bicycling injuries mitchell l. goldflies, md. topics history of bicycles overview of bicycling...

Bicycling Injuries

Mitchell L. Goldflies, MD

Topics History of bicycles Overview of bicycling injuries Bicycle components & riding gear Biomechanics of cycling Bicycle fitting

Topics Evaluation of injuries Overuse injuries Acute injuries Rehabilitation of injuries Training techniques

Bicycle History

Bicycle History Bicycle invented in early 1800’s 2-wheels connected by piece of

wood Penny Farthing bicycle

Pedal on front wheel Height of front wheel variable

Bicycle History Early 1900’s chain-driven bicycle

Bicycle History Early 1900’s chain-driven bicycle Little change in bicycle last 80

years

Bicycling Injuries Overview

Bicycling Injuries Acute

Motor vehicles Road surface Mechanical problems

Bicycling Injuries Acute

Motor vehicles Road surface Mechanical problems

Overuse Too much pedal resistance

Use lower gear ratio Use higher pedal cadence

Bicycling Injuries Prevention

Proper safety equipment Keep bike in top mechanical condition Anticipate errors of others Adopt and practice specific riding

strategies to prevent injuries


Common sense Stretch Sun screen Hydration & nutrition breaks Insect bites


Helmets Standard Full face

Padding Chest Shoulder Extremity

Bicycle Injuries Injury pattern has remained the

same for the past 60 years


same for the past 60 years The knee is involved with the most

common and serious cycling related overuse injuries


same for the past 60 years The knee is involved with the most

common and serious cycling related overuse injuries

Low injury rate compared to running and soccer

Bicycle Injuries Cycling accidents are responsible for

significant morbidity and mortality Death and hospitalization rates are highest

among male children and adolescents 5-19 years of age

Fatal and nonfatal bicycle head injury rates are highest in towns with a population less than 50,000 residents

Most acute injuries occur from simple falls from the bicycle

Bicycle Injuries Cycling accidents are responsible for

significant morbidity and mortality Majority (>60%) of fatalities are caused

by head injuries resulting from accident involving motor vehicles

Up to 85% of cycling fatalities caused by head injuries could be prevented by the use of appropriate cycle helmet

Bicycle Injuries Cycling accidents are responsible

for significant morbidity and mortality In 1997 225 children ages 14 and

under died in bicycle-related crashes Bicycle helmet use

15-25% use among child bicyclists 11% use for ages 11-14

Bicycle Injuries Cycling accidents are responsible

for significant morbidity and mortality Elevated blood alcohol concentrations

are found in 1/3 of fatally injured bicyclists aged 15 years and older

9.4 injury events per 1000 children in Kingston, Ontario in 1994

Bicycle Components & Riding Gear

Bicycle Components Frame material selection

Steel Aluminum Carbon fiber Titanium

Bicycle Components Road frame types

Upright Road Triathlon Touring Track Cruiser

Bicycle Components Frame selection

Upright Suspension-beam


Upright Mountain Cyclecross Hybrid BMX Comfort


Recumbent Steering

Above seat Below seat


Recumbent Tricycle Tadpole tricycle Quadcycle Arm powered Rowing


Tandem

Riding Gear >12 mph wind resistance greatest

factor limiting speed Cycling clothes decrease wind

resistance & chafing

Riding Gear Helmet 1000 cycling deaths per year

Most had head injuries 1/3 head injuries fatal

Glasses Rear view mirror Jersey Pants

Riding Gear Gloves

Decrease hand pressure Decrease abrasion

Socks Shoes

Less foot numbness with clipless pedals

Orthotics

Bicycling Biomechanics & Bicycle adjustment

Biomechanics of Cycling Pedal Cycle 1 complete circular motion of

pedal Power phase-push forward and down

on pedal Recovery phase-pull up and backward

on pedal

Biomechanics of Cycling Pedal Cycle Power phase muscles

Quads-extend knee and push foot forward

Hamstrings-hip extension Calves-ankle plantar flexion Gluteals-hip extension

Biomechanics of Cycling Pedal Cycle Power phase joint motion

Hip 50-75 to 10-20 deg. flex Knee 110 to 35 deg. flex Quadriceps Q angle Spin vs. pushing Ankling-terminal power phase Standing out of saddle and using

upper body

Biomechanics of Cycling Pedal Cycle Recovery phase muscles

Quads-knee extension & hip flexion Hamstrings-knee flexion Anterior tibialis-ankle dorsiflexion Iliopsoas-hip flexion

Biomechanics of Cycling Pedal Cycle Increased pedal cadence

Increase muscular activity No change in joint load

Increase saddle height Decrease maximum knee flexion

moment No change in hip flexion and ankle

dorsiflexion moment

Biomechanics of Cycling Pedal Cycle Cadence

>70 pedal RPM. Best 80-120 RPM. 5000 revolutions per hour

Imbalance of VMO and Vastus lateralis increases Q angle at knee

Biomechanics of Cycling Compared to Walking Moments same

Varus and Valgus at knee Ankle and achilles

Increased lower limb muscular activity VMO Vastus lateralis

Decreased lower limb muscular activity Anterior tibialis

Lower tibio-femoral and ACL shear

Bicycle Adjustments Frame

1” clearance between top tube and crotch when standing

Lower on mountain bike and sloping top tube bike

For recumbents measure the distance from the wall to heels when sitting against the wall

Bicycle Adjustments Seat height

High-spin Low-push Spin with heels on pedals and pelvis level

Seat position Plumb line from behind patella to pedal

spindle with pedal forward Forward-spin Backward-push

Bicycle Adjustments

Bicycle Adjustments Crank arm length

Floor to greater trochanter X 0.185 Longer for push Short for spin

Handlebar-type/width/angle Width-distance between coracoid

processes Keep upper body at 45 to 90 deg.

Bicycle Adjustments Pedal

Angle of gait Width Shims Ball of foot at or forward of pedal

spindle Cleat position

Fore and aft Rotation

Bicycling Injuries

Bicycling InjuriesEvaluation History

General past medical history Cycling specific history

Where in the pedal cycle the pain is experienced

Terrain Gears How was bike fitted Training program

Bicycling InjuriesEvaluation Physical Examination

Gait evaluation General musculoskeletal

biomechanical examination Specific examination of injured area Inspection of bicycle Observation of cycling

Bicycling Injuries Evaluation Imaging studies

Standard Radiographs Bone Scan MRI CT Scan

Compartment pressure EMG-NCV

Bicycling InjuriesOveruse Biomechanical factors

Genu Valgum Genu Varum Internal tibial torsion External tibial torsion Overpronation Leg length discrepancy Patello-femoral malalignment

Bicycling InjuriesOveruse

Bicycling InjuriesOveruse Overtraining/burnout Muscle cramping/spasm Strength imbalance

Cross training Strength training

Bicycling InjuriesOveruse-Spinal Spinal Pain

Up to 60% riders Areas

Neck pain Upper back and shoulder pain

Trapezius Levator Scapulae

Low back pain

Bicycling InjuriesOveruse-Spinal Spinal pain treatment

Bike adjustment/modification for proper fit

Technique change More upright riding position Keep elbows unlocked Vary head position


Use padded gloves Use padded or suspended handlebars Front fork suspension Wider tires Sit more upright Scapular stabilization Rear suspension or seat post


Correct lumbo-pelvic dysfunction Correct leg length difference Cant seat Recumbent bicycle Medical treatment

Bicycling InjuriesOveruse-Hands Upper Extremity problems

Neck Shoulder Elbow tendonitis Wrist tendonitis Neuritis

Bicycling InjuriesOveruse-Upper Extremity Elbow Pain

Medial epicondylitis Lateral epicondylitis Related to repetitive twisting Allow for mild elbow flexion

Wrist and hand tendonitis deQuervain’s tendonitis Grasping and twisting

Bicycling InjuriesOveruse-Hands Hands-Handlebar problems

Neuritis in 15% long distance cyclists Tingling Numbness Weakness

Bicycling InjuriesOveruse-Hands Hands-Handlebar problems

Ulnar Nerve Handlebar neuropathy Most common compression neuropathy Compression in Guyon’s canal

Median Nerve Carpal tunnel syndrome

Bicycling InjuriesOveruse-Hands Hands-Handlebar solutions

Change hand position every 30 sec. Padded gloves and bars Full finger gloves Limit wrist flexion and extension

Bicycling InjuriesOveruse-Hands Hands-Handlebar solutions

Bicycle fit Fit kit Serrota sizing bike

Change handlebars/stem Suspension forks/handlebar stem Recumbent bicycle

Bicycling InjuriesOveruse-Hip/Pelvis Iliotibial Band tendonitis and

bursitis Trochanteric bursitis Include Gluteus Maximus stretch and

move handlebars up and back to decrease hip flexion

Rest/Ice/NSAIDS Surgical release

Bicycling InjuriesOveruse-Knee Patello-femoral Dysfunction

Patellar tracking-functional Q angle Compression syndrome Chondromalacia Patellae

Patello-femoral Dysfunction-Treatment Move seat up Spin in lower gears Adjust pedals-rotation, width and canting Modify pedal design

Bicycling InjuriesOveruse-Knee Quadriceps tendonitis Synovial plica Patellar tendonitis Meniscal injury Pes anserine tendonitis ITB friction syndrome at the knee Baker’s cyst

Bicycling InjuriesOveruse-Lower Extremity Muscle strain/cramping/ Tendonitis/Bursitis

Hamstrings-lateral more than medial Calf & Achilles tendon

Raise seat Stretch Shorter crank arms Heel lift in shoe

Bicycling InjuriesOveruse-Lower Extremity Muscle strain, cramping and

tendonitis Shin splints

Anterior tiblialis muscle Exertional compartment syndrome Soleus syndrome Tibial stress reaction/fracture

Bicycling InjuriesOveruse-Lower Extremity Ankle and foot

Conditions Ankle tendonitis Tarsal tunnel syndrome Retrocalaneal bursitis Plantar fasciitis Foot burning/numbness

Bicycling InjuriesOveruse-Lower Extremity Ankle and foot

Treatment Proper shoe wear and orthotics Adjust pedals Stretch Adjust seat height Night splint Surgery

Bicycling InjuriesOveruse Saddle related injuries

Saddle sores-skin ulceration Irritation Traumatic urethritis


Pudendal nerve compression/neuropathy

Pressure on perineum from racing-saddles

Recurrent numbness in penis and scrotum

Altered sensation of ejaculation


Pudendal nerve compression/neuropathy

Disturbance of urination Reduced awareness of defecation Male impotence


Vulva trauma Chafing Perineal folliculitis Furuncles Subcutaneous perineal nodules

Bicycling InjuriesOveruse Saddle sores

Infection/pressure/friction Skin of upper thigh and rear end Furuncles and folliculitis Ischial bursitis Thigh chafing Skin ulceration

Bicycling InjuriesOveruse Saddle sores

Prevention & treatment Keep dry and clean Padded seat Good seat position Wound care Antibiotics

Topical Oral

Bicycling InjuriesOveruse Crotchitis

Women Warmth Moisture Friction Vaginal infections Allergies Bicycle position

Bicycling InjuriesOveruse-Treatment Manage saddle related problems

Change saddle Pad saddle Pad shorts Modify riding technique Recumbent bicycle

Bicycling InjuriesOveruse-Treatment Manage saddle related problems

Adjust seat Height Angle Fore & aft position

Stand up off the seat more often

Bicycle InjuriesAcute Acute injuries in off-road bicycle

riding & racing 0.20-0.40% overall injury rate for

racing participants 0.30% for recreational participants 20-88% of riders have an injury per

year

Bicycle InjuriesAcute Off-road crashes

Excessive speed Unfamiliar terrain Inattentiveness Riding beyond one’s ability Loss of control

Bicycle InjuriesAcute Off-road crashes

High-speed descent Competition Downhill more than cross-country

More flat tires Mechanical problems

More severe injuries when thrown off bike

Bicycle InjuriesAcute Acute injuries in off-road bicycle riding

& racing Majority of injuries are acute, traumatic

injuries involving the extremities Hand Wrist Lower arm Shoulder Ankle Lower leg


riding & racing Handlebars

Abdominal injury Handlebar hernia

Pelvic Genital injury


riding & racing Abrasions most common injury

Contusions/bruises Lacerations Sprains


riding & racing Fractures

20-30% Clavicle Fingers/metacarpals Scaphoid Colles/Smith/Barton Radial head/neck


riding & racing Dislocations A-C separations Concussions

3-12% Head and face injury

Dental injury & fractured teeth


riding & racing Off-road riders sustain more fractures,

dislocations and concussions that their road event counterparts

Bicycling InjuriesAcute Abrasions and Contusions

60-70% of injuries May include exposed bone Forearm Greater trochanter

Bursitis Lateral thigh

Bicycling InjuriesAcute Abrasions and Contusions

Lateral knee Lateral leg and malleolus Medial malleolus from crank arms Medial leg from chain rings Torso and back

Bicycling InjuriesAcute-Treatment Road-rash

3-grades Clean area frequently Topical antibiotics Cover with dressing

Bicycling InjuriesAcute Neurologic injuries and deaths

Alcohol is a contributing factor Skull fractures Intracranial injuries

Brain contusion Most common fatal injury Frontal lobe Temporal Lobe

Spinal injuries

Bicycling InjuriesAcute Head injuries (1040 ER visits)

4% helmet wearers 11% of non-helmet wearers 18% involving motor vehicles 7% not involving motor vehicles

Bicycling InjuriesAcute Thermal injury

Hypothermia Hyperthermia

Heat cramps Heat exhaustion Exertional heat injury Heat stroke

Layering clothes Acclimatization

Bicycling InjuriesAcute Dehydration

1-bottle every 20 minutes Camel-back

Glycogen depletion-Bonking Eat every 15 miles

Electrolytes Altitude sickness Sunburn Cardiovascular

Bicycling InjuriesAcute-Treatment Prevent further injury to rider ABC’s

Airway Breathing Circulation

Active bleeding Neck-spinal injury Fractures & dislocations

Bicycling InjuriesAcute-Treatment Call for help-911

Unable to sit up Hospital visit Family contact Return of bicycle

Bicycling InjuriesRehabilitation Modify training program PRICEM

Protect Rest Ice Compression Elevation Medication

Bicycling InjuriesRehabilitation Strengthen

Quads Hamstrings Gluteals Calves

Bicycling InjuriesRehabilitation Stretching

Gluteals Quads Hamstrings Calves TFL & Iliotibial band Iliopsoas Hip adductors

Bicycle Training Techniques Protect from cold or hot weather Proper warm-up & cool-down Adequate hydration and nutrition Monitor mileage, frequency,

intensity Limit weekly mileage increase to

10%

Bicycle Training Techniques Low pedal resistance High cadence 80-100 pedal rpm Frequent change in position

Hands Head & Neck

Bicycle Training Techniques Stretching exercises

During ride After ride Neck Calves/Hamstrings Quads/Hip adductors

Strengthening exercises

Conclusion History Hardware Biomechanics Evaluation and Treatment of Injuries

Acute Overuse

Training Techniques

Thank-You

bicycling injuries mitchell l. goldflies, md. topics history of bicycles overview of bicycling...

Documents

bicycle history slide

head injuries

gear slide

md slide

soccer slide

bicycling injuries mitchell

s chaindriven bicycle

wheel variable slide