Mill Valley Herald features Medicine of Cycling on front Page

Posted on May 4, 2012 by hwoodhull

The Abramsons, Mark and Anna, are a Mill Valley couple working to improve the treatment for people who suffer from bicycle injuries.

According to the couple, people have a strange attitude about protecting their brain. It’s as if they think that because they can’t see it, it doesn’t need the same protection other parts of the body do. Brain injuries are injuries you can’t see and others can’t see. So for the last few years the Abramsons’ organization has been putting together guidelines for cyclists with concussions. Last year Medicine of Cycling established a concussion task force and published a guideline report, “Concussions in Cyclists.” The report was distributed to race directors nationally.

To read more, visit - Mill Valley Herald

Dr. Anna Abramson and 2012 Concussion Guidelines Featured in VeloNews Article

Posted on April 26, 2012 by mabramson

VeloNews' Mark Johnson just published a detailed article about head injuries and the work that Medicine of Cycling and USA Cycling have done towards improving concussion management in cycling. It also features MoC Concussion Task Force member Dr. Kristin Wingfield:

Kristin Wingfield, the physician for the Exergy-Twenty12 professional women’s team, explained that cycling is particularly unique when it comes to concussion management in that, unlike other sports, “there is no time out; there are no player substitutions.” Yet putting a rider who has suffered a concussion back into a race can be both harmful to the rider, who may be suffering loss of balance and cognitive function, and the riders around who are depending on her to hold a line, stay upright and exercise sound judgment when diving into corners and sprinting for the finish.

You can read the full article on Velonews' site:

3 Tips for Aspiring Team Docs from Professional Cycling Team Physicians

Posted on March 14, 2012 by hwoodhull

For physicians who are trained and dedicated to practicing high levels of patient advocacy, becoming a pro cycling team doctor offers many the possibility to apply their professional skills to something they are equally passionate about. A pro cycling team doctor largely steers clear of any perverse sponsorship arrangements or scoreboard objectives that might compromise patient care.  Generally speaking, caring for athletes shouldn't be reactionary, as is common, but rather proactive, which means the team doctor may take command of racers' health before they even swing their legs over a bike for the first training ride of the season.  Here are some tips and comments from three team physicians.

The racing season for ProTour team, Movistar, began this year on January 15 in Australia with the Down Under Classic, which would prove a test to how well the team had prepared during pre-season training. For team physician Dr. Jesús Hoyos, it was a chance to see if his careful planning for the health and well-being of the team would pay dividends.

"I have many responsibilities as the team doctor: caring for the health of all team members, not only racers but staff as well; helping to plan out the race season with respect to specific races; supervising racers' training plans; organizing periodic health examinations to insure racers' maximum performance potential; and providing psychological support as necessary," Hoyos said.

Optimize your cyclists' health

Optimizing cyclists' health prior to the racing season starts with obtaining an assessment of athletes' baseline neurologic function so that — in case of a concussion — the information would allow for accurate diagnosis in the event of future injury. Athletes with a history of prior concussion are at an increased risk of repeat injury, so it is particularly imperative for these athletes to have a baseline cognitive assessment. This data will also be invaluable to racers who have sustained a concussion, since the team doctor can compare pre and post-concussion data to assess whether a racer is fit to return to competition.

"This year I have brought on board a neuropsychologist who will perform baseline neuro psych concussion testing on the team at team camp," said Dr. Kristin Wingfield, a primary care sports medicine specialist who works with the Exergy Twenty12 pro women's team. "Then we will use this as a baseline for each athlete and they can re-do the test post head injury on the road. We will then receive their scores and can make decisions about return to play (training and racing in this instance) without being there."

Evaluate each racer's health individually

The team doctor should take the initiative to evaluate each racer individually since athletic performance is keenly linked to a racer's health.

"A lot of times the athletes don't have their health optimized. For example, an athlete with asthma may be overly reliant on a rescue inhaler," explained Dr. Dawn Richardson, team physician for Champion System Pro Cycling Team. "Maybe they just don't know any differently or, for financial reasons, they didn't have access to preventive medicine. I explain that if they're using a rescue inhaler, their airways are inflamed and they don't want that. Just getting on maintenance medication for an asthmatic can make a huge difference in preventing airway inflammation and this in turn improves performance."

Dr. Richardson raced professionally until she retired in 2002; she had already completed her training and board certification as an emergency medicine physician. Her experience as a racer affords her a familiar perspective of the stresses of racing so, in addition to being available to the athletes without being disruptive to their routine, she assists in many ways above and beyond the call of duty.

"It's obvious fairly quickly that the mechanics and soigneurs are working very long days, so if I can do simple errands for them like supermarket runs, gassing up the team vehicles or run the athletes' laundry bags through the laundromat, I do it," Richardson said. "Something as simple as going to the pharmacy for an over-the-counter medication is way too much hassle for the athletes during a stage race, so I end up going on pharmacy runs at least every couple days."

Plan, monitor, and maintain racers' health regularly

Stage racing, especially a Grand Tour like the Tour de France, places heightened demands on a team doctor, like being "on-call" for 21 days straight. In addition to overseeing the team's health, Movistar's Dr. Hoyos maintains a daily routine that starts with waking the racers and recording their heartbeat, blood pressure, weight, sleep quality etc. He then follows up with racers who have suffered wounds that require specific treatment and continues to work with racers on mentally preparing for the day's stage. Following the stage, he records the same data as in the morning and notes each racer's state of health. He also supervises the racers' nutrition and monitors dietary supplements, such as vitamins, protein, and adequate hydration. Lastly, he administers treatments specific to incidents outside the norm (such as lesions, road rash etc.).

Unchecked injuries that can lead to serious health problems run counter to cutthroat competition, which has led to serious medical problems long after the athlete has retired from the sport. Sports like football and basketball are learning this the hard way through federal lawsuits filed by players who say that brain injuries have left them struggling with medical problems years after their playing days ended.

By comparison, doctors — like Dr. Richardson — who are cyclists as well are bringing their professional influence to bear on the sport, which sets a precedent for unparalleled athlete care. Of course a racing career isn't obligatory to becoming a pro cycling team doctor; a successful team physician doesn't need to produce results, just healthy racers.

Interview with @BMCProTeam’s Dr. Massimo “Max” Testa on cycling team physicians, staying healthy and sports medicine

Posted on February 27, 2012 by hwoodhull

Max Testa gets ready for an Event

This week I had the pleasure of interviewing Dr. Massimo Testa.  Dr. Testa is one of the most experienced cycling team physicians and coaches in the US as well as co-author of training manual Faster, Better, Stronger: Your Exercise Bible, for a Leaner, Healthier Body in Just 12 Weeks

In this interview we get a glimps of how this national team physician ensures his athletes succeed while staying healthy, and his advice for the sport.  First, we need to understand how Dr. Testa got his start:

Q.  How did you first become a team physician?
A.  That’s actually an interesting story.  In the early 1980s, I was finishing my fellowship in sports medicine to become a team physician at the University Pavia, Italy.  Unlike the US, in a sports medicine training focuses more on exercise physiology and less musculoskeletal issues.  Additionally, all athletes are considered “employees” so they are required by law to have an overseeing physician in order to do their job.  I loved cycling and was doing a special research in health risks associated with being a full-time professional cyclist.   I was also seeing hundreds of youth athletes for their sport physicals and injuries.  Obviously very busy.  In 1985, for the first time in history, an American team called 7-11 came to race in Italy.  They were the only team in Europe without a physician and this was against UCI rules, so I was assigned to them because of my research interest.  They were very grateful and only expected me to come to the race and fix them up if they got injured.  This is not how I trained or how things were done.  I watched the team warm up, race, and saw them through the recovery, giving advice or medical help as needed.  They liked this so they asked me to be their team doctor, the first one they had.  I visited the US that year, started to understand how American teams operated.  In Italy, many times the physician is also the team coach.  This has advantages and as you can imagine some serious draw backs as that balance between medical help and medical manipulation gets shaky.  I never agreed with that.
So for the next 6 years, I was the physician for Team 7-11, then the team became Motorolla and I was again with them for another 5 years.  After that I took a short break from American teams and was the team physician for Mapei, the largest European team during the late 1990s.  At that time, Dr. Eric Haiden – rider on the Team 7-11 in the 1980s and now orthopedic surgeon, invited me to start a sports performance lab at UC Davis in Sacramento, CA.  I came for one year but stayed for 7 at UC Davis.  After that, I moved to Utah and just never left.  During the past 10 years, I’ve been working with the USA Cycling as the national team physician and more recently as the chief medical officer for team BMC.

Q.  That is an incredible amount of knowledge and experience.  What makes you so successful at what you do?
A.  First of all, I love the sport and I’m a big fan.  Athletes are a great population to work with.  They are all Type A personality, which means they demand a lot out of me, but that also means they are committed, compliant, and motivated.  I owe a lot to my initial training in fellowship, there I learned a lot about applied physiology and pathophysiology of exercise.  I understand what happens to a body during exercise, I believe in the process, and feel we should be prescribing it as physicians.  I know what happens to a hypertensive patient during exercise, know what will be safer for them and what will make them better.  We learned to do all the tests, the echocardiograms, stress electrocardiograms, tilt table tests, pulmonary function tests, and so I can couple those with physiologic processes and easy measurements to know what is happening in my athlete’s body.  Also, to be really in-tune with what happens during training and racing, I’m there for the training and racing.  I travel with the team 180 days a year.  This way the athletes are comfortable telling me about the small changes they experience and I can “see” when they are over-training by their numbers even when I’m not there.  I monitor their physiology, their weight, lactate response, power output, training intensity, heart rate to name a few to pick up early signs of fatigue and over training.  Because of our close relationship, the athletes and the team trust me to make these calls and change the training and racing plans accordingly.

Q.  How do you navigate that difficult conversation with the athlete, when you think they are too sick to race?
A.  Well, first of all we as physicians have to know the rules and have strong internal discipline to guide the team and athletes to make the right decision.  Previously, I guess I could have injected someone’s joint with cortisone to allow the athlete to compete, but that to me means that I am allowing a disease process to cause biological damage for a race.  I tell the cyclist “you can continue racing at this point, but you’re not going to win the race and you’re not helping yourself heal for the next one.”  They are smart, they understand this and with my athletes this is rarely a problem.

Q.  What have you learned as a cycling team physician?  What is your favorite part of the job?
A.  The learning never stops, I’m always travelling and meeting people from other cultures, other physicians, and seeing new perspectives on each problem.  It’s very interesting if you think about it.  Each culture has it’s own focus, a stomach upset for a Spaniard and a stomach upset for an American can simply mean two different polar extremes of urgency.  One can just think about it as a nuisance, while the other can give it the significance of the entire system coming to a halt.  We learn to be sensitive to these issues with time.

Q.  About half of American cycling teams racing in the continental United States do not have a team physician.  What advice would you give the coaches and managers of those teams?
A.  It is still very strange for me to think about that, even after all of these years in the US.  I would recommend that these teams at least find a medical professional who can do a pre-participation questionnaire and screen athletes for significant risk factors such as familiar history of sudden cardiac death, personal history of exercise induced asthma, dizziness, fainting.  There are resources in each community that the team managers should take advantage of.  This can be a local clinic that would be willing to do all the physicals for a fixed fee, or a local business who is willing to sponsor a medical checkup for a team in return for some favorable publicity.  I think being a team coach in the US is very hard, often coaches are the first level of medical care for athletes.  Ideally all teams should have a coach, manager, and physician.

Q.  This year has been a difficult one for concussions and traumatic brain injuries in cycling.  What are your thoughts and practices in this area?
A.  I have always been cautious with possible head trauma.  In fact I pulled Dr. Eric Heiden out of his only Tour de France after he crashed and cracked his helmet.  I’ve seen a few riders die from head injuries, especially in the days before helmets.  No race is worth it.  I like what your group has done with the concussion recommendations and use them for our team.  This is a step in the right direction.  Our team also has Scott Nydam, a rider who unfortunately ended his career after several concussions and an intracranial hemorrhage.  He is a great advocate for the riders and makes sure he asks specific questions to elicit symptoms that a simple once over may not pick up.  The entire team has to be on the same page on an issue like this.

Q.  What are your biggest challenges as a team physician professionally?
A.  There are a few big ones.  We are lucky to have a very well-staffed team, so we can provide good support for our athletes.  If a cyclist doesn’t have insurance, this becomes a huge problem.  I’ve provided a huge number of free physicals and ECGs but in reality all riders should have insurance, and a medical professional who knows them.  Unfortunately, cycling has the highly publicized doping risk.  There are two categories here, intentional and unintentional.  Athletes are sometimes taking supplements, including recovery drinks and vitamins, they don’t think to mention to me, their physician.  But if they are caught the physician is always associated with that athlete, so we have to be super careful.  Supplement companies are selling a myth that these products will make you faster, they’re just trying to sell their product.  Though it takes time, education is the best prevention for doping.  I make sure my guys know that most of the products don’t work, in addition to risk to health and career.

Q.  What is your least favorite part of the job?
A.  I love to travel, and I love the sport.  I love Tour de France, but I’ve now been to 18 of them sitting in a car during the entire month of July.  Most team docs love to ride their bike, well forget about that when you’re travelling with a team, it’s just too busy.  The job has also become a lot more complicated.  I used to just travel to races and make sure nothing happened.  Now there are many more races in the season, biological tests, monitoring, training, keeping up with the rules, and blood tests.

Q.  What advice do you have for team physicians who are just starting out?  Especially those who are managing their athletes remotely?
A.  Know the athlete the best you can.  Have a periodical updates every 2 to 3 months.  A good way to do this is a questionnaire for each cyclist to fill out, especially looking for changes in cardiac symptoms, fainting, dizziness, shortness of breath.  When you don’t travel with the team, you don’t have the connection which encourages more open communication.  You may not hear of the daily nagging headache or some other detail that may be important but not necessarily shared during an infrequent encounter. Depending on access to a performance lab or other metrics, going through this information with the rider, is a good way to get reconnected.  This may also be a good project to do with a fellow or student.

Q.  What is your favorite medical journal?
A.  I like the British Journal of Sport Medicine.  That’s probably my favorite overall.  Now it’s easy to get articles from basically any journal so I just search for my favorite topic, and that is physiology.

Q.  What is your favorite “must attend” medical meeting?
A.  The American Medical Society of Sport Medicine is a great meeting.  It has a good balance of sport medicine, medical performance lab, exercise testing, considerations for exercise restrictions, traditional non-surgical medical management, gait management, and family medicine.

We want to thank Dr. Max Testa for this interesting interview.





Back Pain in Cyclists

Posted on October 20, 2011 by hwoodhull

Back Pain in Cyclists

Anna K. Abramson M.D., Sonny S. Gill M.D. , Michael Ross M.D.

Anna K Abramson M.D.  is an attending physician and Assistant Clinical Professor in the Department of Medicine at the University of California, San Francisco.  She is a co-founder of Medicine of Cycling.

Sonny Gill M.D. is an Adjunct Assistant Professor in the Department of Bioengineering at Clemson University and an orthopaedic spine surgeon with a special interest in cyclists with spine injuries.

Michael J. Ross MD is a sports medicine physician who has been the team physician for numerous professional cycling teams as well as the race doctor for the Philly Week series of races.  He is currently runs the Performance Lab, a sports medicine and exercise testing facility in Philadelphia.

Back pain is the second most common cause for primary care visits and one of the most common causes for discontinuing exercise and missed work days in the United States.  Cyclists are a demographically unique population, but studies of amateur and professional athletes alike indicate that up to 60% suffer from back pain.  Consequences of back pain result in medical visits, costs and increased use of medications for pain control, decreased quality of life, and decreased performance.  In this article, we discuss the most common causes of back pain in cyclists, modalities commonly used to assess and treat back pain, and the role of bike fit in alleviating and preventing back pain in amateur and professional cyclists.

Causes and Evaluation of Spine Pain:

Spine pain is a very common occurrence not only in the general population but also in athletic individuals.  The lifetime incidence of 48.3% of neck pain and 67.8% of back pain is reported in cyclists.  Of these athletes, nearly one-quarter is due to disc disease, with frequency of spine pain increasing with the years in sport.   Bicycle fit has been cited to be the most common problem causing spine pain including improper equipment, training factors, and anatomic factors.

When assessing a cyclist with neck or back pain, a broad range of possible culprits, must be considered and the physician assessing the athlete will likely perform a comprehensive musculoskeletal and neurologic physical exam.  Examples of exam and studies correlating to possible diagnosis include:

  • Palpation over bony prominences of the spine to evaluate for tenderness.
  • Asymmetric strength, altered sensory function, or diminished reflexes may predict a  neurologic compression in the spine.
  • X-rays of the spine to help assess for compression fractures.
  • A computed tomography (CT) scan may be indicated if the clinician is assessing for facet joint arthritis in cyclists who have pain with hyperextension.
  • In athletes with pain that worsens with changes in posture or forward bending, or neurologic features such as weakness, numbness or burning down an arm or leg are present, a physician may recommend a magnetic resonance imaging (MRI) study to evaluate disk Degeneration or herniation.

Diagnosis and Treatment Options:

Common diagnosis causing neck and back pain in cyclists include:

  • Trochanteric bursitis, due to the repetitive motion of pedaling.
  • Hip joint degeneration and arthritis, especially as the cycling population ages.
  • Snapping of the iliopsoas tendon especially during the down stroke of the pedaling motion.
  • Trigger point spasms can produce significant axial pain.
  1. Quite often, the trigger points are on the left side upper back, attributed to the         cyclist straining to look over the left shoulder for overtaking traffic.
  2. The trapezius has also been cited as a source of symmetric trigger points.
  • Hyperextension of the neck can lead to narrowing between the vertebrae and can cause nerve irritation of either the cervical (neck) or lumbar (low back) plexus.
  • “Unicyclist’s sciatica” is a pudendal nerve impingement from prolonged sitting on bike seat.
  • Pedal Pusher’s palsy is a form of sciatic nerve entrapment at the sit bones.

Assessment of a cyclist with back or neck pain should also include discussion about the core muscle strengthening program the cyclist has been undertaking.  The muscles of the low back serve as the platform for powering the bicycle.  A weak core creates a defective link in the chain from the shoulders to the pelvis that is meant to control the bicycle while absorbing the micro-trauma of road shock and vibration.

An aquatic therapy program can be especially important in cyclists because it allows the individual to off-load the core due to the buoyancy of the water but still perform exercises in the water that can progressively strengthen the musculature.  Furthermore, a supervised land-based therapy program that includes back, hip, gluteal and abdominal muscle groups that create pelvic stability in the saddle.   Advanced core strengthening can include activities such as pilates or stand-up paddle boarding.

There are many possible treatment modalities available in the case of an anatomic defect or injury

  • Physical and aquatic therapy program is first line of treatment for cyclists and general population.
  • Selective nerve root blocks or epidural steroid injections have been shown to help approximately two-thirds of patients with pain going down the legs.  NOTE: if treating an elite level cyclist, a onetime temporary use exemption (TUE) may need to be filed for injection steroids.  A full list of restricted medications can be found on the website for the U.S. Anti-Doping Agency.
  • Surgical intervention can be performed when the pain doesn’t decrease with the above measures.    A complete rehabilitation program is required after surgical intervention due to the chronic denervation and deconditioning that has occurred to the athlete over the course of the injury.

Red Flags Symptoms in Back Pain – requires urgent evaluation by a physician
Change in bowel or bladder control
Sudden loss of power or control of the legs
Numbness or “pins and needles” in the legs, groin, or around the anus
Back pain after fall with high velocity or from a height
Onset of back pain along with fever, night sweats, or weight loss
Onset of back pain after an infection

Bike Fit and Back Pain:

In many cyclists, low back pain can be directly related to bicycle position.  Considering that most overuse injuries occur due to lack of core strength or lack of aerobic conditioning to meet the demands of exercise, bicycle fit should be tailored to maximized available core strength.  One test that is extremely valuable in assessing for core weakness is the plank.  This position mimics the forearm/shoulder position during riding and it also mimics the position of the back when riding.

Plank position:

  • The athletes body weight is distributed on the forearms and the toes, back is level to the ground without bending at the waste or sagging.
  • Keep the shoulders over their elbows and keep the back in line with the thighs.
  • Hold position for 1 to 2 minutes.

  • If this position cannot be maintained, place the elbows on a small platform, such as a bench or supportive box. Keep raising the level of the platform until the cyclist can maintain the plank without back pain.  Once a comfortable position is achieved, attempt to set up the saddle/handlebars to replicate this position of comfort.

One of the most common causes of low back pain in cyclists is  a decreased support of the spine, with a long stem and a setback seat post, causing low back loading.  This is a position into which many riders place themselves hoping to increase aerodynamics without any regard for back comfort.  When the distance between stem and seat is too great, the result is in an increased bend in the hip angle.  The gluteal muscles which typically work together with muscles of the low back to stabilize the pelvis become stressed. .  The result is rocking of the pelvis from side to side and low back muscular strain.  Pushing the seat forward can alleviate this stress on the low back.

Some cyclists may resist losing aerodynamic advantage in favor of low back comfort, but shortening the cockpit can alleviate many causes of musculoskeletal pain and possibly avoid excessive forward bend that can result in disc herniation and spine pain discussed above. Additionally, these changes can make riders more efficient on the bike; the same power output can be achieved with less energy use.   One way to demonstrate the impact of low back hyperextension is to have the athlete return to a comfortable plank position with their elbows positioned under their shoulders.  Have the athlete walk the elbows forward ahead of the shoulders while keeping the rest of their body still.  This replicates position of long stem and back position of the saddle in which the cyclist will feel increased stress across the lower back.

Another consideration in bike fit lies with saddle height.  A saddle that is too high for tight hamstrings will pull the pelvis backwards, putting tension across the lower back muscles.  For proper bike fit, the angle between the trunk and thighs should not exceed that formed when lying on the back with the leg comfortably bent at the hip while the knee is kept relatively straight.

Bike fit performed by a trained expert can help prevent acute onset and more insidious onset back pain.  Though most cyclists can continue to train and compete through back pain, this pain reduces power on the bike and quality of life.  If the time is taken to assess the way the body works at rest, positions of maximum comfort may not be the most aerodynamic but will yield the best power output and speed by the cyclist.

Nutrition and Bioenergetics. The Integration of Nutrition, Metabolism and Performance

Posted on October 10, 2011 by hwoodhull

Nutrition and Bioenergetics. The Integration of Nutrition, Metabolism and Performance

Dr. Iñigo San Millán, PhD, University of Colorado School of Medicine

Nutrition is a crucial field in any athlete’s performance as without a proper nutrition it is impossible to obtain good performances. Every athlete is born with a genetic makeup and a defined physiology. The main goal of training is to alter and improve the physiology an athlete is born with. However it doesn’t matter how well we train or how good a coach a cyclist works with is, we will never be able to improve that physiology correctly and therefore improve performance if we don’t eat properly.
I have personally seen many situations where a talented athlete is leaving the exercise physiology laboratory with defined goals, training zones and information to improve performance and everything is ruined by a wrong nutrition. Unfortunately there is too much misleading information on nutrition, magic diets, urban legends and myths that seem to keep hunting not only cyclists but their coaches year after year.
By being part of the academics I am a firm believer of the importance of education in order to have a better understanding about nutrition and its interactions with physiological and metabolic responses and the impact on performance. It is the intention of this article to present a scientific review of the basics of bioenergetics, carbohydrate, fat and protein metabolism and the integration of nutrition, metabolism, physiology and performance.

BASIC EXERCISE BIOENERGETICS - Where do we get the energy and why nutrition is so important?

The capacity of an athlete to exercise ultimately depends on the ability to transform chemical energy into mechanical energy.  For this, skeletal muscle needs to synthesize Adenosine-5’-Triphosphate (ATP) for muscle contraction. ATP is responsible for all energy processes in human cells ATP needs to be synthesized constantly during exercise as it is indispensable for muscle contraction. ATP generation is achieved by two mechanisms: anaerobic and aerobic metabolism as well as through fats and carbohydrates (CHO) mainly, with some contribution from protein. Fats and CHO are stored in skeletal muscle and in the case of fat it is stored primarily in the adipose tissue but also in skeletal muscle and in the liver. Each energy system and substrate will be activated depending on the metabolic and physiological stress, contractile necessities for ATP generation of the muscle (exercise intensity) and the fiber recruitment pattern. A large majority and range of exercise intensities can generate ATP through Fat and CHO generate ATP through aerobic metabolism, also called oxidative phosphorilation. Depending on the level of fitness of an individual fat can sustain the biggest part of ATP generation aerobically up to 55-75% of VO2max intensity although CHO is also used at small rates during low and moderate exercise intensities. Beyond this point ATP generation needs to be faster in order to keep up with a higher frequency and power in muscle contraction and CHO will become the major energy used by skeletal muscle up to 100% of VO2max. When exercise intensities are very high and maximal or close to maximal and therefore above 100% of VO2max, ATP cannot be generated by the aerobic mechanism so the ATP needs to be generated through the anaerobic mechanism also called substrate phosphorilation.

CARBOHYDRATE - Metabolism during Exercise

Carbohydrate (CHO) metabolism is of great importance during exercise, especially during high exercise intensity where it is the predominant energy subtracts for skeletal muscle. Glycogen is the storage form of glucose and carbohydrates (CHO) in animals and humans. Carbohydrates are a very limited source of energy accounting for only about 1-2% of total bodily energy stores (Goodman, 1988). Furthermore, about 80% of total CHO is stored in skeletal muscle, about 14% is stored in the liver and about 6% in blood in the form of glucose, so this would represent about 300-400g of glycogen stored in muscle and about 70-100g stored in the liver (Sherman, 1995). Glycogen cannot be utilized for energy purposes by muscle so it needs to be broken down to Glucose 1-Phosphate by an enzyme called enzyme phosphorylase. This is the process of called glycogenolysis. The process of glucose breakdown in muscle for fuel utilization is called glycolysis which at rest, accounts for 15-20% of peripheral glucose utilization in skeletal muscle. At an exercise intensity of 55-60% VO2 max, glucose utilization by skeletal muscle increases to about 80-85% of wholebody disposal (Kjaer et al., 1991). Since muscle glycogen is crucial for ATP synthesis during exercise, proper glycogen storages are of great importance for athletic performance. Multiple studies show that glycogen depletion is associated with fatigue and decrease in performance and that athletes who have low carbohydrate diets or low glycogen storages will decrease exercise capacity ( Coyle et al., 1983; 1986; Coggan & Coyle, 1991; Sahlin et al., 1990; Maughan et al., 1997; McConell et al., 1999) as well as an increase risk for overtraining (Sherman & Wimer, 1991; Sherman, 1995; Snyder et al., 1995).

Glycolysis occurs mainly in the cytosol and this process can be aerobic through the complete oxidation of Pyruvate (oxidative phosphorilation in the Mitochondria) or anaerobic (substrate phosphorilation in the cytosol). Exercise intensity determines the substrate demands of skeletal muscle to generate ATP. During exercise skeletal muscles use primarily Fat and CHO for energy purposes and at low exercise intensities fat is the preferred substrate although there is always some glucose oxidation. At higher exercise intensities of about 50-60% of VO2max, ATP synthesis demand increases and fat cannot entirely meet the rate of ATP synthesis so glucose oxidation increases. Although the oxidation of fat yields a much higher amount of ATP, glucose utilization is much faster and therefore necessary for ATP synthesis during higher exercise intensities.

Exercise intensity is the main regulator for skeletal muscle CHO utilization and the mechanisms responsible for CHO utilization during exercise involve hormonal and local factors as well as glycogen availability. Epinephrine (Adrenaline) is the main hormone involved in CHO metabolism during exercise. B-adrenergic activity increases with exercise intensity and Phosphorilase is the enzyme responsible for glycogen breakdown to glucose and it is regulated by epinephrine. The release of epinephrine from the adrenal medulla is directly proportional to exercise intensity. Epinephrine stimulates muscle glycogenolysis by increasing phosphorilase activity thus it is a major regulator of CHO metabolism during exercise. Availability of free fatty acids (FFA) during exercise is also closely regulated by epinephrine. During high exercise intensities epinephrine reduces the blood flow to adipose tissue eliciting a constricting effect on adipose tissue therefore reducing plasma FFA availability to the muscles during high intensity exercise (Romijn et al., 1993; Roberts et al., 1996). Muscle fiber composition and activation patterns play an important role in substrate utilization. During high exercise intensities, contraction time is lower, shortening velocity is higher and power production is higher as well so Type II muscle fibers are recruited at these exercise intensities (Gollnick et al., 1974). Since Type II muscle fibers have a higher glycogenolyic capacity and lower mitochondrial density, glucose utilization in these fibers will prevail over fat.

Exercise duration also plays an important role in CHO metabolism during exercise. Since glycogen storage capacity is about 500g in muscle and liver the length of the exercise activity will be very important for the regulation of CHO metabolism. Glucose uptake in skeletal muscle is dependent on glycogen content (Hargreaves et al., 1992) and hypoglycemia during exercise can be prevented by the sufficient intake of CHO (Coggan & Coyle, 1991). Exercise duration is intimately related to glycogen storages as low glycogen storages during endurance events are associated with hypoglycemia, fatigue and decrease of performance (Hermansen et al., 1967; Coggan & Coyle, 1987; Coyle et al., 1983; 1986; Sahlin et al., 1990; Maughan et al., 1997; McConell et al., 1999).


Lipids are a very important energy source for endurance exercise. Although ATP generation for muscle contraction from lipids is slower than carbohydrates, the amount of ATP produced by lipids is far higher than that from CHO which makes lipids the fuel of choice by skeletal muscle during endurance exercise as well as it will have a glycogen sparing effect. The main source for lipid metabolism is subcutaneous adipose tissue. Even the leanest athletes have more than 100,000 Kcal of potential energy in their adipose tissue. Lipid metabolism during exercise is a highly coordinated and integrated process starting at the adipose tissue and ending at the mitochondria in skeletal muscle. This process involves mobilization or breakdown of adipose tissue, circulation from adipose tissue to skeletal muscle, uptake and final mitochondrial oxidation in skeletal muscle. Lipolysis is the first step in lipid metabolism and it is the breakdown of adipose tissue as well as intramuscular triglyceride. Triglycerides in the adipose tissue and muscle are broken down into free fatty acids (FFA) and glycerol by hormone sensitive lipase (HSL). Hormonal control of lypolysis is tightly regulated by several hormones, especially catecholamines (Epinephrine and Norepinephrime) which are probably the major hormones regulating lipolysis. Catecholamines bind to both β-adrenergic and α2- adrenergic receptors on the fat cell (adipocyte) membrane.
This activates a cascade of cellular signals which starts by the activation of adenylate cyclase (AC) which increases cyclic adenosine monophosphate (cAMP) which activates cAMP-dependent protein kinase which ultimately phosphorilates HSL which finally elicits lipolysis. At rest low level of plasma catecholamines bind to α2 receptors eliciting an inhibitory effect on lypolysis while during exercise plasma catecholamines increase and stimulate β-adrenergic receptors stimulating lypolysis (Arner et al., 1990). However, during very high exercise intensities, catecholamines have an inhibitory effect on lypolysis probably by causing a constriction in capillarization and blood flow to adipose tissue (Roberts et al., 1996; Romijn et al., 1993) and eliciting a potent glycogenolytic effect. Although it seems to be different catecholamine thresholds for both lipolysis and glycogenolysis (Galster et al., 1981) the exact mechanisms and catecholamine concentrations to elicit either lipolytic or glycogenolytic effects is not entirely understood.

Insulin also regulates lipolysis although its effects during exercise are not as profound as when at rest or as powerful as catecholamines during exercise. At rest insulin inhibits lipolysis (Jensen et al., 1989; Campbell et al., 1992; Galbo, 1992) but during exercise, insulin secretion decreases allowing higher a lipolytic activity (Wasserman et al., 1989).

Upon adipose tissue lipolysis, FFA must be transported to skeletal muscle. . Once inside the muscles FFA are attached to coenzyme A (CoA) which forms fatty acyl-CoA which then is transported across the outer mitochondrial membrane by carnitine palmitoyl transferase I (CPT-I), and finally transported to the mitochondrial matrix by carnitine. Once inside the mitochondrial matrix, fatty acids undergo β-oxidation where fatty acyl-CoA is degraded to Acetyl CoA which can then enter the citric acid cycle.

Skeletal muscle also contains small lipid droplets called intramuscular triglycerides (IMTG) which are stored in the cytoplasm of skeletal muscle cells close to the mitochondria. Depending on different circumstances such as endurance exercise and low glycogen content IMTG can play an important role in the contribution to lipid metabolism during exercise (Gollnick & Saltin, 1988) which depending on the exercise duration and glycogen availability can contribute to a great extent to lipid metabolism during exercise.


Although not considered a major contributor to energy during exercise, the metabolism of proteins during exercise can be important, especially depending on the exercise intensity, type, duration and nutritional status of the athlete. Proteins are made up of amino acids and there are over 20 amino acids and are divided in two groups: Non-essential, which are those that can be synthesized in the body and essential, those ones that need to be obtained from the diet. Amino acid metabolism is a sum of very complex and different mechanisms. Amino acid metabolism although accounting for a small percentage of total ATP synthesis during exercise may play an important role in the intermediate metabolism and performance as well as recovering after training/competition.

There are several amino acids that play an active role during exercise activity. Amino acids may provide between 3% to 10% of the total energy during exercise depending on exercise intensity and duration (Felig, 1973; Wahren et al., 1973; White & Brooks, 1983; Philips et al., 1993; Tarnopolsky et al., 1995). Although these percentages may not be very high but may play a very important role in exercise performance especially when glycogen levels are low and in this case the contributions to energy from amino acids will be greater (Lemon & Mullin, 1980). There are several amino acids that are quite important during exercise. Alanine is an important glucogenic amino acid, especially during endurance exercise and it is synthesized in the muscle and then exported to the liver to be converted to glucose through what is called the glucose-alamine cycle (Felig, 1973). Leucine, isoleucine and valine make up the branched-chain amino acids (BCAA) and may also play an important part during exercise. Leucine is a ketogenic amino acid, isoleucine is both ketogenic and glucogenic whereas valine is a glucogenic aminoacid. BCAA seem to be the kind of amino acids most used by the muscle during exercise. Since these aminoacids are building blocks of the muscle, an excessive utilization of aminoacids as what happens during intense and long exercise along with decrease glycogen content, may lead to an excessive muscle breakdown and a catabolic situation for the muscles which causes muscle damage and would be detrimental for performance. Therefore a BCAA supplementation during endurance exercise may have some sparing effects on endogenous muscle BCAA utilization and therefore decrease the possibilities of muscle damage (MacLean et al., 1994).


After discussing general bioenergetics and substrate metabolism we can clearly see that nutrition is a key part of the training regime of any athlete. Ingesting insufficient amounts of calories (Kcalories-Kcal) can result in a lack of important macro and micro nutrients. This is especially true when it comes to carbohydrates. Unfortunately many societies “demonize” CHO and there are multiple books and diets out there claiming that high protein and or high fat diets along with an important CHO restriction are the appropriate way for an athlete to lose weight , have a healthy diet and even improve performance. However, most of these books and diets lack of scientific evidence. This is especially true for athletes who restrict CHO as there is massive amount of scientific evidence that clearly shows that a good CHO diet is crucial to maintain performance. As previously discussed, multiple studies show that fatigue and decrease in performance is associated with low carbohydrate diets causing glycogen depletion (Hermansen et al., 1967; Coyle et al., 1983; 1986; Coggan et al., 1987; Sahlin et al., 1990; Maughan et al., 1997, McConell et al., 1999) and how low glycogen levels may cause overtraining (Sherman, 1995; Sherman & Wimer, 1991; Snyder et al., 1995, Achten et al, 2004). Since glycogen storage capacity is very limited many high performance athletes may find it difficult to even keep up with CHO intake and therefore end up with some patterns of glycogen depletion (Costill et al., 1988, Kirwan et al., 1988; San Millan et al., 2011).

The potential problem many cyclists with a low CHO diet face is that if glycogen levels are low or there is glycogen depletion, muscles increases the utilization of protein and amino acid utilization as a gluconeogenic precursor increases (Tarnopolski et al., 1995; Lemon & Mullin, 1980) and since protein and amino acids are the building blocks of muscle, the latter one may enter a catabolic situation (muscle breakdown) as the muscle may “eat itself to feed itself” by increasing the amount of protein and amino acids used for energy purposes. This situation may lead to muscle damage and furthermore this may lead to chronic overtraining as it has been shown that muscle damage limits and interferes with glycogen storage and synthesis (O´Reilly et al., 1987; Costill et al., 1990) so even with a high CHO diet it would be difficult to maintain glycogen storages and therefore enter a vicious circle which may lead to overtraining and decrease in performance.

Endurance athletes elicit a great deal of physiological stress to their bodies activating so many physiologic and metabolic responses. Both macro and micro nutrients are of great importance for the regulation of these responses and therefore for performance. By having a well balanced diet we will assure that we can supply the body with the necessary macro and micronutrients important for all physiological functions during exercise as well as during recovery. Of all macronutrients carbohydrates are of crucial importance for cyclists due to the high rate of utilization on a daily basis and the very small storage capacity in our body (500g). Our body can handle a dietary deficiency of many macro and micronutrients for a few days, but a deficiency of just 1-2 days of carbohydrates for a competitive cyclist may have a strong negative impact on performance. A competitive cyclist should have a good CHO diet with up to 7-12g/Kg/day of CHO both on long and intense training days as well as on competition days. (Costil et al, 1988; Achten et al, 2004, Halson et al 2004) It is important to have a proper CHO intake throughout the entire day and especially during training and competition.

Regarding the necessary daily protein for an endurance athlete, current research indicates that a daily protein intake of 1.2– 1.4 g/d for endurance athletes should be sufficient (Lemon 2004). high quality protein foods like dairy products, eggs, meat, fish and soy products should be chosen.

As a summary, it is important to understand the metabolic responses to exercise and the different substrate utilization patterns in order to properly integrate nutrition, metabolism and performance in competitive cyclists.

Hip and Knee Pain in Cyclists

Posted on October 6, 2011 by mabramson
Claudette M. Lajam, M.D.

Claudette M. Lajam, M.D.

Claudette M. Lajam, M.D., Assistant Professor of Orthopedic Surgery, NYU Hospital For Joint Disease
Dr. Claudette Lajam is an avid cyclist and athlete. She is a team physician for USA Cycling. She served on the Board of Directors of the New York Cycle Club and is a major sponsor of an amateur cycling race team. She cares for recreational and elite cyclists as well as endurance and other athletes.
Dr. Lajam is a Board Certified Orthopedic Surgeon with special interest in joint replacement, revision joint replacement, and sports medicine/arthroscopy. She performs total knee replacement, total hip replacement, arthroscopic ACL reconstruction and arthroscopic rotator cuff repair for the shoulder. Dr. Lajam is a host on The Orthopedic Show for SIRIUS/XM Doctor Radio. You can listen to her on Monday evenings from 6-8 pm, EST on SIRUS 114 or XM 119.

Knee pain is the most common lower extremity problem in cyclists. It can result in decreased participation, enjoyment and performance. Hip dysfunction can also cause significant pain and detriment to performance and enjoyment. While it is impossible to cover all types of pathology in this article, we will address the more common sources of pain. A vexing challenge in treatment of lower extremity pain is to identify the pain generator, or “PG.” Pain can be caused by systemic disease, lumbar spine issues, hip pathology, knee pathology, neurologic conditions and vascular conditions. It is important to seek out a physician who understands cycling and the unique stresses placed on the body when riding. It is also imperative that each cyclist have a primary physician who can monitor general health and who can provide pre-participation evaluation before periods of intense training or competition.

Knee Pain

The knee takes on tremendous stress during cycling. With average cadence of 80 rpm, the knee performs thousands of repetitions of the singular pedaling motion. Most stress is undertaken in the patellofemoral compartment (the area under the kneecap). Injury to this area can result in pain and decreased performance.  Remember that any inflammatory condition within the knee joint can cause a part of the quadriceps muscle to shut down, thus magnifying any muscle imbalances that have already occurred. It is important to heed warnings of pain and swelling in the knee with early treatment so that the problem does not become worse! Also, know that the PG for knee pain can be the hip or the lumbar spine. If pain in the knee is vague or seems to shoot into the groin or the back and does not go away with treatment, evaluation of the hip and spine is recommended.

  1. Chondromalacia of the patella: Chondromalacia means “bad cartilage.” It is characterized by changes in the joint surface cartilage on the undersurface of the patella, on the groove that the patella rides in, or in both areas. These changes can come from trauma, can be age-related or can occur because of natural alignment of the joint.
    1. Symptoms: pain behind the kneecap, swelling, catching (the knee gets stuck in the extended position and needs to be wiggled to bend). Pain precipitated by hilly rides, riding in bigger gears or at slow cadence. Pain also with stairclimbing or descent, squatting or deep knee bends.
    2. Diagnosis: the doctor will examine the knee for alignment (“Valgus” knees are more likely to have this condition), motion and telltale signs of the condition. Xrays are taken to view the joint spaces and to exclude fractures. Cycling history to determine bike fit, riding habits and injury history can help with diagnosis.
    3. Treatment: A period of lower resistance training (high cadence and flat terrain) along with anti-inflammatory medication, icing and muscle balancing exercises – including strengthening quadriceps and stretching IT Band, hamstring and calf muscles – is usually helpful. Cleat and saddle position should be checked to rule out fit issues. If the problem is purely anatomic, sometimes realignment surgery is an option.
  2. Patellar tendonitis: Inflammation of the tendon between the kneecap and the shin bone can be very painful and tough to treat.
    1. Symptoms: Pain when pedaling or extending the knee against resistance. Location is in the tendon and soft tissue just below the tip of the kneecap. There may be swelling of the tendon and tenderness to the touch.
    2. Diagnosis: Physical examination shows swelling and tenderness in these locations. Xrays are usually negative.  MRI will show inflammation of the tendon and the absence of other pathology.
    3. Treatment: Bike fit is very important. Cleat and saddle position should be checked to see if too much lateral stress is being placed on the tendon. Training modification to flat terrain and low resistance riding is recommended until pain-free. Focused icing and NSAID medication is helpful to reduce inflammation. Formal physiotherapy can assist. Injections with steroids are NOT recommended. This condition is very frustrating and may take a long time to treat.
  3. Meniscal or ligamentous tears: Internal pathology of the joint can occur in all age groups. In younger athletes, twisting injury or trauma is usually involved. In older patients, degenerative meniscal tears can cause irritation within the joint and start a cascade of events that can affect performance.
    1. Symptoms: Meniscal tears can cause swelling, locking in a flexed position and catching of the knee. Pain is usually on the inside or the outside of the knee. Ligament tears cause instability and difficulty doing cutting or twisting motions.
    2. Diagnosis: Physical examination alone can give a lot of information. Xrays to rule out fractures or arthritis are performed.  If conservative treatment fails or if ligament tears are suspected, an MRI may be ordered to see the soft tissues.
    3. Treatment: Most meniscal tears in older people can be treated non-surgically. If this fails and MRI shows significant tears, arthroscopic surgery can be helpful. Ligament tears are treated according to the particular needs of the patient.  Many cyclists who are older elect not to have ACL reconstruction, as cycling does not involve cutting and twisting.  Younger patients will usually elect to have ACL reconstruction so as to decrease instability and perhaps delay onset of arthritis in the joint.
  4. Iliotibial band syndrome: results from friction of the expansion of the Iliotibial band (ITB) on the outside of the femur bone during repetitive motion. The band moves from anterior to posterior during pedal motion. When inflamed, it can cause severe pain on the outside of the knee.
    1. Symptoms: Pain on the outside of the knee, often stabbing or burning, that occurs in concert with the pedal stroke.  There may also be pain at the outside flare of the hip and down the lateral thigh to the outside of the shin bone. Pain goes away with rest early on, but with increasing severity there is pain all the time.
    2. Diagnosis: physical examination is the key. Tenderness, positive Ober test for tightness of the ITB and sometimes even snapping of the band along the condyle. MRI has limited utility here, but is performed sometimes to rule out other confounding conditions.
    3. Treatment: nonsurgical treatment is useful in most cases. Bike fit should be examined, particularly cleat positioned too internally rotated or too forward on the shoe. Cleats with too little float can also exacerbate this condition. Focused stretching, cross-fiber ice massage, rest and NSAID are helpful. Foam roller stretching of the ITB can help prevent the condition from returning. Surgery to release the posterior fibers of the band can be performed in the most stubborn cases.
  5. Plica syndrome: The normal knee is enclosed in a capsule of tissue. When this capsule becomes inflamed, sometimes folds or shelves of the capsule become a mechanical source of pain in the knee. These folds are called “plica,” which means “fold.”
    a. Symptoms: Pain, swelling and mechanical clicking, usually on the inside of the knee. Pain is brought on by motion and improves at rest.
    b. Diagnosis: Physical examination is important, since on MRI the plica may appear as normal capsule.
    c. Treatment: Elimination of inflammation is the key to treatment. NSAID medication, focused icing and training modification to exclude painful activity are the best treatment. Surgical treatment with arthroscopy can remove persistent plica.

Hip Pain

The hip is increasingly recognized as a source of pain in athletes. Improvements in understanding of the joint, along with advances in technology have allowed better surgical treatment of early problems. Again, the PG for hip pain may be a lumbar spine condition. If hip pain is unexplained by thorough evaluation, a lumbar spine evaluation is recommended.

  1. Snapping hip syndrome: When snapping is painless it does not require treatment. For painful snapping, there are two types: Internal and External. Internal snapping is caused by the iliopsoas tendon’s sliding over the front of the femur during movement of the hip, particularly during a “frog kick” type of movement. External snapping is caused by the upper portion of the Iliotibial band when it passes over the greater trochanter of the femur.
    1. Symptoms: For internal, the athlete may have deep groin pain and will experience a snap when the hip is moved in a frog kick type of motion.  The snap sometimes can be heard across the room. For external, the athlete may believe that the hip is “dislocating.” The outer edge of the hip can be seen to push out during motion and then come back in. Pain is over the outside of the hip.
    2. Diagnosis: Internal snapping can be tough to diagnose. Physical examination is the key, along with imaging studies to rule out other issues. Bursography, which involves the injection of contrast into the bursa, can be of value in certain cases. External snapping is also diagnosed with physical examination and imaging to rule out other causes if necessary. It is very important to establish an accurate diagnosis before undergoing any surgery.
    3. Treatment: For internal snapping, an intensive stretching program focused on the lower back and hip is recommended.  NSAID treatment and modification of training to exclude painful activities is important until pain is gone.  Core strengthening can be helpful. For external snapping, modification of training and treatment of inflammation are key. Strengthening of abductors and the foam roller may be helpful in decreasing snapping. Surgical treatment for persistent internal snapping involves release of part of the tendon from the lesser trochanter of the hip. This can now be performed arthroscopically, but only after other measures have failed.
  2. Impingement Syndrome: Abutment of the bones in the hip can cause pain and dysfunction. When the cycling pedal stroke causes this event, pain and limitation of performance can occur.
    1. Symptoms: Persistent pain in the groin area, brought on by flexion and usually internal rotation of the hip.
    2. Diagnosis: Physical examination and plain X-rays to rule out other issues are important first steps. MRI is helpful if an associated soft tissue lesion is suspected. Diagnosis is tricky as there are many PGs within the hip joint.
    3. Treatment: Modification of activity, a stretching program and anti-inflammatory medication can be helpful. Bike fit should be assessed to ensure there is no excessive hip flexion during pedal stroke. When pain is persistent, surgical treatment with arthroscopy and removal of the impinging part of the bone can be performed. Recovery from surgery takes 6-12 weeks, depending on the procedures performed.
  3. Labral tears: The soft tissue rim around the hip socket is called the labrum. When tears occur, the loose piece may flip in and out of the joint and cause inflammation and pain. Tears are also thought to cause loss of the suction effect of the joint, thus creating micro-instability.
    1. Symptoms: Groin pain with motion, especially when the hip is brought into flexion. The athlete may feel a click or catch inside the hip. The athlete can sometimes remember a traumatic event after which the pain began.
    2. Diagnosis: Can be difficult, but combination of physical examination, x-rays and MRI with contrast can show the lesion.
    3. Treatment: Early treatment includes training modification, stretching and NSAID medication. If this fails and a labral tear is seen, the athlete may elect for surgical treatment with arthroscopic repair or debridement. If surgery is performed, it is important that the surgeon address any bony impingement. Recovery from surgery is 6-12 weeks.
  4. Arthritis: When the bearing surface cartilage wears away, athletes may feel pain and stiffness in the hip.
    1. Symptoms: Pain and stiffness in the groin and hip. Pain occurs with weight bearing. The athlete may limp on the affected side. Cycling might not be painful, even with severe disease.
    2. Diagnosis: Plain x-rays along with history and physical examination will show arthritis in the hip. MRI is generally not needed if x-rays show the condition.
    3. Treatment: Conservative treatment includes NSAID medication, stretching and core strengthening. Cycling can continue so long as the athlete can tolerate it. Fit may need to be adjusted so that the stiffness in the hip does not affect the other joints and the low back. This can be done by raising the handlebar position to more upright.  Arthroplasty hip surgery is the only reliable surgical treatment. Hip resurfacing or replacement may be performed depending on the severity.
  5. Fractures: Traumatic fractures of the hip can occur after crashes or trauma. These are fairly obvious and should be treated immediately.  However, stress fractures of the femoral neck can occur over time and are more difficult to diagnose. Catastrophic consequences may occur if a stress fracture becomes a complete fracture in a young person. Many cyclists have low bone mineral density from lack of weight bearing activity and are at risk.
    1. Symptoms: Groin pain, mostly with weight bearing activity and sometimes at rest. Pain may be vague. This condition may also present as vague anterior knee pain or thigh pain.
    2. Diagnosis: Evaluation and plain x-rays may not show the fracture. If pain is persistent and not explained by examination, MRI should be performed to rule out stress fracture.
    3. Treatment: Depending on location of the fracture, surgery may be indicated to place screws across the area so as to prevent completion of the fracture. Some types of fractures can be treated conservatively with protected weight bearing and modification of activity. If stress fractures are seen in young athletes, assessment of bone mineral density and evaluation by a general doctor is recommended to rule out other conditions.


Lower extremity pain is common in cyclists, but many conditions can be treated conservatively. It is important to recognize these issues and treat them early so that they do not affect performance long-term. Bike fit is critical in prevention and minimization of lower extremity pain. Most athletes can continue cycling at low intensity during treatment and recovery from injury.

Undiagnosed concussions in cycling cost more than just minutes in the General Classification

Posted on September 22, 2011 by mabramson

On July 8, 2011,  thousands of fans logged on to YouTube to watch Chris Horner cross the finish line following Stage 7 of the Tour de France, repeatedly asking  "Where am I? Did I finish?" when he couldn't remember crashing 35 kilometers earlier.  Many fans could probably guess that Horner, who suffered a massive blow to the head in a multi-rider pileup, had a concussion.  It is a matter of grit and perseverance that a rider climbs back on his or her bike and chases the peloton after a crash, if it is physically possible to do so.   In cycling, post-crash management is generally conflicted and flawed.  Unlike other professional sports, cyclists do not get a time out.  There are no sidelines.   The moment the rider is down, the peloton speeds away.

Video of Chris Horner's post-crash state in the 2011 Tour de France

Video of Chris Horner's post-crash state in the 2011 Tour de France (link to

"Experts in the field of concussion started to recognize the potential long term implications of even a single concussion and we are now making amazing efforts to provide education about the seriousness of these injuries to athletes, parents, family members, coaches, etc." explained Dr. Jason Brayley, sports medicine physician with MultiCare Orthopedics and Sports Medicine in Puyallup, Wash. "Oftentimes concussions are not recognized by athletes or those people around concussed athletes because they are not dramatic. Concussion symptoms can evolve slowly over hours to days and an athlete may not really understand what they are going through. Concussive injuries often do not involve bleeding lacerations, loss of consciousness, or other startling findings that typically earn immediate medical evaluation."

Dr. Brayley, who is the team physician for Kenda/5-Hour Energy Pro Cycling presented by GearGrinder, has experience managing athletes who have sustained a concussion and can attest to the need for greater knowledge of traumatic brain injuries (TBI).  As one of the founding members of a concussion task force, which emerged during last year's inaugural Medicine of Cycling Conference, his goal was to try and correlate current practices in concussion management specifically to the world of cycling, as the sport of cycling has its own set of issues that can make safe evaluation and returning to racing difficult. Led by conference co-chair Dr. Anna K. Abramson of the University of California, San Francisco and co-founder of Medicine of Cycling, members published a concussion statement to educate cycling team managers, coaches and athletes on the symptoms and management of concussion in athletes.

Jason Brayley, MD Presents as part of the 2011 Medicine of Cycling Concussion Panel discussion

Jason Brayley, MD Presents as part of the 2011 Medicine of Cycling Concussion Panel discussion

"Concussed cyclists are more likely to have impaired function that leads to a repeat crash, potentially hurting themselves and others," said Dr. Abramson. "We are drawing on the concussion work in other sports to tailor education and guidelines that make sense for cycling because no one wants to see more athletes end their careers or worse because of poor decisions.  We know that those with previous concussions are at increased risk of repeat concussions and brain injury, and are most susceptible during the post-concussion period.  We want athletes and coaches to know when it's simply too dangerous for a cyclist to get back on the bike."

TBIs rank as the most serious injuries of the half-million emergency room visits recorded by cyclists each year in the US. What makes Horner's case so astonishing - and a string of similar cases reported from the start of the 2011 racing season until now - is the video footage that makes it impossible to ignore the risk of returning to competition that could have led to life-threatening circumstances and/or lasting brain injury for Horner.

In 2006, Zachery Lystedt, a middle school football player from Maple Valley, Wash., was allowed back in the game after suffering a head injury. He later collapsed and was rushed to the hospital where he endured two emergency brain surgeries. Among other elements of his recovery, he's had to learn how to walk again. Now there's a law in Lystedt's name, which requires any athlete to consult a licensed medical professional if there's an apparent injury. Cyclists can significantly decrease their odds of head and skull injury by wearing helmets but, by requiring cyclists to be assessed by medical staff immediately after a crash, far worse problems can be avoided.

Another measure recommended by Medicine of Cycling physicians is to obtain an assessment of athletes' baseline neurologic function because having that information would allow for accurate diagnosis in case of future injury. Knowing an athlete's respective baseline neurologic function is one of the most important aspects of good neurological care for all athletes. Cyclists with a history of prior concussion are at an increased risk of repeat injury, so it is particularly imperative for these athletes to have a baseline cognitive assessment. USA Cycling, the sport's national governing body, has already taken the initiative to test some of its BMX athletes, which signals an emerging trend in both increased awareness of concussions and improved safety for cycling athletes.