Back Pain in Cyclists

Anna K. Abramson M.D., Sonny S. Gill M.D. , Michael Ross M.D.

Anna K Abramson M.D.  is an attending physician and Assistant Clinical Professor in the Department of Medicine at the University of California, San Francisco.  She is a co-founder of Medicine of Cycling.

Sonny Gill M.D. is an Adjunct Assistant Professor in the Department of Bioengineering at Clemson University and an orthopaedic spine surgeon with a special interest in cyclists with spine injuries.

Michael J. Ross MD is a sports medicine physician who has been the team physician for numerous professional cycling teams as well as the race doctor for the Philly Week series of races.  He is currently runs the Performance Lab, a sports medicine and exercise testing facility in Philadelphia.

Back pain is the second most common cause for primary care visits and one of the most common causes for discontinuing exercise and missed work days in the United States.  Cyclists are a demographically unique population, but studies of amateur and professional athletes alike indicate that up to 60% suffer from back pain.  Consequences of back pain result in medical visits, costs and increased use of medications for pain control, decreased quality of life, and decreased performance.  In this article, we discuss the most common causes of back pain in cyclists, modalities commonly used to assess and treat back pain, and the role of bike fit in alleviating and preventing back pain in amateur and professional cyclists.

Causes and Evaluation of Spine Pain:

Spine pain is a very common occurrence not only in the general population but also in athletic individuals.  The lifetime incidence of 48.3% of neck pain and 67.8% of back pain is reported in cyclists.  Of these athletes, nearly one-quarter is due to disc disease, with frequency of spine pain increasing with the years in sport.   Bicycle fit has been cited to be the most common problem causing spine pain including improper equipment, training factors, and anatomic factors.

When assessing a cyclist with neck or back pain, a broad range of possible culprits, must be considered and the physician assessing the athlete will likely perform a comprehensive musculoskeletal and neurologic physical exam.  Examples of exam and studies correlating to possible diagnosis include:

  • Palpation over bony prominences of the spine to evaluate for tenderness.
  • Asymmetric strength, altered sensory function, or diminished reflexes may predict a  neurologic compression in the spine.
  • X-rays of the spine to help assess for compression fractures.
  • A computed tomography (CT) scan may be indicated if the clinician is assessing for facet joint arthritis in cyclists who have pain with hyperextension.
  • In athletes with pain that worsens with changes in posture or forward bending, or neurologic features such as weakness, numbness or burning down an arm or leg are present, a physician may recommend a magnetic resonance imaging (MRI) study to evaluate disk Degeneration or herniation.

Diagnosis and Treatment Options:

Common diagnosis causing neck and back pain in cyclists include:

  • Trochanteric bursitis, due to the repetitive motion of pedaling.
  • Hip joint degeneration and arthritis, especially as the cycling population ages.
  • Snapping of the iliopsoas tendon especially during the down stroke of the pedaling motion.
  • Trigger point spasms can produce significant axial pain.
  1. Quite often, the trigger points are on the left side upper back, attributed to the         cyclist straining to look over the left shoulder for overtaking traffic.
  2. The trapezius has also been cited as a source of symmetric trigger points.
  • Hyperextension of the neck can lead to narrowing between the vertebrae and can cause nerve irritation of either the cervical (neck) or lumbar (low back) plexus.
  • “Unicyclist’s sciatica” is a pudendal nerve impingement from prolonged sitting on bike seat.
  • Pedal Pusher’s palsy is a form of sciatic nerve entrapment at the sit bones.

Assessment of a cyclist with back or neck pain should also include discussion about the core muscle strengthening program the cyclist has been undertaking.  The muscles of the low back serve as the platform for powering the bicycle.  A weak core creates a defective link in the chain from the shoulders to the pelvis that is meant to control the bicycle while absorbing the micro-trauma of road shock and vibration.

An aquatic therapy program can be especially important in cyclists because it allows the individual to off-load the core due to the buoyancy of the water but still perform exercises in the water that can progressively strengthen the musculature.  Furthermore, a supervised land-based therapy program that includes back, hip, gluteal and abdominal muscle groups that create pelvic stability in the saddle.   Advanced core strengthening can include activities such as pilates or stand-up paddle boarding.

There are many possible treatment modalities available in the case of an anatomic defect or injury

  • Physical and aquatic therapy program is first line of treatment for cyclists and general population.
  • Selective nerve root blocks or epidural steroid injections have been shown to help approximately two-thirds of patients with pain going down the legs.  NOTE: if treating an elite level cyclist, a onetime temporary use exemption (TUE) may need to be filed for injection steroids.  A full list of restricted medications can be found on the website for the U.S. Anti-Doping Agency.
  • Surgical intervention can be performed when the pain doesn’t decrease with the above measures.    A complete rehabilitation program is required after surgical intervention due to the chronic denervation and deconditioning that has occurred to the athlete over the course of the injury.

Red Flags Symptoms in Back Pain – requires urgent evaluation by a physician
Change in bowel or bladder control
Sudden loss of power or control of the legs
Numbness or “pins and needles” in the legs, groin, or around the anus
Back pain after fall with high velocity or from a height
Onset of back pain along with fever, night sweats, or weight loss
Onset of back pain after an infection

Bike Fit and Back Pain:

In many cyclists, low back pain can be directly related to bicycle position.  Considering that most overuse injuries occur due to lack of core strength or lack of aerobic conditioning to meet the demands of exercise, bicycle fit should be tailored to maximized available core strength.  One test that is extremely valuable in assessing for core weakness is the plank.  This position mimics the forearm/shoulder position during riding and it also mimics the position of the back when riding.

Plank position:

  • The athletes body weight is distributed on the forearms and the toes, back is level to the ground without bending at the waste or sagging.
  • Keep the shoulders over their elbows and keep the back in line with the thighs.
  • Hold position for 1 to 2 minutes.
Back Pain in Cyclists 1
  • If this position cannot be maintained, place the elbows on a small platform, such as a bench or supportive box. Keep raising the level of the platform until the cyclist can maintain the plank without back pain.  Once a comfortable position is achieved, attempt to set up the saddle/handlebars to replicate this position of comfort.

One of the most common causes of low back pain in cyclists is  a decreased support of the spine, with a long stem and a setback seat post, causing low back loading.  This is a position into which many riders place themselves hoping to increase aerodynamics without any regard for back comfort.  When the distance between stem and seat is too great, the result is in an increased bend in the hip angle.  The gluteal muscles which typically work together with muscles of the low back to stabilize the pelvis become stressed. .  The result is rocking of the pelvis from side to side and low back muscular strain.  Pushing the seat forward can alleviate this stress on the low back.

Some cyclists may resist losing aerodynamic advantage in favor of low back comfort, but shortening the cockpit can alleviate many causes of musculoskeletal pain and possibly avoid excessive forward bend that can result in disc herniation and spine pain discussed above. Additionally, these changes can make riders more efficient on the bike; the same power output can be achieved with less energy use.   One way to demonstrate the impact of low back hyperextension is to have the athlete return to a comfortable plank position with their elbows positioned under their shoulders.  Have the athlete walk the elbows forward ahead of the shoulders while keeping the rest of their body still.  This replicates position of long stem and back position of the saddle in which the cyclist will feel increased stress across the lower back.

Another consideration in bike fit lies with saddle height.  A saddle that is too high for tight hamstrings will pull the pelvis backwards, putting tension across the lower back muscles.  For proper bike fit, the angle between the trunk and thighs should not exceed that formed when lying on the back with the leg comfortably bent at the hip while the knee is kept relatively straight.

Bike fit performed by a trained expert can help prevent acute onset and more insidious onset back pain.  Though most cyclists can continue to train and compete through back pain, this pain reduces power on the bike and quality of life.  If the time is taken to assess the way the body works at rest, positions of maximum comfort may not be the most aerodynamic but will yield the best power output and speed by the cyclist.

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