REVIEW
Lower body problems and injury in cycling

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Summary

Cycling is generally regarded as a low impact sport. It has a range of skills and disciplines, but the majority of cyclists are usually involved in the endurance aspect of the sport. The low impact nature, however, does not preclude cyclists from injury and musculoskeletal problems. Apart from the obvious trauma and sequelae involved in a fall from the bike, the prolonged postural adaptations combined with the repetitive limb movement from spending hours cycling seem to be one of the main reasons for lower limb and lower body problems. Those intending to become involved in the diagnosis and treatment of such problems should be aware of the plethora of mechanical and biomechanical issues when assessing an injured cyclist. This review of lower body problems in cycling highlights the typical patterns of injury and points out that to obtain a diagnosis for a cycling related problem a practitioner must evaluate faults in the bicycle as well as the cyclist. It also highlights that, despite some useful biomechanical input, there is a disturbing lack of evidence base for the treatment of some musculoskeletal complaints. This is unhelpful to those seeking more evidence-based practice, and may encourage an anecdotal approach to treatment for cyclists. All practitioners who are involved in the care of these sports people should continue to press for good quality studies so that cycling injuries of the lower limb may treated more efficaciously in the future.

Introduction

In the last decade, British cycling as an elite sport has seen unprecedented success with a host of world and Olympic champions. Despite this success on the world stage, road cycling, track cycling or mountain biking remain, to all intents and purposes, minority sports in Great Britain and most other countries outside mainland Europe.

British success is due in part to the technical and physiological advances in coaching, which have been matched by similar ‘upgrades’ in the knowledge, diagnosis and treatment of cycling related injuries by both medical and physiotherapy practitioners, as well as other appropriately trained health care providers. This advancement has always been hindered somewhat by a powerful subculture of unqualified practitioners and advisors who distribute advice and treatments based mainly on anecdote and hearsay.

Despite this (or because of it) we still have to question if medical and physiotherapy practitioners are any further advanced in their care of cycling sportsmen and women. This article highlights some of the common musculoskeletal problems that afflict cyclists and investigates the treatment strategies used and their evidence base.

Section snippets

Techniques and strategies for the prevention of injury

The role of the physiotherapist (and other appropriately trained health care providers) in cycling, as with other sports, revolves around the areas of injury care, injury prevention and optimal performance.

Injury prevention is inevitably linked to stretching, which has always been an important component of most programmes aimed at preventing sporting injuries. These programmes have proved difficult to implement mainly because acute muscle tears or strains rarely happen in cycling and cyclists

Techniques and strategies for the treatment of injuries

Cyclists usually acquire injury in two distinct ways. The first is due to tissue macrotrauma usually associated with direct trauma after a crash or fall from the bicycle. The second is tissue microtrauma that can be as a result of overuse injury that does not overtly involve such direct trauma. It is the latter that presents a more challenging diagnostic process, especially when the cyclist may have acquired the microtrauma injury as a result of subtle abnormalities such as a leg length

Vascular and neurological problems in cycling

There are several issues concerning the vascular and neural structures in the leg and around the perineum that are problematic in cycling and are thought to be related to the unique, prolonged seating posture adopted by cyclists. For example, one area in which progress has been made is in the diagnosis of vascular problems in cycling, especially those that may masquerade as referred pain from the lumbar spine or the sacroiliac joint. Unfortunately, for many years doctors, physiotherapists and

Treatment of atraumatic knee injury

In cycling, the treatment of atraumatic knee injuries should be directed to the cyclist's body as well as to the cyclist's bicycle. These two factors have been described as intrinsic and extrinsic factors respectively (Asplund and St Pierre, 2004). Indeed, Holmes et al. (1991) stated that treatment of the injured area would be ineffective if associated biomechanical problems were not also corrected.

Unfortunately, the barrage of treatment to the body and for bike adjustment to alleviate knee and

Correction of intrinsic factors

There are several important intrinsic factors to assess intrinsic factors that can lead to cycling injuries. For example, it is recommended that the body is checked for leg length shortening. Holmes et al. (1993), without any accompanying data, stated that length discrepancies of 1/4 of an inch (6.4 mm) or more should be ‘considered significant’. This was said to cause a stretch of soft tissues resulting in posterior-medial or posterior-lateral knee pain. Suggested treatment strategies revolved

Correction of extrinsic factors

The practitioner treating cyclists has to be aware of the myriad of extrinsic problems that can contribute to pain and the technical issues involved with cycling. Almost any piece of equipment on a bicycle can be faulty and therefore would need checking. As an illustration of this problem the following takes the example of the saddle correction (Table 1):

The saddle may be too high thus putting the rider at increased risk of ITBS (Asplund and St Pierre, 2004; Farrell et al., 2003; Holmes et al.,

The role of orthotics in cycling

There is some debate and confusion about the role of foot orthotics in cycling. This is due to the fact that most evidence of the effectiveness for foot orthotics to correct lower limb alignment problems is extrapolated from running data (Sanderson et al., 1994). As Hannaford et al. (1986) pointed out almost 20 years ago, full length or rearfoot orthotics are often inappropriate in cycling as they are incapable of preventing abnormal knee motion at high forces. This is because in the frontal

Summary

Cycling is a sport that generally has lower impact forces than running but cyclists still suffer from a considerable number of injuries, the most common of which seem to be at the knee. Although various tips for treatment are available in the descriptive literature, there is a dearth of prospective controlled trials which can help treating clinicians to be more certain of the cause and effect of injury and tailor their treatment accordingly. Sadly, the treatment of musculoskeletal problems in

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