Key Considerations When Treating Foot Pain in Cyclists

The newest, hottest fitness trend is of no surprise to anyone. Peloton^® has given new life to indoor cycling. Throughout the pandemic, Peloton is everywhere. I jumped on that bandwagon before the novel coronavirus pandemic started. Indoor cycling provides low impact exercise, to music, in a great community, all in the comfort of my own home while watching my children. I am hooked!

However, recreational utilization of indoor cycling does not come without overuse injuries. One study indicated that non-traumatic injuries in cycling are as high as 85 percent.¹ Most cycling literature reports injuries related to the knees, back, neck, arms, hands, buttocks, and perineum.² However, regarding foot injuries, researchers found that 53.9 percent of cyclists reported foot pain while cycling, with 61 percent of the foot pain localized to the forefoot.²

It is common to see online cycling community threads with foot related concerns such as:

“What can I do for foot pain?” “Why do my toes go numb?” “I think I have a neuroma!” “My plantar fasciitis is getting bad!”

In my clinic, I have seen an increase in forefoot pain associated with indoor cycling and outdoor recreational biking. This triggered me to seek information regarding cycling and foot pain. There is little high-quality research on foot pain and cycling in a recreational athlete. Below, I summarize three main components that, in my experience, one should take into consideration when treating a cyclist.

#1: The Bike and the Person Are One Unit.

The person and the bike function are a whole unit. The person interacts with the bike at three positions: the handlebars; the saddle (seat); and the pedals. This is referred to as the “triangle of contact.”⁴ Cyclists properly fitted to the bike will maximize the efficiency of cycling biomechanics and reduce the risk of injuries. Areas of adjustment in a bike include seat height; forward or backward seat position; handlebar height; handlebar distance from the cyclist; length of the crank; and foot position.³ If the elements in the triangle of contact are not optimal, overuse injuries may result due to unfavorable cycling biomechanics.

#2: The Foot-Pedal Interface

In cycling, the foot-pedal interface is the only transfer of energy propelling the bike forward, or in a stationary bike, making the weighted wheel spin. This transfer of energy takes place through the cleat clip surface area adjacent to the forefoot. This contact surface area is equal to approximately 60mm².The amount of force applied through this surface area is equivalent to 50 percent of the cyclist’s body weight in a seated position and two to three times their body weight when out of the saddle.⁴ Also, cycling shoes are designed as if they had a two to four inch heel, resulting in a slightly plantarflexed ankle throughout the entire cycle rotation.³ This is conclusive as to why 61 percent of foot pain is localized to the ball of the foot.²

Things to consider in the foot-pedal interface when treating foot pain include appropriate shoe fit, clip placement on the shoe, and appropriate transverse plane mobility while clipped into the bike. Clip placement on the cleat should be just proximal to the metatarsal heads.² The cleat position on the pedal is determined by the cyclist’s malleolar torsion. As the foot pronates during push and supinates during recover in the pedal cycle, the cleat-pedal interface should allow for some leg rotation.³

#3: Foot Type and Lower Limb Biomechanical Deformities

The final thing to consider is lower extremity biomechanical or structural deformities such as pes planus, pes cavus, genu varum, forefoot supinatus, ankle joint equinus and limb length inequalities. These factors will alter the torque patterns of the hip, knee, and ankle. Accommodating these deformities through wedging of the cleat on the pedal, custom orthotics or new pedals may reduce risk of injury.³

The most common cycling non-traumatic injuries seen in the foot and ankle include Achilles tendonitis, plantar fasciitis, calf cramping, metatarsalgia, neuroma and medial malleolar contusions.³ I recommend following one’s typical treatment course for these common pathologies. However, in cyclist, clinicians may also consider:

• Raising the seat height in Achilles tendonitis, plantar fasciitis or calf cramping to reduce strain on the gastrocnemius and soleus muscle complex.³
• For metatarsalgia or neuroma symptoms, inspect pedals, shoes size, clip placement, function orthotics, metatarsal pads. It is recommended to emphasize to the cyclist to “actively pull up during recovery phase to reduce pressure.”³
• Custom orthotics and wedge shoe to reduce pronation and help to lessen the risk medial malleolar contusions.³

In my experience, an appropriate fit of the cyclist to the bicycle and shoes will reduce the risk of overuse injuries. If you see a cyclist, I highly recommend discussing these factors with the patient and seeking out a professional bike fitting to reduce cycling injuries.

Dr. Quinn is a board-certified surgical podiatrist through the American Board of Foot and Ankle Surgeons.

^{Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.}

References

1. Dettori NJ, Norvell DC. Non-traumatic bicycle injuries: a review of the literature. Sports Med. 2006;36(1):7-18.

2. Uden H, Jones S, Grimmer K. Foot pain and cycling: a survey of frequency, type, location, association, and amelioration of foot pain. J Sci Cycling. 2012;1(2):28-34.

3. Sanner WH, O’Halloran WD. The Biomechanics, Etiology, and Treatment of Cycling Injuries. J Am Podiatr Med Assoc. 2000;90(7):354-376.

4. Hamilton, A. Frustrating foot pain in cyclists? These 7 treatment strategies can help! Sports Injury Bulletin. Available at: https://www.sportsinjurybulletin.com/frustrating-foot-pain-in-cyclists-these-7-treatment-strategies-can-help/ . Accessed May 10, 2021.