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Road Cycling Reaching the Full Spectrum of Sports Medicine AMSSM Orlando 2018

Road Cycling Reaching the Full Spectrum of Sports Medicine AMSSM Orlando 2018. Marc Silberman, M.D. Gillette, NJ. Disclosure. I declare no conflict of interests I do not have any financial disclosures. Objectives. Address knee pain in the cyclist

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Road Cycling Reaching the Full Spectrum of Sports Medicine AMSSM Orlando 2018

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  1. Road CyclingReaching the Full Spectrum of Sports MedicineAMSSM Orlando 2018 Marc Silberman, M.D. Gillette, NJ

  2. Disclosure I declare no conflict of interests I do not have any financial disclosures

  3. Objectives • Address knee pain in the cyclist • Identify bicycle injuries unique to cyclists • Evaluate and treat bicycle injuries in the context of bike fit and training • Perform a professional bike fit

  4. Petr Vacok

  5. Tour de France • By stage 9 of the 2011 Tour • 14 fractures • 16 riders retired from the race • 1 athlete in the Intensive Care Unit Greve MW, Modabber MR. An Epidemic of Traumatic Brain Injury in Professional Cycling: A Call to Action. Clin. J. Sport Med. 2012; 22:81-82.

  6. Deaths since 2016 • Claudio Clarindo 01/25/2016 Training, vehicle • Antoine Dmoitie 03/27/2016 Race, crash, struck by moto • Daan Myngheer 03/28/2016 Cardiac arrest during a race • Randall Fox 03/29/2016 Race, crash descending • Gijs Verdick 05/09/2016 Cardiac arrest during a race • Diego Robayo 08/30/2016 Race, crash, descending • B.Golbarnezhad 09/17/2016 Race, crash, head injury, cardiac arrest • Dejan Maric 09/25/2016 Race, crash • Eslam Zaki 03/20/2017 Race, velodrome • Mike Hall 03/31/2017 3,300 mile race, struck by car • Chad Young 04/28/2017 Race, crash, descending • Casey Saunders 06/25/2017 Race, crash, hit unsecured barriers • Mathieu Riebel 10/20/2017 Race, crash, descending • Michele Scarponi 04/22/2017 Training, vehicle • Jason Lowndes 12/22/2017 Training, vehicle • Michael Goolaerts04/08/2018 Cardiac arrest during Paris Roubaix

  7. Injuries per year • Cycling 614,594 • Basketball 597,224 • Football 372,380 Tan V et al. In-line skating injuries. Sports Med. 2001; 31:691-9

  8. Classification of Injuries • Traumatic • Overuse • Bicycle Contact Silberman MR, Current Sports Medicine Reports: September/October 2013 - Volume 12 - Issue 5 - p 337-345

  9. Classification of Injuries • Traumatic 38 to 48.5% Greater than 2/3 occur in upper extremity • Overuse 51.5 to 62% Greater than 2/3 occur in lower extremity Barrios C, Sala D, Terrados N, Valenti JR. Traumatic and overuse injuries in elite professional cyclists. Sports Exercise and Injury. 1997; 3(4), 176 – 179. De Bernardo N, Barrios C, Vera P, Laiz C, Hadala M. Incidence and risk for traumatic and overuse injuries in top-level road cyclists. Journal of Sports Sciences. 2012; 30(10):1047– 1053.

  10. Bicycle Contact Injuries • 500 mile 8 day bicycle tour • 57.2 % bicycle contact • 32.8% buttock • 10% palmar • 9.1% groin • 5.3% foot • 42.8 % overuse Weiss B. Nontraumatic injuries in amateur long distance bicyclists. The AmericanJournal of Sports Medicine. 1985; 13 (3):187 – 192.

  11. Bicycle Exam

  12. Supplies • Bicycle trainer • Measuring tape • Goniometer • Plumb line • Electrical tape • Adjustable Torque Driver Wrench Set • Video Camera, Tripod, Monitor

  13. Balance • Comfort • Safety • Injury Prevention • Peak Performance The Flying Scottsman on Old Faithful http://www.cyclingweekly.com/news/latest-news/graeme-obree-old-faithful-bike-put-test-wind-tunnel-heres-373769

  14. Obree on doping • "I still feel I was robbed of part of my career. I was signed up to ride in the prologue of the Tour back in 1995, but it was made very obvious to me I would have to take drugs. I said no, no way, and I was sacked by my team. So there I was, 11 years later, sitting there waiting for the Tour cyclists to come by, and something welled up in me. I feel I was robbed by a lot of these bastards taking drugs. I also hate the way that people think anyone who has ever achieved anything on a bike must have been taking drugs. I was surprised how resentful I felt when I was in Paris. It had obviously been simmering away in there for years. That's something new I'll have to talk to my therapist about." • "In my opinion, 99 percent of riders at élite level take EPO or a similar drug, not particularly to dope themselves but to be at the same level as the others. And that's rather sad."[ • "AND by the way, I never took drugs to improve my performance at any time as has been happening in the sport for a long time. I will be willing to stick my finger into a polygraph test if anyone with big media pull wants to take issue. In other words, if you buy a signed poster now it will not be tarnished later.“ wikipedia

  15. Bicycle Anatomy Seat tube Top tube Seat tube angle 72 - 74°

  16. Crankset and ChainringsStandard Rider Height 60-64 inches 165–167.5mm 65-72 inches 170mm 72-74 inches 172.5mm 74-76 inches 175mm ER Burke 39 53

  17. Crankset and ChainringsPro or mid-compact Rider Height 60-64 inches 165–167.5mm 65-72 inches 170mm 72-74 inches 172.5mm 74-76 inches 175mm ER Burke 36 52

  18. Cycling Clock Diagram Myth: Clipless pedals allow the rider to pull up during steady state US National Rider 300W and 90RPM The limb is lifted but Not as fast as the pedal Is rising Broker and Gregor 1996

  19. Order of Fit 1. Foot-Cleat-Pedal Interface 2. Pelvis-Saddle Interface Saddle Height Saddle Tilt and Fore-Aft Re-check Saddle Height 3. Hands-Handlebar Interface Height, Reach, and Tilt 2 3 1

  20. 1. Foot-Cleat-Pedal • Ball of the foot is over the pedal spindle • 1st metatarsal head

  21. 2. Saddle Height

  22. Saddle Height Most important bicycle position setting • Inseam measurement method (LeMond) • Saddle Height = 0.883 X inseam in cm • Knee angle measurement (Pruitt, Burke) • 25 to 30 degrees knee flexion at 6 o’clock position • Heel to back of pedal method • Leg almost fully extended with no hip rocking

  23. Saddle Height Lemond-Guimard Method. Saddle Height = Inseam in cm X .883

  24. 2. Saddle Height Knee flexed 25-30 degrees with pedal in 6 o’clock position.

  25. Saddle Height Fabian Cancellara and Andy Pruitt

  26. 3. Saddle Fore-Aft-Tilt Tilt Fore-Aft

  27. 3. Saddle Fore-Aft When pedal is in the 3 o’clock position, plumb line dropped from inferior pole of patella falls directly over pedal spindle.

  28. Road vs. Time Trial Position Plumb bob falls over pedal spindle and 1st metatarsal Steeper Seat Tube More Forward Position Higher Saddle

  29. 4. Stem Height 1 to 3 inches

  30. 4. Stem Extension Stem Size 10 –12 cm Tops Hoods Top Tube Drops

  31. 4. Stem Extension Torso flexes about 60 degrees with the hands in the drops. Torso flexes about 45 degrees with the hands on the hoods.

  32. 4. Stem Extension Andre Steensen, neck and lower back pain, shortened stem 1cm

  33. Bicycle Contact Injuries

  34. Bicycle Contact Hands Handlebar Saddle Interface Shoe Pedal Interface

  35. Shoe Pedal Interface

  36. Plantar Neuropathy • Burning feet, “hot foot”, numbness, pain • Compression of interdigital plantar nerves • See riders shaking foot out of pedals

  37. Morton’s Neuroma • Perineural fibroma • Commonly between 3rd and 4th metatarsals

  38. Plantar NeuropathyOn the Bike Treatment • Adjust cleat position, usually further back • Check inside shoe for cleat bolts • Change shoes to wider toe box • Shoe inserts or pads may help

  39. Plantar NeuropathyMedical Treatment • Manual therapy • Nerve Blocks • Cortisone, PRP, BMA • Sclerotherapy • Prolotherapy • Neurectomy • Post stump neuroma

  40. Saddle Interface • Saddle Sore • Perineal Vasculopathy/neuropathy

  41. Saddle Sores Cost Fignon the tour? Won him 7 tours?

  42. Saddle Sores • Moisture + Pressure + Friction • Chafing • Ulceration • Folliculitis • Abcess • Subcutaneous nodules

  43. Saddle Sores On the Bike Treatment • Time off the bike • Check saddle height and tilt • Check handlebar reach and height • Change saddle • Clean chamois, no seams, keep dry • Chamois cream • Don’t sit around in your kit after riding

  44. Saddle SoresMedical Treatment • Prevention • Keep dry, clean, chamois, avoid shaving high • Medical Treatment • Warm soaks • Topical cortisone, anti-fungal, anti-bacterial • Oral antibiotics • Surgical incision and drainage • Surgery

  45. Perineal Vasculopathy/Neuropathy • Compression affected by position and effort • Racing position transfers pressure from the ischial tuberosities to the perineum • tP02 may drop 82% during seated cycling • Hypoxemia is associated with penile fibrosis • ED is reported as high as 24% in amateurs with mileage greater than 400km/week Sommer F et al. Impotence and genital numbness in cyclists. Int.J.Sports 2001; 22: 410-3.

  46. “Cyclist’s Syndrome” • Pudendal Nerve Entrapment in cyclists • Exact pathogenesis is unknown • Compression, friction, and/or stretching • Pain, burning, numbness • Sexual dysfunction, impotence, urine incontinence rare, evaluate prostate

  47. Saddle Type Drop in Penile tPO2 Standard racing saddle 76% Padded with elliptical hole 73% Split V rear and central depression 62% Dettori found increase in ED with cutout saddle among those with numbness Cohen JD, Gross MT. Effect of bicyle racing saddel design on transcutaneous penile oxygen pressure. J. Sports Med. Phys. Fitness. 2005; 45:409-18.

  48. Perineal Compression Treatment • Address position, bike fit, and riding technique • Risk is greatest in time trialing, indoor cycling, in heavier cyclists, and in mountain biking • Prevention by alternating sitting and standing • Treatment: Injection therapies • Bike Fit Causes: High saddle, narrow saddle, saddle tilted up Bars too low or reach to long

  49. Hands Handlebar Interface

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