Friday, July 31, 2009

Cycling and Knee pain

The knee is one of the most common sites for injuries among cyclists. When you consider the number of revolutions our legs make on the bike, it's no wonder we have so many issues with knee pain as cyclist. The knee is a complex biomechanical piece of machinery and when structures are not functioning properly, it will let you know with a nice dose of pain. There are many conditions as well as outside factors that can affect the knee. I see many common knee injuries that come about from cycling such as patellar tendonitis, ITB syndrome, Pes anserine bursitis, chondromalacia patella, as well as plica syndrome, among others. On some occasions I have seen patients that have been to every health care provider possible with no resolution of their symptoms. They have had X-rays and MRI's, as well as bike fittings by experts. Some even had C.T. scans performed to determine and correct leg lengths which were then corrected and the knee pain persisted. In many of these cases, I tend to find a combination of myofascial problems and mechanical joint problems or problems with the muscles and fascia independently. These will not show up on any X-rays or MRIs. In fact, many of the previous knee injuries mentioned also contain myofascial problems that need to be addressed along with the main injury. Here is a case study to help give you some insight into this particular problem.

A patient presents to my office with bilateral knee pain that is present after riding his road bike. Review of his past medical history is non contributory and family history is benign as it relates to his present condition. He reports that he has also seen two other physicians and gives me their reports as well as the knee MRI's and X-rays that were taken. All results were negative and both physicians diagnosed his condition as bilateral knee sprains with no specific areas noted. They recommended that he rest off his bike. After finish
ing his history I proceed to examine him and his physical exam was normal as well as his vital signs. He is in his 20's, physically fit and has been riding for several years. He has recently started training at a higher intensity as well as spending a longer amount of time in the saddle. Range of motion is full in all planes. His arches and gait are normal as well. No excessive rotation is noted in his hip or knee. Leg length was assessed and there are no structural or functional changes noted. I performed several orthopedic tests to his back, hip, knee and ankles with no positive findings. I begin to palpate (touch) his knee and surrounding muscles. When I get to a muscle called the vastus medialis and find several knots called trigger points, the patient says "that's it doc, that's tender" I continue to feel around his knee and find that the quadriceps muscles are very tight overall and contain several more trigger points. Now I ask the patient if the pain that occurs when I press those spots is reproducing the knee pain he gets and he responds “yes that’s it”. If you take a look at fig. 1, I have placed an x and then some small dots so you can see the pattern of referral from the tender points

Next, I take a look at his cleats, bike fit and talk to him about who positioned him on the bike. The name is familiar to me and he has not made andy changes since then. One thing he does note to me is that he has been adding miles over the past few months as well as intensity. At this point, it is likely that his knee pain was associated only with muscle and joint tissue dysfunction. In this is the best case scenario for this patient because with the right treatment, home stretches, as well as self massage, the problem could be fixed. When I talked to him about recovery he admits to me that he doesn't do very much other then eating after he works out and adding some light days. In my opinion, he is missing half of the full picture. Your body builds and adapts between training sessions and during that period is where my interest lies because we have really only scratched the surface of what is occurring on many different levels. Needless to say you need more than good nutrition and hydration. If you look at my flow chart for recovery fig. 2 you will see the six pillars of recovery that your training rests on. If one pillar is missing things will fall apart with your training and/or your body. In this case, he missed on many points and he did not give himself time to recover so his muscles and tissues could adapt to the increased in demanded he placed on it.

For the purpose of this article we will focus on the physical pillar of recovery and what I did as it relates to this injury. I began using electric stimulation and heat to the area and began a manual technique of working out the tight muscle tissue and trigger points in an effort to decrease the tight tissue and increase normal range of motion. I also manipulate or adjust the joints of the foot, knee, hip and low back to restore those normal motion patterns. In addition, I recommend some specific stretches, as well as the use of a Quadballer one of several great tools by trigger point therapy for the patient to use at home as part of his recovery routine. If you look at fig 3, you see an example of a patient using the Quadballer in an effort help maintain the benefits from the care he is given in my office. He responds well to care and is soon riding pain free at a 3 month follow up. . There are many ways to treat knee problems make sure you find the right provider for you so you can fix the problem and not the symptom. Most of all, don't forget the other half of your training recovery! Otherwise you will soon find that pain raising its ugly head.

1 comment:

Sydney Physio Newtown said...

I agree with your statement "There are many ways to treat knee problems make sure you find the right provider for you so you can fix the problem and not the symptom."

Mis-diagnosis can often aggravate or prolong the knee pain.

As an example, a friend of mine was misdiagnosed with osteo-arthritis and advised to manage the pain with painkillers and glucosamine until he was ready for knee surgery.

When properly diagnosed, he only required new prescription orthotics, flexibility exercises and slight modifications to his walking style.

The enormous difference between the two diagnoses, while somewhat frightening was also the difference between massive, unnecessary expense and getting relatively simple relief from his long-term knee pain.