Tuesday, July 7, 2009

Cycling and Leg Pain

Cycling Medicine: Acute Overuse of the Legs

In the rush to cram cycling into our busy lifestyles, recovery is typically the first thing that gets thrown out the window. After all, it’s easy to prescribe training programs but more difficult to prescribe, or adhere to, recovery programs. Dr. Rick Rosa returns with a cautionary tale about what happens when we push our bodies too far by trying to do it all… By Rick Rosa, D.C.,D.A.A.P.M.

Bike-Run Transition
This year for my birthday, my good friend Dave and I rode 100 miles with over 8,000 feet of climbing. It was a hard ride but I had fun. Once the ride was over I went home to recover while Dave figured he would play a little coed soccer with his wife. I’m not sure if it was the lactic acid bath during the ride or the pressure to do things with his wife that clouded his otherwise rock solid judgment, but he set himself up for disaster.

While playing soccer he was running up and down the field making quick accelerations and decelerations as well as lateral movements. At one point he felt a sharp pain in his hamstring, namely the semitendinosus muscle. Soon after that, he began to experience pain in the upper part of his rectus femoris muscle (the middle thigh). He eventually came into my office after the injury did not improve and he noted it was affecting his riding.

Dave is a seasoned 16 year Cat-3 cyclist and, like many cyclists, he is always trying to find time to train. He is well versed on most things associated with cycling including injuries, and he did take it easy for a while, limiting the amount of intervals and power level he was producing. The pain was not improving so he finally brought it up in conversation with me, so I scheduled an appointment to see my good friend and help him with this problem.

Case History
In looking at his past medical history, I discovered that he had injured his ACL ligament in his left knee when he was a child playing soccer and started cycling to keep that knee stable and strong. The injury was a mild tear and more of a stretch of the ligament which left him with a bit of extra play in that knee than I would like.

Upon examination of the legs, I noted that he had some limited flexibility in the injured leg in multiple muscles and planes of movement. In other words, he was a bit tight but he had been working on this since the injury, which means he was previously even more limited in movement. Like many cyclists that I had seen, he had limited movement in the hamstrings and some decreased movement in adduction (bringing the leg into the body). In addition, he had pain on the inside or medial side of his hamstrings in the belly of the semitendinosus muscle and the middle of the thigh, or rectisformis muscle, when I palpated them. Lastly his left hip joint was a bit restricted in movement.

Fatigue and Overload
So how and why did this happen? Well in this case, we don’t have a de-conditioned weekend warrior who has an imbalance between quad strength and hamstring strength because those people can have this very same injury just as easily. Was it the old injury to his knee that made him predisposed to this strain in his leg? Maybe to some degree but the real culprit in this case is muscle fatigue.

Think of your muscles as engines, brakes, stability control, and shock absorbers all in one. When the muscles become fatigued from work such as a long hard climb, they are affected at a physiological level. This affects all fiber types such as type I, IIa IIb, IIc, and III, which can damage and deplete the energy stores. You can still turn the engine on and hit the brakes but the stability control systems are not up to par and you have no shock absorbers at all.

In a study done at Duke University (1), they looked at muscle fatigue and susceptibility to strain injury. What they found was that muscles lose 69.2% to 92% of their ability to absorb shock when they are fatigued. We incur injury to our muscles mostly during eccentric contractions; for example, when we plant our foot down when running during a soccer match, or when the body is fatigued and not able to absorb the shock or control the movement as well, leading to injury.

Prevention and Treatment
Well now that we know how, why, and what to do to prevent and treat this injury, we need to know the initial steps to begin the appropriate treatment. Firstly, playing a rigorous and strenuous sport such as soccer after a cycling 100 miles is not conducive to active recovery which your body needs to rest and heal. Secondly, it is just as important to maintain balance and flexibility in order to prevent these types of injuries.

So, how did I treat my good friend Dave?

First, I told him to stop the co-ed soccer for a bit because that eccentric loading is a killer for an injury like this. On the bike, I asked him to keep the watts down as well as the time and put him into an active recovery mode. I reminded him of the importance of sleep and nutrition and gave him a supplement that helps with recovery. Then, I used electric stimulation, ultrasound, cross friction massage, manipulation and topical creams in an effort to heal the tissue, minimize scar tissue formation, and restore proper biomechanics. I also used a special tape called KINESEO tape that helps with support and healing of the injured muscles. Dave was most impressed with the tape.

Dave responded well and was soon kicking my butt in the Assault on Mt. Mitchell, a nice 102 mile ride with over 11,000 feet of climbing in North Carolina, which oddly makes me feel great!

One important last note, it is important not to rush your way back after large and small injuries because cycling biomechanics can get thrown off very easily. After injury, cycling biomechanics are affected at a minimum, which can lead to a chronic injury. Last but not least, I always recommend seeing a specialist that knows about these types of injuries.

References1. Mair SD, Seaber AV, Glisson RR, Garrett WE Jr. The role of fatigue in susceptibility to acute muscle strain injury. Am J Sports Med. 1996 Mar-Apr;24(2):137-43.2. Hammer WI. Functional soft tissue examination and treatment by manual methods. Aspen Publishers; 1991

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