The Expert View on Bicycling Injuries 4 8 Guy De Schutter

Contents 48.1 Introduction ...... 1056 48.2 Traumatic Injuries ...... 1056 48.2.1 Clavicle Fractures/Shoulder Injuries ...... 1057 48.2.2 Radial Head Fractures ...... 1057 48.2.3 Rib Fractures ...... 1057 48.2.4 Concussions ...... 1058 48.2.5 Abrasions ...... 1058 48.2.6 Contusions...... 1059 48.2.7 Intra-abdominal Cavity Contusions ...... 1059 48.3 Bicycle Contact Injuries ...... 1059 48.3.1 Shoe Pedal Interface ...... 1060 48.3.2 Saddle Interface ...... 1060 48.3.3 Hands-Handlebar Interface ...... 1062 48.4 Overuse Injuries ...... 1062 48.4.1 Knee ...... 1063 48.4.2 Lateral Knee Pain ...... 1063 48.4.3 Anterior Knee Pain...... 1064 48.4.4 Medial Knee Pain ...... 1064 48.4.5 Proximal ITBS or Greater Trochanteric Pain Syndrome ...... 1065 48.4.6 Achilles Tendon ...... 1066 48.4.7 Neck and Back Pain ...... 1066 48.5 Iliac Artery Endoﬁ brosis and Kinking...... 1067 Conclusion ...... 1068 References ...... 1068

G. De Schutter , MD Department of Sports Medicine , Antwerp University and University Hospital , Wilrijkstraat, 10 , 2650 Edegem , Belgium e-mail: [email protected]

48.1 Introduction

Bicycle riding is a popular form of recreation among persons of all ages, and related injuries cause signiﬁ cant morbidity and mortality. Cycling injuries can be classiﬁ ed into bicycle traumatic, contact, and overuse injuries. Few studies, all retrospective, have been conducted on professional cyclists. Incidence of traumatic injuries range from 38 to 48.5 %, and overuse injuries occur in 51.5–62 % of top-level professionals. More than two-thirds of traumatic injuries occur in the upper extremity, and two-thirds of overuse injuries occur in the lower extremity (De Bernardo et al. 2012 ). There are no known studies grouping bicycle contact injury separately from overuse injuries. Muscle tears, common in runners from eccentric load, are rare in cyclists with high quadriceps concentric load. Cyclists are exposed to high traumatic risk racing in a peloton, at high speeds, on various road and weather conditions. In a 4-year study of 51 top-level professionals, 43 cyclists experienced 103 injuries, with 50 (48.5 %) traumatic injuries and 53 (51.5 %) overuse injuries (De Bernardo et al. 2012 ). Only eight cyclists (15.6 %) were injury-free. Twenty-two (43 %) athletes experienced both overuse and traumatic injuries, while 13 (25.5 %) experienced only traumatic lesions and 10 (19.5 %) only overuse injuries. Twenty- nine cyclists (67.4 %) experienced more than one injury. Twenty-eight fractures occurred, with the clavicle having the most common fracture (11 cases). The major- ity (68.5 %) of overuse injuries was located in the lower limbs, most occurring during preseason. Severe injuries requiring more than 1 month off occurred in four cases, and all of them are trauma (8 % of traumatic injuries) requiring surgery.

48.2 Traumatic Injuries

Baker (2003 ) reported on traumatic injuries on 85 cyclists in a racing Masters club. Seventy-nine percent were seen emergently for trauma, 33 % were admitted to the hospital, and 15 % were admitted to an intensive care unit. Fifty-four percent sustained fractures and 45 % a head injury, 34 % reported a concussion, and 9 % sustained multiple concussions. Ninety percent experienced road rash. Sixty-nine percent of injuries occurred riding alone and 31 % occurred riding in groups. Thirty- seven percent of solo road injuries were from crashes with motor vehicles, 9 % from potholes, rocks, or dogs, 12 % from operator errors (cornering too fast or adjusting parts while riding), and 10 % by mechanical reasons (broken fork or ﬂ at tire). Of the injuries during group riding, 17 % occurred riding in a pace line, most trying to avoid crashing into other crashed riders, with 12 % in races, mostly criteriums. Statistics on deaths from motor vehicle collisions speciﬁ cally in athletes do not exist. There is less risk bicycling on good road surfaces, with streetlights, and on mul- tiuse paths versus sidewalks. About 50 % of traumatic cycling injuries result in fractures (De Bernardo et al. 2012). The most common is the clavicle followed by the wrist, ribs, and elbow. Lower extremity fractures are rarer and often involve the pelvis, hip, or femur. Femur fractures are displaced usually, requiring surgery, while pelvis fractures are nondisplaced often, non-life-threatening, and detected often 48 The Expert View on Bicycling Injuries 1057 with computed tomography (CT) or MRI after negative x-rays. Off-road cyclists in events appear to sustain more fractures, dislocations, and concussions than road cyclists in events (Pfeiffer and Kronisch 1995 ).

48.2.1 Clavicle Fractures/Shoulder Injuries

It is joked commonly, “If you race long enough, you will eventually break your col- larbone.” Clavicle fractures are caused by a direct blow to the shoulder from falls, often going over the front end. They are associated often with concussions and rib fractures. Cyclists with clavicle fractures treated nonoperatively usually can ride a stationary trainer within 1 week, ride outdoors within 2–3 weeks, and race in 4–6 weeks. Most clavicle fractures are treated nonoperatively, except when communition, shortening, or severe displacement is present. Initial shortening of displaced middle third fractures greater than or equal to 20 mm was found to have a highly signifi cant association with nonunion and unsatisfactory result (diffi culty lifting heavy objects, pain, paresthesia, or cosmetic complaint) with closed treatment (Hill et al. 1997 ). Displacement of more than one bone width on initial x-ray (0° and 45° tilted view) in another study was found to be the strongest radiographic risk factor for persistent symptoms at 6 months with nonoperative treatment (Nowak et al. 2005 ). Late repairs of painful nonunion or malunion displaced midshaft fractures also have been found to have similar results to immediate fi xation (Potter et al. 2007 ). Fractures treated operatively may allow a cyclist to return to training sooner. If there is suspicion of sterno- clavicular (SC) joint injury, obtain a CT. Posterior dislocations should be reduced operatively. Delayed erosion into vessels and stroke has occurred in chronic SC posterior dislocations. AC separations are equally common, and all but the most severe grade 3 separations are treated nonoperatively. Brief use of sling may be used with return to stationary workouts almost immediately and road riding in 1–2 weeks.

48.2.2 Radial Head Fractures

Radial head fractures are common from falls on an outstretched hand. Aspiration of hemarthrosis with inﬁ ltration of anesthesia helps with pain relief and evaluation for mechanical block. Early range of motion exercises should be encouraged to achieve full extension. Most athletes with nondisplaced fractures can return usually to riding in 1–2 weeks.

48.2.3 Rib Fractures

Rib fractures are common from falls. Single or multiple rib fractures can cause a pneumothorax or an intra-abdominal trauma. Evaluation by chest x-ray and CT scan to evaluate damage can be very useful. Return to racing may take 6–8 weeks (in case of no complications). 1058 G. De Schutter

48.2.4 Concussions

Concussions in cycling historically have been managed differently from other contact/ collision sports like boxing and rugby. In stage races like the Tour de France, a rider must fi nish the stage within a percentage of the stage winner’s time to continue racing. There are no time-outs or substitutions, and the peloton waits for no one. A rider who crashes has to get back on his bike and “chase back on” drafting off team cars. On stage 1 of the 1996 Tour, Luc Leblanc crashed and lay on the side of the road motion- less. He was put back on his bike when he regained consciousness. He went on to win stage 7. A stage win in the Tour de France is a career-defi ning win for a cyclist, bigger than an Olympic medal. It is common to this day to put a rider back in a race after a closed head injury as long as the rider is willing and able to ride. There is no Sideline Concussion Assessment Tool in cycling. Assessment on the side of the road is done rapidly as the race goes on, often by a mechanic or team director. If a rider can get up and mount his bike, he soldiers on. Slower reaction times and impaired speed of pro- cessing information are seen commonly in concussed athletes, and return of a cyclist who might be experiencing a concussion may place the athlete and the peloton at risk from further accidents. Helmets were made mandatory in professional cycling in 2003 after the death of professional road cyclist Andrei Kivilev, who sustained a skull fracture from a crash in Paris-Nice. Helmets have been shown to prevent skull fractures and intracranial hemorrhage (Bergenstal et al. 2012 ). There is no scientifi c evidence that they reduce the incidence of concussions. Bicycle helmets are designed to protect the head by reducing the rate at which the skull and brain are decelerated by an impact. The expanded polystyrene liner upon impact is designed to compress, dissipating the energy over a rapidly increasing area like a cone. After a blow to the head, a helmet should be discarded whether or not it appears broken. Concussions in cycling should be handled as in other sports with recommendations from the Fourth International Consensus Conference on Concussion in Sport held in Zurich in 2012 (McCrory et al. 2013). Any cyclist who is suspected of sustaining a concussion should be evaluated on-site, and if no health care provider is available, the athlete should be removed from the sport, with urgent referral to a physician trained and experienced in management of concussions. Any cyclist diagnosed with a concussion should not be allowed to return to play on the day of the injury. The cornerstone of concussion symptom management is complete physical and cognitive rest until the acute symptoms resolve, although, to date, there is no published scientifi c evidence evaluating the effect or duration of rest. Once asymptomatic, a stepwise graded return to play may be initi- ated, beginning with easy rides on a stationary trainer. Management and return to play should be guided ultimately by clinical judgment on an individual case basis.

48.2.5 Abrasions

The wound should be thoroughly cleaned and scrubbed soon after the injury has occurred. Road rash is the most common crash injury and should be treated with thor- ough cleaning and scrubbing. Embedded dirt particles and stones can serve as a 48 The Expert View on Bicycling Injuries 1059 nidus for infection and thus must be removed. Topical anesthetic should be used. Wounds should not be left uncovered; large scabs inhibit wound healing and inhibit range of motion required to pedal or hold the bars. Open wounds will stick painfully to bedding at night. Wounds can be covered with semipermeable ﬁ lms, hydrocolloid dressings, or occlusive bandages. Alternatively wounds may be covered with nonadherent dressings and antibiotic ointment with daily dress- ing changes and cleansing of exudates until pink healthy granulation tissue forms. Dressings are padded with gauze, wrapped in stretch gauze, and then covered in tube stretch gauze.

48.2.6 Contusions

Contusions are equally common as road rash. The most common site is the quadriceps, from contact with pavement or collision with cars. Immediate placement of the knee in 120° of fl exion for 24 h may allow an athlete to return to sports sooner (Aronen et al. 2006 ). Scientifi c studies on the use of ice or nonsteroidal anti- infl ammatory drugs in contusions are lacking. Localized hematomas or seromas, common from cycling contusions, can be visualized easily by ultrasound and are treated most effectively with aspiration and may require repeat treatments. Prepatellar and olecranon bursitis may be caused by direct blow from a crash or from repetition. If from a crash with road rash, have a high index of suspicion of infection. Most cyclists with bursitis can continue to train at modifi ed intensity. Cortisone is for recalcitrant cases.

48.2.7 Intra-abdominal Cavity Contusions

Intra-abdominal traumas occur more often in children performing BMX stunts and in mountain biking. The cause is often blunt trauma from horizontal bar ends. In a retrospective review of children involved in cycling crashes admitted to a tertiary center over 5 years, 31 out of 196 (16 %) sustained abdominal injuries with 19 major visceral injuries, seven requiring surgery. Over the same period, no child with head trauma required surgery (Muthucumaru et al. 2012 ).

48.2.7.1 Spleen Rupture Niels Albert, 2009 and 2012 cyclocross world champion, fractured his rib in 2008 after a solo crash on a descent, which punctured his lung and ruptured his spleen. Most intra-abdominal contusions are treated with serial observation and diagnostic imaging (Clarnette and Beasley 1997 ).

48.3 Bicycle Contact Injuries

Cyclists contact their bicycles at three areas: the pedals, the seat, and the handlebars. Each contact point is associated with particular cycling ailments. 1060 G. De Schutter

48.3.1 Shoe Pedal Interface

48.3.1.1 Plantar Neuropathy Burning feet, “hot foot,” numbness, or pain is a common complaint as a result of compression of interdigital plantar nerves from a ﬁ xed cleat/pedal interface and narrow rigid cycling shoe. Diagnosis of Morton’s neuroma, a perineural ﬁ broma commonly occurring between the third and fourth metatarsals, should be made only when seen on ultrasound or magnetic resonance imaging (MRI). On ultrasound, it appears as a noncompressible hypoechoic mass greater than 5 mm. Symptoms may be relieved with cleat adjustment (usually with the cleat positioned further back), by wearing a shoe with a wider toe box, by loosening the straps on the shoes, or by using a wider pedal. An insole with a metatarsal pad and manual therapy may be tried. For recalcitrant cases, cortisone injection or sclerosing injections may be considered. Neurectomy, via plantar or dorsal approach, is the mainstay of surgical interven- tion. However limited evidence was found with which to assess the effectiveness of surgical and nonsurgical interventions for Morton’s neuroma (Thomsom et al. 2004 ) .

48.3.2 Saddle Interface

48.3.2.1 Saddle Sore The second area of contact the cyclist has with the bicycle is the seat or saddle. Most riders experience some degree of saddle soreness. This is especially true for recreational riders at the start of the season and for tourists early in a long-distance trip. The combination of moisture, friction, and pressure leads to skin disorders in the perineal region. Soreness is the most common problem, relieved with brief time off and an emollient cream. Cycling in wet clothing, such as in triathlons or the rain, is a frequent cause of chaﬁ ng. Ulceration from severe friction requires wound treatment. Saddle sores, ranging from furuncles and folliculitis, may limit riding for a prolonged period. They often require incision and drainage. Perineal nodular induration (PNI) or “biker’s nodule” is a ﬁ broblastic pseudotumor that presents not only exclusively in male cyclists’ “third testicle” (accessory testicle) but also in female population of cyclists. It develops in the soft tissues of the perineum immediately posterior to the scrotum or in the labial area in women, as a bilateral or single, central or lateralized mass (Gonzalez-Perez et al. 2009 ). Surgical excision is often required. As a means of prevention, time off the bike, warm soaks, cortisone, or antifungal or antibacterial ointment may be considered. Prevention involves riding on a dry, clean chamois and changing clothing immediately after cycling.

48.3.2.2 Perineal Vasculopathy/Neuropathy A signiﬁ cant percentage of body weight may be positioned on the bicycle saddle during seated bicycling depending on variables such as a rider’s position on the bike and rider effort. 48 The Expert View on Bicycling Injuries 1061

Regardless of the saddle design, it is the racing position of a cyclist, in an effort to get good aerodynamics by lowering the torso toward a horizontal fl at back position and tilting the pelvis anteriorly that transfers pressure from the ischial tuberosi- ties to the perineum, where vascular and neural structures reside. Transcutaneous penile oxygen pressure (tPO2 ) monitoring, believed to correlate with penile blood fl ow, has been found to be a reliable method for measuring penile oxygen levels during cycling (Cohen and Gross 2005 ). A signifi cant decrease in penile oxygen perfusion occurs during seated bicycling, with measurement as high as an 82 % drop in tPO2 (Schwarzer et al. 2002 ). The implications of decreased tPO2 over different time intervals when bicycling is unknown and needs to be further researched. Hypoxemia in the corpus cavernosum is associated with penile fi brosis, which is known to lead to erectile dysfunction (ED). ED rates have been reported to occur as high as 24 % in amateurs with weekly mileage greater than 400 km (Sommer et al. 2001 ). Ischemic neuropathy may result also from compression of the neurovascula- ture in the perineum and in Alcock’s canal. Rates of genital numbness have been reported as low as 10 % in amateurs on an 8-d ride of 500 miles to as high as 91 % in a small study of 17 cycling policemen (Schrader et al. 2002). “Cyclist’s syndrome” is a specifi c form of pudendal nerve entrapment related to prolonged bicycling resulting in pain, burning, and numbness, sometimes accompanied by sexual dysfunction, impotence, or urinary incontinence. The pathogenesis of pudendal neuropathy is unknown. Compression, friction, and stretching of nerves are impli- cated. A rider’s position, bike fi t, and riding technique play the greatest roles in prevention and treatment of perineal compression. Risk of compression is greatest during time trialing, in indoor riding on rollers or a trainer without frequent standing, in heavier cyclists, and in mountain biking. Preventive measures such as changing riding style, alternating standing, and sitting often are recommended. Riding on a recumbent bike causes no decrease in penile perfusion, as does standing while cycling. Three minutes of standing are required to produce stable increases in penile oxygen levels after seated compression. An excessively high saddle, narrow saddle, excessive saddle tilted up, or handlebars excessively forward or low can all increase compression. Ergonomic wider saddles, with a split saddle, chopped nose, or central cut out, have all been designed to decrease compression. Cohen and Gross (2005 ) studied tPO 2 in three racing saddle designs (a “standard” narrow saddle, a padded saddle with an elliptical hole in the center and a cutout seam in the nose, and a saddle with a split V in the rear and a central depression from the back to the tip of the nose) and found none of the saddles spared a drop in penile tPO 2 (decreases of 76, 73, and 62 %, respectively). Dettori et al. (2004 ) actually found an increased risk of ED with a cutout saddle among those who experienced numbness versus those who did not experience numbness, possibly due to compression on the cutout edge or decreased surface area. Time off the bike is warranted for prolonged compressive symptoms as irreversible neuropathy can occur (Leibovitch and Mor 2005 ). Physical therapy, manual therapy, and injection therapy are treatment options for relief of pain from neuralgia. The symptoms for most cyclists are transient, but the implications are unknown. 1062 G. De Schutter

Prevention involves proper saddle height and tilt, handlebar reach and height, and saddle type and width. The general rule for a recreational or touring saddle is that it should be 2.5–5.0 cm wider than the interischial distance. This distance is greater in the female pelvis, and many bicycle-seat manufacturers offer saddles designed to accommodate the wider female pelvis. Another anatomical difference between the male and female pelvis is the steepness of the pubic arch in relation to the anterior saddle cant. In the male pelvis, the steeper arch of the pubic symphysis allows some clearance above the nose of the saddle. The shallower arch in the female means that the soft tissue of the perineum presses against the nose of the saddle. Many women attempt to correct this by riding in a more upright posture to take the weight off this area. While the seat should usually be level, some men pre- fer a slight upward tilt. However, too acute an angle can cause pressure on the n. pudendus, resulting in transient numbness of the penis, scrotum, or both.

48.3.3 Hands-Handlebar Interface

The third area of contact between the cyclist and the bike is the handlebars. Cyclist’s palsy, or ulnar neuropathy, is a familiar affl iction of the long-distance cyclist. Stiefl er, in 1927, was the fi rst to report on bicycling causing prolonged compression of the ulnar nerve (“cyclists palsy”), and it is less common in the median nerve (Hankey and Gubbay 1988 ; Maimaris and Zadeh 1990 ). Thirty-two of 89 (36 %) cyclists on a tour of 80 d and 4,500 miles experienced hand numbness, 10 (11 %) in the median nerve distribution, with 1 unable to adduct his thumb, 1 unable to adduct his little fi nger, and 1 unable to abduct his little fi nger (Fairclough et al 2006 ). Mononeuropathy of the deep palmar branch of the ulnar nerve in Guyon’s canal may cause clawing. With a type I lesion, mixed sensory and motor, compression is proximal (outside of Guyon’s canal) and clawing usually is not seen. Isolated lesions of the deep terminal motor branch, with distal sensory branches intact, result in the athlete unaware of any compression until the motor lesion develops. Increased compression occurs with prolonged riding without change in hand position, stationary biking, downhill cycling, rough terrain, handlebars too low or forward, poor padding in gloves or bars, or improper suspension or “death grip” (an overly tight grip on the handlebars caused by fear) in mountain biking. Most cases result in a transient neu- ropraxia, with full recovery with modifi cation or cessation of activity. However rarely permanent damage may occur. Treatments for the cyclist include the follow- ing: reduction in training, changing hand position often, increasing padding in the bars or gloves, shortening the reach or raising the handlebars, or using aerobars.

48.4 Overuse Injuries

Overuse injuries are common in cycling but rarely require prolonged time off the bike. In a study of 108 professionals in 1 season, 58.3 % experienced an overuse injury (Clarsen et al. 2010 ). In a study of 51 professionals over 4 seasons, 62.7 % 48 The Expert View on Bicycling Injuries 1063 reported an overuse injury (De Bernardo et al. 2012 ). In a study of 518 amateur cyclists, 85 % experienced an overuse injury (Wilber et al. 1995 ). Among overuse injuries in professionals, 64 % required less than 7 days off from competition, 32 % required 7–28 days off, and 4 % required more than 28 days off (1 case of osteitis pubis and 1 case of iliac artery endoﬁ brosis) (Barrios et al. 1997 ).

48.4.1 Knee

The knee is the most common overuse injury site in the cyclist. Knee injuries account for 62 % of all overuse injuries in professionals (Barrios et al. 1997 ). Based on the location of pain, bicycle adjustments may be made (Asplund and St Pierre 2004 ). Ultrasound may help localize extra-articular pathology.

48.4.2 Lateral Knee Pain

Iliotibial band syndrome (ITBS) is the most common cause of lateral knee pain in cyclists. Historically regarded as a friction syndrome from a snapping iliotibial band (ITB) over the lateral femoral condyle. Kulund and Brubaker (1978 ) argue that ITBS is not from snapping but from compression of fat beneath the ITB. In cadavers, the ITB was found anchored to the femur by fi brous strands, associated with inner- vated and vascularized fat containing Pacinian corpuscles, suggesting that ITBS is more of an enthesopathy. Some report found no bursal sacs (Fairclough et al. 2006 ). Others have treated ITBS with bursectomy (Hariri et al. 2009 ). Some have removed surgically cyst-like structures, which are possible extensions of the lateral synovial capsule (Costa et al. 2004 ). Holmes et al. (1993 ) reported fi brosis and chronic infl ammatory changes on microscopic examination of excised ITB, while others question if any pathological change takes place in the ITB (Fairclough et al. 2006 ). The syndrome is likely a spectrum of different entities. The causes of ITBS are rapid increase in intensity and mileage, pushing big gears, hills, windy conditions, time trialing, and positional causes such as toes pointing inward, excessive pedal fl oat, or worn cleats. Weak hip abductors may be less of an issue in cyclists than in runners with ITBS since cyclists are seated in the saddle most of the time. Bike fi t treatments involve adjusting cleats, checking bike fi t, and leg length evaluation with shims as needed. Physical therapy, stretching, foam rolling, and massage therapy are treatment options. Professional cycling teams employ soigneurs for daily massage therapy. Manipulation of the pelvis should be performed for somatic dysfunctions, which commonly occur from crashes and are overlooked often. Cortisone injection may be considered. Under ultrasound guidance, injections may be directed at the tendon sheath, if tenosynovitis is present, or between the ITB and femoral condyle, if anechoic or hypoechoic echotexture is noted against the femoral condyle. Many cyclists with ITBS can recover while continuing to ride at a lesser intensity and duration. Surgery for recalcitrant cases has ranged from removal of an elliptical piece of the distal posterior band to the “mesh technique” to surgical lengthening or Z-plasty. 1064 G. De Schutter

Biceps femoris tendinopathy presents with pain more posterior lateral than ITBS. Biceps femoris tendinopathy occurred equally as patella tendinopathy in professionals (De Bernardo et al. 2012 ). Massage therapy, eccentric strengthening, dynamic stretching, and a short time off the bike for severe cases are all treatment options.

48.4.3 Anterior Knee Pain

Anterior knee pain is the most common reason cyclists seek medical care. Anterior knee pain should not be put into one diagnosis of patellofemoral pain syndrome (PFPS) or chondromalacia. Patella tendon pain may occur at the entheses of the tibia tubercle, midportion, or inferior pole of the patella and may be a strain, tear, or tendonosis (Rees et al. 2013 ). Pain can become chronic or recurrent. Common causes in cyclists are similar to ITBS and include pushing big gears, hills, windy conditions, rapidly increasing mileage or intensity, or a bicycle setup with a saddle too low or forward or with cranks too long. Time off the bike or limiting intensity and duration may be needed. Physical therapy, manual therapy, and massage are treatment options. Eccentric strength training on a 25° decline board is a popular home exercise program that may have a positive effect for patella tendinopathy (Visnes and Bahr 2007 ). Sclerosing neovessels outside the tendon for painful chronic tendinopathy is a novel treatment that may challenge the need for surgery (Alfredson and Ohberg 2005 ). Percutaneous tenotomy, platelet-rich plasma therapy, and stem cell injection therapies are other nonsurgical treatments warranting more scientiﬁ c research. PFPS is a diagnosis of exclusion. An effusion indicates intra-articular pathology and warrants an MRI or aspiration for ﬂ uid analysis. PFPS may be caused by a saddle too low or forward or from cranks too long. Cycling causes and treatments are similar to the patella tendon. A diagnosis of chondromalacia patella should be made only after arthroscopy, although it is not treated easily surgically. Barrios et al. ( 1997) found chondromalacia in 10 out of 10 cyclists who underwent arthroscopy for recurrent pain. Anterior knee pain may also result from friction of the quadriceps tendon on the top end of the patella. Common causes include a bicycle setup with a saddle too low or forward, cold conditions, and a history of trauma of the knee (fall or a simple hit by the handlebars). Time off the bike and starting up training at limited intensity and duration may be needed. Cortisone injection may be considered. Surgery for recalcitrant cases may be needed.

48.4.4 Medial Knee Pain

The most common causes of medial knee pain in the cyclist are MCL bursitis, medial plica syndrome, pes anserine syndrome, and less commonly medial meniscus tear. Excessive ﬂ oat or no ﬂ oat in a pedal may contribute to medial knee pain. 48 The Expert View on Bicycling Injuries 1065

Bike fi t evaluation, modifi cation of training, physical and manual therapy, or injections are treatment options. Medial meniscus tears while not caused by pedaling can become symptomatic from twisting out of a pedal. Symptomatic meniscal tears may be treated with modifi cation of activity, pedal tension adjustment, watchful waiting, injections, and even continued cycling prior to entertaining a meniscectomy. Caution should be noted if a cyclist has a tear on MRI; one should not assume it is the cause of pain. Medial plica syndrome presents with pain and a snapping or clicking sensation anterior medial over the femoral condyle. A symptomatic thickened plica may be palpated over the medial condyle while the patient fl exes and extends the knee. Diagnosis of a symptomatic plica is made by exclusion, and presence of a plica does not imply pathology. A plica may be seen on MRI, although a negative MRI does not rule out a symptomatic plica either. Treatments include cortisone injection, physical therapy, and modifi cation of training prior to surgery. Rapid return to cycling after surgical excision is usual.

48.4.5 Proximal ITBS or Greater Trochanteric Pain Syndrome

Proximal ITBS, lateral “hip” pain and tenderness over the greater trochanter, is not as common in cyclists as ITBS at the knee. The athlete is misdiagnosed often with trochanteric bursitis. With ultrasound and MRI, we now know that bursitis is rarely present (Ho and Howard 2012 ). Pathological specimens from patients diagnosed with bursitis contained mostly fi broadipose tissue (Silva et al. 2008 ). In an MRI study on women with “trochanteric bursitis,” 45.8 % had a gluteus medius tear, 62.5 % had gluteus medius tendonitis, and 8 % had bursitis (Bird et al. 2001 ). Some authors contend that gluteal tendinopathy is similar to rotator cuff pathogenesis, with reactive secondary bursitis similar to subacromial bursitis (Kingzett-Taylor et al. 1999 ). Pathology may include a spectrum of entities such as tendonosis, partial tears, complete tears, undersurface tears, and tears with retraction, with the gluteus medius tendon most commonly involved. Dynamic ultrasound of “external hip snapping” has documented snapping of the ITB over the greater trochanter with a hypoechoic and thickened ITB (Choi et al. 2002 ). Whether the source of the pain is the tensor fascia lata or ITB is unclear. There are no specifi c studies involving cyclists (seated athletes), where the mechanism of injury appears different from those who are studied more often such as runners or older nonathletes. The etiology of lateral “hip” pain in the cyclist may be similar to the theory of ITBS at the knee with compression of underlying tissue against the greater trochanter. It can mimic pain from a lumbar disk or tumor, which often causes posterior thigh or buttock pain or osteoarthritis of the hip, which should cause groin pain. The cause usually is riding excessive mileage. Backing off and massage will quickly cure most of these cases. Improper bike fi t may reveal “hip rocking” when pedaling with a high saddle. Recommended treatment includes bike fi t adjustment, physical therapy, manipulation, or cortisone injection. Historically injections are directed at the point of maximal tenderness. With ultrasound guidance, the injection may be directed at any tendonosis, tear, or 1066 G. De Schutter bursitis. A long needle is often required to reach the gluteal entheses at the greater trochanter or deeper bursal structures. There are no known clinical studies compar- ing outcomes of ultrasound-guided injections versus blind technique for the treatment of greater trochanteric pain syndrome. In a randomized clinical control comparison of fl uoroscopic-guided injection versus blind injection, there were no differences in outcomes favoring either group (Cohen et al. 2009 ).

48.4.6 Achilles Tendon

In a 4-year study of 51 professional cyclists, fi ve cases of Achilles tendinopathy were reported compared with three cases of patella and eight cases of ITB tendinopathy (De Bernardo et al. 2012 ). Achilles tendinopathy may occur from riding “too much too soon,” improper pedaling technique, or improper bike fi t. Excessive plantar fl exion at bottom dead center (BDC) from too high a saddle may cause strain. Francis reported that the optimum plantar fl exion in BDC pedal position should be approximately 13°, which corresponds to about 20° plantar fl exion from the horizontal (De Vey Mestdagh 1998 ). Excessive dorsifl exion at BDC from a low saddle or pushing the heel down in an attempt to generate more power also may cause strain of the Achilles. Physical therapy, manual therapy, and eccentric strengthening are treatment options for Achilles tendinopathy. The pedal stroke may be broken down into the downward propulsive phase and upward relaxation phase. Simple observation of cyclists (whether or not they are using clipless pedal systems) reveals that a rider’s heel lowers during the downstroke (ankle dorsifl exes) and a rider’s heel raises during the upstroke (ankle plantar fl exes), mostly due to lower limb movement and the biomechanics of cycling with a rotating pedal spindle on a moving crank. If the saddle height is set correctly, then the heel should not drop below horizontal on the downstroke. “Ankling,” purposely pressing the heel down at the start of the downward pedal stroke to a point below the horizontal and then lifting the heel up on the up stroke, recently has been found to be signifi cantly less effi cient than normal pedaling (Zommers 2000 ) and likely contributes to ankle tendon problems. The leg cannot be pulled actively up faster and harder in the upstroke than the leg pushing down in the downstroke. It is the maximal torque during the downstroke that separates the elite from recreational cyclists (Broker 2003 ).

48.4.7 Neck and Back Pain

Neck (19 %) pain and back pain (60 %) are common overuse injuries in cyclists (Callaghan and Jarvis 1996 ). Neck pain is caused by the tension developed in muscles of the shoulder, neck, and upper spine that are in a hyperextended position. Lengthy excessive extension of the neck results in trigger point development in the muscles of the neck and of the upper back. The vibrating movement that is caused from cycling can aggravate this problem (Simons et al. 1999 ). Isometric contrac- tions of muscles decrease blood fl ow and may cause an ischemic response that may 48 The Expert View on Bicycling Injuries 1067 further cause a muscular spasm and consequently increase pain (Asplund and St Pierre 2004 ). Many activities in cycling involve sitting and leaning forward. The transversus abdominis and multifi dus muscles are weakened in these postures (Simons et al. 1999). Additionally, failure of the hamstring muscles to lengthen normally increases the stress placed on the posterior elements of the lumbar spine, particularly if the spine is in a forward fl exed position as in the cycling posture, because the extensor muscles of the low back are elongated and cannot disperse the applied stress (Schafer and Faye 1989 ). Bicycle fi t position and improper equipment (changing the position of the handlebars/handlebar width and using a shorter stem), training errors (changing hand position more often and keeping elbows unlocked, core strengthening, and stretching programs), and individual anatomic factors (posterior pelvic tilt/hamstring fl exibility, asymmetric upper and lower limbs) are impor- tant evaluation considerations. By learning how to recognize and treat contributing factors, as well as learning a few simple bike fi tting techniques, physicians can treat and prevent many common problems (Asplund and St Pierre 2004 ).

48.5 Iliac Artery Endofibrosis and Kinking

Flow limitations in iliac arteries have been reported mostly in cyclists likely from riding position, although cases exist in speed skaters, runners, soccer players, and cross-country skiers. Flow limitations may be from kinking (functional iliac artery obstruction) or endofi brosis (external iliac artery endofi brosis) (Peach et al. 2012 ). Schep et al. (2002 ) estimate the prevalence to be 10–20 % among elite and professionals. A rider often sees multiple physicians with comprehensive orthopedic and neurological workups prior to diagnosis. The cyclist may report a sensation of dead leg, lack of power, cramp, or pain in the leg worse with steady exertion such as climbing or time trialing. A detailed questionnaire helps differentiate vascular from nonvascular causes. Physical examination is usually normal, although a bruit in the inguinal region may be heard, more often postexercise. A reliable, reproducible imaging modality does not exist. A fl owchart guiding investigation and management exists. Initial test is a provocative ankle brachial index and duplex ultrasound, immediately postcycling with the hip and knee fl exed. Magnetic resonance angiography may assess vessel length or kinking, and digital subtraction angiography may identify tethering of arterial branches. CT angiography also has been used. There are multiple treatment options. Arterial release is performed if stenosis is less than 15 %, and artery is not lengthened. Vessel shortening with endofi brosectomy is performed for a lengthened vessel. Endofi brosectomy and patch angioplasty, or interpositional grafting, are performed for intravascular lesions. Complete resection and replacement with a saphenous vein or synthetic graft have been performed also. Angioplasty or endoluminal stent placement is not recommended. Professionals have returned to racing postsurgery, although no long-term outcomes exist. Conservative treatment in recreational cyclists includes a change in position to one of less hip fl exion or cessation of sport (Peach et al. 2012 ). 1068 G. De Schutter

Conclusion Injuries in cycling occur at a high rate from bicycle contact, traumatic events, and overuse. Overuse ailments occur primarily in the knee. Traumatic lesions occur primarily in the shoulder region. Many bicycle contact and overuse ailments are relieved with bike ﬁ t adjustments. Overuse injuries are treated success- fully with massage, physical therapy, and modiﬁ cation of training. Most injured cyclists are able and willing to train and even race while injured. More evidence- based research on injuries in cycling is needed.

References

Alfredson H, Ohberg L (2005) Neovascularisation in chronic painful patellar tendinosis – promis- ing results after sclerosing neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc 13:74–80 Aronen JG, Garrick JG, Chronister RD, McDevitt ER (2006) Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee fl exion. Clin J Sport Med 16:383–387 Asplund C, St Pierre P (2004) Knee pain and bicycling. Phys Sportsmed 32:1–11 Baker A (2003) Traumatic bicycle injuries in a masters club. Traum Inj 200:1–8 Barrios C, Sala D, Terrados N, Valenti JR (1997) Traumatic and overuse injuries in elite professional cyclists. Sports Exerc Inj 3:176–179 Bergenstal J, Davis SM, Sikora R, Paulson D, Whiteman C (2012) Pediatric bicycle injury prevention and the effect of helmet use: the West Virginia experience. W V Med J 108:78–81 Bird PA, Oakley SP, Shnier R, Krikham BW (2001) Prospective evaluation of magnetic resonance imaging and physical examination fi ndings in patients with greater trochanteric pain syndrome. Arthritis Rheum 44:2138–2145 Broker JP (2003) Cycling biomechanics: road and mountain. In: Burke ER (ed) High tech cycling. Human Kinetics, Champaign, pp 123–138 Callaghan MJ, Jarvis C (1996) Evaluation of elite British cyclists: the role of the squad medical. Br J Sports Med 30(4):349–353 Choi Y, Lee S, Song B et al (2002) Dynamic sonography of external snapping hip syndrome. J Ultrasound Med 21:753–758 Clarnette TD, Beasley SW (1997) Handlebar injuries in children; patterns and prevention. Aust N Z J Surg 67:338–339 Clarsen B, Krosshaug T, Bahr R (2010) Overuse injuries in professional road cyclists. Am J Sports Med 38:2494–2501 Cohen JD, Gross MT (2005) Effect of bicycle racing saddle design on transcutaneous penile oxygen pressure. J Sports Med Phys Fitness 45:409–418 Cohen SP, Strassles SA, Foster L et al (2009) Comparison of fl uoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised con- trolled trial. BMJ 338:b1088 Costa ML, Marshall T, Donell ST, Phillips H (2004) Knee synovial cyst presenting as iliotibial band friction syndrome. Knee 3:247–248 De Bernardo N, Barrios C, Vera P, Laíz C, Hadala M (2012) Incidence and risk for traumatic an overuse injuries in top-level road cyclists. J Sports Sci 30:1047–1053 De Vey Mestdagh K (1998) Personal perspective: in search of an optimum cycling posture. Appl Ergon 29:325–334 Dettori JR, Koepsell TD, Cummings P, Corman JM (2004) Erectile dysfunction after a long- distance cycling event: associations with bicycle characteristics. J Urol 172:637–641 48 The Expert View on Bicycling Injuries 1069

Fairclough J, Hayashi K, Toumi H et al (2006) The functional anatomy of the iliotibial band during fl exion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat 208:309–316 Gonzalez-Perez R, Carnero L, Arbide N, Soloeta R (2009) Perineal nodular induration in cyclists. Actas Dermosifi liogr 100:907–922 Hankey G, Gubbay SS (1988) Compressive mononeuropathy of the deep palmar branch of the ulnar nerve in cyclists. J Neurol Neurosurg Psychiatry 51:1588–1590 Hariri S, Savidge ET, Reinold MM, Zachazewski J, Gill TJ (2009) Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: indications, technique, and clinical outcomes. Am J Sports Med 37:1417–1424 Hill JM, McGuire MH, Crosby LA (1997) Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 79:537–539 Ho GWK, Howard TM (2012) Greater trochanteric pain syndrome: more than bursitis and iliotibial tract friction. Am J Sports Med 11:232–238 Holmes JC, Pruitt AL, Whalen NJ (1993) Iliotibial band syndrome in cyclists. Am J Sports Med 21:419–424 Kingzett-Taylor A, Tirman PFJ, Feller J et al (1999) Tendinosis and tears of gluteus medius and minimus muscles as a cause of hip pain: MR imaging fi ndings. AJR Am J Roentgenol 173:1123–1126 Kulund D, Brubaker C (1978) Injuries in the Bikecentennial tour. Phys Sportsmed 6:74–78 Leibovitch I, Mor Y (2005) The vicious cycling: bicycling related urogenital disorders. Eur Urol 47:277–287 Maimaris C, Zadeh HG (1990) Ulnar nerve compression in the cyclist’s hand: two case reports and review of the literature. Br J Sports Med 24:245–246 McCrory P, Meeuwisse WH, Aubry M et al (2013) Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 47:250–258 Muthucumaru M, Keys C, Kimber C et al (2012) Trend of severe abdominal injuries from bicycle accidents in children: a preventable condition. J Paediatr Child Health 48:259–262 Nowak J, Holgersson M, Larsson S (2005) Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop 76:496–502 Peach G, Schep G, Palfreeman R et al (2012) Endofi brosis and kinking of the iliac arteries in athletes: a systemic review. Eur J Vasc Endovasc Surg 43:208–217 Pfeiffer RP, Kronisch RL (1995) Off-road cycling injuries. An overview. Sports Med 19:311–325 Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD (2007) Does delay matter? The restora- tion of objectively measured shoulder strength and patient-oriented outcome after immediate fi xation versus delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg 16:514–518 Rees JD, Houghton J, Srikanthan A, West A (2013) The location of pathology in patellar tendinopathy. Br J Sports Med 47:9 e2 Schafer RC, Faye LJ (1989) Motion palpation and chiropractic technique, 1st edn. The Motion Palpation Institute, Huntington Beach Schep G, Schmikli SL, Bender MH et al (2002) Recognising vascular causes of leg complains in endurance athletes. Part 1: validation of a decision algorithm. Int J Sports Med 23:313–321 Schrader SM, Breitenstein MJ, Clark JC, Lowe BD, Turner TW (2002) Nocturnal penile tumes- cence and rigidity in bicycling patrol offi cers. J Androl 23:927–934 Schwarzer U, Sommer F, Klotz T, Cremer C, Engelmann U (2002) Cycling and penile oxygen pressure: the type of saddle matters. Eur Urol 41:139–143 Silva F, Adams T, Feinstein J, Arroyo RA (2008) Trochanteric bursitis: refuting the myth of infl ammation. J Clin Rheumatol 14:82–86 Simons DG, Travell JG, Simons LS (1999) Myofascial pain and dysfunction, the trigger point manual, 2nd edn. Williams and Wilkins, Baltimore 1070 G. De Schutter

Sommer F, Konig D, Graft C, Schwarzer U, Bertram C, Klotz T et al (2001) Impotence and genital numbness in cyclists. Int J Sports Med 22:410–413 Thomsom CE, Gibson JN, Martin D (2004) Interventions for the treatment of Morton’s neuroma. Cochrane Database Syst Rev CD003118 http://onlinelibrary.wiley.com/doi/10.1002/14651858. CD003118.pub2/abstract;jsessionid=094DB45CCC1CEF5C8990692E4608E3D1.f04t04 Visnes H, Bahr R (2007) The evolution of eccentric training as treatment for patella tendinopathy (jumper’s knee): a critical review of exercise programmes. Br J Sports Med 1:217–223 Wilber CA, Holland GJ, Madison RE, Loy SF (1995) An epidemiological analysis of overuse injuries among recreational cyclists. Int J Sports Med 16:201–206 Zommers A (2000) Variations in pedaling technique of competitive cyclists: the effect on biologi- cal efﬁ ciency [dissertation]. Victoria University of Technology Australia