When we think of tennis elbow, road cycling probably isn’t the first sport that comes to mind.
Yet road cyclists can spend several hours at a time gripping handlebars, stabilising the front of the bicycle, absorbing road vibration and repeatedly loading the muscles of the forearm.
Clinically, that makes lateral elbow tendinopathy — the condition commonly known as tennis elbow — entirely plausible in road cycling.
What is surprising is how little we actually know about its incidence.
What do the statistics tell us?
The largest study specifically examining gradual-onset injuries in recreational road cyclists included 21,824 riders.
It found that:
- 2.8% of riders reported having experienced a significant gradual-onset cycling injury during their cycling career.
- The estimated annual incidence was 2.5%.
- 19.8% of gradual-onset injuries affected the upper limb.
- Around 50% of affected cyclists experienced symptoms lasting longer than 12 months.
- 37.3% of injuries were severe enough to reduce or prevent cycling. (PubMed)
The most frequently reported sites were the knee, shoulder and lower back.
However, lateral elbow tendinopathy was not recorded as a separate diagnosis.
That is important.
It means we cannot currently say that, for example, “5% of cyclists develop tennis elbow”. The epidemiological research simply has not been designed to answer that question.
Amateur cyclists may be particularly interesting
A systematic review of road-cycling injuries found that reported injury incidence among amateur cyclists varied enormously between studies — from approximately 3.23 to 116 injuries per 1,000 cyclists, depending on how injury was defined and measured.
Some older research found that as many as 85% of recreational cyclists reported at least one form of overuse complaint, although those figures include everything from knee and back pain to hand problems and cannot be interpreted as tennis-elbow prevalence. (PubMed Central (PMC))
Overall, the systematic review concluded that amateur cyclists appeared to experience a greater injury burden than professional cyclists, although comparisons are difficult because studies have used very different definitions and reporting methods. (PubMed Central (PMC))
For lateral elbow problems, that distinction makes biomechanical sense.
An amateur cyclist may be more likely to ride with:
excessive reach, poorly positioned brake hoods, locked elbows, excessive weight through the handlebars or an unnecessarily tight grip.
The professional rider, despite enormously greater mileage, typically has access to professional bike fitting, physiotherapy, strength and conditioning, coaching and regular equipment adjustment.
That doesn’t eliminate the problem — but it may change the exposure.
What happens at professional level?
Professional riders accumulate extraordinary training volumes.
One study following 51 top-level road cyclists found an overall cycling-related injury rate of approximately 0.50 injuries per rider per year. Just over half of the injuries recorded were caused by overuse, and almost 90% of those overuse injuries occurred during training rather than racing. (PubMed)
Another study of 109 professional road cyclists from seven teams was specifically established because surprisingly little epidemiological information existed on professional cycling overuse injuries. (PubMed)
More recent prospective professional-cycling research reinforces the distinction between racing and training.
A year-long study found an overall race injury rate of approximately 4.14 injuries per 1,000 hours, compared with 1.23 per 1,000 training hours. Importantly, all six overuse injuries recorded during that study occurred during training. (PubMed Central (PMC))
But once again, lateral elbow tendinopathy was not separately identified.
The elbow does appear in professional cycling injury statistics
Professional cycling research does record elbow injuries — but most of those occurring in competition are traumatic, rather than repetitive tendon injuries.
During one UCI WorldTour season, the arm and elbow together accounted for 17.6% of recorded race injuries. Most were caused by crashes and consisted of bruising, abrasions and other acute injuries. (PubMed)
A more recent prospective professional study recorded male elbow race injuries at approximately 0.33 injuries per 1,000 race hours, or 0.50 per 365 race days. Again, these were predominantly abrasions rather than tennis elbow. (PubMed Central (PMC))
Tour de France data tell a similar story. Between 2010 and 2017, elbow fractures were recorded, but overuse elbow conditions were rarely sufficiently severe to cause race withdrawal and therefore tended not to appear in the statistics. (PubMed Central (PMC))
This exposes an important weakness in professional cycling data.
If a rider develops mild or moderate lateral elbow pain but continues training and racing, the condition may never appear in an injury database.
Why could road cycling produce tennis elbow?
Tennis elbow primarily involves the common extensor tendon at the lateral epicondyle, particularly the extensor carpi radialis brevis.
The problem is associated with repeated gripping and loading of the wrist-extensor muscles.
Consider what happens during a four-hour road ride.
The cyclist repeatedly:
grips the hoods or drops;
stabilises the handlebars;
maintains wrist position against vibration;
brakes;
changes gear;
pulls against the bars during hard climbing;
and supports part of their upper-body weight through the hands and arms.
The elbow is also intended to remain slightly flexed so that the arm can absorb movement.
If excessive handlebar reach causes the cyclist to ride with almost completely straight arms, the elbow becomes part of a relatively rigid structure transmitting vibration between the handlebars and the shoulder.
The combination of gripping + wrist extension + vibration + prolonged duration provides a credible mechanism for lateral elbow tendon overload.
Amateur versus professional cycling
There is therefore a curious paradox.
Professional cyclists ride vastly greater distances, yet amateur riders may have several additional risk factors:
less sophisticated bike fitting;
less developed conditioning;
poorer riding technique;
excessive grip pressure;
less variation in hand position;
inappropriate handlebar reach;
and less access to physiotherapy when symptoms begin.
Professional riders, on the other hand, have enormous exposure but usually benefit from carefully managed positioning and rapid access to treatment.
Neither group is immune.
The missing statistic
Perhaps the most interesting finding is therefore the statistic that doesn’t exist.
We have reasonably good information about:
knee pain, back pain, hand neuropathy, shoulder injuries, fractures and crash-related elbow injuries.
But we do not yet have a robust incidence figure for lateral elbow tendinopathy in amateur or professional road cyclists.
That should not be interpreted as evidence that tennis elbow is rare in cycling.
It demonstrates that it has largely not been specifically measured.
For an activity involving thousands of repetitive gripping actions, prolonged wrist stabilisation and hours of vibration through the handlebars, that represents an interesting gap in sports-injury research.
And perhaps it is time we stopped thinking of tennis elbow as something that only happens when somebody picks up a racket.
Sometimes the offending piece of sports equipment has two wheels and drop handlebars.
