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Neck and Lower Back Pain: Prevention and Management in Cyclists

Spine pain affects many people – it is one of the main reasons people come into the clinic. In a lifetime, 65% of people will develop neck pain and 25% of health care costs are related to low back pain.¹ ² Because these diagnoses respond episodically, meaning they come and go, a lot of people start to improve and, therefore, wait to see a medical professional.²

The problem is that people typically fall back into a flare up shortly after symptoms improve (no pun intended). This course of ups and downs can continue on for months, or even years. When I evaluate someone for pain in the lower back (lumbar region), mid back (thoracic region), or neck (cervical region) I base a lot on how people move (or have a lack thereof). The neck moves in more planes than the low back or mid back because it does not have as much responsibility to provide stability. Picture a see-saw: balances stability on one side with mobility on the other. On the contrary, our lower back is responsible for a greater deal of stability. Therefore, when I look at people’s response to movement, I expect different things in different areas.

Let’s start from the top and work our way down

The Breakdown

The cervical spine has a variety of different joints that move in certain ways, depending on how you move your neck. I see a lot of problems in adolescents because they are typically on their phones more and have poor posture. That’s not to say that adults aren’t guilty of that, but typically it’s more teenagers. They also respond to treatment faster. There is another population that is at risk of this…yep, it’s cyclists!

The joints in our spine crave variability. Because cyclists have their head positioned in a protruded or forward head position for long durations of time, it places the neck at increased risk for joint problems . These can present themselves in a variety of ways, including shoulder pain (47.6%), elbow pain (44%), and wrist/hand pain (38.5%).³ Symptoms can include pain, numbness, tingling, decreased range of motion, as well as decreased strength in any of these areas.

The best way to determine if you’re experiencing these issues is a thorough history and examination, since not everyone responds the same. Additionally, here are some tips and a series of exercises to help to fix and/or prevent these symptoms.


The Neck

Start with a brief screen of your neck. This includes range of motion and any perception of feeling other than a general stretch sensation. Each movement should be done as far as possible. Make sure to assess how you’re feeling during and at the end of the range of motion.


Flexion rotated

Chin to chest; look down


Extension rotated

Look up.

Side Bending

Side bending

This is sometimes called lateral flexion. Bring your ear towards each side (without moving your shoulder up). Make sure to do on both the left and right sides.

Rotation Right and Left

Rotation left and right

Turn and look over each shoulder. Take note what the furthest thing you can see is.


Protrusion rotated

Poke your head forward, like a turtle coming out of its shell.

One thing to be aware of is the phenomenon of centralization. Centralization is the movement of your symptoms to their origin. If centralization occurs as you exercise, that is a good sign! It means you’ve found the correct exercise. Let’s think about it like this, if you have 100 units of pain spread from your neck to your hands, it might look something like this:

  • Neck: 60 units
  • Shoulder: 20 units
  • Elbow: 10 units
  • Hand: 10 units

Rotation Right and Left

Retraction rotated

Pull chin back like you smelled something bad.

As long as the units are moving out of the area furthest from your spine, it is okay. This would be an example of a good change and a green light to continue.

  • Neck: 70 units
  • Shoulder: 25 units
  • Elbow: 5 units
  • Hand: no pain

The pain may increase in the spine and that’s okay, it will diminish and go away from that point

If these feel abnormal, try the following exercises. If you are noticing that you are getting worse, please reach out to me and I will be happy to help you further.

Exercise 1

Retraction rotated

Retraction in a Seated Position

This exercise is a good place to start for prevention of symptoms. It can help counteract the position you are in during long bouts of cycling. Retract strain or pain is okay during the exercise as long as it is not worse when you are done (has to be either better or the same). Hold each repetition for 2 seconds and return to resting position. Complete 10 reps. Reassess neck movements.

Exercise 2


Retraction in a Seated Position with Overpressure

If you are not worse or better, complete the same movement as exercise 1, but push your chin inward a little bit. This is called overpressure. It helps to keep your teeth closed so you aren’t pushing back on your jaw. Follow the same assessment during the exercise.

Exercise 3

Exercise 3

Repeated Retraction with Extension

If you remain no different- Retract neck and roll your head upwards into extension. Hold 2 seconds. Repeat 10 times, just as in exercises 1 and 2. Remember pain during the exercise is okay, but it shouldn’t get worse as you continue to exercise.

There are many exercises, positions and strategies to address neck pain and not all people are the same. Remember that I would be happy to help out further if these do not work.

To summarize


  • Numbness
  • Tingling
  • Pain in the neck, shoulder blade, arms, and/or hands
  • Loss of motion
  • Loss of strength
  • Headaches
  • Dizziness


  • Retraction
  • Retraction with overpressure
  • Retraction with extension

What are some things that mean I can keep going?

  • Symptoms move closer to your neck (pain in any part of the arms decreases or goes away)
  • Pain decreases
  • Range of motion increases
  • Strength increases
  • Symptoms go from numb to pain

When should I stop?

  • Symptoms increase
  • Pain moves away from your neck
  • Range of motion decreases
  • Symptoms go from pain to numb

The Back

The lumbar spine or lower back is similar in nature to the neck and can be screened the same way – by measuring the range of motion. There are four main movements that come from the low back.


Back rotated

Bend forward to touch your toes.


Back 2 rotated

Bend backwards.

Side Glide

Back rotated

Cross arms across chest in a standing position. Slide just your hips from the right to left.

If any of these movements produce stiffness or pain, begin with the exercise progression below. Compare the side glide to the right and left in terms of equality (do they feel the same when you go one way versus the other?). It is not uncommon to have low back pain for no apparent reason. We bend forward 3,500 to 5,000 times per day, but only achieve full extension less than 300 times per day. This creates a big mismatch in the way we move, and can lead to joint problems. In cyclists, that number can be even higher due to the nature of your positioning as you ride, especially in spin class. This means that you need to balance your movements throughout the day a little better .⁵ ⁶ ⁷

The same rules for centralization apply here, as well. Symptoms must move closer to the back as you exercise. Symptoms in the low back can also present as symptoms in the hips (71%), knees (25.6%), and foot/ankle (29.2%). In the same study by Rosedale and colleagues, they found that 45% of osteoarthritic knees were actually symptoms coming from the low back!³

Exercise 1

Back 2 rotated

Repeated Extension in Standing Position

Stand straight with feet shoulder width apart. Place hands on low back and lean backwards as far as you can, without losing your balance. Hold 2 seconds and return to upright. Repeat 10 times. Remember strain or discomfort is okay at the end of the range.

Exercise 2

Repeated Extension in Lying Position

If Exercise 1 does not improve symptoms, attempt Exercise 2. Laying on your stomach, extend your arms while keeping your hips on the table. Try to extend your arms all the way so your elbows are straight. Hold 2 seconds and return to starting position. Repeat 10 times.

Exercise 3

Back 2 rotated

Prone Lying in Extension

If Exercise 2 does not improve your symptoms, attempt Exercise 3. Prop on your elbows as if you were reading a book. It is okay to use pillows under your chest. I also recommend using the armrest of a couch to achieve a bend in your back. Build up pillows or surface under chest until strain is felt in the low back. Hold 3 minutes. Recheck motion in your back.

To summarize:


  • Numbness
  • Tingling
  • Pain in low back, legs, and/or feet
  • Sciatica 
  • Loss of motion
  • Loss of strength


  • Repeated extension in standing (x10)
  • Repeated extension in lying (x10)
  • Prone lying in extension (x3 minutes)

What are some things that mean I can keep going?

  • Symptoms move closer to your back (pain in any part of the legs decreases or goes away)
  • Pain decreases in your low back or in any part of your legs/feet
  • Range of motion increases
  • Strength increases
  • Symptoms go from numb to pain

When should I stop?

  • Symptoms increase
  • Pain moves away from your back
  • Range of motion decreases
  • Symptoms go from pain to numb

In conclusion, I hope these exercises prove to be helpful in reducing any pain you may be feeling. Additionally, I am including my personal correspondence below for a resource. I am available through Facebook and via email to offer my expertise.

Your on the road PT,


Email me at
Find me on Facebook here

Please remember that the following information is a general recommendation based on typical movements of cyclists and the most frequently used exercise to reduce symptoms in both the neck and low back. If you have any concerns, please reach out to me directly or follow up with a licensed provider to evaluate your symptoms.

  1. Cerezo-Téllez E, Torres-Lacomba M, Mayoral-Del-Moral O, Pacheco-da-Costa S, Prieto-Merino D, Sánchez-Sánchez B. Health related quality of life improvement in chronic non-specific neck pain: secondary analysis from a single blinded, randomized clinical trial. Health And Quality Of Life Outcomes. 2018;16(1):207. doi:10.1186/s12955-018-1032-6.
  2. Frogner B,Harwood K,Andrilla C, Schwartz M, Pines J. Physical Therapy as the First Point of Care toTreat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Cost. Health Serv Res 2018:53:6
  3. Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins S.A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS), Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2019.1661706
  4. Treat Your Own Neck. New Zealand: Spinal Publications New Zealand Ltd: p34. Chapter 4
  5. Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. The Australian Journal Of Physiotherapy. 2004;50(4):209-216.,ip,uid&db=mnh&AN=15574109&site=ehost-live&scope=site.
  6. Edmond SL, Werneke MW, Young M, Grigsby D, McGill T, McClenahan B. Directional preference, cognitive behavioural interventions, and outcomes among patients with chronic low back pain. Physiotherapy Research International: The Journal For Researchers And Clinicians In Physical Therapy. 2019;24(3):e1773. doi:10.1002/pri.1773.
  7. Garcia AN, Costa L da CM, Hancock M, Costa LOP. Identifying Patients With Chronic Low Back Pain Who Respond Best to Mechanical Diagnosis and Therapy: Secondary Analysis of a Randomized Controlled Trial. Physical Therapy. 2016;96(5):623-630. doi:10.2522/ptj.20150295.

Winter Preparation – Get Your Body and Equipment Ready for ESR

Charlie Livermore is back for the 2020 Empire State Ride! Not only will he be joining us on the 500+ mile adventure, but he also lends his expertise to our riders to help with training and preparation.
He will be guest-posting on our blog from now until July. First up, he’s taking us through how to prepare for ESR during the winter.
Happy New Year 2020 ESR Riders!
Let’s get your Empire State Ride training started on the right path from the beginning this year. Riding 500+ miles is a big undertaking for any level cyclist. Whether your goal is to have fun and finish in a healthy state or you’re out to smash the road every day, preparing your body, mindset and equipment prior to, the 2020 Empire State Ride Training Plan will improve your chances for success.
The ESR training plan is available to everyone registered for the ride here. Starting on February 24 and progressing through July 26, the plan is designed to prepare you to have a great ride. Use these next five weeks to get everything ready to go.
Here are some tips to get you ready to train.

Your Bicycle

The greatest piece of advice I can give you here is to make sure your bike fits you well, and is maximized for your comfort and good biomechanics. You’re going to spend a lot of hours on your bike. Over time, small discomfort issues resulting from poor biomechanics can lead to overuse injuries. If you’re one of the smashers, put a limit on your performance. Please do yourself a favor and get a professional bike fit. The industry standard and benchmark for quality bike fitting is Retul.
There’s been a lot of discussion about tire and gear choices for ESR. The trend in these two subjects is clear. From the very best pro riders to the weekend warrior, it’s wider tires and bigger gear ratios. 25-28 mm width tires is the new skinny and 30-38 mm tires are often seen on the road with the advent of gravel bikes. In gearing, a subcompact crankset (50×34) with a 11-30 or 32 cassette is the way to go. I rode last year’s ESR on a gravel bike with 30 mm (slick) tires and a 50×34 with a 11-32 cassette. Whatever you choose, use this time to set it up.

Indoor Training

Due to weather constraints, many of you are going to have to do much, if not all, of your February through April training indoors. Once you have your bike and fit dialed in, it’s time to choose a trainer. There are two basic types: normal and smart.
A normal trainer makes it possible to ride a bike while it remains stationary. A smart trainer adds the benefit of allowing the resistance to be controlled by cycling apps, such as Zwift. If you’re going to train indoors, use this time to research the trainer you want, purchase it, set it up and learn how to use it.

Cycling Computer

A cycling computer is essential for both training and the Empire State Ride. A computer with mapping and navigation functionality is your best bet. If you use your smart phone for navigation, a simple computer that tracks cadence, speed, distance, time, heart rate and power (if you have a power meter) is all you need for training. Use this pre-training period  to learn how to use the one you choose.


To make your bike go forward, you apply a percentage of your body’s energy to produce a mechanical force on the pedals. The interaction between your foot/shoe and the pedals is extremely important. Your best choice is a cycling shoe with a cleat that snaps into your pedals, making the shoe/pedal into a single unit.
If you don’t feel comfortable locking in to your pedals, a MTB cycling shoe is still your best option due to the stiffness of the sole. Soft soled shoes are going to absorb much of that mechanical energy. Fit is extremely important. Comfort is the key here. Get your shoes and cleats dialed in at your bike fit session.


I touched on the importance of comfort in the bike fit and shoes advice, so allow me to give you my advice about cycling shorts. The padding in cycling shorts is designed to add a protective, comfort layer between your body and the seat. The pad should feel like an extension of your body and not a seat pad. What do I mean by that? The pad should move in sync with your body and stay in place when you’re moving on the saddle. If the pad is moving on your skin, it’s causing friction and over time that will become a problem. Your shorts need to fit snug and stay in place. Shorts that are too baggy or old shorts that have lost elasticity are trouble. Make sure your shorts fit tight and stay in place.

Your Schedule

Take a look at the training plan and start to figure out how you’re going to fit it into your busy schedule. The weekday training sessions range from 45’-60’ twice a week through April. Start with that. Make the time by putting it in your schedule. Ask your family for the support. Print out the training plan, stick it on your fridge and rally the whole family behind you. The more people you have cheering you on the better.

Your Body

I can go on forever on this subject. But I’ll keep it short with this: your body is a miraculously smart machine. It can be strong or it can be weak. It can function beyond comprehension or not function well at all. It decides which of these based on input signals. We control a lot of those signals. Nutrition, exercise, mobility and mindfulness are some good examples of the signals we can control to maximize our physical and spiritual state. Before embarking on your ESR training, use these next weeks to prepare your body (mobility), improve your health (nutrition, sleep) and anchor the commitment to achieve your own personal goals for your best Empire State Ride experience.
Stay tuned for my next blog where I will go in depth on the 22 week training plan that begins Monday, February 24.

New Rider Q&A: Kimberly Evering – Gal on the Go

The 2020 Empire State Ride will be here before we know it! In addition to all the fundraising and training our amazing road warriors are doing to prepare for the upcoming challenge, they are also getting to know each other. We were able to catch up with a few of our new riders as well. Check out our Q&A with Kimberly.

You can take the gal out of New York State, but you can’t take New York State out of the gal.
Buffalo, NY native Kimberly Evering is looking forward to cycling across her home state this summer. Being from the Western New York area, she is more familiar with Roswell Park Comprehensive Cancer Center, which is ranked 14th out of 900 cancer hospitals in the United States by U.S. News & World Report, and the beneficiary of the Empire State Ride. When she saw her hometown friends posting about their experiences with another fundraiser for the cancer center, she decided to do some digging. A quick Google search introduced her to the Empire State Ride.
“I was on the fence about signing up because the mileage involved is very intimidating,” said Kimberly. “Then I went to a speaking engagement at the Smithsonian led by Katie Couric in which she passionately shared about the cancer battles her husband and sister lost, her fundraising efforts over the years, and her hopes for major advances in cures soon. I was so inspired by Katie that I signed up for the Empire State Ride the next day!”
So we asked her, what is your history as a cyclist? Have you ever done anything similar to the Empire State Ride?
Kimberly: “I grew up an only child in Buffalo, NY, and received my first bicycle with training wheels around the age of six. It was a liberating experience learning to ride! It was a healthy activity I could enjoy by myself or with my friends. I have done two non-traditional triathlons that included cycling up to 20 miles, but this is my first time doing a ride of this magnitude. It truly is a case of “go big or go home” for me! I’m a mix of nervous and excited. The Empire State Ride message boards on social media have been very helpful to a newbie like me because experienced riders have offered positive support and great tips from previous years.”

Now living in Fairfax, VA, and serving as a bike ambassador for Fairfax County, she also runs an adventure blog called Gal on the Go in her spare time. “I ride my bike all over town when possible instead of driving,” she said. “People have come to know me and sometimes shout, hey, Gal on the Go! I’m lucky to live in an area where we have access to many great trails with a variety of surface conditions that stretch for miles upon miles!” All those miles, plus the time in the saddle at the spin studio she joined, will be great practice for the 500+ mile adventure waiting for her this summer.
Training isn’t the only preparation necessary for the Empire State Ride. Part of what appealed to Kimberly when she was learning about our event was that “the fundraising efforts going toward all cancer research, not just one type.” She said “Six people in my life have or are currently battling cancer, including colon, skin, pancreatic, lung, and brain cancer. I thought to myself, suck it up, train to the best of your ability, and do the ride! These people are fighting for their lives; you are riding a bike, something you have done since you were a little girl.”
So how exactly is she fundraising? “I am fundraising through social media posts,” she said, “emphasizing the broad-range of cancer that the efforts benefit, and the fact that it’s a tax write-off. I also reached out to Liz, the owner of a local spin studio called New Trail Cycling Studio. She agreed to host a fundraising class for me on Friday, April 24, in which I can invite friends and family to a one-hour spin class for $25 in which all but a small admin percentage will go toward the ESR. I will also be reaching out to my new employer, Deloitte, who I learned, offers gift matching of some kind.”
And what is she looking to accomplish by raising funds and completing the ESR challenge? 
“I hope to increase awareness about the work Roswell does and the importance of funding for making breakthroughs and furthering cancer research efforts. I hope seeing and following my ESR journey this summer through social media will inspire others to a call to action financially or physically by participating in similar events!”
How inspiring, Kimberly!
If you want to join Kimberly on the 2020 Empire State Ride, there’s still time! Register today and cross the finish line Kimberly and other cyclists from all over who are committed to changing the state of cancer research for good!

Meet Easton, ESR’s On-the-Road Physical Therapist

Meet Easton, ESR’s On-the-Road Physical Therapist

We are happy to announce that on #ESR20, Easton Osborn, a licensed physical therapist, will be joining us to assist our riders!

Leading up to the 2020 summer adventure, Easton will also be guest writing several posts on our blog to help get our cyclists ready for the 500+ mile adventure. Get to know him below!

Hello, all!

I would like to start by thanking everyone for allowing me to become a part of the ESR family. I am so excited to be a part of this and to know that when a cure is found, we helped provide the boxing gloves that gave the knockout. My name is Easton Osborn and I work as a physical therapist in Niagara Falls, NY. I work predominantly with the orthopedic population, treating anything from sprains/strains to “I’m not sure what happened, but it hurts,” to people who are coming out of surgery and looking to get back to their prior activities.

My degrees include a bachelor’s of natural science with a specialization in health science and my doctorate in physical therapy, both from Daemen College. I practice using mechanical diagnosis and therapy, or McKenzie Therapy as it is sometimes known. This method of treatment helps to classify injuries which is more efficient and effective (a great combination) in getting people back to the things they want to do.


I serve in a consulting role for Strong Memorial, as part of University of Rochester for the colorectal department. Outside of physical therapy, I enjoy working out, hiking or riding my bike, watching different TV shows, spending time with friends and family, and I am a big fan of food, which is definitely “supported” in Western New York with all the different options and great tasting spots! I really do love my profession and I will never turn away a question or the opportunity to teach someone who wants to learn more.


For the adventure itself, I will be there during the week providing treatments for anyone who needs them because as riders you’re pretty much going into battle for 7 days. It is my job to keep you in that battle!

Leading up to the ride, I have the privilege of providing posts that consist of stuff that you are hopefully interested in, like recommendations for training, or common injuries that affect riders on long bouts and I will provide insight on how to fix or prevent them.

The information that I provide is all based on the current research available in the field so it’s top notch! If anyone has any further inquiries on topics I do not cover in these, please feel free to reach out to me. The topics I will cover are as follows:

  1. Neck and Low Back Pain: Prevention and Management in Cyclists
  2. The Specifics of Stretching to Optimize Performance
  3. Body Mechanics and Why Bike Fitting is Important

I have a personal gratitude to Roswell Park as they took amazing care of my grandfather while he was undergoing treatment for lung cancer in 2010 and I cannot emphasize how well he was treated through his illness. Everyone he interacted with was personable and professional and helped him to feel better in any capacity they could. There is not a shred of doubt that Roswell is ranked nationally for these exact reasons, plus the endless work put in, which makes Roswell a leader in cancer treatment and research.

I look forward to meeting everyone (socially, not medically) and am truly thankful for the opportunity to serve as your physical therapist and colleague in our ride to end cancer!