Outdoor Cycling: Key Insights for Podiatrists

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Created in partnership with the American Podiatric Medical Association.

Key Summary

• Cycling biomechanics (US outpatient/sports medicine): Cycling uses forefoot-dominant load transfer, minimal frontal-plane motion, and low impact with no ground-reaction forces, benefiting patients with degenerative joint disease or post-injury recovery; improper forefoot loading may contribute to metatarsalgia, plantar fasciitis, Achilles tendinopathy, PTTD, and peroneal tendinopathy.

• Bike fit determinants: Clinical bike fit centers on saddle height, handlebar reach, cleat position (fore–aft, medial–lateral, wedging, rotation/float), limb-length discrepancy, and shoe stiffness, each directly influencing knee alignment, power transfer, and foot stability.

• Patient-specific adjustments: Women (higher Q-angle, wider pelvis), older adults (reduced flexibility), and patients with deformities (bunions, hallux rigidus, cavus, pes planus) require tailored shoe selection, orthotic volume control, and forefoot–rearfoot support to prevent retrograde compensation and optimize comfort and performance.

Transcript

Jennifer Spector, DPM: Welcome back to Podiatry Today Podcasts, where we bring you the latest in foot and ankle surgery from leaders in the field. I’m Dr. Jennifer Spector, assistant editorial director for Podiatry Today. And today we’re thrilled to have Dr. Clinton Laird with us to talk about outdoor cycling for the podiatrist. I’ll let him give a little bit more information but we’re super excited to have him with us today to talk about this topic. Today’s episode was created in partnership with the American Podiatric Medical Association as well. Welcome, Dr. Laird. 
 
Clinton Laird, DPM: I appreciate you guys letting me come speak to you today about my favorite topic, which is outdoor cycling. I’ve been a cyclist most of my life. I was that crazy kid who was always on my bike all over all over rural East Texas. I'm a graduate of Barry University. I did three-year residency in primary pediatric medicine and surgery. And I did a fourth year of fellowship in pediatric and sports medicine. I've been in private practice for 25 years. I'm a fellow and current president of the American Academy of Podiatric Sports Medicine. I am board certified in foot surgery as well as a fellow of the American College of Foot and Ankle Surgeons. I have been certified by Bike Fit for the last 12 years, and I'm currently certified by the International Bike Fitters Institute based in the United Kingdom, and I practice on the west coast of Florida. 
 
Jennifer Spector, DPM: So why is outdoor cycling an important area of focus for podiatrists, especially those that have sports medicine practices? 
 
Clinton Laird, DPM: Well, outdoor cycling is a fast-growing sport, and the great news is it's something that all ages can do. I happen to have a large population of seniors in my practice, and cycling is a sport for all abilities. I frequently use cycling as a cross-training activity for people with injuries, since it's a relatively non-weight-bearing sport. As our population ages, low-impact activities are very beneficial for their health. I have a cyclists in my practice that range from participating in the senior games on the national level and some that just want to ride out and check the mailbox. 
 
To quote George Sheehan, who was one of the initial founders of the American Academy of Podiatric Sports Medicine, everyone is an athlete. The only difference is some of us are training and some of us are not. The number of Americans who will be over 65 will nearly double by 2040, and seniors are more active than ever. 
 
Understanding the biomechanics of the foot is paramount to us as podiatrist, their improved foot function, therefore improving abilities of their patients to perform their activities of daily living as well as improving or preventing their foot pain. The most important thing to me as a sports medicine podiatrist is understanding the patient, their needs, the activity they want to do, and being able to talk to them about terms that are important to that specific sport. 
 
Jennifer Spector, DPM: I love your characterization of everybody being an athlete. And you mentioned about the biomechanics. What makes the biomechanics of outdoor cycling so unique compared to running or walking, especially in terms of foot and ankle load? 
 
Clinton Laird, DPM: Well, that's an interesting question. Biomechanics of cycling is almost significantly different from walking in terms of foot and ankle function, how the forces are distributed, and which muscles are involved. Cycling is primarily a forefoot contact, so we have a lot of different changes that occur because we don't have a rearfoot stride. 
 
Load distribution in cycling—the foot primary acts as a rigid lever to force, to transfer the force from the leg down to the pedal. It is concentrated in the forefoot, especially out of the metatarsal heads where when we talk about loading for running it is a dynamic foot load where heel strike, midfoot loading and toe-off engage the entire foot and ankle in shock absorption. Also, joint motion is important. In cycling ankle basically acts as a dorsiflexor and plantarflexor and it’s almost all occurring in the sagittal plane. Therefore, there's reduced pronation and supination, which does not have to accommodate for as much shock. Running, on the other hand, the ankle is in a much more dynamic range of motion with the need for pronation as well as supination to adapt to uneven terrain. 
 
Impact forces are probably the most important thing when it comes to cycling because it's low impact and there's no ground reactive forces. So it's ideal for patients with degenerative joint changes as well as recovering from injuries, whereas compared to walking or running, those are high-impact sports where you see one-and-a-half to three times the body weight, which can cause repetitive stress injuries, like plantar fasciitis or stress fractures. 
 
When we look at muscle activation, cycling emphasizes the quadriceps, the gluteus muscles, as well as the calf muscles. The one downside is, we can see weak intrinsic muscles over time. Where running is a much broader range of muscle loading including the stabilizers and flexors and it promotes more neuromuscular coordination and proprioception. Important thing with bike fit, basically when I start a bike fit the first thing I do is a biomechanical exam both static and dynamic, specifically looking for certain things: forefoot to rearfoot relationship, evidence of leg length discrepancy, and flexibility, especially of the hips and knees.
 
Jennifer Spector, DPM: So you mentioned bike fit. Could you explain a little bit more about what that means and why it matters specifically for the lower extremity for this type of athlete?
 
Clinton Laird, DPM: Well, bike fit is systematic approach to adjust the bicycle to match the rider’s body dimensions, ability, and riding style. And that is all done to optimize comfort, performance, and prevention of injury. It involves fine-tuning various components of the bike and assessing the rider’s position, to ensure everything works in harmony. 
 
I really have three different types of bike fit that I do. One is comfort, and comfort is basically I want patients to feel most balanced and feel that they're not overstressing and straining any one joint or area. There's a race fit, which is kind of throws comfort out the window, and I'm only looking for changes in the patient's output as far as power goes. And I use that with a power meter to monitor for changes when I make changes within their bike fit. And then there's a rehabilitative bike fit, which is where I basically will look at an injury, assess the injury, and make changes on the bike fit to allow that injury to heal. And then we will go back to their comfort or race fit as their body adjusts to it. 
 
There are five key elements to a bike fit. First is saddle height and position to ensure that we get proper leg extension and hip alignment. Handle bar reach and drop, which is allowing them to reach the bars, retain a flat back, and most importantly, comfort, and then feeling like they're in a neutral position for control on the bike. Cleat position for clipless pedals is probably where I spend the majority of my time during bike fit. The whole goal of cleat adjustment is to get zero motion in the frontal plane of the knees. It affects pedal stroke, proximal forces, and foot function. Frame size and geometry, sometimes we're limited by that with the patient already having their own bike. So we must assess that bike and see what changes we can make to make it the most comfortable for them. And lastly, I look at flexibility and core strengthening. And that determines how much of an aggressive versus a more upright position that they can be in for the best outcome for the patient. 
 
Jennifer Spector, DPM: You said something interesting about cleat positioning. This makes me wonder about how does cleat positioning or things like shoe stiffness, or the shoe–pedal interface: how does this affect foot biomechanics? 
 
Clinton Laird, DPM: Well, that’s a great question. I basically group cleat position with the foot–pedal interface since they’re closely related in terms of bike fit. Cleat position is the most important factor when it comes to foot biomechanics, specifically with the forefoot to rearfoot deformity to increase power and injury prevention. Adjustment of the cleat affects proximal muscle function, power, stamina, and injury prevention. 
 
Like I said, the vast majority of my time during a bike fit is specifically looking at the cleat adjustments, and there are five basic cleat adjustments. The first is fore and aft position of the cleat on the shoe. Basic terms, you want the pedal to spindle to be somewhere between the first and the fifth metatarsal head. The further before you are more distally towards the first metatarsal head, you're going to have more power. That's going to come at the expense of stamina. The further back you put it, you're going to have more stamina, but you're going to have less power output. 
 
Second is medial and lateral movement of the cleat. And the goal of medial lateral is to get the foot underneath the knee because the more vertical the knee is and the foot underneath it, the better you're going to have power transfer through the pedal. 
 
Third and most important to me is wedging. Wedging is supporting a forefoot deformity since cycling is a forefoot dominant power transfer, you need that to support that deformity to prevent retrograde compensation. 
 
Next is limb length discrepancy, and this is where a lot of my non-clinical bike fit people that I educate, they have the hardest time dealing with limb length discrepancy. As biomechanists, we all know the cues to look for on gait, And then we can do some measurements to determine how much limb length discrepancy that we have. 
 
And last is rotation and float. Rotation is basically where do you put the pedal to put the foot in the most neutral position for the patient. And that's basically the angle of gait. So if it walks like a duck, it's going to ride like a duck. And float is the difference or the movement that's allowed between the cleat and the pedal itself. You want the center of that float to be in the middle of their range of motion so that they have a little bit of internal and external rotation available to them. 
 
When I was trained in bike fit, wedges were what was taught to me to be, and I think it's the most important thing to prevent that collapse or supination of the forefoot, which causes retrograde collapse and or supination of the rearfoot. There are a lot of fitters out there who do not believe in them. I disagree with them somewhat because if we don't support that deformity, it's going to be hard to control that frontal plane motion of the knee. 
 
Stiffness of the shoes is an important factor. It distributes the weight a lot better across the forefoot. Many years ago, they were softer shoe materials, and it ended up creating a lot of hot spots underneath the foot. You may have heard of something called hot foot, which I think is more of a metatarsalgia/neuroma kind of thing. And those stiffer sole shoes have made some strides in eliminating that. 
 
Jennifer Spector, DPM: So that being said, what are some common foot and ankle issues that you see in cyclists, especially those who may have an improper bike fit? 
 
Clinton Laird, DPM: Well, there are quite a number of things that I see regularly, and these are in no particular order. But numbness and tingling of the feet can be caused by a number of different things, the cleat being too far forward directly under the metatarsal heads and pinging the nerves and/or blood supplies. 
 
So common things that we can do if the patient does not have a stiff sole shoe, that's the first thing I would start with. Also, wider cleats, as far as surface area goes, distributes that pressure a lot better. If we move that pleat slightly back to get it off the metatarsal heads, I think that's super important. When I first started with Bike Fit, there was only one company that made wider shoe widths, but nearly every shoe company does that now. And so I think that's been something that helps with a lot of patients in their feet. 
 
Next are all the “itis”-es, starting with planar fasciitis. Just like in our practice, that's one of the more common things that we see. Generally, that's caused by poor arch support or an unsupported forefoot varus, causing rearfoot and midfoot pronation, causing inflammation of the planar fascia leading to heel pain. Solutions out there—custom orthotics, and or over-the-counter, rigid-type orthotic, cycling shoes with better arch support and supporting their forefoot to rearfoot alignment. Intrinsic muscle strengthening, like I said, that cycling can cause some intrinsic muscle weaknesses, gastrocsoleal stretching, and/or eccentric loading, Alfredson's type exercises. 
 
Next is Achilles tendonitis. I frequently see that with patients who have their saddle too high, causing them to be reaching for the pedal at bottom dead center, effectively causing a strain on the Achilles tendon due to the repetitive toe-down spacing or cycling pedal motion. Solutions—lower that saddle, put the cleat farther back so it’s in the middle of the foot and eccentric stretching and strengthening. 
 
I see quite a number of patients with posterior tibial tendon dysfunction, and the generally is caused by an unsupported forefoot varus, and I think wedges are the most important thing to prevent that. Orthotic devices—you have to be careful with not to make too big of a running type device. You have to have a little down the device more like a soccer or a skiing type orthotic. 
 
And peroneal tendinopathy I've seen a number of times in my practice related to the abnormal rotation of their cleats and not being put on right so their foot is fighting against the pedal the whole time and not having enough float to be able to accommodate for that. And also an uncompensated forefoot valgus causing the foot to continue supinating. 
 
Metatarsalgia, this like I mentioned, that the more surface you inherit between the shoe and the cleat, the less pressure or pounds per square pressure there is. I've even had some luck with just a gel-type insert to absorb some shock there. And toe clawing is not something I see too much because it's in the side of the shoe, but I hear patients complain about it all the time that they feel like their toes are always grasping. And I frequently see that with the shoe that is too large or does not have enough support. 
 
Jennifer Spector, DPM: So there's so much to talk about when it comes to outdoor cycling, but I'm curious what your thoughts are on how bike fit considerations might differ for different types of patients, say for female versus male cyclists, older adults, as you mentioned, or patients with diabetes or neuropathy. What's your experience there? 

Clinton Laird, DPM: Well, women are interesting because as we all know from biomechanics, women tend to have a higher Q angle, which affects their knee position. And it becomes more challenging because there's only so much room you can space the cleat medially or laterally to get under the knee. So that's a little bit of a challenge to get that knee vertical. Women also tend to have longer legs versus their torso. So there are several companies out there who make different bike brands, who will have a specific bike design, which I think are fantastic because they tend to have a shorter top tube, which is a distance between the seat and the handlebar stem. So I think that's fantastic for a lot of my female cyclists. They tend to have wider pelvis. And so there are a lot of companies out there who also make wider saddles. And I think that supports a woman's anatomy a lot better. Most saddles these days have a channel in there for as they are described by most people to suspend soft tissue and I think that’s supportive for both men and women. And a lot of women have a lot more flexibility but may lack some core strengthening so it’s important that you have to monitor that because they may be able to get into an aerodynamic position that is fantastic for wind mitigation but they may not be able to support that position for a long period of time due to some core strength. 
 
So my older patients, the biggest problem I see with them is that they lose some flexibility in their neck or back so the race-type bike fit or race-type bike tend to be a little bit too aggressive for them so I encourage them to get on an endurance-type bike or even consider a gravel bike because they have a shorter top tube and place a lot less strain on the neck and back. 
 
As far as diabetics or neuropathy, I don't really see too many issues with that except for the typical, you know, you want to make sure that they shoes aren't too tight. We have to watch out for vascular supply. But as far as neuropathy itself and diabetes in and of itself, I don't really make too many adjustments for that. Obviously, I think cycling is a fantastic sport for my diabetics for weight reduction, insulin resistance. So I think cycling is fantastic for those patients. 
 
Jennifer Spector, DPM: And lastly, what adjustments do you think or what interventions can clinicians take for cyclists that have pre-existing foot deformities, like say those patients with bunions or hallux rigidus or various foot types? 
 
Clinton Laird, DPM: Bunions used to be a real challenge for me because not a lot of shoe companies made wide-forefoot shoes. Now there are companies out there, most companies make a shoe with a wider forefoot. Shimano and Sidi. I really like their shoe design, called Lake. And they have this real interesting grid if you go to their website. And they basically have you measure the length of your foot, like five or seven different parameters and they will then make a specific recommendation of a shoe type. So I really got interested in their shoes. I have not played with them, I have not touched them but I had a number of patients who really liked the fit and the quality of the materials that they used in them so I really am encouraged by that, to have a gride so they can get a proper shoe. They have you measure the width of your foot, the instep and arch height, and whether you actually have a bunion is one of their questions. 
 
As far as hallux rigidus, for the most part, cycling shoes accommodate for that pretty well because they have a rigid outer sole. I have had some patients who have success with me using a rigid forefoot extension, a Morton's extension. The one thing you have to be cognizant of is if you put that extension underneath there, especially if they have a dorsal exostosis, you have to make sure that that doesn't get pushed up into the top of the shoe itself, causing pain and problems with that. 
 
Cavus foot is probably the most challenging because the cavus foot tends to be a higher volume foot. And so many road shoes don't really accommodate very well for that. I encourage my patients to consider going to a mountain bike shoe or a gravel shoe because they tend to have more depth. But the most important thing is controlling the forefoot to rearfoot deformities to prevent retrograde compensation. 
 
Pes planus, I see an awful lot of that. That foot tends to be a lower volume, so it's not quite as problematic. I've seen great success with over-the-counter slash custom inserts. But like I said, with your custom orthotics, you need to make a lower volume insert. So the patient still has plenty of room within the shoe for the device. 
 
Jennifer Spector, DPM: Great. Is there anything else you'd like to add on outdoor cycling and what DPM should know? 
 
Clinton Laird, DPM: The most important thing is encouraging your patients to get out and be active no matter what that is. I can't tell you the number of my patients who are now triathletes that came to me for running. I encourage them to start cycling and swimming as cross-training and they’re now triathletes. The most important things with all types of sporting activities for your average sports medicine podiatrist is to get familiar with the lingo because that’s the one thing that encourages your patients top be more supportive of your decisions and the decisions that you make is understanding the lingo. Pickleball, you need to understand what's going on in the rules and the materials that are being used. Cycling, just having a basic knowledge of a bike and how bike fit can make their lives a lot easier is the most important thing I can recommend to all my colleagues. 
 
Jennifer Spector, DPM: Thank you so much for sharing all of your insights with us today, and thank you to the audience for joining us. You can see this and listen to all other episodes of Podiatry Today Podcasts on Podiatrytoday.com, Spotify, Apple Podcasts, and your favorite podcast platforms.