Cycling and Lower Back Pain

By Alan Bragman, D.C.

I have suffered from periodic bouts of disabling lower back pain since my early 20s. I know all too well from personal experience the feeling of getting off your bike after a long, hard ride and being unable to straighten up or move without great pain. Many years ago a chiropractor in Michigan provided me tremendous relief, and this was one of the primary motivating factors in my decision to become a chiropractor. In the past thirty years I have diagnosed, and treated thousands of patients with lower back pain, many of them cyclists. From my vast experience both professionally and personally, I have developed a comprehensive understanding of how to diagnose, treat and prevent lower back pain in cyclists. Unfortunately, most cyclists suffer from lower back at some time in their lives, especially as they get older. The first step in dealing with lower back pain is to understand the anatomy, physiology and function of the area. There are five vertebrae that comprise the lumbar spine. The 5th lumbar vertebra rests on the sacrum, and at the end of the sacrum is the coccyx. These bones are held in place by an interposed network of ligaments, muscles, cartilage and soft tissue. These structures hold the vertebrae together, add stability and allow motion. The lumbar vertebrae have two types of joints: intervertebral and facet. The facet joint is at the posterior aspect of the vertebrae, and it allows motion between adjacent vertebrae. The facet joint is a true joint with a capsule, synovial lining and an abundant supply of nerves and blood vessels. This large supply of nerve fibers makes this joint especially sensitive with mechanical displacement and inflammation. Between each vertebral body is a joint formed by the intervertebral disc. The disc is a fibrocartilagenous structure that helps to dissipate mechanical stress; it resembles a piece of gristle. The intervertebral disc consists of an inner nucleus polposus and concentric outer layers of a cartilaginous material known as the annular fibers. The nucleus pulposus is a gelatinous material that dries out or desiccates as we enter middle age. This desiccation process causes the disc to lose its pliability, flexibility and the ability to handle mechanical stress and trauma. This explains why disc injuries and lower back pain increase as we age. Severe or repeated injury or insult can cause the annular fibers within the disc to herniate (protrude) or rupture (tear) and cause intense pain to the adjacent spinal nerves and surrounding soft tissue.

The lumbar spine Mechanical lower back pain is classified as either intrinsic (postural and muscular) or extrinsic (pathologic). Extrinsic causes of lower back pain would include tumors, infections, osteoarthritis, scoliosis, and gynecological, prostatic or renal problems. Extrinsic causes of lower back pain can usually be diagnosed with a through history and a comprehensive physical examination. To confirm a diagnosis, lab, imaging, other procedures or studies may be employed. Extrinsic causes of lower back pain can include poor posture, lack of muscle tone, a weak core, and instability of the vertebrae or trauma. In the past, treatment for a serious mechanical lower back injury consisted of traction, bed rest and medication. This regimen is generally ineffective, and may have aggravated the situation by allowing further muscle atrophy due to the inactivity. In addition, this lack of activity can have devastating emotional and psychological consequences on an athlete. The approach that most doctors now take is to actively rehabilitate the injured area. This is done with mild exercise, stretching, and muscle strengthening to prevent further injury. The vast majority of lower back and disc injuries respond well to conservative care, with only a small number requiring surgical intervention. With a lower back injury and other soft tissue and biomechanical disorders, the best way to avoid problems is with prevention and proper bicycle set up. Unfortunately, cycling does little to increase the strength of the abdominal or core muscles. These abdominal and core muscles play a key role in aiding the stability of the lower back and pelvic region. Adequate strength and endurance in the core and lower back is vital to reducing pelvic tilt. Stretching the lower extremities, especially the hamstrings, also helps to reduce pelvic tilt.

BICYCLE SETUP The single most important aspect of a riders position on the bike is being comfortable. If riding a bike causes pain or discomfort in the lower back or other areas of the body, this can turn your favorite activity into a miserable experience. The lumbosacral area provides a base of support that allows the power from the lower extremities to be transmitted to the pedals. Improper fit on the bicycle can generate pain and discomfort in the lower back. The cycling position is unnatural and compresses the anterior aspect of the spinal column and intervertebral disc, while opening up the posterior aspect. This places abnormal loads on the posterior ligaments, fascia, muscles and tendons, and can lead to pain. Adequate core strength and stability with hamstring flexibility can help greatly to overcome this situation. Good fit is also critical for allowing your muscular effort to produce maximum performance, power, and efficiency. Comfort and efficiency have to be modified and balanced based on the individual riders goals and riding conditions. Bicycle fitting involves compromises between comfort, performance, stability, handling, and acceleration. A time trialist strives for the most aerodynamic and efficient position on the bike for maximum speed, while the weekend warrior is mainly interested in comfort. If you are inexperienced or unsure of how to properly set up your bicycle it is strongly recommended that you have your bicycle set up done professionally. The best money a cyclist can spend to enhance comfort and performance is to get a professional bike fit. Many of the higher end bike shops and some coaches offer this service for a fee, and some will do it for no charge if you purchase the bike from them. There are several good fitting methods available, which include: Fit Kit, Smart Fit, Serotta Personal Fitting System, Wobble-Wright Laser Precision Bike Fit, and Kops. If you are planning to set up your own bike, you will need to consider two main factors: the correct saddle height, and the correct saddle-to-bar distance. Other factors to consider are saddle tilt, crank length, cleat position, handlebar style, width and height. To get started, you need to place your bike on a stationary trainer on a level surface in front of a large mirror. These are very basic instructions for setting up your bike; you will need to tweak the position with riding to find what works best for you. When making changes in your position, do them very gradually to allow your body time to adapt. SADDLE HEIGHT: Sit comfortably on the bike and adjust the height of the saddle so that your heel barely touches the pedal at its lowest point. When the ball of your foot is on the pedal at its lowest point, there should be a slight bend in the knee. When riding, you should be able to ride comfortably without rocking the hips. If the saddle height is too low, it will put stress on the anterior knee joint, if too high the pelvis will rock and you will experience posterior knee pain. 3

HANDLEBAR POSITION: For the cyclist, the saddle-to-bar distance should allow the rider to be in a comfortable position whether seated or standing with their hands on the brake hoods. Proper reach gives you easier breathing, better weight distribution, more back and neck comfort, and easier bike handling. The way to achieve a comfortable fore-aft position is by using a plumb line from the front of the kneecap to the center of the pedal spindle. While riding in the drops your view of the front hub should be obstructed and your bent elbows should be within an inch or two of your knees at the top of the stroke. Still another method is to place your hands in a comfortable position on the brake hoods looking straight ahead, and a plumb line dropped from the tip of the nose should intersect the stem. You may have to change the stem length to achieve the proper position. If the seat is too far forward it will force the quadriceps muscles to do too much work, while moving it too far back will overwork the hamstrings. The ideal position will rely heavily on the large, powerful gluteal muscles, which generate the most power and reduce the incidence of lower back pain. For recreational cyclists, the handlebars and the seat should be level. Racing cyclists can drop the handlebar height one or two inches. The width of the handlebars should be the same as the shoulders. Too wide a bar can contribute to neck and shoulder discomfort while too narrow a bar can adversely affect steering control. CLEAT POSITION: The cleat should be mounted directly over the ball of the foot. The cleat angle should allow for your natural movement and range of motion. Most cleats allow for lateral play, which makes it easier to find the correct position and avoids stress on the knees and hips. SADDLE TILT: This has been an issue with cyclists for many years. Most professionals recommend the seat be set near level or with the nose slightly higher than the back. Conventional wisdom was that a downward tilting seat would irritate the crotch, slide you forward and put too much weight on the hands, arms and front wheel. This theory of conventional seat position was recently challenged by researchers at the Chaim sheba Medical Centre in Tel Hashomer, Israel. They performed serial fluoroscopic studies of cyclists sitting on different types of bicycles (sports, mountain and hybrids). The pelvic and spinal angles were measured at different seat positions, and the force vectors affecting the lower back were analyzed. The researchers found that when the seat was level or tilted up at the front, this caused hyperextension of the spine and an increase in forces acting on the spine. By setting the seat so that the back was slightly higher than the front, these forces were reduced --and lower back pain was reduced or eliminated. I was always taught that the proper seat position was a slight upward tilt at the front. 4

Several months ago I changed my position so that my seat tilted down slightly, and it seems to be helping with my chronic lower back pain. CRANK LENGTH: Crank length can vary from 155mm to 185mm, depending on the manufacturer, with the most common lengths being 165, 170,172.5 and 175mm. The following inseam lengths govern the general rule for crank arm length: less than 29 inches-165 mm crank arms; 29-32 inch inseam-170mm crank arms; 32-34 inch inseam-172.5 mm crank arms; greater than 34 inch inseam-175mm crank arm. Longer cranks can add power but inhibit pedaling speed and may increase leg fatigue and back pain. Hopefully, we now have your bike set up properly, and we can move on to increasing flexibility and core strength to prevent and rehabilitate lower back pain and dysfunction. The old phrase an ounce of prevention is worth a pound of cure is key to avoiding lower back problems.

FLEXIBILITY AND CORE STRENGTH Significant contributing factors to lower back discomfort are a weak core, tight pelvic, hamstring, calf and lower back muscles. Stretching and strengthening these areas will lengthen and relax the hamstrings, reduce pelvic tilt and strengthen abdominal, pelvic and supporting lumbar paraspinal musculature. For some of these stretches you will need a soft nylon rope, about 8 foot long and in diameter.

Hamstring Stretch: Lie on your back with the right leg bent. Wrap the rope around the arch or middle of the left foot. Lock the knee and contract the quadriceps muscle group (front of the thigh). "Climb up" the rope with your hands and hold for 2 seconds. Return the left leg to the floor. After 12-15 reps, do the other leg.

Lower Back Stretch: Sit with knees bent, feet flat and pointed straight ahead. Tighten the abdominal muscles and tuck the chin to the chest while gently leaning forward. Pull on the ankles. Sit back and repeat 12-15 times.

Hip, Gluteal and Lower Back stretch: Lie on your back and fully extend the right leg. Bend the left knee and tighten the abdominal muscles. Grab the left leg with the right hand and the thigh with the left hand. Lift the left knee toward the right shoulder and ground as far as possible and hold for 2 seconds. Return to the original position and repeat 12-15 times, then do the other leg.

Gastrocnemius stretch: (calf muscles) Sit with both legs extended and wrap the rope around the ball of the right foot. Bend forward and tighten the quads and shin muscles while polling on the rope, hold for 2 seconds. Repeat 12-15 times, and then do the left leg.

Lower Back and Pelvic Stretch: Lie on your back and bring both thighs up so they are at a 90-degree angle (perpendicular) to the floor. Place your arms at your sides and twist to the right and the left so that the down leg contacts the floor. Do this 25 times to each side.

Scissors: (rectus abdominus) Lie on your back with your arms and legs fully extended, hands and feet touching the floor (top photo). Slowly bring your arms and legs straight up at the same time so they meet directly above your torso, then slowly lower to the starting position. Do 3 sets of 15-25 reps

Trunk Raise: (lower back muscles, erector spinae) Lie on your stomach with your hands behind your neck, arch your back while simultaneously raising both legs and hold for 10-15 seconds. Do 3 sets of 10-12 reps. For additional resistance add ankle weights and a light weight behind the head.

Bird Dog: (Lower back, erector spinae, hamstrings and gluteals) Start on your hands and knees with your back flat. Raise your right leg and left arm so they are parallel to the floor, and hold for 30 seconds. The supporting arm should be perpendicular to the floor. Then do the same thing using the right arm and left leg. Repeat 3-5 reps

Plank: (Abdomen, lower back) Lie face down resting on your forearms, elbows and toes. Keep the back flat, tilt the pelvis and contract the abdominals. Hold for 30-60 seconds and repeat for 3-5 reps. For advanced athletes raise one leg off the ground.

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Modified Side Plank: (Abdomen, gluteals) Lie on your left side, and using your left arm and elbow raise yourself up to form a plank. Raise the right arm up straight so it is perpendicular to the ground and hold for 30-60 seconds. Repeat for 3-5 reps, doing the same on your right side.

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Reverse Table Pose: (Abdomen, Gluteals, lower back) sit on the floor with your hands facing forward and lift yourself up with your hands and feet so that your back is flat and your arms and legs are perpendicular to the floor. Hold for 30-60 seconds and repeat for 3-5 reps. For advanced athletes, hold a leg up parallel to the floor.

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Side Bow: (lower back, Gluteals) Get on all fours and grasp the right ankle with the right hand and raise it as high as possible. Hold for 30-60 seconds and repeat for 3-5 reps. Do the same on the other side.

Cross Bow: (lower back, Gluteals) Get on all fours and grasp the left ankle with the right hand and raise it as high as possible. Hold for 30-60 seconds and repeat for 3-5 reps. Do the same on the other side.

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Lower back pain can also be caused or exacerbated by numerous factors and activities other than cycling -- most commonly, poor posture. Posture problems occur primarily when sitting in a chair or on a bike and, to a lesser extent, while standing. Slouching (while sitting or standing) rounds out the lower back, causes stress and inflames the ligaments, muscles and tendons along the sides of the spine. These secondary factors caused by poor posture are a common cause of lower back pain. Many chairs, couches and car seats provide poor lower back support. A cheap and easy way to increase lower back support while seated is to make a roll out of a thick towel and place it behind the lower back.

TREATMENT OPTIONS FOR LOWER BACK PAIN If you do develop lower back pain dont panic. Most incidents of lower back pain are not serious and will resolve within a couple of weeks with simple home self-care. Approximately 85% of the population experiences back pain at some time in their lives, and 97% of these people get well within 4-6 weeks with mild treatment. There are many treatment options available to deal with this very common condition. Lower back pain falls into one of three general categories: 1. Nonspecific lower back pain. Most of these cases are classified as strains and sprains. (85% of patients fall into this category) 2. Back pain potentially associated with spinal conditions, such as spinal stenosis, disc lesions, vertebral compression and fractures. 3. Back pain potentially associated with another specific cause such as malignancies, space occupying lesions, infection or vascular problems. There are certain signs and symptoms associated with lower back pain that can indicate a serious situation where emergency treatment is needed immediately: 1. Cauda Equina syndrome. This is a serious neurological condition in which there is an acute loss of function of the lumbar plexus (the nerves in the lower back). It is characterized by: sudden loss of bowel and/or bladder control or dysfunction, severe or progressive neurologic changes, saddle anesthesia, weakness of the lower extremities and, possibly, a drop foot. 2. Severe lower back pain following significant trauma. 3. Severe continuous abdominal and lower back pain could indicate an abdominal aortic aneurysm. 4. Night pain, weight loss, fever or other signs of infection or cancer that accompany severe lower back pain. If you have developed lower back pain, it is important to stay active and try to rest in a comfortable position. Take short walks or stretch every few hours to loosen up the muscles and tendons. Staying active is much better for recovery than strict bed rest. In fact, staying in bed for more than one or two days can actually worsen the condition by increasing stiffness and increase muscle weakness. 14

If there is severe pain and muscle spasms, consider applying an ice pack for 15-20 minutes (several times a day) and taking over-the-counter medication. The medications commonly taken for this are known as NSAIDS (non-steroidal anti-inflammatory drugs): Ibuprofen (Advil or Motrin), Naproxen (Aleve or Naprosyn), Salicylates (Aspirin). If the pain, inflammation and muscle spasms persist for more than a couple of weeks, consider seeing a health care professional that specializes in the treatment of musculoskeletal disorders. You could also consider treatment consisting of physical therapy modalities, rehabilitation, and mobilization. The vast majority of patients with lower back pain recover with conservative treatment, and surgery is rarely needed, even in the presence of a disc injury or nerve damage. Once you have a significant incidence of lower back pain, the problem is more likely to recur. To avoid future episodes, keep your abdomen and core muscles strong, use good posture, keep your weight down, lift properly and make sure you are comfortable while riding on a properly fit bike. For additional stretching and core training information see my articles Stretching for Cyclists and Core Training for Cyclists both available in the RBR eBookstore.

About the Author Alan Bragman is a chiropractor living in Atlanta, Georgia. He is a former Cat 3 cyclist and nationally ranked inline speed skater. He was on the medical advisory board at Bicycling magazine for 10 years and has written for other sports publications. In addition to the articles mentioned above, Dr. Bragmans RBR eArticles include: Plyometrics for Cyclists Aging and Cycling Cold-Weather Cycling Hot-Weather Cycling The Recumbent Alternative

Copyright Alan Bragman, D.C.

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