You are in: eMedicine Specialties > Sports Medicine > Neurological Bicycle Seat NeuropathyArticle Last Updated: Jun 17, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: John M Martinez, MD, Medical Director, Primary Care Sports Medicine, Coastal Sports and Wellness Medical Center John M Martinez is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine Coauthor(s): Kenneth Honsik, MD, Consulting Staff, Department of Primary Care Sports Medicine, Kaiser Permanente Editors: David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Author and Editor Disclosure Synonyms and related keywords: saddle numbness, erectile dysfunction, impotence neuropathy, bicycle saddle neuropathy, vascular or neurologic injury of the pudendal nerve, urinary incontinence INTRODUCTIONSection 2 of 11
  BackgroundBicycle seat neuropathy is one of the more common injuries reported by cyclists.1, 2, 3, 4, 5 The injuries and symptoms are due to the cyclist supporting his or her body weight on a narrow seat, and they are believed to be related to either vascular or neurologic injury to the pudendal nerve.2, 5, 6, 7, 8, 9, 10 FrequencyUnited StatesA wide frequency range has been reported for bicycle seat neuropathy, but it is believed to be underreported. The medical literature contains several case reports of reversible neuropathy5, 9 and several retrospective studies surveying participants in long-distance cycling races and tours.8, 11, 12 Andersen and Bovim surveyed 260 cyclists participating in a long-distance bike tour that was 335.54 miles (540 km) in length.8 Of responding males, 35 (22%) reported symptoms of either numbness or pain in the pudendal area. Thirty-three (21%) males reported penile numbness, with 10 (6%) male cyclists reporting symptoms that lasted longer than 1 week. In addition, 21 males (13%) reported symptoms of impotence, 11 of whom experienced symptoms for longer than 1 week, and 3 of whom reported impotence lasting longer than 1 month.8 Kuland and Brubaker reported that during the 1976 Bikecentennial tour, there was a 7% incidence of pudendal and/or penile numbness, but this study only surveyed 89 of 1200 participating cyclists.11 Weiss studied symptoms of cyclists participating in a 500-mile (804.97 km) bicycle tour.12 Of the participating cyclists, 45% reported at least mild and transient perineal numbness; 10% reported the symptoms as severe, and 2% of the cyclists had to temporarily stop riding. Perineal numbness has also been documented in women cyclists. LaSalle et al surveyed 282 female members of a Dallas cycling club.13 In this group, 34% of the women reported perineal numbness. Sport-Specific BiomechanicsThe cause of bicycle seat neuropathy has been attributed to several different ischemic events. Amarenco et al and Oberpenning et al hypothesized that compression of the pudendal nerve as it passes through the Alcock canal causes the condition.9, 15 The Alcock canal is enclosed laterally by the ischial bone and medially by the fascial layer of the obturator internus muscle. The pudendal nerve exits the canal ventrally, below the symphysis pubis, and innervates the genital and perineal regions. Oberpenning et al postulated that long-distance cycling results in the indirect transmission of pressure onto the perineal nerve within the Alcock canal.9 Weiss and Bond separately proposed that bicycle seat neuropathy is due to temporary and transient ischemic injury to the dorsal branch of the pudendal nerve secondary to compression of the nerve between the bicycle seat and the symphysis pubis.12, 16 Weiss also theorized that the genital branch of the genital-femoral nerve could be involved in cases in which scrotal paresthesia is reported.12 Bicycle seat design (eg, shape) may be the major extrinsic factor for the development of bicycle seat neuropathy.1, 4, 6, 17, 18, 19, 20, 21 Results of computer modeling reported by Spears et al showed that wider bicycle seats that support the ischial tuberosities decrease pressure on the perineal area.19 Other studies have also demonstrated the effect bicycle seat design has on penile blood flow20 and penile oxygen pressure.21 CLINICALSection 3 of 11
HistoryA recreational or elite cyclist who complains of numbness or impotence after cycling is the typical presentation of bicycle seat neuropathy.22, 23, 24, 25 The amount of time the athlete spent cycling before the onset of symptoms is variable; however, studies have focused upon longer distance, multiday rides. Use of a stationary bicycle has also been reported as a cause of bicycle seat neuropathy.
Related Medscape topics: PhysicalThe physical examination should focus on the urogenital and neurologic systems. A rectal examination may be indicated. The focus of the examination should be to exclude other diagnoses that may require different treatment and management.
CausesThe cause of bicycle seat neuropathy has been attributed to several different ischemic and neurologic events (see Sport-Specific Biomechanics). DIFFERENTIALSSection 4 of 11
Groin Injury Lumbosacral Disc Injuries Lumbosacral Radiculopathy Other Problems to Be ConsideredAtherosclerotic vascular disease WORKUPSection 5 of 11
Lab Studies
Related Medscape topics: Imaging Studies
TREATMENTSection 6 of 11
Acute PhaseRehabilitation ProgramRecreational TherapyRecreational therapy should include evaluation of the rider's position on the bicycle and could include changing the seat height and tilt position. Medical Issues/ComplicationsMedical issues and complications include continued injury or insult to the area, resulting in continuation of the neuropathy and long-term sequelae such as impotence. Reevaluate the patient after making changes to the bicycle or riding style or after decreasing the training volume to ensure that improvement in symptoms is occurring. Continued symptoms despite changes in the bicycle seat position and training volume may indicate a different source of the symptoms and should warrant reevaluation by the physician. ConsultationsPossible consultations include specialists in urology and neurology, based upon the patient's clinical presentation. Other TreatmentThe mainstay of treatment of bicycle seat neuropathy is the adjustment of the bike seat and bike position, such as tilting the nose of the seat down or lowering the seat height to relieve pressure off the perineum. Other recommendations include having the rider change the style of riding (eg, change positions more frequently or stop riding more frequently). Newer bicycle seats with a split nose or a center cutout may also help to reduce the prevalence of neuropathy by limiting compression on the perineal area (see Image 1). A study by Lowe et al compared pressure measurements in the perineal area of cyclists on these different bicycle seats and found that some of the newer seats reduced perineal pressure by approximately 50%.17 MEDICATIONSection 7 of 11
No medical therapy is recommended. FOLLOW-UPSection 8 of 11
Return to PlayReturn to play is based upon resolution of the athlete's symptoms. The cyclist should be cautioned to change his or her position on the bike (eg, ride with hands on the top of the handlebars vs having hands down in the drops or riding with aerobars [tri-bars]). Also encourage the patient to stand up intermittently to relieve pressure or to stop cycling temporarily until the symptoms resolve. Changing the type and shape of bicycle seat used may also be helpful; elevation of the nose of the bicycle seat may worsen the condition, as more pressure is placed upon the Alcock canal and the pudendal nerve. ComplicationsComplications are variable and appear to be transient based upon the literature review. Cases of bicycle seat neuropathy and its resulting symptoms, such as impotence, resolve over time once the pressure is relieved from the perineal region. Case reports reveal that some cases can take more than 1 month to resolve.1, 5, 8, 9 PreventionPrevention of bicycle seat neuropathy includes riding a bike that is properly fit by a trained professional, as well as changing positions frequently on the bike seat or standing intermittently to relieve perineal pressure. Additionally, newer designs in bicycle seats allow for the reduction of perineal pressure by providing a bicycle seat with the middle portion cut away. PrognosisThe prognosis and recovery from bicycle seat neuropathy is very good. However, the rate of recovery is variable and may be influenced by the amount of time the athlete previously spent cycling. EducationEducate patients about the causes of the neuropathy, about the importance of a proper bike fit, and about the need for changes in seating position. MISCELLANEOUSSection 9 of 11
Medical/Legal Pitfalls
Related Medscape topics: MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Bicycle Seat Neuropathy excerpt Article Last Updated: Jun 17, 2008 | |||||||
