Following the recent UCI Championships, Dr Heron et al discuss what is involved in being a doctor and physiotherapist caring for cycling athletes.

Mr Thomas Fallon^1,2,3,
Dr Niall Elliott ⁴
Dr Emma Lunan⁴
Prof Xavier Bigard⁵
Dr Neil Heron^1,6

 Affiliations:
1) Centre for Public Health, Queen’s University Belfast, Northern Ireland;
2) Edinburgh Sports Medicine Research Network, Institute for Sport, PE and Health Sciences, University of Edinburgh;
3) UK Collaborating Centre on Injury and Illness Prevention in Sport (UKCCIIS), University of Edinburgh;
4) Scottish Institute of Sport, Stirling, FK95PH;
5) Union Cycliste Internationale (UCI), Aigle, Switzerland;
6) School of Medicine, Keele University, Staffordshire, England.

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As we approach the summer months and enjoy the better weather, the sport of cycling starts to enter our TV screens. Cycling is an incredibly popular sport, recreational activity and mode of transport, with an estimated one billion bikes world-wide in 2019 [1]. In terms of professional road cycling, in March and April we have the Belgian classics, in May we have the Giro D’Italia around Italy, in July we have one of the biggest annual sporting events in the world, le Tour de France (TdF) and in August we have the Vuelta in Spain. But cycling is not just about road cycling. Indeed, the sport of cycling consists of several individual sporting disciplines and the world governing body for cycling, Union Cycliste Internationale (UCI), oversees several cycling disciplines. These disciplines include road cycling, cyclocross, mountain bike, BMX freestyle, BMX racing, track, trail, indoor and paracycling and each of these disciplines has several sub-categories of cycling activities. Thus, cycling is an umbrella term for a number of disciplines and this year in August we will see all these cycling disciplines gather together in Scotland for the first time in the form of the inaugural UCI World Championships. This is the first time that all annual world championship events for the different cycling disciplines will be held at the same time and in one place. So, what is involved in being a cycling doctor and what is cycling medicine? Do you know your chamois from your bidon and the peloton from the flame rouge?

 

Common injuries seen

Whilst the health benefits of participating in cycling activities are clear, athletes, particularly professionals at the elite end of the spectrum, can develop injuries and illnesses related to there cycling activities, interfering with their ability to train and compete, both as an individual but also as a team [2,3]. In the first systematic review of road cycling injuries, skin abrasions, lacerations and haematomas were the most common injuries identified, followed by fractures (the commonest fracture being clavicle), concussions and musculotendinous injuries [2]. The upper limb was more commonly affected than the lower limb [2]. Furthermore, this review highlighted the lack of prospective injury surveillance studies within cycling and the inconsistent methods employed to measure the injuries and illness incidences [2,3]. Therefore, due to the lack of prospective research within cycling it is difficult to quantify the prevalence and burden of overuse injuries. However, the voluminous kinematics of cycling can predispose to many overuse injuries. Some common overuse injuries that occur in cycling include patella femoral pain syndrome (PFPS), tendonitis (Patella, quadriceps), and plica syndrome, to name a few (4,5,6). Additionally, within road cycling, the type of injury appears to be more acute in the form of abrasions/lacerations and haematomas with lower incidences of muscle/ligament/tendon injuries, accounting for only 30% of the injuries [2,7]. At the Tokyo Olympics in 2021, BMX racing and BMX freestyle were the second and third highest injury incident sports respectively [8]. Despite differences in cycling disciplines and sporting demands, injury locations within both BMX disciplines were comparative to road, track and enduro cycling [2,7,8].  To help address the deficiency in the scientific literature of injury data in cycling sports, we are planning to undertake the first prospective injury surveillance study at the UCI World Championships this year in Scotland, including within para-cyclists. The study will collect data across all cycling disciplines of accident and injury incidences.

 

Within para-cycling there is limited prospective research around injuries and illness prevalence’s [9]. Recent studies have highlighted injury incidences between 9-17% in para-cycling road/track, with illness rates between 7-58/1000 athlete days [9,10]. From the injury and illness statistics, 71-75% were sudden onset compared to 17-25% being gradual onset [10]. Additionally, para-athletes may have underlying medical conditions that place them at higher illness risk. Knowing this information across cycling disciplines, for the different sexes, different levels of performance and between able-bodied and Paralympic competitors, allows risk mitigation and medical planning to be put in place for major events like the UCI World Championships in Glasgow.

Concussion in Cycling

The athlete and general public awareness and knowledge of concussion is increasing, particularly with the release of the UK concussion guidelines being released for grassroots sports in April 2023 “if in doubt, sit them out” [11]. Cycling has a concussion policy and this is a common injury within most cycling disciplines [2,3,7,12]. This generalised concussion policy has been applied to some cycling disciplines, including road [12], track [13] and downhill mountain biking [14], but further work needs to be done in refining these policies for use in everyday cycling as well as considering how they would apply to the other cycling disciplines, such as cyclocross despite the low incidence rates. Furthermore, as part of the UCI concussion policy to assist with the recognition of the symptoms of concussion, there are published pocket cards (for non-health professionals) and the SCAT5 applied to the 4 major cycling disciplines (including BMX racing), and in 3 languages [15]. Further updates of this policy are currently in progress following the SCAT 6 development [16]. As medical professionals working within cycling, we have a role in educating athletes and stakeholder’s around best practice. Indeed, at the inaugural world championships grand fondo events, there will be further concussion education seminars delivered in a mobile education unit, which is another proactive step in increasing concussion awareness within cycling.

 

How do you manage road rash?

When the cyclists fall off and skid across the ground or track, they develop what is called ‘road rash’ or ‘track burn’. This is essentially taking off the top layer of skin and can be very uncomfortable. When a cyclist develops this, we need to anaesthetise the area, which can be done with a topical local anaesthetic, such as instilligel. It is important that this is a topical preparation as there is a ‘no needle policy in cycling’ and all needle use needs reported to the medical department of the UCI, which is headed by Prof Bigard [17]. Once the area is appropriately anaesthetised, it needs to be cleaned out thoroughly and this is generally done using surgical brushes, impregnated with iodine. After the area is thoroughly cleaned, it then needs dressed, using an initial layer with something such as iodine and then a secondary barrier dressing layer, with something such as mepore. A mesh netting, applied over the secondary barrier layer, is very useful, particularly when the rider will be continuing to ride with the dressings on and keeps the dressings in place. The tetanus status of the rider must also be considered, and a primary course or booster immunisations given as appropriate as well as considering the need for oral antibiotics, such as co-amoxiclav (ensuring to clarify any drug allergies with the rider before prescribing), if the wound was very dirty and extensive. Analgesia needs to be considered and some riders will request occasional muscle relaxants to use at nighttime to help them sleep with extensive road rash.

 

Do you know your saddle sores from your perineal nodules, or do you have a 3^rd testicle?

Saddle sores are common within cycling activities and occur due to friction between the perineal area and the saddle area, including the chamois of the cycling shorts and the saddle [18]. Firstly, it is important to ensure that everyone is using the same terms when describing these lesions. Saddle sores are skin lesions that affect the area of skin in contact with the bicycle saddle and can prove troublesome for cyclists [19]. Friction and compression of the skin can lead to chafing, redness and infections such as folliculitis and furunculitis [18]. Chronic saddle sores can develop into larger lesions with an elastic consistency and normal overlying skin [3]. They are known by different terms within the medical literature, but we feel saddle sore is a more commonly used term within the cycling fraternity and we encourage use of this term rather than others, including perineal nodules and 3^rd testicle. Secondly, a recent scoping review and then infographic, has illustrated how these lesions should be managed. Saddle sores can prove troublesome for cyclists, causing pain and altered movement, reducing performance or necessitating time off the bike [18,19]. Preventative strategies that reduce pressure include a reduction in cycling intensity or distance, increasing handlebar height, modifying saddle design and adjusting/renewing the chamois pad [19]. Saddle-perineal friction can be reduced by optimising seat and perineal hygiene and grooming (e.g. cutting hair rather than shaving), not wearing underwear beneath cycling shorts and using chamois cream [19]. If saddle sores have developed, they can be managed based on size, severity and duration. Small saddle sores in the acute phase can be managed using conservative measures such as increased padding or hot and cold compresses, while medical interventions are reserved for cases requiring urgent treatment or that have severe symptoms [1]. Medical treatments can include antibacterial or steroid creams applied topically or injecting steroid into the saddle sore [5], with appropriate anti-doping guidelines followed. Surgical excision or drainage can be used to treat larger, chronic saddle sores where symptoms indicate although in practice, this is rare [5]. However, this scoping review found that there is limited empirical evidence within scientific research that demonstrates the effectiveness of these strategies in managing or preventing saddle sores or potential side effects [4]. It is proposed that specific randomised controlled trials are conducted in the future to address these research gaps and optimise treatment [4], improving outcomes for cyclists.

 

RED-S in cyclists?

Relative Energy Deficiency in Sport (RED-S) is a syndrome caused by low energy availability, involving impairment of various aspects of health and performance in both male and female athletes [20]. Central to avoiding negative effects of RED-S and ensuring maximal performance is monitoring and early detection, although the best monitoring approach has not yet been identified. Many cycling sports, particularly road cycling, are ‘leanness’ sports, putting cyclists at an increased risk for RED-S, especially pre-Grand Tour when they ‘make-weight’ for optimal performance. A recent blog on this topic was published in the BJSM to summarise the evidence relating to RED-S monitoring methods in athletes, using these findings to develop a protocol to identify and monitor RED-S in elite road cyclists pre-TdF [21]. Testosterone and T₃ (triiodothyronine) were found to be the most sensitive markers for RED-S and responded to management of the energy imbalance within one-week [21]. Further studies in cyclist have shown high blood cortisol values are an indirect marker of REDs [22]. Combining quantitative and qualitative screening tools, with a multi-disciplinary (MDT) approach, provides a sensitive assessment of RED-S risk [21]. There conclusion was therefore to have an MDT approach for RED-S monitoring, including a regular medical evaluation, physical examination, and blood monitoring at six-, three-, and one-week pre-TdF [21]. Further research is needed to understand marker’s response to treatment and markers across diverse sporting cohorts, including within the different cycling disciplines.

 

Strange leg pains?  Rare vascular considerations

Elite cyclists can present with a variety of leg pains that are linked to increasing exercise levels when on a saddle.  One of the rarer conditions is iliac artery endofibrosis, where the intimal lining of the artery thickens as a result of the repetitive hip flexion movement seen in cycling [23].  It presents in an otherwise fit and healthy athlete with symptoms suggestive of exercise-induced claudication [23.24].  There can be delays in diagnosis due to the uncommon symptoms experienced with this condition and more complex imaging requirements [24]. Treatments can include more complex vascular surgical interventions and require careful planning with athlete engagement around risks and a detailed rehabilitation plan [25]. Previous case studies in professional cyclists and triathletes have highlighted the challenges faced in the diagnosis and management of iliac artery endofibrosis, including surgery [23,24], and this can be a career threatening condition for elite cyclists.

 

Can cycling promote public health?

As people come to the UCI World Championships to spectate, we encourage everyone to walk and/or cycle to the different events, where possible. The scientific evidence suggests that undertaking regular cycling activities is associated with general health and well-being benefits and is encouraged within the United Kingdom (UK) Chief Medical Officers’ guidelines for physical activity promotion in the general population as well as the comparable guidelines in the United States of America [26-31].

Also, major sporting events are an ideal time to promote important public health messages to the spectators. Of all road users’, cyclists were the only type where there was no decrease in fatalities since 2010 according to the European commission report published in 2021 [32].  With the number of road accidents involving bicycles, both in urban and rural areas, the promotion of leisure cycling activities must involve safe cycling education, both for young people (who are the adults of tomorrow) and for adults (who must set an example). Additionally, cycling can be an activity, like golf, where you are outdoors for many hours and it is therefore important that skin care is optimised, including minimising UV exposure and knowing your skin well, so that any changes in a mole are reported promptly to your General Practitioner (GP)/family physician. Thirdly and related to the saddle-sore issue, it is important to promote genital health and encourage, e.g. males to self-examine their testicles regularly, and report any changes promptly to their GP. Thus, major sporting events, such as the UCI World Championships, are an ideal opportunity to promote key public health messages, such as physical activity promotion and health screening activities.

 

Can I cycle when I’m pregnant?

We particularly want to promote women cycling during pregnancy and the postpartum periods, including when lactating. Cycling is one of the universally recommended exercises worldwide to engage in during pregnancy and the postpartum period [33]. The UCI are about to release their pregnancy and postpartum guidelines, and this encourages cycling as a form of physical activity throughout pregnancy, although participation in competitive events is limited to the first trimester. Cycling is safe for the mother and unborn child(ren) as well as having a number of health benefits for both and should therefore be actively encouraged throughout pregnancy and the postpartum periods.

 

Cycling and Physiotherapy

Physiotherapists have a broad range of functions within cycling, across all levels from recreational to elite. Physiotherapists will be involved in the pre-season screening of athletes whereby they will perform basic anthropometric and mobility assessments, biomechanical, kinematic and positional appraisals, strength assessments and take various baseline measures. Throughout the year, the physiotherapist will assist in managing acute and overuse injuries, in addition to advise, educate and provide constant reminders on measures to improve on the bike comfort and reduce injury and illness risk.

 

Physiotherapists also play an important role in bike fit, which is fundamental to on the bike comfort, reducing injury risk, positional sustainability and performance [34-36]. There are three main contact points with the bike, the feet with pedals, pelvis with saddle and hands with handlebars [34]. The physiotherapist will correlate their physical assessment findings with on the bike riding position and recommend changes to the bike fit to mitigate injury risk, improve comfort and optimise performance. For example, lower/longer handlebar positions may be aerodynamically advantageous, however, this position will close the hip angle, potentially leading to reductions in power or causing hip impingement symptoms if too aggressive [35]. Similarly, hamstring tightness and poor lumbo-pelvic hip complex mobility may limit the ability of the pelvis to roll forward to accommodate the lower front-end position with lowering the handlebars, thus resulting in greater lumbar spine flexion and over time, causing lower back pain [35]. Conversely, much shorter positions may increase the load going through the upper limb and excessive wrist extension which, over time, may lead to hand paresthesia over the distribution of the ulnar nerve in particular, which will impact ride comfort and bike control [36]. The physiotherapist will be able to guide athletes into measures of addressing mobility and strength deficits, that will improve ride comfort, positional sustainability and performance. Additionally, bike fit is a dynamic process throughout the life course of the cycling athlete. Indeed, just because you have stopped growing does not mean your bike fit does not change nor does one size fit all. Bike geometry differs between manufactures and therefore the physiotherapist plays an important role in helping make the bike fit athlete specific and targeted to their goals and events.

 

With the remarkable growth of female sporting participation over the last decade and the UCI women’s world tour, further consideration should be given to the individual female athlete [38]. It is important that athletes, and women in general, understand the relationship been bike types, bike positions and overall pelvic health [38,39]. Women have anthropometric differences such as wider pelvic bones, increased Q angles, differences in lean muscle masses and torso lengths [38-43]. Undue consideration to the anthropometric and morphological differences between males and females during assessment and bike fitting will influence injury likelihood Furthermore, pregnancy status, rider goals (commute/recreational/performance), event type and exercising environment, will all influence medical advice and physiotherapy input for the female athlete [43].

 

Pelvic health and pelvic floor strengthening is often overlooked within sports medicine [45,46]. Weakness in pelvic floor can be linked with pain, urological dysfunctions, skin lesions and neuropathy which will all impact on the bike comfort, training availability and performance [32,38-43]. In a recent review on sports medicine and the pelvic floor, the authors highlight multiple education resources along with proactive practical advice for sports organizations and sports medicine practitioners [45]. Physiotherapists have an important proactive role with the perinatal athlete and their return to sport (RTS) [47]. A useful framework used by physiotherapist in guiding the RTS is the 6Rs framework [48]. The framework adopts a whole system biopsychosocial approach and the 6Rs represent, ready, review, restore, recondition, return, and refine [48]. Mobile applications such as the Squeezy app developed by in conjunction with NHS can be very helpful in guiding women on pelvic floor strength exercises [49].  Overall, physiotherapists within cycling play an important role in educating and guiding all athletes around the importance of pelvic health and wider associated health domains [47,48].

 

Conclusion

Thus, cycling medicine is unique within the sport and exercise medicine world. As a cycling doctor and physiotherapist, we see unique injury profiles and work within large, multi-disciplinary teams to manage such conditions as RED-S and iliac artery endofibrosis. Large events like the UCI World Championships in Scotland are an ideal time to promote key public health messages, including skin and genital/testicle health and concussion education. We hope this article encourages you to embrace the cycling athletes that you see as well as encouraging you to try cycling as a sport, if you haven’t previously, and see why it is just such an addictive sport for participants and spectators, alike.

 

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