Ulnar Neuropathy in Cyclists

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University of Colorado Health Sciences CenterDepartment of RehabilitationDenver, ColoradoJohn Tobey, MD University of Colorado Sports and Spine Fellowship

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The effect of long distance bicycling on ulnar and median nerves PASSOR RESEARCH FORUM John Tobey, MD 10-07-04

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Acknowledgements Venu Akuthota, MD Christopher Plastaras, MD Kristin Lindberg, MD Joel Press, MD Cyndi Garvan, PhD

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Overview Cyclist palsy History Anatomy Classification Etiology Other studies / reports Our study Electrodiagnostic data

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Cyclist palsy Also known as ‘Handlebar palsy’ Compression or entrapment neuropathy of ulnar nerve at or distal to Guyon’s canal at the wrist

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Cyclist Palsy - History 1896 - Destot Ulnar neuropathy in cyclists first described Paris-Brest-Paris 1200 km bicycling race. European journals 1970’s – American journals

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Guyon’s CanalAnatomy Ulnar Border pisiform bone and FCU tendon Radial Border Hook of Hamate Floor Pisohamate ligament Roof Palmer carpal ligament Palmaris brevis muscle

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Branches: Dorsal ulnar cutaneous Superficial Sensory branch Deep branch Branch to hypothenars Deep motor branch

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Anatomy Location of compression: Within Guyon’s canal Distal to canal

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Wu’s Classification –Ulnar nerve compression at the wrist

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Etiology: Cyclist palsy Chronic repetitive trauma Chronic pressure Vibration Hyperextension

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Cycling specific factors Long biking excursions Hand position Hyperextension of wrist Forward weight shift

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Symptoms Pain Paresthesias Numbness Weakness

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Background Eckman – ’75 3 case reports of ulnar neuropathy at the wrist in cyclists Jackson – ’89 20 long distance cyclists 9 with symptoms Normal NCS of median and ulnar sensory & motor studies Wilmarth – ’88 Ulnar sensory nerve conductions while within normal limits in cyclists did vary signficantly compared to non-cyclists. Patterson – ’03 92% (23 out of 25) cyclists had either motor or sensory symptoms after a 600 km ride.

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The effect of long distance bicycling on ulnar and median nerves:An electrophysiologic evaluation of cyclist’s palsy

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Objective: To objectively quantify changes in the ulnar and median nerves associated with a long distance multi-day cycling event. Design: A prospective cohort study

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Subjects 14 adult subjects Total of 28 hands Seven men, seven women Bike tour 6 day 420 miles (Avg - 70 miles. Max - 85.9 miles) Flat and rolling terrain on asphalt & chip-coat roads

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Nerve Conduction StudiesPre & Post Ride Ulnar motor (Dual Channeled) abductor digiti minimi first dorsal interosseus Median motor abductor pollicis brevis Ulnar sensory little finger Median sensory index finger

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Questionnaire Post ride Demographics Experience level Hand positions Symptoms experienced during ride

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Onset motor latencies p = 0.5020 p = 0.2357 p = 0.0044 p < 0.0001

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Peak sensory latencies p = 0.31 p = 0.6466

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Ulnar nerve results Motor Studies FDI & ADM within normal ranges Comparison of Pre/Post Significant Differences FDI FDI – ADM

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Median nerve results Median nerve palsy due to cycling is rare. No significant difference between the hands before or after the ride for median motor or sensory. Pre-ride – 3/28 hands with onset > 4.2 msec Post-ride – all three with increases of latency Post-ride – 1 hand with 3.9 msec to 4.8 msec

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Discussion Changes occur in the deep branch of the ulnar nerve Despite usual preventative measures Sub-clinical changes Pre-existing nerve abnormalities may be exacerbated

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Limitations Small sample number Lack of temperature measurement Technical errors Submaximal stimulation Distance differences Same electromyographer performed all examinations

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Conclusions Cyclist palsy or handlebar palsy is a compressive neuropathy of the ulnar nerve seen in cyclists Early recognition of symptoms & intervention with rest & cessation of biking, then modification of equipment and alteration in riding style is important for the avoidance of nerve damage

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Conclusions Significant changes can occur to the deep branch of the ulnar nerve May cause or exacerbate symptoms of carpal tunnel syndrome

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Thank you!!!

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