Tandem Cycling - Ulnar nerve compression - right hand weakness

I am a physician training for the AIDS RIDE FOR LIFE in Ithaca, NY. This is a 100 mile circumnavigation of Cayuga Lake in support of the Southern Tier AIDS Program. I am riding a tandem. I went for a 60 mile ride yesterday with my daughter - stopping for a rest break half way through the ride. On the way we were riding on a long incline and I noticed I had difficulty changing into a lower gear. I also noticed some twitching (fasciculation) of the muscle between my right thumb and index finger. I had no loss of sensation. This weakness and muscle twitching has persisted. I bumped into a neurologist colleague at the parking lot of our local hospital and he did a quick neurological examination and told me he thought this was an ulnar nerve palsy. We discussed where it might be compressed. At the elbow it would cause numbness and pins and needles in the 4th and 5th fingers. I had good sensation. When I got to my medical office I used Pub Med to investigate this. I found an article in the Journal of Neurology, Neurosurgery, and Psychiatry 1988; 5:1588-1590 (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1032781). This article precisely defines this syndrome in 2 cyclists. Neither case was as acute as my own. One recovered, the other didn't, despite surgery to decompress the nerve. At present I have difficulty opposing my thumb and index finger. This makes it difficult to turn knobs and hold a pen. My awful doctors handwriting is now even worse!
Here is my question: I would like to continue training and to participate in this Aids Ride for Life as I think it is an important charity ride and also I don't want to disappoint my 13 year old stoker daughter. What modifications should I make to my handlebars or what form of hand protection should I use to complete this ride? I have noticed changing the right gear lever to be difficult as my thumb and index finger on my right hand are now weak. Any suggestions as to how to make my shifter easier to operate (I use Campagnolo Ultra record levers).
If you want to contribute to this worthy cause by sponsoring me, please go to my sponsorship page (http://www.firstgiving.com/adamlaw1) - it has a photo of our Tandem Team and also read about The Southern Tier Aids Program. (http://www.stapinc.org/)
I am cross posting this on the Road Cycling section.

What modifications should I make to my handlebars or what form of hand protection should I use to complete this ride? I have noticed changing the right gear lever to be difficult as my thumb and index finger on my right hand are now weak. Any suggestions as to how to make my shifter easier to operate (I use Campagnolo Ultra record levers).


You could go with Ergos - if the thumb on its own is adequate to the job - the other direction can be more of a gross motor action. Not a cheap modification, but may be worth it.

I'd suggest paying a visit to Chad at the Geneva Bike Center (http://www.genevabikes.com), about 45 miles to your north-west. There you can get on their fitting frame and try all possible bar choices to see what works.

Don't be fooled by the picture on the web site, this place is about twice as wide as the store front pictured, and three stories high.

If you can, try any gloves out on the bars you plan to use, before buying the gloves, and in all the positions you typically use. I spent much of the summer without gloves, and then got a pair that have the padding in the wrong place for several important riding positions. I hadn't realised padding varied that much.:(

What modifications should I make to my handlebars or what form of hand protection should I use to complete this ride? I have noticed changing the right gear lever to be difficult as my thumb and index finger on my right hand are now weak. Any suggestions as to how to make my shifter easier to operate (I use Campagnolo Ultra record levers).

1st: I would pay a visit to a good bike shop who has a bicycle fit tech on staff who can help you to modify your ridiing position to allow you to ride with your arms in a more relaxed (elbow bent) position with less weight on your hands. This could require a different stem and/or saddle position.

2nd: For the shifting, at least until your hand strength recovers, the easiest fix would be to temporarily install a bar-end index shifter as they can be operated using the palm of the hand and wrist vs. the digits and thumb. It will take some time to adjust to the added hand-movement and may feel a bit unstable at first; however, most folks will quickly adapt. The move to bar-ends will most likely reduce the amount of shifting you do and, who knows, perhaps this forced movement of the hand off of the tops and brake hood will double as physical therapy.

Campy shifters in my experience are designed for smaller hands. The knob is narrower than
Shimano or SRAM and the space between the knob and the bar shorter. This results in an
unpleasant compression of the hand gripping the shifter. You might take a look at Shimano
shifters and see if there might be some relief there. My experience in the past on longer
rides on DF singletons (as opposed to stoking on the tandem or riding my preferred Rotator
recumbent) is that paresthesias of both the median and ulnar nerves occur depending on
your riding position. Hands on the bar curve pressure the median N, on the brifter the
ulnar nerve. Hands on the straight part of the bar tend not to do either. I rotate between
these three positions. My campy shiftered bike is not one I like to do long rides on because
of the slightly smaller space for the MC area on gripping the shifters. Shimano has a more
gradual upsweap at the pivot ends which puts less pressure on than the more abrupt upsweap
of the Campy brifters. I have also had some comfort improvement by using the cheap foam
wrap bar tape and double wrapping the bar. Feels a bit bulky at first but more comfy in the
long run. For now I agree with TG: a barend shifter til your ulnar N recovers and stay away
from the first curve of the bar.

Another thing would be to be sure to move your hands around on the bars quite often while riding (and relax your upper body). Raising the handlebars is good too.....

A local rider (also a physician) had similar problems. He swirched to a bar with a flattened top portion. If you are using a round bar,you may try that. If you are on a flattened bar, try round.

Another thing you may try is increasing the diameter of the bar. Maybe try 2-3 layers of bar tape to change your grip.

You might want to try changing your saddle tilt to a more upright position, and shorten your stem 1-2cm. You may also try the opposite:)

As with most of these personal issues with cycling, you are in the area of trial and error.

If you're using a straight bar and it's a pretty far reach, then your wrists have to rotate outwards to keep your palms on the grips. Maybe a bar with more rearward sweep would help. If you're using a road bar, then maybe the stem is too long, as others mentioned.

I never had the pain you described, but I never did more than 30 miles either. Maybe just something to keep in your list of things to try.

I suffered severe ulnar nerve problems starting in the late spring and finally my right arm along with 4 fingers were completely paralyzed. I spent 17 weeks off the bike and have now had 7 rides since returning.
The pain I experienced was the worse pain I've ever had including some major/serious crashes during races, broken bones, deep cuts etc. It took 5 different doctors to pin point the exact problem and location with 3 wanting to do exploratory cervical spine surgery. Finally went to a guy who happened to be a cyclist and was also a neurosurgeon. He pinpointed the problem relatively quickly and sent me to acupuncture.

Nine sessions of acupuncture and I'm back on the bike pain free. I did struggle to ride and finally found after, the paralysis left, my strength was such I could not shift my ergo lever so I installed a bar end on the left side/front derailleur and that allowed me to shirt using the "push/pull" method.

Here's what the set-up looks like:
http://img.photobucket.com/albums/v66/KRhea/Tandems/E02A4308.jpg

I'm now back to riding/training but I'll miss the cross season. I feel great but noticed this past weekend that the cooler temps affected my hand strength and I found it almost impossible to shift, on my single, until the temp warmed up a bit. So, Sunday morning it was cool and raining and I wore long finger gloves and had no problems with my hand.

Give acupuncture a try. No envasive, weird, no pain and works.


KRhea

You might take a look at your gloves.
I can't confirm this, and maybe it is just marketing hype, but http://www.pearlizumi.com/product.php?mode=view&product_id=1236299 Pearl Izumi claims that their padding design "alleviates pressure on both the ulnar and medial nerve". [I don't wear their gloves, but have been considering buying some for next season.]
Most gloves have a continuous pad for the heel of the palm. The PI ones have a gap in the padding, which is probably supposed to line up with those nerves, so that the pressure goes onto the padding and the nerves are kept away.
Maybe it works that way. Comments?

My medical approach (heal thyself) was to put myself on a course of methylprednisolone for 1 week. I hope this will reduce the inflammation in and around the ulnar nerve entrapment in the palm of my hand. Already I am beginning to have strength return.

Websterbikeman: Thanks for the Geneva suggestion - I e-mailed Glenn Swan who is our local bike maven. He is going to look at my position on the bike and make recommendations.

TandemGeek: The bar end shifter is a great idea.

Sch: your analysis of the 3 positions and which nerves they compress is v. helpful. However, I haven't experienced any paresthesiae, just motor weakness. Hence it may be a motor branch that is being compressed - I don't know exactly where that is - I will dust off my Gray's Anatomy! The 2 cases I quoted in the 1988 article had no pain - just weakness. Double taping and cheap foam sound like a good idea.

MB1: I will have to gesticulate more! - I note that on a tandem I move my hands less as I am using them more to balance the bike. I will help my daughter balance so I don't need to do this, and will try to use my trunk and seat to do this.

dfcas: Trial and error - that sounds so true. I plan to just that.

wheelspeed: I am using Reynolds Pro Anatomic bars - ironic name, under the circumstances!

KRhea: Your story makes mine pale in significance. I am sorry you had all the anxiety of those 5 doctors - suggesting exploratory neurosurgery to your neck must have been v. frightening and may have made your problem even worse. A cycling neurosurgeon - we need one of those on the Tandem Cycling Forum! Your attractive solution to the end bar shifter maybe something I will try. Acupuncture - I will certainly seek this out if the corticosteroids fail. I am optimistic at present.

moleman76: I was using Pearl Izumi gloves. I don't have their name, but they are lightweight and have only thin leather padding. These may be the culprit. I am following a suggestion to purchase weight lifters gloves as they are better padded than cyclist gloves - I am checking this out.

Well the ulnar N in the hand innervates the interosseus muscles all the way to the
index interosseus adjacent to the thumb. Median N innervates the thenar muscles.
The branch point is somewhere in the proximal hypothenar area but the motor and
sensory branches are fairly close together (in most people) across the palm with
the motor branch extending further than the sensory branch.
My pressure points have always been sensory. Flexion-extension are, of course,
forearm functions with the innervation close to the elbow where the muscle bodies start. Hand
innervation is something easily forgotten, like the names and positions of the
carpals and tarsals, if not used frequently.
It is certainly possible to have anomalous innervation. My radial artery is easily
felt and seen on top of the index interosseus muscle in my R hand, but not palpable at all
on the L, being buried under the muscle in its customary position. Your symptoms
sound as much or more MEDIAN nerve with loss of thenar function rather than interosseus
function. You can pinch the median nerve with hands on the straight part if the the
point of contact is the base of the palm and not the distal MC part of the palm.

Extra bar tape, proper fit, good gloves, raising handle bars a bit, move hands around on the bars all are less invasive than surgery.
So is acupuncture and chiropractic care.
When in doubt, get a 2nd, 3rd or 4th opinion!
When K had her cancer surgery she got 3 opinions and finally found a great surgeon that suited her.
Pedal on TWOgether!
Rudy and Kay/zonatandem

Extra bar tape, proper fit, good gloves, raising handle bars a bit, move hands around on the bars all are less invasive than surgery.


+1 on all that.

I've found riding long miles on the tandem is harder with regard to numness and comfort than single bikes because you move around less.

Try to avoid cocking your wrists, keeping the surface of your palm and forearm in line as much as possible.

Use lots of positions. "Split finger" fast ball over the hoods (i.e. index and forefinger over the hoods) is not very comfortable, but alleviates pressure for a bit from the ulner nerve.

Make an effort to ride one handed every 10 minutes or so, shaking out the other hand.

Ride no handed for a bit if your comfortable with your handling skills (ok I'll admit this still freeks out my stoker).

Distilled: use padding and multiple positions to minimize the trauma.