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Toolbox: Preventing Cycling Injuries
As with all competitive sports, there is also a risk for injury in competitive bicycling. It is important to understand the pattern and epidemiology of injuries suffered by competitive bicyclists in order to implement appropriate injury prevention and treatment strategies.

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The patterns of injury in bicycling are unique since exposures include high speed, obstacles like cyclists, pedestrians and motor vehicles, and unpredictable road, environmental and weather conditions. Furthermore, bicyclists usually do not have any external protection beyond wearing a helmet. There is a risk of both acute traumatic injuries and overuse injuries. Injury patterns also differ between the type of bicycling, that is, road, cyclo-cross, off-road/mountain bike, and BMX, etc.

The majority of studies examining the epidemiology of injuries in competitive bicycling are retrospective questionnaire and/or interview in design (Bohlmann 1981; Callaghan and Jarvis 1996; Clarsen, Krosshaug, and Bahr 2010; De Bernardo et al. 2012; Pfeiffer 1993; Pfeiffer 1994). That is, bicyclists are surveyed or interviewed as to what injuries they suffered from a preceding period of time.

These types of studies are easier and less expensive to conduct but are susceptible to confounding factors such as incomplete and/or inaccurate details and recall and selection bias. Also, the incidence of injury and rates of injury cannot always be determined since accurate exposure data is not usually known. Finally, in professional and competitive bicycling, bicyclists may not accurately report injuries for strategic reasons. Nonetheless, these studies are still valuable for providing an idea of the epidemiology of competitive bicycling injuries.

A few prospective injury surveillance studies have examined injuries suffered by competitive road bicyclists over a numerous year time period (Barrios et al. 1997; Barrios et al. 2011) or during a single or a series of BMX and off-road bicycle race(s) (Brøgger-Jensen, Hvass, and Bugge 1990; Chow and Kronisch 2002; Kronisch et al. 1996).

The usual outcome measures that injury studies try to quantify include the incidence, rate, location, severity and type of traumatic and overuse injuries. The findings of bicycling injury studies to date can be difficult to compare because definitions of injury, calculations of injury incidence and rates, and descriptors of location, severity and type of injury are not consistent.

Given the high-speeds and unpredictable nature of bicycle racing, it can be difficult to prevent falls and collisions, which result in acute traumatic injuries like fractures. Having a properly maintained bicycle is very important to prevent mechanical failures, which may result in falls and crashes.

In this third article of a three article series on injuries in competitive cycling, injury prevention strategies will be reviewed.

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Bike Fitting
Proper bicycle fitting is the most common recommendation for prevention of overuse injuries of both the upper and lower extremities, neck and low back (Mellion 1991; Holmes, Pruitt, and Whalen 1994). This includes not only having a proper frame size to begin with, but also appropriately adjusted seat height and backwards/forwards positioning, cleat positioning, pedal float, forward reach, and handle bar and brake lever positioning.

It should be noted that there are many methods for fitting a bike fitting including using formulas, laser scanning, dynamic fitting, 2- and 3-D motion analysis. Each method has its own pros and con and the “quality” of fitting is usually fitter dependent. Bike fitting may seem to be more of an “art” than a science.

The position that is optimal for power generation and aerodynamics may not be the best position for prevention of injury. Moreover, the effects of positioning on a bicycle on injury prevention is actually not well studied. For example, Bini, Hume, and Croft (2011) reviewed the few studies examining the effects of seating position (height and forward/backward) on knee joint compressive forces, knee injury risk and bicycling performance and found that the results of the studies were conflicting. Given the uncertainty of how seating position might affect compressive forces in the knee, it was recommended that seat positioning that allows flexion of the knee to 25 to 30 degrees with the foot at the bottom of pedal stroke may be the best position to prevent knee injuries while allowing for optimal performance.

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Progressive and Smart Training
Other aspects of injury prevention include a well-thought out training program which allows for gradual and progressive increases in training volume and intensity with appropriate periods for recovery and cross training. There are fewer guarantees in life than a greatly increased risk of overuse injuries with sudden major increases in training workload. Once the racing season is into full swing, it becomes even more important to plan training to accommodate and maximize recovery from the hard racing efforts.

Care with training must also be taken whenever you try new equipment or alter position, as even seemingly minor things like replacing your worn-out saddle with a brand new identical saddle will likely cause a change in positioning and thus biomechanics. If replacing your cleats, make sure to mark your old position so that you can get the identical positioning. In all cases, it is likely wise to build in a few easy rides to test out and adapt to the new changes before resuming hard or prolonged training.

A complimentary lower body and core strengthening program should also be incorporated into a bicyclist’s overall training program. This will greatly improve the capacity for absorbing the hard training on the bike, along with the vibrations from riding.



Wear Your Helmet!
All bicyclists should wear a safety-approved and properly fitting bicycling helmet. Although not specifically studied in competitive bicyclists per se, there is good evidence that wearing a bicycling helmet reduces the risk of head, brain and severe brain injury by 75 to 88% across all age groups (Thompson, Rivara, and Thompson 2009). Furthermore, there is a protective effect of 65% for upper and mid-face region injuries.

Some bicycle helmet manufacturers are now incorporating a Multi-directional Impact System (MIPS) into the design of their helmets. Helmets with MIPS technology have been shown to reduce the rotational impact forces on the head by 30% in the event of an oblique impact, which may further reduce the severity of a concussion injury.

In summary, there is a high incidence of injury in competitive bicycling. Knee and low back injuries are the most frequently injured body locations. Although the injuries that are sustained are typically minor in severity, many result in prolonged periods of reduced or stopped training and competition. Multiple strategies are required to prevention both traumatic and overuse injuries.

The first article in this series looked at the rates and severity of cycling injuries.

The second article in this series looked at location, type, diagnosis and mechanism of injury.

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.

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Bibliography
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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.

Barrios, C, D Sala, N Terrados, and JR Valenti. 1997. “Traumatic and Overuse Injuries in Elite Professional Cyclists.” Sports Exercise and Injury.

Bini, Rodrigo, Patria A Hume, and James L Croft. 2011. “Effects of Bicycle Saddle Height on Knee Injury Risk and Cycling Performance.” Sports Med 11 (6): 463–76.

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Thompson, Diane C, Fred Rivara, and Robert Thompson. 2009. “Helmets for Preventing Head and Facial Injuries in Bicyclists.” Cochrane Database Syst Rev.of Systematic Reviews, no. 4. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001855/pdf/standard.

Van der Walt, Alta, Dina van Rensburg, Lizelle Fletcher, Catharina Cornelia Grant, and Andrew John van der Walt. 2014. “Non-Traumatic Injury Profile of Amateur Cyclists Entering a One-Day Cycle Challenge.” Submitted for Publication.

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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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