Incidence and risk for traumatic and overuse injuries in top-level road cyclists

Bicycle Set-Up Dimensions and Cycling Kinematics: A Consensus Statement Using Delphi Methodology

Bicycle set-up dimensions and cycling kinematic data are important components of bicycle fitting and cyclist testing protocols. However, there are no guidelines on how bicycles should be measured and how kinematic data should be collected to increase the reliability of outcomes. This article proposes a consensus regarding bicycle set-up dimensions and recommendations for collecting cycling-related kinematic data. Four core members recruited panellists, prepared the document to review in each round for panellists, analysed the scores and comments of the expert panellists, reported the decisions and communicated with panellists. Fourteen experts with experience in research involving cycling kinematics and/or bicycle fitting agreed to participate as panellists. An initial list of 17 statements was proposed, rated using a five-point Likert scale and commented on by panellists in three rounds of anonymous surveys following a Delphi procedure. The consensus was agreed upon when more than 80% of the panellists scored the statement with values of 4 and 5 (moderately and strongly agree) with an interquartile range of less than or equal to 1. A consensus was achieved for eight statements addressing bicycle set-up dimensions (e.g. saddle height, saddle setback, etc.) and nine statements for cycling kinematic assessment (e.g. kinematic method, two-dimensional methodology, etc.). This consensus statement provides a list of recommendations about how bicycle set-up dimensions should be measured and the best practices for collecting cycling kinematic data. These recommendations should improve the transparency, reproducibility, standardisation and interpretation of bicycle measurements and cycling kinematic data for researchers, bicycle fitters and cycling related practitioners.

Hyperthermia and Exertional Heatstroke During Running, Cycling, Open Water Swimming, and Triathlon Events

Few previous epidemiological studies, sports medicine position statements, and expert panel consensus reports have evaluated the similarities and differences of hyperthermia and exertional heatstroke (EHS) during endurance running, cycling, open water swimming, and triathlon competitions. Accordingly, we conducted manual online searches of the PubMed and Google Scholar databases using pre-defined inclusion criteria. The initial manual screenings of 1192 article titles and abstracts, and subsequent reviews of full-length pdf versions identified 80 articles that were acceptable for inclusion. These articles indicated that event medical teams recognized hyperthermia and EHS in the majority of running and triathlon field studies (range, 58.8 to 85.7%), whereas few reports of hyperthermia and EHS appeared in cycling and open water swimming field studies (range, 0 to 20%). Sports medicine position statements and consensus reports also exhibited these event-specific differences. Thus, we proposed mechanisms that involved physiological effector responses (sweating, increased skin blood flow) and biophysical heat transfer to the environment (evaporation, convection, radiation, and conduction). We anticipate that the above information will help race directors to distribute pre-race safety advice to athletes and will assist medical directors to better allocate medical resources (eg, staff number and skill sets, medical equipment) and optimize the management of hyperthermia and EHS.

Muscle Tone, Stiffness, and Elasticity in Elite Female Cyclists after Consecutive Short Competitions

Background

For professional road cyclists, most overload injuries affect the lower limbs. They are mostly represented by contractures or muscle shortening, characterised by a variation of muscular tone, stiffness, and elasticity. This real-life study aimed to assess specific mechanical parameters in top-class female cyclists who participated in 3 races a week. Hypothesis. Muscle tone, stiffness, and elasticity will be affected immediately after competition and at the end of the week due to accumulated fatigue.

Methods

Six professional cyclists were evaluated. This pilot study consisted of a controlled trial and three days of competition, with rest days between them. MyotonPRO was used to measure tone, stiffness, and elasticity in six leg muscles: vastus lateralis (VL), vastus medialis (VM), rectus femoris (RF), biceps femoris (BF), lateral gastrocnemius (LG), and medial gastrocnemius (MG). Daily basal and pre- and postrace measures were carried through to the 3 races in a week.

Results

The muscular tone of VL, VM, LG, and MG and the stiffness of VL, VM, RF, BF, LG, and MG decreased after races. VL and RF were mostly affected by (p=0.05) and (p=0.009), respectively. Basal elasticity improved over time until the last day.

Conclusions

Muscle tone and stiffness decreased after a very intense and exhausting cycling endurance competition. Basal elasticity improved immediately after the race and continued this trend until the end of the week. More research is needed on changes in mechanical properties in competition and risk prevention of injuries.

Clinical characteristics of gradual onset injuries in recreational road cyclists - SAFER XXVII study over 5 years in 62758 race entrants

OBJECTIVE

Gradual onset injuries (GOIs) in recreational cyclists are common but not well described. The aim of this study is to describe the clinical characteristics of GOIs (main anatomical regions, specific anatomical sites, specific GOIs, tissue type, severity of GOIs, and treatment modalities) of GOIs among entrants participating in a community-based mass participation-cycling event over 5 years.

METHODS

During the 2016-2020 Cape Town Cycle Tour, 62,758 consenting race entrants completed an online pre-race medical screening questionnaire. 1879 reported GOIs in the previous 12 months. In this descriptive epidemiological study, we report frequency (% entrants) of GOIs by anatomical region/sites, specific GOI, tissue type, GOI severity, and treatment modalities used.

RESULTS

The main anatomical regions affected by GOIs were lower limb (47.4%), upper limb (20.1%), hip/groin/pelvis (10.0%), and lower back (7.8%). Specifically, GOI were common in the knee (32.1%), shoulder (10.6%), lower back (7.8%) and the hip/buttock muscles (5.2%). The most common specific GOI was anterior knee pain (17.2%). 57.0% of GOIs were in soft tissue. Almost half (43.9%) of cyclists with a GOI reported symptom duration >12 months, and 40.3% of GOIs were severe enough to reduce/prevent cycling. Main treatment modalities used for GOIs were rest (45.9%), physiotherapy (43.0%), stretches (33.2%), and strength exercises (33.1%).

CONCLUSION

In recreational cyclists, >50% of GOIs affect the knees, shoulders, hip/buttock muscles and lower back, and 40% are severe enough to reduce/prevent cycling. Almost 45% of cyclists with GOIs in the lower back; or hip/groin/pelvis; or lower limbs; or upper limb reported a symptom duration of >12 months. Risk factors associated with GOIs need to be determined and preventative programs for GOIs need to be designed, implemented, and evaluated.

Injuries in elite road cyclists during competition in one UCI WorldTour season: a prospective epidemiological study of incidence and injury burden

METHODS

Fifty-four male athletes from two different teams were involved. Accidents and injuries were recorded immediately after the incident by a team physician present at every race. Exposure, location, type and cause of injury have been recorded. Incidence was calculated. Severity was measured as a cumulative severity score and burden depicted in a risk matrix.

RESULTS

Total time of exposure was 12537 hours over 3524 athlete days and 544002 kilometers of racing. 98 accidents were recorded, with 83 leading to injury. The total number of recorded injuries was 193. Injury incidence for all injuries was 54,8 (±SD 47,7-62,8) /1000 athlete days, 15,4 (±SD 13,4-17,7) /1000 athlete hours and 35,5 (±SD 30,8-40,8) /100.000 km raced. By far the most frequent types of injury were hematomas, contusions and bruising (n = 141, 73%) followed by lacerations (n = 22; 11,4%). Most injuries affected the arm and elbow (n = 34, 17,6%) followed by the shoulder and clavicle (n = 28, 14,5%) and occurred with contact (79%). Fractures pose a high injury burden due to long time loss, whereas hematomas, contusions and bruising showed the highest incidence numbers but comparably less time loss.

CONCLUSION

Road cyclists' injuries have been underestimated in previous studies. Hematomas, contusions and bruising pose the highest number of injuries with a broad degree of severity and range of injury burden. Fractures are less common but show the highest injury burden. The upper extremities are involved the most.

Effects of cycling on the morphology and spinal posture in professional and recreational cyclists: a systematic review

The aim was to know if cycling affects spinal morphology in postures off the bicycle, such as adapting the spinal curvatures on the bicycle depending on the handlebar type and position on the handlebars. A systematic review was conducted following the PRISMA guidelines. The studies selected met the following criteria: a) the study design was cross-sectional or longitudinal (experimental or cohorts); b) the study evaluated the sagittal morphology of the spine on the bicycle; c) the study included healthy and trained participants without injuries or cyclists reporting low back pain. Fifteen studies reported that a greater pelvic tilt was observed that when the handlebar was in a lower position. Sixteen studies found that lumbar kyphosis was greater when the handlebar grip was lower and farther from the saddle. Twelve studies reported that a tendency towards greater thoracic flexion as the time spent pedalling on the bicycle increased. In conclusion, the practice of cycling produces adaptations in the morphology of the spine of the cyclist compared to non-cyclists, such as an increase in pelvic tilt and a greater capacity for lumbar flexion in trunk flexion positions, and a greater thoracic kyphosis in the standing position.

Overuse-Related Injuries of the Knee

Overuse-related injuries of the knee joint and periarticular soft tissues include a heterogenous group of sports and nonsports-related injuries. These conditions include friction and impingement syndromes, bone stress injuries, bursitis, and tendon-related pathology such as tendinopathy and snapping. Traction apophysitis are also discussed as commonly seen in the pediatric population. Although multiple imaging modalities can be used, this review focuses on MR imaging, which is the most common and, often, the only modality used.

The relationship between pedal force application technique and the ability to perform supramaximal pedaling cadences

This study aimed to examine the relationship between the pedal force application technique under a specific competitive condition and the ability to perform steady-state pedaling at a supramaximal cadence during a special pedaling test. A total of 15 competitive male cyclists and 13 active, healthy men (novice cyclists, hereafter, novices) performed the pedaling technique test. The test imitated a road cycling competition condition (80% VO2 peak and a cadence of 90 rpm). Additionally, they performed a supramaximal cadence test that evaluated the ability to perform steady-state pedaling for an ultra-high cadence (range of 160–220 rpm) of 30 s stably with a 0.1 kgf. For the pedaling technique test, kinetic data were obtained by the pedal-shaped force platform at 1,000 Hz, and the pedaling technique was determined by the index of force effectiveness (IFE). For the supramaximal cadence test, kinematic data were obtained using a motion capture system at 200 Hz. The supramaximal pedaling cadence (C_max) was determined by measuring exercise time and targeted pedaling cadence. The IFE was 48.0 ± 9.7% in cyclists and 32.0 ± 5.9% in novices. The C_max was 215.5 ± 8.8 rpm in cyclists and 192.2 ± 13.0 rpm in novices. These values were significantly higher for cyclists than for novices. C_max was moderately correlated with IFE (r = 0.64). No significant correlation was observed between C_max and IFE for cyclists only; in contrast, a moderate correlation was observed between these parameters for novices only (r = 0.67). In conclusion, the pedal force application technique under a specific competitive condition is related to the ability to perform steady-state pedaling for supramaximal cadence during the test. Therefore, C_max may be able to explain pedal force application techniques without the need for expensive devices for novices.

A descriptive and comparative analysis of injuries reported in USA Cycling-sanctioned competitive road cycling events

Background

Competition in road cycling events is common, yet little is known about the nature and disposition of injuries sustained in these events. The purpose of this study is to describe injured body regions and the disposition of injuries sustained by cyclists during competitive road cycling events.

Methods

Data regarding body region injured and injury disposition were retrospectively analyzed from a convenience sample of 1053 injury reports (male: n = 650 [61.7%], age = 33.4 ± 13.6 years; female: n = 116 [11.0%], age = 33.3 ± 13.9 years; missing: n = 284 [27.0%]) completed during the 2016 competitive season.

Results

A total of 1808 injuries were reported. Injured body regions included upper extremity (46.5%, n = 841), lower extremity (32.2%, n = 583), head/neck (10.4%, n = 189), torso/back (5.2%, n = 95), face (4%, n = 87), and internal/other (0.7%, n = 13). There were 1.37 ± 0.81 injuries recorded per report. Dispositions following injury were medical attention (34.1%, n = 316), ambulance/EMS (19.3%, n = 179), report only (15% n = 139), referred (13.0% n = 121), released to parent/personal vehicle (12.1% n = 112), refused care (4.1% n = 38), and continued riding (2.5% n = 23). Males (34.0%, n = 212) received medical attention more frequently than females (23.3%), p < 0.05. Females received EMS transport (29.1%, n = 30) more frequently than males (16.8%, n = 105), p < 0.05.

Conclusions

Upper extremity is the most injured body region in this data set. Following injury, racers often receive medical attention and a substantial percentage require transport by EMS.

Clinical relevance

Anticipating the nature of injuries sustained by cyclists may promote positive health outcomes by ensuring medical teams are prepared for the immediate medical needs of cyclists.

[Features of damage to the body parts in bicycle riders when falling from moving bicycles]

The study objective is to analyze the results of forensic medical examination (FME) of fatal cases of falling off a bicycle (9 cases) and a similar non-fatal injury (18 cases). All cases were males aged 8 to 74 years. Of the 27 cases, 6 were children aged 8-17 years. Head and chest injuries were the most common. The nature and localization of these injuries, along with strip-like, linear and parallel abrasions on the skin of the anterolateral surface of the body, indicated that they were a result of collisions and slips of the victim's body on the road surface. A few cases of penetrating injury of the abdomen with internal organs damage were observed; they were related to the impact of the handlebars and were the most characteristic of this type of injury. The data presented may help distinguish the fall of bicycle riders from other types of accidents, in particular from collisions between moving vehicles and pedestrians. The nature of the identified injuries can be considered when providing medical care to the victims.

Lumbar Spine and Lower Extremity Overuse Injuries

Both lower extremities and lower back are common sources of injury for cyclists. For providers to optimize care within this area of sports medicine, they need to understand the most common sources of injury in this population. Cycling presents a unique challenge: treating both the athlete and the complex relationship between rider and bicycle. Physicians should not replace the role of a professional bike fitter and should view these individuals as integral members of the team to alleviate current and prevent future injury. This article explores common lower extremity and lumbar back overuse injuries in cyclists and their medical management.

Fear, Anxiety, and Return to Sport After Cycling Crashes: A Survey of Cyclists

After cycling crashes, orthopedic and neurologic complaints are often the focus of evaluation and management. However, the trauma sustained may not be limited to physical injury; psychological issues brought on by or comorbid with the crash also warrant treatment. In this original research, we evaluated the presence of fear or anxiety after cycling crashes and examined factors associated with this mechanism of injury through a survey. Post-crash fear or anxiety was associated with female gender, a history of depression, and greater crash severity. Few cyclists received treatment and most returned to cycling at their previous level, but the timeline varied.

Methods to determine saddle height in cycling and implications of changes in saddle height in performance and injury risk: A systematic review

The objective of this systematic review was to assess the methods to determine bicycle saddle height and the effects of saddle height on cycling performance and injury risk outcomes. The key motivator of this review was to update and expand the finding reported by a previous narrative review published in 2011. The literature search included all documents from the following databases: Medline, Scopus, CINAHL, OVID and Google Scholar. Studies were screened against the Appraisal tool for Cross-sectional Studies to assess methodological quality and risk of bias. After screening the initial 29,398 articles identified, full-text screening was performed on 66 studies with 41 of these included in the systematic review. Strong evidence suggests that saddle height should be configured using dynamic measurements of the knee angle, and limb kinematics is influenced by changes in saddle height. However, moderate evidence suggests that changes in saddle height less than 4% of the leg length results in trivial to small changes in lower limb loads, and no effect on oxygen uptake and efficiency. It is also possible to state that there is limited evidence on the effects from changes in saddle height on supramaximal cycling performance or injury risk.

Various Workload Models and the Preseason Are Associated With Injuries in Professional Female Cyclists

PURPOSE

To determine if workload and seasonal periods (preseason vs in season) are associated with the incidence of injuries and illnesses in female professional cyclists.

METHODS

Session rating of perceived exertion was used to quantify internal workload and was collected from 15 professional female cyclists, from 33 athlete seasons. One week (acute) workload, 4 weeks (chronic) workload, and 3 acute:chronic workload models were analyzed. Two workload models are based on moving averages of the ratios, the acute:chronic workload ratio (ACWR), and the ACWR uncoupled (ACWRuncoup). The difference between both is the chronic load; in ACWR, the acute load is part of the chronic load, and in ACWRuncoup, the acute and chronic load are uncoupled. The third workload model is based on exponentially weighted moving averages of the ratios. In addition, the athlete season is divided into the preseason and in season.

RESULTS

Generalized estimating equations analysis was used to assess the associations between the workload ratios and the occurrence of injuries and illnesses. High values of acute workload (P = .048), ACWR (P = .02), ACWRuncoup (P = .02), exponentially weighted moving averages of the ratios (P = .01), and the in season (P = .0001) are significantly associated with the occurrence of injury. No significant associations were found between the workload models, the seasonal periods, and the occurrence of illnesses.

CONCLUSIONS

These findings suggest the importance of monitoring workload and workload ratios in female professional cyclists to lower the risk of injuries and therefore improve their performances. Furthermore, these results indicate that, in the preseason, additional stressors occur, which could lead to an increased risk of injuries.

Methods for epidemiological studies in competitive cycling: an extension of the IOC consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sport 2020

In 2020, the IOC released a consensus statement that provides overall guidelines for the recording and reporting of epidemiological data on injury and illness in sport. Some aspects of this statement need to be further specified on a sport-by-sport basis. To extend the IOC consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sports and to meet the sport-specific requirements of all cycling disciplines regulated by the Union Cycliste Internationale (UCI). A panel of 20 experts, all with experience in cycling or cycling medicine, participated in the drafting of this cycling-specific extension of the IOC consensus statement. In preparation, panel members were sent the IOC consensus statement, the first draft of this manuscript and a list of topics to be discussed. The expert panel met in July 2020 for a 1-day video conference to discuss the manuscript and specific topics. The final manuscript was developed in an iterative process involving all panel members. This paper extends the IOC consensus statement to provide cycling-specific recommendations on health problem definitions, mode of onset, injury mechanisms and circumstances, diagnosis classifications, exposure, study population characteristics and data collection methods. Recommendations apply to all UCI cycling disciplines, for both able-bodied cyclists and para-cyclists. The recommendations presented in this consensus statement will improve the consistency and accuracy of future epidemiological studies of injury and illness in cycling.

Equations to Prescribe Bicycle Saddle Height based on Desired Joint Kinematics and Bicycle Geometry

METHODS

Forty healthy adults (17 women, 23 men; mean (SD): 28.6 (7.2) years; 24.2 (2.6) kg/m²) participated. Kinematic analyses were conducted for 18 three-minute bicycling bouts including all combinations of 3 horizontal and 3 vertical saddle positions, and 2 crank arm lengths. For both minimum and maximum knee flexion, predictors were identified using Least Absolute Shrinkage and Selection Operator (LASSO) regression, and final models were fit using linear regression. Secondary analyses determined if saddle height equations were sex dependent.

RESULTS

The equation to predict saddle position from minimum knee flexion angle (R²=0.97; root mean squared error (RMSE) = 1.15 cm) was: Saddle height (cm) = 7.41 + 0.82(inseam cm) - 0.1(minimum knee flexion °) + 0.003(inseam cm)(seat tube angle °). The maximum knee flexion equation (R²=0.97; RMSE=1.15 cm) was: Saddle height (cm) = 41.63 + 0.78(inseam cm) - 0.25(maximum knee flexion °) + 0.002(inseam cm)(seat tube angle °). The saddle height equations were not dependent on sex.

CONCLUSIONS

These equations provide a novel, practical strategy for bicycle-fit that accounts for rider anthropometrics, bicycle geometry and user-defined kinematics. HighlightsThis work developed simple equations to prescribed bicycle saddle height that elicits desired knee kinematics.Separate equations are presented for prescribing minimum or maximum knee flexion angle.Equations can be generalized to riders of both sexes, and a breadth of anthropometrics and ages.

Factors associated with Achilles tendon pain in cyclists in eastern province of Saudi Arabia

BACKGROUND:

Cyclists are predisposed to different types of injuries whose patterns and distribution change over time. During bicycling, the high demand on lower extremities to produce speed places high load on the legs resulting in overuse injuries of which pain in the Achilles tendon is one. This study assessed Achilles tendon pain in cyclists in the eastern province of Saudi Arabia.

MATERIALS AND METHODS:

This was a cross-sectional study of active cyclists in the eastern province of Saudi Arabia. Data were collected using validated and pretested web-based self-administered questionnaire. Of the 511 cyclists invited, 311 completed the questionnaire yielding 60.62% response rate. SPSS was used for data entry and analysis. Descriptive statistics included calculation of frequencies and percentages for categorical variables, and median, mean and standard deviation for continuous variables. Chi-square test measured the associations between Achilles pain and various risk factors. Student's t-test, or Mann–Whitney test as appropriate, was used to compare continuous variables.

RESULTS:

Ten percent of mature and 9.1% professional cyclists reported that they had Achilles tendon pain. The pain was reported by significantly higher proportion of cyclists who raced (25%) and cyclists who rode mountain bicycles off-road (60.0%); average duration of the Achilles tendon pain was 7 days. Of the cyclists who had Achilles tendon pain, 32.1% reported that the pain increased when they were in running load and 28.6% reported increased pain in cycling load. Most cyclists described the pain as mild (67.9%) and moderate (32.1%). Overweight and underweight cyclists reported significantly higher rates of Achilles tendon pain (60% and 12.5%) compared to other body mass index classes.

CONCLUSION:

Achilles tendon pain commonly affects both amateur and professional cyclists. The study underpins the importance of a gradual increase in the training load, proper conditioning, bike fitting, and the maintenance of ideal body weight of cyclists to prevent Achilles tendon pain.

'As easy as riding a bike': a systematic review of injuries and illness in road cycling

OBJECTIVES

To allow the implementation of effective injury and illness prevention programmes for road cyclists, we wanted to first identify the injury/illness burden to this group of athletes. We, therefore, undertook a systematic review of all reported injuries/illness in road cycling.

DESIGN

Systematic review.

DATA SOURCES

Identification of articles was achieved through a comprehensive search of: MEDLINE, Embase, PsycINFO, Web of Science and Cochrane Library from inception until January 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies reporting injuries/illness in adults participating in road cycling. Cycling commuter studies were excluded from the analysis.

METHOD

Two review authors independently screened titles and abstracts for eligibility and trial quality. Initial search criteria returned 52 titles and abstracts to be reviewed, with 12 studies included after reviewing the full text articles.

RESULTS

The most common injuries sustained were abrasions, lacerations and haematomas accounting for 40-60% of the total injuries recorded. Fractures (6-15%) were the second most frequent type of injury. Head injuries (including concussions) accounted for 5-15% of injuries with musculotendinous injuries accounting for 2-17.5%. The upper limb was more frequently affected by injuries than the lower limb, with amateurs appearing to be at higher risk of injury/illness than professionals. Clavicle was the prevalent fracture, with patellofemoral syndrome the number one overuse diagnosis. No meta-analysis of the results was undertaken due to the inconsistent methods of reporting.

CONCLUSION

This is the first systematic review of road cycling injuries. Injuries most often affected the upper limb, with clavicle being the most prevalent fracture and the most common overuse injury being patellofemoral syndrome.

Descriptive profile for lower-limb range of motion in professional road cyclists

BACKGROUND

To describe the lower limb range of motion (ROM) profile in professional road cyclists.

METHODS

Cohort study. One hundred and twenty-one road cyclists volunteered to participate. ROM measurements of passive hip flexion, extension, internal rotation, external rotation, knee flexion and ankle dorsiflexion in dominant and non-dominant limbs were performed using an inclinometer. ROM scores were individually categorized as normal or restricted according to reference values.

RESULTS

Overall, hip flexion was smaller in the non-dominant limb than in the dominant limb (F=12.429, P<0.001), with bilateral differences in male (95% mean diff: 0.5° to 3.3°) and female cyclists (95% mean diff: 0.1° to 3.1°). Sex differences were found in hip flexion (F=18.346, P<0.001), hip internal rotation (F=6.030, P=0.016) and ankle dorsiflexion (F=4.363, P=0.039), with males showing smaller ROM than females. Males and females had restricted knee flexion in dominant (males: 51.6%; females: 42.6%) and non-dominant limbs (males: 45.0%; females: 39.3%). Ankle dorsiflexion was also restricted in dominant (males: 38.3%; females: 31.1%) and non-dominant limbs (males: 41.6%; females: 34.4%).

CONCLUSIONS

Elite road cyclists showed restricted lower-limb ROM according to reference values. In general, male cyclists showed lower values of ROM than females' counterparts. These findings suggest that including specific stretching exercises and resistance training to improve knee and ankle dorsiflexion ROM may prevent muscle imbalances caused by chronic pedaling in professional cyclists.

A Rare Consequence after Shoulder Dislocation in a Professional Cyclist: A Case Report

Background: Cycling is a popular source of recreation and physical activity for children and adults. With regard to the total number of sports injuries, cycling has the highest absolute number of injuries per year in the United States population. Cycling injuries can be classified into bicycle contact, traumatic, or overuse injuries. Aim of this study: The aims of this case report are to report a rare clinical complication of glenohumeral joint anterior dislocation that resulted in a patient experiencing continuous GHJ dislocations secondary to involuntary violent muscular spasms and emphasize the role of the physical therapist's differential diagnosis and clinical decision-making process in a patient following direct access referral. Case presentation: A professional 23-year-old cyclist presented to a physical therapist with spontaneous multidirectional dislocations to the right shoulder after the recurrence of trauma occurred during a recent cycling race. The dislocations do not occur at night, but occur during the day, randomly, and mostly associated with changes in the patient's psychological conditions. Directly from the clinical history, the physical therapist identified a neuro-physiological orange flag as well as an orthopedic red flag and, therefore, decided it was appropriate to refer the patient to a neurologist. It was determined by the physical therapist to be a priority to focus on the patient's neurologic status and then to evaluate the orthopedic problem. The neurological examination revealed a condition of spontaneous multidirectional dislocation associated with recurrent antero-posterior pain spasms of the shoulder joint. The neurologist prescribed medication. Following the second cycle of medication assumption, the patient was able to continue physiotherapy treatment and was referred to the orthopedic specialist to proceed with shoulder stabilization surgery. Discussion and conclusion: Currently, the diagnosis of this unusual clinical condition is still unclear. It is a shared opinion of the authors that the trauma during the past bicycle race awakened an underlying psychological problem of the patient that resulted in a clinical condition of weakness of all the structures of the shoulder, such that these spasms could result in multiple multidirectional dislocations.

A retrospective international study on factors associated with injury, discomfort and pain perception among cyclists

Although cycling has been associated with overuse/fatigue and acute injuries, there is lack of information regarding associated risk factors and prevention factors. The objective of the study was to determine the factors associated with injury, and perceptions of discomfort and pain in cyclists. A total of 739 cyclists completed an online questionnaire between February and October 2016. The questionnaire acquired information on participant demographics, characteristics related to cycling profile and fitness training, bike components and cycling posture, self-reported perceptions of comfort and pain, and injuries sustained in the last 12 months. Logistic regression models estimated odds ratios (OR) and 95% confidence intervals (95%CI) that examined factors associated with reporting overuse/fatigue injury, acute injury, body discomfort, saddle discomfort, and pain while cycling. Odds of reporting an overuse/fatigue injury increased when the cyclists complemented training with running (OR = 1.74; 95%CI = 1.03–2.91) or swimming (OR = 2.17; 95%CI = 1.19–3.88), and with reported pain while cycling (OR = 1.17; 95%CI = 1.05–3.69) and not cycling (OR = 1.76; 95%CI = 1.07–2.90). Odds of reporting an acute injury increased when biking to work (OR = 1.79; 95%CI = 1.07–2.86), and decreased with increased average cycling speed (1-km/h decrease OR = 0.93; 95%CI = 0.88–0.97), and compared to low-end bike, with the use of mid-range (OR = 0.25; 95%CI = 0.09–0.72) and high-end bike (OR = 0.34; 95%CI = 0.13–0.96). Although body discomfort was only associated with saddle discomfort and the presence of pain during cycling, saddle discomfort was also associated with biking to work (OR = 0.46; 95%CI = 0.22–0.88). Finally, pain perception was associated with a number of factors such as ride to work, core training, cycling experience, saddle discomfort, pain while not cycling. Numerous factors are associated with injury, and perceptions of discomfort and pain in cyclists. Such factors should be considered when developing training routines, bicycle maintenance best practices, and injury prevention programs.

The association of bike fitting with injury, comfort, and pain during cycling: An international retrospective survey

Although bike fitting is recommended to help reduce injury risk, little empirical evidence exists to indicate an association between bike fitting and injury incidence. The aim of the study was to determine the effect of bike fitting on self-reported injury, comfort, and pain while cycling from a worldwide survey of cyclists. A total of 849 cyclists completed an online questionnaire between February and October 2016. Questionnaire collected data on respondent demographics, cycling profile, bike fitting, comfort and pain while cycling, and injury history. The main predictor variable was bike fitting (yes, by the respondent, i.e. user bike fitting; yes, by a professional service; or no). Covariates included demographic and cycling profile characteristics. Logistic regression models estimated the odds of injury within the last 12 months, reporting a comfortable body posture while cycling, and not reporting pain while cycling. Odds ratios (OR) with 95% confidence intervals (CI) were reported. User bike fitting was associated with increased odds of reporting a comfortable posture (OR = 2.28, 95%CI: 1.06, 4.68). User (OR = 2.35; 95%CI: 1.48, 3.84) and professional bike fitting (OR = 2.35; 95%CI: 1.42, 3.98) were both associated with increased odds of not reporting pain while cycling. No associations were found between bike fitting and injury within the last 12 months. In conclusion, we found an association between bike fitting and reported comfort and pain while cycling. We recommend integrating bike fitting into cycling maintenance. However, further studies with longer follow-up are necessary to determine the presence of an association between bike fitting and injury.

Prevalence and Epidemiology of Injuries Among Elite Cyclists in the Tour de France

Background:

Cycling injuries are increasing, particularly among elite athletes during major events such as the Tour de France. Many athletes miss considerable time from sport and require surgical intervention. Little is known about the epidemiology of injuries to guide practice participation strategies, return-to-competition expectations, and injury prevention protocols.

Purpose:

To evaluate the injury epidemiology, operative incidence, and return-to-competition timeline among all elite cyclists participating in the 21-stage Tour de France race over a span of 8 years.

Study Design:

Descriptive epidemiological study.

Methods:

All injuries sustained during 1584 unique rides by cyclists participating in the Tour de France from 2010 to 2017 were evaluated. In the absence of an established Tour de France injury database, demographic, injury, surgical, and return-to-competition details from all athletes who withdrew because of a traumatic injury were retrospectively compiled using publicly available data, which were cross-referenced for validity. The inclusion criterion consisted of any cyclist who withdrew from the Tour de France because of an injury; cyclists who withdrew for noninjury reasons were excluded. Independent variables included injury demographics, missed days, and whether the injury required surgery. Injury prevalence, relative frequency distributions, and sample proportions were dependent metrics for this investigation.

Results:

Among the 1584 cycling entries evaluated over the 8-year study period, there were 259 cyclists (16%) who withdrew (17 cyclists/year). A total of 138 withdrawals were caused by acute trauma, 49% of which were fractures (n = 67), which represented the most common reason for withdrawal. A total of 29 (43%) cyclists with fractures underwent surgery. The most commonly fractured bones were the clavicle (n = 21), followed by the wrist (n = 6), hand (n = 5), femur (n = 5), humerus (n = 5), and ribs (n = 5). Cyclists who underwent operative fracture fixation had a longer time between the injury and their next race compared with those who did not undergo surgery (77 vs 44 days, respectively; P = .065).

Conclusion:

The most common injury leading to withdrawal from the Tour de France over the study period was acute fracture, comprising 49% of all injuries. Almost half of the cyclists with fractures underwent surgery. The clavicle was the most commonly fractured bone. For cyclists who underwent operative treatment of their fractures, return to competition was more than 1 month longer than for those who did not. A prospective database is warranted to catalog injuries among these elite cyclists.

Longitudinal Assessment of Bone Mineral Density and Body Composition in Competitive Cyclists

Baker, BS and Reiser II, RF. A longitudinal assessment of bone mineral density and body composition in competitive cyclists. J Strength Cond Res 31(11): 2969-2976, 2017-Competitive cycling has been associated with low bone mineral density (BMD); however, BMD is a multifaceted issue. The purpose of this study was to investigate how age (18-49 years), sex, USA Cycling Category (elite-4), and racing type (road and multiple bikes), influenced body composition across a season in competitive cyclists. February marked the preseason, where 42 participants (22 males, 20 females) completed a health history and cycling questionnaire, 4-day dietary log and a dual-energy X-ray absorptiometry scan, and repeated the measures 180 ± 11 days later. Preseason BMD and Z-Scores were within healthy ranges and similar between sexes, age groups, competition levels and racing-type groups (p ≥ 0.053). Age was significantly correlated with whole group BMD (r = 0.309; p = 0.047). Postseason analysis revealed very encouraging findings as no significant changes in BMD or Z-Score were observed in any group (p ≥ 0.067). A significant main effect for time was found in all groups as lean mass (LM) decreased and fat mass increased across the season (p ≤ 0.001). Additional analysis showed a significant time × group interaction as cat. 1 riders decreased body mass and body mass index, whereas cat. 4 riders responded in the opposite direction (p ≤ 0.037). Postseason correlations highlighted significant positive relationships between BMD and age, LM, and Kcal ingested (r ≥ 0.309; p ≤ 0.047). The only significant negative correlate of BMD was percent body fat (r = -0.359; p = 0.020). Armed with this information, cyclists and coaches should aim to prioritize balance between body mass and caloric intake while meeting the demands of training to minimize risk of cycling related low bone mass.

Incidence and prevalence of patellofemoral pain: A systematic review and meta-analysis

BACKGROUND

Patellofemoral pain is considered one of the most common forms of knee pain, affecting adults, adolescents, and physically active populations. Inconsistencies in reported incidence and prevalence exist and in relation to the allocation of healthcare and research funding, there is a clear need to accurately understand the epidemiology of patellofemoral pain.

METHODS

An electronic database search was conducted, as well as grey literature databases, from inception to June 2017. Two authors independently selected studies, extracted data and appraised methodological quality. If heterogeneous, data were analysed descriptively. Where studies were homogeneous, data were pooled through a meta-analysis.

RESULTS

23 studies were included. Annual prevalence for patellofemoral pain in the general population was reported as 22.7%, and adolescents as 28.9%. Incidence rates in military recruits ranged from 9.7-571.4/1,000 person-years, amateur runners in the general population at 1080.5/1,000 person-years and adolescents amateur athletes 5.1%-14.9% over 1 season. One study reported point prevalence within military populations as 13.5%. The pooled estimate for point prevalence in adolescents was 7.2% (95% Confidence Interval: 6.3%-8.3%), and in female only adolescent athletes was 22.7% (95% Confidence Interval 17.4%-28.0%).

CONCLUSION

This review demonstrates high incidence and prevalence levels for patellofemoral pain. Within the context of this, and poor long term prognosis and high disability levels, PFP should be an urgent research priority.

PROSPERO REGISTRATION

CRD42016038870.

Injuries and Illnesses Occurring on a Recreational Bicycle Tour: The Great Ohio Bicycle Adventure

OBJECTIVE

Recreational multiday cycling events have grown popular in the United States; however, little has been published regarding the injuries and illnesses that occur during these events. The objective of this study was to describe injuries and illnesses that occur in the Great Ohio Bicycle Adventure (GOBA) and to examine associated risk factors.

METHODS

Injury and illness data collected from an on-site medical clinic during the 2013 and 2014 GOBA tours were merged with rider registration data for analysis. Diagnoses were classified as acute injury, overuse injury, or medical illness. The odds ratios of sustaining at least 1 injury/illness, as well as sustaining an acute injury, were assessed adjusting for riders' demographics.

RESULTS

A total of 4005 (2172 in 2013 and 1833 in 2014) cyclists participated in GOBA, with an an age of 50.7±17.6 (2-86) years (mean±SD [range]), of whom 59.8% were male. During the tours, 143 (3.6%) riders reported at least 1 injury/illness, which resulted in 220 clinical diagnoses, including 114 (51.8%) acute injuries, 27 (12.3 %) overuse injuries, and 79 (35.9%) medical illnesses. The lower extremities were the most commonly injured body site (n=71, 50.4%). "Superficial/Abrasions/Contusions" was the most common injury/illness type (n=68, 30.9%). Riders who had no previous tour experience or who were at least 50 years old had a greater risk of injury/illness than their counterparts.

CONCLUSIONS

The prevalence of injury and illness is relatively low in multiday recreational cycling events. Our findings provide important data for planning and preparing for medical coverage at mass recreational cycling events.

The effect of topical thiocolchicoside in preventing and reducing the increase of muscle tone, stiffness, and soreness: A real-life study on top-level road cyclists during stage competition

In professional road cyclists, the majority of overuse injuries affect the lower limbs and are mostly represented by contractures or muscle shortening, characterized by an increase of tone and stiffness and a variation of elasticity. Treatment and prevention of these specific conditions may include physical, supplementary, and pharmacologic support. The aim of this real-life study was to determine: first, the alterations of tone, stiffness, elasticity, and soreness of rectus femoris (RF) and biceps femoris (BF) in top class cyclists engaged in 3 multistage races, and second, whether any variable in the management of the athletes may affect the prevention and/or reduction of such alterations.Twenty-three professional cyclists competing in 3 international, cycling stage races were assessed. Athletes could receive, upon the approval of the medical staff, physical, dietary, and/or pharmacological management which could include treatments with topical over-the-counter myorelaxants to prevent and/or reduce muscle contractures. MyotonPro was used to daily measure tone, stiffness, and elasticity in RF and BF in relaxed and contracted state after every stage. In parallel, BF and RF soreness was also assessed with a Likert scale.All athletes received the same general massage management; none of them received dietary supplements; some of the athletes were treated with a topical myorelaxant thiocolchicoside (TCC 0.25%) foam 3 times daily. TCC was identified as the only variable able to affect these muscle parameters in the cyclists. Tone, stiffness (regardless of the state), and soreness significantly increased over time either in BF or RF in all athletes. In the group of athletes that used TCC (n = 11; TCC+) the increase in tone, stiffness, and soreness was significantly lower than in the group not receiving TCC (n = 12; No-TCC). Elasticity varied coherently with tone and stiffness.A very intense and protracted sport activity increases muscular tone, stiffness, and soreness over time. Topical TCC foam significantly attenuates these alterations and might represent an efficient strategy both to prevent and manage contractures and their consequences in professional cyclists as well in athletes from other disciplines involving similar workloads.

Relationship Between Body Positioning, Muscle Activity, and Spinal Kinematics in Cyclists With and Without Low Back Pain: A Systematic Review

Context:

Low back pain is reported by more than half of cyclists. The pathomechanics and association of risk factors of lumbar spine overuse injuries in cycling are not clearly understood.

Objective:

To determine whether relationships exist between body positioning, spinal kinematics, and muscle activity in active cyclists with nontraumatic low back pain.

Data Sources:

In August of 2015 and April of 2016, a comprehensive search of the PubMed, CINAHL, Ovid MEDLINE, and Scopus databases was performed independently by 5 reviewers.

Study Selection:

Included articles consisted of biomechanical studies examining factors relating to low back pain in cyclists as agreed upon by group consensus.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data Extraction:

Five reviewers appraised by consensus each article using the Downs and Black checklist.

Results:

Eight studies met criteria for this review. There is evidence that cyclists with lower handlebar heights displayed increased lumbosacral flexion angles during cycling. Core muscle activation imbalances, back extensor endurance deficits, and increased lumbar flexion while cycling were found to be present in cyclists with low back pain.

Conclusion:

Spinal and core muscle activation imbalances in a prolonged flexed posture associated with cycling may lead to maladaptive spinal kinematics and increased spinal stresses contributing to overuse low back pain.

Incidence and aetiology of acute injuries during competitive road cycling

INTRODUCTION

Despite the ever-increasing popularity of bicycle racing, the high perceived risk of acute injuries and the recent media attention, studies of acute injuries in road cyclists are rather scarce. The goal of this study is to evaluate the incidence, aetiology and patterns of acute injuries in non-professional competitive road cyclists during cycling races in Flanders.

MATERIAL AND METHODS

All acute injuries that occurred during competition in Flanders in 2002 and 2012, collected in the injury registry, were analysed. The incidence, injury rate, diagnosis, circumstances and level of performance were evaluated.

RESULTS

A total of 777 documented reports of accidents (1230 injuries) were retrieved for the years 2002 and 2012. There was no significant difference between incidence and injury rate between 2002 and 2012. There was a strong significant difference in the incidence between the different levels of performance in both seasons. Severe injuries were seen in 29.5% in 2002 and in 30.1% in 2012. The most common location of a severe injury was the hand. Collision with another rider was the most common cause of injury.

CONCLUSIONS

Almost 1 out of 6 non-professional competitive road cyclists had an accident during cycling races in 2002 and 2012 in Flanders and collision with other riders was the most important cause of a crash. The most common lesion was abrasion, but almost one out of three riders had a severe injury.

Requests for medical assistance during an amateur road cycling race

Requests for medical assistance during an amateur road cycling race, which included 56,700 cyclists over 6 consecutive races between 2006 and 2011, were analysed with the aim of improving injury prevention and medical coverage. Medical assistance was requested by a small percentage of participants (1.7 ± 1.0%), but the actual number seeking assistance was quite high due to the large total number of participants (162 ± 51). 0.17% of all participants did not finish the race for medical reasons. No fatal injuries were recorded. The incidence rate of requests for medical assistance was 0.108/1,000 km, and the incidence of withdrawal was 0.011/1,000 km of the race. Of all medical requests, those due to direct trauma caused by falls accounted for 63%, requests for overload injuries accounted for 4% and requests for non-traumatic complaints accounted for 22% of the total; 11% of requests were not classified. Weather conditions may affect the type and the incidence of requests: requests for traumatic injuries increase if raining; requests for heat-related illnesses if hot. Prevention techniques are aimed at guaranteeing and promoting health and safety and should be implemented by both the race organisers and the cyclists.

Outcome of proximal femoral fractures caused by cycling in the young and mid-aged

BACKGROUND

Cycling is gaining more popularity both as a sport, on and off-road and also as a means of commute. Cycling accidents harbour significant injury risks including fractures. Proximal femoral fractures are uncommonly associated with cycling in the young adult population. The purpose of this study is to describe this unique pattern of injury as well as the outcome of proximal femoral fractures caused by cycling in the young to mid age population.

STUDY DESIGN

retrospective cohort study. 23 fractures in 22 patients were available for analysis. 11 were femoral neck fractures, with six displaced ones, and the rest trochanteric fractures. 21 patients were male patients, and the average age was 42 (range 27-60). All patients but two were operated within 24 h from admission. Radiographic analysis included reduction quality, fracture classification and arthritic changes. Clinical outcome was measured using SF-12 and Oxford hip scores.

RESULTS

All fractures healed. Two patients with displaced femoral neck fractures developed avascular necrosis requiring arthroplasty. One patient developed an AVN 2 years after a stable trochanteric fracture but did not require an arthroplasty as of yet. Eight patients required hardware removal due to symptoms. 77% of patients had resumed cycling at the pre-injury level. Mean SF-12 score was 47.1 ± 11.7 for the physical component and 53.7 ± 6.3 for the mental component. Mean oxford hip score as was 40.1 ± 12.2. Radiographic analysis revealed good to acceptable reduction quality. Fracture type, age, cycling type and reduction were not significantly associated with outcome.

CONCLUSION

Proximal femoral fractures caused by cycling in young to mid-aged adults are an emerging pattern of injury. Overall favourable result can be expected in the majority of cases, with displaced femoral neck fractures having a risk for AVN. Further delineation of the exact cause for this phenomenon is required with possible intervention for injury prevention.