Wrist Pain and Cycling

author : AMSSM
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Wrist pain threatens to take triathlete out of half-ironman

Question from BT Member rjcalhoun:

I am actually considering bowing out from this weekend's 70.3. One I am just not feeling it, I don't feel in shape for it, but mostly I have done something to my wrist.

What I think caused it is too much weight bearing on the bike. I have gained 10lbs and have not been working my core specifically as I normally have in the past. Also my wrists seem to kinda bow inwards on the handle bars when riding. I am truly fearful that the 56 mile bike ride could really do some damage and I am currently uninsured.

It is not carpel tunnel as far as I can tell as I do not have any numbness or tingling. This is just straight pain. The pain is at the wrist line, and dead centered on the palm line. The pain is not constant but it is sharp if I articulate the wrist or try to grasp something. Its kinda hard to explain but the pain is acute to where I will simply drop what ever I might be holding. Picking up a gallon of milk would be nearly impossible. I would have to slide my hand in flat underneath and pick up without grasping or rotating the wrist.

I really would like to do this race and while I know I won't post my best time I still want to get in there and kick butt and give it my best. My wrist is just tweaked and I don't have any clue on what kind of therapy I could do to correct it. I almost feel like if I where to hang from a pull up bar it would pull things back into alignment. It feels like a pinched tendon/nerve, etc.

Perhaps it is carpel tunnel, I just do not and have not had any numbness or tingling. But the pain is in the exact placement of the median nerve and transverse ligament.

IF anyone has any therapy suggestions that might alleviate this issue in a matter of days I am all ears.

Have already scratched Saturdays sprint, really don't want to scratch the 70.3. It would be a painful loss of $300.

Answer by James Suchy, M.D.
Member AMSSM

Hi rjcalhoun,

I’m very sorry to hear about the limiting pain you’ve been having with your wrist. I know from personal experience how frustrating it feels to be unable to compete in a race you’ve been training for months for because of a single problem, such as wrist pain. And I completely understand your desire to get back out there and not miss the race you already paid for. You made no mentioned of prior falls or trauma to your affected hand, so this makes fracture, dislocations and ligament strains unlikely. If you did have a fall or trauma that preceded this pain, I would strongly recommend seeking medical attention to rule out the above causes, which, if not addressed, can have significant long-term consequences such as joint instability, premature arthritis, and chronic pain.

Carpal tunnel syndrome is a common cause of palm-sided wrist pain, but it’s very uncharacteristic for it to present without neurological symptoms such as numbness or tingling in the distribution of the median nerve: thumb, index, and middle fingers. Another common nerve injury affecting cyclists is ulnar neuropathy, due to prolonged periods of wrist extension while cycling. Grip weakness can develop in chronic cases, but like carpal tunnel syndrome, you would experience neurological symptoms affecting the ring and pinky finger with this condition, and not just wrist pain.

The more likely cause of your pain is a wrist flexor tendinopathy. Aside from the media and ulnar nerves, the palmar side of the wrist contains numerous tendons connecting forearm muscles to hand bones, controlling flexion of the fingers and hand. Most of these tendons run through a narrow region of the wrist known as the carpal tunnel, formed by carpal hand bones (e.g. hamate, trapezium, trapezoid, capitate) on the bottom and the carpal ligament on top. When there is repetitive strain or friction on one or several of these wrist tendons, tendinopathy can develop. Coincidentally, the cyclist’s wrist placement against handlebars, puts direct pressure on these wrist tendons, since they run through this very narrow region. Inadequate cushioning, prolonged wrist pressure, and poor hand positioning can all contribute to the development of tendinopathy in a cyclist. Typical symptoms include wrist pain and tenderness with direct pressure. Movements that stress the tendons such as flexing the fingers or wrist against resistance (e.g. grasping a gallon of milk) will also exacerbate pain. If present for a long time, you may feel stiffness.

Unfortunately, if this is a constant problem you’ve been dealing with for more than a few days, regardless of the cause, nothing is going to resolve the pain in just a few days. If you still feel dedicated to racing and can’t tolerate the pressure on your wrist, the best work-around would be adopting an aerobar position on the bike, though I’m sure you’ve considered this as an option. Also, if you’re not accustomed to riding in an aero position for several hours, you could cause a new problem for yourself (e.g. low back pain).

Treatment options for wrist flexor tendinopathy first and foremost include a break from the inciting activity (i.e. cycling). Wearing a wrist brace that immobilizes the flexor tendons can keep you from continuing to aggravate the tendons during your non-cycling activities. Temperature therapy on the painful region is also beneficial to reduce pain. I usually recommend ice in the early stage of injury and heat if it has been going on for some time, but use which ever works best for you. Non-steroidal anti-inflammatories (NSAIDS) like ibuprofen can provide considerable symptomatic pain relief, but talk with your doctor about any contraindications you might have to using them, such as chronic kidney disease or stomach ulcers. Also be aware that NSAIDS are simply masking pain and not contributing to the healing process by being “anti-inflammatory.” We understand better now that these repetitive tendon injuries are more degenerative than inflammatory in nature. Pain is the body’s way of telling us to stop using that tendon because it’s injured, and when we take NSAIDs we are masking pain while still inflicting injury to the tendon. Once the symptoms resolve I would gradually re-introduce your wrist to cycling.

And keep in mind the following tips to prevent this problem from occurring in the future: Bar taping – extra cushioning on handle bars provides that extra protection from bumps and vibrations transmitted from the ground into your hands. Replace old tape that is compressed and provides little cushion. Where do you position your hands when you ride? You could double wrap these areas or put gel pads under the tape. Many tri-specific bikes have bar tape on the hoods but not on the tops of the handlebars.

Padded gloves – gloves offer similar cushioning to bar tapping, reducing pressure on the hands. Are you riding with gloves? It may save you valuable time to not have to put them on during a short-course race, but over a long distance the time-saved may not outweigh the comfort. Make sure your gloves’ cushioning is not old and compressed. The protection provided isn’t just a matter of price. The style/purpose of the gloves makes a big difference. Some of the sleekest racing gloves offering little protection compared to the thickest easy-riding gloves.

Hand Position – despite all padding from bar tape and gloves, hands and wrist still fatigue after hours of riding. Regularly shifting between the tops, hoods, drops, aerobars, and the multiple positions in-between will relieve pressure points. Also try to relax your shoulders always from your ears and loosen the grip of your hand on the bars so you don’t place excessive, unnatural pressure on the wrists.

Bike fit – like other chronic aches and pains in cyclists, wrist pain can be remedied by a proper bike fit. Good custom bike fits cost several hundred dollars, though some shops offer discounts if you purchased your bike there. Bike fits depend on your anatomy, cycling mechanics, desired riding positions, bike-type, etc. A fitting is highly personalized because micro-adjustments in saddle and handle bar position determine if your weight is properly distributed or not. If you have time and motivation there are many quality YouTube videos that describe how to do a bike fitting yourself. An easy modification to relieve pressure on your wrists is to adjust your saddle angle. Angle the nose of your saddle up and you’ll shift more weight from your wrists into your sit bones. Angle the nose of your saddle down and you’ll shift more weight from your sit bones and into your wrists. Don’t make big changes or you could set yourself up for pain elsewhere.

I hope you find this information helpful and can get back out there training and racing soon. Remember to seek the advice of your doctor if symptoms persist as further imaging may be required.




James Suchy, M.D.
Family Medicine Resident, PGY-3
University of California, Irvine

Reference:

Boggess, D. R., DO, FAAFP. (2017, March 21). Evaluation of the adult with subacute or chronic wrist pain. Retrieved October 22, 2017, from https://www.uptodate.com/contents/evaluation-of-the-adult-with-subac...

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date: October 31, 2017

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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