Which is the best route to recovery from injury?

Cycling is a great way to stay fit and boost mood, but nothing’s guaranteed to put you in the doldrums like months off your bike recuperating from injury.

And no matter how careful you are, it’s inevitable that at some point you’ll have to take a break for a little rest and rehab. So, which treatment gives you the best chance of making a swift recovery?

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Cycling injuries fall into two categories: those caused by overuse, and those resulting from trauma. Overuse injuries range from niggling aches and pains to potentially debilitating conditions such as patella tendonitis and illiotibial band syndrome.

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They are often caused by poor bike set-up and are exacerbated by the repetitive nature and constrained body position of cycling. Traumatic injuries are the result of falls, crashes and accidents; they can range from cuts, tears and scrapes to multiple broken bones and life-threatening head injuries.

Regardless of the cause of your injury, if it’s severe enough, surgery and/or physiotherapy are likely to be your first port of call.

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But although physio is the most mainstream treatment, and the one best supported by scientific evidence, many injured cyclists — including our case studies below — undergo a whole range of therapies on their path back to fitness.

What to make of the bewildering array of alternative options on offer? Here, we examine some of the leading treatments, from the everyday to the contentious to the cutting-edge, and assess the avowed and documented effectiveness of each one.

Physiotherapy

Physiotherapy is the first choice for most riders recovering from overuse or traumatic injuries, since it is the preferred rehabilitative treatment of the NHS.

This is because it is based on firm scientific foundations and is the most cost-effective way to treat the widest range of musculoskeletal problems.

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Similar in some respects to chiropractors and osteopaths, physiotherapists use manual manipulation and massage,and sometimes additional techniques such as hydrotherapy, electrotherapy and ultrasound.

Physiotherapy focuses on long-term outcomes and uses stretches, exercise and lifestyle advice to improve flexibility, reduce pain and restore the normal range of motion of joints and muscles.

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A sports-specific physiotherapist will bring additional experience of treating common sports injuries and some are trained in bike-fitting to optimise your riding position and minimise the risk of future injury.

Sessions usually last between 30-60 minutes and typically involve manual therapy and mobilisation techniques, advice on posture, and exercises to strengthen weakened muscles.

What’s it good for?

Physiotherapy is used to alleviate muscular pain and stiffness, restore range of motion after injury or surgery, and address any muscular imbalances that may have led to injury.

As it is an evidence-based practice, you can be assured that any treatment you are given has a proven track record of effectiveness.

Where is it available?

Physiotherapy is available through the NHS and in some areas you can refer yourself directly rather than through your GP. Waiting lists can be long, though, so many people choose to go privately.

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Chiropractic

Chiropractic is the most widely used of the alternatives to regular physiotherapy. It’s based on the idea that small misalignments of the spine can cause interference with the nervous system, leading to pain, mechanical disfunction and even illness.

The most common reason for visiting a chiropractor is to alleviate neck and lower back pain. Long hours stretched out on a road bike can put these muscles under a great deal of strain so chiropractic is a popular option with cyclists.

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Along with physio and osteopathy, chiropractic is a mainstay of the pro peloton, with many WorldTour teams using its manual therapy techniques to ease and loosen aching muscles and address performance-sapping imbalances that can result from long hours in the saddle.

A typical session with a chiropractor involves hands-on manipulation of the bones, muscles and joints of the spine. Short, sharp movements known as adjustments are used to improve the range of motion of poorly functioning vertebrae while slower movements mobilise and stretch the muscles and joints.

What’s it good for?

There is good evidence that manual therapy of the sort practised by chiropractors can be an effective treatment for persistent lower back pain.

To a lesser extent, there is evidence to suggest it may be effective for new-onset back and neck pain, shoulder girdle pain, frozen shoulder, hip and knee osteoarthritis.

Where is it available?

While chiropractic is considered a complementary therapy, it is available through the NHS in certain areas.

However, most patients go privately and chiropractic treatments usually range from £35-£50 for a session. Be sure to use a chiropractor registered with the General Chiropractic Council (GCC).

Osteopathy

Osteopathy’s techniques overlap with those of chiropractic but with less focus on the spine and more on the interconnectedness of the whole musculoskeletal system.

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The purpose of osteopathy is to get your bones, muscles, ligaments and connective tissue functioning smoothly together. To achieve this, an osteopath will use manual therapy, including mobilisation techniques and massage.

This treatment should increase the mobility of joints, relieve muscle tension and enhance blood supply to the tissues, restoring normal pain-free function.

What’s it good for?

There is good evidence that osteopathy is effective in treating persistent lower back pain and the NHS recommends it as a treatment for this condition.

There is limited evidence of effectiveness for neck, shoulder or lower limb pain and recovery after hip or knee operations.

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Where is it available?

Like chiropractic, osteopathy is available on the NHS in certain areas of the country, but most patients go privately. Each session lasts between 35-45 minutes and costs £35-50. Be sure to check that your osteopath is accredited by the General Osteopathic Council (GOsC).

Acupuncture

When Team Astana acupuncturist Eddy de Smedt revealed his part in Vincenzo Nibali’s 2014 Tour de France victory, many an eyebrow was raised.

Cycling and needles have bad associations and, doping gags aside, this ancient Chinese healing technique is still viewed with doubt by sceptics, many of whom point to its lack of scientific rigour.

De Smedt detailed how, before and after each stage, he had used six to 10 needles about an inch long at key points along the Sicilian’s legs, feet, hands and head “to promote recovery and relaxation of the muscles”.

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In traditional Chinese medicine, acupuncture is supposed to harmonise the flow of ‘Qi’ or energy. Evidence-led Western medicine points instead to physical effects such as muscle release and relaxation, increased blood flow and the ‘cancelling out’ of pain impulses in the nerves.

A typical treatment plan involves lying still while between five and 20 needles are inserted and left in place for 10 to 20 minutes. The positioning of the needles varies between different practitioners and schools of acupuncture. The needles may also be manipulated, either manually or by electrostimulation.

What’s it good for?

The evidence for acupuncture’s effectiveness is limited, but is sufficient for the NHS in some areas to recommend it for low back pain, while noting that it may also help with neck pain.

Where is it available?

Acupuncture is sometimes available on the NHS and is often used as an adjunct therapy by physiotherapists, chiropractors and osteopaths.

A session usually costs between £35 and £60, with further sessions costing between £30 and £50.

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Shockwave therapy

Ultrasound is used both for scanning and therapeutic purposes and is often employed by physiotherapists to kickstart tissue repair.

While the evidence supporting the use of regular therapeutic ultrasound is unimpressive, a more powerful variant called shockwave therapy is being used with greater success to treat the tendon-related injuries that can plague cyclists.

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Charles Willis-Owen is an orthopaedic surgeon who uses the technique to treat tendonitis, heel pain and illiotibial band syndrome in both recreational and professional cyclists.

“Shockwave therapy uses high-intensity sound waves to restart the natural healing process,” says Willis-Owen.

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“It can reverse chronic inflammation, stimulate the growth of new tissue and blood vessels and break down calcium deposits. It can help people when other treatments have failed and can be a great way to keep you from having surgery.”

What is it good for?

Evidence for shockwave therapy is limited, but some clinical studies have reported a success rate of 75 per cent. It is most often used to treat tendon-related problems such as Achilles, patella and quadriceps tendonitis, plantar fasciitis (foot pain) and illiotibial band syndrome (pain felt on the outer thigh).

Where is it available?

Shockwave therapy is in some areas available on the NHS and privately through selected physiotherapy, chiropractic and osteopathy practices. It is recognised by most major medical insurance companies.

At Wills-Owen’s Bournemouth and Poole clinics it costs £500-£750 for three treatments.

Cutting-edge treatments used by the pros

Stem cell cartilage regeneration

This state-of-the-art technique involves harvesting stem cells from a patient’s bone marrow before injecting them into a damaged knee joint where they grow into new cartilage. The only drawback is the price; in the absence of private health insurance, expect to pay £5-£6,000.

Low-frequency pulsed ultrasound

Rapid recovery from fractures is essential for the pros, and the Exogen bone healing system is their secret weapon. This portable transducer pulses the effected area with ultrasound and has been found to accelerate fracture healing by 38 per cent. It’s also used to stimulate recovery in a break that hasn’t healed naturally. Cost of treatment is £2,500.

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These treatments are available from Dr Charles Willis-Owen, an orthopaedic surgeon also trained in sports medicine and sports psychology. A keen cyclist himself, he treats cyclists at every level from recreational to professional; sportsorthopaedicspecialist.co.uk

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The expert’s view

Tackling tendonitis

Tendon injuries are notoriously hard to heal, so what’s the best approach? We asked physio Dr Graham Theobald for his tendon-treatment protocol

To try and increase blood flow to the tendon we use treatments such as dry-needling, low level laser, contrast therapy, friction massage, massage.

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With acute tendonitis we need to calm the inflammation down with rest, ice and elevation. Once settled we need to start carefully loading the tendon. Often it can become acute again and so monitoring the progress is key.

With the more degenerative tendonopathies, there is less inflammation and so the approach is one of eccentric loading to force the tendon to ‘re-model’ itself to one that can take the loading that is demanded of it.

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I always scan the tendon using ultrasound in order to determine progress. Tendons are often thickened and by monitoring this we can normally match how it looks with how it feels and therefore manage the progress, rehab and loading accordingly.

Dr Graham Theobald, BSc (Hons), MSST, PhD is a sports injury and musculoskeltal specialist who heads up the The Body Rehab, an injury and rehabilitation based near Kendal, Cumbria. www.thebodyrehab.co.uk