Common Impairments in the Cyclist
December 2024
December. It is hard to know what the season will bring. Last Saturday was Global Fat Bike Day, hinting at winter fun in the snow, and Sunday was near 50°, begging for pedaling road bikes. Regardless of the temperature, winter for the cyclist should be restorative. For those with a penchant for pedaling, dismounting our trusty steads in the off-season may prove more challenging than committing to grueling miles in-season. Cycling can be a critical component of our physical, social and mental well-being. With time being a limited resource, swapping time on the bike for exercise off the bike can be something we resist, or even fear. Understanding that a movement literacy program isn’t stealing time from the bike, but rather improving and extending the ride, can allay those fears. Don’t worry about sounding professional. Sound like you. There are over 1.5 billion websites out there, but your story is what’s going to separate this one from the rest. If you read the words back and don’t hear your own voice in your head, that’s a good sign you still have more work to do.
Building a strong cyclist is relatively straight forward: pedal harder, pedal faster, pedal further, rest and repeat. Building a plastic, resilient and durable cyclist is more complicated and requires more tools in the training toolbox. This newsletter hopes to 1) identify demands in cycling that lead to common musculoskeletal impairments, 2) outline how to triage these impairments. Subsequent newsletters will provide a basic framework for a movement literacy training program to mitigate these impairments and complaints.
Many cyclists find the act of pedaling to be second nature. However, cycling is not a natural part of human movement. While humans have been ambulating upright for nearly 6 million years, movement via bicycle was only recently introduced (roughly 200 years ago). Bodies are not optimized for repetitive motion of the lower extremities with near maximal hip flexion, confined to a single plane with several fixed contact points. Pedaling a bicycle demands opposing muscles in the sagittal plane to be chronically positioned in shortened and lengthened positions, respectively. This posture has a propensity to create musculoskeletal imbalances that can be described as cross-over syndrome. In addition, the lack of impact loading and eccentric contractions can diminish bone health and the tensile strength of tendons.
Cross-over syndrome of the upper extremities is characterized by tightness through the pectoral muscles of the chest, upper trapezius and sub-occipital muscles at the base of the skull. The opposing muscles, namely the middle and lower trapezius and deep neck flexors, may develop weakness as they are chronically held in a sub-optimal lengthened position (stretch weakness). These muscle imbalances are exemplified by a forward head and thoracic kyphotic posture. Cyclists may experience a myriad of symptoms secondary to this postural dysfunction, including neck and shoulder pain. In the lower extremities, the imbalance creates tightness through the hip flexors and low back extensors, which act on the pelvis. The gluteal and abdominal muscles, placed in a non-optimal stretch position, struggle to counter the forces on the tight muscles on the pelvis. The resulting posture is one of increased anterior pelvic tilt and hyper-lordosis. This places ligamentous strain on the lower lumbar vertebrae and sacroiliac joints. Due to the nature of the human kinetic chain, dysfunction at one segment, in this case the lumbo-pelvic segment, frequently leads to dysfunction at adjacent and distal segments, including the hip and knee. Furthermore, cycling is a quadriceps dominated activity. Ensuring the proper hamstring to quadriceps strength ratio is critical for knee stability for sports outside of cycling.
The foot- ankle complex is another region that may suffer cycling. The foot- ankle complex is designed to undergo both supination (plantarflexion, adduction and inversion) and pronation (dorsiflexion, abduction and eversion) during push off and mid-stance phases of gait, respectively. This allows the foot to be locked in a rigid and stable position during push off and unlocked to accommodate ground reaction forces during midstance. The biphasic nature of motion is lost during cycling, with the majority of time spent in the unlocked position of pronation, which may lead to strain on the arch and compression of the neurovascular structures (hot foot).
The cyclist is not doomed for discomfort, but it does take a concerted effort to build a plastic, resilient and durable cyclist that requires tools in the training toolbox beyond pedaling. These tools are part of what is referred to as movement literacy, built on a hierarchy of mobility, flexibility, stability, strength and skill/ functional proficiency. Armed with these tools, musculoskeletal impairments that hinder movement patterns on and off the bike may be mitigated. Finding the right “technician” with mastery of the tools to work on your “machine” can be a daunting task. Many cyclists take the “whack-a-mole approach”. Desperate to be back in the saddle pain free, they engage practitioners across a variety of disciples to render aid. While this approach is rarely dangerous and may ultimately result in resolution of symptoms, collateral damage may occur to your pocket book and delay effective treatment. Time is a precious resource, so why squander it? A silly but relevant analogy is triaging a poorly running vehicle. Desperate to get the car running smoothly, you may solicit a several service technicians who replace the battery, fuel line and alternator before running a diagnostic test, only to learn the problem is a faulty spark plug. No damage was done to the vehicle (in fact, it has lots of new parts that didn’t need replacing), but precious time and money were used treating symptoms rather than identifying the underlying cause. The best place to start when your body isn’t running smoothly is with a proper diagnosis.
If the tools in your toolbox (stretching, yoga, strengthening) aren’t moving the needle, and symptoms have persisted for more than 6 weeks with rest, it would be prudent to investigate the source, rather than continue to treat the symptoms. A physician or physical therapist trained in sports medicine is a good starting point. A physician may order diagnostic tests, such as a radiograph or MRI. While not every musculoskeletal injury requires diagnostic imaging, identify the underlying etiology of the impairment or compliant is paramount to providing effective treatment. While rare, in my role as a physical therapist treating cyclists, I have come across lateral knee pain caused by an osteosarcoma masquerading as iliotibial band syndrome and recalcitrant back pain caused by a tumor. The whack-a-mole approach would have not have served these athletes well. More commonly, cyclists are plagued by overuse musculoskeletal issues such as tendinopathy, patellofemoral stress syndrome, low back, neck and shoulder pain whereby imaging may be ordered to confirm the diagnosis and inform the conservative treatment. These pathologies are often best addressed by a physical therapist with working knowledge of cycling demands and bicycle fit.
Solving biomechanical puzzles can be complicated as cycling involves two machines: one with two legs interfacing with another with two wheels. There are very few other sports whereby the solution may lie with either or both machines. Here is a case scenario to illustrate the point: a cyclist with 20 years of experience presents with a gradual onset of knee pain at the end of his cycling season in October, without changes in training volume or injury. His coach recommends the athlete be seen by a physical therapist. Evaluation reveals lack of hamstring and iliotibial band flexibility with poor gluteal firing, leading to patellofemoral stress syndrome (PFSS). These findings could certainly predispose the athlete to PFSS, but there is little in his history to suggest that these impairments alone, likely present for many years, are the only precipitating factors in developing knee pain late in the season. Further evaluation of his equipment reveals worn cleats and the cyclist recalls a recent adjustment after the saddle became loose, inadvertently resulting with nose down 5°. A myriad of factors contributed to the onset of knee pain, and only careful evaluation of the body and bike together allowed full resolution. Once the underlying factors had been identified, skilled technicians with the appropriate tools were employed. His PT prescribed exercises to address the impairments, a bike mechanic replaced the cleats, readjusted the saddle position and educated the client on how to tighten the saddle without creating tilt, and the client asked his massage therapist to focus the session on his IT band. There is a wide variety of practitioners with similar tools: chiropractors, physical therapists, massage therapists, strength and conditioning coaches, personal trainers. Nobody has every tool in their box. Some offer many tools with little experience using them, while others have only a few tools but have mastered their craft. The best technicians are those who know what they don’t know, and have created a network of technicians to collectively offer the largest tool box for the athlete.
The next newsletter will provide a basic framework for adding tools to your toolbox to build a more plastic, resilient, durable cyclist.
