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Chronic Cycling Injuries, part II

Dana Kotler, MD

Instructor, Harvard Medical SchoolDirector, Cycling Medicine ProgramSpaulding Rehabilitation Hospital Newton-Wellesley Hospital

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Overuse Injury

This article is pretty good

Kotler, 2016

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Genital Numbness:“Carpal tunnel syndrome of the crotch”

• Compression/irritation of the pudendal nerve and blood supply.

• S2-4 anterior divisions, passes through greater sciatic foramen between coccygeus & piriformis

• Crosses lateral to ischial spine, enters ischiorectal fossa through lesser sciatic foramen, enters Alcock’s canal

• 62% of competitive female cyclists had symptoms within 30 days of a race1

• Data related to sexual function is inconclusive1,2,3

– 114 cyclists shows 20% female cyclists with anorgasmia compared to runners (P <.001)

– 3,118 cyclists shows no difference between female cyclists and runners in sexual function (P <.001)

http://support.tpan.com/site/DocServer/Pudendal_nerve.pdf?docID=390http://www.pudendalhope.info/node/13#Female_Pudendal_Nerve.

1 Guess et al, 20062 Hermans et al, 20163 Gaither et al, 2018

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Pudendal nerve

• Innervation of female external genitalia (S2,3,4)

Source: www.artofthaimassage.comMurinova N., Krashin D., Trescot A.M. (2016) Posterior Femoral Cutaneous Nerve Entrapment: Low Back. In: Trescot A.M. (eds) Peripheral Nerve Entrapments. Springer, Champaign, Il.

(A) genitofemoral(B) obturator(C) infrior cluneal(D) peroneal branch of posterior femoral cutaneous(E) ilioinguinal(F) pudendal

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Pudendal Neuralgia

• Symptoms range from perineal numbness to severe pain• Often follows trauma to pudendal nerve but can be idiopathic• Often severe pain with sitting• Allodynia in distribution of pudendal nerve• May have exquisite tenderness to palpation over ischial spine on

vaginal exam• Essential Criteria (Nantes)1

– Pain in territory of pudendal nerve (anus to clitoris)– Predominantly while sitting– Does not wake patient at night– No objective sensory impairment– Relieved by diagnostic pudendal nerve block

Slide courtesy of Dr. Antje Barreveld1Labat JJ et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria).  Neurological Urodynamics, 27: 306‐310, 2008

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Neurologic Injury

• Symptoms– Pain, burning, numbness, dysuria – Sexual dysfunction

• Risk factors– Poor bike fit, inappropriate saddle shape, saddle high– Time trialing, indoor riding, minimal position change– Heavier cyclists

• Treatments– Time off the bike– Technique changes, position changes, bike fit, saddle type, lubrication– PT, manual therapy– Injection options for pain

Hibner et al, 2010

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Labial Hypertrophy“Bicyclist Vulva”

• Vulvar lymphedema: Unilateral swelling of the labium major

• Impaired lymphatic drainage in the genital region and repeated compression of the inguinal lymphatic vessels.

• Cut-out saddles MAY worsen risk• Elevate the lower limbs and ice the area.

Treatment can range from conservative to surgical.

• Use a proper saddle for person’s anatomy.

Baeyens L, 2002Grouin A, 2018

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Musculoskeletal Overuse Injury

• Nontraumatic (overuse and degenerative) injuries predominate within recreational cyclists1

• Cycling is dependent on the repetitive motion of a pedal stroke, from 60 to 120+ rpm for the duration of a ride.

• Most common areas of overuse injury in cycling are the knee, lumbar spine, cervical spine, buttock, Achilles tendon, wrists, and forearm2-6

• Specific details: on/off bike, gears, terrain, etc.1Wilber et al, 19952Asplund,, 20073Clarsen 2010

4De Bernardo 20125Decalzi 20136Perrin 2012 

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Management of overuse injury in cyclists

• Cyclist– Muscular imbalance– Degenerative change– Medical management– Technique/skill/habit

• Shoe– Shoe size, cleat placement, rotation– Support

• Bike– Saddle position and shape

• Up/down/fore/aft/tilt– Crank length (=ROM)– Stance width medial/lateral issues– Cockpit /handlebar position

NESN Celebrity Spotlight Series: Spaulding Cycling Medicine Program https://www.youtube.com/watch?v=SkGAs4REbSE

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Overuse Injury

• Motion of cycling primarily occurs in the sagittal plane– Strength imbalances

• Hip abductor (gluteus medius)– Stabilization of the pelvis,

prevention of excess torque about the knee

– Deficits previously linked with faulty lower extremity biomechanics and injury

• Abnormal recruitment seen in back and hip pain3

3Cooper, 2015

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Difficulty recruiting stabilizing musculatureDifficulty recruiting stabilizing musculature

Excessive hip motion, excess torque about the knee Excessive hip motion, excess torque about the knee

Increased motion in the coronal planeIncreased motion in the coronal plane

Decreased power and increased biomechanical injury2Decreased power and increased biomechanical injury2

Role of the hip abductors

• Lateral ankle sprain, patellofemoral pain, iliotibial band (ITB) friction syndrome, and anterior cruciate ligament injury1

• Not specifically studied in cycling.

1Willson JD et al, 20052Asplund, 2010

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On-the-bike assessment

• “What is your relationship to the saddle?”– Perineal pressure, pain, numbness, sores– Compensatory changes in position

• Pressure distribution saddle : hands– Typically about 60:40

• Feet– Do you feel like you are up against a

stop?• Handling

– Any concerns?

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On-the-bike assessment

• Sagittal plane– Knee angle, ankling saddle height– Spine position, pelvic tilt– Reach, cervical extension

• Coronal Plane– Lateral pelvic motion, knee deviation

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Knee Pain

• Knee is often victim of kinetic chain abnormalities

• Anterior knee pain– Increased patellar contact pressures and

load through tendons– Harder efforts, hill climbing– Saddle low, forward, increased flexion, KOPS

ahead• Posterior knee pain

– Increased stress on posterior chain structures

– Saddle high/aft

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Knee Pain - Approach

Overuse Injury Anatomic Factors Technique Errors Fit/Equipment

Anterior knee pain (patellofemoral pain, patellar or quadriceps tendinopathy)

Weak hip abductors/gluteus medius, weak vastus medialis, excessive foot pronation, valgus alignment, patellar laxity or tilt

Harder gearing, lower cadence (rpm), hill climbing, elevated training volume/mileage

Saddle too low, anterior, crank length too long, foot pronation, inadequate shoe support

Distal ITB syndrome (superolateral)

Varus alignment, weak hip abductors, prominent lateral femoral condyle, ITB tightness/+Ober’s test

Harder gearing, lower cadence (rpm), hill climbing, elevated training volume/mileage

Saddle too high/posterior forcing knee extension, cleats toed-in, pedal position too narrow

Biceps femoristendinopathy (posterolateral)

Varus alignment Elevated training volume/mileage, aggressive cross-training with weights or running

Saddle too high, posterior, cleats toed-in

From Kotler, 2016

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Cycling-Related Knee Pain

• Detailed history, specific triggers• Exacerbating/alleviating factors• Equipment and fitting

• Full knee examination– Standing posture/alignment– Tenderness

• Joint lines, tendons, bursae– Stability

• A/P, M/L– Tracking/mechanics– Provocative maneuvers

• Clarke’s test– Functional testing

• Squat, jump

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Knee Pain – Imaging

• Xray (*Standing)– Joint space narrowing, osteophytes,

patellar deviation, varus/valgus alignment

• MRI– Intra-articular derangement, source of

effusion• Ultrasound

– Extra-articular pathology– Tendinopathy, neovascularization– Guidance for procedures

Remember that normal appearing structures may be painful!

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Knee Pain – Management

• Medications– NSAIDs*, acetaminophen– Nitro patch for chronic tendinopathy

• PT– ENTIRE KINETIC CHAIN– Hip strengthening– VMO– Flexibility (hip flexors, ITB, hams)– Foot strengthening/support

• Injections– Pain reduction– Intra-articular steroids if OA, intra-articular pathology

(meniscus)– Viscosupplementation– Regenerative if chronic tendinopathy

• Data mixed, experimental, not FDA approved, expensive

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Hip Pain

• Intra-articular– Bone– Cartilage– Labrum– Ligamentum Teres– Synovium

• Extra-articular– Everything else!– Pelvic bones– Muscles and tendons

• Gluteal, hamstring, adductor, hip flexor– Trochanteric, ischial bursa– Referred

• Intra-articular hip pain often localized by “C-sign”

• Intra-articular pain:– Groin 55%– Thigh 57% – Buttock 71% – Distal to knee 22%– Lumbar 0%

Lesher et al, 2008

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Hip Pain

• Intra-articular pain triggers– Passive joint motion: rotation, deep flexion– Getting in and out of cars, transitions, first few steps– Cycling often relieves intra-articular pain

• Total hip arthroplasty– Bicycling on level surfaces nearly universally recommended1

• Must correct strength/flexibility imbalances– Evaluate entire kinetic chain– Gluteal strengthening– Fit accommodations, crank length, saddle width/position

1Swanson et al, 2009. 

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Physical Examination: Hip

• ROM (if restricted will shift demand to lumbar spine)

• Provocative hip maneuvers– Impingement Test (FADIR)

• 90° hip flexion, adduction and IR produces pain.

– Posterior Impingement Test• Extension and ER

– FABER• Flexion, abduction, external rotation

– Resisted Hip Flexion (Stinchfield test)– Log Roll

• Not sensitive, but specific for intra-articular pathology

• No stress to extra-articular structures

Lesher JM, Dreyfuss P, Hager N, Kaplan M, Furman M. Hip joint pain referral patterns: a descriptive study. Pain Medicine. 2008 Jan 1;9(1):22‐5.Byrd JW. Femoroacetabular impingement in athletes: current concepts. Am J Sports Med. 2014 Mar;42(3):737‐51. doi: 10.1177/0363546513499136. Epub 2013 Aug 27.

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Hip/Spine Syndromes

• Lumbopelvic Rhythm– Lumbar spine and hips both contribute to flexion and

extension range of motion– Lumbar spine contributes more during early forward

flexion, and later in extension– Pelvis (hip) contributes more motion during final

lumbopelvic flexion, and early lumbopelvic extension• Healthy subjects adapted a lumbopelvic

coordination that diminished L5–S1 compression force, whereas LBP subjects did not.

• Consider role of hip OA, THA, lumbar spondylosis, lumbar fusion…

Tafazzol et al, 2014

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Lumbopelvic rhythm in cycling

• Restricted hip motion increased lumbar flexion

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Hip Pain - Approach

Overuse Injury Anatomic Factors Technique Errors Fit/Equipment

Lateral hip pain (trochantericbursitis, gluteal tendinopathy)

Weak hip abductors, tight lateral structures, +Ober’s test

Longer ridingSeated climbingMashing

Saddle too high, increased pelvic motion during pedaling

Hip joint pain (intra-articular)

Underlying osteoarthritis or labral tear, femoroacetabularimpingement (FAI), weakhip abductors

Trying to bring knees too close together during pedaling, prolonged riding in drops or aero bars

Improper cleat alignment (toed-in), not enoughcleat float, cranks too long, aero position toolow/aggressive (increased hip flexion

From Kotler, 2016

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Hip Pain - Treatment

• Medications– Anti-inflammatories*, analgesics

• PT/Exercise– Must correct strength/flexibility imbalances– Gluteal strengthening

• Bike fit accomodations– Reduce hip flexion, minimize stresses– Saddle height– Fore adjustment– Decrease crank length– Pedal float

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Fit accommodations – hip pain

• Increased hip flexion when:– Saddle low or too far back– Long crank arms– Torso low and long reach– *If not available will result in lateral knee deviation

• Bike fit accommodations to reduce hip flexion, minimize stresses– Saddle adjustment anteriorly

• Opens hip angle– Shorter cranks

• Reduce max hip flexion angle (12 o’clock)– Frame geometry: seat tube angle

• Good for going fast in a straight line, but the sacrifice is handling. – Would not want this bike for lots of climbing, descending, or any technical

terrain.– Pedal float

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Imaging

XR MR (A) CT

Initial diagnostic modality – can identify presence / severity of

deformity

• Labrum, articular cartilage, effusion

• Extra-articular structures, stress reaction, AVN

• Muscular asymmetry

Definition of bony anatomy, surgical

planning, 3D modeling

US

Periarticular soft tissue structures,

operator dependent

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Hip Pain – Interventions

• Injections– Intra-articular hip

• Diagnostic and therapeutic– Iliopsoas bursa– Trochanteric bursa

• Caution with steroid around tendons– Gluteal trigger points

• Surgery– Hip arthroscopy– Labral repair– Osteoplasty– Arthroplasty

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Lumbar Spine and Cycling

• Cycling is a flexion-based activity• Some weight supported by the hands.• 3-46% of injuries (lumbar), 3-66% (cervical).• High prevalence, but tends not to limit from training or competition.

Usabiaga, 1997.Clarsen, 2010.

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Lumbar Spine and Cycling

• Cross-sectional field study of cyclists with and without non-specific chronic low back pain (NS-CLBP)• 8 cyclists with flexion-based low back pain, and 9 matched controls• 2h outdoor cycling task on their personal race bike.

– Lower lumbar kinematics was measured with the BodyGuard! monitoring system. – Pain intensity during and after cycling was measured using a numerical pain rating scale.

• Flexion-based LBP– Significantly more flexed at the lower lumbar spine – Significant increase in pain over the 2 h of cycling (p < 0.001). – Non-significant trend for the NS- CLBP group to have their saddle slightly more posteriorly tilted.

• Adding saddle angle as a covariate reduced the significance (but remained significant)• “Underlying maladaptive motor control pattern”

Van Hoof et al, 2012.

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Lumbar Spine Exam

• Inspection– Scoliosis, prominence of

unilateral paraspinals– Iliac crests even– Atrophy– Scars

• Range of motion– Flexion, extension,

rotation, lateral flexion– Pain vs. limitation

• Palpation– Spinous processes, lumbar

paraspinals, PSIS, trochanters, gluteals

• Neurologic examination– Lower extremity myotomes

and dermatomes• Functional testing

– Gluteus medius testing– Single-leg squat

• Gives lots of good information about hips, knees, feet, balance, strength

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Lumbar Spine Maneuvers

• Seated slump test– Dural tension – Spine flexion + knee extension– Alleviated by neck extension

• Facet loading maneuver– Extension with rotation stresses ipsilateral

facet joints– May also cause provoke SI pain

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Lumbar Spine and Cycling

• Flexion-based pattern more common• Radicular, discogenic• Anatomy and fit factors causing posterior pelvic tilt

excessive lumbar flexion– Saddle discomfort, upward tilt– Tight hamstrings– Excessive reach or saddle/bar drop

• Extension-based pain (i.e. facet and stenosis patterns) may not cause problems on the bike

• Postural habits OFF the bike!

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Cervical Spine Pain

• Neck and low back pain are common complaints1

• Aggressive or a triathlon-specific geometry requiring increased lumbar flexion– Excessive reach to handlebars– Low handlebar position (saddle-bar drop)

• Cervical spine is forced into extension and protraction, thoracic kyphosis

• May improve with time and training– Neck and upper back extensors

• Radiation, numbness, tingling, or weakness warrants further evaluation • Elevation of the stem and handlebars to decrease cervical extension

can be helpful in the short term if pain limits riding3

1Clarsen et al, 20102Deakon et al, 20123Kotler et al, 2016

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Summary

• Cycling medicine involves understanding both medical and biomechanical aspects of chronic injury.

• Cycling involves repetitive motion in the sagittal plane and chronic injuries often relate to imbalances in abductor musculature.

• Treatment is multidisciplinary, involving collaboration between MD, PT, fitter, coach, and athlete.

• Treat/optimize the athlete and adjust the bike to meet the athlete. • Bike fit is dynamic, may require accommodation during rehabilitation.

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References

1. Abt JP, Smoliga JM, Brick MJ, Jolly JT, Lephart SM, Fu FH. Relationship between cycling mechanics and core stability. J Strength Cond Res. 2007 Nov;21(4):1300-4.2. Asplund C, Barkdull T, Weiss BD. Genitourinary problems in bicyclists. Curr. Sports Med. Rep. 2007; 6:333Y9. PubMed PMID: 17883970. 3. Baeyens L, Vermeersch E, and Bourgeois P. Bicyclist’s vulva: Observational study. BMJ 2002; 325:138-139. 4. Byrd JW. Femoroacetabular impingement in athletes: current concepts. Am J Sports Med. 2014 Mar;42(3):737-51. doi: 10.1177/0363546513499136. Epub 2013 Aug 27.5. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med. 2004 Oct-Nov;32(7):1668-74.6. Clarsen B, Krosshaug T, Bahr R. Overuse Injuries in Professional Road Cyclists. Am J Sports Med 2010; 38: 2494-2501.7. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H: Clinical presentation of patients with symptom- atic anterior hip impingement. Clin Orthop Relat Res 2009;467(3):638-644. 8. Cooper NA, Scavo KM, Strickland KJ, et al. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. Eur. Spine J. 2015. doi: 10.1007/s00586-015-4027-6. PubMed PMID: 26006705. 9. Deakon RT. Chronic musculoskeletal conditions associated with the cy- cling segment of the triathlon; prevention and treatment with an emphasis on proper bicycle fitting. Sports Med. Arthrosc. 2012; 20:200Y5. 10. De Bernardo N, Barrios C, Vera P, et al. Incidence and risk for traumatic and overuse injuries in top-level road cyclists. J. Sports Sci. 2012; 30:1047Y53. doi: 10.1080/02640414.2012.687112. PubMed PMID: 22587674. 11. Decalzi JF, Narvy SJ, Vangsness CT Jr. Overview of cycling injuries: results of a cycling club survey. Orthopedics. 2013; 36:287Y9. doi: 10.3928/ 01477447-20130327-07. PubMed PMID: 23590771. 12. Gaither TW, Awad MA, Murphy GP, Metzler I, Sanford T, Eisenberg M, Sutcliffe S, Osterberg EC, and Breyer BN. Cycling and female sexual and urinary function: Results from a large, multinational, cross-sectional study. J Sex Med 2018;15:510-518.13. Grouin A, Rouquette S, Saidani M, Henno S, Lavoue V, and Leveque J. Bicyclist’s vulva: Diagnostic and therapeutics aspects. J Gynecol Obstet Hum Reprod 2018;47:223-225. 14. Guess MK, Connell K, Schrader S, Reutman S, Wang A, LaCombe J, Tennis C, Lowe B, Melman A, and Mikhail MK. Genital sensation and sexual function in women bicyclists and runners: Are your feet safer than your seat? J Sex Med 2006;3:1018-1027. 15. Hermans TJN, Wijn RPWF, Winkens B, and Van Kerrebroeck PEVA. Urogenital and sexual complaints in female club cyclists - A cross-sectional study. J Sex Med 2016;13:40-45. 16. Kivlan BR, Martin RL, Sekiya JK: Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy 2011;27(5):619-627. 17. Kotler DH, Babu AN, Robidoux G. Prevention, Evaluation, and Rehabilitation of Cycling-Related Injury. Curr Sports Med Rep. 2016 May-Jun;15(3):199-206. doi: 10.1249/JSR.0000000000000262.18. Labat JJ et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurological Urodynamics, 27: 306-310, 200819. Lesher JM, Dreyfuss P, Hager N, Kaplan M, Furman M. Hip joint pain referral patterns: a descriptive study. Pain Medicine. 2008 Jan 1;9(1):22-5.20. Maslowski E, Sullivan W, Forster Harwood J, et al: The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology. PM R 2010;2(3):174-181. 21. Morris JM, Lucas DB, Bresler B. Role of the Trunk in Stability of the Spine. J Bone Joint Surg Am, 1961 Apr;43(3):327-351.22. Pateder DB, Hungerford MW: Use of fluoroscopically guided intra-articular hip injection in differentiating the pain source in concomitant hip and lumbar spine arthritis. Am J Orthop (Belle Mead NJ) 2007;36(11):591-593. 23. Perrin AE. Cycling-related injury. Conn. Med. 2012; 76:461Y6. PubMed PMID: 23061210. 24. Silberman MR. Bicycling injuries. Curr Sports Med Rep. 2013 Sep-Oct;12(5):337-45. 25. Swanson EA, Schmalzried TP, Dorey FJ. Activity recommendations after total hip and knee arthroplasty: a survey of the American Association for Hip and Knee Surgeons. J Arthroplasty. 2009 Sep;24(6 Suppl):120-6. 26. Tafazzol A, Arjmand N, Shirazi-Adl A, Parnianpour M. Lumbopelvic rhythm during forward and backward sagittal trunk rotations: combined in vivo measurement with inertial tracking device and biomechanical modeling. Clinical Biomechanics. 2014 Jan 1;29(1):7-13.27. Usabiaga J, Crespo R, Iza I, Aramendi J, Terrados N, Poza JJ. Adaptation of the lumbar spine to different positions in bicycle racing. Spine (Phila Pa 1976). 1997 Sep 1;22(17):1965-9.28. Van Hoof W, Volkaerts K, O'Sullivan K, Verschueren S, Dankaerts W. Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls--field study using a wireless posture monitoring system. Man Ther. 2012

Aug;17(4):312-7.29. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J. Am. Acad. Orthop. Surg. 2005; 13:316Y25. PubMed PMID: 16148357.

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Thank you!dkotler@partners.org

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Comprehensive Evaluation

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Biomechanics and Bike Fit

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Biomechanics

High tech motion capture!(iPhone camera and a laser level)

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CAM / Pincer Impingement

• Impingement caused by overcoverage of the acetabulum

• Often associated labral pathology• Secondarily develop

articular cartilage breakdown

• M:F 1:3• Mean age 40 (40-57)

• Bony prominence of anterolateral femoral head/neck junction

• Causes acetabular articular delamination(relative labral preservation)

• M:F 14:1• Mean age 32 (21-51)

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Femoroacetabular Impingement

• Dynamic phenomenon– Hip structure + demand– Structurally predisposed hip may be

symptomatic with minimal activity– Structurally normal hip can be

symptomatic with extreme activity– “Pre-arthritic,” labral tears/degeneration

• Hip/Spine syndrome– Restricted hip shifts demand to lumbar

spineClohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris‐Hayes M, Prather H: Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res 2009;467(3):638‐644. 

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Intra-articular and Extra-articular

Intra-articular pain

Restricted hip motion

Adaptive movement

Overload / shearing at extra-articular locations

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Physical Examination: Pelvis

• Sacroiliac Joint– No single reliable test: 3+ positive tests

higher predictive value of positive SI block • (Slipman 1998, Broadhurst 1998, Laslett 2005)

– SI joint maneuvers• AP thrust• Patrick’s Test• Active Straight Leg Raise (with pelvic

compression)• Fortin finger test

Slipman, 1998.   Dreyfuss, 1996.  Broadhurst, 1998.  Laslett 2005.

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Diagnostic Injections

• Image guided, intra-articular anesthetic injection • Diagnostic +/- therapeutic• Used to confirm suspected intra-articular disorder.• Can be done with Ultrasound or Fluoroscopy

– Fluoroscopic – small amount radiation, allows visualization of arthrogram– Ultrasound - Limited by quality of equipment, skill of technician, patient

size.

Hungerford MW: Use of fluoroscopically guided intra‐articular hip injection in differentiating the pain source in concomitant hip and lumbar spine arthritis