Experts in medicine, biomechanics, and physical therapy join Dr. Griffin McMath and Trevor Connor to decode the causes of neck pain in cyclists and the strategies that keep athletes strong, steady, and pain-free over the long haul.
Episode Transcript
Griffin McMath 00:00
And hello and welcome to fast talk. Your source for the science of endurance performance. I’m your host. Dr Griffin McMath here with Coach Trevor Connor. Dr Andy Pruitt and Dr Jeff sankoff, every cyclist, and let’s be honest, every desk worker too knows that slow, stubborn ache in the neck after hours looking down at a screen or over the handlebars. In this episode, we explore what really causes it and how to approach it from every angle. Dr Andy Pruitt, Dr Jeff sankoff and physical therapist Dr Carol Passarelli, each bring a different lens from clinical care to real world bike fit, and the conversation quickly turns into a very lively navigation of experience bias and even sometimes misunderstanding. We share personal stories, dig into research and compare how different providers assess and address neck pain and what signs suggest it’s time to go beyond DIY at home remedies. You’ll also hear what to look for in a healthcare provider or bike fitter, and what small things you can start doing today to better support your body’s capacity for the miles, the hours and the demands of everyday life. It’s an energetic, thoughtful, deep dive into how we adapt, recover and keep moving on and off the bike. So roll your shoulders back, ease that tension, and let’s make you fast. Well.
Trevor Connor 01:32
Dr sankoff, Dr Pruitt, we haven’t had either of you on the show for a bit, so pleasure to get you both back. And this is the first time we’ve had the two of you together.
Jeff Sankoff 01:39
It is and I think it’s great. Yeah, it’s great to be here with you, Andy, and great to be here with you again, Griff and Trevor.
Trevor Connor 01:45
So we’re here to talk about neck pain. And the one thing I am going to share, I obviously have been riding my bike for a long time. I have put on huge miles on the bike. And just want to share one example of the sort of things you can deal with with neck pain, because I am somebody who has struggled with migraines, but they didn’t start until my late 30s, and they’re a fairly regular thing, but I have discovered, after a lot of experimenting, that the migraines tend to be a lot worse when my neck is bugging me, and a lot better when my neck is better, to the point that I have a massage therapist who I see mostly to work on my neck, and when the migraines are getting bad, I don’t even tell her, I just show up and she goes, boy, your neck is a mess right now. And for example, I saw her on Tuesday. I’ve been having a lot of migraines, Tuesday, Wednesday, Thursday, we’re now on Friday, I haven’t had a single migraine. It’s been fantastic, but these are the sort of things that just repetitive stress on your neck can do to you. So I think this is a really important topic that often gets kind of ignored for cyclists.
Dr. Andy Pruitt 02:54
I think neck pain is like saddle discomfort. It is something people suffer with and don’t talk about much because they’re afraid that we’re going to put them on a stem extender and set them straight up to relieve their neck pain. And that’s not the solution, necessarily, but I think it is kind of one of those suffering silence issues. And of course, immediately hearing about your migraines and neck vein, I immediately want an x ray. I immediately want to examine you. I just want to go right to the heart of things.
Jeff Sankoff 03:23
It’s a particular issue for triathletes and time trialists, of course, because of the exaggerated position when you’re in aero and having to really extend the neck much more than otherwise. For road cyclists, it can become an issue. But for those of us who are participating in triathlon, it’s something I hear frequently. You know, I can’t get comfortable an arrow because I just have this terrible neck pain that comes on after so much time, and the longer the distance, the worse it can be. So it’s something that I think is increasingly common, certainly as you see older cyclists, but it can afflict anybody. It
Griffin McMath 03:59
obviously doesn’t help with modern day stressors of leaning over and staring at your phone or your computer screen. So I wonder how much neck pain now for cyclists versus neck pain 20 or 30 years ago might make a difference. I think eventually, which I know Dr Pruitt, I think you’re going to have something to say to that. But I also am curious about the introduction of cycling in your younger years, when your body is still forming, versus starting later, and what that could potentially do too. But Dr Pruitt, what do you think about that
Dr. Andy Pruitt 04:31
you just opened up about 10 cans of worms. I love to do it. So for the listeners, cervical extension is looking up, cervical flexion is looking down, right? So what Griffin was just talking about is we spend the day in cervical flexion looking down, and the discs between the vertebra assume a shape. The frontal tissues shorten, the lateral tissues lengthen, and then we go for a new. Bike ride or an evening bike ride, we absolutely reverse those things. So that disc has to reshape itself to a cervical extended position. The frontal, anterior tissues have to lengthen, blah, blah, blah. So that switchover is definitely an issue, and especially if it’s done on a regular basis. I mean, the human head weighs, for a small person, five pounds, up to even 12 pounds. So think about a bowling ball that we’re trying to in a walking posture balance on our top of our torsos, and there’s really very little stress to it, right? It’s like the lady with the big bowl on her head, if it’s balanced correctly, it’s not heavy. But as soon as we extend it forward on a bicycle or looking over a computer, suddenly we have to hold that bowling ball in space, which leads to muscular fatigue, et cetera, et cetera. Now, being a cyclist for the last 60 years, and much of those are an aggressive road or Time Trial position, you add a couple of car wrecks in there, my neck is awful, but I virtually have no neck pain, even in my TT bike, and I attribute that to strength, maintaining my range of motion and strength. Dr Passarelli is going to jump in and go, yes, that means strength and flexibility are the key to maintaining aging joints, whether they’re hips, knees or necks.
Griffin McMath 06:16
Before we get too far into causes, we asked physical therapist, Dr Carol Passarelli, to describe what’s actually happening in the body when we hold that position on the bike for hours.
Dr. Carol Pasarelli 06:28
Let’s just think about that road cyclist who’s on their bike, let’s say 20 hours a week going on some longer rides. What we can envision is when you see someone on their bike, we know that they’re going to have a relatively flexed lumbar spine and cathodic spine in the middle. So when we think about that middle thorax like this is where we’re seeing sort of that hump, and we’re seeing that the shoulder blades are sliding in and around the rib cage so that you can grip forward and hold on to your handlebars at the same time you don’t want to fall over. So we’re also looking, oftentimes, straight ahead. So what that causes is an increase in flexion in your middle spine, and then we have this big inflection point where you have to extend through your neck or look up. So as you can imagine, this, just like if you’re sitting at a desk for eight hours in one position, can cause some strain and can cause some actual physiological and anatomical changes that might make you maybe better at sitting in that position on a bike, but also could probably increase your potential for pain in that position.
Trevor Connor 07:28
Strength is important, and that’s always been an issue for me. I actually went to a PT back at your old center, bcsm, and I remember he did all this analysis on me, and then just went, Wow, you have an extraordinarily weak neck, and I know that’s always been an issue. For me, the strength is a key component.
Griffin McMath 07:47
Once you’ve loosened those tissues, what comes next? Dr Passarelli says the reset is only step one. What you do afterward matters even more.
Dr. Carol Pasarelli 07:58
We often see short term benefits in mobility interventions or manual therapy, so dry needling, manipulation, deep tissue. All of this is something that should be in your healthcare provider’s toolbox. That’s part one. Part two is once we reset that tissue, once we change your pain, then it’s go time. That’s where you have this paradigm shift, this opportunity to change the neuromuscular control and try to improve and change how your muscles are firing and when. And it’s that moment right after a manual therapy to 48 hours after this is where I’d want to get your lower trapezius to fire a little differently, get your shoulder blades to move a little more symmetrically, or get them a little more comfortable in terms of position and strengthening, we oftentimes see much longer benefit from that manual therapy intervention.
Dr. Andy Pruitt 08:48
So Jeff, you’re the coach in the room here, and an ER doc, but when we tell athletes to go to the gym to get strong, how many of them are working on the cervical spine? Yeah, well,
Jeff Sankoff 08:59
there’s only a few ways to do that, right? But I did want to touch on a couple of the things that you said, and there’s this whole field of ergonomics, right, correct? And that has become, I think, something that people are in the last, what, 1015, maybe 20 years, really aware of. I know myself, when I was working more in an office, I had an ergonomics person that came and was able to fit me out with the right chair, and now I use a standing desk at home. I have a treadmill that I actually walk on while I’m working. And so all of those things can lend to better posture, better cervical alignment as you’re working throughout the day, and that can all help you be better prepared to then go to exercise. But to answer your question about exercise in the neck, I think that we exercise our neck as we do other exercises. Certainly we know anytime that we do upper body exercises for the shoulder, we’re engaging a lot of those muscles that are paraspinal, that are up in the trapezius and into the neck. As well, but it’s very hard to, of course, exercise specifically the neck muscles, and that is bit of an issue. I know there’s a device out there that looks like a halo that is supposed to be a neck exerciser. I’ve seen it on social media and been a little bit scared.
Griffin McMath 10:15
So in preparation for this episode, I actually sent in our teams chat to Trevor and Chris a picture of an Amazon review of such a device. Unfortunately, someone posted a picture of their child who had to be what Trevor like under seven, and it’s attached to the door. So this kid is kind of like awkwardly hanging from this neck traction Halo device. It
Trevor Connor 10:38
looks so torture device.
Griffin McMath 10:41
Trevor was like, this looks like a torture device. It’s not just what happens on the bike. Dr Passarelli had one simple phrase for anyone stuck at a desk all day, motion is lotion.
Dr. Carol Pasarelli 10:54
Variety is so important, and motion is lotion. It’s a very simple kindergarten concept, but incredibly important, regardless of who we’re talking about, and regardless of if you’re an Olympic athlete or if you’re that weekend warrior. So how I see that applied here? And this comes up a lot in physical therapy, you know, if I’m giving you 10 minutes, 15 minutes of exercises, mobilization, stability, work, things to be doing prior to your ride, after your ride, then you’re on your bike for a long time. I am touching 15 minutes of your life, up to maybe 15 minutes, plus the ride itself. If we’ve made some edits to your posture or other pieces, there’s a lot of other hours in the day. So when it comes to sleep hygiene, when it comes to how are you sitting at work? Are you taking micro breaks? These are incredibly important questions, and oftentimes the more serious the athlete, the more we overlook these. So where I go with this is, if you are sitting down at your job, I would much rather you do 15 scapular squeezes and resets and 15 seated deep neck flexion, thin nods every hour, as opposed to giving you that really intense 45 minute go into the gym and do this twice a week, I would much rather see that you have more variety in your seated posture and getting in micro movements that are going to facilitate better motor control throughout the day, as opposed to layering on really intense exercises a couple times a week. I will say this, if you think about a cyclist and you think about an office worker, there is a lot of overlap in terms of what’s going on to your spine. So as you have your hands on your keyboard, those shoulder blades are reaching around your rib cage, you tend to have a little bit of extra flexion in your mid spine. Your lumbar spine is going to be in a similar position to that on the bike. And depending on how you sit in your chair, you might even have a similar position with your hips that is sort of an additional load that is similar to what you’re doing on a bike. So thinking about things like a standing desk, ways in which you can have a reset every 30 to 60 Minutes, we’ve seen a lot of studies that indicate that if you do maybe a 2010 ratio, 20 minutes standing, 10 minutes sitting. And it’s understandable if that’s not possible, that tends to be the best in terms of lumbar spine, mobility and health and decreasing pain. I would say that that, coupled with an understanding of where you want your neck to be in space, is a super appropriate ratio that you should be shooting for in your day to day.
Dr. Andy Pruitt 13:25
If I go back to my early days of working sidelines of football, once a player got a cervical injury, we sent them to the weight room and they did multi directional strength training to build up their neck. And if you build up your neck enough, suddenly they lost range of motion to look laterally down the line of scrimmage. So there’s a point of diminishing return between treating a cervical injury with strengthening, because you’re potentially going to lose some range of motion with that added cervical bulk, but that can be strengthened. But like what Jeff said, is that we strengthen it doing the things we do. So as we bend forward, we have to hold that bowling ball out in space, and all those muscles have to fire to hold it in space. So if you start your season with short rides, and you gradually build up your duration in that position, or your career, you build up in that position. So what Jeff is saying is that we’re strengthening the appropriate cycling cervical supporters just by riding our bike.
Griffin McMath 14:25
I think this is such a great introduction and smorgasbord of what we’re about to dive into. And so I think if we can pause and really talk about what this actually looks like, and then start looking at biomechanics, which Dr Pruitt has already talked about, we can really dive into the causes of neck pain, because, though Trevor gave a great example of true neck originating neck pain, neck pain can also come from many other areas. I just left a PT appointment, and we found out that my feet are contributing to my migraines. Of all things. Yeah, so how can riders tell if what they’re feeling is muscular or nerve related? Dr pastorelli walked us through a quick at home screen that almost every cyclist can try.
Dr. Carol Pasarelli 15:12
Given the high prevalence of tingling numbness down and into the arms and some pain in the upper traps, you have to kind of ask yourself, Okay, well, what’s going on? Right? Is this something that is a central spine issue. Is this something that’s more muscular in nature? And I will say this, if you picture yourself on the bike right and with your arms up and in front of you, you’re shortening a lot of tissues that tend to put pressure in and along your vascular and your nervous system. So tingling, numbness, that is not necessarily a red flag. That’s not a time where you have to necessarily go and get imaging, but we can go ahead and suss out. Hey, is this because there’s tightness in my muscles and that’s causing compression down and into my arms? Can I do something about that? That’s where I would start. If you are having some of those symptoms. There’s some special tests that we would do with you in the clinic to see if when your muscles are activated, you start to get those symptoms and reproduce those symptoms. There’s some very simple tests you could do. One of them is the ruse test, where you basically cactus out your arms so that your elbows are out to either side and like a 90 degree position, elbows are bent at 90 degrees. My biceps are straight out from my ears. If you’ve ever done that dance like, you know, don’t want to be a chicken. Don’t want to be a duck, and you start flapping your fingers down and tapping your palms. Well, go ahead and hold that position. See if you can tap at a relatively fast rate for up to three minutes. And if you start to notice that there’s some change in coloration, some sensation changes. While this isn’t a super specific or sensitive test, it can definitely help confirm that there’s compression in the system. And the great news is that means that there are appropriate mobility, stability, things that you can do and changes on your bike to help remedy that.
Griffin McMath 16:51
Dr sankoff, can we dive into the clinical presentation and how it’s not just ow at the neck? Yeah.
Jeff Sankoff 16:58
I mean, if you have an injury of your neck. Obviously, that can sometimes just present as neck pain, but often what ends up happening is, when you have a neck injury, you end up with muscle spasm in that area, and that muscle spasm can propagate downwards, so you can end up with pain in your back. You can end up with pain in your shoulders. And I do want to just take a moment to highlight really the red flags, the things that you have to really pay attention to. So if you have any kind of neck injury that’s associated with numbness, tingling, weakness, especially weakness in your hands, in your legs, I mean, those are things that you have to take very seriously. So you definitely, if you ever are having neck pain that’s associated with those things that needs to be evaluated immediately. That’s not something you mess around with. But most of the time, that’s not going to be what we’re talking about. Most of the time, we’re just talking about, hey, I’ve got some pain when I look to the left, or I’ve got some pain when I look down. Those are things that can be attributed to neck is complicated. It can be the muscles, it can be the myofascial tissue. It can be the ligaments. There are joints that line on both sides, all of the vertebrae running up from the thoracic spine all the way up to the skull. I mean, they can become inflamed and angry, and there’s just all kinds of issues we have, nerves that leave the cervical spine, that can become inflamed, that could become pinched. So it’s a small space, a huge amount of structures that are in there, and each one of them can become irritated to cause symptoms that can be local or can radiate elsewhere.
Dr. Andy Pruitt 18:33
That’s the complexity of the cervical spine. It cannot be overlooked.
Griffin McMath 18:37
Since Dr sankoff brought up red flags, we also wanted Dr pastorelli’s take on when that pain really does or doesn’t need imaging.
Dr. Carol Pasarelli 18:47
What I see oftentimes is that alarm bells tend to go off with folks when they start to notice things like a tingling, a numbness, in addition to pain. And what we often see with these cyclists is there’s a couple of things that could be going on. You could have it in the middle of your neck. Oftentimes we see this as your cervical and your thoracic spine come together at the CT junction. That’s what we would call it. Or it might be more on one side, or maybe on those traps on either side. You then might also start to get some numbness into the hands, some fingers and wrists. And that’s where I start to see folks going, oh my gosh, there’s an alarm bell going off. I really have to go get some imaging from the PT perspective, and actually, just the broader medical perspective, anyone who goes and gets an x ray on the spine is going to have positive findings. You know, it’ll say you have degenerative joint disease, you have stenosis. A lot of things are going to come up. And it’s going to say words like severe, it’s going to say degenerative. And it’s really scary, right? The thing is, that’s not highly correlated at all with pain. All of us have these quote, unquote pathologies, but oftentimes what I see is that we are conflating asymmetries or natural changes with age, with pathology and something that needs to be fixed or something that really requires an intervention. Now I should say pain does require an intervention, but the good news is. We can do that, right? Like your muscles pull on your bones, if you have a structure that doesn’t look very happy, say in your neck or lower down in your spine, that doesn’t mean you should be going to say chiropractor every week for the rest of your life. You shouldn’t go to any healthcare provider for the rest of your life. What you really should be doing is having go to the person who says they ultimately don’t want to see you anymore, right? That’s a bad business model, but it’s a great healthcare model. So ultimately, there are things that we can do to change your system. So oftentimes you don’t need imaging, particularly on your spine. You definitely should go see physical therapist, a do someone else who can look at you first.
Dr. Andy Pruitt 20:38
In preparation for today, I was Googling some really simple questions, and I Googled cycling neck pain, and the first thing I said was bike fit. Well, I don’t totally disagree, but the first thing is physical examination, because you can mess with bike fit forever and never solve the problem. So physical examination, I think, is key before any bike fit. So I’m going to correct that Google search and say cycling neck pain. The number one thing is examination, because you need to identify, is it a facet, is it a disc? Is it muscular? And then you can treat it with bike fit and physical therapy. Absolutely.
Griffin McMath 21:18
I think I love that too, because of the examination, because different providers have different schools of thought for how to do the physical exam, right? Jeff, how you’ve been taught might be different than how I’ve been taught versus you. Dr Pruitt, I’ve had professors in med school who did top down from your ear lobes down to your feet, and then I had a variety of other physicians like dos reuther training and osteopathic manipulation therapy, or maybe you’re a chiropractor or physical therapist who will start from the ankles up right, and then watch the chains as they go up and see how that could impact the neck, and to your point earlier, how you carry your head. So even understanding who you’re going to and I don’t want to say they’re biased towards the physical examination, but sometimes they’re biased of where they begin the physical examination.
Jeff Sankoff 22:06
Well, I think Dr prude and I are probably becoming dinosaurs in that the physical examination is becoming less and less of a thing nowadays. It’s really sad that a lot of younger physicians view the physical examination as the fastest way to get to ordering imaging. And I think that’s really unfortunate, because as a physician, I think the most important thing we do is lay hands on our patient in a way so as to diagnose and treat. And there’s no better way to determine what’s bothering a patient than to do a physical exam. You should never order imaging. I’m going to go on a bit of a proselytizing rant here. I apologize, but you should not be ordering imaging unless you have a sense of what you’re looking for. And the only way you can know what you’re looking for is if you’ve actually taken the time to speak to your patient and then evaluate your patient. And to go back to what Andy was saying about the bike fit. Yeah, the bike fit is a great treatment, but you can’t know that the bike fit is what is needed until you’ve actually spoken to the cyclist, examine the cyclist to determine what actually is a problem. Because I can’t tell you how many times the neck pain has nothing to do with the neck. The neck pain has to do with something going on in their back. It’s all a chain, and you have to be able to tease out what is the issue.
Dr. Andy Pruitt 23:18
You mean, the knee bone is actually connected to the hip bone,
Jeff Sankoff 23:21
I know, to the ham bone, to the trombone.
Dr. Andy Pruitt 23:25
Hallelujah, brother, you’re singing my song. There’s so many schools of bike fit out there. Some of them have no physical examination associated with them. They’ve never touched the rider. And people ask me, How do I find a good fitter? The key is, how do they start interview them? What are you going to do for me? Right? Can I bring my doctor or physical therapist reports to the bike fitter? Can you interpret those you know, bike fit is a science that needs to be associated with data, so beware of bike fitters who don’t do a physical examination or cannot work with your provider or interpret what your provider sends to them.
Griffin McMath 24:01
I think that’s the next deep dive that we do, these fit factors, the cockpit setup, the handlebar, reach, saddle bar relationship. So Andy, can we just go there? How can handlebar or cockpit adjustments reduce strain?
Dr. Andy Pruitt 24:15
Well, a reach too long, a drop too low, is going to accentuate your cervical extension looking up. And the more we accentuate extension, the more we load the little joints that Jeff was alluding to, the facets. The more we load those, we push those joints together, which also reduces the space for the cervical outlet nerve to get out beyond the facet. Those are the worst things. I mean, I don’t think people that have a short reach and a high handle bar suffer nearly as much as those who have a long reach and a low drop so finding that happy medium and in the proper cycling related physical examination, you put them through a range of exercise to see where they’re most comfortable holding their. Bowling ball or their head out in space, and that’s kind of where you start with that. So yes, cockpit is really the own it’s not the only saddle height can affect neck pain, but it’s rare. It’s typically the cockpit. So reach and drop that are going to affect reach and drop can include bar width, so wide bars. It really is frustrating for me in mountain bikes currently not to jump away from triathlon and time trial, but mountain bikes come with these incredibly wide, long bars, 880 millimeters. I think they come and most shops don’t bother cutting those down or fitting them to the small woman. So that’s like having a really long stem, right? So if you bring the hands closer together, that’s like shortening your stem. So there are bikes being manufactured and sold that are going to be the inappropriate fit right out of the box, and very few people are doing much about bar width, just for example. Now time trial bikes might specialize Shiv the base bar. I don’t even know how wide it is because there’s no choice there. It is, yes, what you get that base bar width, but I can manipulate the width of my arrow bars the extension. So the possibilities for cockpit exam are almost unlimited. So finding somebody that can work with all those unlimited positions, it’s really crucial.
Griffin McMath 26:21
Dr Pruitt just mentioned the importance of a proper exam before thinking about bike fit. Dr Passarelli added that sometimes the small adjustments we make on the bike can actually be part of the diagnosis itself.
Dr. Carol Pasarelli 26:35
Something that I often do with my athletes is use the intervention, use the treatment as a diagnostic. So I would just want to double click on hey, if you’re having pain with your bike, go ahead and put in an extra spacer and see if that improves or changes your symptoms. Simple things like that can tell us a lot about what’s going on with the body itself.
Chris Case 26:57
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Jeff Sankoff 28:08
in defense of the bike fitters, so much of what goes into a bike fit is the expectations of the cyclist. Oh, absolutely. And I coach time trialists who come to me and say, I need to look like this person, and I’ll say, Oh, well, that’s great. But are you that person? Because you’re not. And you know, I try to emphasize over and over again that the best position for you on the bike is going to be the position that you can hold comfortably for the duration of your race. Let’s then worry about how aero it is and everything else. And you’ll hear from road cyclists all the time. It’s like, gosh, I love this bike, but it’s really uncomfortable. And I’m like, Well, why are you trying to look like tare pagacia on the bike if you’re not Tade pagacia. So you know, I just learned from a friend of mine about this bike brand called open, which was a collaboration between the owners of Cervelo and BMC. They got together and they wanted to make high end bikes for people my age, who generally love to ride but can’t really ride in those very aggressive positions. And so they’ve been making these really incredible bikes that have geometries and have layups that are much more comfortable for people who have these problems of age. We’re a little stiffer. We don’t have the flexibility to be able to have the slammed front and the long reach. So there are ways around it, and there are things that can be done. But I really do feel for the bike fitter who faces the cyclist who comes in and say, I want my front end as low as possible, and I want this, that and the other. Because if you’re already starting from there. It’s kind of hard to work with that.
Dr. Andy Pruitt 29:42
I had hundreds of those over the years. I love the one who bought their bike online, or they had a custom bike, custom built, oh geez, yeah. And just, I’m sorry, but your $15,000 bike will never fit you. There’s nothing I can do for you. Physical examination wasn’t part of that. Custom design. So Jeff, it’s so right on that there is a customer, client expectation. So my philosophy is the bike needs to look like the athlete, not some other athlete, but your bike needs to look like you, and it can only be made look like you if the fitter does the thorough exam to make that bike look like you. And so the brand you’re talking about is basically building what we call endurance is a family of bikes that started with a specialized Roubaix, which hadn’t been my idea, but waved my flag too loud, but it gave birth to a whole new family of bikes they called endurance bikes. And it was a higher head tube, shorter top tube, some suspension, and it gave birth to, I mean, trek started, everybody started to build them, but as they became known as Old Man bikes, even though they won the Roubaix, what, four times in a row, five times in a row, but they became to be known as Old People’s bikes. So trek specialized and others started to shrink down that head tube and make them racier, and the whole category was virtually lost. So I’m thrilled that open is actually coming back to a bike frame that starts with more potential for a comfortable
Jeff Sankoff 31:15
fit, and they’re pricing them for the people who are going to buy them, so they’re not going to be looking to make them more aggressive. I wanted to go back to what you were saying about the aero bikes, because the nice thing about today’s super bikes is that they are incredibly adaptable and incredibly configurable. And what I tell athletes all the time is you don’t have to stick with the fit you get initially. So go in and let your fitter set you up so that you’re comfortable and recognize that the longer you stick with this, the better you train, the fitter you get, the more flexible you get, that fit can be revisited, and you probably will be able to become more aggressive over time. Just allow that fit to happen over time. Like you said, the bike’s gonna look like you. And as you evolve as an athlete, the bike can evolve with
Dr. Andy Pruitt 31:59
you, and that goes in both directions as you get older, that position might change or during certain parts of your career. So as a young racer, I was riding a bike that was too small for me and too narrow, because that was my job, was to get through that last little hole and lead out my teammate and the crit, that was my job. And suddenly, then I start to work more hours and blah, blah, blah, blah, my bike got bigger, my front end got higher, and then I retired. Got fit again. Guess what my current bikes look like? My bikes in my 30s. So good point, Jeff, fit is dynamic, and should move with you as you go through your career.
Trevor Connor 32:36
So to your point, there was one study that actually did read leading up to this, couldn’t help yourself. I could not help I honestly couldn’t I’m sorry, but the title of it was discomfort, pain and fatigue levels of 160 cyclists after a kinematic bike fitting method and experimental study actually impressed. They brought in 160 cyclists and gave them all bike fits. How long that took? Yeah, but they had three measures. So the point that they made is, there’s lots of studies about bike fit and performance, but there’s been almost no studies on bike fit and comfort. So the three metrics they had in this study were, one was feel, so just the overall feel before and after, Omni, which was fatigue before and after, and then vas, and they did that by neck and back. That’s measure of pain, yep. And it was actually pretty dramatic in all the cyclists, the improvements they saw on all three metrics after a good bike fit. So they’d first do the measures, then do the bike fit, then have them ride for 30 days, and then come back and do the measures, and you saw all of it improve. And they had two really good conclusions, in my opinion, I’m sure both of you would love to address but they said this is really valuable for two reasons. One, because we had a lot of new cyclists in this study, relatively new. They had everything from new to very experienced. And said this could be really important for new cyclists, because how many people try cycling and leave just because it’s painful and is uncomfortable, 100% and this would encourage them to stick around. But they said, stick around. But they said this is also really beneficial for the much higher level cyclists, because if you aren’t fatiguing as quickly, if you’re not dealing with pain, you can probably train better and train harder than if you’re constantly dealing with
Griffin McMath 34:16
issues. And for that, go listen to our pain episode recently,
Dr. Andy Pruitt 34:21
my original comment would be that performance has lots of metrics that we can measure. Did we make them better? Did we make them faster? Comfort, however, is just so difficult and so personal that comfort is just almost an impossible metric to measure when it comes to bike fits. So I love positive feedback from patients. Oh yeah, I’m so much more comfortable, but I hate the way my bike looks. Oh well, so I’ll tell you a funny story. My wife, 25 years ago, had a anterior, posterior lumbar fusion and lost significant range of motion. So we designed and built her a custom bike. I’ve forgotten what the head tube was. But the seat tube was equal to that of a 57 or 58 centimeter bike. The top tube was equal to a 52 centimeter bike, and the toe overlap was so much that we had to put smaller wheels on it. When the bike was leaning up against the cafe wall, it looked like she lost her job in the circus, but they let her keep her bike, but when she was on it, it was a thing of beauty. It was a concert of symbiosis. So the funny looking bike can look great under the right athlete. That
Griffin McMath 35:31
gives me hope. And I want to kind of not pin the two of you against each other, but differentiate between how you can identify neck pain due to bike fit versus a physical musculoskeletal issue. One thing I want to say, just because I just left this appointment, when we talk about neck pain, we talked a lot about localized pain, right? Localized etiology? I, similar to Trevor, have struggled with migraines since my early 20s. I’ve had car crashes and the moose thing that happened last summer and all these different things that could have contributed to very direct, localized neck pain. But very few times when I’ve gone in for assessment of migraines or assessment of my neck pain, has anyone looked anywhere else, right? Imaging check done. And so I’m in such a great mood right now, because I got some really amazing information, but we looked and I have two very different size feet, so much so that I rotate one of my legs internally to almost balance and offset, so that I feel safe when I stand. Now, I’ve been doing that for 30 something years, which has completely rewired so much, but it has structured how one of my hips drops and how one of my thoracic spine has to compensate, and then where my neck pain happens, which, lo and behold, folks, is the side that I always get my migraines on. And So had I continued to just go to get massage therapy or acupuncture, or all these other things, and we never looked beyond the localized pain. I’m not saying that’s the only contributor, but similar to Trevor getting massages in his neck, you have to look more than just what’s the obvious. I just want to give a quick shout out in case anyone else is like, well, we’ve tried everything localized. Maybe look beyond the area for other contributing factors.
Trevor Connor 37:22
Before you two jump on this. I think you brought up an important thing, because I’m going to tell you one of the biggest tricks I pull to make people think I’m a better coach than I am. I have worked with so many athletes who go and get an evaluation, and when I have the call with them after the evaluation, almost every time they go, you wouldn’t believe what the doctor told me. And I always before they have a chance to say, Go, you have a leg leg discrepancy. Like, how do you know that? I’m like, I’m a good coach. True. The matter is, if I ever had an athlete say to me, my legs are the exact same length, I’d be like, Wow, really? Yep. But that’s an important thing, because it is a common thing, and that can lead to issues.
Griffin McMath 37:59
This isn’t common. I’m going to do this because you’re here. Look at the size difference. Holy crap. There we go. I had an orthopedic surgeon when I was younger. Go, oh my goodness. And I looked at him as a teenager, and I was like, you’ve seen club feet. You can’t react to me that way.
Dr. Andy Pruitt 38:13
Well, so the appropriate bike fitter would have examined your feet. Yeah, the right bike fitter is going to notice a leg length. It’s gonna know whether it’s tibial, femoral or some kind of muscle imbalance in the pelvis. They’re gonna know whether one foot collapses more than the other. They’re gonna know whether one foot’s longer than the other. The bike needs to look like you, including foot length,
Griffin McMath 38:34
so I get a cool bike like your wife is what you’re saying.
Dr. Andy Pruitt 38:37
You gotta get a job in the circus. Well,
Griffin McMath 38:40
then that’s great. So let’s go back to this question. Then, Have either of you noticed patterns that can distinguish a fit issue from a true clinical concern? And by true clinical concern, I mean, obviously the etiology has nothing to do with the bike fit. I
Jeff Sankoff 38:55
mean, the problem is, I’m their coach, so if I’m hearing about their neck pain, it’s with respect to their bike or maybe running or something. So I don’t get to sit with them and examine them and get a full history. I make it very clear to all of my athletes, I’m your coach. You know, obviously I’m a physician, so I could sometimes tease out these things, but I’m not your physician, so I try not to be their doctor. So I can’t say, I mean, I can’t say I really have that kind of intimate knowledge of my athletes, so that I would be able to find those kinds of patterns. I think, like Trevor, I know everybody has a leg length discrepancy, and I’ll use that to my advantage, if possible. But I’m not going to be able to really get to the root of like, something like you described Griffin. I mean, that’s just not going to be something I’m going to have that kind of knowledge, and I do want to also, just because I’m a stickler for this kind of stuff. When you and Trevor talk about migraines, you’re talking about severe headaches,
Trevor Connor 39:49
correct? When it comes to both of us, we get all the symptoms. We get, the aura, the digestive issues, yeah, it’s everything. Oh, you do,
Jeff Sankoff 39:56
yep, because that’s a vascular thing. While I do not diminish. The likelihood that there are other things that could contribute to it. There are often triggers for migraines, and there’s all kinds of things. Migraines are the great mystery. I suffer from them as well. I take medication to prevent them. They’re a literal pain, and I sympathize with both of
Trevor Connor 40:16
you. You know, to that point, I was talking with a really good MD A couple days ago, and he made a point which I agree 100% with, which is any disease where there is a single cause and a very clear ideology, we’ve pretty much cured at this point. So all the things that we still are dealing with, it’s because they’re complex, because there’s many causes. So yeah, my neck pain is part of it. I think if we completely solved my neck pain, would I go, Yeah, I’ll stop having migraines now. No, they’ll become less frequent. But there’s multiple
Dr. Andy Pruitt 40:47
causes. I want to go back to Griffin’s original question. So if a patient came to see me and we spent, you know, 45 minutes together for a physical exam, maybe imaging whatever, before he ever went to the bike lab. So the first question is, does your neck only hurt you on the bike and never any place else? Then you got to look at the bike, and if they say, Well, no, you know, my neck hurts me when I drive or when I study, it wakes me up at night, then we’ve got to look way deeper into the etiology that’s not bike related. We would use the bike fit to help support them, to get some relief, but their solution is found somewhere in physical therapy and some other locale other than the bike fit lab, right?
Trevor Connor 41:33
So here’s a question I have for both of you that I’ve really wanted to ask when it comes to neck pain. So we’ve said before on the show that knees are a victim, that when you get pain in your knee, unless you got hit by a car in the knee, the origins tend to be elsewhere. It’s a leg discrepancy or a hip issue or an ankle issue that ends up expressing a knee pain, I think with the neck a lot of times. No, it’s the neck. And cycling is a very tough sport on the neck. So my question to both of you is, if you’re a lifelong cyclist like all of us, is neck issues just an inevitability. And look, that’s kind of been my Zen about it. I get off the bike, my neck is hurting, and I go, I’ve been riding a bike for 30 years. This is just part of it. And oh, well. But is that the case? Because, Dr prude, you’ve been riding longer than me, and you say you get no neck pain. Well, I get
Dr. Andy Pruitt 42:25
lots of neck pain, just not on the bike. Okay? I mean, that’s a pretty interesting thing. I’ve acclimated to that position. No, when I was 16, I rolled a car, and so I deserve all my crepiness, and when I moved my I moved my neck, but I’ve acquired that position with appropriate strength and range that I do, okay, you know, and my TT position, I wish it looked better. I wish I was a little lower in the front. But you can speak to this too, Jeff, that we now know that being low in the front is not the end all to aerodynamics. Being narrow is far more important than being low. So if you look at the latest Iron Man, we’ve been able to convince athletes that there don’t have to be slammed in the front end, that they can be higher and have more cervical and shoulder comfort and still be significantly aerodynamic.
Jeff Sankoff 43:15
Yeah, you know neck pain, unfortunately, the spine, just top to bottom, is fraught. It’s asked to do a lot, and it is very susceptible to breakdown. And the deeper you go down into the spine, although the bones get larger, the discs get larger, the susceptibility to disease also gets greater. But the neck is very special, as I mentioned before, it has motion in several different planes, especially at the junction with the skull, where it really has an incredible amount of motion. And all of that motion means that there is just continual exposure to potential friction points to all kinds of different stresses and forces. Do all cyclists have to end up with neck pain? I would say no, and I don’t think there’s any way to say that one cyclist is not going to get it and another cyclist is knock on wood. I’m fortunate. I don’t have issues. I have other friends who do, and there’s really no major differences between us. I just think it’s honestly just luck of the draw in a lot of ways. And who knows, maybe next year I’ll start having these problems. Hopefully won’t. But yeah, and then, just to go to what Andy was saying about the new sort of thoughts on positioning, he’s absolutely right the whole in the last what, five years, the praying mantis kind of positioning has really changed the way athletes are approaching their setups on their bikes, and we see with tri rig and with vision bars, all of these very wide and comfortable arrow bars that people can really shift the way they are putting their weight forward. I actually. Changed my cockpit this year, and actually, I’m able to get lower down with less weight on my forward just because of the way the new bars are set up, and I have my hands higher than they were before. So it’s a really interesting way that the physics have kind of changed, or at least our understanding of the physics, and have led us to change our fit and allow us to be more comfortable and hopefully have less of these problems with neck pain.
Dr. Andy Pruitt 45:26
Yep, you talk about the praying mantis that you know. If we get low and stretch out our elbow, extend our elbow, it’s going to push us up. And as we bend our elbows, which the snowplow has become more popular again, we get to drop into that position. So fad actually dictates position a lot, and as the snowplow has come back into fad, then we also can get lower and still be comfortable. It’s pretty interesting. I changed mine I’m 75 years old, and trained for the National TT championships this year and snuck onto the podium, and I spent a lot of time refining that front end, and I brought a front end in from England that has lots of adjustability, and I don’t know, I probably had six different consultations with my fit guy. Am I an expert fitter? Yes. Can I fit myself? Absolutely not. So it must have taken me six or eight times to really get it to where was the position I ultimately rode the last six weeks before nationals. So yeah, love the new adjustable bars that let us use a little more elbow flexion, which actually is more comfortable, takes the stress off the shoulders the triceps. So the industry was listening. Thank
Griffin McMath 46:36
you. Congrats to your podium. Yeah,
Jeff Sankoff 46:38
my goal is to hang on to my 80s, so there’ll be sufficient attrition amongst the cyclists so that I can get onto a podium also.
Dr. Andy Pruitt 46:44
Well, I will tell you that as I lined up at Nationals, I looked around, said, I know all these guys, we’ve been racing against you for 50 years.
Griffin McMath 46:53
Well, while we’re wrapping up the etiology of neck pain, the last thing I want to touch on is demographic difference. So, Doctor, Doctor, do you concur or do you not concur with a statement that neck pain manifests differently between triathletes and cyclists?
Dr. Andy Pruitt 47:10
Well, cyclist is too big of a word. That’s too big of a category, right? So a tourist cyclist is going to be on one of the new open bikes Jeff was talking about with more head tube more in, a little bit more up at right position, he’s going to be far more comfortable. He’s a cyclist. There’s going to be the elite road racer whose road position doesn’t look too different than his time trial position. He’s going to be far higher risk of cervical issues. And then you take the elite time trialist. They’re going to have the most aggressive position. They’re all cyclists, the triathlete they were told as soon as they entered their first triathlon, you got to put at least clip on, bars on you got to at least lean over, right? So Jeff, jump here. Help me out here. Help me off the island.
Jeff Sankoff 47:56
I honestly don’t think so Griffin. I think that if you are going to have neck discomfort. It’s going to be in the same place, it’s going to be posterior, it’s going to be on rotation, and it’s going to be no matter what position you’re in. It seems to me that if you are spending most of your time in an arrow position, you’re more likely to get this problem. But I don’t have any science to back that up. I’m speculating, just based on my understanding of all of this, but I have to say, like this is not one of the main complaints I hear from my athletes. My athletes have a lot of complaints, but neck pain doesn’t tend to be one of the major ones. And I think a lot of that has to do with just triathlon in general, because you’re swimming and running, so you’re not spending all of your time biking. Now, I’m sure if I worked like Trevor does coaching just cyclists, I would probably hear more of that.
Dr. Andy Pruitt 48:49
So you just triggered something in my brain swimming. If they breathe out of both sides you they’re gonna have symmetrical rotational strength. I think that’s gonna be a safeguard. Would you not agree? Well,
Jeff Sankoff 49:02
I mean, don’t forget, you’re buoyant in the water, so there’s less muscular force to turn. And then the other thing is, you’re not just turning your head on your neck. You’re actually turning your shoulders as well. Yep, understand, I breathe only to one side, and I don’t tend to have major problems.
Dr. Andy Pruitt 49:18
The side you breathe to Is that easier to look behind you for traffic than the
Jeff Sankoff 49:22
opposite side? Don’t think so. Okay,
Dr. Andy Pruitt 49:26
just testing my theory on a sample. Just did that.
Trevor Connor 49:29
No, but you know, the thing I would bring up is, I think having that mix of sports where you’re doing different motions is gonna be better for the neck, where on the bike you’re in an uncomfortable position, you kind of lock your head in that’s going to lead to some bigger issues. Yep, so to kind of move us into the practical side, let me ask you guys a question to start, which is, if you’re talking to a young cyclist in their early 20s, and they’re looking to become a lifelong cyclist, and you’re having the Connor. Conversation about the neck, what would be the things you’d be telling them to do so that they don’t end up like me in their 50s, where you know to take your point looking at traffic, I literally have to turn my whole body in the car. I can’t turn my neck enough to see traffic coming at me. So to avoid that, to keep that healthy, strong neck through a very long career on the bike. What should they be doing?
Dr. Andy Pruitt 50:24
I think off bike activities are really important. You need to have a whole body stretching and strengthening program that is associated with you as a cyclist, and that program can change as you age. But you can’t just ride your bike. I mean, I just so against just riding your bike. So I think I would encourage them to get started in a off bike program that includes range of motion and all body strengthening. That’s where I would go with it.
Trevor Connor 50:52
So strengthening is definitely important. What about flexibility? Is that going to help or hurt?
Dr. Andy Pruitt 50:57
That’s the range of motion. That’s the Yeah, stretching and strengthening.
Trevor Connor 50:59
Absolutely. Jeff, what’s your thoughts?
Jeff Sankoff 51:01
I was just gonna add on to that and just say we often ignore, like our hip flexors, and we know that cyclists continuously have this problem with like, tight flexors, and I think it’s the same thing with our upper shoulders and neck. And I started this year, I incorporated a new stretching and mobility routine every morning, and I found it helped a lot just in terms of giving me more flexibility. I do not want to say that this is injury prevention, because there’s a ton of evidence that shows that increasing and improving mobility does not necessarily prevent injuries, but I think what it can do is it can give you back some of this range of motion that you’re talking about, Trevor, some of this idea that when you get off the bike, you’re going to feel more comfortable. And just by doing basic things like 20 minutes a day of just shoulder shrugs, rotating the shoulders forward and back, and doing this side to side with the head and the rotations, those things will improve your mobility, improve your flexibility, and can go a long way to just alleviating some of these symptoms. 100%
Dr. Andy Pruitt 52:07
agree, and I actually have a little routine I do before I leave the garage, and it’s hip mobility and low back and neck. And I just figure, if I get them lubed up before I roll out of the garage, I’m gonna have a better day, a better day on the bike. I also
Trevor Connor 52:23
think the two of you touched on something really important, which is, when you’re talking about keeping your body healthy and keeping your mobility, you need to be doing range of motion and strength together. Because there was some research that was very anti working on flexibility, working on stretching, because to use the technical term, if that’s all you do, you get a floppy muscle. So do that stretching, do that range of motion, but it needs to come with strength work as well. So the muscle, as it lengthens, can still do its work. It still has that strength. Yeah.
Dr. Andy Pruitt 52:54
I mean, there are several areas of sports science which so massage. There is zero quality research that says massage helps you. There’s zero quality research that says compression, like compression boots and all things, they help you, but we all know it does, right? It’s just that comfort and that improvement is impossible to quantify. So somebody said, Well, you know, compression doesn’t help you. It’s no proof. Well, then why do in the or we put compression socks on every athlete to help move that stagnant fluid, you know? So there are areas that are tough to measure, and we just we know from long term wives tales that certain things are true
Trevor Connor 53:37
and that research is actually recently starting to change a little. They’re completely changing what they’re looking for. So what they were looking at in the past, you know, they did the typical well, how do you do a study? Well, have them stretch and then have them do a time trial, right? No, you’re not going to stretch and improve and you’re not going to foam roll and then get on a bike and be faster. So they started looking more at recovery metrics, and there’s been a few studies that have actually looked at the immune response, because immune response is responsible for the repair of muscle tissue and adaptations, and they showed that you got a better cytokine profile with massage and foam rolling than you did without So,
Jeff Sankoff 54:15
yeah, listen, I don’t disagree with that. You’re right. I fit massage and compression boots and ice water baths. I put them into a bucket of things, because I’ve reviewed all of these extensively on my program, and I put them into a bucket of things that is, don’t expect anything, but you know what? They feel good, and if they make you feel good, then why not? And I’ve looked at that data about the immune responses, and that’s great. You know, what I care about, though, is performance. And if my white cells or my cytokine levels are better, that’s great. But if I’m not going to perform any better, then who cares? And a lot of this data, that’s what it boils down to. And you know, listen, physiology explains a lot. But. Predicts very little. Like, there are tons of things where you see these kinds of studies that come out, and it’s like, oh, the markers are so much better when we use XYZ. And I’m like, That’s great. Show me how they perform. And once you show me how they perform, if there’s a benefit, I’m all in. And listen, I own a pair of compression boots. And you know why I think compression boots are good for you, because they make you sit still for half an hour or an hour, and if you just sit still for half an hour after you’ve had a hard workout, that alone is going to be good.
Trevor Connor 55:30
Here’s my one counter argument, too. So if the cytokine profile is improved and that both aids adaptation and aids recovery, which would theoretically improve your ability to train you would not see immediate performance gains, but over time, and it might be a year or two years, would you potentially be performing better than if you didn’t do these things? And unfortunately, that’s theoretical. That’s the research that is almost impossible to do. Yeah, that’s
Jeff Sankoff 55:57
the word theoretical. It’s a
Griffin McMath 55:58
guess. Yeah, listen. Dr sainkoff, I say the next episode is gonna be an absolute showdown, because I stand with Trevor so strongly on this point, I’m ready to go just after this episode, because I do have to take us to this next question. But just know that Trevor and I invite you back. I’m speaking on behalf of Trevor on the research on
Jeff Sankoff 56:15
massage. I get massage frequently because, again, it feels good. Oh
Griffin McMath 56:19
my gosh. I’m gonna bring you out of the soft science mentality.
Trevor Connor 56:23
We have to have him in the room because, oh yeah, computers to my side, and my neck is so bad I can’t look at
Griffin McMath 56:30
him full circle. Okay, so to provide some juxtaposition to Trevor’s really great discussion of longevity and neck pain and how to go the distance. Let’s just make sure we’re doing our listeners justice by understanding acute neck pain considerations. This is in case an athlete’s listening or a coach is listening. When does neck pain signal a more serious problem?
Jeff Sankoff 56:56
So as I said before, the red flags are any neurologic symptoms, if you have any tingling, any loss of sensation, and certainly any weakness anywhere, and that’s associated with acute neck pain, you need to immediately seek evaluation. If you have loss of bowel or bladder control. Those are really serious. That’s a whole other level. And then the other one is, if you’ve had an injury, like a trauma, like you fell down, sometimes people fall they land on their face, and they don’t recognize that they’ve put a huge stress on their neck. If somebody runs their fingers down your neck, the bones of their neck and you have specific point tenderness on one of the neck bones, that’s probably an indication you should go get looked at as well, because there are ways that you can actually break a bone in your neck without having any neurologic symptoms. And so you should be careful about all of those things. I love it when somebody
Dr. Andy Pruitt 57:51
says, I broke my neck. Well, did you transverse process? Dorsal spine? What? Yeah, I think it was one of those, okay, you broke your neck.
Trevor Connor 58:02
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Griffin McMath 58:27
So now that we’ve covered long term, we’ve covered acute, I feel like everyone wants to know, okay, well, what do I do about it? So let’s merge into the lane of solutions for neck pain, and maybe a fun place to start is gear innovations, and what we hope to see
Jeff Sankoff 58:46
before you go there, I do think it’s really important to say what you should not do. And I say this at the risk of further inflaming you. Griffin, bring it. Stay away. Do not ever let a chiropractor touch your neck. Ever listen? I know there are people out there who are going to going to say, Oh, he’s a doctor. He doesn’t like chiropractors, just please do not let a chiropractor ever touch your neck. There are legions of stories of chiropractors doing manipulations on people’s necks and causing strokes, and the reason for that is because there are two blood vessels that run through the vertebral bodies of your neck. They’re called the vertebral arteries, and if a chiropractor puts torsion on your neck and trying to do a manipulation, they can tear those blood vessels, and you could get a devastating stroke. And it has happened. It happens every year. If you just do a Google search, you will find numerous cases of this happening, so please, if you have a neck problem, just don’t let a chiropractor touch your neck. That’s the big thing I want to get across
Dr. Andy Pruitt 59:48
here. Well, I would put a little bit of a caveat on that in that I sure wouldn’t have a chiropractor or osteopath manipulate my cervical spine without a significant and appropriate workup prior. I’ve seen too much. Relief occur from cervical manipulation done in the right hands. So I don’t want to throw a blanket over the entire world of osteopathics or chiropractics, but I think that the appropriate imaging and thorough exam first. But I do appreciate what you’re saying about the stroke and the cervical arteries. It is out there. It is in the literature compared to the number of cervical manipulations done in the world. I say it’s probably a very small number, but I absolutely appreciate where you’re coming from, especially as an emergency room physician.
Griffin McMath 1:00:31
Yeah, I’ll round this out. You’re not inflaming me as much as I think you’ll inflame me, other than I really appreciate you calling out that there’s more than just chiropractors who do hvla On the cervical spine. And that could be a chiropractor, that could be an ND like me. That could be a do who does OMT it could be a variety of providers that, being said, a high velocity adjustment is what this would be called, is not something to and I’m going to be a little bit more casual in my speak here to willy nilly, get where it’s one of those revolving door clinics. If it’s the feeling of a revolving door clinic, and you go in and out in 20 or 30 minutes, and you get on the table, you get a rack them and crack them, and then you’re out. That’s not a place that should be touching your neck, because you aren’t getting a proper assessment through that if someone to Dr Pruitt’s point has done extensive history medical exam, there’s been imaging, there’s been a family medical history about different vascular conditions, if there’s been so much done, cervical adjustments in a time and place can be appropriate that being said, after my car crash in 2020 I went to a chiropractor with these exact concerns that Dr sankoff had said, because I had a student adjust my neck after med school so terribly that it looked like I had Bell’s palsy for like two weeks. It was terrible. So I’ve experienced the good and bad, but this chiropractor used a very specific machine, and at first I thought it was pseudoscience, because I was like, I don’t know what this is, but it was so gentle and so subtle that you almost didn’t think it worked. And that’s the only manipulations that were ever done to my cervical spine, and he happened to be a chiropractor. So I think this kind of spectrum of disclaimer and warning is healthy to have in full that we just did. Because one, you should know that more than one provider type are trained in that and that each of those should be held the same scrutiny and two cervical spine high velocity adjustments should be reserved for very, very few circumstances.
Dr. Andy Pruitt 1:02:37
I think it’s the high velocity that that Dr sankoff was really referring to, yeah, I mean physical therapists, the manually trained, especially Australian manually trained, physical therapists, do a lot of cervical mobs, yeah, and do a lot of good, but it’s the High Velocity thing that are going to rip an artery. I
Trevor Connor 1:02:53
did want to add to that, because there are different types of chiropractors have different quality. And if you go see that chiropractor who just you walk in, they crack a bunch of bones and then say, Oh, you need to come back three times a week. Be careful about
Dr. Andy Pruitt 1:03:07
them. Even worse are the ones that do a manual muscle test, and then they wave a magic wand to another magic manual muscle test. Oh, you’re
Griffin McMath 1:03:14
stronger see, oh, I know you’re tired. It’s applied Kinesiology. Is what it’s
Dr. Andy Pruitt 1:03:18
called, yeah. I mean, the second rep is always stronger than the first rep, sorry. So beware of your caregivers.
Griffin McMath 1:03:25
That’s all. I think the last thing I would say this is just from my personal experience watching different providers do this. I always watch to see after someone has done a high velocity if they return the spine really quickly into your anatomical position. So if they make the manipulation and then, like, fling it right back, rather than allowing your body to adjust, that’s always a flag to me, and I’ll never let that person manipulate my spine in any capacity. So if it’s and then back, I won’t do it. If they sit, wait and then they slowly allow the muscles to bring back to center, that’s always a cue to me,
Jeff Sankoff 1:03:58
Wow, I really opened up a can of worms there. Here’s the
Trevor Connor 1:04:02
last thing I’m gonna bring up. Have any of you guys watched America’s Got Talent, I mean, so this year, they had this Indian dance team where they had this one dancer. They literally, in the middle of the dance routine, grab his head and turn it around so that he is looking completely backwards. Oh my gosh. And every time I watch that and just go, I want to see what you’re like when you’re 60, Yeah, or like, two
Griffin McMath 1:04:27
years from now even,
Dr. Andy Pruitt 1:04:29
it’s like circus Soleil. Can you imagine what the low back looks like on those people? The total back bend? Oh, my God.
Jeff Sankoff 1:04:35
All right, I want to bring it back for you. Griffin. You wanted to know about gear. So the one thing I’ll say about geared. One thing I’ll say about gear. You know, we talked about aero before, and there was, for quite a long time, the most aero helmet available to the average age group athlete was the Giro arrowhead. Great helmet. I had it. I loved it. It was great. The problem was it was also like the heaviest helmet you could buy. And. And I didn’t have real neck problems, but I did have a couple friends who did, and they just could not wear that helmet. And we’ve seen now, over the last couple of years, I think an innovation is that aero helmets that are extremely aerodynamic have gotten significantly lighter. And I think that is a innovation, because you still have their you know, an arrow helmet is larger than a road helmet. It is, by necessity, going to have to be a little bit heavier, but it did not have to be as heavy as the arrow head was. And I haven’t seen an arrowhead recently. They might be lighter now, and that is a fantastic helmet. I don’t want to disparage those helmets, because they really are terrific, but it is nice to see the lighter helmets coming out, so that if you do have neck issues, or you’re worried about neck issues, you have options.
Dr. Andy Pruitt 1:05:47
Yeah, like I said, the head weighs from five to 12 pounds, like a bowling ball, so why put a heavy hat on? Yep.
Jeff Sankoff 1:05:53
Also the vision right to not have to extend your neck quite as much to be able to have a field of view with your head down low. We are seeing more and more visors incorporated into helmet that allow for improved vision. And I’d love to see a periscope. I think that would be great.
Dr. Andy Pruitt 1:06:12
It was tried Race Across America. You know, shermers. We didn’t talk about shermer’s disease the ultra endurance race across
Trevor Connor 1:06:19
America, but I can never pronounce it.
Dr. Andy Pruitt 1:06:22
The racers name was his first name, Bill. Anyway, he had such neck drop his he had such fatigue that they taped his helmet to his back to hold up his head so he could finish the race. Which brings
Trevor Connor 1:06:35
us to what should be another episode, which is you can solve everything with duct tape.
Griffin McMath 1:06:41
Triathletes, time trialists, this one’s for you. We asked Carol, how riders can balance that aggressive arrow position with long term spinal health.
Dr. Carol Pasarelli 1:06:51
Being in an arrow bar position exacerbates already the abnormal spinal load and scapular loads that we see that often perpetuate neck symptoms. So that said, as a healthcare provider, I’m a big fan of variety, right? Variety is a really helpful tonic and keeps you away from injury. So obviously anything you don’t want to do too much of, but if we have to get into that training position, okay, we have to get into that training position some really silly things that I have tried before is, let’s say you’re in a home environment, and you’re getting into that aero position and doing an at home ride. Okay, maybe you can pull out your climbing belay goggles so that instead of looking forward, you can basically use those if you do have to peak up, that can save on your neck and over time, that kind of thing does add up. In fact, if you’re doing a home ride at all, those goggles are great if you’re trying to, say, watch some TV at the same time to decrease that load, and that transition from flexion in the mid spine to extension in the upper spine. My other thing too is, if you’re training for a very specific reason, for a very specific task, we don’t have all the time in the world to quote, unquote, correct for what that does to your body, and we shouldn’t put that as a top goal, right? So something that is super appropriate can improve on pain and improve on comfort and longer cycling positions would be looking at your mid spine mobility, so thinking about doing the opposite of what you’re doing on the bike. So extension or think of like a cobra pose, and also rotation, because those are relatively coupled motions. These are things that we’d want to add in, and something that you could do prior to your ride that would likely improve your comfort throughout the ride. That said we shouldn’t look at that and say you have such a deficit because you’re on the bike all the time, and we have to what undo all of that at the end of the day, your body’s doing what it needs to do to be good at the task you’re asking it to do. So with my athletes, I want to balance giving them interventions that sort of change their system while not totally disrupting their training. If I were to pick out the biggest bang for your buck in terms of getting more comfortable on the bike, you definitely should be thinking about your extension and rotation in your mid spine, improving your strength in the periscabular muscles, and thinking about the serratus anterior and your lower trap specifically, those are the muscles that you should probably strengthen. And yes, we want to mobilize and maybe relax or change some things up in the upper trap. But that’s really going to come when you get this lower trap serratus anterior strength. And the other piece of this is, if you can picture on the bike as you’re looking up, you have some length in the front of your neck, and this can be really challenging for the deep neck flexors. And this group of muscles is very specific to train and can feel very awkward when you do it right. But being able to do long isometric holds with the front of your neck, that’s actually an incredibly important component that I would assess the first day in the clinic. And if you can’t hold a deep neck flexor endurance hold, if you can’t do that for as a cyclist, 4045 seconds against gravity, we have a problem. You. We definitely need to hit that as well. So those are sort of the major buckets I would try to. Ill in terms of trying to help with the longevity and the decrease in your symptoms on the bike.
Griffin McMath 1:10:05
You know when we talk about future directions of gear and how that can contribute? I’m also curious about your thoughts on posture feedback devices, especially as it relates to not only day to day for the average person, or when they’re off the bike, but incorporating that technology while on the bike,
Jeff Sankoff 1:10:26
I think that’s an interesting thought. I have seen some of these devices out there. I have not looked into them myself, so I can’t comment on whether or not they do what they say they do, or whether or not when they’re doing what they say they’re doing, if they’re actually providing useful change, but if they do, then I think that’s an interesting kind of premise. And sure, why not. But I’d like to know more about the devices.
Dr. Andy Pruitt 1:10:52
Yeah, it’s basically biofeedback, right? It is. So there was a biofeedback device for golfers to keep their head down, and it basically was a strap that went around their genitalia and around their neck, and if they stood up after the swing, something got yanked on. So that was the original biofeedback machine.
Griffin McMath 1:11:12
You know, I have so many follow up questions Trevor’s duct tape point are for a very different episode on the mental state of the person who created such device, and I don’t see that succeeding. Oh, no. Exciting. I can’t imagine where that would even go.
Dr. Andy Pruitt 1:11:28
But in the early days of time trialing, we wore almost a weightlifting belt. A hole came through our one piece, and we basically used a carabiner to attach it to the top tube, and that it held us down there. Wow. It held us in position and gave us a back support to push against. It was ultimately deemed illegal because we were using it as a performance device,
Trevor Connor 1:11:50
right? It’s gonna say that would probably get
Jeff Sankoff 1:11:51
banned, false. I would think it’s a safety issue also.
Griffin McMath 1:11:55
So we’ve talked about so many different causes of neck pain. We’ve talked about whether or not you two Connor on different demographics, having different presentations. We’ve talked about different solutions, and Dr Passarelli talked about a lot of different treatments that can happen as well. I’m curious, for the potentially overwhelmed listener that’s either an athlete or Coach, how do they put all this together. How do they integrate the bike fit the therapist, where and when? Does each have
Jeff Sankoff 1:12:26
a role? So it is a complicated kind of subject, and the reason for that is because, as we said earlier, the neck is complicated. And I hate to be Debbie Downer about this, but neck problems are not easy to sort out, and they often are not easy to make go away. You may have to adapt to what your neck problem is, and you may have to learn to live with a certain degree of either discomfort or modify whatever it is you’re doing that’s causing the pain so that you can have less of it when you’re doing what you love with that said, I would say that it begins and ends with getting a proper diagnosis. As we’ve touched on a few times today, there are multiple causes of neck pain. I would say that as you get older, the most likely cause is going to be within the spine itself, either the facet joints, hypertrophy or arthropathy, or the discs themselves. And then for younger athletes, it’s probably going to be more related to muscle strain and myofascial different things in those cases that’s actually treatable and should get better. But the older you are, if you’re having neck pain, I’m afraid, then you start getting into things that are going to be harder to make better. But like I said, begins and ends with a diagnosis. If you can get a proper diagnosis of what ails you, then you could start thinking about what you can do to try and make it better. There are things you can do for symptoms, local application of heat, sometimes it’s going to be cold, massage, different kinds of hands on, therapies, different kinds of medications. There are things like injections that can be very efficient and very helpful for some people. At the very most extreme, there is even surgery, which you never want to do unless it’s an absolutely last resort. But these are options, and there are ways that you can get these kinds of pains under control. And of course, there’s just modification of your environment. We’ve talked about, changing the way you work, have a standing desk, get your ergonomics looked at, and look at a bike fit and things like that. So I think being step wise about it and then being realistic about what the outcomes can be are the best way to handle all of
Dr. Andy Pruitt 1:14:33
this. That was beautifully said, I think to put a bow on what he said, it’s really about teamwork, especially at the high, high level. Everybody wants to be in charge. Everybody wants to be the primary caregiver, and it’s hard for them to work together, but they do. I see it happen. It takes work to make all those people give up a little bit of their authority for that athlete. So the athletes that we’re all dealing with. With on a daily basis. They need to build a team. And then the younger athlete, that has to include parents and the adult athlete. You need a coach. You need a fitter. You need a physical therapist. You need a massage therapist. You got to build your team around you. Joe Friel has a great new book out called High Performance cycling. I read it early on. And I said, Joe, we gotta do something about the title. I said, Nobody, because they don’t think they’re a high performance athlete. And he said, What should I do? And I said, Well, here’s my take on this. High performance is a lifestyle. It is not a paycheck. So every one of us who think we’re a high performance athlete but not getting a paycheck, needs to have that same team, same kind of team that the true high performance athlete has right build that team, and they all have to work together.
Trevor Connor 1:15:51
Typically at this point, we would dive into our take homes. But that was so well said by both of you, I feel like that should be your take home. So Griffin, how about we finish out? Do we have a question for the forum?
Griffin McMath 1:16:02
So for those who’ve been listening to this and maybe you want to share what’s been helpful for them, head over to forums.fasttalklabs.com, to answer the following question, what strategy, whether from fit medical care, integrative practice or maybe even gear innovation, has helped you most with preventing or resolving neck pain on the bike. Head over to forum and share what’s worked for you. The one thing I’ll add, though, that’s my take home that is so obvious, but it really is going to be my resounding take home, because, as Trevor knows, I’m really excited about buying my nice bike at this point, is don’t buy it online, and now, thankfully, I have a physical therapist in my team of providers, but I’m going to take that information to my bike fitter, decide on the bike and have that happen, and then, not to discredit those who sell bikes online. But that was such a point to me, of you’re right, so many people will spend so much money on a customized bike online and then get it sent, take it to a fitter, and they go, Oh, you done. Did wrong. And last but not least, here to close is Dr Passarelli on why, the goal isn’t just pain relief but teaching your body a new pattern.
Dr. Carol Pasarelli 1:17:18
You don’t want to necessarily go and get a massage every week, unless you’re following up that massage with some sort of specific motor control training so that you can really stay away from having that pain come back,
Griffin McMath 1:17:34
as you heard today, there are many different perspectives on many different therapies and treatments. Do your research, ask your providers and get that neck pain taken care of.
Trevor Connor 1:17:44
Well, gentlemen, pleasure having you on the show. Thanks for joining us. You’re very welcome. Enjoyed it. Yep. Me too.
Griffin McMath 1:17:49
That was another episode of fast talk. Subscribe to fast talk wherever you prefer to find your favorite podcasts, be sure to leave us a rating and a review. As always, remember the thoughts and opinions expressed on fast talk are those of the individual and are for educational purposes only. None of this is medical advice. If you have any health concerns, please consult your physician directly. We’d love your feedback. Join the conversation at forums, dot fast talk labs.com, or join us on social media at fast talk labs for access to our endurance supports, knowledge base, coach, continuing education, as well as our in person and remote athlete services, run, don’t walk to fast talk labs.com. For Coach Trevor Connor. Dr Carol Passarelli. Dr Andy Pruitt and Dr Jeff sankoff, I’m Dr Griffin McMath. Thanks for listening. You.
