Cycling injuries

The notion that prevention is better than cure applies equally to cycling as to any other sport. In cycling, injuries can be avoided not only by anticipation and skilful riding but also by attainment of the correct position on the bicycle and by ensuring that the bicycle is in first class working order. Fitness also plays a part since some injuries result from congenital abnormality, weakness or lack of the specific physiological requirements for the event undertaken.

There are however two main causes of cycling injuries – the position on the bicycle and crashes. Before these can be considered in any detail the cycling action must first be outlined.

THE CYCLING ACTION

Cycling is a balancing activity with a large amount of effort being spent keeping the machine upright, the rider representing a top-heavy unit. The base is some 1.2m long, 2.5cm wide and rounded and moveable; it defies all requisites of stability in a stationary position. Only when forward momentum is secured, is balance possible. The able track performer who balances in one place is not completely stationary as there is an interplay between right and left pedals, and the position of the front wheel.

The rider cannot depend entirely on the forward momentum but must keep the gravitational line close to the wheel line. The faster the speed, the easier it is to make adjustments when lateral deviations of the gravitational line from the wheel line occur; however, the faster one goes the harder one falls when these lateral adjustments are not made and crashing results. A very large number of the body’s muscles are involved in maintaining balance.

The racing cyclist may be likened to a runner who is only partially weight-bearing, encumbered by a crouched restricted position anchored by the hands and feet. Less fixation is given by the perineum and ischial tuberosities which frequently come off the saddle. Forward movement is begun by lower limb extension, the foot in contact with and fixed to the pedal by toeclip and strap. The extension is started in the quadriceps muscle followed by extension of the hip by the gluteal muscles. Plantar flexion of the ankle by the gastrocnemius and soleus muscles is made more effective by the ball of the foot being over the pedal spindle. A combination of clawing, using the anterior tibial muscles as the pedal comes up, and pushing by the bodyweight as the pedal descends, increases effectiveness but aggravates the problem of balance.

In utility cycling, or when using a fixed wheel, recovery of the leg is achieved by allowing relaxation of the extensor muscles; the foot then rides up passively and the leg is flexed. To reduce inefficiency it is necessary to pull the foot upwards with the tibialis anterior; then the gastrocnemius helps flex the knees. At the same time there is strong flexion at the hip using the psoas and iliacus muscles. The trunk is bent forward by gravity and controlled by the back extensors, thus reducing wind resistance; when moving fast the abdominal muscles are working strongly to stabilise the pelvis thereby allowing more efficient use of the legs in pedalling.

Turning is fairly simple but requires complex muscle action and weight shifting. If the turn is too sharp, forward momentum causes the front wheels to skid and the rider falls. When turning, the cyclist leans to the inside of the curve to counteract centrifugal forces. The greater the speed the greater the curve and the greater is the lean required.

The arms are very important even though they have been neglected in the past in terms of strength training. The arms provide the force through the hands and handlebars which prevent the front wheel wobbling. They also play a crucial role in the power drive of the legs; even by just gripping the bars the trunk is made more stable and so the leg muscles act more ably. By pulling on the handlebars this stabilising of the trunk is enhanced.

The legs are thus the driving force assisted by the arms but unlike the runner no dynamic arm action is possible except in controlling the machine. The trunk is relatively stable and the muscle work of the arms and

I trunk is mainly isometric or dynamic within a small part of the inner range of movement.

The position of the bicycle will differ slightly with the branch of the sport followed. There is an optimum, which when adopted will be less likely to produce injury from propelling the machine. These positions are well detailed in the handbooks of the British and Italian Cycling Federations. They cover variations for time mailing, track and road racing and cyclo-cross.

It must be borne in mind that cycling is an endurance sport, the shortest distance being 1km lasting just over one minute and the longest up to 800km (500 miles) in a 24-hour period. In addition there are multi-stage races, single stage and multi-heat events. A single stage event can involve covering distances up to 580km (362 miles) with 100 to 240km (62 to 150 miles) per day in a multi-stage event lasting for three weeks. A cyclo-cross rider will cover 24km (15 miles) or so and will have some injuries in common with the cross-country runner. Each specialty has its own specific fitness requirements and training schedules should be designed accordingly.

TRAUMA DUE TO POSITION

Broadly speaking, trauma affects the fixed pans of the body due to the cyclist’s position but some moving parts can be affected because of poor alignment or faulty equipment. The more fixed parts are the feet, buttocks, back, chest and the upper limbs. The moving joints are the ankle, knee and hip, and there is some associated movement of the head and the elbow. The handlebars are so designed as to give four or five alternative positions so that the fixed postures of the upper limbs and trunk can be altered.

Fixed body parts

FEET

The feet should be enclosed in good quality leather shoes with a thick sole. These should fit closely and even be a little on the tight side when new, as the leather tends to stretch with use. If the sole is too thin there is an insufficient base for attaching shoe plates and the pressure of the pedal is carried through the sole of the foot and makes it sore. Insufficient anchorage can cause the plates to move, altering the position of the foot on the pedals. When this happens it will lead to mal-alignment and to problems at the ankle, knee and hip. Shoes that are excessively tight can rub causing blisters and corns which will require an Elastoplast dressing or the services of a chiropodist.

The feet are held fixed to the pedals by the shoe plates and toe straps . The toe straps are usually in a line drawn from the head of the fifth metatarsal to just behind the head of the first metatarsal. If the toe strap buckle is not placed on top of the foot, pressure may be exerted at the little toe. Soreness, pain, corns or an exostosis (bony outgrowth) can occur as a consequence; the problem can be avoided by having thicker leather at this part of the shoe.

BUTTOCKS AND CROTCH

The greatest problem in this area is associated with poor hygiene. This part gets very hot and sweaty during a long ride and if not properly washed may lead to infection and so to saddle boils. To this can be added the danger of grit and dirt being thrown up from the road especially when wet and this can lead to increased friction and perineal soreness. Soreness may also be caused if the saddle is too high or too far back so that the rider sits on the point and the narrow section. It is essential to have a good position and it is advisable to wear good quality shorts with a chamois seat insert next to the skin. It may also be appropriate to layer lanolin on the chamois to reduce friction.

Saddle soreness is an acute panniculitis, I.e. inflammation of the superficial fascial tissue, progressing to a localised area of fat necrosis. The immediate treatment is to puncture the lesion with a sterile needle to relieve oedema. If allowed to become chronic it produces ulceration and chronic infection (Williams and Sperryn, 1976). Surgical spirit will keep the perineum clean and harden off the skin.

Occasionally the urethra is damaged from a direct astride blow to the perineum. This may be a partial or complete rupture presenting as a painful swelling. These injuries are serious and need immediate investigation and the rider advised not to pass urine (Williams and Sperryn, 1976).

Priapism, a persistent painful erection, can occur due to pressure on the pudendal nerve from a badly fitting saddle pushing into the perineum. Treatment is sedation and replacement of the saddle (Williams and Sperryn, 1976).

Soreness of the ischial tuberosity can be due to inflammation of the bursa which separates the tuberosity from the gluteus maximus (Stahl, 1978). It is fairly rare as the bursa is often not present, but the soreness seems to be caused by a combination of continuous minor trauma from bouncing on the saddle and repetitive use of the gluteus maximus. Often, after a prolonged period of riding, pain is experienced in the region of the ilium, above and posterior to the head of the femur; palpation over the buttock reveals spasm in the gluteus medius and minimus. One explanation is an ischaemia of the hip abductors due to their use while pedalling and to compression from the gluteus maximus.

TRUNK

All cyclists at some time or another experience backache which is usually in the lumbar region, the sacroiliac or thoracic area. There appears to be four main causes: 1. Spasm of the extensors of the spine arises as a result of prolonged periods in an unnatural position leading to a relative ischaemia. It can be relieved while on the bicycle by moving more, and the onset can be delayed by a progressive resistance exercise regime. Deep massage or ultrasound to the affected area is successful. 2. Tension on the posterior longitudinal and inters-pinous ligaments can occur after muscles weaken through fatigue or where there is mis-alignment; later pain can occur or aching will follow. Massage will relieve the ache but stronger muscles are needed. As with the extensor spasms, pain diminishes when activity is terminated. 3. A more serious but rarer problem is that of protrusion and prolapse of the intervertebral disc. The prolapse or protrusion presses posteriorly or postero-laterally and impinges on the dura of the emerging spinal nerve or the spinal cord (Cyriax, 1978). At best, there is a mild ache and at worst paraesthesiae or anaesthesia. Specialist treatment is required from a doctor and a physiotherapist. It will help to learn to use the legs in lifting; to keep the back straight when off the bicycle and to have strong muscles. A good saddle position , correct sized frame and the avoidance of sudden twists or jerks are essential. 4. Spondylolisthesis is the displacement of one vertebra on the one below, and may not be the cause of any symptoms during a lifetime. However, the condition may lead to a secondary disc lesion or may itself cause symptoms usually of central backache. It is due in part to stretching of the posterior ligaments of the lumbar intervertebral joints, and some days the back may ache, sometimes it may not (Cyriax, 1978).

UPPER LIMB

The gleno-humeral and acromio-clavicular joints are subjected to minor trauma which later leads to arthro-tic changes. There is perhaps an ache when riding which may continue for sometime afterwards. The condition is aggravated by subluxation of the acromioclavicular joint which can occur in a crash.

Subluxation with associated osteoarthrosis is treated by infiltration with hydrocortisone and procaine and this can afford some relief even after long-standing problems. Short wave diathermy or ultrasound may often relieve the symptoms for long periods; they will also relieve associated muscle spasm.

Occasionally, because the arm is held in abduction at the shoulder an associated tenosynovitis develops at the long head of the biceps. It can be relieved by deep transverse massage to the tendon as it lies in the bicipital groove or, if particularly severe, it may be infiltrated with hydrocortisone and procaine.

Three associated muscles at the elbow joint, extensors carpi radialis longus and brevis, and brachialis, may show spasm and a continual ache when riding may be experienced. These muscles are under tension during pushing and pulling on the handlebars and are subject to minor trauma which is transmitted through uneven road surfaces. Deep massage and ultrasound provide relief but it is imperative to have strong flexible muscles.

The wrist is a source of minor aches and pains which again are associated with continual minor trauma. Short wave diathermy or ultrasound to the wrist and passive movements for the accessory range of movement of the joint, are helpful. Sometimes tenosynovitis of abductor pollicis longus and extensor pollicis longus develops; this appears to be due to holding the handlebars for long periods with the thumb abducted and flexed around the bars, and again there is associated minor trauma. The flexors and extensors of the wrist can also be affected. If rest does not achieve relief then deep massage and ultrasound will.

The ulnar nerve is vulnerable at the point at which it enters the palm. Pressure occurs between the handlebars and the hypothenar eminence; this pressure is sometimes increased by riding over uneven terrain or going over pot-holes. Symptoms produced range from anaesthesia and paraesthesiae in the ring and little fingers to weakness of the grip. Prevention is by frequently altering the position of the hands on the handlebars (Faria and Cavanagh, 1978). Permanent changes will need specialist attention from a doctor and a physiotherapist.

The fingers are often affected by the cold and then they become very stiff; occasionally they suffer traumatic osteoarthrosis. Massage and short wave diathermy will help but more easily, frequent active movements while riding can be beneficial. The hands should be protected when training or racing in cold conditions by suitable mitts.

Associated with fixture

THE ANKLE

Cyclists seldom suffer ligamentous injuries at the ankle joint through riding; but there are three tendons associated with the ankle joint which can cause sufficient nuisance as to preclude training and racing. Peritendinitis of the Achilles tendon occurs with intermittent attacks of acute pain which may in some cases gradually become continuous. It is usually an early season problem especially if insufficient attention has been paid to off-season training. The causes are numerous but they all imply overuse. This injury is seen in the single stage rider who changes to multistage events; time trialists who move to the longer competitive distances or the rider who changes from one type of terrain to another. The cyclist who trains on the flat and only occasionally rises from the saddle enters a multi-stage event which involves increased distances and climbing mountains; this means that the rider becomes like a runner for long periods, dancing up and down on the pedals for several days. Specialist physiotherapy is required for the early tendinitis (Cyriax, 1977); if, later, a paratenon develops surgery will be required (Williams, 1967; Williams, 1976). The problem may be eased by wearing a raised heel on the shoe to relax the calf muscles when off the bicycle. Training on the bicycle should be progressive at 50 per cent to 75 per cent of racing pace increasing the distance by 3 to 5km (2 to 3 miles) each day from 9km (5 miles) upwards. Climbing hills and getting out of the saddle must be avoided. The prevention of this peritendinitis is to give thought to training over all kinds of terrain. Cyclo-cross should not be attempted without some running training.

Tenosynovitis of the tibialis anterior and extensor hallucis longus may also be seen in the cyclist. These tendons are affected as they cross the ankle joint. They are treated by transverse frictions or by infiltration of hydrocortisone, and rest.

THE KNEE

The menisci are not normally affected in bicycle riding but damage occurs in training off the bicycle or while playing other sports. The coronary ligaments can suffer strain as a result of the femur pushing forward steadily on the tibial plateau. It is usually associated with the use of high gears especially in long distance events. Transverse frictions produce quick and effective results. The pain or ache that occurs behind the patella can be that of chondromalacia patellae (Fulford, 1969) or a weak vastus medialis muscle, allowing alteration of the line of pull of the patella on the femoral condyles. In chondromalacia, the central medial articular facet on the posterior surface of the patella is eroded, while in a weak vastus medialis the upper medial facet is similarly affected (Williams, 1971). A bent pedal spindle or loose cotter pin can cause the same problem by allowing malalignment at the knee. Very often the pain can be cured by strengthening the quadriceps group, first by straight leg raising and then by progressive resistance exercises. Mechanical faults in the bicycle should be corrected: the cranks must be straight and at right angles to the bottom bracket, the pedal spindles must be at right angles to the cranks, and the shoe plates must be aligned so that the foot rests squarely on the pedal and not at an angle.

It is common for cyclists to develop very painful knees due to the cold weather as a result of wearing shorts too early in the year. It is an easy condition to avoid but difficult to overcome. The answer is to cut down the mileage and to keep the knees covered for as long as possible. Racing in wet weather especially around country lanes causes grit and mud to be thrown up at the rider. This gets lodged in the shorts and works its way into the material. Eventually there is increased friction at the perineal and the adductor regions with ensuing soreness. It is advisable to buy good quality racing shorts with fairly long legs so that there is minimum chafing between thighs and the saddle.

TRAUMA DUE TO CRASHES

Causes of crashes

On the whole, cyclists are skilful at maintaining balance and many crashes are avoided: however, there are some situations in which they become unavoidable and these occur in all branches of the sport. There are two main factors – firstly, loss of adhesion between the road surface and the tyres leading to loss of balance and, second, loss of balance through any other cause including professional fouls.

LOSS OF ADHESION

On a steep descent speeds of 80 to 96kmh_1 (50 to 60mph_1) are reached allowing little time for contact between road surface and tyres. A gust of wind can cause a wobble and then loss of adhesion. Wintry conditions, loose gravel or strong winds, either alone or in combination, can also lead to loss of adhesion. On very steeply banked tracks this loss of contact has spectacular results and may be caused by just a few spots of rain. Equipment is often implicated in loss of adhesion. Tyre tread may be poor, worn out and not replaced for reasons of finances, carelessness or laziness. Tyres can also roll off. Neglect amounts to almost a criminal offence and so all tyres are inspected before track and road meetings to see that they are firm. Occasionally accidents will happen – taking a corner too fast or at too great an angle may cause the tyre to be forced off the rim and cause a crash.

LOSS OF BALANCE

The deliberate fouls which cause crashes are, fortunately, very rare and remediable on a ‘tit for tat’ basis. The very nature of the sport tends to militate against fouling as the culprit may be worse off by being involved in the resultant crash. The main cause of loss of balance is lack of skill which applies more to schoolboy and junior events than to senior level. Switching, I.e. the swinging aside of a cyclist to adjust to the sudden change of position of the rider in front, is the biggest single factor; at fast speeds there is insufficient time to move out of the way. The fact that the rider behind may not be able to avoid the switch may also be due to lack of skill, poor judgement in travelling too close to his opponent, or being not good enough to avoid the move. There is also the domino effect, I.e. one rider knocks another who knocks another until it becomes impossible to avoid a crash no matter how skilful the riders are. The more skilful riders will be able to exercise sufficient control on poor surfaces even when they are exhausted. It is during the period of exhaustion that some crashes occur due to lack of control or loss of concentration. A pedal may accidentally be put into the wheel of an adjacent rider; lines may be changed so that adhesion is lost on corners; another rider is interfered with; or the rider runs off the road. Occasionally, pressure may be such that a rider has to concentrate so hard in single-mindedly pursuing a good time or chasing the escaping group, or trying to catch the bunch after a puncture, that he fails to see a parked vehicle and collides head-on with it. A tight echelon in a cross-wind constitutes a potentially dangerous situation where a lapse of attention can be physically costly.

Many mechanical factors can contribute to crashes by causing imbalance. The most common is snapping cranks or pedal spindles with a resulting lurch to one side. Going over pot-holes can cause wheels to collapse, while breaking seat pillars also causes serious problems.

Trauma associated with crashes

The incidence of crashes is highly unpredictable in any one event. A crop of injuries, because of a multiple pile up rather than a solitary severe case, is usual (Black, 1970). The injuries run the whole gamut of the orthopaedic spectrum. The common fractures are those of the clavicle, scaphoid and the lower end of the radius and ulna. One or two cases of a fractured neck of femur in young cyclists have been recorded (Stahl, 1978). The skull is sometimes fractured with fatal results. The shoulder joint is most frequently dislocated with subluxations of the acromio-clavicular and sterno-clavicular joints being recorded (Stahl, 1978). A likely cause is a direct blow on the shoulder after being thrown from the machine.

Grazes, abrasions, gravel rashes, friction burns are common cycling injuries and always occur as a result of contact with the road surface after crashing. Most, if not all of the riders involved in a crash will have one or more of them, depending on their speed and position when it happens. Although the wound (especially a friction burn) remains clean for up to four hours, it is most important that it is kept clean afterwards. A friction burn is more likely to occur on the track where there is a greater chance of more sophisticated treatment being available. On the other hand a graze with gravel rash can occur on the open road when the rider is competing in a long distance or stage of a multi-stage event. In this case it has been found useful to spray the affected area – mostly the greater trochanter, thigh, knees and shins – with an anaesthetic spray, usually incorporating iodine powder. The wound can then be covered with Netelast while the rider is still moving on tow. There is thus little loss of continuity and the psychological ‘pack barrier’ (I.e. the tendency to give up) is avoided. If it has not already been done on the move, it is essential, later, to scrub the area of the rash so that all debris and grit is removed. It snot advisable to use cotton wool as the small strands may be left behind and become foci for infection. The ability of the rider to continue may be paramount and infiltration with local anaesthetic is advisable to ensure a restful night. It is not usual to apply more than a spray while the rider is on the move. The wound must be well covered to prevent secondary infection and further friction from clothing.

If there is bruising and contusion without an open wound, the area is covered with a hyaluronidase and heparinoid ointment (Lasonil); (Movelat gel or cream).

MISCELLANEOUS INJURIES

There is a risk of conjunctivitis from spray dust and grit thrown up from the racing surface. The problem is not helped, especially on hot dry days, by sweat dripping into the eyes. Regular bathing with Optrex Eye Lotion is soothing and preventive. To avoid aggravating the condition, it is advisable to hand up grit-free wet sponges while the rider is on the move to maintain body fluids so that reduction of eye lubrication does not occur.

In common with chondromalacia patellae, sinusitis seems to be an occupational hazard to cyclists. The major cause is continual irritation of the nasal mucosa from grit and dust; it may also be due to an increase in mucous secretions as effort increases circulation. It is essential to prevent retention and infection of these secretions by blowing the nose properly so that the nares are not held together when blowing: if they are held together pressure forces material into the sinuses and even into the bronchi.

Extreme effort, especially in hill climbing on cold winter days, can produce the phenomenon known as ‘effort bronchitis’; breathing becomes harsh with audible bronchial sounds. There is an increase in pulmonary secretions and much frothy white sputum is produced. The result can resemble an asthmatic attack; indeed, Dekker and Groe (1957) suggested that the secretions of asthma are produced in this way by compression of the trachea and major bronchi when muscular effort increases intrathoracic pressure. The problems soon settle after exertion; if abnormal secretions are not cleared there may be danger of chronic bronchitis.

Corns are due to ill-fitting shoes and wrongly aligned shoe plates so that the foot is not snugly fitted into the toeclips. The strap of the toeclip is a causal factor if pulled too tightly. Corns are best avoided by having well-fitted shoes which do not cause pressure and which allow the feet to spread.

During cold wet weather poor circulation exacerbates chilblains. The condition is not helped by inappropriate shoes and socks which do not afford protection against the weather. Vitamin K taken in accordance with instructions is helpful as is the wearing of socks and shoes without holes but with a fleecy lining in the winter.

Because the need to keep a sharp lookout and to watch opponents involves constant backward glances, minor injuries can occur in the cervical spine. In the United Kingdom, where driving is on the left-hand-side, spasm of the left sternocleidomastoid muscle may develop causing torticollis (wry neck); for those who ride on the right-hand-side of the road, this will develop on the right side. After a hard day’s ride there may be a general neck ache which can be relieved by traction and massage. Occasionally, torticollis may result from a sudden displacement of the disc or appear gradually overnight (Cyriax, 1977). Both Cyriax (1977) and Maidand (1977) have described treatments for this condition.

SAFETY

The racing cyclist is a skilful handler of the bicycle at speed and must have a sound body to propel the machine. The nature of the sport demands a mechanically sound bicycle; gears should be well-adjusted, the chain correctly aligned, the wheels should be true, the tyres secure and the brake blocks should be changed frequently. Adjustments to suit the individual should be made to saddle height, handlebar width and the length of extension.

A lot of problems in cycle racing are caused through crashes so a few brief do’s and don’ts will be useful.

Do’s

DO brake before a corner and never on it, especially in wet conditions.

DO take a smooth line using as much road as is safe to do.

DO look over the shoulder of the man in front. DO look for changes in formation when changing direction.

DO look ahead for oncoming traffic when in an echelon, or when spread from gutter to gutter. DO move to the correct side when working in a small group.

Don’ts

DON’T ride too close to the wheel in front.

DON’T look behind while in a bunch or group.

DON’T ride into a non-existent or rapidly closing gap, especially during a sprint.

DON’T change your line in a corner unless absolutely necessary.

DON’T look down at the wheel in front.

Attaining cycling fitness is time-consuming because of the long training and racing distances involved. It is important that as much consideration is given to the care of the machine as to the body, otherwise fitness may be wasted because of mechanical defects.

REFERENCES

Black, W. A. (1970). Cycling injuries. British Journal of Sports Medicine, 3, 105-107.

Cyriax, J. (1978). Textbook of orthopaedic medicine. Volume 1, Diagnosis of soft tissue injuries. 7th edition. Bailliere Tindall, London.

Cyriax, J. and Russell, G. (1977). Textbook of orthopaedic medicine. Volume 2, Treatment of soft tissue injuries. 9th edition. Bailliere Tindall, London.

Dekker, E. and Groe, J. J. (1957). Asthmatic wheezing, compression of the trachea and major bronchi. Lancet, 1, 1064.

Faria, I. E. and Cavanagh, P. R. (1978). Physiology and biomechanics of cycling. John Wiley and Sons, New York.

Fulford, P. (1969). Chondromalacia of the patella. British Journal of Sports Medicine. 3, 198-202.

Maitland, G. D. (1977). Vertebral manipulation, 4th edition. Butterworths, London.

Stahl, T. (1978). Personal communications.

Williams, J. G. P. (1967). Causes and prevention of Achilles peritendonitis in middle and long distance runners. British Journal ofSports Medicine, 1,16-17.

Williams, J. G. P. (1971). Diagnostic pitfalls in the sportsman’s knee. Proceedings of the Royal Society of Medicine, 64, 640-641.

Williams, J. G. P. and Sperryn, P. N. (1976). Sports Medicine. Edward Arnold, (Publishers) Ltd., London.

Williams, J. G. P., Sperryn, P. N., Boardman, S., Street, M., Mellett, S. and Parsons, C. (1976). Postoperative management of chronic Achilles tendon pain in sportsmen. Physiotherapy, 62, 256-259.

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