Cycling

Contents

Foreword: Cycling to the Finish xiii

Santos F. Martinez

Preface: Cycling Medicine xv

Angela N. Cortez and Dana H. Kotler

A Dynamic Approach to Cycling Biomechanics 1

Wendy Holliday and Jeroen Swart
Cycling biomechanics is a complex analysis of the cyclist and the bicycle.
It is important to assess the cyclist dynamically because kinematics and
muscle patterns are influenced by their type of riding and fatigue and inten-
sity. Intrinsic factors such as anthropometrics and flexibility should guide
the initial bicycle configuration. Static kinematics are a valid and reliable
tool in the process of bike fitting, providing an initial fast and cost-
effective method of assessing the cyclist. Dynamic assessment methods
should then be used to fine tune the bicycle configuration according to
the specific needs and workloads of the cyclist.

A Practical Approach to the Evaluation of a Cyclist with Overuse Injury 15

C. Greg Robidoux
Cycling has grown in popularity over the past 20 to 30 years, serving as
transportation, fitness, and sport. Cycling is unique for several reasons:
it is a non–weight-bearing sport, nearly all of the motion is in the sagittal
plane, and it is one of the only sports where an individual remains attached
to a machine for a long duration. As such, the cycling athlete has unique
needs compared with other endurance-based athletes. The complex
biomechanical interaction of bicycle and rider requires a systematic pro-
cess for assessment, which provides the framework for understanding,
evaluating, and treating overuse injury in cyclists.

Adaptive Cycling: Classification, Adaptations, and Biomechanics 31

Gabrielle T. Goodlin, Lindsey Steinbeck, Deborah Bergfeld, and Alexandria
Haselhorst
Increased awareness, recognition, and accessibility has led to an increase
in the popularity of adaptive cycling. This article aims to provide up-to-date
information for clinicians about available adaptations, participation op-
tions, and resources. We review the para-cycling classification system
and 4 main categories of cycles. There are multiple considerations for
fit and customization depending on an individual’s disability to improve
efficiency and comfort. Virtual platforms that allow riders to train and
compete online have grown in popularity among para-cycling commu-
nities and offer an alternative to riding outdoors. Many national and local
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organizations offer communities and grants to assist with adaptive

equipment.

Adaptive Cycling: Injuries and Health Concerns 45

Gabrielle T. Goodlin, Lindsey Steinbeck, Deborah Bergfeld, and Alexandria
Haselhorst
Para-cycling has high rates of acute injuries. The underlying medical con-
ditions of para-athletes predispose these cyclists to injury patterns and
sequelae different from those of their able-bodied counterparts. Such in-
juries include an increased incidence of upper-extremity and soft tissue in-
juries, along with predisposition for respiratory, skin, genitourinary, and
heat-related illnesses. There are no validated sideline assessment tools
or return-to-play protocols for sports-related concussion in wheelchair
user para-athletes or those with balance deficits. Para-cyclists may be
at increased risk for relative energy deficiency in sport due to competitive
pressure to maintain certain weights and increased incidence of low bone
mineral density.

Unique Concerns of the Woman Cyclist 61

Rozanne M. Puleo, Antje Barreveld, Sarah Rice, Anne M. Althausen Plante, and
Dana H. Kotler
Previously a male-dominated activity, female cyclists now make up nearly
half of all cyclists in the United States. Although cycling provides a signif-
icant number of health benefits, it is an activity that carries risk of injury,
both traumatic and nontraumatic. Sex differences are seen in chest trauma
and breast injury, as well as pelvic, given the inherent differences in anat-
omy. Understanding the relationship of the bicycle to the anatomy of the
rider can help mitigate risks for injury.

Triathlon Considerations 81
Daniel M. Cushman, Nathan Dowling, Meredith Ehn, and Dana H. Kotler
Triathlon is an increasingly popular sport that includes swimming, cycling,
followed by running. The triathlete should not be seen merely as a cyclist
who also swims and runs. Notable differences are seen in the type of bike
used, training patterns, lower extremity demands, and cumulative nature
of the sport. Injury prevention and treatment strategies need to take into
account the triathlon distance, the type of bike used, athletic experience,
prior injuries, risk factors, and a thorough understanding of the demands
placed on the body through all 3 disciplines (swim, bike, and run).

Return to Cycling Following Brain Injury: A Proposed Multidisciplinary Approach 91

Dana H. Kotler, Mary Alexis Iaccarino, Sarah Rice, and Seth Herman
Cycling is an important form of exercise, recreation, and transportation.
Following traumatic brain injury, the benefits of cycling for health, fitness,
and community mobility must be considered alongside potential risk for
recurrent injury. In addition to medical concerns and exercise tolerance,
key domains include motor function, attention, and visuospatial and exec-
utive function, which have previously been explored with regard to driving.
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Cycling skill is a combination of cognitive and motor function, and can be

trained with appropriate education and intervention. We discuss the rela-
tionship of brain injury rehabilitation to specific features of cycling,
including case studies.

Fear, Anxiety, and Return to Sport After Cycling Crashes: A Survey of Cyclists 107
Dana H. Kotler, Daniel M. Cushman, Sarah Rice, Christopher Gilbert, Saurabha
Bhatnagar, C. Greg Robidoux, and Mary Alexis Iaccarino
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 co-
morbid with the crash also warrant treatment. In this original research, we
evaluated the presence of fear or anxiety after cycling crashes and exam-
ined 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.

Infrastructure and Injury Prevention in Cycling 123

Kevin Rix and Isabell Sakamoto
The focus of this article centers on bicycle injury prevention and related
infrastructure. The article discusses the current epidemiology of cycling
injuries, and known prevention strategies, specifically individual recom-
mended practices related to helmet use in both adult and pediatric
populations. The article also discusses different ways in which the environ-
ment plays a role in protecting cyclists from injuries, and what environ-
mental changes have been adopted to reduce the likelihood for cycling
injuries.

Acute Cycling Injuries 135

Mark Greve
The overall activity of cycling, although profoundly heterogenous, often
occurs with mechanisms consistent with motor vehicle collisions.
Advanced trauma life support is the standard of care. Traumatic brain
injury is the leading cause of death, and concussions are common in
cyclists. Road rash is the most common injury, and management should
be synonymous with other kinds of burns. A unique aspect of cycling med-
icine is that it often is done on public roadways in close proximity to the
athletes during competition. Clinicians who care for cyclists in the field
setting should be prepared to manage a broad spectrum of traumatic
injuries.

Nutrition in Cycling 159

Namrita Kumar Brooke and Ludmila Cosio-Lima
Cycling is predominantly an endurance sport in which fuel utilization for
energy production relies on the availability and delivery of oxygen to exer-
cising muscle. Nutrition and training interventions to improve endurance
performance are continually evolving, but ultimately, prescription should
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aim to generate improvements in cycling power and velocity while priori-

tizing athlete health and well-being. The wide range of cycling events
and the different environments in which events take place pose a variety
of nutrition-related challenges for cyclists. This review addresses some
of these challenges and highlights recent advancements in nutrition for
cycling performance.

A Coaching Perspective on Modern Training Metrics and Return from Injury and
Illness 173
Kolie Moore
Guiding cyclists in their return from illness and injury can be managed in
many ways. Understanding how cyclists use power-derived training met-
rics can give care providers a common language to aid in this return. A
general understanding of these metrics may be used to monitor cyclists
for signs of nonfunctional overreaching or overtraining. Understanding as-
pects of training and detraining, particularly hematological, is helpful in
communicating fitness expectations. Three populations of cyclists are dis-
cussed in terms of their expected knowledge of these metrics, typical
training volume and intensity, and relationship with a coach or coaches.

Cervical Spine, Upper Extremity Neuropathies, and Overuse Injuries in Cyclists 187
Andrea Cyr
Upper extremity nerve injuries in cyclists include carpal tunnel syndrome
and ulnar neuropathy at the wrist. Electromyography and nerve conduc-
tion studies aid in the diagnosis of neuropathies. Diagnostic ultrasonogra-
phy or MRI can also be helpful for evaluation. Overuse injuries in the upper
extremity includes biker’s elbow, or a tendinopathy of the common flexor
or extensor tendons, which is more common in mountain biking. Neck pain
is also a common issue for cyclists. Treatment of these conditions varies
from conservative management to surgical options, but a bicycle fit
assessment is recommended for any ongoing symptoms.

Lumbar Spine and Lower Extremity Overuse Injuries 201

Tracey Isidro, Elaine Gregory, Laura Lachman, Stacey Isidro, and Angela N. Cortez
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 popu-
lation. 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 in-
dividuals 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.