Upload
others
View
7
Download
1
Embed Size (px)
Citation preview
3/7/2018
1
Overuse Injuries in Cycling:How, Why, Treatment and
PreventionDrew A. Lansdown, MD
Assistant Professor in Residence
Sports Medicine & Shoulder Surgery
UCSF Department of Orthopaedic Surgery
Disclosures
No relevant financial disclosures for this presenation.
Additional Disclosures:
• Research/Educational Support from:
‒ Arthrex, Inc.
‒ Smith & Nephew
3/7/2018
2
Cycling in San Francisco
128,000 trips made by bicycle daily
16% of San Francisco residents identify as “frequent cyclists”
Unfortunately, Injuries Are Common
3/7/2018
3
Overview
Injury patterns for professional and recreational cyclists
Factors that contribute to overuse injuries in cyclists
Etiology, treatment, and prevention of specific common overuse injuries
What Is Overuse?
Tissue damage from repetitive submaximal loading
Inadequate recovery time for microtrauma to bone, joint, and soft tissue
Cycling is repetitive1,2
• Professional cyclists ride 25,000-35,000 km/year
• Recreational cyclists report >7000 km/year
• 5,000 pedal revolutions per 1 hour of cycling
Histology of Tendinosis
Image: https://www.dovepress.com/cr_data/article_fulltext/s76000/76325/img/fig3.jpg
3/7/2018
4
Interviewed 109 cyclists of 7 professional teams in training camps
Inquired about injuries over the past 1 year
94 total injuries registered
• Low back and knee injuries are most common• Knee injuries responsible for most time missed
• Back pain prevalence constant across season
• Knee pain most common in preseason
• Possibly due to initial strength/coordination
3/7/2018
5
Cross-sectional Study of 518 Recreational Cyclists
85% reported at least 1 non-
traumatic injury over 1 year period
48% Cervical Spine
30.3% Thoracolumbar Spine
41.7% Knee
Affected Joint Severity
31% Required Medical Treatment
2.7% Quit Cycling
11.5% Stopped Cycling, Mean 42.8 Days
Cyclist Anatomy• Quadriceps Angle• Patellar Tracking• Spinal Alignment• Foot Alignment
Cyclist Anatomy• Quadriceps Angle• Patellar Tracking• Spinal Alignment• Foot Alignment
Bicycle Fit• Seat Height
• Seat Position• Handlebar Height
• Foot Position• Crank Length
Bicycle Fit• Seat Height
• Seat Position• Handlebar Height
• Foot Position• Crank Length
Training Factors• Strength• Flexibility• Cadence
• Resistance• Inclines
• Recovery Time
Training Factors• Strength• Flexibility• Cadence
• Resistance• Inclines
• Recovery Time
Potential for Overuse Injury
3/7/2018
6
Seat HeightInfluences knee/hip load and
oxygen consumption
Seat PositionInfluences tibial
alignment over feet
Handlebar Height & ReachLower height = greater
aerodynamics
Crank LengthLonger crank = greater mechanical advantage though more hip/knee
range of motion
FIT
Seat Height Methods4
Method Description
Hamley and Thomas5
• Height set at 109% of inseam leg measurement
• Produce longer time to exhaustion
TrochantericLength6
• 100% of length of greater trochanter to floor• Cycling economy better at 96% of 100%
relative to 104%
Ischial Tuberosity8
• 113% of length of ischial tuberosity to the floor
LeMond7 • 88.3% of distance from top of saddle and center of bottom bracket
3/7/2018
7
Seat Height Methods4
Method Description
Heel7 • When seated on saddle, knee fully straight with heel on pedal
Holmes9 • Knee flexion angle at 6 o’clock set to 25-30 degrees
• 25 degrees has lower VO2 compared to 35 degrees or 109% inseam
Howard7 • Knee flexion angle at 6 o’clock of 30 degrees with neutral foot
Common Overuse Injuries
Knee
Hip
Foot/ankle
Back
Neck/Shoulder
Wrist/Hand
Image: https://decaironmantraining.files.wordpress.com/2014/02/cycling-suffering-pain-barrier.jpg?w=600&h=516
3/7/2018
8
Patellofemoral Syndrome
Common cause of anterior knee pain
• >50% of knee pain was around patella during recreational event11
Presents as pain behind patella during or after activity
Due to:
• Increased pressure across PF joint10
• Patellar maltracking
Bony Alignment Can Contribute to Patellofemoral Syndrome
Q angle
• Clinical measurement of patellar tracking
Lateral tibial tubercle position
External rotation of the tibia
Foot alignment in pronation
Increased femoral anteversion
3/7/2018
9
Cyclist Factors Contributing to PF Syndrome
Rely on quadriceps strength and balance
Patellofemoral pain may be due to:
• Lateral tracking of patella
• Weakness or dysplasia of vastus medialisobliquis muscle
• Tight hamstrings
Image: http://morphopedics.wdfiles.com/local--files/osteoarthritis-of-the-knee/anatomypic.png
Evaluated knee joint loads during ergometric cycling
6 healthy men
Compressive forces can be decreased by:
• Reduction in work load
• Increase in saddle height
3/7/2018
10
Evaluated 17 cyclists:
• 10 without patellofemoral pain
• 7 with patellofemoral pain
PF pain group had:
• Earlier deactivation of vastus medialis
• Earlier biceps femoris contraction than semitendinosus
• Decreased activation of semitendinosus
Bicycle Fit Factors Contributing to PF Syndrome Low seat position
• Adjust so knee is in more extended position with pedal at 6 o’clock
• Aim for 25 degrees of knee flexion
Cleat position in pronation
• Adjust so hindfoot is neutral
Overly high resistance
• Low resistance training to maintain 80-90 rpm cadence
• Avoidance of hills while recovering
Images: https://www.goride.co.nz/wp-content/uploads/http://davesbikeblog.squarespace.com/
3/7/2018
11
Strategies to Treat PF Syndrome
Quadriceps strengthening
• Especially focus on VMO
Stretching
• Quadriceps
• Hamstrings
• Gastrocnemius-soleus
Patellofemoral brace or McConnell taping
Foot orthoses to adjust foot pronation and hindfoot alignment
Image: https://www.physioadvisor.com.au/wp-content/uploads/20193256300x300.jpg
Patellar Tendinitis
Patellar tendon connects patella to tibial tubercle
Repetitive microtrauma at tendon with insufficient time to allow for normal healing
Pain at the front of the knee, along the patellar tendon
Image: https://upload.orthobullets.com/topic/3015/images/mri2.jpg
3/7/2018
12
Patellar Tendinitis Treatment
Treat with stretching quads/hamstring/IT band
• Ice
• NSAIDs
Eccentric strengthening of quadriceps
Reduce training intensity until resolved
Some interest in PRP/biologic injections
Surgical treatment if refractory to all other treatment
Image: http://cdn.fix-knee-pain.com/blog/wp-content/uploads/2013/09/squat_on_flex_n_go_board-copy.jpg
Pes Anserine Bursitis
Pes anserine is insertion of three hamstring tendons on medial aspect of tibia
Bursa is a fluid-filled sac that allows for gliding of these tendons
Pain over medial proximal tibia
Treatment:
• Hamstring stretching
• Oral NSAIDs or topical NSAIDs
• Corticosteroid injection locally
3/7/2018
13
Iliotibial Band Syndrome
Pain at the lateral aspect of the knee
Iliotibial band (ITB) glides over lateral femoral condyle with knee flexion/extension
Causes:
• Higher seat position results in greater knee extension and may provoke this more
• Increased cadence = greater friction
• Tightness in ITB, gluteals, tensor fascia lata
Iliotibial Band Syndrome
Treatment:
• Higher resistance, lower cadence
• Lowering seat height
• ITB stretching
• Foam rolling
3/7/2018
14
Trochanteric Bursitis
Pain over the lateral aspect of the hip
May be caused/worsened with seat being too high
Treatment:
• ITB stretching
• Ice
• NSAIDs
• Corticoteroid injection
Iliopsoas Tendinitis
Psoas muscle
• Originates from lumbar spine
• Inserts at lesser trochanter
• Tightness can contribute to low back pain/core issues
Can manifest as hip/groin pain
Treatment:
• Lowering seat
• Stretching hip flexors
• Core strengthening
3/7/2018
15
Achilles Tendinitis
Pain at posterior aspect of calf/heel
May be caused by:
• Low seat position
‒ Knee flexion limits ability of gastrocnemius to contribute to calf power during pedaling
• Foot positioned posterior to center of pedal axle
‒ Increased motion at the ankle and stress at Achilles tendon
• Tight gastrocnemius/soleus complex
Achilles Tendinitis
Treatment:
• Correct fit problems
• Eccentric strengthening exercises, dorsiflexion stretching
• NSAIDs/ice
• Rest/reduction in training
Images: http://www.sportsinjuryclinic.net/images/stretches/eccentric-heel180a.jpghttp://www.sportsinjuryclinic.net/images/stretches/Calf-stretch-on-step.jpg
3/7/2018
16
Low Back Pain
30% prevalence over 1 year period between men and women in California3
• 75% of this was low back pain
Bicycle fit can contribute to malalignment of spine
• A long top tube extends lordoticlumbar posture
• Low handlebars exaggerate lordosis
Multiple small muscles contribute to stabilization of spine
Image: https://static1.squarespace.com/static/551476f6e4b0403810771cd7/t/55f8f2c3e4b0f3e154bd3e05/1442378962894/?format=1000w
Compared spinal kinematics and trunk muscle activity in cyclists with (N=9) and without (N=9) low back pain
Cyclists with pain trended towards:
• Increased lower lumbar flexion
• Loss of co-contraction of lower lumbar multifidus muscle
3/7/2018
17
Subjects with low back pain showed:
• Fatigue in arm muscles and postural spine musculature
• Reduced abdominal and back muscle thickness at rest and during contraction
• Greater lumbopelvic flexion
Position and pain may be improved with biofeedback training
40 cyclists
Lowered tip of saddle 10-15 degrees from horizontal in group with low back pain
72% reported no back pain
20% reported major reduction in occurrence/magnitude of pain
7% reported no change
3/7/2018
18
Treatment Recommendations for Low Back PainCore strengthening exercises
Biofeedback training for positioning of spine/pelvis
Consider changing saddle tilt
Neck/Shoulder Pain
Recreational cyclists:11
• 66% of riders had mild neck/shoulder injury
• 20% reported really uncomfortable neck/shoulder or had to change riding style or stop
Neck/shoulder problems more common towards the end of a tour-type event17
Image: https://www.exevalleyosteopathy.co.uk/single-post/2016/09/09/Neck-pain-in-road-cyclists---Why-and-what-can-you-do
3/7/2018
19
Neck/Shoulder Pain
Horizontal position
More trunk flexion –more aerodynamic
To compensate, neck hyperextends to allow horizontal gaze
Image: https://www.exevalleyosteopathy.co.uk/single-post/2016/09/09/Neck-pain-in-road-cyclists---Why-and-what-can-you-do
Treatment Strategies for Neck/Shoulder PainBicycle fit adjustments:
• Raise handlebars
• Shorten reach
Stretching:
• Neck
• Thoracic spine
• Paraspinal muscles of cervical spine
3/7/2018
20
Nerve CompressionCommon compression sites:
• Hand:
‒ Ulnar nerve at Guyon’s canal
‒ Median nerve at carpal tunnel
• Foot:
‒ Lateral branch of deep peroneal nerve at dorsum of foot18
Treatment:
• Padded gloves
• Adjust hand position
• Address shoe fit
Image: http://www.shoulderelbowhand.org/carpal-tunnel-syndrome.html
Prevention
Evaluation of bicycle fit
Cross-training and maintenance of strength during off-season
• Cycling relies on core strength but does not really build it
• Stretching/flexibility - Visit sportsrehab.ucsf.edu!
Gradual increase in training duration/intensity when returning to cycling
Complete rehabilitation after traumatic injuries
3/7/2018
21
Conclusions
Overuse injuries unfortunately common in cycling
Treatment and prevention strategies often involve:
• Evaluation of bicycle fit
• Adjustments for specific cyclist anatomy
• Appropriate training regimen
Thank you!
Drew Lansdown, [email protected]
3/7/2018
22
References 1. Asplund C, St Pierre P. Knee pain and
bicycling: fitting concepts for clinicians. The Physician and sportsmedicine. 2004;32(4):23-30.
2. Clarsen B, Krosshaug T, Bahr R. Overuse injuries in professional road cyclists. The American journal of sports medicine. 2010;38(12):2494-2501.
3. Wilber C, Holland G, Madison R, Loy S. An epidemiological analysis of overuse injuries among recreational cyclists. International journal of sports medicine. 1995;16(03):201-206.
4. Bini R, Hume PA, Croft JL. Effects of bicycle saddle height on knee injury risk and cycling performance. Sports medicine. 2011;41(6):463-476.
5. Hamley Ey, Thomas V. Physiological and postural factors in the calibration of the bicycle ergometer. The Journal of physiology. 1967;191(2):55P-56P.
6. Nordeen-Snyder KS. The effect of bicycle seat height variation upon oxygen consumption and lower limb kinematics. Medicine and Science in Sports. 1977;9(2):113-117.
7. Burke E. Perfect positioning. Serious cycling: Human Kinetics. 2002:235-245.
8. Ericson MO, Bratt A, Nisell R, Nemeth G, Ekholm J. Load moments about the hip and knee joints during ergometer cycling. Scandinavian journal of rehabilitation medicine. 1986;18(4):165-172.
9. Holmes J, Pruitt A, Whalen N. Lower extremity overuse in bicycling. Clinics in sports medicine. 1994;13(1):187-205.
10. Kobayashi K, Hosseini A, Sakamoto M, Qi W, Rubash HE, Li G. In vivo kinematics of the extensor mechanism of the knee during deep flexion. Journal of biomechanical engineering. 2013;135(8):081002.
11. Weiss BD. Nontraumatic injuries in amateur long distance bicyclists. The American journal of sports medicine. 1985;13(3):187-192.
12. Ericson MO, Nisell R. Patellofemoral joint forces during ergometric cycling. Physical therapy. 1987;67(9):1365-1369.
13. Dieter BP, McGowan CP, Stoll SK, Vella CA. Muscle activation patterns and patellofemoral pain in cyclists. Med Sci Sports Exerc. 2014;46(4):753-761.
14. Burnett AF, Cornelius MW, Dankaerts W, O’Sullivan PB. Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects—a pilot investigation. Manual therapy. 2004;9(4):211-219.
15. Streisfeld GM, Bartoszek C, Creran E, Inge B, McShane MD, Johnston T. Relationship between body positioning, muscle activity, and spinal kinematics in cyclists with and without low back pain: a systematic review. Sports health. 2017;9(1):75-79.
16. Salai M, Brosh T, Blankstein A, Oran A, Chechik A. Effect of changing the saddle angle on the incidence of low back pain in recreational bicyclists. British journal of sports medicine. 1999;33(6):398-400.
17. Kulund D, Brubaker C. Injuries in the Bikecentennial tour. Phys Sportsmed. 1978;6(6):74-78.
18. Wanich T, Hodgkins C, Columbier J-A, Muraski E, Kennedy JG. Cycling injuries of the lower extremity. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2007;15(12):748-756.