knee pain and bicycling

8/14/2019 Knee Pain and Bicycling

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Knee Pain and BicyclingFitting Concepts for Clinicians

CPT Chad Asplund, MD; COL Patrick St Pierre, MD

THE PHYSICIAN AND SPO TS!EDICINE - VOL 32 - NO ! - AP"#L2$$!

In Brief" Anteri%r knee pain and patell%&e'%ral pain s(ndr%'e are a'%n) the '%stc%''%n le) %*eruse in+uries in c(clists ic(cle &it, recent chan)e in e uip'ent,trainin) distance and intensit(, and indi*idual anat%'ic &act%rs are i'p%rtante*aluati%n c%nsiderati%ns Clinicians need a .asic understandin) %& .ic(cle &ittin) andh%/ anat%'ic &act%rs and trainin) err%rs c%ntri.ute t% repetiti*e stress in+uries A&terpr%.le's are addressed, a )radual return t% acti*it( is rec%''ended t% a*%id &urther

in+ur( and i'pr%*e per&%r'ance

0ith Lance Ar'str%n)1s successes in the T%ur de rance and the increasin)p%pularit( %& '%untain .ikin), participati%n in .ic(clin) has steadil( increased %*erthe past $ (ears C(clin) is an e4cellent alternati*e &%r runners and %ther athletesseekin) l%/-i'pact e4ercise The ureau %& Transp%rtati%n Statistics at the 5SDepart'ent %& Transp%rtati%n esti'ates that '%re than !6 'illi%n A'ericans ride.ic(cles at least '%nthl(, /ith %*er 7 'illi%n pe%ple ridin) at least 2$ da(s per'%nth

The nu'.er %& c(clin)-related in+uries has als% risen, /ith the 'a+%rit( caused .(%*eruse #n+uries 'a( als% .e related t% i'pr%per .ic(cle &it %r e uip'ent, p%%rtechni ue, %r inappr%priate trainin) patterns C(clin) is *er( repetiti*e; durin) h%ur%& c(clin), a rider 'a( a*era)e up t% 7,$$$ pedal re*%luti%ns The s'allest a'%unt %&'alali)n'ent, /hether anat%'ic %r e uip'ent related, can lead t% d(s&uncti%n,i'paired per&%r'ance, and pain

Se*eral studies in athletes 2-7 ha*e de'%nstrated that knee in+uries, includin) anteri%rknee pain and patell%&e'%ral pain s(ndr%'e, are the '%st c%''%n %*eruse in+uriese*aluated in sp%rts 'edicine centers O*eruse in+uries %ccur /hen a tissueaccu'ulates da'a)e caused .( repetiti*e su.'a4i'al l%adin) "epetiti*e acti*it(&ati)ues a speci&ic structure, such as tend%n %r .%ne 0ith%ut ade uate rec%*er(,'icr%trau'a sti'ulates an in&la''at%r( resp%nse, causin) the release %& *as%acti*esu.stances, in&la''at%r( cells, and en8('es that da'a)e l%cal tissue Cu'ulati*e'icr%trau'a &r%' &urther repetiti*e acti*it( e*entuall( leads t% clinical in+ur(

#n chr%nic cases, c%ntinued acti*it( pr%duces de)enerati*e chan)es that lead t%/eakness, l%ss %& &le4i.ilit(, and chr%nic pain Thus, in %*eruse in+uries, the pr%.le'is %&ten n%t acute tissue in&la''ati%n, .ut chr%nic de)enerati%n %r tendin%sis instead%& tendinitis 9 Pain in %*eruse in+uries t(picall( has insidi%us %nset, .ut it 'a( ha*e anacute-%n-chr%nic presentati%n O*eruse in+uries '%st likel( %ccur /hen an athletechan)es the '%de, intensit(, %r durati%n %& trainin) i%'echanic :intrinsic &act%rsand e uip'ent %r trainin) :e4trinsic issues are the 'ain c%ntri.ut%rs t% %*erusein+uries

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i%'echanic a.n%r'alities 'a( arise &r%' anat%'ic as /ell as &uncti%nal &act%rsMuscular in&le4i.ilit( is a leadin) c%ntri.ut%r t% in+ur( M%st c(clists1 uadriceps andha'strin)s /ill ti)hten /ith pr%l%n)ed ridin) #n&le4i.ilit( %& the uadriceps,ha'strin)s, %r ili%ti.ial .and :#T 'a( restrict ran)e %& '%ti%n ar%und the knee andare likel( t% increase the &%rces %n the knee 9 0eakness in the le) 'uscles 'a( lead

t% &ati)ue-induced alterati%ns in pedalin) techni ue, /hich /ill als% alter the &%rces %nthe knee #nappr%priate saddle hei)ht %r i'p r%perl( ali)ned sh%e cleats trans'itincreased repetiti*e &%rces thr%u)h the knee, /ith a )reater likelih%%d %& in+ur( 2

Anterior Knee Pain

Patients &re uentl( rep%rt anteri%r knee pain that 'a( .e related t% repetiti*e stress %rt% in&la''ati%n #n &act, anteri%r knee pain is the '%st c%''%n reas%n .ic(clists seekph(sician care 3 Causes %& anteri%r knee pain include patell%&e'%ral pain s(ndr%'e,ch%ndr%'alacia, uadriceps tendin%sis, patellar tendin%sis, and, %ccasi%nall(,prepatellar .ur sit is

Patellofe(oral pain syndro(e+ als% called retr%patellar pain s(ndr%'e, re&ers t%anteri%r knee pain e'anatin) &r%' the patell%&e'%ral +%int and supp%rtin) s%&t tissuesPatell%&e'%ral pain s(ndr%'e is an earl( indicati%n %& cartila)e s%&tenin) that canpr%)ress t% &rank cartila)in%us da'a)e :ch%ndr%'alacia Patell%&e'%ral pains(ndr%'e is t(picall( an %&&ice dia)n%sis, /hile ch%ndr%'alacia is a sur)ical %rradi%l%)ic dia)n%sis ecause .%th usuall( arise &r%' c%lla)en .reakd%/n rather than&rank in&la''ati%n, the( are currentl( seen as tendin%sis rather than tendinitis 9

Patell%&e'%ral pain s(ndr%'e is related t% a c%'.inati%n %& &act%rs in*%l*in)'alali)n'ent %& the knee e4tens%r 'echanis' !, 7 Patients )enerall( rep%rt thatanteri%r knee pain is /%rse /hen the knee is l%aded :e), /hen cli'.in) %r descendin)stairs, durin) pr%l%n)ed sittin) %r s uattin) Pa tell %&e'%ral +%int pr%.le's &re uentl(di&&er .et/een c(clists and runners--'an( c(clists /ill p%int t% the center %& theirpatella and descri.e the pain as .ein) directl( under the patella, rather than %n the'edial %r lateral side 2 The pain, s%'eti'es se*ere, %&ten %ccurs a&ter c(clin), ratherthan durin) the ride

C*ondro(alacia+ characteri8ed .( pain %r crepitati%n in the retr%patellar area, isdescri.ed as a )ratin) sensati%n /ith anteri%r patell%&e'%ral disc%'&%rt that /%rsens/ith cli'.in), s uattin), %r pr%l%n)ed sittin) The c%nditi%n 'a( .e caused .(articular cartila)e .reakd%/n %r chr%nic s(n%*ial in&la''ati%n 4cessi*e patellarshear &%rces %*er the &e'%ral c%nd(les and patellar )r%%*e /ith 'alali)n'ent %& thepatella c%ntri.ute t% cartila)in%us .reakd%/n C(clists /h% ha*e pes planus,%*erpr%nati%n %& the &%%t, %r hind&%%t *al)u' 'a( als% ha*e a )reater de)ree %&patellar 'alali)n'ent Durin) c(clin), the pain is precipitated .( ridin) up hills %r/hen the rider pushes hi)her )ears /ith a sl%/ pedal cadence

,&adriceps tendinosis is characteri8ed .( pain at the uadriceps tend%n1s inserti%nint% the patella The pain 'a( .e l%cated 'ediall( %r laterall( t% the suprapatellar area.ut is '%re c%''%nl( seen %n the lateral side in c(clists Tendin%sis 'a( &%ll%/ anacute trau'atic e*ent .ut is usuall( caused .( repetiti*e stress, /ith p%%r .ike &it as ac%''%n c%ntri.utin) &act%r

Patellar tendinosis can result &r%' irritati%n %& the patellar tend%n and is '%st likel(caused .( e4cess an)ular tracti%n %n the tend%n /hen the rider pedals /ithi'pr%perl( p%siti%ned cleats > C(clists usuall( rep%rt si)ni&icant patellar tend%n pain

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related t% pedalin) and %ther knee-e4tensi%n acti*ities %cal s/ellin) ar%und thepatellar tend%n /ith palpa.le crepitus 'a( .e seen

Prepatellar '&rsitis+ less c%''%n in c(clin), sh%uld .e suspected /hen s/ellin) andtenderness anteri%r t% the patella e4ist and can arise &r%' acute trau'a Chr%nic

prepatellar .ursitis is '%re c%''%n than the acute &%r' and usuall( results &r%'repeated 'icr%trau'a, such as .ic(cle pedalin)

Caref&l Inspection

0hen e*aluatin) a c(clist /h% has anteri%r knee pain, inspect the .ic(cle &it Thesaddle 'a( .e t%% l%/, t%% &ar &%r/ard, %r .%th, causin) e4cessi*e patell%&e'%rall%adin) thr%u)h%ut the pedal c(cle 0hen the saddle is l%/, the knee &uncti%ns inh(per&le4i%n, increasin) c%'pressi%n %& the patella %n the &e'ur

#'pr%per sh%e cleat p%siti%n %r &l%at 'a( &%rce the rider t% pedal /ith p%%r.i%'echanics, increasin) patellar &%rces l%at is the '%ti%n %& the cleat %n the .%d( %&the pedal and is usuall( 'easured in de)rees %& internal %r e4ternal an)ulati%n :ie, 6F%& &l%at 'eans that the &%%t 'a( r%tate 6F in/ard %r %ut/ard relati*e t% the pedal.%d( Cleats /ith e4cessi*e internal %r e4ternal r%tati%n 'a( cause e4a))erated ti.ialr%tati%n, placin) '%re stress %n the anteri%r knee

!edial Knee Pain

The n%r'al pedalin) '%ti%n causes the ti.ia t% internall( r%tate /hen the knee ise4tended Medial knee pain results /hen increased stress &r%' i'pr%per saddlehei)ht, saddle &%re-and-a&t p%siti%n, %r cleat p%siti%n :t%es p%inted t%% &ar %ut/ardincreases internal ti.ial r%tati%n P%%r le) &le4i.ilit( and trainin) err%rs, such as ridin)in )ears that are t%% hi)h %r e4cessi*e hill cli'.in), increase stress and e4acer.ate'edial knee c%nditi%ns Anat%'ic a.n%r'alities, such as )enu *arus, %*erpr%nati%n,

inherent ti.ial r%tati%n, and ha'strin) ti)htness, 'a( als% e4acer.ate 'edial kneepain Medial knee pain %&ten is caused .( pes anserine .ursitis %r 'edi%patellar plicas(ndr%'e

Pes anserine '&rsitis is identi&ied .( insidi%us-%nset pain %*er the 'edial pr%4i'alti.ial 'etaph(sis appr%4i'atel( 2 t% ! c' .el%/ the +%int line 9 Direct trau'a %rrepeated &ricti%n %*er the .ursa can lead t% in&la''ati%n 0hen the .ursa is in&la'ed,c%ntracti%n %& the ha'strin) 'uscles, ti.ial r%tati%n, and direct pressure %*er the pesanserine .ursa usuall( pr%duce pain The p%pliteal an)le sh%u ld .e 'easured andti)htness treated /ith ha'strin)-stretchin) e4ercises

!ediopatellar plica syndro(e causes pain %*er the 'edial retinaculu' A plica is as(n%*ial septu' re'nant &r%' the e'.r(%l%)ic knee Medial plica %ccurs in up t% 3$%& the p%pulati%n > Medial plica 'a( i'pin)e %n the &e'%ral c%nd(le durin) knee&le4i%n, leadin) t% in&la''ati%n and s/ellin) #& a n%r'al 'edial plica is chr%nicall(in&la'ed and turns &i.r%tic, it 'a( .%/-strin) %*er the 'edial &e'%ral c%nd(le durin)knee &le4i%n and ca use irritati%n and a snappin) sensati%n The c(clist /h% has plicas('pt%'s 'a( descri.e a disa.lin) 'edial knee pain acc%'panied .( a sensati%n %&'edial p%ppin) that %ccurs /ith each pedalin) str%ke Treat'ent &%r a s('pt%'aticplica in*%l*es ad+ustin) the saddle &it and cleat p%siti%n t% reduce &%rces %n theanteri%r knee A l%cal anesthetic 'a( .e in+ected directl( int% the plica t% )i*ete'p%rar( relie& Orth%pedic re&erral sh%uld .e 'ade i& s('pt%'s persist l%n)er than

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'a( .e acc%'plished .( c%rrectin) anat%'ic, &uncti%nal, %r e uip'ent rel a ted err%rs

Bicycle ad-&st(ent% M%st .ic(cle sh%ps /ill e*aluate and ad+ust .ike &it &%r thepri'ar( rider at a reas%na.le c%st The ualit( %& .ike &its can .e uite *aria.le, andl%cal .ike clu.s sh%uld .e a.le t% pr%*ide re&erences

A si'ple saddle hei)ht ad+ust'ent 'a( ease the &%rces placed %n the knee #& thesaddle is t%% l%/, t%% 'uch stress is placed %n the knee &r%' the patellar anduadriceps tend%ns #& the saddle is t%% hi)h, pain 'a( de*el%p .ehind the kneePr%per saddle hei)ht can .e deter'ined in se*eral di&&erent /a(s The easiest /a( ist% all%/ %ne pedal t% dr%p t% the 9-%1cl%ck p%siti%n and %.ser*e the an)le %& &le4i%n inthe knee +%int There sh%uld .e a 27F t% 3$F &le4i%n in the knee /hen the pedal is atthe .%tt%'-'%st p%int > An%ther 'eth%d is t% 'easure the insea' :in c' and'ultipl( .( $ @@3 t% )e t the c%rrect distance &r%' the t%p %& the saddle t% the center%& the .%tt%' .racket @ #& the hips r%ck .ack and &%rth /hen pedalin), the saddle ist%% hi)h; l%/er the sa dd le until a s'%%th pedal str%ke is achie*ed

Saddle &%re-and-a&t p%siti%ns and sh%e cleat p%siti%n 'a( als% c%ntri.ute t% knee painSaddles that are t%% &ar .ack cause the c(clist t% reach &%r the pedal and stretch the#T , resultin) in knee pain Saddles that are t%% &ar &%r/ard /ill &%rce pedalin) in ah(per&le4ed p%siti%n, increasin) the &%rce %n the anteri%r knee Saddle p%siti%n can .ee*aluated /ith the plu'. .%. techni ue Seated /ith the pedal in the 3-%1cl%ckp%siti%n, a plu'. hun) &r%' the '%st anteri%r p%rti%n %& the knee sh%uld intersect the.all %& the &%%t and the a4le %& the pedal

Cleats that are internall( r%tated t%% &ar 'a( increase stress %n the #T as it cr%ssesthe %utside %& the knee 4cessi*e e4ternal r%tati%n /ill cause 'edial knee stressCleats sh%uld .e p%siti%ned &%re %r a&t s% that the .all %& the &%%t is directl( %*er thea4le %& the pedal "%tati%nal cleat p%siti%n can .e e*aluated /ith a .ike sh%p G&it kitG%r r%tati%nal ad+ust'ent de*ice--this is '%re i'p%rtant &%r cleats /ith less than 7F %&&l%at M%st ne/ r%ad cleats all%/ )reater de)rees %& &l%at t% pr%tect the knees

Correcting anato(ic pro'le(s% #ndi*idual c(clist anat%'( 'a( c%ntri.ute t% kneeand hip pain C(clists /ith le)-len)th discrepancies 'a( de*el%p knee pain, .ecause%nl( %ne side is c%rrectl( &itted t% the .ic(cle

C(clists /ith &lat &eet 'a( .e '%re pr%ne t% e4cessi*e pr%nati%n :internal r%tati%n %&the le), causin) )reater stress %n the #T at the knee, as /ell as %n the 'edial kneeCust%'i8ed %rth%ses 'a( c%rrect the ali)n'ent %& the knee and decrease %r pre*ent'edial %r lateral r%tati%nal stress %n the c%nnecti*e tissue in the ankle, knee, %r hip,thus reducin) pain Orth%ses 'a( in&luence the pattern %& le) '%*e'ent thr%u)h ac%'.inati%n %& 'echanical c%ntr%l and .i%&eed.ack 6 %r the clinical &uncti%ns %& '%ti%nc%ntr%l, pressure relie&, and redistri.uti%n %& &%rces 2$ C(clists re uire a di&&erent t(pe

%& %rth%ses than runners; c(clin) %rth%ses are l%n) er and pr%*ide additi%nal'etatarsal supp%rt Pedal shi's %r sh%e li&ts 'a( help c%rrect 'alali)n'ent %r le)-len)th discrepancies

et&rn After In-&ry

The &irst )uideline durin) a re.uildin) peri%d is t% start sl%/l( #n the earl( sta)es %& ac%'e.ack, c(clists sh%uld d% a c%ndensed *ersi%n %& their n%r'al trainin) schedule,pr%)ressin) %nl( /hen eas( rides are pain-&ree :ta.le 2 Durin) this transiti%n, the

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athlete sh%uld use l%/er resistance and hi)her cadence t% all%/ a )radual return t%acti*it( A )%%d rule is that &%r e*er( /eek %& c(clin)-speci&ic trainin) 'issed, all%/ t% 2 /eeks %& trainin) t% return t% pre*i%us &%r' 2 ,22

TAB#E .% eco((ended Progra( for et&rn to Cycling After In-&ry

#engt* of e*a'ilitationMultipl( the durati%n %& the la(%&& :in /eeks .( :&%r less se*ere in+uries %r 2 :&%r '%rese*ere in+uriest% esti'ate h%/ 'an( /eeks it /ill take t% return t% prein+ur( trainin) le*el4a'pleH La(%&& &%r a '%re se*ere in+ur(:2 /k 'issed I 2 ! /k %& reduced trainin)

Stages for a /0 to 102) e*a'ilitationSta)e : -2 /k H as( rides /ith%ut &ati)ue %r painSta)e 2 : -2 /k H ndurance pace /%rk at 7$ t% >7 %& e&&%rt and distance %& prein+ur(/%rk%utsSta)e 3 : /k H M%derate-intensit( /%rk until the c(clist can c%'plete &ull prein+ur( distanceSta)e ! : /k H =i)h-intensit( /%rk at &ull prein+ur( distance

Sta)e 7H "eturn t% &ull c%'petiti%n

Note" C(clists 'a( ad*ance t% the ne4t sta)e /hen the(can per&%r' the current sta)e %n 2 c%nsecuti*e da(s/ith%ut pain

Pre3enting O3er&se In-&ries

The preparticipati%n ph(sical e4a' is an e4cellent %pp%rtunit( t% ask a.%ut andaddress pre*i%us %*eruse in+uries The c(clist sh%uld .e c%unseled a.%ut increasin)acti*it( usin) the G $ ruleG--increasin) distance and intensit( .( $ each /eekdurin) earl(- seas%n and .uild-up peri%ds 23 Athletes /h% ha*e a hist%r( %& %*erusein+uries sh%uld .e e4a'ined &%r /eakness a nd &le4i.ilit( de&icits and 'a( .ene&it &r%'

earl(-seas%n stretchin) and stren)thenin) pr%)ra's 7 A pre- and p%st/%rk%utstretchin) r%utine is i'p%rtant &%r c%ntinu%us pain-&r e e ridin)

0eakness %& the uadriceps, ha'strin)s, %r hip &le4%rs 'a( .e assessed .( 'anuall(testin) resisted e4tensi%n %& the knee, &le4i%n %& the knee, and &le4i%n %& the hip,respecti*el( M%re accurate, uanti&ia.le results can .e %.tained .( per&%r'in)'echanical is%kinetic testin) /ith a c%''ercial 'achine such as the i%de4 S(ste' 3: i%de4 Medical S(ste's, #nc, Shirle(, Ne/ J%rk le4i.ilit( %& the uadriceps 'a( .eassessed .( per&%r'in) l(1s test and c%'parin) the a'%unt %& passi*e knee &le4i%n ineach le) =a'strin) &le4i.ilit( can .e e*aluated usin) the p%pliteal an)le %r the sit-and-reach test =ip &le4%rs can .e e*aluated /ith the Th%'as test, and &le4i.ilit( %& the#T 'a( .e tested /ith the O.er test 2!

Pr%)ressi*e stren)thenin) e4ercises are /arranted &%r patients /h% ha*e 'uscle/eakness 9 #nitial acti*ities include is%'etric uadriceps and ha'strin) e4ercises, suchas uad se t s and ha'strin) sets #s%t%nic e4ercises such as strai)ht-le) e4tensi%n and&le4i%n are the ne4t phase in stren)thenin) inall(, patients per&%r' eccentricall(resisted knee &le4i%n and e4tensi%n /ith /ei)hts 27 le4i.ilit( &%cusin) %n theuadriceps, ha'strin)s, hip &le4%rs, and #T is i' p %rtant and sh%uld .e a re)ular part%& a c(clist1s trainin) re)i'en

As '%re pe%ple seek l%/-i'pact /a(s t% i'pr%*e and 'aintain their cardi%*ascular

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6@@;>:3 H76 -9 $2! Ma)ee DKH Orth%pedic Ph(sical Assess'ent Philadelphia, 0 Saunders, 66>, pp !@2-

!@727 Shel.%urne ?D, "ask P, =unt SH ?nee in+uries, in Schenck "C :ed H Athletic Trainin) and

Sp%rts Medicine, ed 3 "%se'%nt, #L, A'erican Acade'( %& Orth%paedic Sur)e%ns, 666,pp !>2-!@

Dr Aspl&nd is a &a'il( practice ph(sician in the depart'ent %& &a'il( practice at De/itt Ar'(C%''unit( =%spital in %rt el*%ir, Vir)inia Dr St Pierre is an assistant pr%&ess%r %& sur)er( atthe 5ni&%r'ed Ser*ices 5ni*ersit( %& =ealth Sciences in ethesda, Mar(land, and ass%ciatedirect%r at Nirschl Orth%paedic and Sp%rts Medicine in Arlin)t%n, Vir)inia Addresscorrespondence to CPT Chad Asplund, MD, 7993 Marshall "d, %rt el*%ir, VA 22$9$; e-'ail t%chad asplund us ar'( 'il

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mailto:[email protected]

knee pain and bicycling

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