Cycling Injuries

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Common Cycling injuries.

Research shows that the most common sites of overuse injury in cyclist are:

  • knee (patella-femoral pain, ITB)
  • lower back
  • Perineum 
  • Hand
  • Foot 

The knee is the most common site, affecting an estimated 40% to 60% of all regular recreational and elite cyclists, both on and off the road

Common Causes of Cycling Injury


  • Increased training (volume, milage, intensity, frequency)
  • Muscle weakness or joint restrictions
  • Previous Injury History
  • Poor Bike Set up/ Position
  • Incorrect cleat position
  • Saddle Height/  tilt


The vast majority of overuse injuries are caused by an improper riding position (Bikefit) and/or anatomical and biomechanical issues associated with the rider. An improper body position (cycle set-up) is a frequent cause of overuse injury.

The most common factors that contribute to overuse injury include pedal systems, issues at the shoe/pedal interface, saddle height, saddle tilt, saddle design and trunk angle, handlebar position and improper biomechanics linked to misalignment of the foot or leg.

Common Overuse Injuries

Research shows that the most common sites of overuse injury are the knee, lower back, perineum (the region between the coccyx and the pubic bone), hand and foot. The knee is the most common site, affecting an estimated 40% to 60% of all regular recreational and elite cyclists, both on and off the road.

Cause of injury

An improper body position (cycle set-up) is a frequent cause of overuse injury. The most common factors that contribute to overuse injury include pedal systems, issues at the shoe/pedal interface, saddle height, saddle tilt, saddle design and trunk angle, handlebar position and improper biomechanics linked to misalignment of the foot or leg.

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Patellofemoral pain syndrome

The most commonly reported overuse knee problem in cyclists is patellofemoral  joint pain, often labelled‘cyclists knee’ . The condition is characterised by pain or discomfort behind or around the Patella (kneecap). Cycling typically involves a piston like, symmetrical motion of the legs for power generation and requires a smooth rolling transition between the contact points of the joint surfaces. 

Abnormal movement or ‘tracking’ of the patella can affect this transition and result in wear on the posterior (back) surface of the patella.  Causes of abnormal tracking include improper saddle height i.e. too low, saddle position that’s too far forward and problems at the shoe/pedal interface. This includes pronation (rolling inward of the foot) and improper foot position linked with misalignment of the foot or leg.

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ITB syndrome (Iliotibial band)

ITB syndrome is arguably the second most frequently reported knee problem in cyclists. ITB stands for iliotibial band, which can also be known as the iliotibial tract. ITB syndrome is an inflammatory condition which develops when the band repeatedly rubs over the lateral condyle (outside) of the knee during repeated flexion and extension of the knee joint during pedalling. The pain occurs on the outside of the knee and is often represented by a sharp or stabbing pain.

The ITB is not a muscle, it’s a band of strong connective tissue (fascia) that runs the entire length of the thigh, from the top of the hip to the knee attaching at the outside of the lower knee. Similar to most overuse injuries, successful treatment of ITB problems requires an understanding of its cause(s), which can be multifactorial. Common causes include improper saddle height i.e. too high; saddle too far back, improper cleat position, and excessive pronation linked with leg and foot alignment problems..

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Lower Back Pain

Lower back pain (LBP) appears to be common in cycling, yet few scientific studies exist that try to explain the cause and risk factors. The prevalence of LBP in cyclists has been reported as up to 50% in recreational cyclists and 22% in professional cyclists. Contributing factors to the development of LBP have been linked to increased training loads, improper cycle set-up i.e. low handlebars provoking increased trunk flexion, and improper saddle level/tilt. Generally, the conventional saddle (with nose) should be set horizontally ‘level’, or with a slight tilt (±3º), using a spirit level.

Women often prefer the front to be angled slightly downwards to reduce pressure on the perineal area and in some cases of LBP. Cyclists adopting the classic aero position, with a highly flexed trunk, often prefer a more drastic forward tilt (≤10º), or prefer to use a ‘no-nose’ saddle. Cyclists that adopt an upright trunk position, typically mountain-bike and recreational cyclists often prefer a level saddle or tilted slightly backwards. This position can also help alleviate pressure on the ulnar nerve by redistributing the body weight.

Perineum

Research shows that cyclists are more likely to suffer from urogenital symptoms than their sedentary counterparts. For men, typical symptoms include temporary groin numbness, pain, tingling sensations, erectile dysfunction, and frequent need to urinate. For women, typical symptoms include frequent bladder infections and painful skin irritations.


The problem lies with the vulnerable perineum, the area between the genitals and the anus that is a mass of soft tissue, nerves and blood vessels. When we sit on a saddle for prolonged periods we compress the delicate structures (nerves and blood vessels) which can lead to the aforementioned urogenital symptoms and conditions. Complaints associated with increased perineum saddle pressures are common in male and female cyclists. A recent review of research studies reported complaints in 50-91% of cyclists. The main reasons for perineum pain and urogenital symptoms include prolonged saddle pressure, more specifically, excessive body weight and saddle design, saddle level/tilt and improper handlebar position, most of which can be alleviated by a proper discipline-specific Bikefit.

When we look closely at the anatomy of our sit bones, they are wide at the back and gradually become narrower at the front. This anatomical feature has implications on riding position – meaning the contact point with the saddle moves depending on riding position. Riders that use an upright riding position sit towards the back part of their sit bones, thus require a wider saddle. When we bend forward as in an aero position (triathlete) our body weight (contact point) moves forwards on to the narrower frontal part of the sit bone, thus necessitates a narrow saddle.

On average, the pelvic (sit bone) width is 118mm for males and 130mm for females. Many modern saddles have a partial or complete cut-out designed to decrease pressure on the perineum. Some saddles are nose-less – designed to leave the perineum totally unloaded.

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 In a recent study involving USA police officers, traditional saddles were replaced with a nose-less variety. Although the nose-less saddle requires some getting used to, the majority of officers found the transition fairly straightforward.

After a six month trial the number of men reporting improvements in genital sensation increased dramatically. Men reporting lack of genital numbness increased from 27% to 82% after using nose-less saddle. Moreover, around 97% of officers continued to use the nose-less saddle after the trial had finished. In summary, perineum pain and urogenital problems are common in both male and female cyclists. Although saddle design is down to personal choice, proper riding-position (Bikefit), pelvic-width and saddle-tilt are critical factors in minimising urogenital problems and achieving cycling comfort.

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Foot

‘Hot foot’ or the medical term ‘Metatarsalgia’ is arguably the most common problem affecting cyclists. It is a condition where the nerves and tissues close to the ball of your foot are repeatedly squeezed and aggravated by the long metatarsal bones. The symptoms represent throbbing, burning pain and tenderness on the sole of the foot, usually over the 3rd and 4th metatarsophalangeal (toe) joints, with pain radiating along corresponding toes.

The cause can simply be shoes that are too tight leading to compression of the nerves, or more frequently the cause is related to either under-pronation (pes cavus) or over-pronation of the foot, which in turn, places extra loading on the forefoot. Although there are no robust research studies on cause and subsequent treatment of metatarsalgia in cycling, anecdotally the use of appropriate shoe inserts to support the relevant arch(s) and forefoot wedges appear to help.

Hand

The most common overuse hand injury is chronic ulnar nerve compression, a condition termed ‘Cyclist’s Palsy’; the median nerve is less commonly involved. Ulnar and median nerve compression is common in experienced and inexperienced cyclists, in long distance cyclists and mountain bikers. Symptoms of ulna nerve compression typically present as numbness and/or paresthesia in the fourth and fifth finger as a result of sustained pressure on the hypothenar eminence (fatty part of the palm of your hand below the little finger). As it would appear, the simple solution is to reduce pressure on the hypothenar eminence. Often, this can be achieved by simple adjustments to body position, designed to unload hand pressure on the handlebars, by regular changes in hand position, or by wearing padded gloves. A nose down saddle (forward tilt) tends to redistribute the body-weight, moving it forwards, as a result this can lead to increased pressure on the hands and hypothenar eminence. Likewise, hand pressures tend to increase when the handlebars are lower than the saddle.


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