Cycling

1. Hip and Groin Pain

Hip and groin pain can be multifactorial in nature and the most common presentations are described below: 

1. Femoroacetabular impingement: 

It is a painful condition in the groin due to underlying morphological abnormalities of the hip joint. However, underlying abnormalities may be present on radiological examination but without pain and it is common in the majority of population. A non-symptomatic femoroacetabular impingement is more likely to become symptomatic with athletes or due to changes in activities or training. The grading of the pathology depends upon your clinical presentation and not on your radiological imaging.

Symptoms include intermittent catching pain in the groin region with specific positions of the hip, such as flexion when the knee approximates the chest or rotation, as so in cycling. This condition rarely affects sleeping and it is normally pain-free soon after cessation of aggravating activity or position. If the pathology has been present for a while, inflammation will result in more generalised pain that can become a constant ache and can affect other structures. It can also lead to morning stiffness or stiffness after a period of rest, which will ease off with a few minutes of walking. Pain medication and especially anti-inflammatories can temporarily relieve the symptoms but it is important to understand that it will not cure the underlying condition. Signs of bruising or inflammation are rarely seen with a naked eye but examination will reproduce the symptoms. If there is a need for confirmation, further imaging may accompany the clinical examination.   

2. Labrum tear: 

The labrum is a fibrocartilaginous structure that surrounds the joint and it is necessary for stability. Tears in the labrum are frequently seen in the athletic population but they also develop in the ageing population. A tear in the labrum is most commonly causing groin pain but it can also result into buttock pain.

Symptoms are similar to the latter and include intermittent catching pain in the groin region with specific positions of the hip, such as flexion when the knee approximates the chest or rotation. This condition may affect sleeping and symptoms are likely to last for a few hours after cessation of aggravating activity. Symptoms of locking, clicking, catching and giving way may be present in the symptomatic population. If the pathology has been present for a while, inflammation will result in more generalised pain that can become a constant ache and affect other structures. It can also lead to morning stiffness or stiffness after a period of rest, which will ease off with a few minutes of walking. Pain medication with anti-inflammatories may temporarily relieve the symptoms but it is important to understand that it will not cure the underlying condition. Signs of bruising or inflammation are rarely seen with a naked eye but examination will reproduce the symptoms. Confirmation requires further imaging which may accompany the clinical examination.   

3. Tendinopathy related groin pain  

Pain in the groin area can be a result of adductor muscle tendinopathy or hip flexor tendinopathy. It is present normally with sudden increase in activity or training levels or a result of secondary irritation in the presence of the abovementioned. Usually it presents as stiffness at the groin and pain appears at the beginning of the training but then is relieved with continuation of activity. If this condition has been present for a while it may not be relieved with continuation of aggravating activities and may even become painful with activities of daily life. 

Management:

The management of the abovementioned is similar as they are interconnected. It includes a combination of activity modification to protect the affected area from further irritation and evaluation of cycling posture will allow the clinician to advise you on changes that can be made according to your pain. Followed by exercise rehabilitation beginning with simple exercises which are the basis for then progressing and loading the joint to allow for necessary adaptations in posture and structures in order for you to return to cycling. In addition, in the initial stages, ice or pain medication may be advised to allow for progression with exercise rehabilitation. Manual techniques may be used with to decrease your pain and improving function. Other treatment modalities may be considered depending on your symptoms and rehabilitation is tailored towards each individual. 

In severe cases operation of the labrum and femoroacetabular impingement may be considered and it is very unlikely that this will be the choice for primary tendinopathy. Following your operation, the rehabilitation will begin with a combination of ice and pain medication as well as using crutches in the initial days. This will be combined with simple lying down or standing exercises to re-activate muscles that are now malfunctioning due to the operation. As you progress the pain from the operation will decrease and you will be able to tolerate walking and more exercises. Static cycling without resistance starts after you are able to normally walk unsupported. Then progressive exercise rehabilitation and manual techniques may be used as in the non-operative approach. 

Neck Pain

Neck pain in cycling is common especially with the use of racing bikes and with long distances. Racing bikes a lot of times cause people to ride with a bad posture, meaning flexed lower and upper spine causing hyper-extension in the neck. The neck as any part of the spine has joints that if they are fixated in a specific position for long time, such as long-distance cycling, can result into mechanical neck pain. However, as the body degenerates in the aging population, these symptoms may come sooner and persist longer.  

The symptoms of neck discomfort include pain with prolonged cycling that worsens as you continue your activity. These may be accompanied with stiffness around the neck and shoulder muscles as the body attempt to protect an irritated area. As this worsens, headaches and inability to find comfortable positions in your day are not uncommon. Sleeping is not normally affected, however in the presence of stiff muscles it may be difficult to find a comfortable position for your head. During the morning the feeling of stiffness may be experienced as more severe and a hot shower may give temporary relieve. The pain may range from mild ache to severe discomfort depending on the irritation of the underlying structures and your daily activities. Desk job is associated with the protracted extended position in the neck that will result in pain at work. Feelings of clicking and grinding of the neck or radiating pain in the arm or fingers are due to underlying pathologies such as degenerative changes in the disks or from nerve irritation respectively.

Examination will commonly reveal a protracted neck posture with weakness in the deep stabilizing muscles of the neck as a result of persistent hyper-extension. In addition, there is commonly provocation of symptoms with specific neck positions and total range of movement may be limited, especially in rotation or tilting of your head. Stiffness of the surrounding muscles as explained before is not uncommon and is secondary causing the reduced range of movement. Strength in the shoulders is unlikely to be affected but can result in a case of secondary nerve irritation. 

Management: 

The management of the cyclist’s neck is with conservative management and may include analgesia or heat application in the initial stages of rehabilitation. In addition, instruction of correcting posture in activities of daily life and in cycling will allow for gradual resolution of the underlying irritation. In order to maintain a correct posture, exercises for the neck and upper back muscles will be initiated and will be combined with a variety of manual techniques. These include a combination of soft tissue work on the surrounding stiff muscles and mobilization of the spine to increase mobility of the affected segments in your spine. This will allow you to progress to returning to your previous levels of activity without discomfort. 

Shoulder bursitis

Bursa refers to a water-like structure found in various locations in the body aiming to prevent friction between areas which are compressed. They are highly innervated structures which are extremely painful if they become symptomatic. The bursitis in the shoulder refers to a pathologic inflammation of the sub-acromial bursa which has been inflamed due to an injury. The common mechanism of this injury would be a direct fall onto the shoulder. This will lead to immediate pain which over the hours will limit the range of movement due to significant discomfort. 

The person with a typical shoulder bursitis will complain of aching pain on the shoulder with sharp pain during arm elevation. He/ She will not be able to lying on the affected side and may report waking up at night due to rolling on the side. The pain will be difficult to localise and may refer around the shoulder. There will be a typical mechanism of injury with a direct trauma on the shoulder. However, it is important to mention that a bursitis may have a non-traumatic cause that has developed over a different pathology; however this will not be the typical case with a cyclist. 

Examination will reveal pain and difficulty elevating the arm. There will not be any underlying shoulder weakness unless if this result due to pain. Functional daily tasks may become difficult because of the inability to use the shoulder as previously. Specific assessment manoeuvres will help guide the clinical towards its diagnosis, however specific radiology with ultrasound may be used to rule in the bursitis and exclude other tissue damage. 

Management: 

The management of the shoulder bursitis is commonly conservative with great outcomes. This is achieved with ice, anti-inflammatory medication, and activity modification. However, in cases of severe bursitis a corticosteroid injection may be used directly into the bursa. This has great outcomes and will be used in a shoulder that has failed conservative management. 

Patellofemoral Joint Pain 

Patellofemoral joint refers to the articulation between the knee-cup and the long bone of your upper leg. This joint is highly mobility and helps to distribute load from the muscles to the bones. Its mobility depends on several factors such as muscle stability and balance, joint appearance and forces directed in the knee. Pain in this joint is likely to be a combination of the latter. In cyclists it is common and especially in the athlete with poor balance between the muscles.    

The pain in this joint will be either acute with a sudden movement while cycling or may have a gradual onset and worsens over time. It is activity dependent therefore periods of less intense training may reduce your symptoms. However, increase of your training load again may result in the recurrence of this issue. 

Examination is aiming to identify weakness, body alignment and technique as well as other contributing factors that result to this pathology. A structured assessment may show underlying weakness in the gluteal muscles and potential hyperactivity in adductor muscles and hip flexors. In addition, a technique analysis may reveal a cycling style that will predispose to this pathology. 

Management: 

The management of the patellofemoral joint pain will be conservative with specific physiotherapy techniques aiming to relieve the symptoms. Secondly the rehabilitation will continue aiming to prevent recurrence of the pain addressing potential contributing factors that have been identified from the examination.