May 2011 Newsletter

Archived Newsletters

Cycling Injuries
By Dr. Stephen A. Hunt

As spring slowly approaches, many people start to get that bike out of the garage, tune it up, and hit the road. Statistics from 10 years ago found that 33 million Americans road a bike at least six times a month. Just drive around New Jersey on a Wednesday evening or a Weekend morning and you’ll see that the numbers have probably increased tremendously. Cycling is a great form of high intensity but low impact exercise. However, anytime you’re riding at high speeds or working out for intense and long periods, there is a risk of injury. Many people are aware of the head and upper extremity injuries that occur from falls, however, the legs are at risk for injury as well. Below, we will review some common lower extremity cycling injuries and some basic tips for treatment and prevention.

Warm up before you ride
While time is short and riding does not carry the impact of running or other sports activities, it is essential to warm up properly prior to going for a vigorous ride. Additionally, inflexibility of the back, hips, knee, calves, and ankles can predispose one to injury. If you are starting a new season, or just beginning to ride for the first time, it is essential to maintain good flexibility and warm up routines to prevent injuries.

Hip Injuries
The Iliotibial Band is a long tendon that stretches from the side of the hip to the side of the knee. Around the knee, this tendon rubs on the outside of the thigh bone (or femur). With the repetitive knee motion of cycling, irritation can develop causing a sharp pain in the outside aspect of the knee.

The trochanteric bursa is a small sac that helps the tendon glide over the outside bone of the hip. Repetitive hip flexion and extension can similarly cause a bursitis that causes pain on the outside aspect of the hip. Both of these conditions can be triggered by tightness of the Iliotibial Band tendon. Treatment is focused on stretches to lengthen the tendon, anti-inflammatory medications, and modifying activities. Occasionally, injections can be performed in cases not responding to traditional and less invasive treatments.

Knee Injuries
The knee is the most common region for overuse in the lower extremity in cyclists. Both soft tissue (muscle and tendon) and joint (bone and cartilage) injuries can occur.

Pain in the front of the knee is most commonly from the cartilage of the knee cap. Whether the cartilage is just soft (chondromalacia) or has arthritis, both situations can result in significant pain in the front of the knee. Often times, the pain from these problems can be alleviated by some therapeutic exercises (hamstring stretching, quadriceps strengthening, and hip/core strengthening), as well as anti-inflammatory medications. Often, the pain will be exacerbated by rising out of the saddle, so keeping your butt down and working in lower gears may decrease symptoms as well. Taping or bracing can be utilized in cases of true instability but may or may not be helpful in cases of cartilage irritation. Taping or bracing may be an option for recreational cyclists, but often competitive cyclists may find these options too cumbersome.

Occasionally, pain in the front of the knee may be a result of tendonitis of the quadriceps or patellar tendon. In this scenario, often the injured area is very easily touched along the tendon. Treatment options are very similar to patella chondromalacia as it is usually the same biomechanical forces that result in the injury.

Pain on the outside of the knee may be a result of Iliotibial band friction syndrome. The IT band crosses the knee on the outside of the knee and as described above repetitively rubs on the outside of the thigh bone. This can result in a tendonitis or a bursitis and occasionally a mechanical pop on the outside of the knee. Treatment is focused on tendon stretching, anti-inflammatory medications, and occasionally modalities or injections.

Pain on the inside of the knee may be a result of pes tendonitis or medial plica syndrome. The Pes tendons are the inner hamstring tendons that wrap around the knee to the front of the shin bone. They can get irritated (tendonitis) or the bursa that helps them glide around the bone can get irritated (bursitis). Medial plica syndrome is an irritated fold of joint lining (synovium) on the inner side of the knee. If it gets irritated from overuse, it can result in snapping and pain on the inner side of the knee. Treatments are similar to what has been described above, however, medial plica syndrome often responds well to an arthroscopic surgery to release the tissue.

Leg
Stress fractures of the shin bone (tibia) have been reported in cyclists and may be related to foot position and sudden change in activity. Rest is the main treatment.

Exertional compartment syndrome (ECS) is also a problem that can occur in cyclists. ECS is a problem with pressure in the muscle compartments of the leg. As the muscles swell with activity, the pressure within their “casing” exceeds your blood pressure and can lead to muscle and nerve injury. People who experience leg pain, swelling, and numbness in their legs should see a physician to make sure this is not a problem. There are tests that can diagnose ECS after other more common cause of leg pain have been ruled out. If ECS fails to respond to nonoperative management, surgery can be performed to release the pressure in the leg compartments.

Foot and Ankle
Achilles tendonitis can result from an improperly fitted bicycle and preexisting tightness of the calf muscles. The repetitive nature of ankle motion results in the inflammation and injury to the tendon.

Nerve compression has also been reported in the feet of cyclists. This is usually related to the straps about the shoewear and pedals. Adjustment of this equipment usually resolves these issues.

Finally, metatarsalgia has been reported in cyclists who pedal slowly with excessive force. This results in overload of the forefoot bones and causes pain in bottom of the foot. Shoewear changes and cushioned pads placed in the shoes can alleviate this issue.

Proper Fit and Technique
While there are many common interventions that help alleviate the conditions described above, perhaps the best way to prevent and heal injuries during cycling is to have your bike properly fitted and learn appropriate riding techniques. Variables such as seat height, saddle position, handlebar reach and height, crank length and type of pedal and shoe wear can dramatically change the forces experienced by your muscles, joints, and bones. While it is certainly recommended that you make sure your bike fit and technique are appropriate, if you continue to experience pain, you should seek the evaluation of a medical expert.

REFERENCES:

1. Wanich et al. Cycling Injuries of the Lower Extremity. J Amer Acad Orthop Surg 2007; 15: 748-56.