As the weather warms, clinicians will see increased numbers of patients with pain related to bicycling. Clinicians and researchers at Cleveland University-Kansas City (CUKC) recently partnered to present a review and case study, “Median nerve entrapment in a cyclist: a case study and review of bicycle-fitting guidelines for the clinician.” The paper was presented at the recent Association of Chiropractic Colleges Research Agenda Conference, held in March 2021.
Distal neuropathies in the upper extremity related to excessive handlebar gripping are commonly seen in cyclists. Both ulnar and median neuropathies are common among cyclists, with ulnar neuropathy (cyclist’s palsy) present in 19% to 35% of cyclists.
This case describes the treatment and ergonomic interventions for a recreational cyclist with bilateral median nerve entrapment syndrome. This 62-year-old male experienced a new episode of severe, bilateral hand pain and numbness in the median nerve distribution (digits 1, 2, and 3) following a significant increase in bicycle session times while riding a newly acquired bicycle.
Bicycle-related upper extremity palsy is a handlebar contact point injury involving compression of the ulnar or median nerve at the wrist. It can be a result of excessive vibration from the road and may be exacerbated by prolonged, excessive hyper-extension of the wrist which increases traction (stretching) on nerves in the region. These injuries are termed a neuropraxia, a peripheral nerve injury associated with temporary loss of motor and sensory function due to decrease in nerve conduction.
In this case, the patient presented for care at the Cleveland University-Kansas City Chiropractic Health Center and was diagnosed with bilateral median nerve entrapment related to bicycle grip pressure. Pain and sensory changes were present without motor (strength) deficit.
The patient was treated with multimodal chiropractic care, including spinal and extremity manipulation, and instrument-assisted soft tissue mobilization. After three sessions, the patient reported a significant reduction in pain, but symptoms returned after additional cycling sessions.
The patient brought his bicycle into the clinic for a cursory assessment. Several potential ergonomic faults were identified. Basic changes were made, including moving the saddle forward, raising the handlebar height, and adding bar-end extensions to promote grip variety. The patient was encouraged to always wear gloves with gel padding.
The patient was evaluated and treated during two additional visits, and after returning to cycling following the ergonomic changes, had a lasting improvement in upper extremity symptoms.
Dr. Mark Pfefer, director of research at CUKC, said the results support being proactive with such injuries.
“This case points out the importance of early intervention with a conservative approach, and the significance of addressing ergonomic concerns that commonly lead to cycling neuropathies,” Pfefer said. “Our experience also demonstrates that cyclists with upper extremity symptoms also frequently have cervical, upper thoracic, and thoracic outlet dysfunction which should be assessed and addressed along with the treatment directed to the distal extremity sites.”
A specific evaluation overview can be helpful when determining the most beneficial treatments for a cyclist. Effective rehabilitation involves identification and correction of contributing biomechanical factors in both the cyclist and the bicycle. Evaluation of the cyclist begins with a detailed history of the injury or discomfort, and presence of symptoms off the bike, on the bike, or both. There must be inquiry regarding cycling activities, such as climbing, sprinting, long distances, or specific gears, which provoke symptoms.
Degenerative joint disease or spondylosis can affect the cyclist’s biomechanics and may require accommodations on the bicycle. A full cycling history should also include the athlete’s disciplines of cycling, training, and racing schedule, cross-training, as well as prior crashes, injuries, and treatments. For athletes with neurologic symptoms, questions regarding head injury and a brief concussion screen may be appropriate.
The cycling-specific physical examination should be tailored to the athlete’s complaint; however, there are certain tests that may be helpful in a number of different scenarios. The single-leg squat test is a simple and very useful in-office test for weakness or decreased recruitment of hip abductors and may show contralateral pelvic tilt or ipsilateral medial knee deviation, frequently seen in cyclists and in individuals with patellofemoral or lumbar spine complaints.
Assessment of lumbosacral and hamstring flexibility is useful in determining how much forward flexion an athlete is prepared to tolerate on the bicycle. For lumbar spine complaints, assessment of directional preference and dural tension (seated slump test) is often useful.
If available, the third part of the cycling-specific evaluation should include an assessment of the cyclist’s position and biomechanics on the bicycle. This requires relatively little equipment, a stationary bike trainer, and a keen eye for mechanics.
The clinician should not double as a bike fitter without the appropriate training and certification; however, should be familiar with the basic principles. A collaborative evaluation with a certified bike fitter is extremely helpful in making specific recommendations regarding modifications to fit, or the addition of components.
If upper extremity neuropathy is present, the following causes should be explored:
Pfefer says if treated early, most cycling-related neuropathies are reversible. For a complete return to cycling, treatment interventions should be combined with ergonomic assessment and clinicians should be aware of basic bicycle fitting strategies to optimize outcomes.
