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cycle injury

Cycle Injury overview

Sean Fyfe highlights the importance of bike set-up in avoiding cycling injuries.

In 2003 I was lucky enough to have the opportunity to venture into the Pyrenees mountain range in the south of France to witness the penultimate mountain stage of the Tour de France. It was one of the greatest stages in recent years, when Lance Armstrong fell off his bike in the final ascent only to remount, attack and put the winning time on Jan Ullrich to clinch his fifth consecutive tour victory. I had watched the tour on TV before, but it wasn’t until I was on the mountain that I could grasp the passion and fanaticism surrounding the sport of cycling. Injury to any cyclist with even the smallest amount of the commitment I saw on the mountain that memorable day would be devastating.

Fortunately, in the sports injury world cycling is more often a benign force than a cause of trouble. Because it is low impact, it provides many people who otherwise would struggle to perform regular exercise with the chance to stay healthy and active. Among recreational and competitive cyclists, compared to high impact sports such as road running, the rate of injury is favourable and injuries are often easier to prevent and address.

Nevertheless, clinicians should have a clear appreciation of the sport’s biomechanics and in particular how bike set-up relates to injury. It can often be something as simple as a small change in bike or shoe set-up that is the direct cause of an injury, so unless this is accounted for during assessment and management, the injury will never be properly resolved.

Acute cycle injury

Because cycling is such a widespread leisure activity (and bicycle ownership almost endemic), injury statistics are not hugely informative. US figures, for instance, estimate that 85 million Americans are cyclists; and of these 540,000 end up in hospital accident and emergency departments each year. Among the casualties, 67,000 have head injuries and 600 die (1).

For any competitive cyclist, to train on the road is to accept the risk of serious injury, because of the twin hazards of vehicle traffic and speed. A multitude of orthopaedic injuries occur with high-speed accidents, but of most concern are head injuries. As a result of fatal injuries during competitive cycling, the compulsory use of helmets has been in place for a number of years at the Tour de France, except for the finishing climb in the mountain stages. In Australia, all cyclists (from everyday users to pro competitors) are required to wear helmets or face hefty fines. Throughout Europe, by contrast, there is no such compulsion. Despite legislation and campaigns promoting awareness of cyclists to other road users, acute injuries in cycling will always be a big concern for those participating in the on-road sport.

Chronic injury

Several studies highlight the neck and back as the main sources of overuse injuries. After a six- to eight-day cycling tour for recreational cyclists, Wilber et al reported that 54.9% of females and 44.2% of males presented with neck pain for medical treatment, and 30% of both males and females with back pain (2). Patterson et al (3) analysed ulnar and median nerve palsy – often referred to as ‘cyclist’s palsy’ – after a 600km bicycle ride. Of the 25 riders given physical and questionnaire assessments, 23 had either motor or sensory symptoms. Most symptoms were reported in the hands in the ulnar nerve distribution.

Wilber et al (2) found 85% of cyclists suffering with one or more overuse injuries: 48.8% had neck problems, 41.7% had knee trouble, 36.1% groin and buttocks, 31.1% hands and 30.3% backs. The study also found that female cyclists are approximately 1.5 times more likely than males to develop neck symptoms. Although neck symptoms are the most common, in my experience knee injuries are of more concern, as they pose a greater long-term risk.


A single pedal cycle involves a power phase from 12 o’clock to 6 o’clock and a recovery phase from 6 o’clock to 12 o’clock. The power phase delivers most of the force that generates forward momentum. This force is produced via the extensors of the lower limb chain: quadriceps, glut max, hamstrings (working at the hip) and calves (working at the ankle). The recovery phase also contributes to overall power delivered in one cycle by the upward pull of the attached shoes via the flexors: hip flexors, hamstrings (working at the knee) and calves (working at the knee).

At 12 o’clock, the knee is flexed to 110 degrees and then extends 75 degrees through the power phase to 35 degrees flexion at the beginning of the recovery phase. It is important to note that during the power phase the knee will drift medially because of the normal valgus orientation of the femoral condyles (more pronounced in females).

The foot pronates during the power phase, imparting an internally rotating force to the knee, much the same as during the stance phase of running, thereby increasing the stress to the inner side of the knee. The opposite happens during the recovery phase in preparation for another power phase. At the bottom of the power phase the foot should be parallel to the ground. The lumbar and thoracic spine have to tolerate prolonged flexion and the cervical spine prolonged extension.

Assessment of chronic injury

When a cyclist presents with an overuse injury, the clinician needs to gain an understanding of the following areas to determine the underlying cause:

  • the athlete’s anatomical alignment
  • musculoskeletal function
  • bike set-up
  • training history and changes in regime.

It is imperative that the athlete’s bike is correctly adjusted to suit their specific anatomical alignment, in order to achieve bike-body harmony. Static measurements are useful of:

  • left and right leg length
  • Q angle (alignment of the shaft of the femur with the tibia)
  • foot position relative to the tibia (degree of external or internal rotation)
  • foot alignment (including heel position relative to the tibia, forefoot position relative to the heel and big toe position).

For each injury, the therapist should be aware of the relevant flexibility and muscle balances in order to establish technique faults contributing to injury (for instance, the cyclist may be medially deviating with the left knee or the pelvis may be dropping to the right when the right foot reaches 6 o’clock).

Bike set-up

Correct bike set-up is crucial both to maximise performance and to avoid injuries. But very few recreational cyclists are aware of this. If you venture on to the roads on a Sunday morning, you will see droves of cyclists with their seats set too high or their knees grossly deviating left and right.

Table 1 below sets out the key positions that the clinician should ensure their client is achieving in the set-up of their bike.

Table 1: Features of bike set-up
Key position Where to adjust
At 3 o’clock the anterior aspect of the patella should line up with the centre of the pedal axle
  • Saddle position: move the saddle forward or back
  • Adjust seat height
  • Cleat position: adjust forward or backward on the shoe
At 3 o’clock, the centre of the patella should be directly in line with the centre of the pedal when looking from the front
  • Cleat position: the cleat can be rotated depending on the rotational position of the foot relative to the tibia
  • Forefoot support: a forefoot varus will produce increased medial translation of the knee
At 6 o’clock, the knee should be flexed to 30-35 degrees
  • Adjust seat height
i. Length between seat and handlebars
ii. Height of handlebars

Both settings should allow a comfortable position through the upper trunk, relaxed position on the saddle and be as aerodynamic as possible
  • Frame: length of top tube (from seat pole to headset) must be correct at purchase of bike
  • Stem (connecting the frame and handlebars): adjust length and angle to vary height of handlebars

(The cleat is a plastic piece screwed into the bottom of the shoe to enable the rider to clip into the pedal.)

Bike set-up can be assisted greatly by two small pieces of equipment: full shoe-length leg raises compensate for leg-length discrepancies, and forefoot varus wedges placed between the cleat and shoe correct knee alignment by allowing the foot to operate in its normal position. Specific cycling orthotics are also commonly used.

The cyclist also needs to be made aware that they should adjust their bike set-up to suit variables such as the length of race or competitive goal in order to achieve the best balance of efficiency and comfort. In endurance races, the rider will usually opt for a slightly less aerodynamic position to improve comfort, whereas for a short time trial, the tightest possible aerodynamic position and lowest trunk position will deliver maximum speed advantage.

Chronic injury risks


When pedalling, the largest force produced acts through the knee up to 5,000 times an hour, so it is no wonder that the slightest incorrect distribution in load can end up in a serious knee injury. Table 2 below summarises the main injury risks.

Table 2: Cycling injury risks to the knee
Area of knee Injury Special notes
Front Patellofemoral pain syndrome (anterior knee pain, variety of causations)

  • Excessive medial drift of the knee during the power phase (very common)
  • Weak VMO (vastus medialis) and lateral knee structures
  • Seat set too low, can increase compression through the joint
  • Can involve medial or lateral retinaculum (kneecap ligaments)

  • (all anterior knee pain can relate to the first two points)
Chondromalacia (damage to articular cartilage under the kneecap)
  • A progression of above involving breakdown of the cartilage
Patellar tendinosis (inflamed patella tendon)
  • Excessive lateral traction of the kneecap
Quadriceps tendinosis (inflamed quadriceps tendon)
  • Not very common but tends to affect the lateral aspect of the tendon
Outside edge Iliotibial band (ITB) friction syndrome

  • Excessive pressure on the ITB as it passes over the lateral femoral condyle
  • Can relate to incorrect bike set-up that increases the stretch on the ITB: saddle too high or too far back
  • Leg length discrepancy: increased stretch on ITB in the shorter leg
  • Excessive tibial internal rotation which increases the pressure between the femoral condyle and the ITB. Can be anatomical or related to positioning of the cleat
Inside edge Pes anserinus bursitis (inflamed bursa at hamstring tendinous insertion)
  • Excessive traction of the tendon over the bursa
  • Externally rotated tibial position, anatomical or related to cleat position
Mediopatellar plica syndrome (inflamed thickened knee capsular fold)
  • Not very common, but can impinge on the femoral condyle during knee flexion
Back Biceps femoris tendinosis (inflamed hamstring tendon insertion)
  • Saddle too high or too far back increases stretch on hamstrings
  • Excessive tibial internal rotation increases stretch on hamstrings

Ongoing soft tissue massage, trigger point work and stretching for iliopsoas, TFL, vastus lateralis, ITB and gluteus muscles are all very important, as is maintaining patellofemoral joint mobility. Activation and strengthening of VMO and glut max should be included where necessary.

Neck and back

Neck pain usually relates to the prolonged time that cyclists spend in an extended position. Constant compression of any joint over a long period can lead to the transmission of noxious stimuli; muscle fatigue and trigger points will lead to further joint compression and chronic muscle pain. Any prolonged position will also result in cumulative tensile stress on joint capsules and ligaments, which can bring both pain and long-term structural changes to joint arthrokinematics.

Cervical extension with shoulders in a depressed position increases neural tension, which can be exacerbated by handlebars set too low or the cyclist failing to keep their elbows slightly bent. Excessive or prolonged traction to the nerves can result in ulnar or median neuropathy. This will present as pain, numbness or tingling in the nerve distribution.

To prevent the build-up of tension, the cyclist must learn to do regular cervical flexion movements, lateral flexion and shoulder shrugs on the bike, as well as sitting upright from time to time. Treatment should focus on ensuring adequate thoracic spine mobility, first rib mobility and flexibility in scalene, levator scapulae, rhomboids and upper trapezius muscles. In recalcitrant cases, surgery may be needed to widen the nerve space.

Lower back injuries are very similar in principle to neck pain in cycling, except that the aggravating position is prolonged flexion. Muscle fatigue, chronic tension to posterior vertebral ligaments and prolonged compression to intervertebral discs can all be responsible for ongoing backache. Clinicians need to evaluate gluts, psoas and lumbar extensors for tone and flexibility. It is imperative that cyclists have an adequate range of lumbar spine and hip flexion.

The cyclist’s pelvic position during riding is also significant. Sitting in a posteriorly tilted position increases lumbar flexion, so many clinicians look to achieve a more anterior position through the pelvis. This should be addressed when assessing bike set-up and cycling technique.

As cyclists build up their training volume, they often suffer from aches in the cervical, thoracic or lumbar spine, because of the lengthy periods for which they maintain their flexed trunk position. This is normally a matter of building up their tolerance, during which time the therapist should ensure that any joint stiffness or muscle tightness is attended to. For any cyclists intending to build up to a high weekly mileage, the training should be gradual and structured.

As with all postural problems, whether on a bike or not, core stability function is crucial. Regular exercises focusing on muscle endurance should be an integral part of treatment and prevention. Postural exercises for scapular retractors, and especially lower trapezius activation, are essential to minimise neck problems. The lumbopelvic stability muscles not only have to tolerate prolonged flexion but also to continually stabilise the lumbar spine and pelvis to provide a stable platform for the major force- producing muscles. Core stability exercises for the lumbopelvic area are therefore crucial in the treatment and prevention of lumbar spine pain, especially for any cyclists increasing training volume.

Good hip flexibility also matters greatly, to relieve pressure on the knee and lumbar spine. The hip during cycling always remains in a relatively flexed position, so chronic tightness through TFL/ITB, iliopsoas and adductors is very common. This can also lead to hip and groin problems such as greater trochanter bursitis or hip tendinopathies. All cyclists should perform regular stretches and do trigger point work on these areas. Gluteal and hamstring range also needs to be maintained to be able to sit comfortably in lumbar flexion and to avoid falling too far into posterior tilt. Although a relatively high incidence of hip and groin pain is recorded, my own experience is that, as with many sports, much of this is related to the lumbar spine and pelvis.

Cyclists are also at risk of urogenital problems, such as erectile dysfunction and infertility, mainly affecting those who put in large training volumes. Pudendal neuropathy is the most common presentation, caused by compression of the pudendal nerve against the pubic bone. Statistics range from 50% to 91% of cyclists reporting symptoms (4). A change of saddle to one with an increased width or padding, altering the tilt of saddle and using increased padding in the rider’s cycling shorts may all help to relieve the pressure.

Sean Fyfe is a physiotherapist, tennis coach and director of TFP (Tennis Fitness Physio), a Queensland based company specialising in sports medicine, elite tennis player development, strength and conditioning and childhood motor learning programmes


  1. – bicycle helmet statistics
  2. Wilber CA, Holland GJ, Madison RE, Loy SF, ‘An epidemiological analysis of overuse injuries among recreational cyclists’ Int J Sports Med 1995 Apr;16(3):201-6
  3. Patterson JM, Jaggars MM, Boyer MI ‘Ulnar and Median nerve palsy in long-distance cyclists. A prospective study’ Am J of Sports Med 2003 Jul-Aug; 31(4):585-9
  4. Leibovitch I, Mor Y ‘The vicious cycling: bicycling related urogenital disorders’ Eur Urol 2005 Mar;47(3):277-86

cycle injury