Cycling and Back Pain Part III

How can something so good for you as cycling be so bad for you? In exploring the various potential causes for back pain while cycling, it’s time to face up to the problems caused by improper bike fit or the act of cycling itself…

By Rick Rosa, D.C.,D.A.A.P.M.Get Fit(ted)We’ve plugged it here on RecoveryDoc before, but the best thing you can do for yourself is to get a proper bike fit to make sure you and your bike are a pair of happy amigos throughout your long and passionate relationship. Much of the way we set up of bikes often has more to do with style and what we think the pros do, rather than what type of riding we actually do and the way our body works. With bike fit we have several areas to consider when it comes to influences on pain. Please note that the below are just general principles to consider along with recent trends, and that your exact needs are individual and can only be discerned by professional bike fitters.

• First off, improper position of the saddle will increase the load on the lumbar spine, and we definitely don’t want to do that. In fact, a study done at Chaim Sheba medical center in Tel Hashomer Israel examined saddle position and found that if they changed the seat height from a horizontal to 10 to 15 degrees rise, it decreased symptoms in 70% of the study population.

• Next, chances are that with proper saddle height you avoid the rocking back and forth motion in an effort to reach the pedals as well as the change in lumbar muscle recruitment patterns by having the seat too low. • An overly long reach to the bars may also stretch your back an increase spine loading, and two recent studies found benefit from moving the seat forward. Next, you can use a handle bar with less drop, especially if the problem occurs while racing. Remember to train in the drops as well as on the tops to allow your body to be adapted to both positions. Another quick fix is a shorter stem and/or raising the stem as this will help with the position of your spine and create less stress. Bad Bike Bad!Apart from the way we fit ourselves to our bikes, the very act of biking itself, with its restricted and repetitive range of motion, can conspire to magnify any existing problems with physiology or bike fit. Some things to consider about the act of cycling itself, and more importantly what we can do to minimize the stress:

• Road vibration on the road or the trails can really pound on your back, especially as it’s in a stretched out position horizontal to the vibration itself. So what can you do to decrease this road vibration? Change hand positions, don’t lock your elbows, and use padded gloves and handle bars. Consider some of the elastomer inserts that are appearing on the road market in forks and handle bars and tape, and seat tubes. Lastly, wider tires can also help decrease road vibration.

• Most of us are aware that leg length discrepancies can be problematic with cycling. However, most people do not realize that many changes in leg length can be functional in origin, meaning that the muscle and joint tissue on one side is causing the decrease in leg length as opposed to say a shorter femur on one side. Functional changes can be treated by a professional only and can basically even out the legs. Structural changes need to be evaluated as well. You may have either a custom orthotic measured or you can use some of the shims that are used at the pedal. This will correct the biomechanics and thus correct the problem.

• The riding position also creates strength differences between your back and abdominal muscles. You are flexed over the bike for extended periods of time and this not only stresses the lumbar spine, but over activates it. This means that the signal that is sent to the brain and back kinda keeps ringing while the abdominals get less and less signal so that over time you develop comparatively weak abdominals. In addition, riding a big gear and climbing up hills changes the recruitment pattern and utilizes the muscles of the lumbar erector group as well as gluteals to a higher degree. So what can you do to correct this problem? Core training does not just mean abs and back. It also involves the hips and shoulders.

• Active stretching, along with other workouts including pilates, yoga, and resistance training, results in flexibility of the back and hips. This will increase the length of the muscle and will decrease the pull on the pelvis and low back marinating normal biomechanics. One quick fix while on the road is to stretch back first (assuming you do not have a disc herniation or facet syndrome) and contract those back muscle while holding that position make sure your knees are bent slightly. Then flex forward trying to touch you toes. Lastly, turn your feet in and then out and repeat. This will target the inner hamstring fibers and adductors as well as gluteal muscles and hip rotators. You’ve heard it since you were a wee lad/lass in gym class, but these off-bike flexibility and core based workouts really pay off in decreased injury risk in both the short and long-term.

• One other problem I see with athletes, especially during the off-season, is that they will miss a few workouts and then proceed with a super hard work out in the trainer with the front wheel elevated. Needless to say, the next day their ass and back are screaming. Well that’s because they just overloaded the muscle group with little rest. Don’t make up for lost pedaling by going nuts when you get back on the bike. It never, ever, works out and you will end up injured, I promise.

References1. Fanucci E, Masala S, Fasoli F,Cammarata R, Squillaci E, Simonetti G. Cineradiographic study of spine during cycling: effects of chaning the pedal unit position on the dorso-lumbar spine angle. Radiol Med (torino) 2002 Nov-Dec;104(5-6):472-62. M Salai, T Brosh, A Blankstein, A Oran and A Chechik Effects of changing the saddle angle on the incidence of low back pain in recreational bicyclists. Br. J. Sports Med. 1999;33;398-4003. Ganzit GP, Chisotti L, Albertini G, Martore M, Gribaudo CG. Isokinetic testing of flexor and extensor muscles in athletes suffering from low back pain. J sports med phys fitness 1998 Dec;38(4):330-6.4. Bressel E, Larson BJ. Bicycle seat designs and their effect on pelvic angle, trunk angle, and comfort Med Sci Sports Exerc. 2003 Feb;35(2):327-325. Green BN, Johnson CD, Maloney A. Effects of altering cycling technique on gluteus medius syndrome. J Manipulative Physical Ther. 1999feb;22(2):108-136. Callaghan MJ Jarvis C. Evaluation of elite British cyclists: the role of the squad medical. Br J Sports Med. 1996 Dec:30(4):349-537. Mellion MB Common Cycling Injuries. Management and prevention. Sports Med.1991 Jan;11(1) 52:-708. Angus F. Burnett, Mary W. Cornelius, Wim Dankaerts and Peter B. O’Sullivan. Spinal Kinematics and trunk muscle activity in cyclist: a comparison between healthy controls and non-specific Chronic low back pain Subjects-a pilot investigation.9. Salai M, Brosh T, Blankstein A, Oran A, Chechik A. Effect of changing the saddle angle on the incidence of low back pain in recreational bicyclists. Br J Sports Med 1999;6;398-40010. Usabiaga J Crespo R, Iza I, Aramendi J, Terrados N, Poza J. Adaptation of the lumbar spine to different positions in bicycle racing. Spine 1997;17:1965-911. Mellion M. Neck and back pain in bicycling. Clin Sports Med 1994;1:137-64
About Rick:Rick Rosa, DC, DAAPM, is a practising chiropractor based in Maryland. He is the owner of Rosa Rehab in the Washington, DC area, and has worked as a team doctor for a wide variety of champion boxers and cycling teams.

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Cycling and Back Pain Part II

Ok, so your back hurts and you want to know what to do. First off, you CANNOT ride your back better. Even though as you warm up, you may increase blood flow to the lumbar region of your spine and decrease your pain level, chances are that the back will continue to produce pain. As a result, you will be riding with altered biomechanics. This is never a good idea because it will only increase your problem.
By Rick Rosa, D.C.,D.A.A.P.M.

What's going on inside my back?
If we go back over the items that we mentioned in the first article on back pain, we had spinal disease listed first. The obvious thing here is that you get the problem treated. If that’s some type of organic disease like metastasis, SLE, gout, etc. you need to get that disease treated first by your physician and then explore when and if you may return to the bike.



Now, if the cause is a herniated lumbar disc you should progress through conservative treatments first like chiropractic, physical therapy, nutrition, and medications (we combine these in my office). The earlier you get treatment the better the chances are for the inflammation and tissue to shrink so to speak and stop putting pressure or chemical irritation on the nerve root. I advise cyclists to get treated ASAP and to combine some of the conservative treatment options because this condition can be very difficult to treat for a cyclist.

Why you ask? Well, when you ride your bike you are in a flexed position and this tractions or pulls the nerve root over the herniation or disc material. Once you have been treated successfully for this condition, you can move into a rehabilitative phase where you can incorporate some of the methods I will present in the other treatment sections.

Not Good Reading…
If you don’t respond to conservative treatments, then what? In my clinic we then combine epidural blocks (injections of medication into the spine near the nerve) in a series of up to 3 total blocks for 3-4 weeks combined with various forms of traction and rehab. If all of this fun stuff still doesn’t provide you with the relief you’ve been searching for, surgery may be in your future. If this becomes the only option, you would want to go with a neurosurgeon that can perform a minimally invasive technique if they can and will be followed up with rehab.

Another spinal disease that may affect the more mature cyclist is Degenerative Joint Disease (aka Osteoarthritis). This is where a build up of bone can cause spinal stenosis (a decrease in the size of the hole where the spinal cord and spinal nerve roots travel through. It is a build up of bone due to various stressors being placed on the joints over time. In fact, most of us will develop at least a small amount of DJD over time but it is only when the spine or nerve roots become compromised where we get a serious problem. The symptoms are similar to a disc herniation but your doctor will obviously be the one that will determine your condition. The treatments are similar to the ones previously mentioned but the chances are smaller that you will respond to care.

Don't Fall
Of course we can’t forget to mention trauma. Oh the glorious pain of falling of your bike and if you haven’t yet taken a tumble, you will at some point. If you happen to fracture one of the vertebrae, you may have a medical emergency so don’t move your body. In a serious fall, let the EMT handle the situation. You don’t want a fractured spinal segment cutting into the cauda equina (bottom of spinal cord.) If your broken back does not require major spinal reconstruction and you don’t have a compression fracture of the vertebrae, then rest or a new procedure called vertebroplasy may be recommended. This is where they inject a cement like material into the bone to butteress the vertebrae from within.

In the best case scenario, you sprain your lumbar spine and this can be very painful. The amount of fluid that develops from the inflammation is a lot less then say your knee but the joints are much smaller and tighter. The result is pain. Typically, you strain the muscles of the spine which means you tear some of the fibers and strain the joint tissue which means over stretching of the ligaments. The worst part is the muscle spasms that are an inherent reflex mechanism that will be present the following morning when you wake up in pain and as stiff as titanium.

So what do you do? Well see your doctor (I know you are sick of me saying that) and you should begin a combination of acute care treatment, physical therapy, spinal manipulation, and proper nutrition and or medication. The idea is to decrease the amount of scar tissue formation, restoration of proper spinal biomechanics, decrease of inflammation and pain. Most cases responded very well to this combination of treatment and you will soon be in the final or rehabilitative phase.

In Part III I will discuss the final two areas, namely bike fit and the problems that occur from the act of cycling. You will be able to pick up there when you have recovered enough from the previous mentioned injuries.

Reference

1. White III,AA and Panjabi, MM:Clinical Biomechanics of the Spine. Lippincott Williams & Wilkins Baltimore ed. 2, 1990
2. Cilliet, R: Low Back Pain Syndrome. F.A. Davis Company Philadelphia ed 4, 1992
3. Cox, J: Low Back Pain. Williams & Wilkins Baltimore ed 5, 1990
4. Reilly: Practical Strategies in Outpatient medicine. Sounders ed 2 1984

Back Pain and Cycling

I think many of you might be surprised to hear that the number one complaint reported by cyclist has been back pain, with numbers ranging from 60-70% in various studies. The first question that should be answered is what the cause of back pain is for cyclist.




One interesting study was done by the British Cycling Federation on the squad medicals of its elite cyclists and found that 60% of the 500 elite riders had low back pain. Bicycling is one of those unique sports where the human-machine interface is paramount. As we discussed previously when discussing cadence and PowerCranks, the repetitive and constrained motion of cycling is an invitation to injury if the interface is not optimal. While everyone can benefit from a top-notch bike fitting session, it’s not always the primary reason behind back pain, and the first question that should be answered is what the cause of back pain is for cyclist.

Four major sources of problems that may bring about back problems include:

1. The first cause can be some type of spinal disease that may or may not be related to the activity of cycling (i.e. Disc herniation, arthritis, metastatic disease.)

2. Acute trauma from a fall or crash while ridding like Tyler Hamilton had in the 2004 Tour de France.

3. Bike fit, from proper seat angle and height to stem length and drop position has been shown to cause back pain.

4. The biomechanics of cycling itself and your body’s ability to adjust.


First thing I would recommend that you have your back pain evaluated by a chiropractor, physical medicine specialist or orthopedic surgeon that has a background in sports injuries. One potential serious cause of back pain, namely spinal disease, can only be determined by a proper examination that may include x-rays, MRI, Bone scans and blood work. Due to the many cause of spinal disease some may limit or take you off the bike while others would actually benefit from riding. The key here is to have a proper diagnosis made so you can treat the problem properly.

Second, acute trauma from a fall or crash can result in a fracture of the spine which is very serious injury and should require immediate attention (except if your name is Robbie McEwen and you finish Le Tour 2004 and win the Maillot Vert anyway – wow!). If we don’t fracture the spine we can bruise the muscle and joint tissue and as well as cause a sprain/strain injury of the ligaments, tendons and muscle that support the spine. This can be very painful and would leave you with a significant decrease in power. This was evident a few years back at the Tour when Tyler Hamilton had to abandon due to back pain. Remember, this is the same guy who rode the Tour de France with a fracture collar bone the year before, so it’s not always something you can shrug off!

Bike fit is very important because small changes in biomechanics of the spine can lead to increase in load, stretch or compression on bone, muscle, ligaments and tendons. Seat position and angle, the length and angle of the stem, as well as the amount of drop of the handle bars all can contribute to low back pain and stiffness. Lastly vibration while riding can aggravate any symptoms you may have.

The biomechanics of cycling itself, even if perfectly fitted to the bicycle, can cause back pain. A study done In Australia in June of 2004 looked at muscle activity of cyclist that did and did not have back pain and they found that the more forward flexed the rider was during the test the more likely he was to develop pain in the muscles that are on each side of the spine ( lumbar erectors). In addition, a small spinal muscle that is a stabilizer called the lumbar multifidus muscle was not contracting when it was supposed to and the abdominal muscles showed decrease activity. Both muscles are spinal stabilizes. So what? You say. Well basically this sets up an imbalance and puts a large demand on the low back.

So what can you do to help yourself with any of these problems or better yet prevent them from occurring in the first place?

Check out part II of cycling and back pain.