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Thomsen, L. The Relationship Between Postural Asymmetry and Cycling Injuries: Part I. Performance Cycling Conditioning. 2007:3(13).
(Lori Thomsen, MPT, PRC

The Relationship between Postural Asymmetry and Cycling Injuries

Introduction

Wedges in cleats, adding padding to the right saddle and modifying bike fit are current trends to assist with postural mal-alignment in cyclists. Cycling is a sport that requires a person to maintain a postural position for hours during a normal workout. The average cyclist will perform 80-110 rpms per minute. If you take this coupled with the repetitive position that cyclist’s workout in, injuries will result. Common injuries include pain found in the neck, IT band, knee, low back and feet. If the body is not in the right position with normal sitting, standing, and walking activity how will it be in the right position sitting on a bike? This article will assist cyclists in preventing injury by discussing postural symmetry of the body prior to getting on a bike.

Cyclist Patient Example

A regionally competitive 34-year old cyclist who rides 200-350 miles per week came to physical therapy with complaints of pain in his left knee, left TFL, and low back along with reported pain in his right side with difficulty breathing during hard workouts and performances. During pedal stroke he noticed that his hip bones did not sit evenly on his seat and he was “losing power”. He also noted that he was pushing off through his right leg only. He also experienced dramatic changes in his running form and wear on the outside soles of his shoes with the right greater than the left. Two years prior to the onset of symptoms, he switched bike positions to extreme forward aft seat position.

Physical therapy assessment of this patient found that he had postural mal-alignment. He demonstrated a forwardly rotated and anteriorly tipped left pelvis along with incorrect mechanics of his upper body which contributed to ineffective “belly” versus diaphragmatic breathing. This will be a three part series. The first part will discuss the physical therapy findings and an explanation of pelvic asymmetry. The second will discuss the importance of diaphragmatic breathing and its vital role with postural restoration along with the physical therapy assessment. In part three the treatment and patient results will be explained.

Upon initial visit the patient demonstrated these objective findings:
1) Adduction Drop Test: positive on the left (Figure 1A) and negative on the right (Figure1B)
2) Extension Drop Test: positive on the left (Figure 2A) and negative on the right (Figure 2B)
3) Straight Leg Raise: 75º on the left with 90º being ideal
4) Leg length: left leg longer than the right by 1/4 inch
5) Inability to stand on his left leg with his pant zipper (pubic bone) going over his left big toe.
6) Wear pattern of his saddle: dramatic wear on the right versus the left.

When considering the above findings, it is common for the injured cyclist to be advised in stretching their IT band, hip flexor, and hamstrings, and to use a heel lift in the right shoe. However, stretching and heel lifts are most effective when considered following an assessment of muscle position as improper position can be an underlying cause of symptoms. Using a Postural Restoration approach, the pelvis is repositioned prior to evaluating the need for a stretching program.
Postural Asymmetry

A common pattern exists in everyone that contributes to pelvic asymmetry. How people compensate for this pattern can vary, however, the underlying dominant pattern exists in all humans. This asymmetrical pattern has been identified as early as 1914 and has further evolved with the clinical experience of Ron Hruska, MPA, PT through the Postural Restoration Institute™. Everyone favors their right leg. Whether left or right handed our right leg is dominant. We have a liver on the right side of our body that weights approximately three to four pounds and on the opposite side we have a spleen that does not even weigh a pound. We have three lobes of our lung on the right and only two on the left. In our upper trunk, we have a heart that lays more to the left. This organ asymmetry coupled with gravity and environmental factors result in a tendency to stand on our right leg and rotate our upper body to the left. Consider how the world is set up to reinforce this asymmetrical body. When we cycle or run around a track which way do we go? Counterclockwise. When we grab a grocery cart to shop which way do we go? Counterclockwise. When a Checker scans our products at the grocery store which way is it done? Counterclockwise. Always pushing off a right leg and rotating your upper body to the left.

Now take into consideration that the majority of people are right handed. They reach with their right hand for the phone, toothbrush, refrigerator, etc reinforcing the weight shift to the right and upper trunk rotating to the left. Even some left handed people, bat, golf, and throw right handed. The tendency to favor our right leg and rotate our upper trunk to the left with everyday tasks is overwhelming. Organ asymmetry, a counterclockwise world and right handedness reinforce this neuromotor right dominant pattern. The result of this right dominant pattern is a pelvis that is forwardly rotated and anteriorly tipped on the left and a trunk that is rotated to the left.

Do not misunderstand that standing on the right leg and rotating the upper body to the left is wrong. This neuromotor right pattern is half of walking, stair climbing, and cycling. However, the inability to stand on the left leg and rotate your upper body to the right creates imbalance throughout the body. This imbalance affects joints, bones, and muscles. In this right dominant pattern you tend to stand on your right leg, shifting your right hip back with your left hip forward. When the patient in this case study was asked to shift his weight over to his right leg he did so with ease. However, when asked to stand on his left leg, his pelvis still remained forward on the left. He went into a hemi-lordosis (increase back arch) on the left to compensate for his inability to shift into his left hip socket correctly, therefore creating his low back pain. If asked to perform the task correctly he would have shifted back into his left hip letting his right hip come forward. This would have allowed for the head of the hip to position properly into the hip socket (acetabulum). When someone lacks the ability to stand on the left leg correctly, most often they will have a tight posterior hip capsule (ischial-femoral ligament) which visually creates a shorter left leg.

The inability of this patient to shift his left hip back and right hip forward properly had resulted in wearing of the lateral border of the soles of his shoe. This patient had to carry his weight on the outside portion of his right foot. The arch of his right foot was higher from the ground (forefoot varus) compared to the left. The way to have correct biomechanics of the foot is to have the right hip shift forward and the left back. This would allow for the heel to strike and increase weight through the arch of the foot and push off with the big toe for correct propulsion during gait. The patient could not do this, therefore wearing out the lateral soles of his shoes.

This pelvic asymmetry on the left which orients the pelvis and weight bearing to the right now causes rotation at the sacrum (base of the spine) and lower lumbar spine at L4-L5 to the right. The femurs (thigh bones) also compensate for this forwardly rotated and anteriorly tipped pelvis. The left femur bone actively goes out (external rotation) and the right goes in (internal rotation). This is required for the patient to walk or cycle straight ahead. Now if the left femur bone is actively in external rotation the lower shin bone (tibia) is oriented in, the patella (knee cap) will not track correctly and knee pain results as was demonstrated with this patient (Figure 4).

Joint and bone position are affected by pelvic asymmetry, but what about the muscles? Muscles that cross the back, pelvis and hip region can affect movement patterns on each side of the body. If these muscles are balanced they should turn “on” and “off” to allow reciprocal activity in this region. For instance, if the pelvis goes back on one side then it goes forward on the other. If one hip goes “in” then the other goes “out”. This reciprocal movement is needed for correct biomechanics with walking, cycling, running, etc. If this does not occur, as in the case with a forwardly rotated and anterior tipped pelvis on the left, then asymmetrical muscle position occurs. These mal-positioned muscles then cannot work correctly. You now have muscles in the incorrect position that cannot "turn on" to do their job and others that cannot "turn off." This overactive chain of muscle has been described by Hruska and is taught through the Postural Restoration Institute. The left psoas, iliacus, TFL, and piriformis and right adductor magnus, piriformis and vastus lateralis are all muscles that need to be inhibited in a forwardly rotated and anteriorly tipped left pelvis. This patient had left TFL pain due to over-activity; this was a muscle that was “on” all the time. In comparison, the muscles this patient could not turn “on” were his left hamstring, left adductor and left gluteus medius and right gluteus maximus. These muscles are those that support this patient’s ability to move his pelvis back and to shift into his left hip to allow for reciprocal activity with cycling.

The patient who has an asymmetrical pelvis with joints, bones, and muscles not in the appropriate position when he stands and walks now also cycles competitively for hundreds of miles a week. The position up on the feet is going to reflect what happens on the bike. For example, this patient’s saddle was worn down on the right. This reflects a forwardly rotated and anteriorly tipped pelvis on the left causing the weight shift over to the right. The patient also was aware that something was unbalanced as he was using his right leg to power through his workouts versus his left. The patient’s extreme forward aft seat position also affected his forward positioned pelvis. This seat position does not allow the knees to be at the level of the hips, therefore causing the pelvis to go forward and increasing a lumbar lordosis. Muscles discussed earlier are no longer in a position to work and the TFL, quadriceps, hip flexors, and back extensors are overactive. These muscles work with the patient in a repetitive position on his bike contributing to developing mal-adaptive patterns influencing respiration and biomechanics. The result is pain in a multitude of areas and inability to breathe.

Seat position and fit to a bike is rider specific and a science in itself. It is suggested to the cyclist that cleat wedges, added height to the right side of the saddle, and placing your seat back are passive alterations to adjust for the asymmetrical pelvis. A neutral pelvis can be attained using Postural Restoration Institute (PRI) techniques. PRI was developed with the mission of ongoing research, education, and application of treating the asymmetrical body. Article number two will discuss the asymmetry that exists in the upper trunk and how it affects breathing. The last article will discuss Postural Restoration treatment with ideas to assist with injuries and prevention for the cyclist.

For more information and references, please visit www.posturalrestoration.com.

Thomsen, L. The Relationship Between Postural Asymmetry and Cycling Injuries: Part II. Performance Cycling Conditioning. 2007
(Lori Thomsen, MPT, PRC

The Relationship between Postural Asymmetry and Cycling Injuries

Faulty breathing patterns affect cycling performance. Coaches, athletic trainers and physical therapists will at times get complaints from athletes feeling fatigued or short of breath more than expected from a normal workout or difficulty with "side stitches." Often times these complaints are dismissed for reasons being that the athlete started cycling too fast, had too much resistance pushing up hill, or is suffering from exercise induced asthma. Rib alignment and position and its affect on respiratory dysfunction can easily be overlooked. The diaphragm and abdominal obliques are not only important muscles for breathing with correct rib mechanics, but they also are important for maintaining pelvic symmetry.

In part one, we discussed a 34 year old cyclist who presented to physical therapy with a forwardly rotated and anteriorly tipped left pelvis. This influenced the cyclist’s center of gravity which shifted him over his right leg. This asymmetry no longer allowed this patient to be able to turn muscles "on" and "off" correctly to allow for reciprocal activity to occur at his pelvis resulting in pain in his left TFL and knee, affecting power stroke on the left lower extremity and improper wear pattern on the outside sole of his right shoe with forefoot varus. Important symptoms of this patient include difficulty breathing with competition, right side stitch pain, right psoas discomfort, and low back pain. Physical therapy observations included "belly" breathing and poor chest expansion with inhalation, dropped right shoulder compared to the left, and elevated ribs on the left.

Upper body rib and trunk position as a result of a forwardly rotated and anteriorly tipped left pelvis.

Left pelvis asymmetry results in lower lumbar spine (L4-L5) and sacrum orientation to the right. As a result, the upper body will be rotated to the left to allow for forward walking. This rotation to the left is further reinforced by the liver positioned on the right side and the heart positioned in the left upper trunk of the body as well as our counterclockwise and right handed dominant world. People tend to reach with their right hand for objects and turn to their left. Postural asymmetry from this left trunk rotation will be noticeable with the right shoulder below the left and a more prominent rib flare on the left (Figure 1). This is a result of rib rotation that accompanies trunk rotation. The ribs on the front of this asymmetrical body are elevated and up (externally rotated) on the left and down and in (internally rotated) on the right again reinforcing trunk rotation to the left. Rib rotation also allows the trunk and lungs to inflate and deflate during respiration. The left front ribs are externally rotated with the left lung hyperinflated making it hard for our cyclist to get air out. On the right the ribs were internally rotated with the lungs deflated making it difficult for the right chest to expand. This was easily observed during the physical therapy evaluation. The cyclist, lying on his back, was asked to inhale through his nose and exhale through his mouth while the examiner gently assisted the lower ribs down. The guidance of the ribs down on the right was easy for the cyclist which allowed air in his left chest wall as observed by the chest expanding. On the left, however, not only was it difficult for the cyclist to get the left lower ribs down it was hard for the cyclist to take a breath of air in and expand his right chest wall (Figure 2). Effective diaphragmatic breathing, therefore, has been compromised with the reliance of accessory muscles to assist with breathing. This accessory muscle overuse is noted by the cyclist "pulling" his air in. Observation of his shoulders shrugging, anterior neck muscles contracting, active lumbar extension and belly expansion were noted with inability of the chest wall to expand during deep inhalation.

Rib movement also accompanies further motion of the thoracic and lumbar spine. During inhalation, as noted on the left side of our cyclist, the ribs in front were up (external rotation) while the ribs in back were down (internal rotation). This accompanies trunk extension. The opposite was true on the right side of our cyclist. He was in a state of trunk flexion with the right front ribs in internal rotation while the back ribs were in external rotation. The coupling of the cyclist's rib and trunk position to the left, lower spine orientation to the right, and inability to shift into his left hip socket (discussed in article one) with every walking and running step and cycling revolution forced him into extensive left lumbar extension (lordosis) resulting in his low back pain. Therefore, the importance of correct rib and trunk motion in the cyclist's physical therapy program is of paramount with his pelvic position. The number one influence on rib position affecting trunk motion is BREATHING!

Inspiratory Muscle

The most important muscle when it comes to inspiration is the diaphragm. It is responsible for 70% to 80% of the work under breathing conditions. The diaphragm is dome-shaped, like an "upside down bowl," and attaches to the lower lumbar spine, lower ribs, and the bottom of the breastbone (sternum). The fibers of this muscle go inward to a central tendon. The diaphragm separates the thorax from the abdomen with support from the liver on the right side and no organ support on the left. During inspiration, the diaphragm contracts and moves down causing the chest to expand as the lungs fill with air.

Expiratory Muscle

Abdominal muscles are accessory expiratory muscles secondary to the elastic recoil of healthy lungs. These muscles, especially the obliques, are important for maximizing the action of the diaphragm. The obliques help to maintain the dome shape of the diaphragm resulting in increased lung volumes because of the length tension curve they provide the diaphragm. During exhalation, the obliques assist with pulling the ribs down and in or internal rotation with ability to get air out of the lungs which maximizes the dome shape of the diaphragm for inhalation. They also assist with maintaining trunk rotation and stability of the rib cage. If the obliques are weak, the dome shape of the diaphragm is lost and becomes flat resembling a "plate" instead of a dome which results in hyperinflation of the lungs, passive rib flares and overuse and development of dyssynchronous breathing patterns with accessory muscle overuse (Figure 3).

Inspiratory and Expiratory Muscles with Upper Trunk Asymmetry

In the cyclist with postural asymmetry, the lower lumbar spine is oriented to the right with the upper trunk rotated to the left. Trunk rotation to the left causes the left front ribs to be externally rotated and the right to be internally rotated. In addition to this rib rotation, remember our cyclist favors his right leg. This position reinforces the length tension relationship of the right diaphragm with its dome shape which is also reinforced by the liver. This right sided diaphragm is over-active contributing to spasms contributing to the "stitch in his side." On the left side, our cyclist’s ribs are externally rotated with left oblique weakness, therefore, the diaphragm is shaped more like a plate and is not as effective in respiration. This again results in decreased chest expansion, overuse of the neck, back and shoulder muscles to assist inhalation, and lung hyperinflation.

Treatment Considerations

Balancing the respiratory system with diaphragmatic breathing techniques that are carried out at the same time with oblique strengthening exercises is important for postural symmetry of the pelvis and upper trunk. This will be emphasized on the left side of our cyclist to help increase the dome shape of the diaphragm and to assist with trunk rotation to the right with left front rib internal rotation and right front rib external rotation. This emphasis will therefore create synchronous breathing patterns and postural balance throughout the trunk and pelvis. Exercises should reflect the following: 1) inhaling through the nose 2) exhaling through pursed lips or "sighing out" the air reinforcing the ribs and the sternum moving down and in with internal rotation 3) pausing 3-4 seconds after the exhalation to allow the diaphragm to set for inhalation 4) exhalation should be two to three times longer than inhalation and 5) quiet breathing outside of exercise activity should be done through the nose.

Treatment recommendations with exercise examples will be discussed in our third and final part of this series.

For more information and references, please visit www.posturalrestoration.com.