Pedaling Past Injury

Alex Fraser-Maraun is an emerging elite Canadian road cyclist who competes as a member of Vancouver’s Hewdog Racing Team. His plans are to turn pro. That never would have been possible had he not sought out help and advice from Erik Moen, PT, owner of BikePT and Corpore Sano PT, both located in the Puget Sound area of Washington.

For years, Fraser-Maraun had experienced a string of injuries—affecting his iliotibial bands, right hamstring, gluteus medius, and knees—but the health care professionals he consulted in Vancouver never put the puzzle together—the pieces being his position on the bike, his training, and the bike itself.

“I started seeing Erik in late 2015 and learned these injuries all stemmed from poor training and recovery practices, and from poor bike fits,” Fraser-Maraun says. “I needed someone to take my entire situation—training, gym, stretching, pedal stroke, bike fit—and prescribe me a path to recovery.”

Moen had his new patient send him both front and side video of his pedal stroke. During their first visit, Moen spent a lot of time reviewing the entire chronology of the injuries and talked about ways to prevent them in the future.

“Physical therapy can help bicyclists achieve their goals by identifying musculoskeletal limiters in their ability to pedal well and maintain positions consistent with bicycling,” Moen says. “Specially trained PTs can work with bicyclists and their equipment to ensure proper positioning of the bicycle.”

“One of the key things Erik noted was that my cadence [number of pedal revolutions per minute] was too low. I was grinding my knees down,” Fraser-Maraun says. “On that initial visit, he made changes to my bike fit. Those immediately resulted in a substantial improvement in feel. Erik and I discussed my goals for subsequent training and, eventually, a return to racing.”

Moen instructed Fraser-Maraun to resume riding but, this time, at low intensity and high cadence, and gave him a timeline for increasing volume and intensity. Moen also prescribed certain exercises for Fraser-Maraun’s hamstrings and quads, as well as core exercises.

Today, Fraser-Maraun is a leading rider on his team and is considered 1 of Canada’s top cyclists to watch.

The Sport of Cycling

Although the bicycle was invented in the early 1800s—credit often is given to a German baron­—it didn’t become widely popular for another 50 years. (See “About Bicycling” on pages 20-22.) Riding a bike is something most people learn to do when they’re young, and riding can serve many purposes.

A recent survey by the Breakaway Research Group for People for Bikes, an industry-backed advocacy organization, noted that more than 100 million Americans ride a bike each year. This includes those who ride recreationally, for exercise, as a means of transportation to work or school, and who compete in cycling competitions.

The “Super Bowl” of bike competitions, the Tour de France, is being held this month—July 7 through 29. The cyclists are world-class athletes, and many regularly work with a physical therapist (PT) to deal with injuries or to prevent issues that could take them off the course.

Taylor Phinney is making his second consecutive Tour de France appearance, 4 years after fearing he would never ride again. In a 2014 US championship road race, he crashed hard into a guardrail, sustaining a compound fracture of the tibia and a severed patellar tendon.

He worked with a PT in Colorado, starting with small movements on a massage table, as well as knee and hip abductions and stretching. After a lot of hard work, Phinney was back on track.

“I would not be where I am today if not for all the help and love I received in getting me back on top of my game from my physical therapy team,” Phinney says. “It’s easy to want to give up after a fall like that, but I was determined to return to Olympic-level status and worked hard to return to the sport I love.”

Elite female cyclist Tayler Wiles also offers a testimonial. “As a professional cyclist, taking care of my body and being in the best form I can be is my job. I went to Cindy Lewton Dehan [PT, MSPT] with severe chronic back pain due to winged scapula and abnormal spine curvature. She worked with me to develop a set of exercises I could do daily to help improve my flexibility and strength and counteract the negative position I put my body in everyday while training and racing. The work she has done with me has helped my posture, reduced my pain, and improved my performance as a cyclist.” Dehan is owner of Active Marin Physical Therapy in Mill Valley, California.

Robert Wellmon, PT, DPT, PhD, is an associate professor at the Institute for Physical Therapy Education at Widener University in Chester, Pennsylvania. He’s been an avid competitive amateur cyclist for more than 40 years.

“I have commuted to work on a bicycle as a physical therapist, and I continue to compete primarily in the masters age group, doing 15 to 20 races per season. On occasion, I’ll race against individuals who are half my age,” he says.

During his career, he often has consulted with cyclists on such issues as overuse injuries, fractures, concussions, and wound healing from crashes.

There’s a saying among competitive cyclists: It’s not if you’re going to fall, it’s when. Studies have shown that nearly a third of bicyclists will fall off their bikes. This includes riders of all abilities. Therefore, PTs interviewed for this article suggest, it’s wise for riders to learn how to fall. And, they add, PTs can help their patients learn this skill. Part of the technique involves rolling or sliding during a fall. Yes, that likely will result in some loss of skin. Nevertheless, it allows a rider to return to the bike much sooner than if a fall results in broken bones.

A common traumatic injury for cyclists is a fractured clavicle, which usually occurs by falling on an outstretched arm. When falling, a cyclist’s natural inclination is to extend an arm, like a long lever, for protection. The extended arm can apply extreme force and torque on the shoulder, which can cause a variety of fractures or tears. The clavicle is the most common victim.

“There is also the potential for other FOOSH [fall onto outstretched hand] injuries such as wrist fractures,” Wellmon adds.

Separate from falling, Wellmon notes risks associated with overuse injuries, which can be exacerbated by factors such as an ill-fitting bike, ill-fitting shorts and shoes, too many miles of training, and too quickly increasing the intensity or amount of riding. These, he says, can cause knee, hip, foot, neck, and back pain.

When dealing with overuse musculoskeletal problems in cyclists, Wellmon’s recommended treatment starts with rest, evaluating bike fit, looking for musculoskeletal imbalances (areas where simple stretching can be effective), and gradually reintroducing the cyclist to riding, with the emphasis on limiting the time toward pain-free sessions.

“Rehab returns the person to pain-free riding as it relates to overuse musculoskeletal injuries and dealing with problems related to numbness,” Wellmon says. “The fun part of riding is riding hard for the sheer joy and fun if you are a competitive cyclist­—or, for the recreational cyclist, the feeling of getting a good workout, which includes some minor muscle soreness that goes away within 48 hours.”

Cyclists can face myriad issues, ranging from acute injuries such as abrasions, fractures, and contusions; to chronic injuries including bursitis, muscle strains, and nerve compression; to postural intolerances including neck, shoulder, and back pain.

“Any chronic injury or postural intolerance should first be evaluated by the rider’s position on the bicycle,” Moen says. “This includes a table evaluation that screens the cyclist for irregularities inconsistent with normal bike mobility and strength. Once an adjustment of bicycle position or change of equipment is made, you can instruct with exercises for best adaptation to bicycling function.”

A proper strength training program is essential for a cyclist to stave off injury, the PTs interviewed for this article say. Paramount for an injury prevention program are exercises in all anatomical planes (sagittal, coronal, and transverse), targeting muscles that are chronically weak or underactive in cyclists (typically gluteus medius, hamstrings, and glutes)—including single-leg exercises, and strengthening the core. Stretching and foam rolling as often as daily can both bolster injury prevention and accelerate recovery from that day’s ride.

David Kell, PTA, MS, MPH, graduated as a physical therapist assistant (PTA) in May. He is employed at Orthopedic Neurosurgery Specialists in Greenwich, Connecticut. He also is a certified strength and conditioning specialist and USA Triathlon Level 1 coach. He notes that cyclists are in a unique sport—being attached to a machine for the duration of participation. If the bike is even only slightly out of adjustment, that lack of adjustment is compounded by thousands of pedal strokes (typically 80 to 110 a minute), potentially contributing to the cyclist’s injury.

A commonly injured area of the body is the knee, Kell says, because it’s “stuck” between the foot and hips, both of which are affixed to the bike. If the foot is turned slightly in or out, unable to move naturally, the tibia will rotate and put undue stress on the knee. If the seat is set incorrectly—too high, low, far forward, or far back—the hips can be forced to tilt forward, backward, left, or right. The femur then is forced to adjust, again adding stress to the knee.

“It is also common for cyclists to have large muscle imbalances, as their sport allows them to work only in the sagittal plane, causing muscles that work in other planes to turn off,” Kell says. “For example, their gluteus medius causes abduction of the hip. This muscle is turned off due to the activity only occurring in the sagittal plane. Cyclists also tend to use quadriceps muscles more than glutes and hamstrings. This can cause excess strain on the patella and patella tendon, which in time can cause injury in either.”

Common knee injuries in cyclists are patellofemoral pain syndrome (PFPS), patella tendinitis, and illiotibial (IT) band syndrome. PFPS typically is caused by the patella tracking too far laterally and rubbing outside its groove on the femur, leading to inflammation and pain. This can be due to lateral musculature (ie, vastus lateralis) pulling the patella laterally more than does the opposing musculature (ie, vastus medialis oblique), which pulls the patella medially. The muscles can be strengthened with the terminal knee extension (TKE) exercise to even out the imbalance, Kell says.

It also is likely that the femur is angling in too much, causing the groove to move medially and the patella to track laterally, according to the PTs. This can occur if a bicyclist’s hip abductors (primarily gluteus medius) are weak or aren’t activated.

Strengthening the posterior chain with double- and single-leg deadlifts and bridges with hamstring curls on a physioball also will help reduce the muscle imbalances leading to knee injuries on the bike, the PTs say. And foam rolling the IT bands and quadriceps also can help keep things in working order.

Istvan Takacs, PT, DPT, who practices at a clinic in Portland, Oregon, says that the most common issues by far at any level of riding are overuse injuries. The low load but highly repetitive nature of pedaling can irritate joints if they are out of their physiologically acceptable range of motion and their biomechanically acceptable vector loads. These injuries can include small joint sprain, various tendinopathies, and nerve tissue irritation.

The Occasional Cyclist

Not everyone who rides a bicycle is interested in competition, of course. Most riders do it for occasional recreation or for transportation. Although it’s true that an estimated 103.7 million Americans rode a bicycle in the past year, less than half rode more than twice a month. About 42% rode for transportation, but 40% of those rode just 6 or fewer days during the past year. One barrier, it turns out, is that nearly half the adults don’t have access to an operational bicycle.¹

Nevertheless, those still are large numbers of Americans who ride. And even bicyclists who ride for fun in their neighborhoods experience many of the same issues as elite cyclists do.

For example, Kell says, “One [common issue] is riding outside on roads, where conditions vary and one has to contend with automobiles. Even in perfect conditions, cyclists can have accidents, but roads, weather, and drivers all can increase the likelihood of traumatic injuries.”

“I think those who ride for recreation and commuting are not necessarily aware of the risks of falling down—beyond an encounter with an automobile,” Wellmon says. “Injuries due to falling are a consideration and can vary from simple ‘road rash,’ which is an integumentary system problem, to deeper soft tissue trauma to muscles—bruising and hematomas.”

In addition, Wellmon says it’s important for bike riders to understand how to feel comfortable moving their hands on the handlebars and standing up periodically to reduce perineal pressure. Reaching the handlebars should not cause neck and back pain, he says. If that’s happening, there is a bike fit problem.

“One of the best ways to avoid these problems is having a bike that fits well: the seat is the right height and width, and aligned properly. This avoids the tendency to place too much weight on the hands by ensuring appropriate distribution of weight between the seat and the handlebars,” he says. “When bending over to reach the handlebars, the weight between the ischial tuberosities—the ‘sit bones’—and the hands is balanced. Aligning the ball of the foot appropriately over the pedal spindle helps prevent foot numbness and compression on nerves.”

Wellmon also suggests cyclists wear padded cycling gloves to reduce pressure on hands. Another piece of advice: Purchase handlebar tape with ample padding to reduce road vibration.

For the recreational rider or commuter who may experience overuse injuries, Takacs says, “For the bike commuter who has a 20- to 30-minute trip twice a day, a general mobility practice 3 or 4 days per week will go a long way. This can include some type of basic yoga, swimming, Pilates, dance, or general gym work. Avoiding prolonged positions during the day typically keeps most clients happy and healthy.”

The Proper Fit

Working with Takacs is Kevin Schmidt, PT, MSPT, a bike fitting specialist in Portland, Oregon, who spoke on bike-friendly physical therapy at APTA’s Combined Sections Meeting in 2017. He says the higher-level the cyclist, the more cumulative micro-trauma and repetitive stress-type injuries he sees. That’s usually a result of training errors and bike fit issues. Additionally, in higher-level and serious sport cyclists, he sees musculoskeletal injury from crashes—including contusions, fractures, and concussions.

On the other hand, he says, “commuters, newer cyclists, and shorter-distance cyclists usually have symptoms due to poor bike fitting, incorrect bike sizing, poor cycling posture, and poor pedaling and shifting skills. Saddle area pain, chafing, and tingling or numbness are common, particularly in the female population due to a wider pelvis and less vertical distance between ischial tuberosity and pubic symphysis. These symptoms usually are related to individual bike fit—such as saddle type, height, tilt, and reach to bars.”

At the clinic, the key question Schmidt asks any patient who cycles is, “Do you also experience your symptoms when you are not cycling?” If the answer is yes, he addresses the symptoms as he would those in any other patient, including specific rehab interventions such as manual techniques, education, and specific exercises.

“We work on those symptoms off the bike. Then, as symptoms stabilize, we gradually work back into fitness and bike fitting,” Takacs says. “A professional bike fitting first helps us evaluate the client’s body to address any restrictions, determine causation for symptoms, and review health systems. We then are able to apply that knowledge to positioning on a bicycle, taking into consideration the client’s goals for cycling.”

Challenge of Care

When it comes to working with bike riders, the biggest challenge, in Takacs’ experience, is that cyclists tend not to want to spend any time off the bike. It’s important, therefore, that a PT work with patients to set clear expectations and provide detailed instructions, to help ensure they can return to cycling as quickly and safely as possible “without reinjuring themselves by going too hard, too fast.”

Being diligent as a PT and explaining this healing process is essential. Putting it in terms a cyclist can understand often helps, the PTs interviewed for this article say.

“Cycling often gets billed as ‘the safe sport,’ as there is no impact as with other sports, but sometimes even cycling alone is too much,” Kell says. “The body needs time to clear the inflammation and let healing take place. Even once cyclists feel better, they can’t jump back in too quickly, as that can reset the whole process.”

Unlike injuries that result from walking or running, Moen says that bicycling injuries require a steep learning curve for PTs, as there are differences in stability posture and torque production for each rider. Beyond that, factors involved in injury and recovery include not just the patient but also bicycle parts, control of speed, proper mechanical work to adjust position on the bicycle, and determination of bicycling gait.

“From my perspective, getting the competitive cyclist to rest is an issue,” Wellmon says. “For someone who is driven and has a high pain tolerance, experiencing discomfort is seen as part of the sport, which isn’t true when it comes to musculoskeletal problems. The rider’s body is providing feedback that something is wrong, and it can’t wait until the end of the season to be addressed. It can be difficult to get those who are competitive to let go of riding, because they are mentally conditioned to ride almost daily, on a particular schedule. Taking off a few weeks, or even a few days, is difficult.”

To that, Fraser-Maraun offers advice to his fellow cyclists: “I would recommend a PT to anyone who wants a sweeping level of analysis, from diagnosis to prevention,” he says. “Listen to your PT’s advice and ask questions. I know, from my experience with Erik, that I have never left a session without the overwhelming sensation of having made a huge amount of progress.”

Credit: PT in Motion July 2018