Overuse injuries in cycling

NewsBot · Sep 17, 2010

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Overuse Injuries in Professional Road Cyclists
Benjamin Clarsen, Tron Krosshaug, Roald Bahr
American Journal of Sports Medicine (in press)

Background: Little epidemiological information exists on overuse injuries in elite road cyclists. Anecdotal reports indicate anterior knee pain and lower back pain may be common problems.

Purpose: This study was conducted to register overuse injuries among professional road cyclists with special focus on anterior knee and lower back pain.

Study Design: Descriptive epidemiology study.

Methods: We attended training camps of 7 professional teams and interviewed 109 of 116 cyclists (94%) on overuse injuries they had experienced in the previous 12 months. Injuries that required attention from medical personnel or involved time loss from cycling were registered. Additional information on anterior knee pain and lower back pain was collected using specific questionnaires.

Results: A total of 94 injuries were registered; 45% were in the lower back and 23% in the knee. Twenty-three time-loss injuries were registered—57% in the knee, 22% in the lower back, and 13% in the lower leg. Fifty-eight percent of all cyclists had experienced lower back pain in the previous 12 months, and 41% of all cyclists had sought medical attention for it. Thirty-six percent had experienced anterior knee pain and 19% had sought medical attention for it. Few cyclists had missed competitions because of pain in the lower back (6%) or anterior knee (9%).

Conclusion: Lower back pain and anterior knee pain were the most prevalent overuse injuries, with knee injuries most likely to cause time loss and lower back pain causing the highest rates of functional impairment and medical attention.

Clinical Relevance: Future efforts to prevent overuse injuries in competitive cyclists should focus on lower back pain and anterior knee pain.
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NewsBot · May 29, 2011

Effects of bicycle saddle height on knee injury risk and cycling performance.
Bini R, Hume PA, Croft JL.
Sports Med. 2011 Jun 1;41(6):463-76.

Incorrect bicycle configuration may predispose athletes to injury and reduce their cycling performance. There is disagreement within scientific and coaching communities regarding optimal configuration of bicycles for athletes. This review summarizes literature on methods for determining bicycle saddle height and the effects of bicycle saddle height on measures of cycling performance and lower limb injury risk. Peer-reviewed journals, books, theses and conference proceedings published since 1960 were searched using MEDLINE, Scopus, ISI Web of Knowledge, EBSCO and Google Scholar databases, resulting in 62 references being reviewed. Keywords searched included 'body positioning', 'saddle', 'posture, 'cycling' and 'injury'. The review revealed that methods for determining optimal saddle height are varied and not well established, and have been based on relationships between saddle height and lower limb length (Hamley and Thomas, trochanteric length, length from ischial tuberosity to floor, LeMond, heel methods) or a reference range of knee joint flexion. There is limited information on the effects of saddle height on lower limb injury risk (lower limb kinematics, knee joint forces and moments and muscle mechanics), but more information on the effects of saddle height on cycling performance (performance time, energy expenditure/oxygen uptake, power output, pedal force application). Increasing saddle height can cause increased shortening of the vastii muscle group, but no change in hamstring length. Length and velocity of contraction in the soleus seems to be more affected by saddle height than that in the gastrocnemius. The majority of evidence suggested that a 5% change in saddle height affected knee joint kinematics by 35% and moments by 16%. Patellofemoral compressive force seems to be inversely related to saddle height but the effects on tibiofemoral forces are uncertain. Changes of less than 4% in trochanteric length do not seem to affect injury risk or performance. The main limitations from the reported studies are that different methods have been employed for determining saddle height, small sample sizes have been used, cyclists with low levels of expertise have mostly been evaluated and different outcome variables have been measured. Given that the occurrence of overuse knee joint pain is 50% in cyclists, future studies may focus on how saddle height can be optimized to improve cycling performance and reduce knee joint forces to reduce lower limb injury risk. On the basis of the conflicting evidence on the effects of saddle height changes on performance and lower limb injury risk in cycling, we suggest the saddle height may be set using the knee flexion angle method (25-30°) to reduce the risk of knee injuries and to minimize oxygen uptake.
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Kevin Kirby · May 29, 2011

NewsBot said: ↑

Effects of bicycle saddle height on knee injury risk and cycling performance.
Bini R, Hume PA, Croft JL.
Sports Med. 2011 Jun 1;41(6):463-76.
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One of the ways I try to determine optimum saddle height in my cyclist patients is to incrementally raise the saddle height until the pelvis starts rotating excessively within the frontal plane while doing seated cycling. This is best done on a wind-trainer in the office. I use the formula of 109% of inseam length (crotch to floor distance while in standing on floor in bike shoe) as the proper distance from the top of saddle to the top of the pedal at the bottom dead center position of the pedal cycle. Of course, it is probably much more complicated than that but this seems to have worked well for my cyclist patients in the past.

Here is a nice little article discussing some of the mechanical considerations in making this determination.

http://www.noncircularchainring.be/pdf/Biomechanical study - Project 003 Dead Centre.pdf

David Wedemeyer · May 29, 2011

This is really good stuff Kevin thank you. I'm enjoying my road bike again after having a fitting and some tinkering! My left knee was beginning to get irritated and we changed a couple things, including the shoes. My last couple rides were much more comfortable, keeping my fingers crossed!

Kevin Kirby · May 30, 2011

David Wedemeyer said: ↑

This is really good stuff Kevin thank you. I'm enjoying my road bike again after having a fitting and some tinkering! My left knee was beginning to get irritated and we changed a couple things, including the shoes. My last couple rides were much more comfortable, keeping my fingers crossed!
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David:

One of the things I learned from Drs. Harry Hlavac and Bill Sanner during my Biomechanics Fellowship (26 years ago) is that it is best to evaluate the cyclist from in front of the bike (on wind trainer) and with video analysis (or careful visual analysis) of their frontal plane knee motion. Ideally, the knees should track nearly straight up and straight down, with little wasted side-to-side motion or in a very tight "figure of 8 pattern". As the loops of the "figure of 8" of the anterior knees become larger then we assumed cycling mechanics were worse and the knee strain was greater.

Additionally, I have noted in feet with medially deviated STJ axes during cycling, that the knee will adduct fairly rapidly toward the top tube during the initiation of the power phase. Additionally, in more severe cases of varus forefoot deformities, the medial knee may even strike the top tube during the power phase. In these feet, a combination of a foot orthosis inside the cycling shoe and a varus wedge between the shoe cleat and the shoe sole makes a huge difference in cycling efficiency and comfort.

NewsBot · May 24, 2018

Potential factors associated with knee pain in cyclists: a systematic review
Authors Bini RR, Flores Bini A
Open Access Journal of Sports Medicine 23 May 2018 Volume 2018:9 Pages 99—106 (full text)

The potential factors associated with overuse injuries and pain in cyclists that are supported by evidence remain unclear. Our study aimed at assessing, using a systematic search of the most updated evidence, the main factors related to overuse knee-related pain and/or injuries in cyclists. The search assessed any potential mechanism related to knee pain or injury that could be used in the clinical practice. Databases were searched (i.e., PubMed, Scopus, Web of Science, and EBSCO). Studies were included if they presented results from original studies. They had to include, preferably but not limited to, recreational and/or competitive cyclists with or without knee pain. Quality of articles was assessed. Eleven articles were deemed eligible for full text appraisal. Studies involved generally the assessment of biomechanical outcomes associated with knee pain in cyclists. Overall, studies showed that cyclists with knee pain present larger knee adduction and larger ankle dorsiflexion and differences in activation for hamstrings and quadriceps muscles. Unclear results were observed for knee moments and no differences were observed for knee flexion angle, tibiofemoral and patellofemoral forces. It is important to state that varied types of knee pain were mixed in most studies, with 2 focused on anterior-related pain. Cyclists with overuse-related pain or injuries on their knees presented an increased medial projection of their knees and an altered activation of the Vastus Medialis and Vastus Lateralis muscles. However, this limited evidence is based on retrospective studies comparing cyclists with and without pain, which limits the conclusion on how cyclists develop knee pain and what are the main options for treatment of knee pain.
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NewsBot · Oct 2, 2019

Lower Limb Biomechanics in Walking, Running and Cycling: Implications for Overuse Injury
Chuang, Tyler
Source

A common anecdotal theory among endurance athletes is that cycling results in fewer knee injuries compared to running. This is thought to be due in part to a lower impact ground reaction force in cycling, compared to running. Thus, as these endurance athletes age, there is a tendency to shift from running participation to cycling participation in order to avoid injury. However, the knee has been reported to be the most commonly injured region in both sports, with similar injury rates (Clarsen, Krosshaug, & Bahr, 2010; James, 1995). While it has been found that cycling does typically result in a lower peak ground reaction force compared to running (Gatti et al., 2017), it is unknown how other mechanisms (which could potentially lead to injuries such as iliotibial band syndrome and patellofemoral pain syndrome) differ between these exercise modalities. There has been an abundance of research conducted assessing the impacts of cycling on subsequent running performance (i.e. triathlon performance), specifically from a physiological point of view (Heiden & Burnett, 2003; Hue, Le Gallais, Chollet, Boussana, & Préfaut, 1998). No study to date, however, has explicitly compared the biomechanics of running and cycling. The purpose of the current study was to compare dynamic joint stiffness, co-contraction of the muscles surrounding the knee, segment coordination variability and iliotibial band impingement measures between walking, running and cycling in young, experienced runner/cyclists, in order to elucidate the risk of developing knee injury in one activity over the other. Fifteen healthy, trained runner/cyclists (11M, 4F, age: 25.1 ± 4.7 years, height: 1.80 ± 0.1 m, mass: 72.1 ± 8.2 kg) were recruited. Muscle activity for 7 lower limb muscles were collected using wireless surface electromyography. External ground reaction forces were collected using force plates for the walking and running trials and an instrumented force pedal for the cycling trials. 3D kinematics were collected using an active motion capture system. Participants performed 6 trials of walking at a self-selected pace, 6 trials of running at a pace equivalent to 70% of their maximal heart rate and 6 minutes of cycling at an intensity of 65% of their maximal heart rate. These intensities were selected to represent a typical, social weekend activity. A walking or running trial consisted of one progression overground on a 20m runway and a cycling trial consisted of 30 second efforts extracted from a continuous, steady state, 6-minute trial on the cycle ergometer. Walking was assumed to be a relatively low injury-risk activity and was performed to act as a baseline to which running and cycling could be compared. Kinematic, kinetic and electromyographical signals were analyzed during the stance phase of walking/running and the downstroke of cycling. These portions of the respective activities were chosen since they are the main propulsion producing phases of their respective activities. Compared to walking and cycling, running generally had a larger dynamic joint stiffness and co-contraction index. For the entire stance/downstroke, and when it was broken into an initial and terminal phase, running had the largest DJS, followed by walking and then cycling (all p<0.0001). For stance/downstroke as well as the terminal phase, for all muscle groupings, running had a greater CCI compared to walking and cycling (all p<0.05/4), which were not different from each other. For the initial phase, for the VLLG and VMMG muscle groupings, running had a greater CCI compared to walking and cycling (both p<0.05/4), which were not different from each other. For the VLBF muscle grouping, running had a greater CCI compared to walking, which was greater than cycling (p=0.002) and for the VMST muscle grouping, walking and running were larger than cycling, but were not different from each other (p=0.002). The coordination variability was not different between walking, running or cycling for the sagittal thigh / sagittal shank or sagittal shank / sagittal foot segment coupling (both p>0.05). In terms of IT band impingement measures, running had a larger ITBEX compared to walking and cycling, which were not different from each other (p=0.0001). In terms of IT band impingement duration over an equivalent cumulative load, there were no differences between walking, running and cycling (p=0.164). The outcome measures that were different from walking (assumed to be a relatively low-injury risk activity) might be a contributor to injury for that activity. Of the outcomes analyzed in the current study, joint stiffness and co-contraction thus could potentially play a role in running injuries. None of the studied outcomes, however, when interpreted in isolation, likely play a role in cycling injuries. At the large knee flexion angles, such as those exhibited during the downstroke of cycling, the patellofemoral contact pressure, area and force have been found to be increased compared to full extension (Lewallen, Riegger, Myers, & Hayes, 1990). Thus, perhaps large flexion angles may be an important factor, either in isolation in combination with the outcome measures analyzed such as the co-contraction indices and coordination variability, to overuse injuries in cycling. This was the first study to explicitly compare the biomechanics of running and cycling in the same study. When comparing walking, running, and cycling, significant differences were found in the dynamic joint stiffness and co-contraction index. Since injury rates between the two sports are very similar, these findings suggest that the same injuries could manifest from different injury mechanisms. Runners may opt to cross train in cycling but should be warned that due to large knee flexion angles under load, there are mechanisms of injury during cycling that may also result in overuse injury.
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NewsBot · Aug 25, 2020

Epidemiology, clinical characteristics and severity of gradual onset injuries in recreational road cyclists: A cross-sectional study in 21824 cyclists - SAFER X
Françoisdu Toit et al
Physical Therapy in Sport; 23 August 2020

Highlights
•We describe the epidemiology of gradual onset injuries in 21824 recreational cyclists.
•About 2.8% (1 in 35) of recreational cyclists report ever suffering from a gradual onset injury.
•The knee (26%), shoulder (13%) and lower back (11%) are common sites of gradual onset injury.
•More than 37% of gradual onset injuries are severe enough to affect training and competition.
•More than 50% of cyclists report a symptom duration >12 months for gradual onset injuries.
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Objectives
Prevalence, clinical characteristics and severity of gradual onset injuries (GOIs) in cyclists are poorly documented. We determine the prevalence, anatomical regions/sites affected and severity of GOIs among entrants in a community-based mass participation event.

Design
Cross-sectional study;

Setting
Cape Town Cycle Tour;

Participants
Race entrants

Main Outcome Measures
Of 35914 entrants, 27349 completed pre-race medical questionnaires. We studied 21824 consenting cyclists (60.8% of entrants). Crude lifetime prevalence, retrospective annual incidence, anatomical region/sites, specific GOI, tissue type and GOI severity is reported.

Results
The lifetime prevalence of GOIs was 2.8%, with an annual incidence of 2.5%. More common anatomical regions affected by GOIs were lower limb (43.4%), upper limb (19.8%), and lower back (11.5%). The knee (26.3%), shoulder (13%), and lower back (11.5%) regions were mostly affected. The most common GOI was anterior knee pain (14.2%). Of the GOIs, 55% were in soft tissue. 50% of cyclists reported symptom duration >12 months, and 37.3% of GOIs were severe enough to reduce/prevent cycling.

Conclusion
2.5% recreational cyclists report a GOI annually. >50% of GOIs affect the knee, lower back and shoulder. GOIs negatively affect cycling. Risk factors related to GOIs in cyclists need to be determined to develop and implement prevention programs.
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NewsBot · Sep 1, 2020

History of chronic disease is a novel intrinsic risk factor associated with gradual onset injuries in recreational road cyclists: A cross-sectional study in 21824 cyclists - SAFER XI
Françoisdu Toit et al
Physical Therapy in Sport; 29 August 2020

HIGHLIGHTS
•Increased weekly training/racing frequency is associated with gradual onset cycling injuries.
•Gradual onset injuries in cyclists are associated with a history of chronic disease.
•Gradual onset injuries in cyclists are associated with analgesic anti-inflammatory drugs use.
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Objectives
Risk factors related to Gradual onset injuries (GOIs) in cyclists need to be identified to enable effective injury prevention strategies. We aim to determine risk factors related to GOIs in cyclists participating in mass community-based events.

Design
Cross-sectional study.

Setting
Cape Town Cycle Tour

Participants
Race entrants (n=35914)

Main Outcome Measures
Completion of pre-race medical questionnaires. 21824 consenting cyclists (60.8%) were studied. 617 cyclists reported GOIs. Selected risk factors associated with GOIs: demographics, training/racing history, chronic disease history, and medication use, were explored using multi-variate analyses.

Results
Prevalence ratio (PR) of GOIs was similar in males and females, but higher in older age categories [>50 yrs vs. categories: <30yrs (PR=1.6); 31 to <40yrs (PR=1.5); 41 to <50yrs (PR=1.4)] (p<0.0001). Intrinsic risk factors associated with GOIs (adjusted for gender and age) were: 1) increased weekly training/racing frequency (PR=1.1, p=0.0003), 2) chronic disease history [cardiovascular disease symptoms (PR=2.3, p=0.0026), respiratory disease (PR=1.6, p<0.0001), nervous system/psychiatric disease (PR=1.5, p=0.0082)], and 3) history of analgesic/anti-inflammatory medication (AAIM) used before/during racing (PR=5.1, p<0.0001).

Conclusion
Increased training frequency, chronic disease and AAIM use are risk factors associated with GOIs in cyclists. A novel finding is that in recreational cyclists, chronic disease history could be considered when managing GOIs and implementing prevention programs.
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NewsBot · Jan 12, 2021

Etiology of knee pain in elite cyclists: A 14-month consecutive case series
Anton Borgers et al
Acta Orthop. Belg

Overuse injuries of the knee are a common cause of
missed training and competition days in elite cyclists,
however the underlying conditions causing this knee
pain are not well defined. We conducted a diagnostic
study, investigating a consecutive series of 53 high
level cyclists with non-traumatic knee pain over a 14
month period. Demographic data on the participants’
cycling specialty and training level was noted. Clinical
information concerning knee pain intensity, location
and occurrence were collected using a questionnaire.
Our results show 7 different overuse injuries were
identified. The prepatellar friction syndrome
accounted for the majority of these overuse injuries
(46%), while medial plica syndrome (15%), biceps
femoris tendinopathy (7.5%), patellar tendinopathy
(9.4%), infrapatellar plica friction syndrome (7.5%),
infrapatellar fat pad impingement (5.7%) and
iliotibial band syndrome (3.7%) were other causes
of knee pain in these athletes. In contrast to current
belief, our results show that instead of patellofemoral
cartilage overload, friction related overuse injuries
are the most frequent and underestimated cause of
knee pain in high level cyclists.
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NewsBot · Jan 27, 2021

A review of the etiology, biomechanics, diagnosis, and management of patellofemoral pain in cyclists
Timothy D. Noakes Elize Van Zyl Martin P. Schwellnus
International SportMed JournalVol. 2, No. 1 :1 Jan 2001

Patellofemoral pain (PFP) is a common overuse injury in cycling, but its etiology in cycling is not well understood. It is associated with poor patellar alignment during knee movement from flexion to extension. Biomechanical factors associated with patellar malalignment include poor quadriceps function, vastus medialis obliquus insufficiency, extensive subtalar-joint pronation, and poor muscle flexibility. Factors in the biomechanics of PFP in cyclists include abnormal lower-limb biomechanics, incorrect bicycle and equipment setting, and incorrect training methods. Abnormal forefoot and rear-foot alignment are associated with patellar maltracking. There is anecdotal evidence that leg-length discrepancies and varus or valgus knee malalignment are implicated in PFP in cyclists. Incorrect equipment settings include saddle height, incorrect cleat position, and the type of cleat and shoe. Training factors associated with PFP in cyclists are hill training, cycling with high gears at a low cadence, and a sudden increase in training volume. The article reviews the etiology, biomechanics, clinical diagnosis, and management of PFP in cyclists.
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NewsBot · Jan 3, 2022

Factors associated with overuse injury in cyclists: A systematic review
Paul J. Visentini et al
December 28, 2021

Objective
To identify risk factors associated with overuse injuries in cyclists.
Design
Systematic Review.
Methods
Data sources: Medline, CINAHL, EMBASE, SPORTDiscus, and the Cochrane Library were systematically searched. Reference checking and citation tracking of included articles was undertaken. Grey literature searches and a review of key publications by known experts in the industry were conducted.
Eligibility criteria for selecting studies: Studies evaluating the association between specific measures of the bike, the cyclist's body and load characteristics, and overuse pain or injury in cycling.
Results
Of the 3596 studies yielded in the search, 18 studies were included in the review with only 3 of these studies deemed to have a low risk of bias. Best evidence synthesis showed moderate evidence of a relationship between load and symptoms, as well as moderate evidence of no relationship between cycling overuse injury or pain and many measures traditionally used in bike fitting. Conflicting evidence of a relationship exists between seat height and symptoms.
Conclusions
Cycling is popular on a world scale for transport and exercise with cyclists experiencing a high prevalence of overuse pain and injury. Many theories exist as to the cause of these symptoms, however there are limited high quality studies of risk factors for overuse injuries. This review highlights that there is no strong evidence relating any measure of the bike, body or load to cycling overuse pain or injury.
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NewsBot · Jul 29, 2022

How important is foot position and posture for cyclists?

NewsBot · Feb 28, 2023

Overuse Injuries in Professional Cycling: A Cross
Sectional Survey (Road and Track Cycling)
Himanshu Rakheja et al
Research Square

Background
Cycling is considered as a physical activity that excellently induces the cardiorespiratory and metabolic
functions of the whole body and thus offers itself to many paybacks. The level of involvement is more in
cycling, and it is an emergent sport. According to the journey of modern times, cycling emerged from an
Elite European sport to worldwide partaking sport (Visentini et al., 2003). As the cycling is prone to injury,
the overuse injury is a type of injury which occurs more in cycling. It is defined as the event of injury
which is not directly related to the traumatic event and occurs due to more use.
Objective
Occurrence of overuse injuries in professional competitive cycling sports was considered as an aim of the
study.
Methods – The population included was 102 and the method of data collection was schedule interview.
The interview was developed conferring to the kind of injury. According to various research, the injury was
accredited in the respective Performa which were framed on the basis of type of injury with respect to its
duration.
Results – Among 102 subjects, the results screening (34.5%) subjects as an injured players at the time of
collection of data. 20 cyclists were with new occurrence of injury among the total 35 injured cyclists,
whereas the 15 cyclists were found to be injured earlier also. The overuse injury 21 (60%) was more
predominant in contrast to acute injuries and Knee overuse injury was considered as more dominant
among these in contrast to another anatomical location.
Conclusion - Cycling is considered as a hazardous game in which cyclists are more prone to overuse
injuries, with more chances of injury in lower extremity and upper-extremity including the trunk along with
some factors causing the incidence of injury. The researchers are needed to focus on an extra prospective
study on epidemiology of cycling injuries and dimensions of bicycle as hazard factor of prevalence of
injury.
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Overuse injuries in cycling

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Age and Sex Differences in Overuse Injuries Presenting to Pediatric Sports Medicine Clinics

Effectiveness of foot orthoses for the prevention of lower limb overuse injuries in naval recruits:

Acute:chronic workload ratio and lower extremity overuse injuries

Girls suffer more overuse injuries in teen sports

Overuse Injuries Associated with Mountain Biking

Specialized Training in Young Athletes Linked to Serious Overuse Injuries

Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomis

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Overuse injuries in cycling

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Kevin Kirby MVP

David Wedemeyer Well-Known Member

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Age and Sex Differences in Overuse Injuries Presenting to Pediatric Sports Medicine Clinics

Effectiveness of foot orthoses for the prevention of lower limb overuse injuries in naval recruits:

Acute:chronic workload ratio and lower extremity overuse injuries

Girls suffer more overuse injuries in teen sports

Overuse Injuries Associated with Mountain Biking

Specialized Training in Young Athletes Linked to Serious Overuse Injuries

Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomis

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