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Indoor cycling using a spinning flywheel ("spinning") is an increasingly popular and typically safe method of working out. However, as with all forms of exercise, injuries may arise, particularly with overuse, improper use or form, and/or improper fit of the bicycle or cycling gear.
This slideshow will discuss 7 common indoor cycling injuries, as well as how to avoid and treat them when they arise.
Images courtesy of (1) Waryasz GR, McDermott AY. Dyn Med. 2008;7:9. [Open access.] PMID: 18582383, PMCID: PMC2443365 (left); Craig Young (center top, middle, and bottom); and Sam Shlomo Spaeth and Yonah Korngold (right).
Handlebar palsy is also known as Guyon's canal/tunnel syndrome, cyclist's palsy, and ulnar neuropathy. This condition is caused by irritation of the ulnar nerve at the hand or elbow, which may occur from stretching of the nerve from either holding the handlebar for a prolonged time or by direct compression with the pressure from riding with the hands gripping the drop handlebars ("drops").[1]
Signs/symptoms are usually temporary and typically include numbness and tingling in the fifth digit and the half of the ring finger adjacent to the fifth digit.[2,3] In more severe cases, weakness in these fingers also occurs.
Images courtesy of Craig Young, MD (top left) and Physiopedia/Vanessa Rhule (bottom right).
Management
Conservative therapy is often simple and effective.[2,3] Because the most common cause of handlebar palsy is prolonged irritation of the nerve, the simplest treatment is to intermittently change hand positions (shown) and thus take pressure off the nerve. If signs/symptoms recur with each cycling session, moving the position of the handlebar may provide relief.
Physical therapy, temporary splinting, and rest, as well as the use of nonsteroidal anti-inflammatories, tricyclic (and related) antidepressants, anticonvulsants, or corticosteroid injections may also be helpful.[2,3]
If signs/symptoms persist for a prolonged period (eg, more than a few minutes), affected individuals should seek medical evaluation. Potential surgical measures for severe cases include decompression procedures.[2,3]
Images courtesy of Craig Young, MD.
Prevention
The following adjustments may help cyclists to avoid handlebar palsy[4-8]:
Image of left handlebar palsy courtesy of Flickr/elyob (left); image of cycling gloves courtesy of Craig Young, MD (right).
Neck pain is common in indoor cyclists, particularly when using a bicycle that places the rider in the traditional forward flexed riding position (left images). This problem is more likely to occur when the rider's head is held upward (extended) for prolonged periods to watch a cycling group leader or a video monitor (right images).
Images courtesy of Craig Young, MD.
Management and prevention
Neck pain from cycling is typically managed with rest, ice, and anti-inflammatory medication (eg, ibuprofen).
Tips for preventing neck pain include the following[4-7]:
Adapted image courtesy of Freimann T, Merisalu E, Paasuke M. BMC Sports Sci Med Rehabil. 2015;7:31. [Open access.] PMID: 26640694, PMCID: PMC4670527.
Low back pain in cyclists is more common when they ride a more traditional road-style bicycle with the back bent forward as compared to an upright or recumbent-style bicycle. Biomechanical analysis of the lumbar spine has shown that changes in lumbar disc pressures increase with preload forces and with changes in posture, particularly in flexion (shown).[9]
Factors that contribute to low back pain in indoor cyclists include a poor bike fit, poor posture, prolonged use, and weak core muscle strength.[10]
Images courtesy of Craig Young, MD (left) and Kuo CS, Hu HT, Lin RM, et al. BMC Musculoskelet Disord. 2010;11:151. [Open access.] PMID: 20602783, PMCID: PMC2913991 (bar charts).
Management and prevention
Management of low back pain generally consists of rest, ice, and anti-inflammatory medication (eg, ibuprofen). More severe cases may require medical evaluation for physical therapy and/or therapeutic injections or, potentially, surgical intervention.[11]
The following adjustments may help cyclists to avoid low back pain[4-7]:
Cycling images courtesy of Craig Young, MD; example of a core-strengthening exercise courtesy of Dreamstime/Nicholas Piccillo.
Bicycle seat neuropathy is also known as perineal or genital numbness, in which the pudendal nerve is compressed between the pelvis and saddle.[12] This is a very common condition in cyclists, especially after prolonged riding on narrow seats.[12,13]
Signs/symptoms are generally self-limited and include numbness, tingling, or pain in the groin or perineum; men may report impotence.[12,13]
Image courtesy of Sam Shlomo Spaeth.
Management and prevention
The mainstay of treatment for bicycle seat neuropathy is adjustment of the bicycle seat and bicycle position (eg, tilting the nose of the seat down or lowering the seat height to relieve pressure off the perineum). Changing the style of riding, such as periodically standing up from the seat and making other positional changes, and/or changing the saddle may be helpful.
As discussed previously, bicycle adjustments such as the lowering the saddle, raising the handlebars, and bringing the handlebars closer to the saddle may provide relief.[4-7] The saddle should be level.
Although many different seat styles and types of padding have been studied, to date no specific style or padding has been shown to prevent bicycle seat neuropathy.[12-15] However, recent studies have shown some promise in decreasing perineal numbness in seats with "no nose" (the narrow portion of the saddle).[2,12,13]
Image of simulated seat pressure distribution courtesy of Sam Shlomo Spaeth.
Saddle sores are caused by skin breakdown from pressure and friction, and they range in severity from mild chafing to ulcers. Contributing factors include heat and moisture combined with improperly fitting clothing, prolonged riding, and improper seat position/fit.[16,17]
Signs/symptoms include tenderness and erythema in the regions that have contact with the saddle (eg, groin, perineum, inner/back of thighs); the affected skin may be raised and/or accompanied by a rash.[16]
The left image depicts the skin and tissue layers involved in skin breakdown. The right image shows epidermal inflammation from chafing.
Images courtesy of Wikimedia Commons/Nanoxyde (adapted image) (left) and Sam Shlomo Spaeth (right).
Management and prevention
Saddle sores are generally self-limited following a short period of rest from riding and with maintenance of good hygiene.[16,17]
Protect the affected skin with a bandage if friction is unavoidable; otherwise, allow it to "breathe" or air out, as feasible. If inflammation persists or progresses, an abscess or ulcer forms, and/or pus drains from lesions, seeking medical evaluation is appropriate. Antimicrobial therapy may be warranted.[16]
Preventive measures include wearing clean, well-fitting, padded bicycle shorts, and/or using a wider and more padded seat.[4-7] Gel seat covers may provide additional padding and reduced friction.
Images courtesy of Sam Shlomo Spaeth.
Patellofemoral pain syndrome (PFPS), or cyclist's knee, is an overuse condition caused by repetitive friction between the kneecap and the thigh bone.[18]
Signs/symptoms include generalized knee pain, joint line pain, or retropatellar pain that manifests most often during activities requiring knee flexion and contraction of the quadriceps or occur afterward.[18,19]
The left image depicts quadriceps-patellar vector forces exerted by the surrounding muscles, which have relevance in PFPS. LR = lateral retinaculum; MR = medial retinaculum; P = patella; RF = rectus femoris; T = tibia; TT = tibial tubercle; VI = vastus intermedius; VLL = vastus lateralis longus; VLO = vastus lateralis obliquus; VML = vastus medialis longus; VMO = vastus medialis obliquus.
The center image shows that biomechanical causes for functional or dynamic valgus (functional malalignment) in PFPS can involve internal rotation of the femur, the tibia, or both.
The right radiograph was obtained from a patient with PFPS.
Images courtesy of (1) Waryasz GR, McDermott AY. Dyn Med. 2008;7:9. [Open access.] PMID: 18582383, PMCID: PMC2443365 (left); (2) Petersen W, Ellermann A, Gosele-Koppenburg A, et al. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264-74. [Open access.] PMID: 24221245, PMCID: PMC4169618 (center); and (3) Craig Young, MD (right).
Management and prevention
The initial treatment for PFPS is rest and ice.[19] Short-term use of anti-inflammatory medications (eg, ibuprofen) and/or medially directed taping may be helpful for acute pain.[20] If signs/symptoms persist, a course of physical therapy for strengthening and stretching the muscles may be useful.[18-20] Surgical intervention is typically reserved for cases when at least 6 months of conservative management has not resolved the problem[19]; it may involve arthroscopic evaluation followed by release of the lateral attachments of the patella.[18]
Preventive measures include the following[4-7,19]:
The images show examples of hip- and knee-muscle strengthening exercises: straight leg raise with slight hip extension (top left); abduction and lateral rotation at 30° of hip flexion with a resistance elastic around the knee (top right); quadriceps strengthening without weight bearing (bottom left); and squatting until reaching 30° of knee flexion (such that the knee position does not exceed the position of the midfoot) (bottom right).
Images courtesy of Rabelo ND, Lima B, Reis AC, et al. BMC Musculoskelet Disord. 2014;15:157. [Open access.] PMID: 24884455, PMCID: PMC4036089.
Burning and tingling in the feet (metatarsalgia, "hot foot" syndrome, foot numbness) are frequent complaints of cyclists. Compression of one of the smaller nerves of the forefoot against the metatarsal bones of the foot is the culprit.[21,22]
Causative factors include pressure between the foot and the pedal, wearing shoes that are too tight, and improper positioning of the bicycle cleats.[21,22]
Adapted image courtesy of Science Source/Pixologic Studio.
Management and prevention
Usually, temporarily taking the foot off the pedal and shaking it will allow the symptoms to resolve.[21,22] Placing a metatarsal pad on the insole of the shoe may relieve the pressure on the nerve.
Preventive measures include reducing the intensity of the workout, changing the shoes to a larger size or with a different stiffness of the sole, moving the cleats back, lowering the saddle, and/or changing to a different pedal type.[4-7,21,22]
The radiograph on the left was obtained from a patient with metatarsalgia. The image on the right shows examples of different types and positions of forefoot pads with the use of cardboard templates. The "X's" indicate the metatarsal head position. From bottom to top: (i) represents a shoe, without forefoot padding; (ii) shows the metatarsal dome of a pad positioned 10 mm proximal to the metatarsal heads; (iii) demonstrates the metatarsal dome positioned 5 mm distal to the metatarsal heads; (iv) uses a metatarsal bar—type pad; and (v) represents a plantar cover. A study found that the most effective forefoot pads for reducing forefoot pressure and pain in older people were those that placed the metatarsal dome 5 mm distal to the metatarsal heads (iii) and the plantar cover (v).[23]
Images courtesy of Craig Young, MD (left) and Lee PY, Landorf KB, Bonanno DR, Menz HB. J Foot Ankle Res. 2014;7(1):18. [Open access.] PMID: 24594070, PMCID: PMC4016518. (right).
Keys to avoiding indoor cycling injuries include the following:
Cyclists should seek medical evaluation when signs/symptoms do not resolve.
Images courtesy of Sam Shlomo Spaeth and Yonah Korngold.
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