Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 635–644 635

DOI 10.3233/BMR-140559
IOS Press

Ultrasound assessment of trunk muscles and

back flexibility, strength and endurance in
off-road cyclists with and without low back
pain
Mohsen Rostamia,b , Majid Ansaria , Pardis Noormohammadpoura,∗, Mohammad Ali Mansourniac and
Ramin Kordia,b
a
Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
b
Spine Division, Noorafshar Rehabilitation & Sports Medicine Hospital, Tehran, Iran
c
Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Science,
Tehran, Iran

Abstract.
OBJECTIVES: To compare the thickness of lateral abdominal muscles and Cross Sectional Area (CSA) of lumbar Multifidus
Spinae (LM) muscles of competitive off-road cyclists with and without Low Back Pain (LBP). We also aimed to compare the
maximum isometric back strength and endurance, as well as flexibility of lower back in cyclists with LBP and in the controls.
METHODS: The thickness of Transversus Abdominis (TrA), Internal Oblique (IO) and External Oblique (EO) along with the
CSA of LM muscles of 14 professional competitive off-road cyclists with LBP and 24 controls were measured by ultrasound
(US) in hook-lying position on the examination table, and mounted on the bicycle. In addition, the back strength and endurance
of the subjects and the flexibility of the participants were measured.
RESULTS: Data showed a significantly lower thickness of Transversus Abdominis (TrA) and CSA of LM muscles in cyclists
with LBP comparing to controls in all positions. No significant result regarding the flexibility of the subjects in case group
comparing with the controls was found (p = 0.674). In addition, it was found that there is no significant difference in isometric
back strength of the subjects between the groups (p = 0.105). However, we found that subjects with LBP have a lower endurance
in back dynamometry with 50% of their maximum isometric back strength (p = 0.016).
CONCLUSION: In this study, useful information regarding possible factors associated with low back pain in off- road cyclists
was found (lower thickness of TrA and LM muscles and decreased back endurance).

Keywords: Ultrasound, flexibility, strength, lateral abdominal muscle, lumbar multifidus spinae, cycling

1. Introduction recreational and competitive mountain biking in differ-

International attention to mountain biking (also
known as off-road cycling) is increasing since its in-
ception in 1970s [1]. Parallel to growing popularity of
∗ Corresponding author: Pardis Noormohammadpour, Sports
Medicine Research Center, Tehran University of Medical Sciences,
No 7, Al-e-Ahmad Highway, Tehran, P.O. Box: 14395-578, Iran.
Tel.: +98 21 88630227 8; E-mail: normohamadpour@tums.ac.ir.
ent communities [2,3], higher numbers of cycling re-
lated injuries and complaints could be expected. There-
fore, some efforts were done to run research studies
on injuries and medical complaints of off-road cyclists,
but these studies continue to lag behind progress of the
sport [4].
Incidence and prevalence of spinal pain in athletes
have been shown to vary, depending on the physical
demands necessary for different sports. Spinal pain

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636 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance
is among the most common overuse injuries in cy-
clists [5,6] and it is reported that cyclists are vulnera-
ble to LBP [7]. Callaghan and his colleagues reported
LBP as the most common problem encountered by
elite British riders (60%) [8]. In another study, Clarsen
and colleagues reported that 58% of the elite road cy-
clists participating in their cross-sectional cohort had
experienced LBP during the past 12 months and 22%
of all time-loss injuries were due to LBP. While only
6% of all cyclists had missed competition due to LBP,
41% had sought medical attention to treat LBP [6].
They also suggested that the different prevalence of in-
juries among recreational and competitive cyclists can
be due to differences in exposure rate of the two groups
to the sport [6]. However few studies have addressed
the risk factors of low back pain among off-road cy-
clists. Most of available information on risk factors of
LBP in off-road cyclists comes from the few epidemio-
logical studies which have suggested improper bicycle
fit, riding technique and training methods as exacerbat-
ing factors of LBP and dysfunction in the cyclists [7].
Similarly, data on therapeutic interventions for treat-
ment of cyclists with LBP are also scarce and to our
knowledge no specific therapeutic approaches are still
developed for cyclists with LBP. However in recent
decades, many studies aimed to find an effective ther-
apeutic intervention for general population with LBP
and an extensive list of treatments are already sug-
gested [9]. Core stability exercises is one of these treat-
ments which its effectiveness in the treatment of pa-
tients with LBP has been widely investigated over the
past decade. In this regards, the lateral abdominal (par-
ticularly TrA) and Lumbar Multifidus (LM) muscles
are known to play an important role in lumbopelvic
stabilization and strengthening of these muscles is one
of the major goals of the treatment which can lead to
improvement of LBP in the patients.
The early evidence of biomechanical involvement of
TrA in patients with LBP comes from findings which
showed a delayed TrA muscle activation prior to limb
movement in patients with LBP [10]. Therefore, it was
suggested that TrA may play an essential role in the
stability of spinal column, and thereby in LBP [11].
These findings were further confirmed by finding that
TrA strengthening exercises reduce the pain intensity
in patients with LBP [12]. LM muscles also play a
unique role in lumbopelvic stabilization and contribute
to majority of lumbar spine stability especially in the
lower lumbar section [13]. LM is the predominantly
affected paraspinal muscle in patients with LBP [14]
and its atrophy is a common finding (around 80%) in
patients with chronic LBP [15].
Measurement of changes in lateral abdominal and
LM muscles thicknesses (which are associated with
LBP) can lead to development of selective interven-
tions to reverse the identified impairment. For exam-
ple, retraining contraction of the transabdominal (par-
ticularly TrA) and LM muscles may be considered as
one of the cardinal constituents of an exercise-therapy
approach for patients with current LBP [16]. Although
the changes of LM and lateral abdominal muscle thick-
ness of general population with LBP have been exten-
sively studies, there are still limited data on the thick-
ness of these muscles among the athletes. Therefore, in
this study we aimed to compare the thickness of lateral
abdominal and LM muscles in competitive off-road cy-
clists with and without chronic LBP in different posi-
tions such as hook-lying (at rest and during abdomi-
nal drawing-in maneuver) and functional mounted po-
sitions.
In addition, based on some clinical findings, sev-
eral factors such as the flexibility and back muscle
strength are associated with the development of LBP
in subjects; however, inconclusive results regarding
the role of these mechanical factors have been re-
ported [17–19]. To the best of our knowledge, the rela-
tionship of flexibility and back muscle strength of com-
petitive cyclists with LBP have not been studied yet.
Therefore, as a secondary objective of this study, back
and hamstring flexibility and isometric back muscle
strength and endurance of the subjects in symptomatic
and control groups were measured and compared.
2. Method
2.1. Participants
In this study, fourteen professional competitive off-
road cyclists who had actively competed in the na-
tional and international cross-country mountain bike
races during the past 12 months, and had bilateral non
specific low back pain for more than 12 months were
recruited. Also, 24 control healthy subjects who met
the inclusion criteria of the study and were relatively
matched with cases regarding the age and BMI [20]
were recruited. Based on the previous studies, we used
a standard definition for LBP. In this regards, LBP was
defined as “Pain limited to the area between the twelfth
rib and the inferior gluteal fold and was bad enough
to limit the usual activity or change the daily routine
of the subjects for more than one day during the past
4 weeks” [21]. Only male mountain-bikers between
 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance
18 and 50 years of age who were screened for med-
ical and medication history that could adversely af-
fect muscle health or contraindicate testing included in
the study. Also the criteria to select professional moun-
tain bikers were as follow: 1) total cycling distance
more than 100 kilometers per week. 2) Off-road cy-
cling distance of more than 25 kilometers per week. In
addition, cyclists who participated in road or triathlon
bicycle races without participation in mountain biking
competitions were not included. Those with obvious
red flags of low back pain or prior history of cardio-
vascular, metabolic and pulmonary diseases were ex-
cluded from the study. Because we had just a few cy-
clists with low back pain, to maintain the study power,
we had to increase the number of healthy cyclists. All
subjects received written and oral information about
the study procedures before participation. Also the
study protocol was approved by the Ethical Committee
of university.
2.2. Procedures
All recruited subjects of the study were invited to the
Sport Medicine Research Center for performing ultra-
sonic measurements. At the beginning, general infor-
mation of the subjects was asked. Then, body weight
and height of the cyclists were measured according to
standard protocols [22,23]. Also the characteristics of
the bicycle that the subjects usually use were all mea-
sured and recorded. Afterwards, the ultrasonic mea-
surements of the lateral abdominal muscles thicknesses
and Cross Sectional Area (CSA) of Lumbar Multifidus
muscle as well as measurement of hamstring flexibility
and also back strength and endurance of the subjects
were performed respectively.
2.3. Ultrasonic measurements
The Diameters of lateral abdominal muscles (TrA,
IO and EO), were measured on both sides of the sub-
jects while resting at hook-lying position (supine po-
sition with 30 degrees of hips flexion), and in the
same position during abdominal drawing-in maneuver
(ADiM) as described by Mannion and colleagues [24].
A Sonosite Micromaxx (Sonosite Inc., Bothell, WA,
USA) ultrasound machine with a linear transducer (6–
13 MHz) was employed to record the thickness of ab-
dominal muscles in B-mode format. A point 25 mm
anteromedial to the midpoint between the inferior rib
and the iliac crest on the mid-axillary line was set for
transducer position. This point was selected on the ba-
637
sis of previous studies to measure abdominal muscles
thickness [22,25]. The transducer was positioned in the
transverse plane and measurement of muscle thickness
was made at the center point of the image using the
caliper of the machine [22]. Prior the assessment of
lateral abdominal muscles in ADiM, all subjects were
taught to activate their TrA muscle via the drawing-in
maneuver. They were instructed to draw in their lower
abdominal muscles gently toward their spine as they
exhaled and held for 10 seconds, while maintaining
a neutral posture of the lumbar spine and continuing
to breathe normally. Then the subjects were asked to
repeat 5 contraction attempts each side for training,
while using ultrasound for feedback and controlling
the drawing in maneuver before obtaining ultrasound
measurements. Finally, for minimizing the effect of fa-
tigue, 15 minutes of rest was provided after the training
session and prior to assessment of the lateral abdomi-
nal muscles thickness [20,26].
In addition to the thickness of muscles at rest and
during ADiM, the contraction value which was calcu-
lated by subtracting the resting values from thickness
of the muscles during ADiM, was also recorded for
each subject and included in the final analysis of the
study.
The Cross Sectional Area (CSA) of LM muscle of
both sides of the subjects was also measured at rest and
during contraction using a curve transducer (5 MHz).
To measure CSA of this muscle, the protocol devel-
oped by Hides et al. [27] was used. In this regard, the
subject was positioned in prone lying, and to minimize
the effect of lumbar lordosis of the subjects a small pil-
low was placed under the abdomen. An assessor with
3 years of musculoskeletal US experience palpated the
lumbar vertebral levels and marked the location of the
spinous process of L4 vertebrae of the cyclists on the
skin with a pen. After finding the LM muscle into the
monitor and capturing the image, the researcher traced
around the muscle border to measure the CSA of the
muscle. To measure the CSA of LM muscle in con-
tracted condition, while the subjects were in prone ly-
ing position, they were asked to lift up their ipsilateral
thigh and contralateral upper extremity.
The thickness of lateral abdominal muscles and also
CSA of LM muscles were also measured while the
subjects were positioned on the bicycle (Fig. 1). In
this regard, each of the subjects was positioned on a
standard mountain bike that was fixed on a stationary
trainer fit for him. The cyclists were asked to look for-
ward and not to hold the bar-ends. Then, ultrasonic
measurements of the thickness of lateral abdominal
638 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance

A B

Fig. 1. The experimental set up of the study while the subjects were mounted on the bicycle is shown. The thickness of lateral abdominal muscles
(A) and the Cross-Sectional Area of Lumbar Multifidus muscles (B) were measured by the assessor.

and CSA of LM muscles of both sides of the subjects
were performed while the ipsilateral crank of the bi-
cycle was fixed at following positions: 1) Top Dead
Center (TDC) position: the bicycle crank was fixed at
12 o’clock. 2) Full Front (FF) position: the bicycle
crank was fixed at 3 o’clock and 9 o’clock positions for
the right and left sides respectively. 3) Bottom Dead
Center (BDC) position: the bicycle crank was fixed at
6 o’clock. 4) Full Rear (FR) position: the bicycle crank
was fixed at 9 o’clock and 3 o’clock for the right and
left sides respectively.
In course of US measurements following instruc-
tions were considered to improve the accuracy of the
measurements: 1) To prevent feedback effects, subjects
could not see the scanner screen. 2) Adequate ultra-
sound gel was used between the transducer and the
skin to increase the area of contact and to minimize
the need for inadequate inward probe pressure [22,25].
3) The assessor was allowed to adjust the angle of the
probe (< 10 degrees) until a clear image of muscles
was achieved [27]. 4) Freezing of the view for the mea-
surement was timed to coincide with the end of normal
expiration [29]. 5) The ultrasound assessor was blind
regarding the allocation of the cyclists into LBP and
control groups.
2.4. Flexibility
The flexibility of the subjects was assessed using
the box sit-and-reach test. Following American Col-
lege of Sports Medicine (ACSM) recommendations,
the participants performed a 5-minute identical warm-
up, including light to moderate aerobic exercises and
modified hurdler’s stretches prior to sit-and-reach test.
They were advised against any jerky, rapid movements
including ballistic stretches. Also three practice tries
were undertaken before this test [30]. Afterwards, they
sat on the floor with knees fully extended and the feet
on the vertical side of the test box. Then they were in-
structed to curl smoothly forward, with hands extended
forward in parallel, to reach the maximum possible
low-back flexion. Another researcher who was blinded
towards the groups, recorded the distance the tip of
subjects’ fingers could reach. To minimize the error of
the measurements, the subjects repeated the test three
times and the highest value was recorded as their final
flexibility score.
2.5. Dynamometry
Using a back dynamometer (Lafayette Instrument
Company, Lafayette, IN, USA) the back strength of
the subjects was tested by two assessors blinded to the
subjects’ groups. The subjects were asked to keep their
knees extended and lift the bar upward with alternate
grip on the bar while they kept their knees fully ex-
tended, feet flat on the dynamometer plate and the back
almost straight. The data was recorded by a researcher
while another researcher monitored the subjects to per-
 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance 639

Table 1
Baseline characteristics of participants in the study
Variables Case (n = 14) Control (n = 24) 95% confidence interval (95%CI) P value
Demographic findings
Age (years) 27.2 (4.74) 27.8 (5.26) −4.0 to 2.9 0.737
Height (cm) 172.7 (5.45) 179.7 (5.66) −10.8 to −3.1 0.001
Weight (Kg) 71.5 (11.99) 80.2 (10.51) −16.2 to −1.1 0.026
BMI (Kg/m2 ) 24.0 (4.12) 24.9 (3.49) −3.4 to 1.7 0.488
Body Fat Percentage (%) 20.1 (7.39) 18.95 (6.38) −3.5 to 5.7 0.620
Bicycle Features
Frame size (cm) 44.8 (2.32) 46.8 (3.41) −4.0 to 0.1 0.064
Crank Size (cm) 172.5 (2.59) 174.4 (2.68) −3.7 to −0.1 0.043
Stem Size (cm) 112.1 (6.99) 115.4 (7.21) −8.1 to 1.6 0.181
Professional Level of the Subjects
Cycling Distance/week (Km) 236.1 (116.16) 299.6 (169.13) −167.3 to 40.3 0.223
Road Cycling Distance/week (Km) 165.0 (88.82) 240.4 (161.82) −170.8 to 20.0 0.118
Off-Road Cycling Distance/Week (Km) 71.1 (40.96) 58.7 (20.50) −7.8 to 32.5 0.223
Pre-test questions
Fasting Time (Hours) 3.8 (1.84) 3.7 (1.58) −107 to 1.22 0.892
Current Intensity of Pain (VAS 0-10) 1.6 (2.03) 0.00 − −
Current Intensity of Pain (VAS 0–100): Intensity of low-back pain based on Visual Analogue Scale (0–10) at the time of the study.

form the test correctly. After 3 minutes of active rest of
the subjects, they were asked to hold the bar of the dy-
namometer at 50% of their maximum strength as long
as they could [31]. This time, the duration of holding
the bar by the subjects was recorded in seconds, as
a measure of low-back muscular endurance. Subjects
performed these procedures for two times and asses-
sors recorded the mean of values regarding the strength
and endurance of back muscles, respectively.
2.6. Statistical analysis
Data analysis was performed using SPSS 16 (SPSS
Inc, Illinois, USA). Data normality was assessed us-
ing 1-sample Kolmogorov-Smirnov test. Independent
2-sample t-test was carried out for inter-group compar-
ison of the continuous variables. Data are expressed as
Mean ± SD and statistical significance was determined
at P < 0.05.
3. Results
In total, 14 male competitive off-road cyclists with
LBP and 24 controls participated in this study. Demo-
graphic data of the participants is presented in Table 1.
ues of TrA muscle between the groups, it was found
that although the thickness of TrA muscles of both
sides of the athletes were less increased in symp-
tomatic group comparing to the controls, the difference
was statistically significant only for the left side mea-
surements (p = 0.011).
Comparing the thickness of external oblique (EO)
and internal oblique (IO) muscles between the groups,
no significant relation was found, except the left Int
Obl muscle which in contracted position was signifi-
cantly thicker in control group comparing to the symp-
tomatic cyclists (p = 0.044).
Regarding the LM muscle, it was found that the
thickness of the left LM in resting condition and right
LM in contraction was significantly lower in the case
group comparing with the controls (p = 0.014 and 0.01
respectively). Also, the contraction value of right LM
was significantly less than the controls (p = 0.009).
3.2. Functional mounted positions
In all 4 positions, the mean thickness of TrA and
CSA of LM muscles of both sides of the subjects in
case group were significantly lower than the controls
(Table 3).

3.1. On bed position 3.3. Flexibility

As it is shown in Table 2, the thickness of TrA mus- Comparing the Mean ± SD scores of the sit and
cles in hook-lying position in both resting and during reach test between the case (38.92 ± 8.95 cm) and con-
ADiM were significantly lower in LBP group com- trol groups (40.06 ± 5.59 cm), no significant difference
pared to the controls. Comparing the contraction val- was found (p = 0.674).
640 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance

Table 2
Thickness of Transabdominal muscles and Cross Sectional Area (CSA) of Lumbar Multifidus Muscles while the subjects were positioned on the
bed
Side Condition of measurements Case Control Mean difference (95% of confidence interval) P value
EO (cm)
Right Resting 0.68 (0.15) 0.69 (0.15) −0.01 (−0.12 to 0.09) 0.793
ADiM 0.69 (0.16) 0.68 (0.15) 0.006 (−0.10 to 0.11) 0.896
Contraction value 0.01 (0.05) −0.006 (0.11) −0.02 (−0.08 to 0.04) 0.519
Left Resting 0.64 (0.16) 0.69 (0.12) −0.04 (−0.14 to 0.04) 0.307
ADiM 0.68 (0.15) 0.68 (0.14) −0.004 (−0.10 to 0.09) 0.928
Contraction value 0.04 (0.05) −0.001 (0.09) −0.04 (−0.10 to 0.01) 0.14
IO (cm)
Right Resting 0.83 (0.14) 0.85 (0.16) −0.02 (−0.13 to 0.08) 0.647
ADiM 0.94 (0.16) 0.94 (0.16) 0.002 (−0.11 to 0.11) 0.960
Contraction value 0.11 (0.06) 0.09 (0.05) −0.02 (−0.06 to 0.01) 0.189
Left Resting 0.75 (0.13) 0.84 (0.16) −0.09 (0.50 to 0.01) 0.077
ADiM 0.86 (0.18) 0.97 (0.15) −0.11 (0.05 to −0.003) 0.044∗
Contraction value 0.10 (0.06) 0.13 (0.05) 0.02 (−0.01 to 0.06) 0.219
TrA (cm)
Right Resting 0.28 (0.05) 0.37 (0.07) −0.09 (−0.13 to −0.04) < 0.001∗
ADiM 0.43 (0.10) 0.59 (0.10) −0.15 (−0.22 to −0.08) < 0.001∗
Contraction value 0.14 (0.09) 0.21 (0.10) −0.06 (−0.13 to 0.002) 0.057
Left Resting 0.29 (0.06) 0.36 (0.06) −0.06 (−0.11 to −0.02) 0.002∗
ADiM 0.45 (0.10) 0.60 (0.10) −0.15 (−0.22 to −0.08) < 0.001∗
Contraction value 0.15 (0.09) 0.23 (0.08) −0.08 (−0.14 to −0.02) 0.011∗
LM (cm2 )
Right Resting 5.59 (0.59) 6.01 (0.67) −0.41 (−0.85 to 0.01) 0.060
Contracted 6.47 (0.94) 7.30 (0.87) −0.82 (−1.4 to −0.20) 0.01∗
Contraction value 0.88 (0.45) 1.28 (0.41) 0.40 (0.10 to 0.69) 0.009∗
Left Resting 5.67 (0.52) 6.17 (0.59) −0.49 (−0.88 to −0.10) 0.014∗
Contracted 6.72 (0.85) 7.19 (0.91) −0.47 (−1.07 to 0.13) 0.124
Contraction value 1.04 (0.47) 1.02 (0.58) −0.02 (−0.40 to 0.35) 0.897
Data is presented as Mean (SD) for case and control groups. TrA, Transversus Abdominis; IO, Internal Oblique; EO, External Oblique; ADiM,
Abdominal Drawing-in Manuever; Contraction value, The difference between contracted thickness and resting thickness; ∗ Statistically Signifi-
cant: (p-value < 0.05).

3.4. Back dynamometry
Maximum force generated by back extensor mus-
cles, did not significantly differ between the groups,
however, the 50% of maximum strength endurance
time was significantly lower in subjects with LBP in
comparison to controls (Table 4).
4. Discussion
4.1. Ultrasound measurements
The results of this study show that TrA muscle thick-
ness of cyclists with LBP is significantly lower than
the controls while the subjects were positioned on bed
or bicycle. These findings are similar to the results
obtained from comparison of the TrA muscle thick-
ness between non-athletic subjects with and without
LBP [25]. Different responses of the lateral abdomi-
nal and LM muscles to different postures were previ-
ously reported by other authors [11,32,33], therefore
in this study we also compared the thickness of lateral
abdominal muscles and CSA of LM muscles of the cy-
clists with and without LBP while they were positioned
on the bicycle. However, results showed that similar
to “on bed” positions, at the time of positioning of the
subjects on the bicycle, the thickness of TrA and CSA
of LM in subjects with LBP is lower than the controls.
Hides et al. [16] previously reported an altered abil-
ity in drawing-in maneuver in elite Australian foot-
ballers with LBP. This study findings also showed that
the TrA contraction value of the subjects while they
were positioned on bed is lower in subjects with LBP
comparing to controls, although this difference was
statistically significant only on the left side. The results
of this study also showed a lower CSA of LM mus-
cles in cyclists with LBP comparing to the controls.
This finding supports the hypothesis that the flexion-
relaxation phenomenon (FRP) may be a possible con-
tributor to LBP in cyclists [34,35]. According to this
phenomenon, deactivation of the paraspinal muscles
which occurs following prolonged flexed position of
the spine, may lead to increased strain on posterior ele-
 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance 641

Table 3
Thickness of transabdominal and cross sectional area (CSA) of lumbar multifidus muscles while the subjects were positioned on the bicycle
Side Time of measurements Case (n = 14) Control (n = 24) Mean diff (95% of CI) P-value
TDC
Right TrA (cm) 0.30 (0.06) 0.41 (0.10) −0.11 (−0.17 to −0.04) 0.001∗
IO (cm) 0.98 (0.24) 1.11 (0.21) −0.129 (−0.28 to 0.02) 0.099
EO (cm) 0.60 (0.16) 0.71 (0.20) −0.106 (−0.23 to 0.02) 0.101
LM (cm2 ) 4.91 (0.55) 5.39 (0.71) −0.47 (−0.92 to −0.02) 0.039∗
Left TrA (cm) 0.28 (0.05) 0.38 (0.04) −0.10 (−0.13 to −0.06) < 0.001∗
IO (cm) 1.00 (0.32) 1.19 (0.25) −0.18 (−0.38 to 0.005) 0.057
EO (cm) 0.66 (0.13) 0.74 (0.16) −0.07 (−0.18 to 0.03) 0.179
LM (cm2 ) 4.80 ( 0.52) 5.48 (0.76) −0.68 (−1.15 to −0.21) 0.006∗
FF
Right TrA (cm) 0.29 (0.05) 0.43 (0.11) −0.13 (−0.20 to −0.06) < 0.001∗
IO (cm) 1.05 (0.24) 1.21 (0.25) −0.16 (−0.33 to 0.009) 0.063
EO (cm) 0.61 (0.16) 0.73 (0.20) −0.11 (−0.24 to 0.01) 0.078
LM (cm2 ) 4.85 (0.50) 5.46 (0.71) −0.61 (−1.05 to −0.17) 0.008∗
Left TrA (cm) 0.29 (0.07) 0.40 (0.06) −0.11 (−0.16 to −0.06) < 0.001∗
IO (cm) 0.97 (0.33) 1.22 (0.27) −0.24 (−0.44 to −0.04) 0.019∗
EO (cm) 0.59 (0.20) 0.74 (0.16) −0.15 (−0.28 to −0.03) 0.015∗
LM (cm2 ) 4.77 (0.59) 5.51 (0.76) −0.73 (−1.22 to −0.25) 0.004∗
BDC
Right TrA (cm) 0.31 (0.06) 0.43 (0.11) −0.11 (−0.18 to −0.05) 0.001∗
IO (cm) 1.13 (0.21) 1.33 (0.29) −0.20 (−0.38 to −0.02) 0.029∗
EO (cm) 0.65 (0.18) 0.71 (0.22) −0.05 (−0.19 to 0.08) 0.412
LM (cm2 ) 4.86 (0.50) 5.58 (0.71) −0.71 (−1.15 to −0.27) 0.002∗
Left TrA (cm) 0.29 (0.06) 0.38 (0.04) −0.09 (−0.12 to −0.05) < 0.001∗
IO (cm) 1.03 (0.29) 1.32 (0.29) −0.28 (−0.48 to −0.08) 0.007∗
EO (cm) 0.61 (0.17) 0.70 (0.17) −0.09 (−0.21 to 0.02) 0.118
LM (cm2 ) 4.80 (0.48) 5.41 (0.68) −0.61 (−1.03 to −0.18) 0.006∗
FR
Right TrA (cm) 0.30 (0.05) 0.43 (0.11) −0.13 (−0.20 to −0.06) < 0.001∗
IO (cm) 1.07 (0.24) 1.20 (0.23) −0.13 (−0.29 to 0.03) 0.112
EO (cm) 0.67 (0.18) 0.71 (0.19) −0.03 (−0.17 to 0.09) 0.561
LM (cm2 ) 4.88 (0.46) 5.43 (0.65) −0.54 (−0.95 to −0.13) 0.010∗
Left TrA (cm) 0.29 (0.07) 0.38 (0.04) −0.09 (−0.13 to −0.05) < 0.001∗
IO (cm) 0.96 (0.31) 1.23 (0.28) −0.26 (−0.46 to −0.06) 0.010∗
EO (cm) 0.61 (0.03) 0.75 (0.18) −0.14 (−0.26 to −0.01) 0.028∗
LM (cm2 ) 4.84 (0.54) 5.31 (0.73) −0.47 (−0.93 to −0.01) 0.044∗
TDC, Top Dead Center Position; FF, Full Front; BDC, Bottom Dead Center; FR, Full Rear; TrA, Transversus Abdominis; IO, Internal Oblique;
EO, External Oblique; LM, Lumbar Multifidus; CI, Confidence interval. ∗ Statistically significant, p < 0.05.

ments of the spinal column, which by itself may lead to
increased chance of LBP in the cyclists [34]. The de-
creased CSA of LM in LBP group of cyclists may have
played an additional role by decreasing the support of
posterior elements following this phenomenon. On this
basis, development of selective interventions to reverse
the identified impairment of the paraspinal muscles in
cyclists could be targeted by the clinicians.
ing the relation between the lumbar flexibility of the
subjects and LBP could be found [17,19]. This might
be related to the enhanced level of flexibility of the
athletes in comparison to general population and use
of different designs and testing procedures in different
studies.
4.3. Dynamometry

4.2. Flexibility
Comparing the lumbar flexibility of the subjects,
results showed no significant difference between the
groups. This result is in concordance with the previous
studies that found no significant difference in flexibil-
ity of athletes with and without LBP [36,37]. Review-
ing the existing literature, inconclusive findings regard-
To the best of our knowledge, this study is the first
to report significantly lower back muscle endurance in
off-road cyclists with LBP, while there was no signifi-
cant difference between the groups regarding the max-
imal force of their backs. Some longitudinal studies
have previously reported a significant relationship be-
tween endurance of back muscles and prevention of
LBP [36] and low endurance of trunk muscles could
642 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance
Table 4
Comparison between the results of back dynamometry of subjects with and without Low Back Pain
Back dynamometry
Maximal Force of the subjects (kg)
Time of holding the bar at 50% of maximum strength (Seconds)
CI, Confidence Interval; ∗ Statistically significant, p < 0.05.
be a discriminating factor between healthy subjects
and those with a history of LBP [39]. Also, a recent
study has shown that dancers with low back pain have
a lower level of trunk muscles endurance [40]. Sev-
eral studies have also discussed regarding the differ-
ence between the maximum back muscle strength of
patients with LBP and controls. Because they have re-
ported controversial results [41,42], the issue of asso-
ciation of maximal back strength to LBP development
may be moot, although according to long term follow
up studies, the power of back muscles is not a risk
factor of low back pain [18,19]. It can also be sug-
gested that back endurance in cyclists with LBP might
be more important than strength alone in the preven-
tion and treatment of LBP. Regarding the role of im-
provement of back muscle endurance in treatment of
cyclists with LBP, further studies are needed.
4.4. Reliability of measurements
In this study we used ultrasound for measurements
of the lateral abdominal muscle thickness and Cross
Sectional Area (CSA) of LM muscles. The reliabil-
ity of Ultrasonography (US) in such measurements has
extensively been tested. According to these studies, it
has been found that US is a reliable way in measur-
ing the transabdominal muscles thickness in controlled
contraction and resting condition [43,44]. Also the re-
liability of using US to measure the size of paraspinal
musculature has been shown to be fair to excellent
(ICC = 0.72–0.98), which is acceptable for clinical ap-
plication [45–47]. In this regard, validity studies have
shown that CSA of LM muscles can be considered as
the indicator of muscle size. In addition, it is reported
that there is no significant difference regarding CSA
measurements between US and MRI findings [48].
4.5. Limitations
Excess lordosis of the lumbar spine which might be
due to low height of the handle bars is previously men-
tioned as a possible cause of LBP in cyclists [34]. Also,
downward saddle angle [49] and incorrect distance be-
tween the handle bar of the bicycle and center of the
Case group Control group Mean difference P-value
(n = 14) (n = 24) (95% of CI)
84.46 (8.41) 88.69 (5.13) −4.22 (−9.41 to 0.97) 0.105
38.61 (12.76) 50.54 (14.81) −11.93 (−21.55 to −2.31) 0.016∗
seat [5,50] are other suggested parameters that might
affect the position of the cyclist and thereby lead to
LBP. However, in the current study we did not evaluate
these parameters which are related to the set-up of the
bicycle. Lack of control on the posture of the subjects
on the bicycle could be considered as a limiting fac-
tor of the study. In addition, exclusion of cyclists with
unilateral symptoms was helpful in more homogene-
ity of the subjects which leads to more consistent re-
sults. Also a larger number of control subjects than the
symptomatic group and inclusion of only male cyclists
could be considered as another limitations of the study.
Although the previous studies have shown a good to
high reliability for ultrasound assessment of lateral ab-
dominal muscles and multifidus, there is limited data
regarding the reliability of such measurements in cy-
cling position.
5. Conclusion
This study results showed a significantly lower
thickness of TrA and CSA of LM muscles and lower
back muscle endurance in cyclist with the LBP com-
paring with the controls. This finding could be bene-
ficial to develop sport-specific clinical guidelines for
approach to LBP in athletes.
Acknowledgements
The authors of this manuscript would like to ex-
press their gratitude towards Mr. Afshin Ramezani, Mr.
Mohsen Mohammadi and Mr. Benyamin Aghassi (the
official coaches of the cycling federation of Iran) for
their kind help in motivation of cyclists for partici-
pation in this study. We also acknowledge Dr. Farzin
Farahbakhsh for his assistance in preparing the figure
of the study. The authors also wish to thank the contri-
bution of Mr. Hadi Amani towards providing the bicy-
cles for running of the study.
Funding
This research has been supported by Tehran Univer-
sity of Medical Sciences & health Services grant.
 M. Rostami et al. / Ultrasound assessment of trunk muscles and back flexibility, strength and endurance
Conflict of interest
None to declare.
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