Cyclist physio approach to knee injury

[Lister Farrar]

Mike, your post reminded me that Brian S's experience with physio Barb Bialokoz might be of interest to you and your knees. She's a strong local rider with Bob Cameron's club IRC, and Carly's former tandem partner.

Brian S also had tendonitis, and went to see her for advice on bike fit. She suggested changing his position to take the strain off his quads (and knees) and put more on his hamstrings. She lowered the stem, pushed the seat back, and moved the cleats back on his shoes. He says it feels a bit weird and not necessarily a performance advantage, but it definitely takes the strain off his knees.

Maybe you could comment Brian?

w (250) 704-6308
http://bbphysio.ca/index.html

[steve]

As a physio myself, I'm going to strongly support Lister's advice; Bike fit is where I would start with respect to any injuries that occur on the bike. Small changes in cleat position, seat position and height etc. can make a significant difference on the biomechanical implications on your body, particularly when you consider that you are doing somewhere in the neighborhood of 5000 revolutions per hour of the same movement.

Barb is well respected within the physio community and a very experienced cyclist.

Steve

[wonger]

Alec are you reading this!?

[FairweatherMike]

Thanks, Lister and Steve, for your continued concern and good ideas - much appreciated. I'll keep the info about Barb in the hip pocket and may contact her when I'm back on the "fast bike." I've only recently resumed the short cycle commute to work (10 minutes, mostly flat) - I was even taking the bus to work this summer (bummer)... things had reached the point where just walking was irritating.

The long and short of it is that cycling had, I believe, nothing to do with my injury - OK, the new year's day ride on an old commuter that couldn't get into low gear on Sayward hill may have done some damage, but it is becoming clear that I had pre-existing torn menisci (running? tennis? wear and tear?) and the clear overuse with two weeks of pavement pounding on Maui in December pushed things over the edge. The crack in the road, so to speak, turned into a pothole. I suspect I've got some junk (cartilage fragments) floating around in the knees, plus meniscal flaps that love to snap, so I'm waiting for surgery (Dr. Zarzour, orthopod). And in a couple of days I'm going for a "lube job" (Synvisc injection - synthetic higher-viscosity synovial fluid) which I'm hoping will speed the healing of the chondromalacia. Confining my cardio activity to the pool has been great upper body exercise - just what every cyclist needs.

I hope to be getting back to some road work following surgery (or maybe following Synvisc). It's almost a year ago exactly that I did that crazy Victoria-Nanaimo 260 km round trip; the wonderful thing about that is that the joints came through with flying colours - not even a twinge. The butt was on fire (saddle issue), but having had a professional bike fitting the week before made all the difference. It was the evil pavement pounding that awakened mostly-dormant injuries and forced the issue. Time for an overhaul. While I wait for surgery I continue to get fine physio (covered 100% - thank you, extended health) from triathlete Cheryl Murphy, with whom I talk bike while she works me over...my "joint education" continues...

Cheers -

Mike

[Lister Farrar]

Glad to hear you're on the mend Mike. It might be splitting hairs, but what I noticed about Barb's suggestion is that the bike fit was not done for optimum fit/performance, but that a variation of Bryan's normal position was employed to allow him to ride with less strain on his knees while they healed. Since your injury happened after the previous fitting, I thought a different fit might help if you still have pain when you start to ride again.

Steve, thanks for the feedback on Barb. I'm interested in your opinion. My kids have had a couple of biomechanical assessments for sport by physios at Lifemark PISE and the starting point there seemed to be stretching and strength. What's your take on stretching and strength in injury prevention for cycling? It was stretching hams, glutes, and upper back that cured a bad back (lumbar) problem for me, vs a change in my position (which I tried and did nothing). The 'aha' moment there was that the stretching was almost every body part except the injury site. I still imagine as I stretch that all the links in the chain are loosening and taking the pressure off the injured place. Hell, my butt even feels better on the saddle when I stretch. I think we tend to ignore flexibility in cycling because we don't have the range of movement that other sports do, but we do have hours of muscles tugging on joints, if they're tight, that must add up.

[FairweatherMike]

Got your point, Lister, and thank you. It will be a matter for fine tuning once I'm back in the saddle (I'd love to be able to get out of the saddle occasionally - tha's the real high stress position. Real cyclists have to stand occasionally).

On the exercise thing, I couldn't agree more. The stretch and strength thing is critical to patellar tracking and ensuring that all muscles in the drivetrain are doing their job. Patellar mistracking is a prime cause of chondromalacia: I was diagnosed with weak VMOs (inner thigh muscle that balances lateral force on the patella from the usually-larger vastus lateralis, the outer quad) and dormant glutes (occupational hazard for office workers), the latter being an essential muscle in the drivetrain. I also have tight IT bands and am using a foam roller daily to minimize the effects of that. And I will be going for a full biomechanical assessment at Lifemark once things are more or less healed up - correct me if you've learned differently, but I don't think it would be useful or wise to do it now with so many of the muscles in protective mode given the ongoing defects in the joints.

One thing's for sure, my approach to sports and conditioning is being permanently altered. We'll see if I remember any of the lessons once the joints are feeling great and the traumas are just a memory...

Mike

Per Ardua ad Astra

[Lister Farrar]

And I will be going for a full biomechanical assessment at Lifemark once things are more or less healed up - correct me if you've learned differently, but I don't think it would be useful or wise to do it now with so many of the muscles in protective mode given the ongoing defects in the joints.

I really don't know when treatment ought to start. Sounds like you ahve a physio who knows cycling. Steve? IIRC my physio had me doing pretty intensive stretching while I was still hobbling around, unable to sit. I'd had my second visit to a surgeon, but wasn't in line for surgery as you are. As for the assessment, Lifemark was doing assessments for my son's soccer team; I don't know if they have cycling experience or if that matters. Steve?

[watwin]

Thanks Geoff, I have seen this now, really good suggestions and I think a new bike fit will be key once I'm up to biking again, unfortunately knees appear to heal quite slowly. I've had some success taping my patellas and pulling them inwards/sideway (its got me walking again, albeit rather tentatively), which makes me think my problem is more then just tendonitis, likely a bit of chondromalacia due to a muscle imbalance from rowing pulling my patellas out of line. I think getting the right muscles strengthened once the inflammation is under control will be key to injury prevention. I'm afraid to think about what kind of shape I'll be in when I get back to cycling, but it'll be worth it!

[steve]

Lister,

I don't think you have to have a physio who has experience cycling as its relatively easy to figure out the mechanics of the sport but at the same time, it certainly doesn't hurt! I would argue that although cycling is great cardiovascular exercise, it tends to be hard on backs, necks and knees because it is a relatively static position sport with a very repetitive movement pattern. Exercise to address the areas that become weak and stretching for the areas that are tight should help minimize the chance you will develop an injury. There is also good evidence that long term cycling (As it is non weight bearing) leads to a significant decrease in bone density in master cyclist. Weight bearing exercise helps us to maintain and in our younger years, build our bone density.

From a performance perspective it is also worth considering weight training. Original studies found that only the novice cyclist benefited from weight training as untrained individuals improve with any type of activity. Intermediate and high level cyclists didn't improve with traditional weight training when tested on a stationary bike but it should be noted that the weight training benefit may have been lost secondary to being tested on a stationary bike - if anyone has seen Adam Kreek climb hills on the bike, they will have seen that the upper body can be extremely helpful in generating power! Downsides to traditional strength training may be increased muscle mass that weights you down on those hills.

More recently, studies have looked at pro cyclist performing explosive high intensity type leg exercises - weeks of training twice a week led to significant improvements in 1 and 4 km times with increased power and decreased oxygen costs noted.

On this basis, I'm going to be hitting the gym this year - God knows my wife will be happy if I put on a bit of weight! Lister, have you had much experience with the performance part of weight training for cycling?

Steve

[BryanS]

As Lister was saying I did have tendinitis and went to Barb soon after for treatment. She set me up with ultra sound on the affected area, as well as a bike fitting. For around $100 the fitting, was well worth the money. To begin she adjusted my cleats so that they were as far back as possible. What this did, was take some strain off of my knee area. I found that I was peddling more with the tips of my toes. She also put some shoe inserts in to get my feet more aligned. She then told me to go bike on it for a week and see how it felt. With her fitting, she allows you to come back for adjustments at anytime free of charge, which is great to fine tune your positioning. On my first ride, I immediately noticed more strain on the glute and hamstring area. It wasn't fun, but I could feel that there was definitely less of a load on the front knee. After two weeks had passed I went in for a second fitting. We further tried to reduce the load on my knees by moving the seat back, which put even more load on my hamstring area. Another thing she did was assess my flexibility, and we decided to flip the stem, so that I would be in a lower position. This felt awesome!