Neck and Shoulder
Posterior neck pain in cycling is generally caused by positioning on the bike and is commonplace, particularly for those adopting a more aerodynamic position or when dramatically increasing training volume beyond what is 'normal' for you as an individual. Road cyclists are typically holding the neck for long periods of time in extension. This can irritate neck (cervical) extensors by means of overuse. Superficially the upper fibres of the trapezius may feel uncomfortable, however deeper muscles that extend, rotate and stabilise the cervical spine are all susceptible to discomfort through overuse when holding a typical position on a road bike. Bike fit changes or gradual increases in training load can help, as can specific strength training. Sports massage and stretching can help alleviate the symptoms and improve range of motion. More complicated issues that may present with similar symptoms could include irritation of the cervical facet joints or intervertebral disc bulge or herniation. The proximity of these structures to spinal nerves also presents the possibility of a 'pinched' nerve, which would typically result in more specific symptoms as opposed to general fatigue, such as sharp pain, numbness or tingling that may radiate beyond the affected site. Pain or discomfort around the shoulder (pectoral) girdle may well be referred pain from an issue in the neck if it's closer to the midline. Due to the constantly protracted shoulder position we adopt as cyclists, muscle imbalances are likely without intervention. The resulting compression of shoulders that are 'rolled' forward can contribute to rotator cuff tendinopathy which further exacerbates the issue and this will generally be felt around the shoulder joint (glenohumeral joint). Rest and strength training will help, while massage and stretching can help alleviate symptoms.
Back and Chest
Mid-back (thoracic) pain or discomfort is less common in cyclists when compared to lower back pain, but for some it can be limiting. As described in the ‘Neck and Shoulder’ section, herniated or bulging intervertebral discs will cause pain or discomfort, as will compressed nerves, soft tissue inflammation and degeneration to tissues that surround facet joints. This applies to all areas of the spine and professional medical advice is essential. More generalised soft tissue discomfort often occurs in cyclists due to the postures held for long periods of time, and in the mid-back this can be due to prolonged curvature of the thoracic spine so that you can hold the hoods, drops or bars on a poorly fitted bike or for more aggressive set-ups. Bike fit changes can help to flatten the thoracic spine, and strength training can help reinforce and stabilise the mid-back and surrounding muscles. Massage and stretching of the erector spinae muscle group, QL and superficial mid and lower trapezius fibres can help alleviate symptoms, improve flexibility and reduce time between training sessions. Lower back pain is far more common and there are many possible causes, but it’s fair to say a strong ‘core’ through various exercises to address any possible muscle imbalances and provide stability to the trunk will be helpful. However, something as simple as your saddle being too high will likely be destabilising the hips (and knees, and ankles) and thus the soft tissues trying to stabilise and mobilise these joints are over-stressed, including those in the lower back, so bike fit is very important. Sciatica is a common problem and is in simple terms nerves that are being compressed. Because the sciatic nerve runs from the lumbar spine and down the legs via the pelvis, pain and other sensations (weakness, tingling, etc) can be felt at different sites as the symptoms radiate, such as lower back, deep to the glutes and down the back of the leg. A condition that presents similarly is piriformis syndrome - the piriformis muscle is deep to the glutes and primarily externally rotates and stabilises the hip joint, along with several other rotator muscles. If in spasm, it can irritate the nearby sciatic nerve and be confused for sciatica. Sports massage for lower back pain can be very effective for temporary relief from symptoms, but identifying the root cause of your lower back pain is really important and may require professional medical advice.
Hips and Gluteals
Gluteus maximus (the big one in your buttock!) is the largest muscle in the human body and a very powerful hip extensor and hip stabiliser. Weak or tight glute max can lead to unwanted hip rotation or pelvic misalignment. Naturally other muscles will overcompensate to try and address the imbalance and will likely result in discomfort. The glute max lies superiorly to all the other gluteals (with the exception of the superior fibres of glute medius) so is easily identified and palpated. Deeper massage techniques in this area can be performed discreetly, through clothing or towels if required. Deep to glute max are a number of muscles but one of note is the piriformis, which I’ve touched on in the ‘Back and chest’ section. Pain in the hips can come from the acetabulofemoral joint (the ball and socket of your hip) or laterally to the greater trochanter of the femur and associated soft tissues. The former may feel like a deeper discomfort in your hip and the latter more towards the outside of your hip. The acetabulofemoral joint features protective soft tissues that may become irritated or damaged through impingement (excessive compression or contact between structures) and is common in cyclists due to the constant hip extension/flexion. If the discomfort you are experiencing is coming from what feels like the ball and socket joint then there are a number of potential issues which will require professional medical examination. If the pain is ‘further out’ towards the large bony prominence you can feel with your fingers on the hip (the greater trochanter), then trochanteric bursitis may be the problem. In simple terms this is often an overuse injury, brought on by the motion of muscles and tendons moving over the bursae, which are essentially fluid filled sacs that improve glide between muscles, tendons and joint structures. They can easily become inflamed (bursitis) and will require adequate rest before improvement is seen. Massage and stretching can help alleviate tension in the muscles surrounding these structures and so reduce symptoms, but bike fit will also play a critical role, as will riding within your limits and avoiding overuse.
Upper Leg
The quadriceps work hard during the power / push phase of the pedal stroke, contributing to thousands of revolutions in a typical ride. Repetitive contraction over a long period of time without counter measures (stretching, strength training etc.) can lead to shortened, tight muscles. This is especially true for rectus femoris, the quadriceps muscle that crosses both the knee (for extension) and the hip joint (for flexion). That dull ache in the anterior aspect of your quad post training ride is likely your quads and these respond well to massage for relieving tension and relaxing the muscle group as a whole whilst potentially reducing DOMS. The above is largely true for the hamstrings, which also play a critical role in extending and stabilising the hip through the ‘power’ stroke and pull stroke. With the thousands of revolutions in a long ride, with varying power and torque input, it’s easy to see how these muscle groups can fatigue and feel sore or achey after a ride! As a large, broad group of muscles, deeper massage techniques can be employed when there’s no suspected trauma to the muscle and this usually feels very good for most clients. An acute injury or severe overuse injury to any of the muscles listed above will likely be accompanied by pain and professional medical advice should be sought. Lighter ‘effluerage’ massage techniques may still be beneficial with appropriate referral from a health professional.
Knee Pain
This must be one of the most common problems for cyclists and can be really debilitating. Careful management of knee pain is essential and professional medical advice is advised if the issue persists or the pain is severe. The knee as a joint can extend and flex but doesn’t allow for much internal or external rotation. Ligaments supporting the knee joint (ACL/PCL/MCL and LCL) provide stability whilst allowing just enough movement for the knee to ‘unlock’ in flexion. In front of the knee lies the patellar, a ‘sesamoid’ bone as it is encased in thick tendinous tissue. The knee cap tracks carefully through a groove in the thigh (femur) bone during normal extension and flexion. Pedalling technique, bike fit, muscle imbalance or tension can cause the patella to maltrack and irritation occurs, causing pain in the front of the knee. Patellofemoral Pain Syndrome generally refers to any pain around the knee cap area, but there are many different causes. Massage and stretching can help with symptoms by relieving tension in the associated muscles. Tendinopathy (a general term for irritation of a tendon) of the patella tendon will also result in anterior knee pain but often usually just below the knee cap. If you feel just below the knee cap, you’ll easily identify the thick tendinous tissue that can become problematic. The possible causes in athletes are the same as most other overuse injuries such as bike fit, increase in training load, or in this case low cadence high torque scenarios (hillclimbing). Pain on the outside of your knee (lateral) could well be ITB syndrome (iliotibial band), which is the IT band rubbing against a bony prominence on the side of your femur (lateral epicondyle). The repetitive motion of cycling means constant movement of the tendinous IT band over the bone and the protective bursa between them, leading to irritation and inflammation. As mentioned above there are a number of possible causes from bike fit to muscle imbalances, and whilst sports massage and stretching cannot lengthen or loosen your IT band, it can help reduce tension in associated muscle groups, including TFL and glute medius. It’s also worth considering your feet as they are the key contact points that transfers power to the bike and are typically fixed in position by cleats. Any issue here such as pronation or supination (your ankle rolling inwards or outwards relative to the leg above it), poor pedalling technique or bike fit issues can lead to instability further up the chain. The knock on effect is often knee pain due to poor patella tracking, or pain localised to the feet. Please see the section on ‘Feet’.
Lower Leg and Feet
Issues in the distal leg and foot are less common but can be a problem for some. The gastrocnemius and deeper soleus (calf muscles) can become achey or fatigued as they work hard during the pedal stroke to flex (plantarflexion) and stabilise the ankle joint. Massage and stretching of these muscles can be very effective for relief from soreness and usually feels very good. Pain further down the posterior leg towards the heel may be a sign of tendinopathy in the achilles (calcaneal) tendon and is much harder to manage - proper rest is very important as tendons generally heal far slower than muscle fibres. Stretching may need to be avoided so as not to further aggravate or damage any connective tissue that’s in a repair phase, but careful massage can help with symptoms of discomfort. If pain is felt under the foot, between the heel and ball of your foot, fasciitis may be the cause. In simple terms this is inflammation or irritation of the plantar fascia (connective tissues on the sole of your foot). Rest and adequate recovery is important, but looking at bike fit, particularly saddle height and shoe / insole fit may be required. If you’re experiencing ‘hot spots’ on the sole of the forefoot there’s the possibility that nerves are being compressed and a compressed nerve can make its presence known in a number of ways, from a hot, burning sensation, to tingling or numbness. You’ll notice ‘wide-fit’ cycling shoes are commonly available from manufacturers so it’s important to check you’ve got the right shoes for your feet. Too tight and you’ll further aggravate the issue. Sometimes nerves may be compressed as a result of Morton’s neuroma - a thickening of tissues that surround nerves that run between your toes. As always professional medical advice is advised if you have persistent symptoms.