How is cyclist palsy managed and treated?

Management and Treatment of Cyclist's Palsy

Cyclist's palsy should be treated with conservative measures including rest, proper bike fitting, padded gloves, and frequent hand position changes; most cases resolve with these interventions alone.

What is Cyclist's Palsy?

Cyclist's palsy (also known as handlebar palsy) is a compression neuropathy of the ulnar nerve that occurs in cyclists due to prolonged pressure on the hands during riding. It typically presents with:

• Numbness and tingling in the 4th and 5th fingers
• Weakness in the intrinsic hand muscles
• Loss of coordination in the affected hand(s)
• Symptoms usually appear after several days of cycling 1

Pathophysiology

The condition results from:

• Compression of the ulnar nerve at the wrist (Guyon's canal)
• Extended wrist posture, particularly in the "drops" position on handlebars
• Pressure on the hypothenar region of the hand
• Studies show average peak hypothenar pressures of 134-165 kPa when cycling without gloves 2
• Both motor and sensory branches of the ulnar nerve can be affected 3

Diagnosis

The diagnosis is primarily clinical:

• History of cycling, especially long-distance riding
• Pattern of sensory loss in ulnar nerve distribution (4th and 5th fingers)
• Weakness of intrinsic hand muscles
• High incidence: 92% of cyclists in one study experienced either motor or sensory symptoms after a 600-km ride 4

Treatment Approach

1. Conservative Management (First-Line)

• Rest from cycling: Allow the nerve to recover by temporarily stopping or reducing cycling

• Proper bike fitting:

  • Correct frame size
  • Appropriate distance from seat to stem
  • Handlebar height and reach adjustments to reduce wrist extension

• Equipment modifications:

  • Padded cycling gloves: Reduce hypothenar pressure by 10-28% 2
  • Padded handlebars: Distribute pressure more evenly
  • Foam padding is slightly more effective than gel padding for pressure reduction 2

• Technique adjustments:

  • Frequent changes in hand position on handlebars
  • Avoid excessive weight-bearing through the hands
  • Reduce time spent in the "drops" position, which causes the greatest hypothenar pressure and most extended wrist posture 2

2. Recovery Monitoring

• Most cases resolve with conservative management
• Complete recovery may take several months 3
• Monitor for improvement in both sensory and motor symptoms

3. When to Consider Further Intervention

• For persisting or progressive symptoms despite conservative management:
  • Thorough neurological examination to confirm diagnosis and rule out other sites of nerve compression 5
  • Electrodiagnostic testing (EMG/NCS) to document the degree of nerve injury
  • Nerve decompression surgery may be indicated for symptoms that persist despite adequate conservative treatment 5

Prevention Strategies

• Proper bike fitting before long rides
• Use of padded cycling gloves for all rides
• Regular hand position changes during cycling
• Handlebar padding
• Gradual increase in cycling distance and duration
• Awareness of early symptoms and prompt intervention

Prognosis

The majority of cases resolve with appropriate rest and conservative treatment. However, some patients may experience symptoms that persist for several months, with functionally significant hand muscle weakness potentially lasting for an extended period 3.