D3 Multisport is proud to release the video series, “The Triathlon Minute”. Invest 1 minute each Friday and you may learn something you didn’t know.

Dreaming about, or already committed to racing your first Ironman? Consider what 10 time Kona finisher Coach Simon has to say about Ironman planning in the video above. Yes, that’s TEN Kona race finishes for Coach Simon!

D3 Multisport is proud to release the video series, "The Triathlon Minute". Invest 1 minute each Friday and you may learn something you didn't know.

Enhance your workout by rehearsing it in your mind and defining it's purpose! D3 is proud to partner with mental skills coach, Will Murray. Will helps athletes gain personal, practical and immediate performance strategies using NLP and other proven approaches for athletic achievement. Learn more about Will Murray and his mental skills talents!

‍

D3 Multisport is proud to release the video series, “The Triathlon Minute”. Invest 1 minute each Friday and you may learn something you didn’t know.

Winter training has a purpose! Watch this week’s video tip above.

Coach Simon has over 20 years of race experience including 13 Kona championship races, and enjoys helping each individual athlete he coaches define what winning means to them!

‍

D3 Multisport is proud to release the video series, "The Triathlon Minute". Invest 1 minute each Friday and you may learn something you didn’t know.

Intimidating your competition on race day is an art "watch this week's video tip above, enjoy the humor!

Learn how Coach's recognition that each athlete is an individual, despite common goals, will shape your training.

D3 Multisport is proud to release the video series, “The Triathlon Minute”. Invest 1 minute each Friday and you may learn something you didn’t know.

You are a seasoned athlete and you think you are ready for an Ironman, but can you honestly answer these tough questions? Consider what 10 time Kona finisher Coach Simon has to say about Ironman in the video above. Yes, that’s TEN Kona race finishes for Coach Simon!

D3 Multisport is proud to release the video series, “The Triathlon Minute”. Invest 1 minute each Friday and you may learn something you didn’t know.

Strength Train while you Travel! Coach Martina shares a a few tips to help you maintain strength in a creative way while you travel.

D3 Multisport is proud to release the video series, "The Triathlon Minute". Invest 1 minute each Friday and you may learn something you didn't know.

Smile and say, "I feel great"! Watch this week's tip and learn to build your own positive feedback system. Learn more about our go-to mental skills coach, Will Murray.

https://vimeo.com/80676933

3 Great Drills for Beginner Swimmers:
1. The Bob
2. Kick and Breathe
3. Kick, Breathe and Stroke

D3 Beginner Drills for Swimmers from D3 Multisport on Vimeo.

A simple one arm drill to improve balance in the water and single arm efficiency.

Coach Mike demonstrates a post run flex band routine. This is great for a quick stretch.

Using swim paddles can help build upper body strength and teach you to have a more powerful underwater catch. Paddles are bigger than the surface area of your hand and will increase the resistance in the water.

A fist drill, or FD, is a great way to work on using your forearm for catching water during the pull phase of your stroke.

The catch-up drill can help you work on body alignment. Staying long and straight, from the tip of your fingers, which are an extension of your fully extended arm, and then all the way down through your shoulder and side all the way to your feet.

D3 Multisport is proud to release the video series, ‚ÄúThe Triathlon Minute‚Äù. Invest 1 minute each Friday and you may learn something you didn‚Äôt know.  In this week‚Äôs Triathlon Minute, Coach Mike offers a nutrition formula for recovering after a workout. If you like our videos please share them with your family and friends.

Running injuries to the lower extremity are common and are very often caused by cumulative trauma. Even an acute injury such as a hamstring strain can occur as a result of chronic muscle imbalances in the body. Uncovering weak links in the musculoskeletal system is one of the key prerequisites prior to building a strengthening plan and a key component for a successful rehabilitation program.Three common injuries addressed here: hamstring strain, patellofemoral pain and plantar fasciitis were chosen due to their frequency of occurrence as well as due to some common factors likely causing those injuries to occur. Overactive hip flexor complex and outer calve musculature in conjunction with a weak core seems to be the recipe for getting hurt.

A muscle imbalance that develops in the body often begins with poor static posture such as prolonged sitting at the desk, which causes certain muscles such as pectoralis major and minor as well as the upper trapezius and hip flexors to shorten and become overactive while their antagonist lengthen and become weak, lower trapezius and gluteus maximus for example. Poor static posture that leads to changes in the muscle and muscle-tendon junction leads to biomechanical changes in the joint biomechanics and alter typical movement patterns.

Hamstring strain

Hamstring strain usually occurs while the hamstring is lengthening under the load. During the gait the leg goes from push off to pull through to landing (simplified). While preparing for landing, the limb starts extending at the knee. Hamstrings regulate the rate of this extension and prevent it from occurring too rapidly. If hamstrings are weak, fibrous or compromised in any other way, a tear can happen in the muscle fibers: any where from minor grade one tears, to severe avulsions when the muscle tears at the attachment on the "sit bone" and a piece of bone is chipped along with the muscle.

The best treatment is rest and ice in the acute stages followed by cross friction massage and eccentric training to aid in scar tissue management followed by a functional screen to determine why the injury occurred in the first place.

Likely overactive muscles in the case of a hamstring strain are the hip flexor complex, abdominal complex and lateral gastrocnemius. Underactive muscles are usually gluteus maximus and core muscles such as transverse abdominis, multifidus, transversospinalis and internal obliques as well as the pelvic floor.

Best injury prevention is myofascial treatment of abdominal muscles as well as the hip flexor complex followed by a lengthening program of those muscles. Muscles that need strengthening are the core and gluteus maximus. Note that the core and the gluteus maximus might be strong statically but need to ‚Äúre-learn‚Äù how to engage in a dynamic situation.  Recommended exercises are alternating hyperexetension on a physioball and walk around the clock on the physioball.

Patellofemoral pain

Patellofemoral pain is pain in the knee area. It is often caused by softening of the cartilage behind the kneecap due to improper patellar tracking. Instead of staying in the groove during straightening and bending the knee, patella tracks laterally and grinds over a small bony prominence, which functions as a side barrier preventing the knee cap from dislocating in a healthy knee.

Likely overactive muscle in this case would be adductor muscles (which can be overactive due to a weak core musculature therefore they work overtime to stabilize the pelvis), lateral side of quadriceps, gastrocnemius and the hamstrings. Likely weak muscles would be gluteus medius and minimus (stabilizers of the hip), medial portion of the quadriceps and anterior tibialis .

The advised strategy to take care of the patellofemoral pain is myofascial release of the overactive muscles and lengthening of adductors, outer hamstrings and quads as well as the calves. Strengthening exercises recommended in this case are a lunge in transverse plane and single leg deadlift.

Plantar Fasciitis

Connective tissue at the bottom of the foot is called plantar fascia. Plantar fasciitis is an inflammation of this fascia and the common symptoms include sharp pain when first stepping on the foot in the morning, temporarily eased with activity. There is a tender spot at the attachment of plantar fascia on the inner side of the heel. People with flat feet or high arches are predisposed to this injury.

Musculature on the outer side of the leg above and below the knee that is shortened and overactive can affect foot mechanics and irritate the plantar fascia. Muscle release techniques in combination with lengthening techniques can re-set those muscles to their proper length. Disengaged or weak muscles in the case of plantar fasciitis are anterior and posterior tibialis, inner part of the calves and gluteus medius. Good exercises in this case would be side lunge on the BOSU, single leg stance on the BOSU and bare foot walking whenever possible.

Injury and pain during running is wrongly perceived a necessary evil. Proper assessment of athlete's baseline state particularly from a musculoskeletal perspective can produce invaluable information on how to properly design a training plan, which should include corrective exercises. "Off-season" is an ideal opportunity to identify the weak links, strengthen them and prepare for the healthiest season yet.

To contact Coach Martina use the link below.

D3 Multisport is proud to release the video series, “The Triathlon Minute”. Invest 1 minute each Friday and you may learn something you didn’t know. Periodization for the experienced athlete! Coach Mike shares a tip for training through the winter is in this week’s Triathlon Minute. All followers between now and #950 will be entered into the drawing. If you like our videos please share them with your family and friends.

There are several factors that can contribute to getting injured in sports. Most commonly discussed are overtraining, undertraining or improper kind of training along side poor technique. As an example, in triathlon 80-85% of injuries are due to functional overuse1. The underlying culprit to all those factors in many instances is, however, muscle imbalance.

Muscle imbalance is by definition an alteration of muscle length surrounding a joint. Certain muscles become shortened and overactive while the opposing muscles become lengthened and weaker due the phenomenon knows as reciprocal inhibition. Put in simple words, the body is designed so that when a prime mover, such as biceps brachii, for example, fires, the opposing muscle, in this case triceps brachii, needs to relax for the movement to happen. The brain cannot distinguish when the prime mover is acutely engaged or when it is chronically shortened and overactive, therefore it will shut off the opposing muscle in either instance. A good example would be an overactive illiopsoas causing a weakened gluteus maximus.

In the early 1970s Janda described three basic postural distortion syndromes that translate into movement impairments2.

Lower Crossed Syndrome

Lower crossed syndrome is characterized by increased arching of the back also know as increased lumbar lordosis and anteriror pelvic tilt. The overactive muscles in this case are hip flexor complex as well as latissimus dorsi and erector spinae, while gluteus maximus and medius, internal oblique and transevrse abdominis are commonly weak and lengthened.

A common injury related to the lower crossed syndrome is a hamstring complex strain. Biomechanical analysis shows that hamstrings are active for the entire gait cycle with the peak during the terminal swing and early stance phases3. Of the two phases the terminal swing phase is considered to be more hazardous because muscle-tendon units are at their maximum length or the gait cycle and must heavily activated. One of the major risk factors for developing a hamstring strain is indeed strength imbalance. The low ratio of knee flexor to knee extensor strength (also known as hamstring (H) to quadriceps (Q) ratio) is the most significant. Athletes (in this study football players were assessed)3 with a ratio H:Q less than 0.5 are believed to be at an elevated risk of hamstring strain injury. The best course of treatment is correction of the imbalance: releasing the quadriceps (using foam roller for 30 sec on each sensitive spot on the quadriceps followed by static stretching) and strengthening the hamstrings.

Upper Crossed syndrome

The upper crossed syndrome is characterized by rounded shoulders and forward head posture. Overactive and shortened muscles in this case are pectoralis major and minor, subscapularis, latissimus dorsi, levator scapulae, upper trapezius and sternocleidomastoid to name the major ones. The lengthened and weak muscles include (but are not limited to) rhomboids, lower trapezius, serratus anteriror and deep cervical flexors.

A common injury related to the upper crossed syndrome is functional shoulder impingement. Shoulder impingement accounts for 44-65% of shoulder injuries4. There are two kinds of shoulder impingement: structural and functional. Due to the nature of this article the focus will be placed on the later. Functional impingement occurs due to glenohumeral instability and is most common in overhead athletes over the age of 354. The main contributor to stability in the shoulder is the muscular system hence any imbalance between agonistic and antagonistic muscles in terms of strength and flexibility will likely result in dysfunction and consequent injury. A tight pectoral (major) musculature will create an anterior pull on the glenohumeral joint leading to instability. A tight pectoralis minor, on the other hand, will alter proper scapular motion (when the arm is moved to the side greater than 30 degrees, the shoulder blade must upwardly rotate, tilt and externally rotate to allow for the arm to move properly). Releasing the pectoral girdle using the foam roller (see appendix) together with strengthening the middle and lower trapezius would be a good start. Further, overly active deltoid, can generate excessive force and jam the humerus in the socket of the shoulder causing pain when moving the arm when swimming for example. The over active deltoid musculature needs to balanced by the rotator cuff. The best exercises to strengthen the middle/lower trapezius and the rotator cuff were presented in the article “Coaching Tips to Gain Swimming Speed written by this author and published in the March Newsletter.

Pronation distortion syndrome

Pronation distortion syndrome is characterized by excessive foot pronation. The overactive and short muscles in this case are peroneal muscles, gastrocnemius, soleus, iliotibial band, hamstring and adductor complex as well as iliopsoas. Weak and lengthened muscles are porterior and anterior tibialis, vastus medialis, gluteus medius, maximus and external hip rotators.

A common injury related to the pronation distortion syndrome is patella-femoral pain syndrome (PFPS) also known as runners knee. Research shows that one of the most common factors contributing to PFPS is muscle imbalance between the medial and lateral quadriceps muscles5. Vastus medialis obliquus (VMO) is a medial stabilizer of the patella and is often overpowered by the vastus lateralis. Further, tightness in the iliotibial band can alter the patellar excursion and cause lateral patellar tilt as well as lateral tracking. A good strategy to correct the imbalance is myofascial release of the TFL and quadriceps on the foam roller, followed by static stretching of both muscles. Despite common practice research has not confirmed the effectiveness of exercises aiming to isolate VMO, therefore the agreement to rehabilitate PFPS seems to be inclusion of dynamic strengthening such as step down with controlled eccentric motion, which also engages the core and the hip musculature.

There is a quick and reliable test to gain a general insight in muscle imbalance and it is called an Overhead Squat.

Overhead Squat

The overhead squat is executed with bare feet on firm ground. The subject lifts the arms over the head and squats down as close to parallel to the ground as he or she can without lifting the heels. The observation is done form the front (anterior) side (lateral) and the back (posterior). In each instance the subjects squats five times. From the front the observer looks at the knee (are they travelling inward or outward) and ankles (are the toes moving outward). From the side the observer checks for the excessive forward lean, arms falling forward and arching or rounding of the lower back. The rear view checks for the collapse of the arches (excessive pronation).

Each movement alteration indicate over and under-activity of a respective muscle and calls for an intervention that includes releasing and lengthening overactive and short muscles while re-engaging the inhibited muscles.

A typical scenario would include overactive gastrocnemius and weak anterior and posterior tibialis. The best way to treat gastrocnemius is perform a self myofascial release on the foam roller by holding on the tender area for at least 30 seconds followed by a static stretch. To engage the anterior and posterior tibialis towel scrunches 10-15 reps with 2-second hold plus, 10-15 repetitions of weighted cable pulls with the foot (dorsiflexion) also with a 2-second hold and 4-second eccentric release. The dynamic strengthening would include a single balance reach forward, back and to the side (touching cones with the foot).

Balance in anything with do in life is the best recipe for success and muscle balance is no exception. For initial evaluation and consultation I can be reached through D3 Multisport.

REFERENCES:

1). Migliorini, Sergio. "Risk Factors and injury mechanism in Triathlon." Journal of Human Sport & Science 6 (2011): 309-314.

2) Clark, Michael, Lucett Scott. NASM Essentials of Corrective Exercise Training. Baltimore: Lippincott Williams & Wilkins, 2011

3) Opar, David A et all. "Hamtring Strain Injuries." Sport Med 42 (2012):209-226

4) Page, Phil. "Shoulder Muscle Imbalance and Subacromial Impingement Syndrome in Overhead Athletes." IJSPT 6 (2011): 51-58

5) Collado, Herve, Frederickson, Michael. "Patellofemoral Pain Syndrome". Clin Sport Med 29 (2011): 379-398

6) Hirth, Christopher. "Clinical Movement Analysis to Identify Muscle Imbalances and Guide Exercise. Athletic Physical Therapy Today 12 (2007):10-14

For some it's instantaneous, for others a long, drawn out affair. Either way, injuries can put your triathlon season on hold. Unfortunately injuries are a part of training and learning how to avoid them, and what to do if you are hurt can make the difference between a great season and what could have been.Let's start with the best way to treat an injury, avoidance. Injuries caused by accidents, a turned ankle or bike accident, can't be helped, but others can. Pulled muscles are a much greater risk if you are dehydrated or not properly warmed up. Proper technique in the weight room and in the pool are critical to avoid over-stressing a joint or muscle. Piling on extra miles because it's your first outdoor workout, or you"just felt good" may leave you stricken the next day. Consistent training requires you to listen to your body and do the little things properly in order to stay healthy. Preventive care is your first line of defense.

But just in case you couldn't help it and tagged along with your buddies for an epic day and now you have a twinge in your calf, let's discuss your options. First, you can do what many do and that is pretend it will just go away. This strategy has it's roots in the belief that somehow your body is different and despite medical knowledge to the contrary, exercising the injury is actually good for you. I also call this the "Rocky Effec". This strategy is further confirmation of the poor judgment that got you to this point. The better option is to pull back the training. No matter where you are in the season, this is a must. Continuing to train through the pain can often times lead to another injury. Your body will need to compensate in some way for the lack of fluid motion. That overload of stress can lead to another injury and create a new muscle firing pattern. When the knee hurts, your gait changes. When your gait changes new joint and muscles have to carry the load. That may lead to another issue.

Next you need to decide on treatment for the injury. For some, it may be a simple matter of resting. Other, usually more traumatic injuries will require outside treatment. Again, somehow this eludes many athletes. They worry about missing two or three days of workouts. The big picture is that if you don't seek immediate help, your down time may double or triple. Even if you can get the workouts in the quality suffers and you are left with good numbers for your log, but no real training effect. A general rule I have for athletes and myself is that on the day I feel no pain and think I could get back into training, I take one more day. It is worth it to miss one more day of training in order to increase my chances of remaining healthy.

Some injuries are recurring no matter what. Those lingering issues we all deal with due to the nature of training. For some it's a bad shoulder, for others it's the knee. With these niggles and pains the goal is minimization. Over time you should learn what aggravates your condition, and what methods are best for treatment. With that knowledge you then need to make smart decisions. If you have a rest day coming up you may be able to get away with pushing the limit. On the other hand when you are in the middle of a large block of training you probably need to stay well within the envelope.

I hope that you never have to put this information in action, but the truth is that it is practically unavoidable. In triathlon, consistency is the key, and remaining healthy is the key to consistency. When stricken with an injury you need to make good decisions, be rational and you'll get back to your training quickly.

Some of the best examples of how a body works can be found in the culinary world. It translates, really! For example, pancakes can be made by throwing all the ingredients in a bowl and mixing them together. Another option for making pancakes is to separate the eggs, mix the yolk, flour and water first, then add the beater egg whites. The mix appears the same on the surface but the second recipe will make for a much lighter and bouncier meal. Believe it or not, this sequence of ingredients is similar to what happens in our body.How, when and which muscles are called into action when we move is very critical for injury prevention. Order matters. Sure an athlete can get by with random movement patterns but with time, the out of order sequencing will cause a chain reaction that will lead to debilitating setbacks from activities.

Movement spectrum consists of acceleration, stabilization and deceleration and specific muscles should be called to duty depending on what is asked of the body. Momentum and gravity ground reaction forces. For example, both dictate the pattern of muscle recruitment. Muscles can be agonists (primary movers), antagonists (opposing the movement/decelerating the movement), synergists (helpers of the primary movers), stabilizers (core musculature) and neutralizers (think of the keel on a boat to keep the boat on course). Dysfunctional recruitment will result in a faulty movement pattern and trigger injury and pain.

Athletes, particularly runners, appear to have trouble with motor control and/or strength of the gluteus maximus. One of the jobs that gluteus maximus has is a deceleration of internal rotation of the femur during single leg stance. In other words, as we walk and run, the long bone of our leg (the femur) ever so slightly turns inward to properly absorb the ground forces. Weak gluteus maximus causes an increased internal rotation of the femur, which triggers the eccentric load of the posterior tibialis, gastrocnemius, flexor hallucis and digitorum longus, often resulting in plantar fasciitis. What does that mean?

If the long bone of the leg is observed in slow motion the movement from starting position to the end position would happen over ten frames. In a weak gluteus maximus situation the movement happens more quickly, lets say over five frames. As a result the muscles that regulate the leg from the knee through the ankle to the foot have to do their job for a longer period of time (they have to turn on too quickly), which causes strain and overuse. The proper way to cure plantar fasciitis in this case would be a rehabilitation focusing on gluteus maximus function.

How do we know if gluteus maximus is weak? A trained professional will be able to assess patients single leg stance and hurdle step, to name a couple of functional tests, to be able to assess the quality of movement and isolate the faulty pattern. If motor control dysfunction and/or weakness are the cause of the faulty pattern (and not poor mobility), corrective exercises are given.

For the gluteus maximus I recommend a single leg stance with a thera-band above the knee, anchored so that the band is pulling the knee inward. The glutes maximus and medius (on the stance leg) have to counterbalance the band by pulling the femur in an outwardly fashion, so that the knee is aligned over the second toe.

This Triathlon Minute video will provide a good visual for this exercise.

My patients also perform bridges with feet on the foam roller. Laying flat with the face up, feet are far back so that they touch fingers on hands. The foam roller is positioned under the feet. Then the bridge performed trying to flatten the foam roller.

This Triathlon Minute video will provide a good visual for this exercise.

This article is an example of regional interdependence and certain concepts are simplified for easier understanding. Chronic pain is often a result of inaccurate diagnosis. Ceasing a sport due to stubborn injuries is often unnecessary. Our body should be understood and treated like a garden with each part contributing to the well being of the other and not like a pile of parts operating independently. Referring back to the analogy of pancakes, the idea is to have a light and bouncy meal that is satisfying. Your training should be the same! Injury prevention and proper rehabilitation should focus on the whole picture with movement analysis at the core of each evaluation.

Coach Martina Young is a doctor of physical therapy in addition to being a USAT Level I Certified Triathlon Coach. She shares that if you have specific goals that you want to reach in triathlon, a coach is a good place to start – but it’s not the answer of and by itself. Desire, Determination, and Discipline (the 3 D’s !) – all play a role. When you’re ready to do the work to get to the next level then you’re ready for a coach!

The hand is a complex, tightly connected structure of bones, ligaments, tendons, nerves and muscles, which allow for small and complicated motions. Thus, an injury to any particular structural component will have a significant effect on the function of the whole hand1.

In looking at the onset of wrist injuries related to athletics, the focus of the analysis will be on cycling due to its high popularity. According to a study sponsored by the US Department of Transportation?s National Highway Traffic Safety Administration (NHTSA) and Bureau of Transportation Statistics approximately 57 million people or 27.3% of the adult population, age 16 and over, rode a bicycle at least once during the summer of 20022.

Research about cycling injuries revealed an interesting pathology in cyclists: handlebar palsy. Handlebar palsy, a form of ulna neuropathy, is a compression syndrome of the deep terminal motor branch of the ulna nerve while it passes though the Guyon canal. The Guyon canal is formed by the pisiform and hamate bones and the ligament that passes between them. The narrowest section of the canal is at the connective tissue closer to the hamate bone, which makes this site prone to compression injuries. The deep branch of the ulna nerve divides off in proximity to the pisiform bone and then dives between the hypothenar muscles as it approaches the hook of the hamate. Due to the compression at the hamate, only the intrinsic muscles of the hand are affected while hypothenar muscles and all the sensation of the hand, provided by the ulna nerve, are spared.

Handlebar palsy has been most commonly associated with chronic repetitive trauma and chronic pressure3 applied to the wrist. Kronisch & Pfeiffer4 reported that 90% of interviewed cyclists experienced symptoms consistent with overuse injuries, 35% of them occurring at the wrist. Subjects described the discomfort as cramping and weakness in the hand and fingers, a common indicator for handlebar palsy.

Case studies:

The first case study presents a cyclist who participated in the Bicycle Ride Across the United States when he rode an average of 347 miles per day for 9 days. He began to experience weakness of the right hand after the third day of riding. Numbness and weakness in his hand persisted upon completion of the race. An examination revealed atrophy of all intrinsic hand muscles that are supplied by the ulna nerve. The hypothenar muscles were not affected and there was no sensory loss. In a similar case, a 49-year-old physician experienced clumsiness and cramps in both hands upon returning from his 2 weeks long mountain bike trip. He was unable to hold syringes at work or play the piano at home. After an MRI showed no lesions to the cervical spine an examination of the hand revealed paresis and atrophy of intrinsic hand muscles on both sides. Hypothenar muscles were spared and the sensation was preserved.

Both subjects were advised to refrain from offensive activities. Like in many nerve injuries, handlebar palsy resolves with rest. Wearing padded cycling gloves has also shown to provide relief from handlebar palsy as it eases the compression on the ulna nerve.

Handlebar Palsy can evolve into a debilitating condition. The most effective way to prevent handlebar palsy, according to research, is changing grip position during bicycling and wearing protective bicycling gloves. Therefore, do not leave your gloves at home next time you go out for a ride and check in with your hands every here and then – if they tingle, switch the grip position!

The article is an excerpt from a kinesiology project “Kinesiology of the hand and wrist” written by Fournier R, Merrill A, Newberry J and Young M, students of physical therapy at Regis University.

1 Moran, AC. Anatomy of the hand. Physical Therapy. 1989; 1007(7)

2 Available at https://www.bikeleague.org/media/facts/. Accessed January 27, 2008

3 Capitani D, Beer S. Handlebar Palsy-a compression syndrome of the deep terminal (motor) branch of the ulna nerve in biking. J Neurol. 2002; 249 1441-1445

4 Kronisch LK, Pfeifer PP. Mountain Biking Injuries: an update. Sports Medicine. 2002; 32(8):523-537