Without peeking at the next paragraph, quickly answer this question: which part of the body is the most frequent site of injury among cyclists? If you answered “the leg”, or “the knee”, or even “the wrist and forearm” (a particularly decent answer since the wrist and lower part of the arm are often used to brace bicycle falls), you would be in good company: many cyclists believe that those are the most vulnerable parts of their anatomy. However, the answer is... the face! Recent research indicates that about 20% of all cycling injuries occur to the face (“Sports Causing Most Injuries in Hong Kong,” British Journal of Sports Medicine, Vol. 27(4), pp. 263-267, 1993). This is quite different from football, basketball, volleyball, and long-distance running; in these sports, the knee and ankle dominate the injury-occurrence list.
Cycling differs from the other four sports in another key way: in cycling, there are about twice as many upper-limb injuries, compared with lower-limb ones, whereas in football, basketball, volleyball, and running the lower-limb injuries dominate. Interestingly enough, one of the most common upper-limb injuries in cycling is something called “handlebar palsy”.
Also known as ulnar neuropathy, handlebar palsy is actually an inflammation of the nerve that runs along the entire length of the arm to the hand. This nerve, which is also known as the ulnar nerve, provides for both movement and feeling in the arm and hand (e.g., it possesses both a motor and sensory function).
So why does this nerve have a tendency to become irritated during cycling? In general, the ulnar nerve becomes inflamed, usually either at the elbow or the wrist, when it has to absorb vibration and shock transmitted to the arm via some apparatus or tool (it can also flare up when the hand and arm are maintained in a fixed position for a long time). In the case of cyclists, shock and vibration are transmitted directly from the handlebars to the arms – and to the ulnar nerves in each arm, raising the risk of ulnar neuropathy.
As you might expect, the frequency of handlebar palsy has increased dramatically as mountain bikes and off-road cycling have become more popular (since mountain-bike riding and off-road cycling tend to take place on fairly rugged or at least uneven terrain, the amount of shock and vibration passing through the handlebars increases, putting extra stress on the ulnar nerve). However, bumpy surfaces are not the only cause of ulnar pain. Evidence suggests that improper adjustment of the bicycle to the size and anatomical characteristics of the rider may make handlebar palsy more likely. Basically, ulnar distress is more likely to occur if the handlebars are too low relative to the height of the saddle. In addition, if the front of the saddle is tilted downward, thrusting body weight forward on to the hands and arms, or if the bicycle frame is too large for the rider, necessitating a stretch to reach the handlebars, the risk of handlebar palsy increases significantly (“Handlebar Palsy,” (Online). Available at www.esportmed.com).
Cyclists experience different kinds of discomfort in their upper limbs, so how can they be sure that handlebar palsy is the reason for their distress? Basically, symptoms of handlebar palsy include tingling, numbness, or pain on the outside or middle of the forearm; this sensation of discomfort may run all the way to the little finger. It’s important to note, too, that during early stages of the injury symptoms might be limited to tingling (the familiar “pins-and-needles” sensation) while riding with drop handlebars; this distress should disappear if one removes the hands from the lower position on the bars. If ignored, however, the tingling can rapidly progress to numbness and intense pain. In fact, the pain can be sufficiently intense to prevent cycling altogether, except for pedalling a stationary bicycle without placing the hands on the handlebars. Handlebar palsy should never be taken lightly: in severe cases which go untreated, the ulnar nerve may become compressed due to swelling of surrounding muscles and connective tissues, and its ability to transmit messages to the muscles of the forearm may be significantly reduced. The result is a loss of strength in the muscles of the hand, often first reflected in an inability to spread the fingers.
Naturally, if you think you are developing handlebar palsy, you will want to get a confirming diagnosis from a health professional. Your doctor should take a detailed history of the development of the injury and should examine your neck, the affected arm, and the shoulder on the same side. She/he should check your grip strength (remember that grip strength tends to weaken as handlebar palsy progresses), and your doctor may also want to complete a nerve-conduction study and/or electromyogram to determine whether your ulnar nerve is providing adequate stimulation of the muscles of the forearm and hand. Don’t be alarmed by the fact that both the nerve-conduction study and electromyogram require that electrodes be placed either on the surface of your skin or just under it in the form of tiny needles. While the electromyogram measures nerve impulses, the nerve-conduction test assesses the rate, strength, and frequency of nerve impulses sent down the ulnar nerve to the muscles of the forearm.
The bad news for cycling addicts is that if handlebar palsy is present, it is really best to refrain from cycling until symptoms disappear. Of course, this may be impractical for professional cyclists, as it would be for pro tennis players, golfers, cricketers, or baseball players, who also are at risk for handlebar palsy (even though no handlebars are apparent in their sports). If an athlete must continue to participate in his/her sport, wrist and forearm splints may be prescribed and fitted by a doctor or sports therapist.
“In most cases, if a cyclist refrains from cycling and receives appropriate treatment, the inflammation and pain will disappear within two to four weeks”
Naturally, non-steroidal anti-inflammatory drugs may be prescribed, and wearing padded gloves and fitting the handlebars of the bike with extra padding may be helpful. Some physicians may prescribe B-complex vitamins in hopes of reducing inflammation of the ulnar nerve, but there is little controlled scientific research to support this practice. Surgical intervention is also a possibility: the goal of such surgery is to re-position the ulnar nerve so that it is under less pressure during cycling (or during the swinging of a cricket or baseball bat, tennis racket, or golf club). One bit of good news is that handlebar palsy usually does not last as long as other inflammatory conditions, such as Achilles tendinitis or plantar fasciitis, for example. In most cases, if a cyclist refrains from cycling and receives appropriate treatment from a doctor, the inflammation and pain associated with handlebar palsy will disappear within two to four weeks. Unfortunately, however, cases lasting as long as eight weeks and longer are not unknown. In many cases, these lengthier recovery periods are observed in athletes who attempt to return to cycling too quickly; returning to full activity before all symptoms of handlebar palsy are gone is definitely a bad idea, since it retards recovery and also invites a more serious condition which might require surgery. It’s also important to note that the recovery time from handlebar palsy can vary significantly among individuals; just because your cycling friend is fully recovered in two weeks, that doesn’t mean that there is something wrong with you if your symptoms persist longer. In all cases, return to full activity depends on how long it takes for the inflammation of the ulnar nerve to subside.
As mentioned, full participation in cycling training and competition should be delayed until symptoms of handlebar palsy disappear (as indicated, this ordinarily takes from two to eight weeks). In reality, however, partial return to activity is sometimes achieved earlier – without hindering recovery. For example, a cyclist suffering from handlebar palsy might continue to cycle in an upright position which does not require body weight to be supported by the hands, wrists, or forearms (on a stationary cycle, for instance). A baseball or cricket player could practice fielding skills, a golfer could work on putting (as long as it is not painful), and a tennis player could even hit some light ground strokes, provided pain did not appear.
If you are a cyclist suffering from handlebar palsy, remember that other activities can do a good job of maintaining your cardiovascular fitness during your non-cycling recovery period. Running, swimming, stair climbing, and upright cycling on a stationary bicycle (without using the handlebars) should all be effective. The goal in such workouts is to attempt to achieve a relatively high intensity of training, rather than a high volume, since intensity is both the best producer and maintainer of fitness. Be aware, though, that cyclists who do not have a running “history” are prone to running-related injuries if they make a steep plunge into that sport. It is best to start with just two modest running workouts per week and to gradually augment the frequency and intensity of these training sessions.
If you have had some “pins and needles” in your forearms in the past but no clear handlebar palsy and you would like to prevent the injury in the future, what should you do? First, remember that handlebar palsy is clearly caused by overuse, e.g., doing more cycling than your ulnar nerves can stand. The best way to prevent this, then, is to understand exactly how much training your ulnar nerves can stand. Beyond that, however, careful attention should be paid to specific factors which increase the risk of handlebar-palsy problems. Specifically, it may be a good idea to have a professional evaluate your position on the bicycle and make adjustments to assure that your weight is not too far forward and supported excessively by the hands on the handlebars. You should definitely wear padded gloves and consider the addition of padding to your handlebars. During prolonged cycling, it is important, too, to shift the position of your hands regularly and to not stay in the fully “down” position for more than 10 to 15 minutes at a time. If you are a baseball player, cricketer, golfer, or tennis enthusiast, a professional can help you identify flaws in your swing which may be putting undue pressure on your ulnar nerve.
To prevent handlebar palsy from occurring, it makes sense to increase the strength of your forearms and the range of motion of your wrists. The exercises described below, which can be completed three to four times per week, increase the strength of the forearm muscles, but they should not be performed if they produce significant pain. Additional resistance should be added only when the exercise can be performed for the designated number of repetitions with no discomfort.
The next two exercises help to increase the range of motion of the wrist. They should be performed to the initial point of pain only.