Central Annals of Sports Medicine and Research

Mini Review *Corresponding author Michael T. Lebec, Department of Physical Therapy and Athletic Training, P.O. Box 15105, Flagstaff, AZ 86005, Etiology and Intervention for USA, Tel: 928-523-9971; Fax: 928-523-9289; Email:

Submitted: 15 February 2015 Common Overuse Syndromes Accepted: 06 April 2015 Published: 07 April 2015 Associated with Mountain Copyright © 2015 Lebec et al. Biking OPEN ACCESS Marin L. Campbell and Michael T. Lebec* Keywords Department of Physical Therapy and Athletic Training, Northern Arizona University, • USA • Overuse • Injuries • Management Abstract Though mountain biking is more often associated with traumatic injuries, athletes who participate in this sport are also at significant risk for developing overuse syndromes. Overuse problems associated with mountain biking are thought to occur due to a combination of repeated, vibratory stresses and the sustained but unnatural positions assumed by participants during long hours of riding over trail-like surfaces. The most commonly reported conditions afflict low back, neck, or knees and are the result of inefficient patterns of motor recruitment as well as environmental factors within the rider’s control. This review describes the mechanisms by which mountain biking- associated overuse conditions are proposed to develop and describes how education and a proper training regimen may help mountain bike riders recover from overuse syndromes or prevent their onset altogether.

ABBREVIATIONS LBP: Low Back Pain; TA: Transversus Abdominis; LM: overtraining. In addition to these factors, a growing of studies have established correlations between specific variables such as improper bike fit, gearing choice, and riding volume with Lumbar Multifidis; PFPS: Patellofemoral Pain Syndrome; ITBS: the onset of overuse injuries. IlliotibialINTRODUCTION Band Syndrome; TFL: Tensor Fascia Lata Although 45 - 90% of mountain bikers experience overuse syndromes [4,11,12], the literature primarily describes Mountain biking has quickly grown from a niche activity into acute mountain biking injuries [13–18]. The most common a popular international sport [1,2]. Fundamental to the practice mountain biking-associated overuse syndromes – low back is the rider’s ability to navigate rocky, steep, or slippery trails recommendationspain (LBP), neck pain,regarding and kneehow to pain best – avoid may beor resolvedmanage these with known as “single-track” [3]. Riding over rough surfaces produces conservative treatment. However, the literature offers minimal vibration and often-unpredictable impacts that are partially dispersed by equipment, with the remainder introduced to body conditions. Therefore, the focus of this review is to summarize tissues through contact points with the bike. Such repetitive with mountain biking, illustrate how common overuse problems to connective tissues. Races, endurance events, and even the existing literature describing overuse injuries associated recreationalforces absorbed mountain by the bike rider’s riding body can can demand result that in micro-trauma a participant alleviating such problems. develop, and provide basic recommendations for preventing or Etiology of LBP in Mountain Bikers spend hours in the saddle, creating an ample portion of “at risk” time on the bike [4–7]. Fatigue may further increase the risk of overuse injury due to loss of motor control and decreased balance, [8] which potentially allow lapses in optimal body proposedThe low mechanisms. back is a Most common research source describing of pain LBP in 24 in mountain - 41% of position. A rider’s training habits can also affect overall fitness mountain bike riders [4,11,12] and occurs via a variety of and contribute to the onset of overuse syndromes. In this way, overtraining can be negatively associated with physical fitness biking populations is theoretical and based on factors unique to [9,10]. The exploratory nature of mountain biking, in which riders ridersoff-road attempt riding. to This maintain includes balance the introduction and negotiate of ground rough reaction terrain. venture forth on trails for multiple hours or even day-long rides, forces and increased demand on trunk muscles that occur while renders these athletes susceptible to the adverse effects of such Cite this article: Campbell ML, Lebec MT (2015) Etiology and Intervention for Common Overuse Syndromes Associated with Mountain Biking. Ann Sports Med Res 2(3): 1022. Lebec et al. (2015) Email: Central

ountain biking population. In addition, much of the literature linking spinal pathology and Often described as the “neutral” or “functional” position, assuming general is relevant to the m this protective posture places the spine in a position of stability and minimizes mechanical stress caused by distal perturbations Fröbose and colleagues propose that a combination of [34].The next step is to perform small and precise movements vibrations and jolts during rough downhill riding as well as of targeted muscles which are then expanded into controlled a relatively static, flexed riding posture stress the spine of contractions performed in a variety of contexts [32]. Because mountain bikers [4]. The literature describing pathology in road of typical recruitment patterns in individuals with LBP, Hodges cyclists affirms the role of the cyclist’s physiologically unnatural, flexed position in causing LBP [19–21]. This is largely due to and Richardson suggest that training programs for this condition anterior loading of vertebral discs and traction forces on dorsal focus on the TA and LM muscles [27,28,35,36]. A common starting point is performance of a “drawing-in” maneuver, in viscostructures elastic which structures are placed which in occurs a position over of time sustained when passive stretch which abdominal muscles such as the TA are recruited by having spinal[22–24]. components Such stresses are placed are thought under an to resultextended in deformationload [25,26]. of the athlete lightly and inwardly contract the muscles of the lower abdomen. This engages stabilizing musculature and thus facilitates the maintenance of ideal pelvic position [37]. BecauseIn the core general muscles population, such as lumbar the transverse pain is often abdominis associated (TA) with and impaired motor control of the deep trunk musculature [22,27,28]. Advancement of this approach includes performing exercise in progressively less-stable positions until the skill is lumbar multifidi (LM) are not preferentially recruited during the shouldintegrated be maintained into activity-specific during riding. movements The literature involving recommends whole pedaling motion in mountain biking, it stands to reason that they body motions [38,39]. Eventually, activation of core muscles may become inhibited due to underuse. During trail riding, the upper and lower extremities are somewhat fixed relative to the alignmentincorporating [29,40–43]. year-round core conditioning into training bike. Therefore, with the body in a posture of trunk flexion, core regimens to promote trunk stability and lower extremity Neck and Upper Back Pain Due to the “Head Up” tissuemusculature increases may [22]. not play its customary role of segmental spinal stabilization and the risk of micro-trauma to spinal connective Position

Finally, some literature proposes that over-activity of spinal Mountain bikers must sustain a position of cervical extension extensors and/or hip flexors may lead to low back pain. In this and simultaneously stabilize the weight of their heads against way, isometric spinal contractions produced due to the sustained pain. This is because prolonged muscle contractions compress perturbing forces while fixing their gaze on the trail ahead. position experienced during long rides may produce ischemic Predictably, neck and upper back pain are common complaints, found in approximately 16% - 43% of mountain bikers [4,12]. capillaries, which in turn decreases blood flow and limits oxygen Several authors have suggested that “trigger points”– local areas delivery to and waste product removal from the area [4,29].This of pain and spasm – in overactive levator scapulae and trapezius idea was supported in a study which found et that al proposed a cycling taskthat [24,29,44,45]. Mellion proposed a “multiple micro-whiplash” induced significant fatigue in the erector spinae muscles [30]. muscles may contribute to symptoms in cyclists’ painful necks With respect to hip flexor activity, Usabiago excess use of the psoas major muscles during pedaling results mechanism among road cyclists due to prolonged vibratory forces during endurance efforts that results in connective vertebraein intermittent [31]. rotary forces on the spine due to their laterally positioned attachments on the transverse processes of lumbar tissue injury and the formation of cervical trigger points. It Management of Mountain Biking-Associated LBP: follows that larger and often unpredictable ground reaction Effective Recruitment of Spinal Stabilizers forces experienced during off- may result in similar sequelae [29]. Furthermore, because cyclists’ neck extensors are continually recruited, the levator scapulae and upper trapezius attempt to compensate and can become overworked if they are groupsThe toliterature improve is clearneuromuscular that exercise control is effective and coordination in reducing LBP. Most authors recommend the training of “core” muscle not supported by larger and more powerful muscles in the upper LBP [32]. This approach helps limit imbalances that occur back. Hyperactivity in these muscles, therefore, is most likely of trunk musculature which are inhibited in the presence of when there is corresponding weakness or fatigue of the middle [46,47].and lower trapezius and deep cervical flexors, demonstrating a when athletes perform their sport in asymmetrical positions, a compensatory strategy that may lead to dysfunction and pain situation that encourages over-activity and decreased flexibility Another consideration is the biomechanics associated with in certain muscle groups and inactivity in others [33]. The flexed position associated with mountain biking, for example, may the on-bike position of prolonged cervical extension, scapular promote repetitive contractions and functional shortening of the over-lengthened posterior shoulder and thoracic muscles and protraction, and thoracic flexion. This posture can result in hip flexors as well as inhibition of abdominal activity. musculatureTherefore, within training an ideal programs spinal forposture. improving This involves motor controlhaving pectoralmay place muscles the anterior can become cervical shortened, musculature [49] contributing at a mechanical to the of the spine should emphasize recruitment of stabilizing disadvantage [48].Simultaneously, anterior tissues like the the participant identify the most asymptomatic position of the excessive kyphosis and rounded shoulders sometimes seen in spine in which to initiate training and functional movements. cyclists. Ann Sports Med Res 2(3): 1022 (2015) 2/5 Lebec et al. (2015) Email: Central

Minimizing Neck Pain for Mountain Bikers ociated with suboptimal alignment in athletes’ Similarly, a lack of proximal strength surrounding the hip joint has been ass Goals during rehabilitation of cervical problems should groups such as scapular retractors and depressors (i.e., middle knees [61]. Because mountain bikers primarily utilize muscles include regaining neuromuscular control of inhibited muscle which function in the sagittal plane, muscles of the lateral hip that provide frontal plane stability may become under-developed and lower fibers of the trapezius), and deep neck flexors [46,50– unless they are specifically targeted for strengthening and 53].In the short term, stretching as well as manual therapy – endurance. Friction at the patella or ITB may also be exacerbated as would be performed by a licensed health care practitioner – have been found to decrease neck pain [54]. Stretching is vastusby increased lateralis. tension This, in however, the muscles is still inserting thought into to this be relatedstructure, to recommended to facilitate lengthening of functionally-shortened including the tensor fascia lata (TFL), gluteus maximus, and stretchinganterior tissue combined and is commonly with trigger focused point on compression the pectoral, has scalene, been upper trapezius, and levator scapulae muscles [51,55]. Manual overloading of the TFL and subsequent increased tension on the ITB due to lack of strength in the primary hip abductors [59]. have also been correlated with knee pain in mountain bikers shown to reduce pain in the upper trapezius [56]. Published External factors such as choice of gearing ratio and bike fit Clinical Practice Guidelines for neck pain also recommend joint spine in addition to improving strength, coordination, and undue stress on patellar structures,[57,62] mountain bikers mobilization and/or manipulation of the cervical and thoracic [3,4,11]. Because pedaling in a higher-than-necessary gear places endurance in the affected muscles [55].Self-stretching, self- Lebec et al. reported that riders alternating between multiple- gearedmust be and efficient single-geared in shifting mountain through the bike optimal riding gear reported options. a [48].massage, and relaxation training can also be effective techniques for soft tissue lengthening and relaxation, and are easily taught Subtle Changes in Alignment and Biomechanics May Lead to Knee Pain significantly higher incidence of knee pain than those riding only multiple-geared bikes. This study suggests a possible linkage tobetween be associated excessive with gear inappropriate choice and mountain overuse injurybike seat [12]. settings With respect to bike fit, multiple authors have found PFPS and ITBS Knee pain most frequently occurs at the anterior and/or lateral aspect of the knee and has been reported in 20 -27% of mountain [3,4]. An improperly adjusted saddle or pedal cleat position have bikers [4,11,12]. Anterior knee pain, known as patellofemoral both been correlated to unwanted forces because these affect pain syndrome (PFPS), occurs due to excessive shearing forces on the underside of the patella in the trochlear groove of the the location of the cyclist’s knee between two fixed points and femur, and can result in pathological changes to the cartilage in may lead to misalignment and micro-trauma over the course of this area [4,24,57]. Cyclists prone to this condition experience kneethousands into excess of pedal internal revolutions rotation [3,58].Additionally,[4,24,57,58,63]. Tension improperly on the symptoms during uphill climbs, while using high gears, and/or adjusted cleats can produce stress on knee tissues by forcing the while pedaling at low cadences [3,57]. Lateral knee pain is often associated with a condition known as Iliotibial Band Syndrome ITB and subsequent irritation of the lateral knee can result from (ITBS) and is common among athletes such as mountain bikers, an excessively high or posteriorly situated seat or positioning who engage in repetitive knee flexion and extension.[20,58]It has thatLimiting causes Kneeover-pronation Pain on of the the Trail:foot [57] Optimal Alignment been proposed that pain and inflammation at the distal iliotibial and Proximal Control band (ITB) insertion occurs when the posterior fibers of this tract repetitively slide over the lateral femur in an “impingement zone” of approximately 20 to 30 degrees of flexion [58,59]. To minimize knee pain, regardless of its location, knee structures must be properly aligned and excess joint forces Factors that disturb the optimal alignment of the knee during training core musculature [40]. Recent studies involving athletes should be reduced. Alignment can be further maximized by cycling predispose mountain bikers to the above conditions. One factor affecting alignment is the strength of proximal have supported the strengthening of proximal hip musculature as musculature and its effect on biomechanical positioning of the a means of controlling alignment and reducing knee pain [64–66]. hip, knee, ankle, and foot [57,60]. As described in the previous Pinpointing a single source of pain in the knee can be difficult due section outlining etiologies for LBP in cyclists, lower extremity trunk musculature such as the TA and LM [27,36,40,42].Trunk to the interaction of a variety of internal and external factors that movements are preceded and thus stabilized by contractions of must all be investigated to determine the best course of treatment. the lower extremities as the core becomes less able to provide a Internal biomechanical factors may include anatomical variants weakness or fatigue can therefore result in altered kinematics in such as leg length discrepancies, degree of foot pronation, and stable platform from which the leg muscles may work. Research anatomical rotation at the hip or lower leg. External influences demonstrates that core muscle fatigue plays a prominent role in include training variables, gearing and cadence choices, bike fit, altering lower extremity joint mechanics in cyclists [40]. Mountain and type of terrain ridden. Cleat rotation is especially important biking conditions, such as highly technical trail sections, may haveto assess been when implicated seeking in the mountain source ofbikers lateral with knee knee pain pain, [59,62,67]. [3,4,20] demand heightened balance, agility, and stability and require Because uphill pedaling, low cadence, and heavy training load additional recruitment of core musculature. Over time, these fatigued trunk muscles may result in inadequate lower extremity these are behavioral factors that should be adjusted early in the biomechanics as the stability of the pedaling platform diminishes. rehabilitation process to minimize stress to the knee. Ann Sports Med Res 2(3): 1022 (2015) 3/5 Lebec et al. (2015) Email: Central

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Cite this article Campbell ML, Lebec MT (2015) Etiology and Intervention for Common Overuse Syndromes Associated with Mountain Biking. Ann Sports Med Res 2(3): 1022.

Ann Sports Med Res 2(3): 1022 (2015) 5/5