, orienteerers, and nonathletic
controls. Spine 2004;29(4):449-454.
(6) Bahr R. No injuries, but plenty of pain? On the methodology for recording
overuse symptoms in sports. Br J Sports Med. 2009: 43 (13): 966-972.

(7) Barrios C, Sala D, Terrados N, Valenti JR. Traumatic and overuse injuries in elite
professional cyclists. Sports Exercise and Injury 1997;3:176-179.
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
(8) Bender MH, Schep G, de Vries WR, Hoogeveen AR, Wijn PF. Sports-related
flow limitations in the iliac arteries in endurance athletes: aetiology, diagnosis,
treatment and future developments. Sports Med 2004;34(7):427-442.
(9) Bjørneboe, J, Flørenes TW, Bahr R, Andersen TE. Injury surveillance in male
professional football; is medical staff reporting complete and accurate? Scand J
Med Sci Sports. In press.
(10) Callaghan MJ, Jarvis C. Evaluation of elite British cyclists: the role of the squad
medical. Br J Sports Med 1996;30(4):349-353.
(11) Dannenberg AL, Needle S, Mullady D, Kolodner KB. Predictors of injury among
1638 riders in a recreational long-distance bicycle tour: Cycle Across Maryland.
Am J Sports Med 1996;24(6):747-753.
(12) Flørenes TW, Nordsletten L, Heir S, Bahr R. Recording injuries among world cup
skiers and snowboarders - A methodological study. Scand J Med Sci Sports 2009
Dec 18. [Epub ahead of print].
(13) Fuller CW, Ekstrand J, Junge A et al. Consensus statement on injury definitions
and data collection procedures in studies of football (soccer) injuries. Br J Sports
Med 2006;40(3):193-201.

(14) Fuller CW, Molloy MG, Bagate C et al. Consensus statement on injury definitions
and data collection procedures for studies of injuries in rugby union. Br J Sports
Med 2007;41(5):328-331.
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
(15) Hagglund M, Walden M, Bahr R, Ekstrand J. Methods for epidemiological study
of injuries to professional football players: developing the UEFA model. Br J
Sports Med 2005;39(6):340-346.
(16) Holmes J, Pruitt A, Whalen N. Cycling Knee Injuries. Common mistakes that
cause injuries and how to avoid them. Cycling Science 1991;3:11-14.
(17) Holmes JC, Pruitt AL, Whalen NJ. Lower extremity overuse in bicycling. Clin
Sports Med 1994;13(1):187-205.
(18) Jeukendrup A, Craig N, Hawley J. The bioenergetics of world class cycling. J Sci
Med Sport 2000;4:414-433.
(19) Junge A, Dvorak J. Influence of definition and data collection on the incidence of
injuries in football. Am J Sports Med 2000;28(5)(suppl):S40-S46.
(20) Junge A, Engebretsen L, Alonso JM et al. Injury surveillance in multi-sport
events: the International Olympic Committee approach. Br J Sports Med
2008;42(6):413-421.

(21) Klesges RC, Eck LH, Mellon MW, Fulliton W, Somes GW, Hanson CL. The
accuracy of self-reports of physical activity. Med Sci Sports Exerc
1990;22(5):690-697.
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
(22) Kulund D, Brubaker C. Injuries in the bikecentennial tour. Phys Sportsmed
1978;6:74-78.
(23) Kuorinka I, Jonsson B, Kilbom A et al. Standardised Nordic questionnaires for
the analysis of musculoskeletal symptoms. Appl Ergon 1987;18(3):233-237.
(24) Mellion M. Neck and back pain in bicycling. Clin Sports Med 1994;13(1):137-
164.
(25) Mellion MB. Common cycling injuries. Management and prevention. Sports Med
1991;11(1):52-70.
(26) Mujika I, Padilla S. Physiological and performance characteristics of male
professional road cyclists. Sports Med 2001;31(7):479-487.
(27) Patterson JM, Jaggars MM, Boyer MI. Ulnar and median nerve palsy in long-
distance cyclists. A prospective study. Am J Sports Med 2003;31(4):585-589.
(28) Schep G, Bender MH, van de TG, Wijn PF, de Vries WR, Eikelboom BC.
Detection and treatment of claudication due to functional iliac obstruction in top
endurance athletes: a prospective study. Lancet 2002;359(9305):466-473.

(29) Weiss BD. Nontraumatic injuries in amateur long distance bicyclists. Am J Sports
Med 1985;13(3):187-192.
458
459
460
461
462
463
464
465
(30) Wijesinghe LD, Coughlin PA, Robertson I, Kessel D, Kent PJ, Kester RC.
Cyclist's iliac syndrome: temporary relief by balloon angioplasty. Br J Sports Med
2001;35(1):70-71.
(31) Wilber CA, Holland GJ, Madison RE, Loy SF. An epidemiological analysis of
overuse injuries among recreational cyclists. Int J Sports Med 1995;16(3):201-
206.

Tables 466
Table1SubjectCharacteristics
EuropeTour(n=60)WorldTour(n=49)Total(n=109)
Age 25(4)28 (5)26(4)
Height(cm) 182(6)181 (6)181(6)
Weight(kg) 71(6)69 (6)70(6)
YearsProfessional 3.2(2.5)6.0 (3.9)4.5(4.0)
AnnualRacingDays 53 (19)77 (16)64(21)
AnnualTrainingHours 869 (134)952 (99)904(127)
Valuesshownaremean(SD)

467
Table2LocationandSeverityofMedicalAttentionInjuries(numberofinjuries)
 Normaltraining
andracing
Reduced
performance
Couldnotride
bicycle
Career
endingTotal
LowerLeg/AchillesTendon21306
Knee4513022
Thigh14106
Hip/Groin01001
Lowerback/Pelvis/Sacrum20 19 3 1 43
Abdomen11002
Sternum/Ribs/Upperback01001
Hand/Finger/Thumb10001
Forearm10001
Shoulder/Clavicle10001
Neck/Cervicalspine622010
Total37 34 22 1 94
468
Table3LocationandSeverityofTimeLossInjuries(numberofinjuries)
 Slight
(1‐3days)
Mild
(4‐7days)
Moderate
(8‐28days)
Severe
(>28days)
Career
EndingTotal
LowerLeg/AchillesTendon111003
Knee1372013
Thigh001001
Lowerback/Pelvis/Sacrum101114
Neck/Cervicalspine100102
Total4410 4 123
469

470
Table4.Responses(numberofriders)tolowbackpain/anteriorkneepainquestionnaires(n=109)
LowerBackPainAnteriorKneePain
Symptomsever71 61
Symptomsinprevious12months63 39
Totalsymptomduration
1‐7days21 11
8‐30days23 21
>30daysbutnotdaily16 7
Daily3 0
Outpatientmedicalassistance45 21
NSAIDsinprevious12months15 20
Hospitalisation8 7
Surgery2 3
Missedtraininginprevious12months12 29
Numberofdaysofmissedtraining
1‐7days9 21
8‐30days2 8
>30days2 0
Missedracesinprevious12months6 10
Numberofmissedcompetitions    
1‐3races3 7
4‐10races0 2
>10races3 1
Referralofsymptoms
Glutealregion5 ‐ 
Thigh7 ‐ 
Knee7 ‐ 
Lowerlegorfoot13 ‐ 
471

Figures 472
473
474 Figure 1. Prevalence of anterior knee pain and lower back pain throughout the season