Clinical Pearl: Clinical Perspective on Treating a Cyclist

By Ryan Gary, PT, DPT

Aux Champs Elysées! The pinnacle of a road cyclists’ season ends in Paris, after a 3,350-kilometer ride over 21 days. From time trial sprints to steep mountain climbs, road cyclists are unique athletes that rely heavily on the hard work of physios around the world. For those who treat cyclists or follow the pro-circuit, we know that it often takes a village to help athletes like 2018 Tour de France champion Geraint Thomas stay at the top of their game.

Cycling injuries are often divided into two categories: injuries due to trauma and injuries due to overuse. Traumatic injuries, usually high impact, often result in a coordinated effort with physicians and surgeons, as these injuries often involve broken bones or varieties of head injuries. While I can’t emphasize enough the need for dry needling in the treatment of post-concussive head injuries (check out Adam’s discussion here), we are going to discuss injuries due to overuse because this is a far more common problem that we will see as physical therapists.


Injury or Performance?

Cyclists are constantly nursing nagging aches and pains. Due to the repetitive pedal strokes and hours spent in tight aerodynamic positions (not always the most ergonomic), it’s fairly common to see cyclists seeking the help of a good physical therapist.  However, a cyclist problem does not always have an origin in pain, but can be related to a lapse in performance. This leads us to our initial crossroads:  “Are we treating the cyclist for an injury, or for his/her performance?”

  1. Injuries mean that something is wrong, ultimately resulting in injury.
  2. Performance means something isn’t necessarily wrong, but imperfect, and this is out chance to make someone better.

At a glance, expect to see plenty of overuse tendonopathies, impingements, and let’s not forget the always looming back pain. Many times, the manipulation of treatment volume and comprehensive load can help to manage these issues. However, it’s exceptionally important to identify the cause and  develop a treatment plan involving management of such. Small changes make big impacts! Remember that phrase when dealing with uni-modular repetitive sports like running, cycling, swimming!

What about the performance side of cycling?  What can we do to make this person better? Is he/she weak? Are they inefficient/wasting energy? Is this person getting fatigued after 3 hours in the saddle due to poor  tissue endurance?

What can we do to change “that”? There is plenty out there to address performance:

  • Try to find a cyclist that has good posterior chain recruitment.
    • Unless they work their glutes and hamstrings on a consistent basis, posterior chain strength in cyclists is notoriously poor. If we can work to address those gluts and hamstrings, we will see huge leaps in power.
  • Don’t forget about bike fits.
    • Correct a poor bike fit and it will solve a multitude of cyclist problems.
  • Give correctives.
    • Cyclists love homework.


What about Dry Needling?

WHY should we needle?

Sometimes we NEED to make a neurophysiological change. Our patient is weak, inefficient, fatiguing…We want to change the way that our alpha motor neurons impact our skeletal muscles to hopefully create a change and an improvement in neuromuscular firing. We want to create a change with alpha-gama coactivation and try to directly impact performance. Let’s needle!

What should we needle?

Let’s talk about which muscles cyclists tend to overuse. Cyclists are positioned in a forward flexed position, forcing them to heavily rely on their quads and hip flexors. Depending on the efficiency of the cyclist and whether they are riding a lot of hills, we will also see recruitment of their hamstrings, glutes, and gastroc/soleus.

Like all good answers, our treatment should depend on our exam/assessment. I will typically go through a myotomal assessment paired with a series of functional movements to test activation and control. Often times, our findings of dysfunction are consistent with the muscles that cyclists tend to overuse.

I have very rarely found a cyclist who doesn’t have some inhibition over L2-3 and good activation of his/her hip flexors. One of my favorite circuits involves the TFL, iliacus, psoas, and rec fem. I will then use a multi-channel stim pattern working towards higher frequencies for the recruitment of more and more motor units. Pair that with those lumbar multifidi in a sidelying position, and you’ll really do that cyclist some good.


Personal Example!

I had a cyclist that I needled a few years ago that came back the a few days later baffled that he had seen a 15% improvement in his power output (watts) following our session. The Neurologic system is so powerful! There’s a reason that tour riders and professional cyclists rely on physical therapists like us. Be confident in your ability to make a change!


Final Thoughts

Cyclists are some of the most enjoyable patients to work with. A cyclist motto goes something like:

“The best rides are the ones where you bite off much more than you can chew, and live through it.”

Cyclists can sometimes be “hard-headed”, but they work hard and are grateful for the impact that we can make. Don’t forget to always meet the athlete where they are and be open to adjusting treatment strategies mid-session. We are experts at helping them to excel and can make a major change in correcting dysfunction and improving performance. Go ride a bike!



About the Author

Ryan Gary is a physical therapist and owner of Good Life Physical Therapy and Sports Performance in Grand Rapids Michigan. His interest in athletics and participation in endurance sports, including the completion of a multitude of race distances from the marathon to the Ironman, has given him an appreciation for what the body is capable of in conjunction with sports performance. Ryan also coaches track and cross-country at a local high school in Michigan and is passionate about using his skillset for the betterment of his community.