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3 parts

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3 Ways to Solve Knee Injuries in Cycling – Part 3

Introduction

Knee pain is one of the most common injuries in cycling, accounting for between 30-60% of all injuries, depending on what you read. In my experience, it is certainly the most common complaint I see and deal with.

In parts 1 and 2 we covered load management and strength/mobility. It’s certainly reasonable to try a few things before rushing off for advice. However, I would caution against ignoring injury for too long. It’s all too easy to stay in denial for months and dig. yourself a big hole.

So when should you seek advice? and where from?

3 – Seeking Professional Advice from Therapist or Bike Fitter

I’d probably split this down into 2 broad categories:

 

  1. Influencing the body
  2. Influencing the bike

 

Clearly, there’s a big overlap between these two, but to try and keep it simple, lets go with it.

Influencing the body can be anything from manual work on muscles, joints, neural mobility, balance, strength, coordination and many more. Again, you will see the overlap with our second strategy (Strength and Mobility)…a strong, skilful body with help you.

A lot of these gains are possible with exercise and the strategies outlined in part 2. However, sometimes more help is required and manual work from a physiotherapist can save a lot of time allowing you to progress the on bike and off bike exercises more quickly.

For example, we’ve all seen cyclists where one or both of their knees flare out at the top of the pedal stroke. This is most commonly due to stiffness in the hips, where hip flexion and/or hip internal rotation are limited meaning that to get the foot over the top of the pedal stroke the hip ‘buys’ some range using external rotation. This is what makes the knee flare out.

Now as we’ve said, this may not be optimal for the knee, but the knee can’t change it, it’s forced into this pattern by the hips. Manual therapy and exercise can really help increase hip range and change this pattern for the knee to a pattern of movement that no longer causes undue stress on the knee.

This is just one example, but similar could be seen all over the body. A little targeted help from a physio can allow self-help/maintenance to be far more rapid and sustained.

 

Influencing the bike is simply a way of influencing the body through the bike, but is no less effective. Changing the position on the bike is something we are all familiar with. I tinkered with my position for years, before I finally got a bike fit. I was totally blown away by how much more effective a bike fit was than my endless changes.

Since then of course I have extensively studied bike fitting and completed my qualifications to help my patients and clients directly. As well as the formal qualifications I have studied informally through Steve Hogg’s ebooks and blogs (which are incredibly detailed) and also I have spent a large amount of time researching bike fitting through my Clinical  Biomechanics MSc.

In the example above we looked at the knees flaring out due to stiff hips. If the pattern persists even after you have achieved as much range as you can from the hips/body, you need to look elsewhere for help. Here is where bike fitting can be so important. You can set the bike up so less hip flexion is required by making sure the saddle is at the right height, bar reach/height, altering the crank lengths, looking at pedal stack, pedal spacers and I’m sure many other options. This solution is never a generic 1+1=2 scenario. Everyone is an individual and comes with their own bike set up, their own movement patterns, their own injury history, their own set of beliefs. Everyone is an individual and the best results come from always treating my patients and clients with the highest level of individual attention.

The other advantage of influencing the bike is that the changes to the bike can be done instantly. Though this won’t necessarily solve all your pain instantly, you can buy some ROM so you can keep training while you work on the body. The bike fit can then evolve as the body improves, making for a quicker outcome that allows training to continue.

In Summary

Preventing injuries is the best-case scenario and having a good quality bike fit and a good movement regime off the bike are the best ways to achieve this.

If injuries do occur, don’t stay too long in denial! Look at the issue and its possible causes and try to address them. If it is beyond your knowledge or skill set then it is time to seek the advice from those who can help.

I’d caution against asking the internet…I see these posts all the time. You get a million answers all saying different things, each from an individual with a biased perspect. For example ‘raise your saddle 5-10mm, takes pressure off the knee…I’ve had no pain since I did it’ (I see that one a lot!). That’s great for that individual, but who. knows why they had knee pain? It may be for completely different reasons to you…your saddle may be the perfect height.

That is where the value of a trusted physio/bike fitter can really pay off.  If they are good, they minimise the bias, have an objective view and can look at you as an individual. This gives you a much better chance of understanding why you have knee pain and how you can solve it.

 

I really hope these posts are helpful, but if you have any questions at all leave them in the comments below or you can email me directly.

coach@summitcyclecoaching.co.uk

 

Neil Poulton

BSc. Physiotherapy

BSc. Sports Science

MSc. Clinical Biomechanics (ongoing)

ABCC Level 3 Cycling Coach

Bike Fitter


 

Any questions

If you have any questions or comments you can ask them in the comments section below or email:

coach@summitcyclecoaching.co.uk

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Should I Get a Bike FIt?

Neil Poulton

Bike Fitter

“Do I need a bike fit and if so, when should I get a bike fit?”

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Do i need a bike fit?

This is an excellent question and not always easy to answer. I remember reading the Cyclist Training Bible by Joe Friel (which is an awesome book!) and he recommended not only getting a bike fit, but getting one every year. The rationale being that things change and what works one year may not the next. At the high end of performance I can see this, but it may be hard to justify at a more recreational level, especially if things haven’t really changed.

I think that is really the key to answering this question, is there a good reason for getting a bike fit? In the next section I’ve outlined the reasons that may lead you to consider a bike fit, take a look and see how you fit in.

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When Should I get a bke fit?

Given the cost of cycling as a whole, adding a bike fit into the set up really isn’t a big expense, certainly not compared to the cost of physio to recover from an injury or the time of the bike that an injury might cause.

There are a couple of reasons that would start signalling me towards recommending a bike fit:

  • You are New to Cycling:
    • If you are new to cycling, getting a basic fit will be a great way to get comfortable and avoiding potential pitfalls of a bad fit and the pain and discomfort this may cause.
    • A basic bike fit will get you a long way. Over the months/years as your riding experience and mileage increases you may find yourself fitting into another of these categories and another fit may be required to refine your position.
  • Pain or Discomfort on the bike:
    • This is probably the most urgent reason. I see lost of posts on Facebook groups asking how to solve pain and discomfort on a bike. This is a tough challenge at any time, let alone asking random strangers for the solution. If you are asking around for advice, you need a bike fit.
    • Cycling is a sport that embraces suffering, so we often dig in for too long before we admit we need to sort out our injuries. If you have pain, discomfort, pins and needles, numbness, etc it is time to seek the advice of someone that can take a look at the big picture and help you get back to enjoying riding your bike.
  • Niggly Issues:
    • This is a tricky one, because we can often ‘manage’. But if niggly issues are creeping in it may be time for a fit/re-fit. A good example is starting to get pain/discomfort towards the ends of rides, that over time starts to creep in earlier and earlier in the ride. It’s only a matter of time before this problem is limiting your training, so consider a fit for niggles that appear and become persistent.
  • Change of bike/Type of Bike:
    • This can apply to anyone, but if you started cycling, had a fit and increase your cycling over a few years. You now go out and buy a new bike, try to get it into the same position, but that is a lot easier said than done.
    • This is a great time to get a bike fit. Bikes all have slightly different geometry and getting comfy on a new bike can be tricky. A bike fit can get you in a good position on your new bike and get you out enjoying it avoiding the discomfort a big change might have caused.
    • If you change type of bike, for example, from a sportive type road bike to a more aggressive racing machine or from a road bike to a time trial bike it is inevitable that your fit will be different. A bike fit would be highly recommended in this case.
  • Something Changes or Forces a Change:
    • This could be anything from feeling stiffer as you get a bit older, making your normal position uncomfortable.
    • Or it could be an injury has forced you to sit/ride differently or is making it impossible to hold your normal poison.
    • It could be that you’ve started doing a few triathlons and you want a different fit to help you in the bike/run transition.
    • If something changes and you are finding it hard to adapt, maybe the bike needs to adapt to you a bit, so a bike fit is indicated.

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when don’t i need one?

Pain is the most common reason for needing a bike fit and it’s a bit of a no-brainer, if pain is limiting your riding or your enjoyment of riding, it’s time to get it sorted.

There are seemingly a lot of reasons to get a bike fit, probably plenty more than I’ve outlined above. However, not everyone is going to be needing constant bike fitting. If you are confident and comfortable on the bike and you are able to complete your riding with no issues then I wouldn’t rush out and try and change things…there has to be a good reason.

I certainly wouldn’t recommend going looking for changes that are not necessary, so if all is good, just enjoy your riding.

 

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On Monday, we looked at Hip Mobility in Cycling. It’s certainly an interesting thing to look at as it can have many causes and like almost anything else, does not have a single solution. Today, we’ll have a look at assessing off weight bearing and a 3D on weight bearing assessment.

Off Weight Bearing

Clearly, a thorough assessment to check elsewhere to make sure you are dealing with an MSK hip problem. Once I rule out other things and I’m satisfied that it’s the hip, I like to have a feel of the quality of the hip movement off weight bearing (OWB).

In supine you can take the hip through passive ROM. I’m looking for both the amount of range available how it feels. How does it feel at the end of range (EOR)? Often in these cases there’s a stiffness at EOR flexion. You can then explore the EOR, adding a little adduction/abduction, then internal/external rotation (IR/ER). See what kind of feel there is with the different combinations…gives you an idea of what is limited and how much gain you can make with treatment.

This takes no more than a couple of minutes, but it’s great to see how things are now and how it compares to what you see once you get them on their feet and moving.

On Weight Bearing

There’s a fair bit to do, so it’s best to keep it simple to start with. A quick pass through each of the moments and then you can dig a little deeper with anything that flags up as an issue.

Sagittal Plane

The simplest of starts…get them lifting their knees towards their chest and see what happens. Is there movement into ER or abduction? when does this happen?

Then a simple squat and single leg squat lets you see how things work under a bit of load. Have a look at left vs right (L/R) in the double leg squat and see if there’s any difficulty getting into flexion. Then compare that to their single leg squat. When there is less stability you can sometimes see the hip struggle more, tells you are little something about how to solve the problem 🙂

Again you are looking at what happens when you stress the flexion, do you get added movements? Does the pattern fit with what you’ve seen on the bike? Or with their pattern of symptoms?

Frontal Plane

A nice simple hip adduction assessment is to put your feet together, hands above your head and then reach/sway laterally as far as you can each side with your hands. Watch the reaction at the hips, how much movement R/L and do they bail out into rotation if one side is limited? This is really good to look out for and will be a good place to start when you start building a treatment plan.

You can get a bit more complicated here, if you want? Get the patient into a bit of flexion…use a step or box to bring one hip into flexion, then test out the frontal plane with the over head lateral reaches as before. See how that compares left to right and also how it compares to the more neutral stance.

Transverse Plane

To keep it simple, stand with arms out in front of you at chest height. Rotate your hands/arms left and right. Compare L/R for ROM. If it’s hard to see a difference, stand with your feet turned in towards each other and repeat the arm movements. Like in the frontal plane, you can get unilateral assessment with a foot on a box/step. See what happens when you combine the IR/ER with flexion.

Bringing it Together

This is the information gathering part of the process. Everyone is different, so try and piece together what you see on the bike with what you see happening in the different planes of movement.

In the scenario we talked about on Monday, it was the knees moving laterally at the top of the pedal stroke that we looked at, so how does what you see in your assessment fit with that? Is there a marked lack of adduction or IR that is really stopping the flexion? If you find something like that you will have a lot more success getting the flexion back if you address the other restrictions first. To finish off this little mini series, I’ll write about some possible scenarios and treatment strategies on Monday.

 

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