Which overuse injuries are prevalent in elite, competitive cyclists?

I have come across many friends posting on Facebook about their hobbies and exercise toys these days, and most of them are related to cycling. It seems like a trend that is not going to end soon.

Perhaps, I have grown into the age that my peers deem cycling as affordable and fun, or the camaraderie that cycle groups foster that creates the interest in cycling. Be it cycling along the Park Connectors or along the roads in the wee hours in the morning, we can say that Singaporeans are getting more cycling-savvy.

Although I find cycling occasionally in East Coast Park quite relaxing, I am not fond of the 2 wheel machine. I still prefer running over cycling as a form of aerobic exercise. Cycling is just too much of a hassle for me! Everyone is entitled to their own opinions, right?

With a view that the prevalence of cycling is increasing, it would be of interest to learn more about the common cycling injuries and developing strategies to treat them.

I have recently come across a research article that sought to examine the prevalence of cycling injuries in professional road cyclists, published in the American Journal of Sports Medicine. It being a retrospective study, it was conducted by experienced physiotherapists interviewing professional, elite road cycling teams competing in European and World Tours.

I would like to highlight the word ‘elite’ and ‘professional’, to emphasize on the difference between the mileage among the elite and recreational cyclist. Also, I would like to state that what we observe in the elite may not be observed in the amateur/recreational cyclists. For example,

“… recreational touring cyclists reported an average annual training volume of 7114 km and an average participation rate of 2.9 noncompetitive events per year.31 Professional cyclists, on the other hand, have been reported to ride between 25 000 and 35 000 km and complete 50 to 110 days of intense racing each year.”

elite road cyclingrecreational road cycling

What did the report say?

  • 7 teams of
  • 105 active (101 responded) and
  • 11 (7 responded) former elite cyclists were involved.

In this paper, it was reported that, ‘anterior knee pain’ (36%) and ‘lower back pain’ (58%) are the most common cycling overuse injuries reported in the year of study. (Not all reported injuries require medical attention.)

63 participants reported 94 overuse injuries that required medical attention:

  1. lower back pain (46%)
  2. anterior knee pain (23%)
  3. neck pain (10%)

Despite medical attention, 39% can still carry on training/racing.

36% of these injuries led to reduced performance or training volume.

24% of injuries led to participants missing at least 1 day of training/racing:

  1. 57% anterior knee pain
  2. 17% lower back pain
  3. 13% lower leg or achilles tendon injuries

The average number of days loss was 13.5 days, while the worst case (low back pain) ended one participant’s cycling career.

Iliac Artery Flow Limitations

An interesting medical condition that I have not come across was ‘Iliac Artery Flow Limitations’.

This condition can cause symptoms of:

  • pain
  • numbness
  • and loss of power due to flow limitations of their external iliac arteries.

external iliac arteries

Symptoms usually gets worse with more cycling, resolve with relative rest (soft pedaling), but recover may be hours to days, and the condition may get worse as the disease pathology worsens. Complains of symptoms in multiple muscle groups should raise suspicion of a vascular cause, especially when physical examination is normal (Getzin & Silberman, 2010).

In this group of elite cyclists, 2 had previous history of undergoing surgery to fix this problem.


As a physiotherapist, what can I learn from this paper?

  1. Anterior knee pain is the most prevalent condition that will limit the performance/career in this group of cyclists
  2. Cyclists tend to seek help for lower back problems most commonly, but may not suffer from a dip in performance despite pain; it is probably safe to reassure and advice clients to continue cycling while working on their problems
  3. There may be a role in screening for all cyclists to reduce risks of knee and back problems in the future
  4. Consider arterial flow insufficiency if physical exam does not seem to correlate with history

What can we do to help cyclists with persistent low back pain?

There is some evidence that cyclists with low back pain tend to adopt postures that are more ‘slouched’ than cyclists without lower back pain (Van Hoof et al., 2012; Burnett et al., 2004). This can be due to the machine’s fault (bike set-up) or the cyclist’s problem (postural habits and/or lower back muscle endurance). Perhaps screening for this (bike fitting and physiotherapy assessment) and treating an underlying habitual lumbar posture may improve lower back pain.

cyclist back posture

Once again, thank you for reading!



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