This document reviews the treatment of cyclist’s syndrome, also known as pudendal neuralgia, through osteopathic manipulative therapy. It discusses the rise in cycling popularity during the COVID-19 pandemic, the impact of saddle design on pudendal nerve compression, and the potential effectiveness of osteopathic treatments like counterstrain and myofascial release in alleviating symptoms. Further research is recommended to explore osteopathic practices for managing this condition among cyclists.

1. Treatment of Cyclist’s Syndrome (Pudendal
Neuralgia) with Osteopathic Manipulative
Therapy Techniques: A Review
By: Jeffrey Addley
Diploma in Osteopathic Manual Practice
London College of Osteopathy and Health Sciences
Supervisor: Konstantin Firsov M.D, Ph.D, DO

2. I
Declaration
Treatment of Cyclist’s Syndrome (Pudendal Neuralgia) with Osteopathic Manipulative Therapy
Techniques: A Review
Supervisor: Konstantin Firsov M.D, Ph.D, DO
This Project is presented in partial fulfilment of the requirements for the diploma in Osteopathic
Manual Practice (DOMP). It is entirely my own work and has not been submitted to any other
university or higher education institution, or for any other academic award in this institute. Where
use has been made of the work of other people, it has been fully acknowledged and fully referenced.
Jeffrey Addley
September 2, 2020

3. II
Acknowledgements
I would like to thank Tania Maalouli for the help and support she has given me over the past year
during my studies for the diploma in osteopathic manipulative practice. You have always been
there to keep me on track and encourage this next step in my career.

4. III
Table of Contents
Declaration .............................................................................................................................. I
Acknowledgements ................................................................................................................ II
List of Figures ........................................................................................................................ IV
Abstract ................................................................................................................................. V
Chapter 1: Introduction .......................................................................................................... 1
Chapter 2: Discussion ............................................................................................................. 2
Saddle Pressure in Cycling ................................................................................................................ 3
Cyclist’s Syndrome (Pudendal Neuralgia) .......................................................................................... 5
Osteopathic Manipulative Treatment ............................................................................................... 6
Chapter 3: Conclusion ............................................................................................................ 11
References: ........................................................................................................................... 13

5. IV
List of Figures
Figure 1. Saddle design, Performance Saddles, and Cushioning Saddles Page 2
Figure 2. Ridding Hand Positions Page 4

6. V
Abstract
Cycling in North America has grown in popularity since the sudden arrival of the COVID-19
pandemic in early 2020. The rise in bike sales suggest that more people are taking up this activity
as a means of transportation and recreation. Hard saddles that are often fitted to road bikes can
produce compressive forces on the perineal region and have lasting effects known as ‘Cyclist’s
Syndrome’. This rarely reported compressive condition of the pudendal nerve is seen in frequent
and long distance bike riders. Symptoms of this condition vary from pain and/or numbness with
prolonged sitting in the perineum, rectum, labia, vagina, scrotum, and penis. In more severe
cases, pain can be present during intercourse in females, and erectile dysfunction in males.
Literature has shown the Nates criteria to be the most current and up to date diagnostic tool for
identifying pudendal nerve compression, but it is still not a 100% effective due to overlapping
symptoms with other pelvic floor conditions. Current literature on the treatment of pudendal
neuralgia using osteopathic manipulative therapy is scarce, although it is suggesting to be
effective, especially with the use of counterstrain and myofascial release techniques to reduce
local tenderness and compressive factors surrounding the pudendal nerve roots within the
sacroiliac region. Further research on this condition in recreational and professional cyclists is
needed along with the use of more non-invasive practices such as osteopathic manipulative
therapy.

7. 1
Chapter 1: Introduction
Cycling in North America has grown in popularity since the sudden arrival of the COVID-19
pandemic in early 2020. As community centers, gyms, and fitness studios have been forced to
close during the global lockdown, sales in March of 2020 for children’s bikes have risen 56%
and 121% for adult leisure bike sales, in comparison to 2019 figures.
1
Relatable figures are also
presented with indoor stationary bikes. Peloton Interactive Inc., an American exercise equipment
and media company, reports quarterly revenues to have soared 66%, and paid digital
subscriptions have risen 64% following the onset of the COVID-19 pandemic.
2
As cycling is a
relatively inexpensive and widely used form of transportation, a greater number of adults have
opted to ride their bikes to work as a means of exercise, social distancing, and a form of stress
relief. Trek Bikes and the research firm, Engine Insights, surveyed over a thousand American
adults and reported nearly 63% of Americans feel bike riding helps relieve stress and anxiety
during the COVID-19 pandemic, and 27% of Americans that own a bike turn to bike riding for
mental health management and to destress.
3
This sudden rise in cyclists increases the number of cycling related injuries. Recreational and
professional ridders alike suffer from various acute and overuse injuries, with most injuries to
recreational riders being associated with overuse or improper fit of bicycles. Whereas
professional racers suffer from injuries associated with high speed cycling, which predispose
riders to muscle stains, collisions, and falls.
4, 5
Within the overuse injuries category, the most
common regions affected in cyclist are the neck, back, hand/wrist, buttock/perineum, hip, knee,
and foot/ankle.
6,7
The purpose of this review is to examine the available literature on osteopathic manipulative
treatment on pudendal neuralgia in cyclists, and further explore osteopathic manipulative
treatment in an athletic setting of recreational and competitive cycling.

8. 2
Chapter 2: Discussion
Overuse injuries to the buttock and perineum region are most commonly a result of poor saddle
positioning or poor choice in shape and design. The rider’s preference and purpose of the bike
will determine the type of saddle needed. Traditional saddles fitted on road bikes often feature a
solid frame and long-nose shape, whereas recreational bike saddles differ in design, featuring a
short-nose and wide seat for optimal comfort.
Figure 1: Saddle design, performance saddles and cushioning saddles. Taken from REI Co-op 2018
8
More serious riders and racers may upgrade their bikes and choose to replace the manufacturer’s
saddle for a more supportive aftermarket option. Designs of these saddles can vary in shape and
general features; with a long or short-nose, center grooves, holes, and different padding options.
Current trends in 2020 lean towards short-nosed performance saddles, which originated with
ridders looking to optimize soft-tissue comfort while leaning forward.
9
Comfort for cyclists can
mean the difference in an enjoyable ride and a potential overuse injury.

9. 3
Saddle Pressure in Cycling
Saddle pressure on the perineum region has been extensively researched in literature. Ridding
positon and saddle design being major factors with regards to comfort and performance. Saddles
fitted to road bikes tend to fall under traditional design; firm, narrow, and long-nose. Though not
specifically designed for comfort, traditional sport/racing saddles have been associated with
providing more than two times the pressure in the perineal region than the saddles without a
protruding nose.
10, 11, 12
Male and female ridders can experience discomfort along the perineum and ischial tuberosities.
Carpes et al.
13
describe the different saddle pressure in relation to workload in both men and
women. Plain saddle average pressure for men is correlated with workload. As one increases, so
does the other. Using a ‘holed’ saddle resulted in increased pressure to the perineum in both men
and women, as workload increased.
Potter et al.
14
found a correlation between saddle pressure and hand positioning on handle bars.
In both male and female ridders, a hand resting position along the top of the handle bars (‘tops’
position) is associated with increased posterior pressure on the ischial tuberosities. When in a
crouched position, with hands resting on the lower scooped handle bar (‘drops’ position), the
center of pressure shifts forward onto the ischial tuberosities, with males having increasingly
more anterior compression compared to females.

10. 4
Figure 2 Ridding hand positions; 'tops' (left), and 'drops' (right). Taken from Cyclists Life, 201515
Capes et al.
16
found similar results to Potter et al. They suggest trunk positioning / lumbar
flexion to be a risk factor with regards to perineal compression, and that it varies between male
and female cyclists. They found that when lumbar flexion is at 600
and 900
, there is no
significant difference in perineal pressure for women using a solid or ‘holed’ saddle. However, a
more upright ridding position for men was found to decrease pressure when the cyclists use a
‘holed’ saddle versus a solid design.
Cyclists that train and compete over long distances (i.e. road racers), hold their trunks in an
increasingly flexed position to reduce aerodynamic drag and maximize average speed
17
. As
previously suggested, increased lumbar flexion has its drawbacks for long distance and frequent
ridders. Common symptoms include: constant rubbing in the perineal region, which can result in
chafing, perineal folliculitis and furuncles, subcutaneous perineal nodules, pudendal neuropathy,
male impotence, traumatic urethritis, and a variety of vulvar trauma.
18, 19
The poor cushioning
and firm structure of these saddles can cause intense and prolonged compression of the pudendal
nerve, most common following repeated and multi-day rides, which may result in transient
impotence.
20

11. 5
Anderson et al.
21
surveyed 169 amateur cyclists taking part in an annual non-stop 540-km
bicycle tour, and the occurrence of symptoms of neurological injuries as a result of this event.
Numbness of the genitals that lasted for a day or more was reported in 21% of male participants,
and 6% of those participants have symptoms lasting between 1 week to four months’ post event.
Nine of the 169 amateur ridders were female, none of which reported any neurological injuries.
Baran et al.
22
revealed similar findings, suggesting perineal numbness and erectile dysfunction
to be the most commonly reported symptoms in the male population due to compression of the
pudendal nerve as a result of long distance cycling. Sommer et al.,
23
noted that 61% of male
cyclists, in a study of 40 healthy participants, experienced numbness in the genital region, along
with 19% experiencing erectile dysfunction after weekly cycling distances of more than 400km.
Cyclist’s Syndrome (Pudendal Neuralgia)
Pressure on the perineum from bike saddles can result in the compression of the pudendal nerve.
Recreational and professional cyclists alike, that long-distance ride frequently refer to this as
“cyclist’s syndrome.”
24
Symptoms of this condition vary from pain and/or numbness with
prolonged sitting in the perineum, rectum, labia, vagina, scrotum, and penis. In more severe
cases, pain can be present during intercourse in females, and erectile dysfunction in males.
25
The pudendal nerve originates from the S2-S4 nerve roots, traveling behind the sacrospinous
ligament and medial to the spine of the ischium. Within the gluteal region, the nerve passes
between the sacrospinous and sacrotuberous ligaments, and moves towards the inner surface of
the obturator internus muscle. The nerve enters the pudendal (Alcock’s) canal below the pubic
bone and splits into three branches upon its exit; the inferior rectal nerve, perineal nerve, and the
dorsal nerve of the clitoris in females, and dorsal nerve of the penis in males.
26, 27
The pudendal
nerve provides somatic motor efferent fibers to the urethral rhabdosphincter, external anal

12. 6
sphincter, and select perineal muscles. The sensory afferent fibers innervate the majority of the
perineum as well as the urethra, rectum, clitoris in females, and penis in males.
28, 29
Pudendal neuralgia via compression of the pudendal nerve is commonly examined in three
mechanisms of injury: compression in an acute or chronic lesion, stretch injury as a result of
childbirth, or transection injury.
30, 31, 32, 33
Though pudendal neuralgia is documented in both
sexes, six out of ten cases are observed in women, with pain usually arising insidiously,
sometimes preceded by a phase of paresthesia in the same territory. Prolonged sitting or driving
appears to be predisposing factors, with the most common being cycling.
34
The primary
mechanisms leading to these symptoms in both genders is suggested to be perineal compression
of the pudendal nerve within the Alcock’s canal.
35, 36, 37, 38, 39, 40
In 2009, Filler et al.
41
described a collective report of 200 patients experiencing pudendal
neuralgia, and evaluated primary locations of nerve entrapment. Four primary types were
discovered based on location of entrapment: Type I, entrapment at the exit of the greater sciatic
notch in concert with piriformis muscle spasm; Type II, entrapment at the level of the ischial
spine, sactotuberous ligament, and lesser sciatic notch entrance; Type III, entrapment in
association with obturator internus muscle spasm at the entrance of Alcock canal; Type IV, distal
entrapment of terminal branches.
Osteopathic Manipulative Treatment
Osteopathic manipulative treatment therapy is a non-invasive therapy defined as: the therapeutic
application of manually guided forces to improve physiologic function and/or support
homeostasis that has been altered by somatic (body framework) dysfunction. Osteopathic
manipulative therapy methods include a collection of techniques that apply a set of distinct
unified principles that guide individualized treatments including high-velocity low-amplitude
thrusts, muscle energy, cranial, counterstrain, myofascial release, facilitated positional release,

13. 7
facial ligamentous release, lymphatic, and soft tissue therapy.
42
These techniques can be further
categorized as either direct or indirect. Direct techniques consist of the practitioner moving the
body into positions of laxity to facilitate neurological resetting and local tissue relaxation.
Indirect techniques consist of the practitioner moving the body into restricting positions to
facilitate improved motion.
43
The range of techniques practitioners use in daily practice can be quite broad. Johnson et al.,
44
describes a 2003 questionnaire of 955 practicing osteopathic manipulative practitioners and the
likelihood of using various osteopathic manipulative treatment techniques in practice. Use of soft
tissue, high-velocity low-amplitude thrusts, and muscle energy were among the most preferred,
with cranial, facilitated positional release, and fascial ligamentous release used the least.
Technique preferences for specific demographics were also present, as female and older
practitioners were most likely to use indirect techniques, whereas male and younger practitioners
preferred direct techniques.
Somatic dysfunction, as diagnosed by osteopathic practitioners, is characterized using the
mnemonic TART: Tissue texture abnormalities, Asymmetry, Restriction of Motion, and
Tenderness. Any of these must be present for diagnosis.
45
Screening tests such as static posture,
gait, range of motion, and static palpation, are used to assess patients, determine location of
somatic dysfunction, and better direct treatment. A proper diagnosis and reliving somatic
dysfunction enables a practitioner to promote health and wellness in a patient presenting with
acute or chronic symptoms.
A proper diagnosis of pudendal neuralgia is difficult due to the similarities of symptoms with
prostatitis, prostate or testicular cancer, and ovarian cysts or dyspareunia in females. Patients are
often misdiagnosed and present with a history of seeing multiple physicians, with no evidence of
disease, normal urogynecological and colorectal evaluations, and failed multiple
pharmacological treatments.
46, 47
There is limited literature identifying pudendal neuralgia as a
positive source of perineal pain. Nates criteria is the most recognized and utilized method in the
diagnosis of this condition, though not widely used. This system uses five essential diagnostic

14. 8
criteria: (1) pain in the anatomical territory of the pudendal nerve, (2) worsened by sitting, (3) the
patient is not woken at night by the pain, (4) no objective sensory loss on clinical examination,
and (5) positive anesthetic pudendal nerve block.
48, 49
Patients seeking relief of pudendal neuralgia symptoms are often given an assortment of
treatment options, varying between behavioral modifications, physiotherapy, analgesics and
nerve block, surgical pudendal nerve decompression, radiofrequency, and spinal cord
stimulation.
50, 51
Manual therapists, such as pelvic floor physiotherapists, chiropractors, and
osteopaths, provide less invasive options to treating neuropathies that are often as effective and
generally more readily available than a surgical alternative.
Durante et al.
52
describe one case treating a 41-year-old male competitive Ironman athlete with
diagnosed “cyclist syndrome” presenting with constant penis and perineal pain from a 12–24-
hour ride. The patient was treated over a four-week period, twice weekly, where the main
treatment was soft tissue techniques on the obturator internus muscle. The first treatment initially
further aggravated the patient’s symptoms. By the second week, his pain had decreased from a
9/10 on the numerical pain scale, to a 5/10. The following two weeks of treatment continued with
the same soft tissue approach, further progressing the decline in pain to a 1/10. The patient
quickly returned to his regular cycling training without any residual perineal pain.
Crow
53
, produced similar results in a 24-year-old water polo player with a 6-months history of
impotence following multiple hits to the groin and testicles during a water polo match. The
osteopathic manipulative therapy approach consisted of ischiorectal fossa, prostatic, and perineal
release. Forces applied were to achieve a stretch of the obturator internus, as well as the
iliococygeus muscle of the levator ani. In addition to the impotence, somatic dysfunction was
identified at the thoracolumbar region, and was treated using high velocity-low amplitude
techniques. In a follow-up treatment later that same week, the patient reported his impotence had
completely resolved following the initial treatment. This suggests fascial restrictions may play a
role in impotence in patients with a history of trauma to the groin and pudendal nerve.

15. 9
Lafave et al.
54
documented in detail a unique case treating a 31-year-old bareback rodeo cowboy
with pudendal nerve entrapment over four consecutive days, during a lucrative and prestigious
invitation-only rodeo competition. Osteopathic manipulative treatment therapy consisted of
myofascial release, osteo-articular mobilization, and cranial and visceral release techniques. The
initial treatment primarily targeted the release of the root of the mesentery and ischial
intraosseous lesion, which provided the patient with a 50% improvement in symptoms. The
second treatment focused on the sigmoid colon, posterior abdominal wall, iliopsoas muscle, and
thoracolumbar fascia, which provided an additional 25% in relief. The third day targeted the
release of the pelvic floor musculature, including balancing the three diaphragms, and
harmonizing the primary respiratory mechanism within the cranio-sacral system. The final day of
treatment further worked on mobility of the pelvic girdle and viscera, and normalized the
remnant cranio-sacral and spinal lesions. On the fourth day, the patient reported no pain or other
symptoms following treatment.
According to Olson,
55
a 43-year-old female patient with consistent pudendal nerve pain, and
saddle-like paresthesia over a year and a half had a complete resolution of symptoms over 5
weeks of therapy. Diagnosed with pudendal neuralgia, the patient was treated over a one-month
period, starting with sessions twice weekly for three weeks, followed by weekly appointments
over the last two weeks. The practitioner used a combination of myofascial release, and
instrument-assisted soft-tissue mobilization techniques directed to the pelvic musculature,
focusing primarily on the right obturator internus. Treatment included chiropractic manipulative
therapy on the lower back and pelvis when segmental restrictions were noted at each visit. Over
the 5-weeks of therapy, the patient reported that her paresthesia had completely resolved.
Similar literature in treating patients of non-athletic backgrounds presenting with pudendal
neuralgia described relatable results using osteopathic manipulative therapy for this condition.
Origo et al.
56
describes the case management of a 40-year-old female who struggled with intense
pelvic pain over a year. Diagnosed with functional pudendal nerve entrapment, she was treated
with osteopathic manipulative treatment techniques over five consecutive weekly treatments.
Sessions included a combination of direct and indirect techniques over the pelvic region. The

16. 10
first two treatments targeted pelvic floor release: balanced ligamentous tension technique to the
sacroiliac joints, fascial unwinding of the hypogastric region, lumbar-sacral decompression, and
internal direct sacro-coccygeal mobilization. The following three sessions continued with fascial
unwinding techniques to the thoracic diaphragm, pelvic floor, and crural fascia. Balance
ligamentous tension techniques of the sacrotuberous ligament were used in combination with
tension balancing of the extracranial fascia and the dura mater for both the skull and sacral base.
Upon completion of the fifth session, the patient reported substantial improvement in activities of
daily living, and at the 6-month follow-up, outcome measures confirmed a stable progressive
reduction of disability and fear of movement, conducive to a full recovery of the patient’s
functionality.
Origo et al.
57
examined the treatment of chronic coccydynia with osteopathic manipulative
therapy compared to physical therapy and pharmacological treatments, and further on the effect
of osteopathic manipulative therapy on lower back and radicular pain associated with
coccydynia. A total of 50 patients fell into these categories, and received three sessions of
osteopathic manipulative therapy over a five-week period. Sessions were a combination of direct
and indirect techniques which included balance ligamentous tension techniques of the sacroiliac
joints, pelvic floor myofascial release, fascial unwinding, and intra-rectal mobilization
techniques. The report’s findings showed in all subjects a successful reduction in pain and a
higher significant reduction in disability.

17. 11
Chapter 3: Conclusion
This literature review illustrates the difficulty in diagnosing pudendal neuralgia and the limited
evidence based literature available to treat this condition with traditional non-invasive
manipulative techniques. Compression of the pudendal nerve in many cases were most common
in the Alcock canal and along the obturator internus muscle. As osteopathic manipulative therapy
utilizes a range of soft tissue techniques, such as counterstrain and myofascial release, which
have been shown to reduce tenderness and compression of pudendal nerve roots in the sacroiliac
region.
58
Manual therapies, such as pelvic floor physiotherapy, chiropractic, and osteopathy, tend to
follow the lead of medical practitioners, such as urologists and gynecologists, when it comes to
pelvic pain and numbness. Patients are often misdiagnosed and given unnecessary and
ineffective pharmaceutical and surgical solutions prior to seeking out more noninvasive options
for pain relief.
In sports, such as professional cycling, support teams consisting of trainers, coaches, medical
doctors, physiotherapists, and massage therapists are more readily available. This may be the
reason as to why there are fewer reported incidences of overuse injuries, such as ‘cyclist’s
syndrome’, among professional cyclists. Professional cyclists’ bike setup is continuously
monitored and adjusted to each ridder, and regular manual therapy is readily available and
utilized to keep the athletes in top physical form throughout the season.
Orientation of the pudendal nerve and its branches along the deep structures of the perineum is
particularly susceptible to compression in a sitting position. Cyclists using traditional saddles are
provided with minimal cushioning and a protruding nose design that over time compress the
perineal region resulting in potential symptoms of pain, numbness and impotence, especially in
males.

18. 12
Injury to the pudendal nerve seen in recreational and competitive cyclists is commonly
experienced but often short lived. Individuals that ride long distances are more susceptible to
pudendal neuralgia due to repetitive and prolonged compression of this nerve.
Nates criteria is the most current and up to date diagnostic technique for diagnosing pudendal
nerve compression, but it is still not a 100% effective due to overlapping symptoms with other
pelvic floor conditions. However, once diagnosed, osteopathic manipulative treatment techniques
may provide quick and long lasting relief of symptoms. That said, current literature on ‘cyclist’s
syndrome’ and the treatment of pudendal neuralgia using osteopathic manipulative therapy is
scarce. Further research on this condition in recreational and professional cyclists is needed
along with the use of more non-invasive practices such as osteopathic manipulative therapy.
Perhaps with the rise in popularity of cycling in North America this past year, an increase in
pudendal neuralgia cases may present itself, providing an opportunity for practicing manual
osteopathic practitioners to further study the effects of osteopathic manipulative therapy on
cycling related injuries such as ‘cyclists syndrome’.

19. 13
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