REVIEW ARTICLE
Chronic Musculoskeletal Conditions Associated With
the Cycling Segment of the Triathlon; Prevention and
Treatment With an Emphasis on Proper Bicycle Fitting
Robert T. Deakon, MD, FRCSC
Abstract: Cycling-related injuries account for 20% of all injuries
occurring during triathlons. Traumatic injuries caused by falls or
accidents are thankfully rare but can be highly variable and very
serious in nature. The best approach to these injuries is prevention.
The majority of complaints arising from cycling are due to overuse
or poor technique. The knee joint, lower back, neck, and Achilles
tendon are the most frequently aected anatomic sites. Anterior
knee pain, lower back and neck myofascial pain, iliotibial band
friction syndrome, and Achilles tendonitis are the most common
diagnoses. Initial treatment should always use rest, ice, com-
pression, and elevation. Muscle strengthening and stretching as
well as other physical modalities are helpful in the subacute setting.
The need for surgery is rare. Improper bike t contributes to the
causation of a signicant number of these conditions. Bike geom-
etry may also be altered to alleviate symptoms.
Key Words: triathlon, chronic bicycling injuries, bike t, anterior
knee pain with cycling, patellar tendinitis, quadriceps tendinitis,
iliotibial band syndrome, back pain and cycling, neck pain and
cycling, wrist pain and cycling, tips for avoiding cycling injuries
(Sports Med Arthrosc Rev 2012;20:200205)
A s the majority of chronic conditions associated with the
cycling segment of the triathlon can be traced back to
improper bicycle tting or incorrect cycling technique, it is
essential for the treating physician to have a thorough
understanding of the basic principles of proper triathlon
bicycle setup.
PROPER TRIATHLON BICYCLE FITTING
The cycling segments of triathlons are solo events and
are governed by rules prohibiting drafting or group riding
(except for the elite level Olympic distance triathlons where
drafting is permitted). The technical rules, however, do
allow the use of triathlon specic handlebars or aero bars
that allow the rider to obtain a highly aerodynamic position
on the bicycle. Wind resistance is the most signicant force
limiting the speed of the cyclist and obtaining a more aer-
odynamic position is the single most important means by
which a triathlete of a given tness level can go faster on the
bike portion of the event (Fig. 1).13
To optimize the use of these aero bars, the geometry of
triathlon-specic bikes has been altered by making the
eective seat post angle (the angle from the center of the
bottom bracket to the center of the seat mount) more ver-
tical. This more vertical seat post position rotates the rider
From the Halton Healthcare Services, Oakville, ON, Canada.
Disclosure: The author declares no conict of interest.
Reprints: Robert T. Deakon, MD, FRCSC, Halton Healthcare
Services, 327 Reynolds Street, Oakville, ON L6J 3L8, Canada.
Copyright r 2012 by Lippincott Williams & Wilkins
200 | www.sportsmedarthro.com Sports Med Arthrosc Rev
forward on the bicycle bringing the riders back from a
more upright position, as seen on a road bike, to a more
horizontal position that is closer to parallel with the
ground. The use of aero bars and this forward rotated
position improves the aerodynamics of the rider-bicycle
construct and in turn, this decreases the power output
necessary to maintain a given speed. It is this decrease in the
power output necessary to maintain a given speed that is
the single biggest advantage of a triathlon-specic bicycle
frame and aero bar combination. This advantage of tri-
athlon-specic bike geometry is only realized, however,
when the rider is able to remain in the more aerodynamic
position, with the forearms supported in the aero bar
armrests. If this position is uncomfortable and the rider
needs to sit up, then the aerodynamic advantage of the
tribike is lost and the rider may as well be riding a road
bike, with its more relaxed and comfortable position and
better handling geometry.
There are a number of dierent approaches to
obtaining an ideal tribike t. Two of the more popular ones
being that of Dave Empelds Fit Institute Slowtwitch4 and
that of the Serotta International Cycling Institute.5 What-
ever method is selected, an aerodynamic position, which is
comfortable to maintain for the duration of the cycling
portion of a given triathlon event is the desired goal. Most
of these approaches begin by determining the appropriate
seat tube angle and seat height to work from. The cockpit
distance (the distance from the seat to the forearm rest and
handle bar extensions) and the handle bar drop (the dis-
tance from the top of the saddle to the forearm rests) are
then determined. A proper triathlon bike setup usually
begins with a seat-post angle of about 78 to 80 degrees (as
opposed to a road bike where the seat-post angle is usually
around 72 degrees). Beginning with this seat-post angle, the
proper seat height is adjusted, aiming for a knee exion
angle with the foot at bottom dead center (the point of
peddle rotation furthest away from the seat) of about 30
degrees. This seat position can be adjusted upward and
downward and usually falls between an angle of exion at
the knee of 35 to 25 degrees with the pedal at bottom dead
center. It is often easiest to establish the correct seat height
by observing the pedal motion of the rider and nding what
looks smoothest and feels most comfortable. A high seat
position without rocking of the pelvis during the pedal
stroke is essential.
The next dimension to be addressed is that of the
cockpit length, which is the distance from the saddle to the
forearm rests and aero bar extensions. When properly
positioned, the elbows should be exed at approximately 90
degrees and the upper arm should form roughly a 90-degree
angle with the long axis of the trunk. The last tting
parameter to be adjusted is that of armrest drop (the dif-
ference in height from the top of the seat to the forearm
 Volume 20, Number 4, December 2012
Sports Med Arthrosc Rev  Volume 20, Number 4, December 2012
FIGURE 1. The highly aerodynamic triathlon cycling position
made possible with the use of tri or aero bars.
rests). Although there are formulas available to give an
approximate armrest drop for a given seat height and seat
angle, this dimension is usually nalized based on rider feel
and comfort. These steps should produce a given hip angle
that should not change signicantly from a similar tting
exercise on a road bike (Fig. 2).
The nal variable that is subject to adjustment is that
of crank length. There is considerable debate as to what
constitutes the ideal crank length for a given rider and how
to determine this measurement. Historically, a value of
170 mm for an average size male has been used. Studies on
the eect of changes in crank length on maximal power
output for an average height male cyclist have arrived at
optimal dimensions of 164 to 180 mm.68 However, these
studies also seem to demonstrate that signicant changes in
crank length6 (> 35 mm7) are necessary to show a readily
apparent negative eect on power output. However, there
may be other factors at play for the triathlete where a
higher cycling cadence is desirable to avoid injury and
where cockpit interference of the knee relative to the
handlebars and chest may come into play. For both these
situations, a shorter crank length will be advantageous.
A signicant change in crank length may require all of the
other tting measurements to be reassessed.
Some authors have postulated that an advantage arises
in using triathlon-specic bike frame geometry versus a
road bike in transitioning to the run as a more vertical seat
post angle is used and therefore a less acute hip angle
obtained. However, the most eective triathlon bike tting
methods obtain hip exion ankles that are identical to or
closely match that of road bike geometry. The rider is
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Cycling Injuries in Triathlon Training and Competition
FIGURE 2. A knee flexion angle with the foot at bottom dead
center of 25 degrees, a hip angle of 97 degrees, a near horizontal
back position, and good arm position.
simply rotated forward with the back brought into a more
horizontal and more aerodynamic position. Therefore, as
stated previously, the single largest advantage to using tri-
athlon-specic bicycle geometry is that of improved aero-
dynamic eciency and decreased power output necessary to
maintain a given speed as a result of less wind resistance.
This reduced power output saves and rests the legs for their
running portion of the triathlon. Because the hip angle is
not signicantly altered, the concept of decreasing tension
in the hamstring muscles and increasing tension in the hip
exors by using a more open hip angle (a muscle condition
that would be closer to that of upright running stance) is
not actually valid.
Diculty can arise in selecting the appropriate bicycle
for a given riders physique. It is important to understand
the concepts of stack and reach as measures of the given
bicycle frames geometry. Stack is the distance from the
center of the bottom bracket to the top center of the head
tube and reach is the distance from a vertical line drawn
through the center of a bottom bracket to a vertical line
through the center of the top of the head tube. It is also
often known as eective top tube length. Triathlon bicycles
come in 3 basic geometries known as a tall and narrow,
long and low, and neutral overall geometry. An individual
with relatively long legs and a shorter trunk tends to t a
tall and narrow frame better whereas an individual with
shorter legs and a longer trunk would be more appropri-
ately tted on a bike with a long and low geometry.
Recently more triathlon-specic bicycles have been devel-
oped with a neutral geometry between that of tall and
narrow, and long and low, and with increasing modularity
to allow a given bike frame to accommodate dierent rider
physiques. A rider must be matched to an appropriate tri-
athlon bicycle geometry by an expert tter to obtain the
most aerodynamic and comfortable rider-bicycle construct.
A note on bicycle seats. Triathlon athletes participat-
ing in longer events such as a half-ironman and ironman
need to maintain the seated aero position for a prolonged
www.sportsmedarthro.com | 201
Deakon
period of time. This puts an increased strain on the fore-
arms, the ischial tuberosities, and perineum. The triathlete
should try a number of the available seats to nd the seat
that is most comfortable. Turning the seat slightly right
or left may more evenly balance pressure on the ischial
tuberosities as there is often side to side asymmetry in these
structures. The triathlete may also nd that swapping out
2 or 3 dierent types of seats with dierent pressure point
congurations may decrease the overall discomfort and the
likelihood of formation of saddle sores. For training, well-
cushioned cycling shorts and the use of chamois creme is
also helpful in preventing saddle sores.
CYCLING INJURIES IN TRIATHLON TRAINING
AND COMPETITION
Introduction
Cycling injuries account for approximately 20% (range
of 13% to 22%911) of all injuries sustained by triathletes
during training and competition. Egermann et al12 in their
retrospective survey of Ironman distance triathletes found
the incidence of injuries associated with cycling to be higher
at 54.8% and attributed this dierence from the incidence
noted in other studies to the volume of training hours spent
on the bike by these long-distance competitors. Cycling
injuries can be classied as either acute/traumatic or chronic
in nature. As a majority of training for the cycling portion
of a triathlon takes place on public roadways, the triathlete
is at risk of injury from falls and encounters with obstacles
and other vehicles on the roadway. The acute traumatic
injuries produced by these accidents are highly variable in
their presentation, their severity and complexity, and are
better covered in a traumatology periodical. However, the
best approach to preventing acute traumatic injuries is that
of prevention and a table outlining guidelines for the cyclist
to avoid or minimize injury on the public roadways is pre-
sented in List X. This section will focus primarily on chronic
or overuse injuries associated with the cycling segment of
triathlon training and competition.
Chronic and Overuse Injuries Associated
With Cycling
The most common anatomic areas aected by cycling
are that of the knee, lower back, neck, Achilles tendon,
wrists, and forearm.1315
Anterior Knee Pain
The most common knee complaint is that of anterior
knee pain. This is characterized by pain in the parapatellar,
retropatellar, or patellar tendon area. The pain usually
comes on with riding and is made worse with prolonged
duration of riding. The pain may radiate inferiorly from the
knee. The pain is usually made worse by prolonged sitting
and by stair climbing. It may be associated with crepitus or
grinding arising from the patellofemoral joint with knee
extension or deep knee bends. The athlete often has a
previous history of anterior knee pain. Physical examina-
tion may show predisposing factors such as patella alta or
baha, an increased Q angle, patellar tilt or positive J-sign,16
or a tight lateral patellar retinaculum. An imbalance in the
quadriceps muscle distribution may also be perceived with a
relative deciency of the vastus medialis obliquus muscle
group. Examinations may also reveal crepitus in the
patellofemoral articulation, and as well include positive
compression tests of the patellofemoral joint and a positive
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Sports Med Arthrosc Rev  Volume 20, Number 4, December 2012
apprehension test. Radiographic analysis will be helpful in
conrming patellar alta or baha and computed tomo-
graphic scan may demonstrate an increased tibial tubercle
and femoral sulcus angle increased tibial tubercle to fem-
oral sulcus distance.17
The cause of anterior knee pain in cyclists is thought
to be associated with an increase in patellofemoral contact
pressures.14 The 2 main factors contributing to this elevated
patellofemoral stress are excessive quadriceps muscle force,
as may be seen with climbing hills and using harder
gear ratios resulting in a lower cycling cadence, and maldis-
tribution of these forces across the joint due to malalignment.
Acute treatment of anterior knee pain in cyclists
focuses on the application of rest, ice, compression, and
elevation, as well as the use of a brief period of nonsteroidal
anti-inammatory drugs (NSAIDs). Treatment of a sub-
acute case involves eorts to rebalance the quadriceps
muscle distribution, emphasizing straight leg rising, and
near full extension of the knee in an attempt to specically
recruit the vastus medialis obliquus muscle group. It is
important to emphasize to the athlete that rebalancing of
the quadriceps muscle group usually requires a minimum of
4 to 6 weeks of the diligent performance of proper exercises
to realize a clinical improvement.
It is also important to assess the athletes bicycle t and
cycling technique to ensure that both of these are optimized
to decrease patellofemoral contact pressures.14 Often a bicy-
cle seat position that is too low will produce a higher angle of
exion in the knee and thereby increase the compressive
forces in the patellofemoral joint. Raising the bicycle seat will
diminish these compressive forces and decrease the relative
activity of the quadriceps muscle group.18 Another approach
is to shorten the bicycle crank length in conjunction with
raising the seat. This will decrease the overall acuity of the
angle of exion of the knee in the top dead center pedal
position, thereby decreasing the patellofemoral contact
stresses and the relative recruitment of the vastus lateralis
muscle group (which is recruited to a greater extent with
increasing exion of the knee). The triathlete should also be
assessed for hyperpronation and internal tibial torsion as
these malalignments lead to an eective increase in the Q
angle and an increased patellofemoral strain. Use of
orthotics in the cycling shoes and adjustment of the position
and/or canting of the cleats can be used to correct the
abnormal forces on the knee joint during the pedal stroke.19
Cyclists should also be encouraged to maintain a
higher cadence. Triathletes, particularly those who come
from a running background, tend to use a lower cadence
and push bigger gears.20 This practice increases the work
of the quadriceps muscle group and increases the patello-
femoral contact stresses. In contrast, experienced cyclists
tend to use much higher cadence in the range of 100 to 110
rotations per minute. MacIntosh et al21 showed, using
muscle electromyographic measurements during cycling at
variable loads, that optimal cadence increased with
increasing load. This higher cadence also has been shown to
recruit more of the hamstring muscle group and extensor
muscle group at the hip including the gluteal muscles,22
thereby decreasing the percentage of the overall workload
performed by the quadriceps muscle group.2224 Studies,
however, show that the electromyographic activity of
the quadriceps muscles remains relatively constant with
increasing cadence25 and therefore only the contribution of
the hamstring, gastrocnemius, and gluteus muscles groups
increase with increases in cadence.
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Sports Med Arthrosc Rev  Volume 20, Number 4, December 2012
Patellar Tendinitis
Another common complaint of cyclists is that of pain
in the patellar tendon. This is usually an acute onset pain
and is associated with an extreme increase in strain through
the patellofemoral joint mechanism.13,14 This usually occurs
when a cyclist uses a very low cadence or extremely hard
gearing and is associated with hill climbing and standing
pedaling. Standing up out of the saddle signicantly in-
creases the workload performed by the knee extensors on
the downstroke and virtually eliminates muscle activity on
the upstroke.26 Pain is usually localized to the patellar
tendon and is increased by extension of the knee. It may or
may not be associated with patellofemoral joint pain or
discomfort. Physical examination is characterized by ten-
derness over the patellar tendon, particularly at the inser-
tion of the tendon into the inferior pole of the patella.
The area of tenderness is often more pronounced when the
patellar ligament is relaxed rather than tense. This con-
dition is best treated by activity modication and the use of
a brief pulse of NSAIDs. Corticosteroid injections are
reserved for cases not responsive to conservative measures.
Surgery is rarely indicated and involves excision of the area
of myxoid degeneration from the tendon.
Quadriceps Tendinitis
Less common but similar in presentation to patellar
tendinitis is quadriceps tendinitis. In this condition the pain
occurs at the superior or superior-lateral region of the
patella. Usually the athlete is older (> 40 y of age) and may
have history of an underlying enthesopathy. Dierentiation
must be made from patellofemoral and iliotibial (IT) band
origins of the pain. Tenderness with rm palpation is
present along the superior pole of the patella but is usually
not as localized as that seen in patellar tendonitis. X-rays of
chronic cases frequently reveal calcication of the tendon
insertion into the superior pole of the patella. Treatment is
initiated with rest and activity modication in addition to
the use of NSAIDs such as indomethacin. A similar
approach to bike tting as that used for anterior knee pain
can be used for both patellar and quadriceps tendonitis.
IT Band Friction Syndrome
A third common complaint of cyclists is that of pain
on the lateral aspect of the knee. This pain usually occurs
superior to the lateral joint line and is often described as
burning in nature. The pain may radiate up the lateral
aspect of the thigh. It is usually made worse by walking or
running down an incline and it characteristically comes on
some distance into the run but may also develop a few
kilometers into a cycling session. Physical examination is
characterized by point tenderness over the lateral epi-
condyle of the knee. This pain is dierentiated from that of
meniscal pain in that it usually occurs superior to the lateral
joint line, is not associated with point tenderness along
the lateral joint line, there is no increase in the pain
with marked exion of the knee, and there is a negative
McMurray test, and an absence of clicking, clunking, or
crepitus in the lateral compartment. An Ober test is often
positive indicating a tight IT band.27 The diagnosis is IT
band friction syndrome and the most appropriate treatment
is the use of NSAIDs and stretching of the IT band in
conjunction with active release therapy massage.28 An
excessive seat height has been implicated in the causation of
IT band friction syndrome as the duration of the knee joint
in the impingement zone of the IT band on the lateral
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Cycling Injuries in Triathlon Training and Competition
epicondyle is increased with knee extension.29 Lowering
seat position and ensuring that the hip is not adducted at
any point in the pedal stroke will decrease the extrinsic
tension on the IT band from the tensor fascia lata and the
gluteus maximus muscle groups. This condition may also be
produced by an improper foot position on the bicycle
pedals. It can also be produced by a bicycle pedal that does
not allow for a slight inward and outward movement of the
foot during the pedal stroke.30 Correction therefore should
involve assessment of the foot position on the bicycle pedal
during the pedaling stroke, with a correction of the cleat
position. Possible canting of the cleat and changing for
a cleat that allows more freedom of movement during the
pedal stroke should also diminish symptoms.
If the condition is recalcitrant to conservative treat-
ment, an injection of the point of maximal tenderness with
corticosteroid is indicated. Only rarely is surgery necessary
and involves releasing the tight portion of the posterior IT
band31 or excising an ellipse of the IT band near the lateral
epicondyle.28
Back Pain
Lower back pain (LBP) is another common complaint
of cyclists in general, but seems to occur in an even greater
frequency in individuals using bicycles with dedicated tri-
bike frame geometry. Villavicencio et al32,33 surveyed tri-
athletes in the Boulder Colorado area and found a lifetime
incidence of LBP of 67.8%, whereas OToole et al34 found
an incidence of 72% in ultraendurance triathletes. Tri-
athlon-specic frame geometry places the lumbar spine in a
more horizontal position and puts an increasing strain on
the lower lumbar spine and sacroiliac joints. This may lead
to complaints of LBP. Thankfully, the majority of these
complaints of LBP are short-lived in nature, lasting <7
days in 54%35 to 62.7%32 of triathletes surveyed. LBP
persisting for >3 months in duration is associated with
an increased incidence of spinal pathology, including dis-
cogenic pain and disk protrusions,36 as well as facet joint
pathology.37,38 Back pain persisting for >3 months
occurred in approximately 20% of triathletes surveyed35,32
and warrants further investigation. The only strongly pre-
dictive factor for the occurrence of LBP in triathletes was
a history of previous sports-related injury.32 Most episodes
of LBP in the triathlete during cycling can be addressed by
relative rest (substitution of cycling with swimming or other
cross training activity). The excessive performance of trunk
exor exercises has been linked to LBP in this group of
athletes and therefore this practice should be discouraged.35
Ensuring that the triathlete increases his time on the tri-
athlon-specic geometry bike in a gradual manner will also
minimize the incidence and severity of lower back com-
plaints. Initially while training on the tribike, the triathlete
may want to use a less aggressive aero bar position with a
decreased seat-to-armrest drop to place the lower back in a
more vertical position, thereby decreasing the strain to the
lower lumbar spine. As the competitive season progresses
and as the athlete gains increased lumbar spine endurance,
the armrest drop can be increased to maximize aerody-
namic eciency. Alternatively, a bicycle with road geome-
try may be used for a larger portion of the cycling training.
Neck Pain
According to Villavicencio et al32 the lifetime incidence
of neck pain seems to be slightly lower (48.3%) than that of
back pain in the triathlete. As with back pain, the single
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Deakon
most predictive factor for the occurrence of neck pain is a
previous history of sports-related injury. The more aero-
dynamic position aorded by tribicycle geometry also pla-
ces the neck at increased risk of strain. The more horizontal
position of the back forces the rider to hyperextend the
neck to be able to look far enough down the road. This
causes increased strain on the upper 3 levels of the cervical
spine. Strain in these musculoligamentous structures has
been implicated in the generation of cervicogenic head-
aches.39 The majority (66.7%32) of these complaints are
short-lived in nature and are associated with the beginning
sessions of the training season. In a similar manner to that
with lower back complaints, the occurrence of neck pain
can be minimized by gradually increasing the duration
of sessions with the cyclist in the aerodynamic position.
The aero bar armrests can also be initially placed in a
higher, less aggressive position40 and gradually dropped to
the optimal aerodynamic position as the triathlete gains
endurance in the cervical musculature. Also using a wider
armrest position may decrease strain on the neck muscles.
Any complaints of radicular pain or neurological abnor-
malities in the upper extremities in the form of numbness or
weakness warrants immediate further investigation and a
cessation of all cycling activities in the full aerodynamic
position.
Achilles Tendon Pain
Achilles tendinitis is a common complaint of cyclists
participating in the longer endurance events. This is usually
associated with an abnormal cycling technique where the
heel drops below the pedal in the lower portion of the
pedaling stroke.14,41 It is also associated with a lower
cadence and standing up out of the saddle for hills. Physical
examination is characterized by discomfort on palpation
of the Achilles tendon, by pain during toe rising, and in
severe cases swelling may be noted in the Achilles tendon.
Treatment usually involves rest, the use of anti-inamma-
tory medications, and the application of ice, as well as
modication of cycling technique. Such modications may
include repositioning the pedal cleat more rearward on the
cycling shoe, raising the seat, and encouraging increased
cadence and cycling in the seated position.
Wrist and Elbow Pain
Triathletes training for and competing in the cycling
portion of the event frequently complain of wrist and elbow
pain. Wrist pain arising from training in a nonaero setup
using traditional handle bars produces compressive forces
on wrist in extended position and may produce ulnar nerve
compression or carpal tunnel syndrome. Motor and sensory
decits are more common in the ulnar nerve distribution
than the median nerve in long-distance cyclists.42,43 The
recommended treatment is avoiding prolonged static posi-
tion of the hand and wrists in a hyperextended, compressed
position. The use of cushioned gloves and handle bar tape
may also diminish the symptoms associated with ulnar and
median nerve compression.42 For athletes spending a pro-
longed period of time in the armrests on the aero bars, local
pressure on the forearms is also common complaint. This
can be addressed by custom tting of the foam and gel
supports of the proximal forearm rests and by gradually
increasing the duration of sessions to improve soft tissue
tolerance in the dorsal proximal forearm.
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Sports Med Arthrosc Rev  Volume 20, Number 4, December 2012
Tips for Avoiding Injury While Road Cycling
1. Always wear an approved and properly tted helmet
with the chin strap rmly buckled. Wear identication,
ideally a brightly colored bracelet with contact and
medical information and allergy status.
2. Inspect your bike before each ride, checking the tires,
tire pressure, and ensuring that tubulars are properly
glued. Check the bike for loose or missing nuts and
bolts. Inspect the chain and gearing and ensure that
they are properly lubricated.
3. Use a ashing light on the front and back of the bike.
4. Ride to the left of the edge of the road, away from the
curb. The faster the pace, the more the cyclist should
ride with the ow of trac and in their own lane.
5. Obey the rules of the road and be particularly careful at
intersections. If possible, signal all turns, attempt to
make eye contact with motorists, and if necessary wave
at or talk to motorists to get their attention.
6. Make yourself obvious by wearing bright colors or
reective clothing. Assume that you are invisible to the
motorist.
7. Know and abide by group-riding etiquette when riding
in a peloton (group of cyclists). Do not ride on the
tribars while in a group ride.
8. Choose streets with bike lanes, wide roads, and ones
with lower speed limits.
9. Avoid riding at night, in slippery conditions, or when
visibility is poor.
10. Be alert for road obstacles, potholes, loose gravel, pets,
or wildlife. Watch out for opening doors when passing
parked cars.
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