Low back pain in cyclists

1. F I T N E S S
B E AT
BACK
PA I NMaking his first tentative steps back onto the bike
after months out with back trouble, CW’s James Shrubsall
declares war on cycling’s number-one ride-spoiler
Photos Daniel Gould, Chris Catctpole, SW Pics
46 | 8 October, 2020 | Cycling Weekly

2. Cycling Weekly |Month ??, 2018 | 47

3. t the time of writing, the defending Tour
de France champion Egan Bernal has just
abandoned the race with back pain. I may
be twice his age, and barely champion
of my own bike shed, but I know how he
feels... sort of. Whether it’s a dull ache
that sets in towards the end of a ride, the
odd twinge getting in and out of the chair
at the coffee stop, or a raging sciatica
that prevents cycling altogether, many
of us have experienced some form of
back issue. And the sad truth is, these
problems often seem to be brought on –
or at least exacerbated – by riding a bike.
You might be frustrated; you might
be in pain; but one thing you certainly
won’t be is alone. The UK Health & Safety
Executive put the number of work days
lost to back pain at 2.8 million in 12
months across 2018-19. More seriously,
it’s not unreasonable to estimate that
the number of bike rides missed runs to
seven figures, or at least not far off.
Cyclists seem to get a raw deal in the
back pain stakes. A Norwegian study
of 116 pro cyclists found low back pain
(LBP) to be the most prevalent overuse
injury in the group, with 49 cyclists
reporting the issue. This was backed up
by a study of 111 Swiss national team
cyclists, which found one in three had
some back pain and poor core strength.
These may be elite riders, but
anecdotally most of us know someone
who has had to take time off the bike
now and then because of LBP. It stands
to reason – if young professional
sportspeople with multi-million-pound
back-up structures are suffering with
back pain, what chance do the rest of us
stand? Going headbanging on Zwift or
at the evening 10 on a regular basis – or
even just upping your mileage a bit too far
– with no health guidance and especially
for riders in their 40s and beyond, seems
like a recipe for a pain in the back.
So what’s going on?
“Number one is our lifestyle,” says Dan
Boyd, a physiotherapist and bike-fitter
at Complete Physio in London (com-
plete-physio.co.uk) as to why backs seem
so vulnerable to injury. “Unfortunately,
we spend a lot of time at a desk and we
weren’t particularly designed to sit at
desks, which puts a lot of strain on our
thoracic [mid] and lower back. That’s
pretty unavoidable for most people,
certainly recently.”
The posterior chain – the muscles in
your back, bum and the backs of your legs
– is king. Unfortunately, these muscles
get ‘switched off’ by sitting for long
periods. Studies have also shown that
fatiguing other muscles in the posterior
chain can lead to undesirable movement
patterns in the back, and that maintaining
a forward-flexed position for too long can
compromise the extensor muscles we use
to straighten up, and thus spinal stability.
48 | 8 October, 2020 | Cycling Weekly
F I T N E S S
CW’sShrubbyinhappier
timesbeforehisbackordeal

4. Physio Dan Boyd and GB pro
Kian Emadi’s favourite back pain
maintenance exercises
Glute/hamstring hold: Using a
back extension machine, this
is an exercise Emadi says
“really switches on
my lower back”.
Side plank: Emadi also
recommends this slightly
trickier sibling of the standard
face-down plank, which works key
muscles in keeping the back strong
and pain free.
Thoracic extension: Working
to avoid the typical ‘rounded
shoulders’ posture is important
says Boyd. A supple thoracic spine
can take the pressure off the low
back. Using a foam roller to work
the thoracic (mid-back) area
can help.
Strength to weight: “Your
quads, hamstrings and glutes
need to be strong enough
to cope with the pressures
put through them,”
says Boyd. Bodyweight
squats and a simple
glutes/hamstring bridge
are a good place to start.
*If you are already suffering with
a back issue, seek advice from a
health professional before trying
these exercises.
T I P S F R O M T H E T O P
Moves to keep
you mobile
“Number two,” Boyd adds, “is that the
back is a crossover point in the body.
Pretty much all the forces we have travel
through our back, whether it’s rotational
or position-based, and also it’s the bit that
holds us together.”
It sounds like a recipe for disaster, but
Boyd insists: “To be fair, the back is an
exceptionally well designed bit of kit, but
what we ask of it is probably quite a lot,
particularly through cycling... Some of
the endurance events people get injured
doing are pretty extreme.” As an Ironman
triathlete, he speaks from experience.
The blame, Boyd says, lies not so
much with our backs, but with our
expectations; as the
movie line goes, our
egos are writing
cheques our bodies
can’t cash.
“The
expectations
of cyclists and
triathletes, in my
experience,” Boyd
hesitates trying
to find diplomatic words. “The level of
normality gets somewhat distorted.”
Some of us need to view our bodies a
little more sympathetically.
“Cycling 100 miles is an awful lot to put
on your body, but quite normal for a lot of
people, particularly nowadays.”
So what if you enjoy riding long
distances? If you’re a regular racer, club
rider or Audax rider, rides of up to 100
miles are probably part of what you love
about bike riding. Thankfully, Boyd says
you don’t necessarily have to give these
up to preserve back health. Much back
pain seems to be preventable given a little
attention, both on and off the bike.
My back pain struggle
As a sufferer of ongoing back problems
myself, it’s an issue I’ve found myself
occupied with a great deal over the last
eight years, having been through a
number of episodes which have kept me
off the bike for several months at a time.
In my case, the culprit is the good old
‘slipped disc’ — more correctly known as
a herniated disc. This has caused spasms
and led to chronic deep, jangling nerve
pain radiating down my leg, rendering
riding a no-no. In fact, in the most recent
flare-up, which began last summer and
is still refusing to settle, even walking
was painful and for months, I needed a
walking stick just to get from the living
room to the kitchen. Painkillers of all
kinds layered extravagantly on top of
each other and a steroid injection all
helped, but only to take the edge off.
I also tried electrical stimulation,
courtesy of a device called Mibody,
made by British company Nurokor (£99,
nurokor.co.uk). A neat little device
housed in two small pads applied to
the skin, it delivers electrical pulsing
patterns designed to be painkilling and
therapeutic. I found the sensations –
adjustable from
an unobtrusive
‘hum’ to a fairly
hefty buzz, which I
couldn’t tolerate –
worked quite well
at blocking out the
pain, and in the
case of my leg, the
painkilling effect
lasted well. But like
all of the above, it was no silver bullet.
Thankfully, most back sufferers won’t
experience this sort of discomfort,
with muscle aches being relatively
straightforward healers, and even
troublesome disc and nerve issues often
healing in around three months. But
back pain, particularly where discs are
concerned, is a pretty capricious sparring
partner — you really don’t know what
you’re going to get.
For example: a 2015 review in the
American Journal of Neuroradiology
looked at more than 3,000 people of all
ages, and found that 30 per cent of 20-year-
olds, rising to 84 per cent of 80-year-olds,
had some sort of disc bulge – the classic
slipped disc, often associated with pain.
Yet none of the people in the review had
symptoms. So, though attempting to
protect yourself from a slipped disc might
be futile – seeing as you may well have
one already without knowing it – there
are some guidelines that will help you stay
mobile and back pain-free, which let’s face
it, is what matters.
Put in the work off the bike, urges
Boyd: “Just hopping on, say, twice a week
to do a 50km and 100km ride, is certainly
not uncommon among your readers, I’m
“The blame lies
not so much
with our backs
as with our
expectations”
Cycling Weekly | 8 October, 2020 | 49

5. sure,” he says, “while not putting any
work in the gym, or at home, in terms
of simple push-ups, planks, any sort of
mobility work at all.”
The time commitment does not need to
be huge.
“Literally 20 minutes of yoga will
do the job. Appreciating the effort you
have to put in off the bike to manage
those sorts of
distances is key.”
And if you’re at
all unsure about
your set-up, get a
bike-fit – or at least
do a little research
and get some
benchmark advice.
“I see a lot of people in pain who want
a bike-fit, but bike position is one of the
things that can cause back pain just as
easily as it can solve it,” Boyd says. “One
of the silliest things I see is people riding
with their saddle on an upward tilt. That’s
frankly bonkers. Then there are other
things like not even having a saddle on
straight. Honestly — decent-level riders
coming in with their saddle on wonky…
Over six hours, it’ll have an effect.”
So much for keeping yourself pain-free.
But best-laid plans and all that — what do
you do if you do find yourself one of the
“Walking certainly is one of the best
things you can do for back pain. So
keeping active sensibly, I think –
basically limiting impact exercise and not
putting too much load… usually guided by
someone who’s had a look at your scans
and whatever pathology you’ve got.”
In my case – at least in this most recent
episode – it was regular sessions with
a physiotherapist that put me back on
track. She helped me mobilise my spine
and ironed out some of the tension in
my lower back muscles. Things quickly
dialled down from ‘very bad’ to simply
‘bad’ on the ‘How messed up is my
back-o-meter’, which I was eternally
grateful for. (It’s worth adding that in the
past I have had good results with both a
chiropractor and an osteopath).
Two steps forward, one step back
It was around this point, after nearly four
months off the bike, that I first turned
the pedals again: six minutes on Zwift
There are many different types of back
pain but the headlines are ‘muscles’
and ‘discs’.
Muscles suffer as a result of
poor posture and a weak core, and
combined with going a bit too far
or hard on the bike – or even lifting
something too heavy – is a recipe for
a strain. A strain can cause painful
spasms, your body’s way of ‘freezing’
your back to stop you doing any more
damage, and can take weeks to heal.
The good news, as Boyd says, is that
exercise and movement can help the
healing process.
Discs issues, as we have seen, are
extremely common – though many
such cases involve no pain, and the
effects are difficult to predict. The
classic cause of pain is a damaged disc
that bulges outwards from the spinal
column (a so-called slipped disc) and
impedes the sciatic nerve, resulting in
pain, often down the leg, that can vary
from mild to severe. Disc issues can
also cause spasming.
One last brief, but important,
point that will be among the first
raised by any medical practitioner
– if your back pain is accompanied
by any bladder or bowel issues, do
not delay but go straight to hospital.
Impeded nerves in this area are a
medical emergency and, without
urgent care, can leave the sufferer with
permanent damage.
C W E X P L A I N E R
What is back pain?
many bike riders troubled by LBP? The
NHS UK website states that most back
pain is not serious and usually gets better
over time, and suggests keeping active,
taking ibuprofen if it’s safe for you to do
so, and trying hot or cold packs. It adds
that if it doesn’t start to improve within
a few weeks, stops you from doing day to
day things, or is severe, “it’s a good idea
to get help.”
Patience is key
A GP can refer you
to a physiotherapist
or musculoskeletal
consultant or, in
order to be seen
straight away,
you can opt to go privately to a physio,
chiropractor (not widely endorsed by the
NHS) or osteopath. If at this point you
are diagnosed with a disc problem, be
prepared to make two new friends:
patience and light exercise.
“Unfortunately, once we know it’s a disc
or a nerve impingement, you’re coming off
the bike,” Boyd says, “because they’re very
difficult to manage during sport.”
Out with cycling, then, but in with
lighter forms of exercise.
“‘Activity modification’ is the phrase
used in the literature,” Boyd continues.
“Once we know
it’s a disc,
you’re coming
off the bike”
50 | 8 October, 2020 | Cycling Weekly
F I T N E S S

6. averaging 85 watts. But it was a start. Six
weeks later, I was up to an hour outside,
but that proved a bridge too far and
necessitated a further month off the bike.
As Boyd says: “It’s about expectation
alteration. When someone’s expectation
is not aligned with the underlying
physiology [of the issue], that’s where it
goes wrong.”
Thankfully, more small steps, more
physio, daily stretching and a good
deal of core work saw me reach the
60-mile benchmark this month, and
painkillers are a thing of the past, bar
the occasional paracetamol.
The last key healer in the equation has
undoubtedly been time. Sadly, without
going under the knife (and even that is
no guarantee), nerve and disc issues like
sciatica require patience. I’m still waiting
for it to resolve itself completely, but as
it’s still improving, I’m confident that one
day I’ll be pain-free. Now, if you’ll excuse
me, I have some core exercises to do.
One rider
who knows
all about the
frustrations
of a disc
injury is Team
GB trackie
Kian Emadi.
Originally
a sprinter,
Emadi was
lifting weights
in the gym
when the
injury came
on in 2014.
“It was a
herniated
disc, which
I got from deadlifting in the gym,”
says the 28-year-old from Stoke. He
was able to get back into training
after a couple of months, but: “I just
kept having recurring issues related
to that.”
By late 2015, Emadi realised that
being selected for the sprint events
at Rio the following August was
going to be a big ask. “I decided
I couldn’t really couldn’t really
continue training hard enough to
hope to make the Olympics, so
I decided to give endurance a go.”
Moving away from the heavy gym
work required as a sprinter showed
that a bad back doesn’t need to be
catastrophic — and that sometimes
a change of focus can help: Emadi
helped the team pursuiters to two
World Cup golds and a rainbow
jersey in 2018. Unfortunately
last summer Emadi’s back issues
returned; after suffering more and
more on the bike, he eventually had
to take a month out, but was able to
return to ride the individual pursuit
in November’s Track World Cup.
As anyone with ongoing back
issues will want to do, Emadi, with
the help of
specialists,
eventually
established
what sorts
of treatment
and exercises
helped most
in keeping
him mobile
and pain-free.
“The thing
we find works
for me is
leaving the
lower back
alone and
just working
on keeping
the hip muscles loose,” he explains.
“Plus a bit of massage in the upper
back, and it keeps both sides of
things around the lower back loose.”
As to what caused the original
issue, it wasn’t due to deadlifting
per se. “I wasn’t moving properly
and there’d been issues that had
been niggling for a while, and the
deadlift set those off,” Emadi says.
“But I think if you’re lifting with good
form and good control, the gym can
be a great way to strengthen your
back.” Off-bike work, provided it’s
done with correct technique, is an
effective preventative measure.
“The bike is good for training
your legs, but puts hardly any
load on your core and back, so
anything you can do in the gym
to give you some balance is useful.”
For any readers who do find
themselves suffering with a
back issue, Emadi advises our
old friend patience: “Just be
patient. It can take time. And
when you are getting back into
it, remember you can’t get back
straight away. It takes a bit of
patience just to build back up.”
C A S E S T U D Y : K I A N E M A D I
Negotiating disc issues
to stay on track
Cycling Weekly | 8 October, 2020 | 51
TeamGB’sKianEmadihassuffered
fromrecurringbackissues
Timeisthekeyhealerin
gettingbackonthebike