Mountain Biking

General Principles


  • The term “mountain biking” broadly refers to riding bikes with specific design characteristics in various off-road settings.

  • Mountain bikes generally differ from road bikes in several ways: a smaller frame, stronger wheels, larger range of gears, a wider flat or upright handlebar, hydraulic brakes, suspension, and wider, knobby tires.

  • There are many riding and bike types, with some overlap between bikes and riding styles.

  • The five main mountain biking categories are cross-country (XC), trail/all-mountain (AM), downhill (DH), Enduro (essentially hybrid between DH and AM), and freeride (FR), which includes trials and urban riding (TR) ( Fig. 95.1 ).

    Figure 95.1, Mountain bike styles and characteristics.


  • Participation is open to all age groups, with the average age dependent on the type of biking; 22–36 years is the gross average, with most competitors aged between 19 and 44 years. There are more males than females, but female participation is increasing; the sport is especially popular among young males.

  • Mountain bikes are the largest category of bikes sold in US bike shops.

  • Racing/competition is now common in XC, Enduro, DH, FR, and other styles.

  • The sport attracts risk-tolerant personalities.

  • The number of noncompetitive mountain bikers is increasing; less is known about their injury epidemiology. The National Interscholastic Cycling Association (NICA), founded in 2012 in the United States and currently with individual leagues in 30 states, has led to an impressive upsurge in participation in mountain biking, primarily XC racing, in thousands of children and adolescents since its inception, both on junior developmental teams (“Devo,” grades 7–8) and high schoolers. There were 22,752 participants nationwide in 2019 alone. The NICA has developed a surveillance system for coaches, riders, and parents to report and collect injury data for high school student-athletes to improve our knowledge of injury epidemiology, especially in young riders.


  • Injuries are reported inconsistently in the literature, ranging from specific injuries to general types of injury (e.g., laceration, fracture) to injured body areas (e.g., joint, upper or lower extremity, head).

  • Early data are from competitive XC; more data are now available from all areas: XC, DH, Enduro, and FR. Although recreational data are still sparse, more large organizations and events (i.e., Enduro World Series, Olympic Games data) have begun surveillance and reporting injuries.

  • Available studies are primarily descriptive and focus mainly on epidemiology or injuries themselves (generally defined by body or joint area); there are fewer details available regarding mechanisms of injury.

  • Most injury studies have a preponderance of male participants (75%–80%). Many studies depend on victim recall.


  • XC still popular, but a shift to Enduro, DH, and other events is being seen.

    • The origin of NICA has led to the addition of a number of high school races (XC) in participating leagues

  • Categories are established based on age, gender, and rider skill.

  • Rider skill categories were changed in 2009 (applicable to riders 15 years of age and above): Pro, Category 1 (previously Expert), Category 2 (previously Sport), and Category 3 (previously Beginner); previous riders classified as “Semi-Pro” must choose between the new Pro or Category 1 tiers. Some races still use classification categories of novice/beginner, sport, expert, and elite/pro.

  • Age categories: Youth (<10 years old), Junior (10–18 years old), Under 23 (19–22 years old), Senior (23–29 years old), and Master (>30 years old)

Protective Equipment

  • Protective torso armor and extremity padding: Primarily for FR and DH; use of lighter, flexible pads increasing in XC

  • Helmet designs: Full face (mainly DH, FR) and standard (mainly XC, Trail/AM); helmets should be Snell-, Consumer Product Safety Commission (CPSC)-, or American National Standards Institute (ANSI)-approved and tested. Recommend replacement after any significant crash.

  • Shorts: Multiple types of synthetic moisture-wicking chamois; some have built-in hip padding; loose-fitting shorts with inner chamois are becoming more popular

  • Gloves: Varying thickness, with shell protection (dorsal fingers and hand) and padding

  • Eyewear: Ultraviolet protection, shatterproof, changeable light-reducing and colored lenses for varying conditions; clear lenses for night/low light riding; goggles in DH and extreme cold

Mountain Bike Fit

  • May start with a professional fit (see Chapter 94 : “Road Biking”).

  • Mountain bike fit not as straightforward as road fit; use the initial road fit to help achieve a mountain bike fit window (an ideal, individualized fit that may deviate slightly from a virtual perfect fit).

  • Correct fit important for prevention and treatment of acute and chronic injuries

Mountain Bike Fit

  • Directly applicable to overuse injuries, indirectly to acute traumatic injuries

  • A static bike fit (using a standardized bike fit system) is a good place to start in order to identify a neutral position as a starting point for individualized adjustments.

  • Dynamic fit is better than static because of better individualization and customization; digital video and anatomic markers are sometimes used.

  • Experienced physician’s office or a high-end bike shop will offer help with fit customization.

  • Important to note that riding position and repetitive forces remain relatively constant in road cycling, but mountain bikers frequently change rider position while riding over varied terrain; leads to broader, less repetitive forces

  • Fit adjustments for a mountain bike follow the same order as a road bike: frame size, saddle height, saddle fore-aft (to establish neutral knee), saddle tilt, reach and stem/handlebar height. Keep in mind that changing one usually affects the others. Various fit guide tips are available online.

  • Frame size for a mountain bike is likely smaller than that for a comparable road bike, depending on riding style.

    • Top tube should have 3–6 inches clearance with standover (applicable with nonsloping or minimally sloping tube) (shoes on).

    • Mountain bike inseam method: (____ cm inseam × 0.67) × 10–12 cm = ___ − ___ cm frame size (shoes off).

    • Mountain bike frame designs vary broadly, so check specific seat tube and top tube lengths; top tube length is more important than seat tube length (the latter is more adjustable) with mountain bike fit; frame angles and suspension type and design must be factored in because they will affect resultant ride.

    • Take measurements and frame angles from a previous mountain bike that fit well; sometimes difficult to transfer over because of variations in frame, suspension designs, and geometry

Rider Area Distance (Rad)

  • RAD = distance between center of bottom bracket and grips ( eFig. 95.1 )

    eFigure 95.1, Rider–bike–terrain interface.

  • Likely the most important single measurement for mountain bike fit

  • Probably best measurement to determine overall frame size

  • Helps avoid purchasing a bike that is too large, which is common, even with local shop recommendations

  • Allows optimal range for overall bike handling and generating power/torque

  • RAD is the hypotenuse of a triangle made up by the reach and stack of your cockpit, from the bottom bracket to your grips, and includes (see eFig. 95.1 ):

    • Frame reach

    • Frame stack

    • Height of spacers under stem

    • Tallness of stem’s steerer clamp

    • Handlebar rise

    • Handlebar setback: the horizontal distance from the stem clamp to the grip

  • Two ways to determine RAD quickly:

    • Measure its RAD on a current bike if it fits you well and try to match that number when you purchase or set up a new bike.

    • Use a simple multiplier. Calculation assumes average proportions, appropriate handlebar width, height-appropriate crank length, and average pedal and shoe thickness. Use as starting points for setup.

      • Male: multiply height in centimeters by 4.47

      • Female: multiply height in centimeters by 4.60

Saddle Height

  • Many mountain bikers lower seat at least 1 cm from a road riding position to increase control, assist with steep climbing, and to allow easier dismounts; can measure crank arms and lower the seat by an amount equal to the difference in crank arm length between the mountain and road bike (e.g., mountain, 175 mm, road, 170 mm; therefore, lower mountain saddle by 5 mm).

  • Quick-adjust drop seatposts are now popular (riders often drop post before the downhill section after a long climb): a lower saddle is more maneuverable and controllable (DH and FR); higher achieves more aerodynamic position (XC racing).

Saddle Fore-Aft

  • A plumb line or level dropped from the inferior pole of patella with the pedal at 3 o’clock (forward, parallel to ground) should bisect the pedal axle (some perform the drop behind the crank arm, in which case it should bisect the center); make sure suspension sag set appropriately.

  • Long climbs: some mountain riders prefer to set seat back from this position to increase rear wheel traction and leverage (especially if pushing large gears)

  • Sprinters: some prefer forward cleat position; neutral is safest

  • Seatpost: standard (clamp on top of post) or setback (clamp rearward from top of post) available

  • Do not use fore-aft setting to compensate for improper reach

Handlebar Width

  • Male: multiply height in millimeters by 0.440

  • Female: multiply height in millimeters by 0.426

  • Bars tend to be wider for Enduro and downhill; narrower for cross-country; individual preference varies

  • Rise/upsweep and setback/backsweep should all be taken into consideration

  • RAD calculation helps determine starting point, which can be adjusted by feel

Reach And Stem/Handlebar Height

  • Most individualized part of mountain bike fit; style of riding will affect adjustment/setup significantly

  • Initial reach should be set so that torso is 45 degrees to ground; reach typically more upright than in road cycling; influenced by riding style, flexibility, and comfort

  • RAD calculation is also a good way to determine best reach

  • Longer reach and lower drop for competitive XC riders; shorter and higher to achieve a more upright posture for novices and for certain riding styles (e.g., DH, FR, DJ)

  • Reach is affected by stem length and angle, flat or upright handlebars, top tube length, saddle fore-aft position

  • Handlebar and stem heights are adjustable: initial steerer tube length (determined by cutting initially long tube; take care not to cut too short), spacers between headset and stem, stem angle, and handlebar type (flat or upright, width, sweep)

  • Handlebar width: grips initially set at or wider than shoulder width; a narrower setup increases steering responsiveness; a wider setup increases stability and leverage


  • Various suspension settings combined with a broad range of frame designs can make the initial setup challenging; settings may include sag, preload, rebound, and/or compression damping, as well as pedal platform adjustments.

  • Sag: amount that the travel suspension compresses with static body weight over it. Preload: the amount of initial spring compression, which controls when the spring begins to move.

  • Less preload = more sag; more preload = less sag

  • Sag is set by placing the bike on a trainer, starting with no preload or the easiest valve setting and recommended air pressure, having the rider gently climb on bike to weight suspension, placing a zip tie around shock stanchion, and measuring the amount it slides (percentage of total suspension travel in mm) with rider weight; add or remove air pressure or change preload setting to achieve ideal.

  • General sag recommendations: XC racers: 12%–20%; DH racers: 30%–40%; recreational cyclists: 20%–30% (see manufacturer’s manual or discuss with a bike shop professional for variations)

Shoe–Cleat–Pedal Interface

  • FR, TR, and DH use platform pedals with studs or “pins” that dig into flat shoes, this setup can cause significant pretibial and other soft tissue injuries if feet slip off pedals; DH (especially during competition) cyclists often uses clipless pedals, but some use platform or hybrids.

  • XC uses clipless (mini ski binding) with adjustable release spring; clipless mechanism and platform size vary.

  • Cleat placement is adjustable fore/aft, medial/lateral, and rotationally; usually with two Allen screws attaching to shoe.

  • Foot moves opposite of cleat adjustment.

  • Initial cleat placement so that ball of foot (metatarsal heads) directly over pedal axle.

  • Rotational “float” (amount of allowable rotation on pedal before release) varies with clipless pedal designs: Shimano and most other SPD-type (≤4 degrees) have less float than Time ATAC (approximately 5 degrees), Crank Brothers Candy, Eggbeater (approximately 6 degrees), or Speedplay Frog (20 degrees “free float”).

    • The ideal amount of float varies with terrain and the biomechanics of the rider–bike interface and must be individualized; less float results in more power, whereas more float results in increased muscle work to maintain foot stability on the pedal, but more versatility for small adjustments over rough terrain.

    • Set the initial rotational cleat position (center of float; toe-in, neutral, or out) to individual foot mechanics: may estimate by observing foot rotation of the rider sitting on a table with legs dangling (hip and knees at 90 degrees, ankles at neutral, have rider bend forward to see if affects foot position), or may determine more exactly using rotational adjustment device.


  • Mountain bike shoes: less stiff than road, more traction on sole (can interfere with clipless mechanism), hybrid hiking-clipless shoes available (some ultraendurance riders use because of significant time spent hiking off bike)

  • Crank arm length: mountain bikers use long levers, 170–175 mm is typical

  • Cycling orthosis and anatomic footbeds:

    • Extend through metatarsal head where force transfer occurs

    • More rigid than running orthotics to provide better control and force transfer (with varying foot orientation on pedal)

    • Anatomic footbeds often incorporate a varus wedge to accommodate a canted forefoot position, longitudinal arch support to optimize force transfer, and a metatarsal button to minimize nerve and vessel compression at metatarsal heads with pedaling

  • Shims, medial (varus) wedges, and spacers:

    • Make adjustments to longest leg first.

    • Shims: if leg length discrepancy (LLD) is more than 6 mm, use shim (especially with back and knee pain); between 3 and 6 mm, it is possible to simply move the cleat on the long leg back and/or the cleat on the short leg forward 1–2 mm; also possible to combine shims and cleat position adjustments (especially for femoral-based LLD)

    • Commercial wedges, biowedges, or custom wedges available (use material with minimally compressibility and high torsional rigidity)

    • Threaded spacers better than washers to achieve ideal stance and accommodate varus knee malalignment; placed between pedal and crank arm

    • May correct femoral LLD using combination of shim on shorter leg and cleat position

  • Rider–bike–terrain interface: See eFig. 95.1 for factors and components to consider with bike fit and terrain goals.

Physiology And Training


  • High-intensity sport—generally higher (especially XC) than road stage races

  • XC circuits span 1–2 hours (depending on age/racing category), performed at a heart rate (HR) of approximately 90% (±3%) of HRmax, corresponding to a
    V ˙
    O 2 max of approximately 84%; more than 80% of race time is spent above the lactate threshold (LT).

  • Intensity is related to a fast start, several climbs, rolling resistance, and isometric and eccentric arm and leg muscle contractions that are required for shock absorption, bike handling, and stability over rough terrains (increases HR response to submaximal cycling).

  • Start has fundamental importance to the entire race. XC races are generally on single track (narrow trail where only one biker could fit); however, typically start on a wider course (either paved or dirt road) and race to the single-track portion to achieve a good position; fast starts and early steep climbs lead to high intensity and HRmax early in the race.

  • Anaerobic energy systems taxed, especially during steep climbs (require high power output: up to 250–500 watts); anaerobic power and ability to sustain high work rates for prolonged periods are prerequisites for competing in high-level off-road cycling events.

  • Various factors may affect off-road XC performance, especially in elite cyclists:
    V ˙
    O 2 max, peak power output (PPO), power output (PO), and
    V ˙
    O 2 at the ventilatory threshold (VT) and at the respiratory compression threshold (RCT); studies are conflicting regarding which is most important:

    • PO and
      V ˙
      O 2 at the RCT normalized to body mass are predictors of off-road performance times.

    • V ˙
      O 2 max, PPO, and LT normalized to body mass correlate with XC performance in some studies.

    • PO at the VT may correlate with time trial performance.

  • Body mass is a factor: power-to-weight characteristics are important for success in off-road events; high power-to-weight ratio is good for strong hill climbing ability; higher mass may assist with rapid descents.

  • Factors other than aerobic power and capacity may affect off-road cycling performance: cycling experience and economy (specificity of principle); technical ability; and nutrition before, during, and after competition.


  • Need to develop good aerobic endurance, anaerobic capacity, overall muscle strength, good coordination, balance, and bike-handling skills.

  • Significant upper body and core muscular strength is necessary for repeated isometric and/or eccentric muscle contractions required to absorb shocks and constantly adjust to changing terrain; accomplished using weight training and riding off-road.

  • Many competitive XC riders train for 10–14 hours weekly; some XC racers train systematically in a similar fashion to road racers. Others train with much less structure.

  • Athletes ride at varying aerobic and anaerobic intensities (zones); it is helpful to use an HR monitor.

  • Mountain bikers train both on- and off-road.

    • Use different types of training in a similar manner to other endurance events (listed in order of decreasing intensity): race pace, intervals and hills, speed and tempo, endurance, strength, and recovery.

    • Training cycle (depends on peaking goals): base (4 months), intensity (4 months), peak (4–6 weeks), racing (8–12 weeks), or recovery (4–6 weeks).

    • Off-road terrain incorporates various training types and is less flexible than road riding under controlled intensity.

    • Long off-road rides over rough, technical terrain, especially if at altitude, require longer recovery compared with equidistant road rides.

    • Use periodization and monitor overtraining, especially if training at high altitude and/or frequently on rough terrain.

    • More injuries reported during training than during competitions, where there is less access to medical personnel and treatment.

Injury Overview


  • Injury types and numbers likely grossly underreported secondary to varying and limited study design, difference in injury definitions, understudy of a large population of recreational and noncompetitive aggressive riders in all styles.

  • Peak incidence: June to August

  • Mixed competition and noncompetition data indicate that 50%–90% of riders have been injured in the previous year; one study showed 20% had a significant injury requiring medical attention and were prevented from cycling for at least 1 day; competitive cyclists were injured more than recreational cyclists in earlier studies, but unclear if this still reflects the current trend.

  • Reported injury rates (multiyear data) is as low as 0.45%–0.6% per year in XC, DH, and DS competitions; 0.30% injury rate for recreational cyclists, but some reports are higher; definition of injury rate may vary (e.g., number of injured cyclists per number of starts per 100; number of injured cyclists per 100 hours of race time).

  • Injury rates are greater for DH versus XC relative to time spent on bike (0.37 injuries per 100 hours on bike for XC vs. 4.34 injuries per 100 hours on bike for DH).

  • There is a possible association between increased hours on bike and injury severity, but some data indicate the presence of fewer injuries in competitive cyclists who spent 1 hour per week more on the bike during the competition season and 3.5 hours per week more on bike during the off-season compared with those who experienced major injuries.

  • A large study with 2029 competitive Enduro riders showed an injury rate of 8.9% in 10 events; almost a third of the injuries occurred in inexperienced riders (those who only raced one previous Enduro World Series event).

  • Cannot extrapolate injury data from road bikers because road bike crashes are often specific to riding on pavement; many more collisions with motor vehicles, which is rare in off-road cycling (a few case reports of serious injury resulting from mountain bike–motor vehicle collisions do exist)

  • Experienced cyclists injure bones and joints more frequently than beginners.

  • Injuries tend to occur when riding downhill or losing control. Professional DH racers are more likely to sustain injuries than amateurs.

  • Young males are the most frequently injured population because of the popularity of the sport in this group and the likelihood to engage in aggressive and technically demanding riding styles.

  • In high school riders, most common injured areas include head/brain, wrist/hand, shoulder, and knee (in order).

  • Injury risk in competing females appears higher than in males, but injury severity is higher in males than in females.

    • Risk factors in females: loss of bike control, poor upper extremity strength, fewer riding years

  • The number of injuries occurring during racing and training are about equal, but traumatic injuries are more common in races, whereas overuse injuries are more common in training.

Mechanisms of Injury and Risk Factors

  • Most commonly reported: excessive speed, unfamiliar terrain, loss of control (encompasses multiple factors), inattentiveness, riding beyond ability, and riding DH, slippery terrain (approximately 90% may be viewed as errors in judgment) ( Table 95.1 )

    Table 95.1
    Specific Reported Causes and Risk Factors
    Rider-related Errors in judgment and riding technique
    Excessive speed
    Riding beyond ability and loss of control
    Incorrect braking
    Improper training and overtraining
    Female or young male
    No helmet; especially children
    Bike/equipment-related Mechanical failures (more common in DH): flat tires, brakes, chains, forks, handlebars, pedals, suspension parts, seatposts, frames
    Improper fit
    Terrain-related Surface: mud, gravel, loose dirt, wet
    Obstacles and jumps
    Environment-related Competition
    Orienteering mishaps
    Animals and reptiles (attacks and collisions)

  • Most crashes occur while riding DH.

  • Injuries from loss of control, loss of traction, and mechanical failure result in similar injury patterns.

  • Special attention is applied to the cyclist–bike–terrain interface and how it relates to injuries.


  • Forward fall over handlebar (“endo”)

    • Most common direction of fall and mechanism of acute traumatic injury

    • Common causes: rapid deceleration during downhill descent (most common cause of severe injury), hitting an object, improper jump landing, improper braking

    • Reported injuries: soft tissue injuries and trauma to head, torso, shoulder, upper extremity; head, neck, and face injury

  • Side falls

    • Common causes: sliding out around corners (sideslip), misjudged handling resulting in tipping over, dabbing of hand after losing balance in technical terrain

    • Reported injuries: mainly soft tissue injuries; leg injuries, especially to knee and ankle; some upper extremity (reaching out or a fall on elbow or lateral shoulder)

  • Rear falls

    • Common causes: forceful wheelie, preloading (compressing suspension) to adjust for change in terrain, jumping too early

    • Reported injuries: soft tissue, upper extremity (especially hand and wrist), head, spine and torso, tailbone


  • Other cyclists (common in XC/AM)

  • Stationary object (trees or rocks)

  • Bike parts; especially bar, stem, and pedals; frame, brakes, and seat less common

  • Animals (prairie dogs and other)

  • Injuries from collision and noncollision similar in severity and anatomic location

  • One reported fatality in 2015 from blunt force trauma to the chest in an Enduro event



  • Acute traumatic injury typically requires no specific history other than fall mechanism, whereas specific historical features are more useful when evaluating overuse injury.

  • Review athlete training history to detect common errors (e.g., volume, intensity, hill work, periodization).

  • Bike fit history (professional vs. self)

  • Experience, type of bike and riding, type of terrain and challenges

  • Helmet and other protective equipment use


  • Use stationary trainer in the office for overuse and fit issues (dynamic evaluation); consider use of digital video.

  • Evaluate on and off the bike. Identify anatomic variations or malalignments (e.g., excessive knee valgus, LLD) and errors in bike fit; adjust rider; evaluate shoes and orthotics if used.

  • Helpful tools: bike trainer, plumb line, long carpenter’s level, laser level, goniometer, suspension pump, zip ties (for sag settings), Allen wrenches and screwdrivers (for quick office adjustments)

General Treatment

  • General treatment approaches for traumatic and overuse injuries in off-road cyclists are similar to approaches used with other athletes (e.g., physical therapy, cryotherapy, antiinflammatory medication).

  • Specific cycling injury diagnosis and treatment is a highly individualized area; affected by multiple variables, including training, experience, riding style/type, and bike fit.

  • Treatment options

    • Relative rest and activity modification: temporarily decrease mileage, intensity, hill work; spin using low-resistance and high-cadence pedaling; correct training errors.

    • Bike fit: consider placing rider back to neutral position, especially if bike was never fit; adjust from there

    • Medication: nonsteroidal antiinflammatory drugs (NSAIDs) for analgesia and inflammation, bacitracin ointment for soft tissue trauma

    • Heat and ice: ice appropriate overuse injuries after rides and intermittently throughout day; keep the affected joint warm during ride (e.g., knee warmers)

    • Physical therapy (see specific injuries)

      • Lower extremity (especially hamstring, iliotibial band) flexibility

      • Back and neck flexibility

      • Strengthening: lower extremity (eccentric programs for Achilles, patellar, and hamstring tendinopathy), dynamic core stabilization

      • Plyometrics, proprioceptive, and other cycling-specific coordination training

      • Deep tissue massage and release techniques

      • Neural stretching maneuvers

    • Bracing, strapping, or taping where appropriate

      • Knee: soft patellofemoral brace, infrapatellar strap, McConnell taping

      • Hand and wrist: use an off-the-shelf wrist or thumb spica splint (can bend steel stay to handlebar, most cycling gloves fit over), custom-molded orthosis (e.g., Orthoplast)

    • Corticosteroid injection

      • Upper extremity: carpal tunnel syndrome, de Quervain tenosynovitis, intersection syndrome

      • Lower extremity: pes anserine bursitis, trochanteric bursitis, iliotibial band syndrome, Morton neuroma

Specific Injuries

  • Injuries are divided into overuse, acute traumatic, and environmental.

Overuse Injuries


  • Retrospective questionnaire surveys indicate 45%–90% of mountain bikers have had an overuse injury in their career.

  • Body regions most commonly involved (in order): knee and low back, hand, wrist, neck, and buttocks/saddle region

  • Likely grossly underreported: poorly studied

  • Many studies only capture injuries resulting in lost time on bike; this would exclude many overuse injuries

  • Bike fit is closely linked; interaction between cyclist, bike, and terrain. See Table 95.2 for bike fit problems for common chronic injuries.

    Table 95.2
    Common Modifiable Bike Fit Problems Based on Common Chronic Injuries in Mountain Bikers
    From Ansari M, Nourian R, Khodaee M. Mountain biking injuries. Curr Sports Med Rep . 2017;16(6):404–412.
    Injury/Interface Saddle/Buttocks Handlebar/Hand Foot/Shoe/Pedal
    Neck pain Improper saddle tilt, too high Long stem, low handlebar NA
    Ulnar/median neuropathy Forward tilt, too aft Low or narrow handlebar, thin grip NA
    Chronic LBP Improper saddle height, fore/aft, tilt Low handlebar NA
    Genitourinary complaints Improper saddle height, fore/aft, tilt Long stem, low handlebar NA
    Patellofemoral pain syndrome Seat too low, fore NA Hyperpronation, improper cleat positioning, cleat valgus tilt
    ITBFS at the knee Seat too high, aft Low handlebar Hyperpronation, improper cleat positioning, and tilt, excessive float
    Quadriceps/infrapatellar tendinopathy Seat too low, fore NA Hyperpronation, improper cleat positioning and tilt, excessive float
    Achilles tendinopathy Too low NA Hyperpronation, posterior positioning, excessive float
    Metatarsalgia NA NA Cleat position too forward; shoe too narrow
    ITBFS , Iliotibial band friction syndrome; LBP, low back pain; NA, not applicable.

  • Anatomic variations and fit errors (even by a few millimeters) are magnified by many hours of training and cumulative repetition, especially in the lower extremity

  • Upper extremity injuries related to weight distribution over the front of the bike and are affected by bars, bar ends, grips, and stem height relative to saddle; also related to shifter type and front suspension (travel, preload, rebound)

  • Causes and risk factors: excessive training/racing, improper training progression (e.g., sudden increases in mileage or riding intensity, climbing too many hills during the early season, inadequate recovery), improper fit, too many different types of riding, too much rough terrain, anatomic variations and faults, incorrect saddle position (dynamic), insufficient stretching, incorrect gear ratio (pushing large gears too much, especially during the early season), not enough warm-up, wrong shoes, inadequate preseason conditioning, cold weather

  • Treatment and prevention focus on training and fit.

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