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References

  1. Slane J, Timmerman M, Ploeg HL, Thelen DG. The influence of glove and hand position on pressure over the ulnar nerve during cycling. Clin Biomech (Bristol, Avon). 2011 Jul;26(6):642-8. PMID: 21458120
  2. Guardia CF III, Berman SA. Ulnar neuropathy. Updated April 19, 2016. Medscape Drugs & Diseases from WebMD. Available at: http://emedicine.medscape.com/article/1141515-overview. Accessed June 10, 2016.
  3. Wilhelmi BJ, Neumeister M, Naffziger R. Nerve compression syndromes of the hand. Updated March 21, 2016. Medscape Drugs & Diseases from WebMD. Available at: http://emedicine.medscape.com/article/1285531-overview. Accessed June 10, 2016.
  4. Madden CC, Collina SJ. Mountain biking. In: Madden CC, Putukian M, Young CC, McCarty EC, eds. Netter's Sports Medicine. Philadelphia, Pa: Saunders; 2010: 580-91.
  5. Silberman MR. Road biking. In: Madden CC, Putukian M, Young CC, McCarty EC, eds. Netter's Sports Medicine. Philadelphia, Pa: Saunders; 2010: 571-80.
  6. Silberman MR. Bicycling injuries. Curr Sports Med Rep. 2013 Sep-Oct;12(5):337-45. PMID: 24030309
  7. Silberman MR, Webner D, Collina S, Shiple BJ. Road bicycle fit. Clin J Sport Med. 2005 Jul;15(4):271-6. PMID: 16003043
  8. Slane J, Timmerman M, Ploeg HL, Thelen DG. The influence of glove and hand position on pressure over the ulnar nerve during cycling. Clin Biomech (Bristol, Avon). 2011 Jul;26(6):642-8. PMID: 21458120
  9. Kuo CS, Hu HT, Lin RM, et al. Biomechanical analysis of the lumbar spine on facet joint force and intradiscal pressure--a finite element study. BMC Musculoskelet Disord. 2010 Jul 5;11:151. PMID: 20602783
  10. McCoy K. How to avoid lower back pain while cycling. Active.com. Available at: http://www.active.com/cycling/articles/how-to-avoid-lower-back-pain-while-cycling. Accessed June 10, 2016.
  11. Wheeler AH. Low back pain and sciatica. Updated February 3, 2016. Medscape Drugs & Diseases from WebMD. Available at: http://emedicine.medscape.com/article/1144130-overview. Accessed June 10, 2016.
  12. Martinez JM. Bicycle seat neuropathy. Updated April 21, 2016. Medscape Drugs & Diseases from WebMD. Available at: http://emedicine.medscape.com/article/91896-overview. Accessed June 10, 2016.
  13. Wishhart M. Bicycle seat neuropathy. Live Healthy [online]. Available at: http://livehealthy.chron.com/bike-seat-neuropathy-2005.html. Accessed June 10, 2016.
  14. Huang V, Munarriz R, Goldstein I. Bicycle riding and erectile dysfunction: an increase in interest (and concern). J Sex Med. 2005 Sep;2(5):596-604. PMID: 16422816
  15. Parthiban S, Hotaling JM, Kathrins M, Baftiri AP, Freels S, Niederberger CS. A novel method to determine perineal artery occlusion among male bicyclists. PeerJ. 2015 Dec 21;3:e1477.
  16. Hurford M. How to diagnose, treat, and avoid saddle sores. December 14, 2015. Bicycling.com. Available at: http://www.bicycling.com/training/health-injuries/how-to-diagnose-treat-and-avoid-saddle-sores. Accessed June 10, 2016.
  17. Lloyd D. How to avoid and treat saddle sores. August 28, 2014. BikeRadar.com. Available at: http://www.bikeradar.com/us/gear/article/how-to-avoid-and-treat-saddle-sores-25103/. Accessed June 10, 2016.
  18. Potter PJ, Sequeira KA. Patellofemoral syndrome. Updated May 23, 2016. Medscape Drugs & Diseases from WebMD. Available at: http://emedicine.medscape.com/article/308471-overview. Accessed June 10, 2016.
  19. Servi JT. Patellofemoral joint syndromes. Updated October 21, 2015. Medscape Drugs & Diseases from WebMD. Available at: http://emedicine.medscape.com/article/90286-overview. Accessed June 10, 2016.
  20. Petersen W, Ellermann A, Gosele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014 Oct;22(10):2264-74. PMID: 24221245
  21. Allen J. Causes and prevention of hot foot in cyclists. Active.com. Available at: http://www.active.com/cycling/articles/causes-and-prevention-of-hot-foot-in-cyclists. Accessed June 10, 2016.
  22. Erickson R. Foot numbness and cycling. December 14, 2015. Livestrong.com. Available at: http://www.livestrong.com/article/387684-foot-numbness-and-cycling/. Accessed June 10, 2016.
  23. Lee PY, Landorf KB, Bonanno DR, Menz HB. Comparison of the pressure-relieving properties of various types of forefoot pads in older people with forefoot pain. J Foot Ankle Res. 2014 Mar 5;7(1):18. PMID: 24594070

Image Sources

  1. Slides 1 (left) and 13 (left): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2443365/. Accessed May 27, 2016.
  2. Slide 2 (right): http://www.physio-pedia.com/File:Cyclists_palsy_ulnar_involvement.jpg. Accessed May 27, 2016.
  3. Slide 4 (left): https://www.flickr.com/photos/elyob/601259161/. Accessed May 27, 2016.
  4. Slide 6: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4670527/. Accessed May 27, 2016.
  5. Slide 7 (right): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913991/. Accessed May 27, 2016.
  6. Slide 11 (left): https://commons.wikimedia.org/wiki/File:Schema_stades_escarres.svg. Accessed May 31, 2016.
  7. Slide 13 (center): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4169618/. Accessed May 31, 2016.
  8. Slide 14: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036089/. Accessed May 31, 2016.
  9. Slide 16 (right): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4016518/. Accessed May 31, 2016.
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Contributor Information

Author

Craig Young, MD
Professor of Orthopaedic Surgery & Community and Family Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin

Disclosure: Craig Young, MD, has disclosed no relevant financial relationships.

Editor

Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York

Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.

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7 Common Indoor Cycling Injuries

Craig Young, MD  |  June 15, 2016

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Slide 1

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).

Slide 2

Handlebar Palsy

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).

Slide 3

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.

Slide 4

Prevention

The following adjustments may help cyclists to avoid handlebar palsy[4-8]:

  • Raise the handlebar position, and move the saddle (seat) back
  • Ensure the saddle is level, not tilted down
  • Wear cycling gloves, or add padding to the handlebars
  • Change the bicycle to one with an upright style

Image of left handlebar palsy courtesy of Flickr/elyob (left); image of cycling gloves courtesy of Craig Young, MD (right).

Slide 5

Neck Pain

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.

Slide 6

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]:

  • Frequently alter the head and neck positions
  • Change the bicycle to an upright style or use a recumbent bicycle
  • Raise the handlebar height and/or bring the handlebar position closer to the saddle
  • If on a bicycle with drop handlebars, ride with the hands on the hoods or top bar
  • Perform neck-strengthening exercises (example shown)

Adapted image courtesy of Freimann T, Merisalu E, Paasuke M. BMC Sports Sci Med Rehabil. 2015;7:31. [Open access.] PMID: 26640694, PMCID: PMC4670527.

Slide 7

Low Back Pain

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).

Slide 8

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]:

  • Select an appropriately fitting bicycle
  • Use an upright or recumbent-style bicycle
  • Raise the handlebar height and/or move the saddle forward
  • Perform core muscle–strengthening exercises

Cycling images courtesy of Craig Young, MD; example of a core-strengthening exercise courtesy of Dreamstime/Nicholas Piccillo.

Slide 9

Bicycle Seat Neuropathy

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.

Slide 10

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.

Slide 11

Saddle Sores

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).

Slide 12

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.

Slide 13

Patellofemoral Pain Syndrome (Cyclist's Knee)

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).

Slide 14

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]:

  • Ensure the saddle is not too low
  • Raise the seat or move the seat back to decrease the amount of knee flexion
  • Use shorter length crankshafts
  • Ride in smaller (lower) gears with a higher cadence
  • Perform muscle-strengthening exercises, particularly of the vastus medialis obliquus

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.

Slide 15

Metatarsalgia (Hot Foot Syndrome)

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.

Slide 16

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).

Slide 17

Takeaways

Keys to avoiding indoor cycling injuries include the following:

  • Starting out slowly and gradually increasing the intensity of the workout. Cyclists should pay attention to their bodies, reduce the frequency/intensity before any signs/symptoms progress, and allow their bodies time recover between training sessions
  • Changing positions often
  • Adjusting the bicycle to fit properly. Keep in mind that fit for performance, fit for comfort, and fit for treatment of an injury may all result in different adjustments
  • Potentially changing the bicycle, seat, or peddle styles
  • Wearing padded shorts and gloves

Cyclists should seek medical evaluation when signs/symptoms do not resolve.

Images courtesy of Sam Shlomo Spaeth and Yonah Korngold.

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