What's Cool In Road Cycling

Toolbox: Lower Back and Neck Pain

The Giro’s decisive Chianti TT this past Sunday placed a heavy emphasis on both massive power AND aerodynamics. The key to both is a healthy and strong lower back and neck. What are some symptoms and management of pain in these areas?

Aerodynamic positioning on a bicycle requires bending forward at the low back and hips and maintaining the neck in an extended position in order to see ahead and maintain an aerodynamic position. This is true of both time trialing but also of all cycling in general.

Given the prolonged duration that bicyclists maintain this position, it is not surprising that 13 to 60% of competitive bicyclists complain about low back and neck pain (Barrios et al. 2011; Callaghan and Jarvis 1996). The potential patho-mechanical reasons for the development of low back pain in bicyclists includes: flexion relaxation, muscle fatigue, spinal extensor over-activation, mechanical creep, and disc ischemia (Marsden and Schwellnus 2010).

Greve - Italy - wielrennen - cycling - radsport - cyclisme - Gianluca Brambilla (Etixx - Quick Step)  pictured during  stage 9 of the 99th Giro d'Italia 2016 from Radda  to Greve ITT - Time Trial individual - foto LB/RB/Cor Vos © 2016Giro d’Italia leader Gianluca Brambilla: Aero, but comfortable?

Diagnosis
Fortunately, low back and neck pain in bicycling is usually benign in nature, involving strains of the paravertebral soft tissues (muscles and ligaments) and/or facet joints of the lumbar and cervical spine. If one experiences persistent pain when not bicycling and/or associated symptoms of radiation of pain, numbness and/or tingling down the upper or lower extremities, sensory changes in the hands and feet, muscle weakness, loss of deep tendon reflexes, loss of control of bowel and/or bladder function, then more serious causes of neck and back pain include disc herniation, nerve root impingement, facet joint osteoarthritis, and spinal stenosis, may need to be considered. Further evaluation by a physician and with diagnostic imaging, including x-rays and spine MRI may be required.

Management
Management strategies to prevent or reduce neck and back pain includes:

1. Modified training. Training intensity and volume should be decreased to a level which does not cause the reproduction of one’s symptoms.

2. Changing position. Avoiding staying in one riding position for too long by regularly flexing and rotating the neck and extending and rotating the low back during a ride. Standing up on the pedals and stretching the hamstring muscle can also be relieving.

3. Medication. For more severe symptoms of an acute cervical or lumbar spine strain, oral and topical NSAIDs, oral analgesics and muscle relaxants and can be tried.

4. Therapy and Muscle Strengthening. Cervical spine, lumbar spine and pelvis “core” stability strengthening exercises should be incorporated into one’s off-bike conditioning program. Real-time ultrasound may be used by one’s therapist to evaluate the size and activation pattern of the paraspinal stabilizing muscles of the lumbar spine and to provide biofeedback to ensure that one is performing their strengthening exercises properly. For more acute or recurrent symptoms, massage therapy, chiropractic and physiotherapy treatments can be tried and may include spinal manipulations, manual therapy, acupuncture and intra-muscular stimulation (IMS).

5. Stay flexible. In bicycling, the spine, pelvis and legs act as a kinetic chain and tightness in one area may also affect the other areas. So it’s important to stretch the spine, pelvis, glutes, quadriceps, and hamstring muscles both on and off the bike to maintain and improve the flexibility of entire spine and it’s tolerance to biking position. Adding yoga to one’s training routine might also help.

6. Adjusting bicycle positioning. Assuming that one’s bike has already been fit relatively appropriately, adjusting reach distance and saddle tilt have been suggested to be the more critical bicycle positioning adjustments for the management of low back pain (Marsden and Schwellnus 2010). Tilting the saddle downwards, and thus tilting the pelvis forward, may help to reduce tensile forces on the low back tissues. The optimal reach distance is debated and a trial of both increasing and decreasing one’s reach distance may need to tried in order to determine one’s least provocative reach distance.

References
1. Barrios, C, Nieves De Bernardo, Pablo Vera, C Laiz, and Michal Hadala. 2011. “Clinical Patterns and Injury Exposure Rates in Elite Road Cycling Are Changing over the Last Decade.” Br J Sports Med 45: 310–84. doi:10.1136/bjsm.2011.084038.

2. Callaghan, Micheal J, and Christopher Jarvis. 1996. “Evaluation of Elite British Cyclists: The Role of the Squad Medical.” Br J Sports Med 30: 349–53.

3. Marsden, Mandy, and Martin Schwellnus. 2010. “Lower Back Pain in Cyclists: A Review of Epidemiology, Pathomechanics and Risk Factors.” International SportMed Journal 11 (1): 216–25.

Loano - Italy  - wielrennen - cycling - radsport - cyclisme - Elena Novikova stretching (Forno d'Asolo)    pictured during  stage 7 of the Giro d'Italia Internazionale Femminile 2015 (2.1) from  Arenzano to Loano - photo Anton Vos/Cor Vos © 2015Stay flexible


Written By: Dr. Victor Lun, MSc., MD, CCFP, Dip. Sport Med is a Sport Medicine physician who practices at the University of Calgary Sport Medicine Centre. He is the team physician for several winter and summer sport Canadian national sport teams.

Medical Advice Disclaimer
The information included in this article is for educational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult their healthcare provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a medical condition or treatment plan. Reading the information on this article does not create a physician-patient relationship.

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