Here’s the good news about cycling: It has significantly less weight bearing and impact load than it’s more popular aerobic counterpart, running. Meaning, it’s easier on your body. Here’s the bad news: Cycling injuries are not that much less prevalent than those seen in running. Aside from crashes, cycling injuries tend to be overuse in nature, and are based more on how a rider’s body functions in relation to their bike—i.e. a rider’s biomechanics.

By making a series of small tweaks to the geometry of the bike, professional bike fitters can do amazing things to make a rider comfortable. Fitters, based on their methodology and level of expertise, will take many factors into consideration when ultimately settling on a fit for their client. These factors include (but are definitely not limited to) seat height and fore-aft position, handle bar and brake lever/shifter position, pedal type, and cleat position. Unfortunately a proper discussion about bike fitting would be far too extensive for this article, but one must consider it an absolutely vital role in meshing the asymmetrical human body to the symmetrical bicycle. Undoubtedly, a good bike fit is worth every penny a cyclist spends on one.

For the orthopedic physical therapist treating a cyclist (that’s me), the key to treating injuries is in understanding the inherent asymmetry of the body. When specific joint and soft tissue dysfunctions are present, poor postural patterns can result on the bike, leading to habitual tendencies—and pain. The key to treating these tendencies is in examining the cyclist, and understanding how they compensate for poor biomechanics on the bike. A cyclist’s tendency to compensate for biomechanical misalignment is intensified when the cyclist (or any athlete) encounters a greater workload, higher respiratory demands, and ultimately, fatigue. The following is a discussion of common spine injuries that cyclists sustain.

Low Back Pain

Cyclists encounter low back pain on the bike when their position demands greater extension (arching) or flexion (rounding) of their spine than their soft tissues or joints are capable of. Most often I find that cyclists with back pain are set up in a position that 1) excessively spreads them out from their hand position to their hip position on the saddle; 2) excessively lengthens their hip position to their foot position; 3) or both. These situations will cause their pelvis to tilt forward too much, arching their back.

In the situation of too long of a reach, the resultant rib cage position causes even more problems. As the arms reach too far forward the lower front ribs will flare out. This disengages the core abdominal muscles and changes breathing mechanics to where the cyclist will use their lower back muscles more than those muscles can tolerate for sustained periods. When the back muscles become tonic and overdeveloped the pelvis begins to tilt forward even more, and over time compressive issues such as disc herniation and nerve irritation start to occur.

A cyclist’s lower back rounds (or flexes) too much when their position from hands to hips, or hips to feet, is too compact. This causes the pelvis to tilt back too far or, in the case of not having a long enough reach to the pedals, forces the hips to flex beyond their range of motion capabilities. Cyclists need to be able to flex their hips a minimum of 115 degrees. If that isn’t possible then the pelvis will be forced to rock back while seated on the bike (hyper-flexing the low back), especially when the hands are in the drops. In this situation the hips (femur bone) will also be forced to compensate by rotating outward causing the pelvis to rock or spin on the saddle.  Now the whole lower leg is out of alignment, opening up the cyclist to other lower extremity issues.

We will often find the problem occurring on one side and not the other. This is because the body is not symmetrical. Some of our most important organs are predominantly located on one side of our body (heart, liver) and our diaphragm and lungs are shaped differently on either side. This sets us up to position ourselves, move, and function in slightly (and sometimes very) asymmetrical ways. The diaphragm and lungs are of particular importance as there is often an asymmetrical look to the rib cage and a slight, but significant, difference in respiratory mechanics on one side of the body compared to the other. There is a school of thought that this is the root of a lot of the problems seen in cycling. The cyclist is basically fixed into position at the feet and the hands, so if they can’t control the asymmetrical tendencies of their body (i.e. breathing) then they will compensate and eventually have problems.

Neck Pain

Neck and shoulder strain is usually caused by a problem with the cyclist’s position on the front end of the bike. Having to reach too far for the handlebar hoods or too low for the handlebar drops may put the neck and upper back soft tissues and joints at or near their limits. This usually causes strain on both sides of the neck/shoulder junction or centrally in the middle part of the neck. But, again, if the cyclist is sitting with poor hip alignment then they will be have to reach their arms differently and position their head and shoulder girdle asymmetrically.

I have found that asymmetrical breathing patterns, caused by or in conjunction with an asymmetrically positioned pelvis, are the most common finding with cyclists. Again, there are very common patterns, and my example here is one of them. Let’s say a cyclist has more difficulty breathing into their right chest wall. Their posture may compress the rib cage on that side so that it’s hard for the ribs to expand for greater air intake. They may make several compensations. One of them may be to recruit their neck muscles to help pull air in. Some of these muscles have a direct attachment to the first few ribs and sternum and can be used excessively to move these ribs to expand the chest, especially under increased cardiovascular demands. The result is neck pain, over-activity and tightness, and a potential cascade of cervical spine problems.

These are just a few examples of spine issues we find in cyclists. The bottom line is that there are asymmetrical postural tendencies in the human body. Most people can control them with good awareness, strong core muscles, and healthy soft tissues. A good bike fit can also correct some of these postural influences. But, if problems persist, the cyclist may need to visit a good orthopedic physical therapist or chiropractor to evaluate and sort out their twisted body.

By far, dysfunctional breathing mechanics drive most of the problems that my cyclist patients have.  What I find is that the rib cage doesn’t move in the manner it’s supposed to or it is has poor structure (genetically, because of trauma, or because of years of habitual incorrect posture) to the point that breathing is stressed and inefficient.  During cycling our demands for oxygenated air increase so much that we WILL find a way to get air in and out whether it’s through proper mechanics or not.

The cyclist, by nature of the position on the bike (regardless of discipline- road, mountain, or cyclocross; or set-up- standard or time trial) and because of the increase in cardiopulmonary demands (air), needs to be able to expand both the front and back of their chest wall efficiently.  If they can’t they will compensate by overusing neck and back muscles or by improperly positioning their pelvis and hips.  Performance may suffer due to diminished air exchange in the lungs.

The cycling position is actually a very nice position in a postural sense IF we have good breathing mechanics.  But problems occur when there are restrictions in the back and front of the chest wall and an inability to expand on inhalation.  Normal breathing mechanics call for expansion of both the belly and the chest on inhalation.  In quiet, relaxed breathing we should be able to see both the belly and the chest rise and fall with each breath.  If we round our backs and reach our arms forward (as if in the riding position) the front of the chest can’t expand as easily, so the back of the chest wall should expand and retract with each breath.

Competitive cyclists are sometimes taught to “breath from their diaphragm”.  I see article after article and video after video describing that as maximally expanding the belly.  That isn’t a proper description of diaphragmatic breathing.  The diaphragm drops with each breath in and, yes, the belly should expand.  But if we have a properly position positioned pelvis, spine, and rib cage, and, most importantly, decent abdominal muscle tone, the diaphragm will cause some belly expansion, but it will be held in check so that some of the expansion occurs through the front and back of the chest wall as well.

The rib cage has a high elastic component and is designed to expand and retract with each breath.  So if we focus on just breathing into the belly, letting the abdominal muscles totally relax with each breath in, we will lose the elasticity of the rib cage over time and lock ourselves into a belly breathing pattern.  This is a HUGE reason that a lot of people (not just cyclists) develop problems and have significant postural changes over time.  We become so reliant on belly breathing that even relaxed breathing requires compensatory muscle use (neck and low back) and postural alterations.  It only gets worse as time goes on and it makes getting into some positions, like on a bike, difficult and really stressed from a breathing perspective.

I’m going to do another post on how breathing problems are usually more asymmetrical in nature (most problems occur on one side more than the other) contributing to some of the typical one-sided problems that cyclists have, but for now I want to give just a couple examples of my favorite breathing exercises for cyclists.  Both simulate (and slightly exaggerate) the position on the bike and demand chest wall expansion, abdominal tone, and a properly positioned pelvis.  The hips, shoulder, head, and neck are all positioned roughly as if on a bike and emphasis is on avoiding compensatory use of neck and back muscles during inhalation.

We should be able to squat fully with shoes on.  Feet and knees should be close together and you should be able to reach your arms forward.  You should be able to breath fine and the expansion should be felt in the back of the chest wall.  This signifies your ability to expand somewhere other than the belly.  THIS is diaphragmatic breathing and means our diaphragm position is held in check by the roundness of the spine and the inability of the lower ribs to flare excessively.  Spending some time in this position (even if you have to lightly hold onto something in front of you) and breathing into the back of the chest wall will help reduced the extraneous muscle activity in the neck, back, and hips that cyclist are prone to.

Photo courtesy of the Postural Restoration Institute®

Another is essentially the same but with added resistance to turn on the abdominals to ensure that lower rib flare is held in check.  It’s done by attaching resistive tubing to the wall or door at shoulder level, standing close to a foot away from the wall with the hips hips resting on the wall.  Squat and reach against the resistance of the tubing. Forward reach should come from rounding your back, not by hinging at the hips.  A small ball or towel roll between your knees serves as a good reminder to keep knees moving inward rather than allowing outward hip rotation. You should feel your abs working.  You should feel muscles around your shoulder blades working (these muscles actually help with expansion of the ribs).  You can squat as deep as you want, with the head up in a position similar to that while on the bike.

Both of these techniques are great for gaining awareness of how to expand the back of your chest wall, because once you lose the ability to do this on a bike you’re much more prone to compensations that will cause a variety of strains leading to injury.  They are great ones to do as a warm-up prior to riding or racing or when breathing feels restricted or back or neck muscles seem overactive and strained.

Stay tuned for Part 2 which will discuss how faulty asymmetrical breathing patterns lead to a variety of compensatory changes throughout the body.

Dry needling (DN) is the procedure of inserting solid filament needles (acupuncture needles) through the skin and soft tissues, strategically targeting dysfunctional areas in order to restore normal function.  It is something that I use on a lot, but not all of my patients.  I find it to be an incredibly useful modality for the treatment of both acute and chronic musculoskeletal conditions because of its effect on both the local tissues and the nervous system in general.

The practice is not to be compared to acupuncture except that we use similar types of needles.  Acupuncture is the cornerstone of Traditional Chinese Medicine.  It is an effective treatment approach for a variety of health issues and is based on over 2500 years of evidence.  Dry needling, on the other hand, is increasingly being used by physical therapists, chiropractors, and some medical doctors as an adjunct to more traditional Western medical therapies.  I use it in conjunction with the variety of other manual therapy techniques that I employ.

The advantages of DN are well-documented and include an immediate and latent reduction in localized, referred, and even more widespread pain.  I also often see immediate increases in range of motion and reduction in muscle tone (spasm).  And I really appreciate that the system that I’ve been trained in pays particular attention to the effects that DN can have on more chronic types of pain, called peripheral and central sensitization.

Dry needling has been traditionally used to treat myofascial trigger points (TP), which are focal areas of hyperactive muscle and hypersensitized nerve endings.  Trigger points can have far-reaching consequences beyond their localized area of pain.  Trigger points can refer pain to other areas of the body, and they can result in loss of motion and function.  And when they stick around long enough, TPs can turn a simple painful problem into a chronic pain state.

When utilized in a more systemic manner, DN can have a more long-lastic effect on TPs or other chronic pain states of musculoskeletal origin.  The approach of Integrative Systemic Dry Neeling™ utilizes some of the principles of more traditional TP needling as well as the targeting of spinal and other soft tissues that are associated with the peripheral symptoms and the formation of a hypersensitized state.

I believe that when we think of pain as more “neural” (nerve, nervous system, how pain is interpreted by our bodies and brain) than strictly “tissue” (what’s happening right where, or around where our pain is) then we will have more success treating pain conditions.  Dry needling is providing me with another modality to go along those lines.  It allows me to treat more globally and in line with a lot of the Postural Restoration® concepts that I use.  After all, treating the injured tissue locally only goes so far.  Literally.

This weekend we’ll be celebrating the life of our friend Paolo Minissi, who passed away last week.  Paolo was the owner of Castle Hill Fitness in Austin, a truly spectacular gym with incredible people and services.  I regularly refer my patients to Castle Hill for aftercare personal training, pilates, yoga, bicycle fitting, and massage.  At the very least, I say, go by their cafe and treat yourself to a kooky smoothie concoction or some coconut pudding.  The place, for a fitness and health geek like myself, is a dreamland, with the best of the best of everything, from the equipment, to the classes, to especially the people who work there.  Paolo had a vision for Castle Hill and he didn’t rest until that vision was complete and the gym and cafe were the cream of the crop of Austin.

I’m compelled to write about Paolo because of what he has done for me and how he contributed to what my practice philosophy is today.  Through circumstances, I joined physical therapists Mark Hernandez and Mark Lang in the Physical Therapy department at Castle Hill.  Paolo brought me in and allowed me to build a fee-for-service practice there, surrounded by some of the most skilled people I had ever met.  He encouraged me to truly believe in what I do, to market myself as someone who has something to offer that no one else in Austin has.  Through what he was doing to Castle Hill he demonstrated to me that a vision for a business of the highest quality would, through thick and thin, always succeed.  And not to sound too cliche, but Paolo instilled in me that success in business doesn’t come easy, but when you treat the people around you really well, especially your customers, and you are true to yourself and what you believe in, things will work out and you will do just fine.

I don’t know how many times over the years I’ve said that the thing that exemplifies Paolo and Castle Hill the best is that it is truly staggering how many employees he retained over the years.  Most of the people that were there when I was (around 2003-2004) are still there.  He created a great working environment for people which has only gotten better over the years.  He treated people very fairly and he fostered their careers-mine included.  I may not work there now, but I’m still a gym member and frequent consumer of their coconut pudding.  I love the place and will continue referring people there for as long as there is a Castle Hill.

Thank you, Paolo, for making Castle Hill Fitness what it is today.  For giving me (and many others) an opportunity to start a career in the wacky but incredibly fulfilling world of fee-for-service.  Thank you for the ideas and just a smidge of your keen business acumen.  And thank you for your freindship and encouragement.  You will be missed.

I have a fairly good excuse for not posting in a while- our beautiful, healthy daughter Lulu was born last month and, well, I’ve been a little busy in my free time.

I wanted this post to be about Postural Restoration (PRI), what it is and what it means in my practice.  Talk about physical therapy can frankly be a little dry, so I wanted to make sure when I blogged about PRI I could put an interesting spin on explaining it.  It came to me after I sent the email below to a patient recently.

I’ve seen this patient a handful of times over the past several months.  She had some siginficant back pain that was limiting all aspects of her life.  The really interesting thing was her history and how it played into her problem.

The science behind PRI is based on the body’s aymmetrical anatomical and physiological patterns and how one deals with them.  We as humans have anatomical differences in our bodies on one side compared to the other and we are either going to compensate and accomodate well for them or we are going to compensate poorly and ultimately develop problems.  PRI utilizes a system of evaluating the postural and biomechanical patterns that we develop based on these asymmetries.

My patient had some very obvious asymmetrical issues, from how her spine, hips, and shoulders were positioned to how her face, jaw, and teeth looked.  She had some fairly significant issues with her jaw that she had been working on with a dentist and other therapists for many years.  She was “obsessed with her asymmetries” (her words).  Results from therapy had been nominal at best and we believed that her current problems were a direct result of these persistent issues.

The program I’ve put her on together with consistent use and reworking of her oral appliance (a night splint) have helped a lot.  She’s doing much better and she’s basically back to living her life the way she was before the back pain.

I sent her this email the other day and I wanted to share it because it sums up nicely what a lot of my patients are going through.  I had to write this email to her because I’ve woken up a few times since Lulu was born with some familiar postural problems, torqued and twisted.  I’ve realized that I hold and feed Lulu predominantly on one side and the asymmetrical muscle tone I’ve created has really played a number on me.

Ok, I have an advantage since I can recognize it quickly and know what I need to do to change the habitual postures, but it’s frustrating (and painful) nonetheless.  My patients, however, need a lot of education and, most importantly, an understanding that to change these postures and ways of moving it takes some time. And when you’ve got obvious cranial (dental and vision) issues then it may take a lot longer for your body to change.

Here’s what I shared with her:

“I woke up this morning and thought of you.  Holding and feeding the baby has occasionally gotten the best of me and on a couple of occasions I’ve woken up torqued and unable to make tooth contact on the left.  This morning is one of those times. Of course there’s some head and jaw pain, as well as back pain.  Nothing I’m unfamiliar with but frustrating nonetheless.  I see where the jaw thing can drive the most sane individual crazy (not that I’m the most sane person…).

I wanted to write because, for lack of a better way of stating it, I’m proud of you for sticking with the program. Nothing you’ve gone through emotionally is out of the ordinary.  It’s a long and difficult road to go down.  But you have to be commended on sticking with it, following all of my crazy advice to a tee, and doing your homework.  I know that you’ve basically known all of this all along- that you needed to be doing this.  You have good body awareness and that has paid off in the end.

So, I just wanted to say thank you for hanging in there and to encourage you to keep sticking with the process.  It really is a process.”

After almost 20 years in the field of physical therapy I feel that I have a pretty good understanding of what works and what doesn’t.  I feel that I’ve seen the good, the bad, and the ugly.  I’ve seen some really great, exciting stuff and some things that make me cringe.  And I have the experience to figure out what a patient needs very quickly and the skills to help them resolve their problems in a very efficient and timely manner.

I decided that I would set out on my own, into the world of fee-for-service physical therapy, free of the requirements and limitations inherent in insurance-driven practice.  The time that I can spend with my patients, free of the distractions of having to work with one or two or even three other patients at the same time, is invaluable.  The amount of time I have to get to the root cause and find the most effective method of fixing problems is such a relief, and I know that my patients will get better faster and have long-lasting success.

My practice is based on 20+ years of working with patients and athletes and accumulating knowledge of how the human body works and heals (athletic training and PT).  I’ve had some incredible training and some brilliant mentors.  I’ve learned some treatment techniques that really work well and I’ve seen some that don’t work very well and frankly don’t make sense.  But In the last five to six years I’ve found a methodology that really ties together some of the injury and postural patterns that I’ve been seeing all along.  I think a lot of us see the patterns, the injuries that seem to come up more than others.  We see that some injuries seem to occur more often on one side of the body and others on the other side.  And we see these things that we just can’t seem to help the patient resolve, some of these really difficult postural patterns that neither exercise or our hands can take care of.

My practice is centered around the principles of the Postural Restoration Institute (PRI) in Lincoln, NE.  I’ll discuss it more in my next blog entry, but this organization is the first to put together and make sense of these things that we see over and over.  It recognizes that there is a reason why we see them time and again, and it’s because the human body is slightly asymmetrical and driven towards some very specific postural patterns.  When we as therapist just keep this in mind we can figure out and treat much more effectively since we are working towards getting our patients away from these patterns.

This approach, together with my skills as a manual therapist (hands-on), makes what I do at Steve Cuddy Physical Therapy very effective.  It’s unique but it works.  And most importantly, I have the time to do these things because the insurance company isn’t telling me I have to do less, and I don’t have to spend time fighting for reimbursement, and I won’t have to work with other patients at the same time.