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Long-term injuries, especially in the knees, common for cyclists – SA study

More than half of the injuries suffered by cyclists, especially men over 50, as after-effects of the more gruelling rides and events: the twinges in the shoulder, lower back or buttock, but most often, in the knees, will have been noticeable for more than a year.

Recently, reports Financial Mail, some sports medics published their findings after collecting data about niggling injuries from almost 63 000 Cape Town Cycle Tour entrants between 2016 and 2020.

Only about 3% of riders said that in the previous year they had suffered gradual-onset injuries severe enough to interfere with cycling or require treatment. Almost one third of the injuries were in the knees, usually the patella region.

Many of the injuries (40%) were severe enough for the riders to reduce or stop training, and 20% eventually required surgery, according to Professor Martin Schwellnus and his colleagues, who include PhD candidate Francois du Toit, at the University of Pretoria’s Sport, Exercise Medicine and Lifestyle Institute (Semli).

This is why recreational cyclists fit perfectly into a programme Schwellnus has been running since he moved north from the University of Cape Town to open SEMLI seven years ago.

The paper his team has just published in The Physician & Sportsmedicine is the 27th in its “Safer” studies series, which aims to reduce injuries, illnesses and even fatalities during mass sporting events.

The studies have led to the development of screening and educational intervention programmes that have reduced overall medical incidents by 30% during events such as the Two Oceans Marathon, and have cut life-threatening incidents by 60%. The online screening and educational intervention system was used at the Comrades Marathon for the first time this year.

After working out which gradual-onset injuries plague recreational cyclists, and which demographic suffers the most, the Pretoria scientists have moved on to asking why. Papers based on this work are in peer review, and Schwellnus is reluctant to jump the gun by revealing the findings.

However, SEMLI’s statistics on the ways cyclists tackled their injuries show that 33% tried medication, less than half the number had a bike set-up, while 2.5% bought new shoes, pants or gloves.

Anterior knee pain – soreness around the kneecap, in layman’s terms –  is one of the most common injuries in active people in general, especially runners.

In cyclists, it’s linked to the way various muscles are engaged during the push phase of pedalling. Over-development of muscles in the outer thigh pulls the patella out of alignment, leading to pain.

SEMLI’s latest findings echo a 2012 study at what was then the 94.7 Cycle Challenge. Of those who took part, 88% said they had experienced non-traumatic injury, pain or neurological symptoms in the past year.

“Knee pain was responsible for the need to stop training for the largest percentage of respondents,” the paper reported.

This is a key worry, says Schwellnus, because exercise and activity are so important to well-being. “As doctors, we need to be able to mitigate the risk of injury or medical problems when we prescribe exercise,” he says.

The Safer research studies he has led since 2015 aim to tackle this in four steps: identifying a problem and its extent, understanding why people have the problem, implementing a prevention programme and monitoring the outcome.

The work has its genesis in Schwellnus’ experience as a medical officer for the Two Oceans Marathon.

Several competitors died during the 56km race in Cape Town between 2008 and 2011.

One of the early Safer studies analysed 539 medical incidents, including three cardiac arrests and one death, that took place during the Cape Town Cycle Tour between 2012 and 2014. This led to an investigation into risk factors for injuries during the event: the biggest were being a woman, being older, cycling faster and cycling when wind speed is high.

Being older and cycling slower were the main risk factors for serious, life-threatening or fatal illnesses while cycling 109km round the Cape Peninsula.

Study details

Clinical characteristics of gradual onset injuries in recreational road cyclists – SAFER XXVII study over 5 years in 62758 race entrants

François du Toit, Martin Schwellnus, Esme Jordaan, Sonja Swanevelder & Paola Wood.

Published in The Physician & Sportsmedicine on 25 October 2022



Gradual onset injuries (GOIs) in recreational cyclists are common but not well described. The aim of this study is to describe the clinical characteristics of GOIs (main anatomical regions, specific anatomical sites, specific GOIs, tissue type, severity of GOIs, and treatment modalities) of GOIs among entrants participating in a community-based mass participation-cycling event over 5 years.

During the 2016–2020 Cape Town Cycle Tour, 62,758 consenting race entrants completed an online pre-race medical screening questionnaire. 1879 reported GOIs in the previous 12 months. In this descriptive epidemiological study, we report frequency (% entrants) of GOIs by anatomical region/sites, specific GOI, tissue type, GOI severity, and treatment modalities used.

The main anatomical regions affected by GOIs were lower limb (47.4%), upper limb (20.1%), hip/groin/pelvis (10.0%), and lower back (7.8%). Specifically, GOI were common in the knee (32.1%), shoulder (10.6%), lower back (7.8%) and the hip/buttock muscles (5.2%). The most common specific GOI was anterior knee pain (17.2%). 57.0% of GOIs were in soft tissue. Almost half (43.9%) of cyclists with a GOI reported symptom duration >12 months, and 40.3% of GOIs were severe enough to reduce/prevent cycling. Main treatment modalities used for GOIs were rest (45.9%), physiotherapy (43.0%), stretches (33.2%), and strength exercises (33.1%).

In recreational cyclists, >50% of GOIs affect the knees, shoulders, hip/buttock muscles and lower back, and 40% are severe enough to reduce/prevent cycling. Almost 45% of cyclists with GOIs in the lower back; or hip/groin/pelvis; or lower limbs; or upper limb reported a symptom duration of >12 months. Risk factors associated with GOIs need to be determined and preventative programs for GOIs need to be designed, implemented, and evaluated.


The Physician & Sportsmedicine article – Clinical characteristics of gradual onset injuries in recreational road cyclists – SAFER XXVII study over 5 years in 62758 race entrants (Open access)


FinancialMail article – The pain of cycling runs knee-deep (Restricted access)


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