Introduction

Cycling is an enjoyable activity for all ages - whether it’s a leisurely ride with the family or a race in an elite cycling competition. However, things can go wrong (quickly) and injuries do occur.

Please take note that your insurance might not cover your injuries or loss sustained during participation during an event, as the risk in falling-injury is substantially raised when cycling in a peloton. When one goes down, everybody behind him goes down…

Approximately 250 –300 cyclist are killed or maimed on South African roads annually, all of which occur during either training rides or whilst commuting.

Dress for the fall - not for the ride!

Interestingly:  

• About six cyclists out of every 10 who are injured are children (aged 5 - 14 years). 
• Less than 10% of cycling injuries involve collisions with other vehicles (you are much more likely to hurt yourself by falling off your bike or hitting a stationary object).
• About 20% of all cycling injuries occur to the face (this is quite different from football, basketball, volleyball, and long-distance running; in these sports, the knee and ankle dominate the injury-occurrence list).
• With cycling there are about twice as many upper-limb injuries ( compared with lower-limb ones), whereas in football, basketball, volleyball, and running the lower-limb injuries dominate.
• The most common upper-limb injury in cycling is something called “handlebar palsy”.  
• Children, particularly those of primary school age, are most at risk of injury (the group most often not wearing a helmet). 

Traumatic injuries. Most cycling accidents are minor, but of the cycling injuries that do get treated in hospital, around 20% are fractures, 30% bruises or contusions and the remainder lacerations and abrasions. More than half of all traumatic cycling injuries are to the head and face, most often either as a result of falling off, or some form of collision.

Head injuries. Head injuries are prevalent in 80% of cycling accidents where a rider dies. Most of these riders were not wearing helmets at the time of their accident, and research shows that a good cycling helmet can prevent 90% of potential head injuries.

Abrasions or grazes. These are probably the most common cycling injury and are usually minor, although painful, and may result in the need for plastic surgery. By their nature these injuries collect gravel and dirt, and must be carefully cleaned. A local anaesthetic spray can reduce the pain, and an antiseptic spray will minimise the risk of infection.

Lacerations. About 10% of cycling injuries are lacerations where the skin is torn and there may be injury to the underlying tissues. You should always seek medical attention for these, since they may contain foreign bodies that must be removed, and they may be deep enough to need stitching. Always make sure that the doctor checks when you last had an anti-tetanus vaccination, since deep wounds are vulnerable to this particular infection.

Contusions. Contusions are bruising of deep tissue - particularly muscle - which often occur with other injuries. These result from bleeding of small vessels into the surrounding tissue and can be minimised by applying ice to the area for around 20 minutes. Firm bandaging will also reduce the area of damage.  If there is significant bleeding into the underlying muscle then a condition known as "compartment syndrome" can result when bleeding between muscle layers leads to reduced blood supply and tissue death. The main sign of this is extreme pain, which gets worse rather than better. The affected area feels rock hard and is extremely tender to the touch or on movement. Seek medical help immediately as this is an emergency.

Fractures. The most common fractures in cyclists are of the ribs and collarbone (clavicle). Fractures of the collarbone and ribs can sometimes result in a punctured lung - if the cyclist is having trouble breathing tell the ambulance when you call them, and stress the urgency of the situation.  Arm and leg fractures are also relatively common. The affected limb should be splinted immediately at the site of the accident, by any means possible (a newspaper or towel). This reduces pain and bleeding.
Always remember that if the head is injured there may be a neck or back injury as well.

Any cyclist who is unconscious after an accident must bee deemed to have a neck injury until proven otherwise:

• do not take the injured cyclist's helmet off, 
• stabilise the neck and (if possible) the back, and 
• do not move the person, unless there happens to be a qualified person on the scene who can direct the way in which the person is moved. Only move the person if traffic makes it dangerous for them to remain in that position.

Common bicycling injuries

Pressure injuries. Pressure on the hands, the perineum and buttocks and the feet can be a problem, particularly on long rides.  If you bike is properly set up, you have good gloves and good padded cycling shorts and a decent saddle this will be minimised and should not lead to long-term damage. However, there are times when excessive, prolonged pressure can lead to nerve and tissue damage.

• Handlebar palsy.  Ulnar neuropathy is an inflammation of the nerve that runs along the entire length of the arm to the hand. This nerve  provides for both movement and feeling in the arm and hand. The nerve becomes inflamed, usually either at the elbow or the wrist, when it has to absorb vibration and shock transmitted to the arm, or it can flare up when the hand and arm are maintained in a fixed position for a long time. Symptoms of handlebar palsy include tingling, numbness, or pain on the outside or middle of the forearm; this sensation of discomfort may run all the way to the little finger. It’s important to note, too, that during early stages of the injury symptoms might be limited to tingling (the familiar “pins-and-needles” sensation) while riding, but can rapidly progress to numbness and even intense pain. Handlebar palsy should never be taken lightly, as the ulnar nerve may become compressed due to swelling of surrounding muscles and connective tissues, and its ability to transmit messages to the muscles of the forearm may be reduced. The result is a loss of strength in the muscles of the hand, often first reflected in an inability to spread the fingers.  If handlebar palsy is present, it is really best to refrain from cycling until symptoms disappear. Manage handlebar palsy by having a professional evaluate your position on the bicycle and to make adjustments to assure that your weight is not too far forward (excessively supported by your hands on the handlebars), and:
  o    Observe how you are gripping the handlebars. The grip should be firm, yet relaxed. Increase the strength of your forearms and the range of motion of your wrists.
  o    Try padded gloves or handlebar tape to reduce the vibration, (and to protect the hand in the case of a fall during cycling).
  o    Shift the position of your hands regularly - remember to keep the wrist straight.
  o    Don't ride long distances on successive days if your hands are constantly going numb (rest).
• Numb feet. Numbness or ‘burning feet’ is commonly caused when the nerves are squashed due to tight shoes, road vibration or too much climbing (which puts continuous pressure on the feet). Wearing shoes with a stiff sole, which fit properly, can alleviate numb feet on long rides, or an inner sole helps to spread pressure over a wider area. Make sure your feet are straight when you clip into the pedals if you use cleats.  Remove any irregular seams, straps or buckles from your shoe that may be pressing against your foot. Slight adjustments to your shoes, straps or cleats on a riding shoe may correct the problem.  
• Saddle sores. Perineal nodules are painful lumps that can develop in people who put in long hours of heavy training. They result from prolonged and repeated pressure causing chronic changes in the subcutaneous tissues of the perineum resulting in hard, tender nodules. If neglected these will grow and become more painful.  Corn plasters placed over the nodule when it is first noticed will generally take the weight off the nodule when you ride, and allow it to settle. If it doesn't settle then stop riding for a few days. These can become a real problem if neglected, so don't ignore them. Most new cyclist find that their rear end is painful and numb when they first start out. As long as you have well cared for, clean cycling shorts, this will diminish with training. Remember Greg LeMond:  "It never gets easier, you just go faster."
• Urogenital problems - such as erectile dysfunction and infertility -  mainly affects 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. 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.

Shoulder pain. Injury to the shoulder usually occurs during longer rides. Placing too much weight on the hands, and riding with straight elbows cause it. Keep the elbows slightly flexed to stop the ‘road shock’ transferring to the arms and upper body. This will reduce the risk of shoulder injury.

Knee injury.  The three main reasons why overuse injuries occur are as a result of poor biomechanics, mechanics and cycling technique. These areas can cause problems that are hard to detect, as the errors may be small in themselves and may not seem significant or noticeable. A cyclist training 120km per week will bend and straighten the knee about 200,000 times, which is when all the small faults starts to have a knock on effect. Many cyclists suffer pain and discomfort in their knee(s), often at and just below the kneecap, although pain on either side of the kneecap is also common. Knee injury is generally due to overuse and occurs when a cyclist is doing too much too fast. Cyclists commonly suffer from tendonitis, bursitis, or irritation of the joint. The injury itself is due to inflammation at the point where the kneecap attaches to the bones in the lower leg, however, other structures may also be involved. The most likely cause is incorrect alignment of your knees and feet. Cycling with knees at right angles to the bike puts abnormal stress on the ligaments of the knee, and ‘pointing’ your feet outward pulling the knee with it often causes. Similarly, pointing your feet inward will lead to ligament stress. Overloading the muscles of your leg by pushing at a high resistance for long periods will also damage the ligaments surrounding the kneecap. Don't strength train every day! Incorrect saddle height - too low - will cause your knee to remain flexed during the entire pedal cycle, which will cause ligament strain as well.

• Biomechanical faults - These are problems due to the tissues of the body not functioning correctly, including bones, muscles, tendons and ligaments. Some riders have slight misalignment of the kneecap, which can be measured. Other riders may have tightness of the tendons and soft tissue structures around the knee causing the kneecap to be pulled to one side. The lower back is sometimes a problem too since it may refer pain to the front of the knee, fooling riders into thinking the problem is with the knee when, in fact, it is the back all along.
• Mechanical faults - Any minor fault in the cranks, pedals or spindles can cause overuse injury. This is most likely to happen after a crash, but even an unspectacular prang could cause slight twisting of the equipment. This often shows itself days or weeks later with pain in the kneecap area. Some riders get kneecap pain after switching to clipless pedals systems, but floating clipless systems were introduced to allow some slight movement of the foot. Saddle height is also worth considering when you're getting unexplained knee pain. We know that lowering the saddle causes more knee bend and increases the force going through the quadriceps muscles and tendon; these two in turn will put more pressure on the patellofemoral joint. 
• Cycling technique. Improper position on the bike (this is very conducive to developing knee problems because of excessive bend at the knee when the pedal is at or just past top-dead-centre), and poor pedalling technique can lead to biomechanical faults due to i) bad foot position on the pedals, ii) poor leg position, iii) sitting skewed on the saddle, or iv) being too stretched out. If these are not corrected, problems can easily occur. Usually knee problems are caused by riding too hard, too soon, too much, at too low a cadence (or excessive crank length). Save those big ring climbs and big gear sprints for later in the season. 

How to prevent knee problems. Pay attention to setting up your bike. Make sure that your saddle is at the correct height, and that your feet are in a comfortable, neutral position when you ride.

• THE SADDLE. Adjust the height of your seat correctly. If the seat is too high or too low, stress is placed on the knees. Seek the advice of a professional bike fitter to determine the appropriate height for your seat. Varying the saddle height can relieve some harmful stresses on the knee ligaments. More importantly, if your kneecap is causing trouble it may be wise to raise the saddle slightly to stop the knee from bending too much.
• THE PEDALS - If the knee joint is really beginning to bug you, then the pedals should always be checked and adjusted for abnormal play due to faulty plates, spindles etc. Some experts reckon that this is the most common cause of knee pain, and it's worth spending time to check your foot position on the pedal.
• Make sure your seat and cleats are adjusted properly, and check for leg length differences both below and above the knee. If the difference is between 2 to 8 millimetres you can correct it by putting spacers under one cleat. 
• Slowly build up your strength through training to minimise strain on the knees, and reduce the amount of hard training or hill work.
• Use shorter cranks if need be, as for some riders this helps keep pedal speed up and knee stress down, and cut back on mileage and intensity. Sometimes a prolonged rest is the only way to regain full functionality and is usually required only after trying to "train through" pain. Rest is the only sure cure for cyclist’s knee. 

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. Eextension with shoulders in a depressed position increases tension which is exacerbated by handlebars set too low, or by the rider failing to keep their elbows slightly bent. Excessive or prolonged traction to the nerves can result in pain, numbness or tingling in the nerve distribution. To prevent the build-up of tension, the cyclist must learn to do regular shoulder shrugs on the bike, as well as occasionally sitting upright from time to time.

• Lower back The back can be a weak link for many riders. Cyclists usually develop strong leg muscles but don’t always have the torso strength to support and resist the force from the legs. This forces the lower back to overwork causing spasm. Get into the habit of riding with a straight back when pedalling en danseuse, as it will ease stress from the lower back and improve your riding experience. Lower back injuries injuries are very similar in principle to neck pain, except that prolonged flexion aggravates the result. Muscle fatigue, chronic tension to posterior vertebral ligaments and prolonged compression can all be responsible for ongoing backache. It is imperative that cyclists have an adequate range of lumbar spine and hip flexion.

Cramping & muscle pain

There are three types of muscle pain related to exercise:

• pain occurring during or immediately after exercise
• delayed onset muscle pain
• muscle cramps.

Muscle pain during exercise. Exercise requiring significant effort, either from high-energy demands (low resistance, rapid contraction rate) or substantial muscle effort (high resistance, low contraction rate) is often associated with muscle pain or discomfort. No study has identified a single cause for this discomfort, although the fact that it occurs more quickly in a muscle with a limited blood supply suggests that the culprit is a product of muscle metabolism.

Lactic acid is considered the likeliest candidate, although other metabolites such as pyruvic acid and ammonia have also been suggested. Based on the differing results in various papers in literature, it is most likely that pain in the actively contracting muscle is related to a combination of substances, including the build-up of acidic intermediate metabolites, ionic shifts at the cell membrane level and actual changes in the muscle cell proteins themselves. The fact that training will increase the level of activity at which discomfort first occurs indicates that the muscle cell can adapt to these factors.

It is interesting that the body also has a mechanism to deal with this discomfort. Endorphins are secreted into the central nervous system during endurance exercise and will alter the perception of pain during prolonged high intensity exercise. Thus we have a mechanism to warn of muscle overuse, and also one to suppress pain during prolonged exercise that may be beneficial in fleeing from dangerous situations.

Although conventional wisdom holds that taking aspirin before a ride will cut down on muscle pain during exercise, a study at the University of Georgia recently concluded that even at large doses (20 mg per kg or 4 standard aspirin for the average rider), aspirin did not delay the onset of muscle pain during exercise or reduce the perceived intensity when it occurred.

Aspirin might not help muscle pain directly, but it does relieve symptoms associated with inflammation.

Delayed onset muscle soreness (doms). This is the stiffness that begins after 24 to 48 hours and peaks by 48 to 72 hours after exercise. It indicate a high tension on muscle fibres and connective tissue, and is accompanied by a decrease in muscle strength, a reduced range of motion, and leakage of muscle cell proteins into the blood that indicate muscle damage most likely related to minute tears and physical damage,  as opposed to the build-up of metabolic by-products during exercise.

Generally DOMS is noted after unaccustomed eccentric exercise. It does not appear that soreness from previous exercise increases the chance of further muscle damage. In fact the adaptive process of healing, even from microscopic injury with minimal pain, appears to have a significant protective effect on the development of muscle damage and soreness from subsequent exercise – its the reason why one should use a gradually progressive exercise program.

Muscle cramps . Cramps are most common when you use your muscles beyond their accustomed limit (either for a longer than normal duration or at a higher than normal level of activity) - which explains why cramps are more common at the end of a long or particularly strenuous ride or vigorous sprint. In fact, cramps are among the most frequent complaints by all athletes.

The pain is brought on by an intense, active contraction of the muscle cells. Although cramps may occasionally be the result of fluid and electrolyte (sodium) imbalance from sweating, that is not universally the case as individuals involved in activities requiring chronic use of a muscle without sweating (musicians for example) will also experience cramps.

In one study of marathon runners, there were no differences in sodium or hydration levels between the 15 participants who developed cramps and the 67 who didn't. And although a low magnesium level can cause severe muscle cramping, another study of magnesium supplements in triathletes failed to show any benefits as far as cramping.

There are 4 issues to be considered in the prevention of muscle cramps:

• training - as with the two other forms of activity related muscle pain, training to the level of the anticipated activity will decrease the possibility of cramps.
• hydration - dehydration is the second most common cause of muscle cramps after exerting beyond your training.
• electrolyte replacement - sweat contains approximately 2 grams sodium/litre, 1 gram chloride/litre, 0.2 gram potassium /litre, and 0.1 gram magnesium/litre - and if you are acclimated, these concentrations are even lower. Except in extreme circumstances, dietary intake will replace these losses, but if you are going to be exercising in excessively hot or humid conditions, most trainers would suggest paying close attention to salt intake and even adding 1/2 tsp of salt (150 mg of sodium) per day to your food. A sports drink might help, but it is likely that maintaining adequate hydration is more important than the small amount of electrolytes they contain - and water is a lot less expensive. The role of other micronutrients and vitamins are questionable.
• muscle glycogen reserves - replenishment of ATP is important for proper muscle cell functioning, with adequate caloric intake needed to achieve optimal physical performance.

Everyone's physiology is different, and thus the answer to preventing cramps almost certainly varies from person to person as well. Maintaining adequate fluid replacement and nutrition is essential for optimal physical performance above and beyond the benefits in preventing muscle cramps. From there it becomes a trial and error approach to see what might help you. If you suffer from muscle cramps, try manipulating supplements - potassium, magnesium, calcium – or one of the commercial brands. For the vast majority who only rarely suffer from cramps it will be training, fluids and carbs that are the key to cramp management. Supplements is just an added expense without any clear benefit.

If cramps do occur gently stretching the affected muscle will give relief. Calf cramps can be relieved by standing on the bike and dropping your heel, while anterior thigh cramps can be stretched-out by unclipping and moving your thigh backwards towards your buttocks. Although a number of medications have been suggested as treatments for muscle cramps only quinine has been shown to be effective in scientifically controlled studies, sadly the  high incidence of side effects limit its usefulness as a routine treatment

To cut a long story short, lack of training is most often the culprit in cramping. A cramp is your bodies "override" to get you to slow down, as you have pushed yourself too much. When you are attacked by a cramp, rest, have a drink, walk/stretch the cramp out and nurture the muscle from thereon. You need rest.

Note. Taking cramping "medication" that you have not tried & tested on a practise run is not recommended. Always ride your race with what you have found to be effective in training!

Generally preventing injury

Stretching. Tight soft tissue structures (especially of the muscles and tendons) have been found to increase the risk of pain around the kneecap. To help ease and prevent this problem, stretching should be done to the calves, quadriceps, hamstrings, and the bands on the knee and thigh... regularly!

Cadence. Riding with brisk cadences reduces the force applied, and reduces the stress on your knees. Mashing the pedals is a great way to wreck your knees.

Keep Warm. If the weather is cool, cover yourself. Wear tights or leg warmers even if you're not uncomfortably cold.

Warm Up. Spin in an easy gear for the first 10 minutes of your ride. Gradually increase your pace, avoiding hammering up hills for the first half hour of your ride. Don't push big gears, especially early in the season or in cold weather. Gear down for climbs: minimum rpm’s in a climb should be 75-80. Learn to spin in the 90's on the flats. Get off your bike after the first ten minutes and stretch your hamstrings, calf muscles, and quads.

Cool down. Go easy the last 10 minutes of your ride to cool down properly. This will wash toxins out of your muscles and allow you to cool down, which will greatly improve your performance the day after. If you feel leg strains coming on, try an anti-inflammatory together, and:

• rest the injury;
• ice it for 20 min on, 10 off;
• compression wrap it in bandage; and
• elevate it (raise the injured part to reduce swelling).

Though it may feel good at first, avoid hot tubs, spas and saunas for at least 48 hours. If pain persists, see your doctor.

Gym work. Use the leg-curl machine to strengthen your hamstrings. Cyclists tend to overdevelop quads and under develop hamstrings, leading to injury problems. Avoid the leg extension machine. It's not necessary for cyclists, is hard on the knees, and is really only useful for getting extra loft when kicking a beercan after you loose a race.

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 they should ensure that any joint stiffness or muscle tightness is attended to. For any cyclists intending to build up to a high weekly mileage, training should be gradual and structured. (Spinning. First develop fast twitch muscle fibres, which means spin, spin, & spin a bit more.)

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 - 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, and 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.

Fit your bike. The bike frame needs to be the right size, you need the right size and rise of stem, size of handlebars, and proper adjustments to stem, seat post and seat rails, and shoe cleat positioning. A good rule of thumb: if the front of you knees hurts, raise the seat. If the back of your knees hurts, lower the seat. Don't move the seat height more than 1/8th inch per week if you can help it, to allow your body time to adapt. Some people have leg length inequalities that require shimming cleats: check with your orthopaedist if you suspect this is a problem. He may be able to spot this problem quickly, or confirm it with an x-ray.

Maintain the bicycle. It is vital to maintain the bicycle in good working order. Children, particularly those of primary school age, are most at risk of injury from equipment failure. Common equipment failures include:

• slipped chain - the chain comes off while the bike is in motion.
• wheel loss - the wheel (commonly the front) comes off while the bike is in motion.
• handlebar malfunction - for example, the handlebars break, fall off or come loose. This can result in the rider losing control of the bike.
• broken pedals - the pedal comes loose or breaks while the bike is in motion.

Always brake smoothly. - wheels may lock-up causing the rider to lose control,

Clip out! Think before you stop & clip out of yout pedals long before you have to,

Wear gloves.

Never cycle without a proper shirt.

NO HELMET, NO RIDE!