Indoor Cycling: What the Podiatrist Should Know

When COVID-19 began, the increase of at-home workouts, specifically indoor cycling, increased tenfold.¹ At the height of the pandemic, Peloton was on top of the world. Its stock pushed $171 per share and its market cap hovered around $50 billion.² In 2020, stocks for Peloton hit an all-time high and since that time, I noticed an uptick in indoor cycling injuries in my private practice. As someone who is also an avid indoor cycler, I came to appreciate the correlation between foot and ankle injuries associated with improper positioning and improper shoe gear leading to a detrimental ride for an indoor cycler.

From the elite to the occasional cyclist, a proper bike fitting is important for everyone, as it ensures efficient biomechanics, preventing overuse injuries and maximizing performance. An improper bike fit can cause one to experience pain in various parts of the body, including the neck, back, hand, buttock, hip, and knee. The most common injuries I see associated with improper bike fitting include metatarsalgia, dorsal foot irritation, sesamoiditis, numbness, knee pain, plantar fasciitis, and tendonitis.

A Closer Look at 5 Important Cycling Principles

To understand how to correct your patients and give them guidance to prevent injury, it’s imperative to understand proper positioning and principles within a recumbent bike. Those 5 principles are saddle height, horizontal saddle position, foot position, handlebar height, and proper cleat gear.

Saddle height. I find saddle heights range from “1” at the shortest and “42” at the tallest (bike brand may vary). To find the proper saddle height, riders should stand alongside the bike and bring the saddle up until it is in line with their hip bone. Once they set the proper height, they should sit on the stabilized saddle. The rider is at the proper saddle height, in my experience, when they are seated with the leg extended and the knee has a slight bend.

Horizontal saddle position. The horizontal saddle position guide runs alphabetically. “A” is closest to the handlebars and “J” is farthest away (bike brand may vary). When seated in the saddle, riders’ elbows should have a slight bend. If their arms are too straight, I find they need to bring the horizontal saddle position forward. However, if their back is hunched over then they may need to move the saddle away from the handlebars. Another way to look at this is when at the 3 o’clock position of the pedal stroke, the kneecap should align directly over the pedal spindle.

Foot position. Riders should always align the ball of the foot over the center of the pedal to achieve the most effective and comfortable position. Two types of pedals can accompany an indoor cycling bike: toe cages and clip-in. Toe cages are the easiest to get the foot in and out of; however, they provide minimal stability and force the patient’s foot into a plantarflexed position when moving out of the saddle. Unfortunately, in my observation, toe cages are one of the worst culprits for peroneal and tibialis anterior tendonitis as they cause patients to overfire these tendons to compensate for the plantarflexory position. Clip-in pedals, on the contrary, provide more power and efficiency, but require clip-specific shoe gear. The patient’s feet will not slip from the pedal, and they will likely feel most stable, potentially mitigating or eliminating points of compensation from the rest of the body.

Handlebar height. Correct handlebar height is imperative for equal force distribution in the arms and hips, with preferably more weight landing in the lower body than the upper body. What I mean by this is that I advise patients not to easily rest their body on the handlebars, as their weight should be evenly distributed. Technically a rider should aim to have the handlebars at the same height level as the saddle; however, this can be very uncomfortable for a new rider. In my opinion, new riders should position their handlebar  height slightly higher in comparison to the saddle.

Proper cleat gear. Cleats are the metal or plastic components that allow the rider to attach their cycling shoe to the pedal clip. There are two types of indoor cycling cleats: SPD, which are two-hole cleats, and Delta, which are three-hole cleats. In my experience, riders often find SPD cleats harder to clip in at first. However, they are smaller and recessed, which makes them easier to walk in compared to the Delta cleats. All of the shoes branded by one popular cycling company are formulated with a Delta cleat; however, this is a common source of metatarsalgia pain in my clinic, as they take up most of the forefoot as they sit on top of the shoe. Most cleats and clips can be substituted for SPD clips and cleats. In my experience, most indoor cycling classes will also accommodate an SPD cleat and clip.

Another important feature of a cycling shoe is the closure type. Two- and three-strap Velcro shoes are the most accommodating, in my experience, for a wider and higher arch foot type. All the Velcro closures are adjustable. Conversely, I find that BOA, or stainless-steel wire closure, provides a uniform closure across the dorsum of the foot, fitting snugger and accommodating comparatively narrower foot types. Please note, that this type of closure specifically cannot be adjusted for different areas of the foot (ie, accommodating a dorsal exostosis).

Advice for Patients When It’s Time to Ride

It’s not just proper positioning and shoe gear that can cause serious podiatric ailments but also indecorous riding. As such, next I will discuss some of the most common mistakes I find riders making and how I advise them in my practice to avoid or change these practices.  

The biggest mistake I see indoor cyclists make is starting the push of the pedal with the ankle in a plantarflexed position, basically leading the push with the toe. Not only can this cause a serious forefoot strain, but it can also cause horrible shin splints. This is especially dangerous for the saddle as it can cause the rider to put more strain on their arms causing a shoulder injury.

Advice: Focus on pulling up as opposed to pushing down. This pull will trick your brain into dorsiflexing your foot putting you into the safest position for your feet.

Flaring of the knees is another disastrous mistake cyclists make, especially when they get tired. Instead of creating a smooth rotation, the knees can go off-axis, which causes knee pain and forces the foot into a plantarflexed ride. This wobbling of the knees can cause external rotation of the hips, which can cause tight hip flexors and other lower body injuries.

Advice: Keep the knee directly over the toe of the pedal. Parallelism is key.

The “bounce” is another common mistake. It refers to the cyclist looking like they’re bouncing in, but more commonly out, of the saddle. In contrast with someone looking like they are running in place, it looks like they’re bobbing in place. This is common at higher speeds, possibly due to a lack of core and quadricep stability. This is also due to a lack of resistance on the bike. Believe it or not, the bike should always have some small amount of resistance even at increased speeds (80–100 RPM). Bouncing causes severe knee pain and makes the mistakes mentioned above more prominent.

Advice: Engage your core, add resistance, and move your hips directly over the saddle.

Finally, excessive lateral body translation out of the saddle is very common. Mild “side to side” motion is natural but when we excessively sway side to side, we tend to bounce and strain the lateral knee ligaments in the bike. It’s very easy for cyclists who are riding to music to allow their bodies to sway from side to side to stay on the beat, especially in a cycling gym class. But again, excessive translation can exacerbate the bounce, the flare, and the plantarflexion, setting us up for disaster.

Advice: Pull your hips and buttocks directly over the saddle. Think of moving up and down as opposed to side-to-side.

In Conclusion

Now that you understand positioning, proper shoe gear, and how to have a successful ride, see Table 1 for a quick adjustment checklist for ailments related to indoor cycling. Hopefully, this list will help you guide your patients when they start presenting signs of injury from indoor cycling.

Lisa Levick-Doane, DPM, FACFAS practices at Kipferl Foot & Ankle Centers in the Chicagoland area. She is Faculty at the RUSH University Residency Program in Chicago and is the CEO of BoardsBlast.

References

1.    Morley R. The rise of indoor cycling during COVID-19. BikeBiz. Published June 23, 2020.
2.     Hartmans A, Tobin B, Mayer G. Peloton wants to expand beyond at-home fitness with a push into gyms, businesses, and hotels. Here’s how it went from a pandemic-era success story to losing money. Business Insider. Published Aug. 18, 2023.