Bike Without Wrist Pain

By Emma Maaranen

Perfect fall weather along the Wasatch Front has the masses on their bikes commuting to work, getting a last hit of the Crest Trail or bike-touring the Nebo Scenic Loop to gawk at the colors. In the clinic we are seeing a lot of disgruntled cyclists who are not getting to pedal as much as they want due to wrist pain. A few simple adjustments to your bike may be all you need to get back in the saddle.

Your cockpit (shifters, brake levers and handlebars) and saddle are the most typical culprit for bike-fit related wrist pain. If either or both of these are just a millimeter or two adjusted in an unfavorable position for you, too much weight is transferred onto the tiny bones that make up your wrist (the carpal bones).

Elbow - wrist -  index finger position on a road bike

Elbow – wrist – index finger position on a road bike

Elbow - wrist - index finger position on a mt. bike

Elbow – wrist – index finger position on a mt. bike

Ideal cockpit position for both a road or mountain bike style handlebars creates a straight line from your elbow through your wrists to your outstretched index finger on the brake levers. If this alignment is strait, the carpal bones are stacked on top of each other to perfectly bear weight. If there is a bend in your wrist the bones are not stacked.  Unstacked carpals cause the muscles, tendons and ligaments at your wrist overwork and can lead to injury.

Adjusting angle of road-style handlebars

Adjusting angle of road-style handlebars

Adjusting shifters and levers on mt. bike

Adjusting shifters and levers on mt. bike

You can loosen the shifters and levers on a mountain bike style handlebar and adjust the angle of the shifters/levers to achieve a straight line from elbow through index finger. On a road bike handlebar type you can loosen the screws at the bike stem to adjust the angle of the handlebars to accommodate a straight line from elbows through index finger.

Too wide mt. bike handle bars with a lever angled too far down put excessive weight on the thumb side of the wrist.

Too wide mt. bike handlebars with the lever angled too far down and too wide on the bars.

The ease of using your shifters and brake levers also effects your wrists. On a mountain bike style handlebar you can move the shifters and levers in or out on the bar. You want the end of the brake lever (most mechanical advantage so you don’t have to squeeze very hard to brake) in-line with your index finger. Your hands should rest on the handlebar grips so your index finger is as wide as your armpit. (For some disciplines of mountain bike riding you may want your hands wider, but this is a good biomechanical place to start from.) Here is a link to walk you easily through doing these mechanical tweaks yourself.

Too wide road-style handlebars causing the wrists to bow outward.

Too wide road-style handlebars causing the wrists to bow outward.

The width of the bars is really important for a road bike set-up. They should be as wide as the rider’s armpits. Too narrow and the wrists will bow inward causing pain on the pinkie side of your wrist. Too wide and excessive weight is placed on the thumb side of the wrist. The only fix for too narrow or wide road bike handlebars is a new set, but they can be inexpensive at your bike shop, you may be able to just trade them out if your bike is a relatively new purchase, or you may be able to swap them out at a bike collective. Added bonus – you can put new fun handlebar tape on your bike while you are at it!

Speaking of re-wrapping your road handlebars; a thick, squishy foam or cork tape will provide some padding for your hands. There are also adhesive gel strips you put on the handlebars where you hold them before you wrap the bars with tape adding even more personalized padding. Your bike shop can help you with this.

Mountain bikes have grips you hold onto. All too often these are a compacted, torn mess on the end of the handlebars. These are cheap and a new set will not only be kind on your hands but may make your bike look fresh too. There are ergonomic grips made by Ergon that create a platform for your hands to rest on. Several of our dedicated bike commuting clients swear by these.

Padded Bike Gloves

Padded Bike Gloves

Adding a little padding where your hands contact the handlebars can ease pressure spots and absorb some of the vibrations. Invest in a good pair of bike gloves with padding on the palms.

Level Bike Saddle

Level Bike Saddle

If your saddle is tipped forward (and just a millimeter can cause a huge shift in your weight distribution on the bike) more of your weight will be placed on your hands instead of in the saddle. I recommend using a level to check your saddle angle.

Finally, how you hold the handlebars can exacerbate wrist pain. No Death Gripping! You should be able to wiggle your fingers, chicken-wing your elbows, roll your shoulders and bobble head your neck at all times. It sounds silly, but smiling will relaxes you into a loose position on the bike where you are securely contacting the bike so you don’t let go if you hit a blind pot-hole.

If all these simple customizations to your bike do not alleviate your wrist pain while biking, you may need help from a professional. Most bike shops have a professional bike fitter on staff who can pinpoint an error in your fit that is compromising your wrists.

And, this should be obvious, any wrist pain that is debilitating, lasts for weeks, is the result of trauma, causes numbness that does not go away shortly after you get off the bike, or simply feels like it is an injury should be evaluated by a physician.

Our business plug: At Focus Bodywork we can treat the wrists through massage therapy if there is some irritation and inflammation created from your old bike set-up, do an evaluation of your bike position and help you train to support better biomechanics through movement therapy, and diagnose wrist injuries through physical therapy. We love addressing specific problems such as bike induced wrist pain by treating your pain source AND your contributing factors to come up with a complete solution.

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Photo Diary of Injury Care

My dirt face after my bike crash

Post bike wreck grimace

By Emma Maaranen

Often I’m asked by clients, “What do you do when you get hurt?”  Unfortunately I did get hurt a few weeks ago, so I have a fresh example of what professional care I seek and what home care I perform to treat my injuries.

My Accident/Injury About a quarter mile from the finish of a mountain bike race, I took a high speed crash onto my right leg.  On impact I experienced sharp pain in my lower leg/ankle region, heard a snap and had a wave of nausea wash over me.  I rolled out of the way of chasing bikers to avoid further injury and quickly assessed my leg before the adrenaline wore off and pain set in.  Visually I was okay; there was no serious bleeding or visible

Care from the medic tent

Care from the medic tent

deformity to the injury area.  I was tender to the touch on the lateral maleoleus (the bony bump on the outside of the ankle) and along the bottom third of the fibula (outside lower leg bone).  I could put weight on my leg, but it was painful.  I performed a few orthopedic assessments to rule out ankle ligament ruptures or Achilles tendon tears (I know most readers won’t know how to do this, but if you have some special skills, you should use em’).  I knew I did not need immediate medical attention because of the lack of bleeding, or deformity, and because of my ability to move my leg and bear some weight.  I carefully got back on my bike, rolled through the finish line and into the medical tent.  The medical team repeated my assessment, decided I was just banged up, and sent me on my way with an ace bandage, ice and ibuprofen.

Icing my ankle

Icing my ankle

Immediate Self Care for my Trauma Injury I strictly follow the RICE (Rest, Ice, Compress and Elevate) protocol after any trauma.  Once home from my race I applied arnica, an herbal preparation that aids in inflammation reduction, and continued the RICE-ing through the evening.  I was confident that the injury I sustained could wait until the morning for medical attention.  It was possible that is was just really sore from impact, but I suspected that I had fractured my fibula.

Day 2 Before I got out of bed I assessed my ankle and leg again.  The swelling had increased, and bruising was apparent around my ankle and through my toes.  My ankle was stiff, but I could almost move it through a full range of motion.  Weight-bearing elicited the same level of pain as the day before.  I begin RICE-ing again and called a sports medicine clinic to schedule some x-rays this morning.

Walking boot

Walking boot

Diagnosis I had a stable distal right spiral fibula fracture.  This means: I broke the bottom third of my right lower leg. It is stable, meaning that only one structure (bone or ligament) in the ankle complex is severed, and the other structures will maintain ankle alignment so that surgical stabilization (pins and plates) are not needed to allow the bones to heal.  Because the fibula only bears about 20% of the body’s weight,  a walking boot was all I needed for added stability.  We decide to x-ray my injury again in two weeks to make sure the fracture is healing well and the ankle is still stable.

Throwing Everything Into Healing I am a believer that to heal an injury best, you need to provide it all the nutrients and support it could possibly need.  Now that I know what I’m dealing with for an injury, I can be active in my healing.

Some of my nutrition products to aid bone healing

Some of my nutrition products to aid bone healing

Nutrition Healing takes a lot of energy (calories!), this is the worst time ever to think about losing a few pounds.  I often struggle to keep weight on when I am injured because so much fuel is needed to repair tissue.

Muscle is mostly protein so I increase my protein intake to provide my body the building blocks needed to repair soft tissue.  My nutritionist recommended I increase my protein intake from 40g/day to 100g/day.  This is a lot, so I incorporate a protein shake in my daily diet to fill this need. (My favorite protein smoothie is a scoop of Vega vanilla chai protein powder blended with 1c. almond milk, 1T peanut butter, 1T cocoa powder, 1t. vanilla extract, a pinch of salt and a frozen banana.)

Bone requires minerals to rebuild.  I take a bone-specific formula that has calcium, magnesium and potassium along with other minerals needed for bone remodeling.  I also take vitamin D, which is necessary for the body to actually process calcium.  Otherwise most of the minerals you are taking pass right through you!  Just in case I’m missing some nutrient, I also take a multivitamin and fish oil.  Fish oil is high in omega fatty acids, which work as an anti-inflammatory.  In addition I take a homeopathic remedy for bone fractures (available at any holistic grocer).

Spiral compression wrap

Spiral compression wrap

Swelling When you first injure yourself, swelling runs rampant to act as a cast and stabilize the injury site.  Swelling is great at protecting the injury from movement, but the swelling actually impedes healing.  Wanting to heal fast, I put myself to the task of reducing the swelling.  RICE is the first step to swelling management.  (A  note on compression: you do not want to wrap an injury so tight that you restrict circulation.  For acute swelling I apply an ace bandage starting at my toes and spiraling the bandage up to my knee.) I also performed MLD (manual lymphatic

Kinesiotape application for swelling

Kinesiotape application for swelling

draining) therapy to my leg twice daily.  MLD is a gentle massage technique that assists the lymphatic system to vacuum up the inflammation (bits of torn cells, blood leaked from capillaries, fluid, etc.).  I applied kinesiotape in a web fashion to aid the lymphatic system and continue using arnica.

Exercise No, I wasn’t about to get a cleat fitted for my boot so I could get back on my bike, but I did need to get my heart rate up!  Yes, I was antsy to be active, but getting circulation cruising through an injury also helps push out inflammation and deliver the nutrients to where they are needed.  I headed to the pool and put a buoy between my legs so I could swim with my arms and went to my favorite Pilates class where I modified any activity that might have compromised my injury.  I also took my ankle through all its pain-free ranges of motion before I iced (which I did as often as I could).

Acupuncture to aid healing

Acupuncture to aid healing

Day 4 At this point I was out of the acute injury phase, so I could start doing some real massage therapy on it.  Daily I spent 30 minutes self-massaging all the soft tissue in my foot, ankle and lower leg.  I was able to move inflammation out, gently move the joints my foot, treat sprained ankle ligaments, address trigger points in the muscles, and drive more circulation to the healing area.  I also set up an appointment with my acupuncturist to help in pain management and aid in healing.

Day 11 I had another visit with my sports medicine doctor to make sure we did not miss any serious soft tissue injuries (torn ligaments, tendons or muscles), to x-ray my leg again to make sure the fracture is healing in alignment and to check that the ankle is in fact stable.  My doctor found that everything is looking great!  Over the next two weeks I can start adding in some stationary biking, and two weeks after that I can start weaning off my boot.  I should be back on my mountain bike in four more weeks, and my fracture will continue healing for 6 months before it is completely healed.  I will keep up my regiment of home therapy and have scheduled physical therapy and massage therapy appointments to begin in two weeks.

Every injury is different and has specific needs to heal.  I hope this “diary” entry gives you a few ideas of what you can do to heal proactively rather than just waiting for your injury to heal.  Being active in your healing process will improve your recovery and help you stay sane while you are side-lined!

Since your egg can be in only one basket, it might as well be a helmet!

Will this helmet make me faster?

Will this helmet make me faster?

By Emma Maaranen

It is spring, and after a cold and inverted winter along the Wasatch Front the bikers have taken to the streets again.  As I pedal around town running my errands, I cannot help but feel love for my fellow cyclists: the serious commuter bogged down in panniers, a hipster on a fixie, the matching-kit roadies headed up Emigration, and the mountain biker dusty from the just-dry bobsled trail.  But many of these cyclists are testing heart by not wearing helmets!  This appears to be a new trend, and it terrifies me.

I have heard all the excuses and arguments against wearing a brain-bucket. “It will flatten my hair”, “I’m just riding on the sidewalk to the corner market”, “I’m a careful rider.” I’ve even been in a debate with a guy who thinks buying and wearing helmets prevents more people form riding bikes and therefore a “critical mass” is not being reached.  A critical mass of cyclists, he believes, would change motorists driving habits thus alleviating auto/bike accidents.  I say that even a careful driver can be surprised by a cyclist from time to time, but fear of auto/bike accidents is not the only reason to don a brain bucket.

A tire puncture on a steep descent, a railroad track that grabbed a wheel, sand, ice, operator error… I have been victim to each of these, and once I walked off the sting of the ground I was able to ride home with only a rattle to my noggin and a renewed apprehension of gravity.  My ER doc friend has seen minor plops to the ground from bikes lead to concussions, traumatic brain injuries, strokes, comas and deaths that he believes a helmet would have prevented.

Some facts from the CDC (Center for Disease Control and Prevention):

* Head injury is the most common cause of death and serious disability in bicycle-related crashes; head injuries are involved in about 60 percent of the deaths.

* Many nonfatal head injuries from bike accidents produce lifelong disability from irreversible brain damage.

* Bicycle helmets are a proven intervention that reduces the risk of bicycle-related head injury by about 80 percent, yet bicycle helmets are not worn by most riders. Only 19 percent of adults and 15 percent of children use helmets all or most of the time while cycling.

Much research has been published in the past year about the long term effects of head trauma, and stories about athletes experiencing serious neurological and psychological diseases believed to be a result of repeated head trauma are surfacing.  Early onset Alzheimer disease, dementia and depression are believed to be directly related to a history of head trauma.  What’s frightening is that these diseases are turning up at high rates in athletes who experienced only a few hard head hits over their careers or who experienced many mild ones.  This is not a consequence of boxers and football players alone.  There is also evidence that brain deterioration is more profound if the individual is younger and if there are repeat injurys before the brain has completely healed.  For example, a mild (grade 1) concussion, which causes temporary amnesia but not loss of consciousness, will reduce motor control and the ability to focus while the brain is healing.  This may take up to as long as three months!  With these afflictions, the individual is at greater risk of another trauma.  Another head injury in this window is likely to have more severe symptoms and increased future consequences.

I think the new research into head injuries and especially repeat trauma may be enough to inspire any intelligent cyclist into the pro-helmet camp.  I’m going to invest in a few more helmets and see if I can start a fashion forward health trend!

The Slippery Slope to Becoming a Dope

By Emma Maaranen

I don’t think I engaged in as many conversations about Lance Armstrong when he was topping podiums daily at the grand tours of Europe as I have been the past few months regarding Lance’s illegal doping scandal.  Serious cyclists argue about the edge gained and strategies employed with doping on cycling teams, parents ponder the safety of their athlete children in professional sports, even my Grandfather debated the role of politics and economics in the celebrated athlete falling from grace, but beneath each persons rants is a little voice inside cautioning us that if we had been in Lance’s shoes we may have befallen the same fate.

Me, trying not to be passed at the finish line of a race.

I am a competitive athlete.  I systematically train for races, I have a nutritional strategy to maximize my fueling for efforts, and I spend hours reading and discussing the nuances of my sport, mountain biking.  I know that I must suck down a gel twenty minutes before the start of a race to ensure I don’t bonk at the 40 minute mark.  I know I must carefully warm-up my adductors (inner thigh muscles) to prevent cramping.  I spend extra time training technical descents at speed because they are my weakness and visualize my success on these before I go to sleep.  I am not afraid to put in the time to train and try out new things to improve my athletic success, even if they are a bit strange.  This year I read an article about a molecule found in beets that would increase vasodialation (allowing more nutrients to reach muscles faster) if consumed pre-effort and actually tried it on a training ride just to see if it might give me more sprinting power.  If it worked, the effect was negated by having to slow down for vegetal burps.  I decided to stick with the pre-race gel.  However silly as my personal guinea-pig experiments may be, I wonder if this is a healthy scientific quandary into my athletic potential or if this is the first step into logic that can lead one to think using illegal substances for sport is ok?

This May at the Grand Fondo New York several amateur riders tested positive for EPO and HGH.  These were not twenty year old semi-pro riders on the cusp of being asked onto team Rabobank, these were fifty-something Cat. 2 or lower riders in recreational cycling clubs!  They may take their sport seriously, but they can not think they will “go pro” or get some serious monetary payout for their performances. These athletes simply got caught up in trying to be the best cyclist they could be.  By their accounts, dabbling with performance enhancing drugs started in an effort to keep up on the club rides as they aged.  But the gains in speed, endurance and recovery soon put them at the lead of the pack.  This new found role was exhilarating, enough not to want to let it go.  Soon they were adding more drugs into the mix, altering doses scientifically to match training and race day needs, even lying to doctors about medical conditions to get prescriptions for banned substances.  If you stopped, would your training partners become suspicious since your performance would drop? Who would ever think to drug test a recreational cyclist? But a podium finish in this case did warrant a sample collection and the gig was up.

In a candid account by one of the dopers, it becomes clear that the motivation to start performance enhancing drugs came from a desire to maintain a competitive level that was harder and harder to maintain with age, career and family obligations, not to cheat into victory.  But once you have success, how willing are you to do what it takes to have more?

It is obvious that using performance enhancing drugs is bad.  The side effects range from increased body hair growth and tender breasts to stroke and cardiac arrest.  Being caught will ostracize you from your sporting community and may hit your bank account. But is the seduction of glory so strong that these possibilities seem minor? As an amateur, bragging rights to my friends will not be enough to tempt me, plus I’m so terrified of unknown side effects of pharmaceuticals that I avoid OTC’s.  Still, I wonder if the possibility of success on the world stage along with pressure from a professional team would tip the scales?  For Lance it seems it was.  I take this as a cautionary tale, it is a slippery slope to become a dope!

ITBS (Illio Tibial Band Syndrome) is not IBS (Irritable Bowel Syndrome), but it is Irritable

By Emma Maaranen

ITBS is a repetitive stress injury common to both runners and cyclists.  If you participate in either of these sports, either you or your training partners have likely experienced this injury.  ITBS is characterized by pain on the outside of the knee.  Unless you have experienced knee trauma recently, ITBS is most likely the sports injury you are dealing with, not a torn meniscus or knee ligament.

What is the ITB?

ITB anatomyThe ITB (Illio Tibial Band) is a long tendon (rubber-band like structure that connects muscle to bone) that runs on the outside of the thigh from the hip the knee.  The Gluteus Maximus and Tensor Fascia Latta are the muscles that connect to the ITB.  These muscles make a fan shape between the outside top of your pelvis (if you put your hands on your hips, they span from your index finger to thumb), and they narrow to the bony spot at the top outside of your thigh.  (Insert image here) The ITB starts at the bottom of this fan shape and travels down the outside of the thigh.  It then crosses the knee and inserts just below the knee on the outside of the tibia (lower leg bone). The ITB separates the quadriceps (front thigh muscles) from the hamstrings (back of thigh muscles).  If you have ITBS, pain is felt just above the outside of the knee.

How did this happen?

Most of us do sports that move forward and have little side-to-side motion with the legs.  Over time forward only motion weakens the muscles of the ITB.  To walk, run or to pedal these muscles work in a small range of motion, which trains the muscles to be strong only in a small zone and causes a loss of flexibility.  Sudden increases in training distance or intensity, as well as adding steep hills into run training, can overtax these muscles and tighten them.  This creates excessive tension in the ITB and begins to cause friction at the lateral epicondyle (the bony knob at the outside bottom of the thigh bone).  When you bend your knee about 30 degrees the ITB normally glides over this bony knob, but if it is too tight the ITB grates over it and gets irritated.  Once inflamed, the ITB becomes swollen and will grind over the lateral epicondyle more, making the condition worse as you push through the pain!

You have pain at the outside of your knee; what do you do?

The first time you experience pain at the outside of the knee it is important to end your workout.  Go home and ice the painful area.  Rest and ice for three days (no running/hiking/biking; avoid stairs and other activities that involve repetitive bending of the knee).  After three days, see how it feels.  A minor one-time irritation of the ITB should recover after this rest period, but be on notice that you need to strengthen and lengthen the muscles of the ITB.

If, however, three days of gentle care for your inflamed ITB does not alleviate the pain, you most likely have ITBS.  ITBS is a fancy tendonitis.  For it to heal, you will not only have to address the inflamed tendon, but you will have to address the cause of the excessive tension in the ITB as well.  The cause is often a combination of weak/tight ITB muscles, adhesions along the ITB to the quads and hamstrings, muscular or structural imbalances in the pelvis/hip complex, and foot/ankle biomechanics. Cyclists need to make sure they are not in excessive toe-in position when clipped in and runners should replace their running shoes if they have over 250 miles on them.

At Focus Bodywork we can help you sleuth the factors in your ITBS, address adhesions in the ITB, treat the associated muscles and recommend self-care practices.  Occasionally ITBS is stubborn and needs a physician’s care.  In these cases you may need a cortisone injection, orthotics or a regiment prescribed by a physical therapist.  We are happy to recommend some fantastic practitioners for you to work with and be a part of your return-to-play team.

In our next post we will cover self-care for ITB health.