Common Injuries and Conditions in Competitive and Recreational Cycling
While competitive and recreational cycling rely principally upon lower extremity strength and endurance, it is actually the upper extremity which is usually involved in traumatic or overuse injuries. This is due to the simple fact that the legs are constrained in the pedals, and the participant has to use the upper limb to cushion a fall. This leads to a wide variety of both traumatic and atraumatic injuries involving the hand, wrist, elbow and shoulder region. Fortunately, most of these injuries will not prevent the athlete from returning to their sport. It is, of course, head injuries that are the true danger. Nearly 50% of cyclist admissions to a hospital emergency room department are for head and facial injuries; the majority of these can be prevented by the simple use of a helmet. Protective gear is not practical for the upper limb since hand, wrist and elbow mobility is critical to performing the complex functions needed to maneuver a bicycle.
Traumatic injuries are most common. However, there are certain chronic injuries or conditions that can develop with the prolonged akward position required during road biking. Tendinitis usually involving the flexor tendons can be aggravated by gripping the handlebars and using brake or gear pedals. Carpal tunnel syndrome, which is a compression neuropathy of the median nerve at the wrist, can be exacerbated by the prolonged hyperextension posture of the wrist during cycling. This requires evaluation by a hand surgeon or a neurologist and simple nerve conduction studies will establish the diagnosis., The definitive treatment is, despite popular opinion, quite simple. This involves release of the transverse carpal ligament which is a 5-minute outpatient surgical procedure under local anesthesia that is often done endoscopically. It is an unfortunate myth that the public has been led to believe that this is due to typing or computer use.
Other chronic conditions such as lateral epicondylitis (tennis elbow) as well as shoulder bursitis can often be aggravated and conservative treatment usually suffices. Both tennis and golfers elbow can now be managed by non-invasive means utilizing Relef, a radiofrequency treatment that can resolve the problem painlessly.
Osteoarthritis, particularly at the base of the thumb, as is common in middle-aged women, is aggravated by hand positioning during cycling. The key for these chronic injuries is to be evaluated by a hand and upper extremity specialist because these diagnoses are often less clear-cut. The upper limb fractures are obviously less subtle in their diagnosis.
Most common fractures amongst cycling
The classic fracture discussed amongst cycling is the fracture of the collarbone or clavicle. This occurs when the rider tumbles over the handlebars and the resultant force on the arm and shoulder girdle leads to a break in this bone. Fortunately, most clavicle fractures are treated conservatively with a sling or figure-eight-type brace, but it has become increasingly common to perform operative reduction of these fractures in order to achieve the best result.
Much more frequent than the much-talked-about collarbone fracture are fractures about the wrist. The most common would be a fracture of the distal radius, which is the spongy bone portion of the forearm where it meets the hand, and is far-and-away the most common fracture seen in the adult population in general.
Treatment of these fractures in road cyclists
Treatment of these fractures has been revolutionized by a new method of fixation that was developed by my previous colleagues and I over 10 years ago. This involves an anatomic correction of the displaced bone and placement of a titanium plate and screws on the palmar aspect of the wrist that fixate the bone in the anatomic position. This allows for rapid recovery of function with essentially no long-term deficit. Cyclists can return to their sport within several months after this injury using this new technique.
Other injuries about the wrist include the common scaphoid fracture now managed with a compression screw to allow early motion and avoid stiffness and atrophy from prolonged casting. More subtle injuries to the wrist include ligament tears between the small carpal bones which require an astute examination by a wrist specialist in order to establish a diagnosis. This is the most common cause of chronic wrist pain and is an entity that requires careful attention. The clinician should be experienced in wrist arthroscopy since this is the only sure way to establish the diagnosis, and can offer minimally invasive treatment. The smaller bones in the hand can also be involved in trauma from a fall including phalangeal and metacarpal fractures, but these tend to be less common.
Fortunately, major fractures occur only during high-speed falls or in older riders who may have osteoporosis. Complex fractures about the elbow can occur and there is a great variation in the fracture patterns. It is important that an upper extremity specialist evaluate these injuries as recovery of full elbow range of motion is often difficult. Fractures of the upper arm (humerus) may also result from a fall and can even extend into the shoulder joint.
Cyclists are tough. @Kielreijnen is very banged up after this crash, with a swollen elbow the worst of his injuries. We will know more on his status tomorrow and hope he will get the green light to take the start. pic.twitter.com/Pi9N5T6DVk
— Trek-Segafredo (@TrekSegafredo) June 4, 2018
The key point is to seek evaluation by a dedicated upper extremity specialist
This implies that the cyclist be appropriately immobilized during the visit to the emergency room but then should seek the appropriate specialist on a less-emergent basis. Simple fractures are often addressed by the general orthopaedic surgeon, but the highly competitive cyclist truly needs an optimal result in order to maximize their return to full function.
How to successfully bounce back after a crash
A case in point is a cyclist I recently treated from the Martin County area in Florida. This young lady was participating in a century ride when she fell in the upper Keys area and was seen at the local small hospital emergency room. Fortunately, she was immobilized in a long-arm splint to stabilize a very complex wrist fracture as well as an intercondylar distal humerus fracture. This is an elbow fracture where the bone splits into the joint and requires a very complex type of internal fixation with plate and screws. She and her husband researched the type of specialist that she would need, and she presented to me with this complex injury. In an outpatient procedure requiring nearly four hours, I was able to use stainless steel plates to address the elbow fracture and pin fixation for the fracture in the wrist. Within three months, she was again teaching her spinning class and has since gone back to road biking.
The #FLKeys Scenic Highway, Florida's only All American Road, is ideal for cycling with a view! #FLTravelChat pic.twitter.com/RiDRkq4cqw
— The Florida Keys (@thefloridakeys) October 17, 2017
This case simply highlights the need for the injury to be properly immobilized and then in a semi-elective manner, seek the ideal specialist for this type of injury. Given timely and precise treatment, there is no reason why a cyclist should not be able to return to their chosen sport no matter what the level of injury to the upper limb.
By Alejandro Badia, M.D, F.A.C.S.
Orthopedic Hand Surgeon
Upper Extremity Specialist of Hand, Thumb, Wrist, Elbow & Shoulder
Badia Hand to Shoulder Center
Founder, OrthoNOW Orthopedic Urgent Care Center
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