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Sunday, 26 January 2014

Low Back Pain in Cycling: The Experts View.

The season is fast approaching and people are getting back into training. As with any sport, injuries are an inevitable risk. One of the most common injuries seen in cyclists of all levels is low back pain, with the literature suggesting it accounts for up to 45% of all injuries reported in cyclists. Therefore it's a good time to speak with some of the leading experts on managing low back pain and injuries suffered from cycling to see how it can be prevented and allow you to go through the year injury free.  

Bryan McCullough from Pure Sports Medicine organised a great meeting of minds at Bespoke including top consultant spinal surgeon Alexander Montgomery from London Sports Orthopaedics and Team Sky's Sports Doctor Phil Riley who also practices at Pure Sports Medicine. We ran through the Bespoke fitting process and bounced around ideas about cycling and back pain. It was a very productive and enjoyable evening. Below are each experts thoughts on lower back pain in cycling and the role of each professional in its treatment.

From Left to Right: Ben Hallam, Alexander Montgomery, Bryan McCullough, Phil Riley 

Low Back Pain and Cycling - Part 1 - A Sports Spinal Surgeon’s View 
Mr Alexander Montgomery – Consultant Spinal Surgeon, London Sports Orthopaedics 

Most of us have high pressured desk jobs, and use cycling both as a way of improving fitness, as well as a form of relaxation. The benefits are undoubted, but what most of us don’t realise is that it can often cause problems with your back or neck. 

According to a study in the International Journal of Sports Medicine, California State University researchers questioned 518 recreational cyclists and found 79.1% reported neck or back problems, almost twice that of any other joint in the body. Perhaps the most worrying finding was that just 36% sought any professional help to ease the pain. One interesting study was done by the British Cycling Federation on the squad medicals of its elite cyclists, and found that 60% of the 500 elite riders had low back pain. 

What most of us don’t realize is that the process of spinal disc and joint ‘degeneration’ begins from your mid to late twenties. The discs act as shock absorbers to the bones, they give flexibility, and maintain the height between two vertebra to allow the nerves to pass from the spine down to the legs. In this process the water and protein content of the centre of the disc decreases, and with it the shock absorbing capacity, flexibility, and space for the nerves to pass to the legs. The facet joints therefore take more stress, and they then start to degenerate. In order to take the extra stress placed upon them, the joints and ligaments react by getting larger, and in turn can start pushing against the nerves going down the legs (sciatica) and arms (neck). Alternatively, the disc can come out from between the bones, prolapsing and causing pressure on the nerves as well. 

Many of us have some or all of the above mentioned changes in our spine without having any symptoms, so we are therefore unaware of this. The pressure in the disc is lowest when lying down (sleeping), intermediate when standing, and highest when sitting and flexed forward, especially with a weight in the hands. You can then see why sitting at your desk the whole day bent forward, and then cycling, can put a great deal of stress on your back. Cycling can trigger symptoms in our spine that have been manifesting for some time. 

My role is to: 
1. Do a thorough and formal assessment of your back and your spinal nervous system, both for a provisional diagnosis of the problem, and to ensure there is nothing unusual or worrying occurring in your spine. 
2. Ensure you have followed and exhausted all conservative ways of dealing with your pain, and have been through your life with a fine toothcomb to seek the exacerbating factors of your current symptoms. 
3. Request an MRI of your spine when indicated to obtain the detailed anatomy of your spine for a formal diagnosis. 
4. Recommend any intervention if it is indicated and all conservative measures have been exhausted. 

Treatment Options if Conservative Management Fails 

Spinal Injections: 
These can be broadly divided in to nerve root (formainal) injections for leg or arm pain, facet joint injections (for facet based back pain, and caudal epidurals. These are done under sterile conditions, and using image guidance to ensure positioning of the needle. 

The purpose of these injections is to reduce the inflammation causing pain in your back or limbs, and allow you to get back to working on your bike position, posture, and core muscle strength in a pain free manner. It breaks the pain cycle, makes you feel more positive about your progress, and gives you a chance to persist with more conservative measures for a longer period of time . 

The injections and extended rehab programme can be tried more than once. If, however, this has failed, which it sometimes does in a small percentage of people, then surgery may need to take place. 

For leg pain can be done in a minimally invasive manner with the aid of a microscope. This is known as a Microdiscectomy, where the disc that is putting pressure on the nerve is taken away. 

Surgery for persistent pain or weakness in the arms normally involves a small incision at the front of the neck, again using a microscope to take the disc away. Often an artificial disc replacement can be put in it’s place, but sometimes a fusion has to be done. 

Surgery for back pain is more complicated, and will involve a much more extensive rehab programme not only for those treatments already mentioned, but looking at all aspects of your lifestyle including your nutrition, work / life balance, smoking and / or drinking habits. 

Low Back Pain in Cycling - Part 2 – A Bike Fitter’s View 
Ben Hallam – Former GB Track Cyclist, Bike Fitter at Bespoke Cycling London 

During my racing career, I was dogged with recurring episodes of lower back pain which ruined my preparation during a number of seasons. This, however, is a common story throughout the professional peloton: Clarsen and Krosshaug (2010) found the 45% of the injuries reported by professional riders were lower back issues and a common story can be seen in recreational cyclists (Marsden 2010). 

A survey of recreational riders by Schlutz & Gordon (2010) indicated that riding more than 160km per week increases the risk of lower back pain by 3.6 times. But what can we do to minimise the risk? Adjusting the bike set up is certainly one piece of the puzzle. 

At Bespoke, we use a 3D motion tracking system called Retul to measure all of the body angles and movements that the set is creating. We then combine this with information from the body assessment to adjust the set up. Bars that are too low and/or too far away can cause increased lumbar flexion which is a contributing factor to lower back pain (Marsden 2010, Van Hoof et. al. 2012). Correct saddle selection is very important as increased perineum pressure can lead to altered hip angles and lumbar mechanics (Bressel & Larson 2003). Incorrect set up of these contact points can lead to potentially negative changes in the activity levels and control of our trunk and leg muscles (Van Hoof et. al. 2012). While adjusting the saddle angle has been shown to help relieve lower back pain in some cases (Salai et. al. 1999), changes in saddle angle have not been shown to correct the altered muscle activity (maladaptive motor control patterns) associated with lower back pain (Van Hoof et. al. 2012). 

Therefore, it is my belief that changes in bike set up need to happen in tandem with corrective exercise and suitable rehabilitation to correct cycling posture and increase a rider’s core stability. 

Low Back Pain in Cycling – Part 3 – A Sports Physiotherapist’s View 
Bryan McCullough – Specialist Musculoskeletal Physiotherapist at Pure Sports Medicine 

Musculoskeletal screening performed by a specifically trained physiotherapist can help to address any potential factors that may contribute to developing low back pain from cycling. This may range from inadequate flexibility of certain muscles and joints to weakness in certain areas, particularly the spinal extensor muscles and muscles of the core (O’Sullivan 2006, Abt 2010). A specific conditioning program can then be tailored to the rider covering the necessary components of muscle balance, core strength, and flexibility. 

However, we are more likely to see people when they come into our clinic having developed back pain already. In this instance it is of utmost importance to establish which tissue structures have been injured or being placed under excessive strain. Once this has been established we then must work backwards and establish the contributing factors that have led to the development of the pain in the first place. Treatment may then range from joint mobilization, soft tissue release, acupuncture and dry needling, to the development of a specific rehabilitation program to address the needs of the rider. 

Research into the origins of lower back pain in cyclists has identified a number of factors that are linked to the development of low back pain: 

Altered activation and control of trunk muscles (Burnett 2004, 2007) 

 Reduced endurance of spinal extensors (O’Sullivan 2006) 

 Incorrect saddle angle (Marsden 2010) 

Incorrect fit of certain parameters of bike (Marsden 2010) 

From the short list above we can see that low back pain in cyclists will often necessitate a multidisciplinary approach to fully address the problem. The greater the volume of cycling undertaken the greater the importance of an individualised bike fit. If the cause of the pain or dysfunction is not fully elucidated from clinical examination or the pain is severe and resistant to treatment it may be necessary to arrange referral to either a sports doctor or orthopaedic surgeon with experience in the field. In this way we can work closely together to find the solution and get the rider back on their bike as soon as possible. 

Low Back Pain in Cycling – Part 4 – A Sports Doctor’s View 
Dr Phil Riley – Sports Doctor at Pure Sports Medicine and Team Sky Procycling 

A typical patient may present with gradual onset low back pain, commonly related to having just taken up the sport, or having a recently increased training load. The medical assessment would incorporate a full medical history including previous musculoskeletal problems, a detailed activity/sporting history and family history. 

A general enquiry into associated symptoms may reveal a complaint of pain or pins and needles down the back of the leg, and this may be a sign that the sciatic nerve is being trapped or stretched. This may be as a result of the above predisposing factors, or maybe due to pressure within the piriformis muscle, which lies deep to the gluteal (buttock) muscles, and which can be compressed against the saddle of a bike, or possibly even a disc prolapse or bulge. Additional biomechanical factors such as leg-length discrepancy, spinal posture and poor core stability can exacerbate any potential problem, which in turn can be compounded by excessive load, for example hill-riding or using big gears. 

The role of the Sports Doctor is to evaluate the cyclist, hopefully prior to the onset of injury or pain, and therefore be in a position to prevent musculoskeletal problems. Inevitably, however, virtually all ‘patients’ will present with established symptoms, and the Physician has to establish the cause of the problem, advise regarding the need for investigation, and refer for appropriate treatment, which is likely to be in the form of physiotherapy, chiropractic or osteopathy.

Tuesday, 7 January 2014

Body Fit: The Missing Piece of the Puzzle

"The underlying principle of positioning a cyclist on a bicycle is to remember that the bicycle is adjustable, and the cyclist is adaptable." (Burke 1994). This is the underlying principle that drives our fitting protocol at Bespoke. This principle can be applied to many situations. 

If a rider's position is incorrect, the body will adapted to try and interact with the contact points. Often this leads to the body making compromises to make the position work (e.g. dropping the heels to extend the knee when the saddle's too low, flexing the spine to shorten the body on a bike that has too short a cockpit). Every day life can cause the body to adapt in sub optimal ways (e.g. extended periods sitting can cause hip flexors to become short and tight etc.). Adjusting the bike to these adaptations only reinforces these movement patterns and does not challenge the body to change. A bike fit adjusts the bike's contact points but is only 50% of the puzzle as it doesn't alter the learnt movement patterns that have been in-ground over many thousands of pedal revolutions. The body will adapt to new demands that are placed on it, therefore subjecting the body to specific exercises will force it to adapt to biomechanically more efficient movements, increasing power and efficiency while reducing injury risk.  This is where Bespoke's Body Fit sessions step in.

Each Body Fit session is tailored to the riders specific needs. This can incorporate pedalling technique modification, cycling specific posture correction, core or hip stability exercise, release of muscular restrictions, activation and strengthening of inactive muscles. Let's look at a case study:

Stuart came to Bespoke wanting to buy a Pinarello Dogma. The Dogma is an awesome performance machine but the geometries are long and low. Stuart had very tight hip flexors which caused an anterior pelvic tilt. This reduced the range that was available for the leg to come up over the top of the pedal stroke. Stuart's body had adapted to this by rotate his pelvis backwards allowing him to clear the top of the pedal stroke without hitting the end of range. In addition to this, Stuart was very weak in his the extensor muscles in his upper back causing him to slouch on the bike, dropping his body weight through his hands. Finally, Stuart had very poor strength and activation in his glute and was relying on his quads to drive the pedals. All this meant that to achieve a usable position on a Dogma, we needed maximum spacers and a slightly upward pointing stem.

We progressed Stuart through four sessions:
1) Stretches to address the tightness.
2) Activation and strengthening exercises to address the weaknesses and pedalling technique exercises to incorporate the muscles into the pedal stroke.
3) Cycling specific core, hip and ankle stability exercises.
4) Strength and power exercises to produce force at higher velocities.

Stuart's body adapted very well during this process and at a refit, we were able to drop the bars 5.5cm and extend them out nearly 2cm. And all this over just a 4 month period. Stuart is now able to hold a long neutral spine posture comfortably for over 100 miles while producing much more power from the increased glute activation. Stuart is my shining example of what can be achieved when someone follows advice to the letter.

Body Fit sessions take 30 minutes and cost £50. We suggest that at least four sessions are required to make significant changes. Therefore we are offering a buy 3 and get the 4th free offer. For more information or to book a session, contact the shop on 02078370647 or

Monday, 6 January 2014

Why track riding helps sportive riders.

I love track riding. I grew up on it, it's in my blood, I'm a Hallam. But I don't just love the track for the buzz of riding on a steep banking, feeling like I'm breaking the laws of physics. It is awesome training as well. The track forced me to be efficient in my pedal stroke, to be able to accelerate quickly through gaps and provide a fitness that is hard to replicate on the road. These are all things that would benefit sportive riders as well.

And we're not talking about racing here. Tracks like Manchester, Newport, Glasgow and eventually Stratford all put on public training sessions. Once you've completed the track's accreditation process (to learn the skills needed to safely ride the track), these structured training sessions give an hour to 2 hours of group riding that includes short sprint efforts. This type of riding will help your general sportive fitness in a number of ways.

Due to the laws of physics, you have to ride over a certain speed just to stay up right and not slide off the track. Due to the fact that there are no traffic lights to stop and catch a cheeky breather and no free wheel to coast along not trying, you are forced to hold your heart rate up slightly higher than you normally would on the road. This means that you're forced to recover from a short effort while still riding at a reasonable pace. This is exactly like climbing a mountain in a sportive: when you hit a steeper section, your heart rate climbs over your threshold to keep going. But when the gradient backs off a tiny bit you can't just stop to recover. You've got to be able to metabolise the lactate that your muscles have produced while still riding just under your threshold. This is exactly the same on the track.

Because a track bike only has one gear, you're forced to spin the pedals faster when going quick. This helps develop an efficient pedal stroke that will carry you up hills and into headwinds quicker. Look at all the riders from Great Britain that have seen great success on the road while coming from a track background: Bradley Wiggins, Mark Cavendish, Peter Kennaugh, Ben Swift, Geraint Thomas, Alex Dowsett. They've all got beautifully smooth pedal strokes particularly at high cadences. I've had many sportive riders say to me that they are "spinning out" on a compact chainset. If I'm genuinely spinning out a 50x11 gear, then I'll be travelling at well over 50mph! Most people are reaching for their brakes long before then. Only having one gear also forces your muscles to be more efficient at contracting at different speeds: contracting slowly with high torque to get going and contracting quickly with high power when travelling fast. This will broaden your available RPM band and increase both your low speed and high speed pedalling efficiency.

While riding around a city, we have to make lots of little accelerations to get through gaps, this is also true in a sportive. When the large group comes rumbling past, if you can efficiently make a quick acceleration, you can jump on the back and get sucked along with minimal effort. When that guy in front of you loses the wheel, you've got to be able to make a quick burst to bridge the gap he's just left and then recover again on the wheel at speed. This is exactly like riding on the track.

This is why we're really excited about our beginner track day on Saturday 1st March. The session will cost £100 include bike hire, 4 hours of track time and personal coaching from David Le Grys (a multiple world masters champion and former GB coach). During the session, David will progress you through getting to know the bikes, getting onto the track and then safely riding at greater speeds and with other riders on track. This will give you valuable experience for when the velodrome opens at Stratford. To keep the coach standard high, there will be limited places available so if you're interested, book early. To confirm your place, contact David Le Grys on