May - June 2006

Overuse Injuries in Cycling

Gloria C. Cohen M.D.
Sports Medicine Physician
Former Canadian Cycling Team Physician and Canadian Olympic Team Physician

Like all activities engaged in regularly, bicycling has its share of common ailments and injuries. Many of the overuse injuries result from attempting to do too much too soon, poor riding technique, and improper frame fit for the individual. Riding too many miles or tackling too many hills in too high a gear, particularly at the start of the cycling season, will stress the musculoskeletal system.

Knee pain is the most common complaint and is usually related to the tracking of the kneecap, or “patella” in the mid groove of the thigh bone or “femur”. The symptoms of “biker’s knee”, also known as “patellofemoral pain syndrome”, usually result from a combination of malalignment of the extensor mechanism of the knee and improper set-up of the bike. Each cyclist presents with differences in biomechanics (flat pronated feet, bow legs, etc.) and muscle conditioning (strength and flexibility) that can predispose to this condition. It is important to avoid riding with high pedal resistance at a low cadence as this puts excessive pressure across the knee joint. The rule of the road is “if the knees hurt, gear down”.

Some common riding errors are riding with the saddle too low or too far forward, and poor foot position or improper cleat adjustment. In some cases it may be necessary to be fitted with a pair of orthotics to insert into the cycling shoes to modify foot movement. These modifications redirect the forces transmitted to the lower extremity and can alleviate the symptoms. It may be helpful to have an experienced individual assess your set-up while watching or videotaping you cycling.

If your symptoms persist despite these changes, you should see your doctor for assessment and management. Treatment includes strengthening and stretching of the involved muscle groups, ice massage, possibly anti-inflammatory medication if inflammation is present, and physical therapy.

Achilles tendonitis is the commonest overuse ankle injury in cycling. This can be caused by too low a saddle height as this forces the ankle into an exaggerated flexed position during pedal rotation. Improper technique is another cause, such as excessive use of the ankles (“ankling”) or applying too much force during hill climbing. Inadequate warm-up and biomechanical malalignment, as noted above, can also be contributing factors.

The mechanical approach to management involves raising the seat if necessary, and modifying the pedaling technique. Medical treatment is as above for the knee, as well as heel pads in footwear and a stretching and strengthening program for the Achilles. Avoid cortisone injections as this can weaken the tendon and predispose it to rupture. Most cases of Achilles tendonitis will respond to the above treatment regime, but if the symptoms persist you may need to take some time off the bike. Occasionally nodular thickening and swelling of the tendon develops in the chronic situation. This suggests that microtrauma has led to an area of degeneration within the tendon. In this situation an orthopedic consultation may be indicated for further assessment and management.

So consult your physician early on when you start to notice discomfort in the knee or Achilles tendon.

Dr. Cohen spoke on bicycling injuries and sports medicine at the 5BBC General Meeting on April 25, 2006.