Neck pain tips bicycling

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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“Bicyclists, particularly recreational cyclists who attempt long-distance rides, commonly report back and neck pain after long rides.

And a new study says the pain is probably caused by their riding position. Possible causes, as mentioned earlier, include poor handlebar or saddle position. A poorly placed handlebar might be too low, too far away, or too short a reach. A saddle with excessive downward tilt can also be a source of neck pain.

The report recommends raising the handlebars, moving the seat forward, riding with unlocked elbows, and stretching neck muscles regularly during a ride.

Neck and back pain are common in bicycle riders because of the body’s positioning during riding. Several studies have demonstrated that neck and back injuries are the most common overuse injuries evaluated following six to eight-day distance bicycle tours. Wilber, et al. (Wilber CA, Holland GJ, Madison RE, Loy SF, ‘An epidemiological analysis of overuse injuries among recreational cyclists’ Int J Sports Med 1995 Apr;16(3):201-6) found that 44.2 % of male and 54.9% of female recreational cyclists presented for medical treatment of neck pain, while approximately 30% presented with back pain. Weiss also reported that 66.4 % of recreational cyclists reported neck and shoulder symptoms following an 8-day, 500-mile bicycle tour.

Overuse injuries occur when a tissue incurs damage caused by repetitive sub-maximal loading. Repetitive activity fatigues a tendons, muscles, or bones. Without adequate recovery, micro trauma stimulates an inflammatory response. Over time, this trauma leads to injury. In overuse injuries, the problem is not necessarily acute tissue inflammation (tendonitis), but chronic degeneration, or tendinosis.

Pain in overuse injuries typically begins slowly. However, it may also have an acute-on-chronic presentation. Overuse injuries most likely occur when an athlete changes the mode, intensity, or duration of training. Biomechanical (intrinsic) factors and equipment or training regimen (extrinsic) issues are the main contributors to overuse injuries. It is felt that it is the extrinsic issues that cause most of the overuse injuries in cyclists.

One must consider bicycle fit, training distance and intensity, and anatomic factors to determine the exact mechanism. Often, adjustments in the bicycle or the individual’s exercise regimen may be all that is necessary to correct symptoms.

If the handlebars are too low, excess lordosis of the lumbar spine and increased hyperextension of the cervical spine occurs, leading to both low back and neck pain. Measure the handlebar height by holding a yardstick on the seat so that the yardstick extends over the bars noting the difference between the seat and the bars. Ideally, the handlebars should be even with the seat or between even and 4 centimeters lower. Extremely fit, flexible cyclists may have their handlebars up to 5-9 centimeters below the level of the seat.

Because cycling demands prolonged back flexion and neck extension, ensuring that your neck and back are flexible is very important. The cycling process demands repetitive hip and leg flexion anchored by a stable pelvis. Core strength and stability should be sought for all riders. A physical therapist can easily teach common back and neck stretches and back core-strengthening exercises.

Neck pain can be due to several factors to include riding position, technique, and other medical conditions. With riding, the neck is extended and the back flexed for prolonged periods. Riding in drop handlebars for long periods increases the load on the arms and shoulders as well as hyperextension of the neck, leading to muscle fatigue and pain. If the virtual top tube length (top tube plus stem length) is too long for the rider, hyperextension of the neck is further increased. Prolonged hyperextension of the neck and associated muscle strain may lead to myofascial pain syndrome. This presents as trigger points in the muscles of the neck and upper back. Trigger points are small rubbery knots that form in muscle and adjacent muscle sheaths (fascia), which send pain signals to the brain and contribute to a pain-spasm-pain cycle. Trigger points are frequently caused by repetitive microtrauma, similar to any overuse athletic injuries. Certain techniques common to cyclists may also cause trigger point pain. Cyclists frequently present with pain in their left levator scapula (muscle that helps lift the shoulder blade) caused by frequently looking over their left shoulder for oncoming traffic. Additionally, comorbidities must be assessed; in older riders, for example, it is prudent to question about radicular symptoms because a certain degree of neck pain may be secondary to osteoarthritis in the cervical spine.


Thoracic outlet syndrome (TOS) is a less common, but important cause of neck pain. TOS may present with tingling in the fingers; pain in the neck, shoulder, and arm; headaches in the back of the head; weakness of the arm and hand; cold or cyanotic hands. These symptoms may worsen with such activities as elevating the arm to comb their hair or drive a car. TOS is most often produced by hyperextension neck injuries, typically traumatic, but may also be caused by repetitive over hyperextension of the neck. This condition may be accompanied by other peripheral entrapment neuropathies.

Riders suffering from neck pain should inspect the fit of their bicycle. One way to reduce neck hyperextension is by raising the handlebars, or using handlebars with a shallower drop. Another method is to reduce the virtual top tube length, by using a shorter stem. Moving the saddle forward also reduces virtual top tube length, but the rider should be cautious as improper fore/aft saddle position can lead to knee pain.

(Asplund C, Webb C, Barkdull T.Neck and back pain in bicycling.Curr Sports Med Rep. 2005 Oct;4(5):271-4.)

Changes to riding technique can also help with neck pain. A rigid riding position transmits more shock directly to the neck and shoulders. Riding with unlocked loose relaxed elbows and changing hand position (i.e. from drops to brake hoods) can alter neck posture minimizing pain. Although some handlebar materials provide a softer or stiffer ride, there is currently little evidence that changing handlebar material affects neck pain. Educating cyclists to frequently stretch their neck during more leisurely parts of the ride may reduce the frequency and severity of neck pain.

Other factors contributing to neck pain are helmet fit and handlebar width. The helmet should be worn so that it is snug, stable, and level on the head with the front rim barely visible to the rider’s eye. Improperly fitted helmets may cause excessive neck extension in order to maintain visibility, resulting in further neck pain as described above. Handlebars should be shoulder width apart [measured from acromion to acromion ( the part of the scapula that articulates with the clavicle) across the anterior chest] and comfortable. Handlebars that are too wide may cause excessive trapezius and rhomboid strain leading to muscle spasm and pain.

To summarize:

Neck and back pain is a common complaint among cyclists. By making a few select adjustments to the bicycle added to a core strengthening and stretching program, this problem can be easily remedied. Proper fit should be ensured; this is accomplished by relieving over extension by using handlebars with less drop, shorter stem, elevating the stem or adjusting the seat position. Changing hand position frequently, relaxing the elbows, and varying head position will decrease the likelihood of developing neck and back pain. As more people seek low-impact ways to improve and maintain their cardiovascular fitness, physicians will no doubt see more patients who have neck and back pain related to bicycling. By learning a few simple bike-fitting techniques, physicians can treat and prevent many common problems


Bottom line common sense tips:

Try not to ride with your neck in the same position for long periods of time. Try tilting your neck from side to side, or stretching it. Always remember safety first when taking your eyes off the road.


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