Knee Pain and Bicycling

Fitting Concepts for Clinicians

CPT Chad Asplund, MD; COL Patrick St Pierre, MD THE PHYSICIAN AND SPO TS!EDICINE - VOL 32 - NO ! - AP"#L 2$$!
In Brief" Anteri%r knee pain and patell%&e'%ral pain s(ndr%'e are a'%n) the '%st c%''%n le) %*eruse in+uries in c(clists ,ic(cle &it, recent chan)e in e-uip'ent, trainin) distance and intensit(, and indi*idual anat%'ic &act%rs are i'p%rtant e*aluati%n c%nsiderati%ns Clinicians need a .asic understandin) %& .ic(cle &ittin) and h%/ anat%'ic &act%rs and trainin) err%rs c%ntri.ute t% repetiti*e stress in+uries A&ter pr%.le's are addressed, a )radual return t% acti*it( is rec%''ended t% a*%id &urther in+ur( and i'pr%*e per&%r'ance 0ith Lance Ar'str%n)1s successes in the T%ur de 2rance and the increasin) p%pularit( %& '%untain .ikin), participati%n in .ic(clin) has steadil( increased %*er the past 3$ (ears C(clin) is an e4cellent alternati*e &%r runners and %ther athletes seekin) l%/-i'pact e4ercise The ,ureau %& Transp%rtati%n Statistics at the 5S Depart'ent %& Transp%rtati%n esti'ates that '%re than !6 'illi%n A'ericans ride .ic(cles at least '%nthl(, /ith %*er 7 'illi%n pe%ple ridin) at least 2$ da(s per '%nth 3 The nu'.er %& c(clin)-related in+uries has als% risen, /ith the 'a+%rit( caused .( %*eruse #n+uries 'a( als% .e related t% i'pr%per .ic(cle &it %r e-uip'ent, p%%r techni-ue, %r inappr%priate trainin) patterns C(clin) is *er( repetiti*e; durin) 3 h%ur %& c(clin), a rider 'a( a*era)e up t% 7,$$$ 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 athletes2-7 ha*e de'%nstrated that knee in+uries, includin) anteri%r knee pain and patell%&e'%ral pain s(ndr%'e, are the '%st c%''%n %*eruse in+uries e*aluated in sp%rts 'edicine centers O*eruse in+uries %ccur /hen a tissue accu'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*e su.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 an acute-%n-chr%nic presentati%n O*eruse in+uries '%st likel( %ccur /hen an athlete chan)es the '%de, intensit(, %r durati%n %& trainin) ,i%'echanic :intrinsic; &act%rs and e-uip'ent %r trainin) :e4trinsic; issues are the 'ain c%ntri.ut%rs t% %*eruse in+uries

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Trainin) err%rs are leadin) causes %& %*eruse knee in+uries =%l'es et al > sh%/ed that hea*( trainin) l%ads and hi)h 'ilea)e c%ntri.ute su.stantiall( t% knee in+uries Like/ise, a rapid increase in trainin) distance %r intensit(, seen in the earl( c(clin) seas%n, als% leads t% %*eruse in+uries ?nee pain is the '%st c%''%n l%/er-e4tre'it( %*eruse pr%.le' in c(clists >,@ #n %ne recreati%nal l%n)-distance .ic(clin) t%ur, 97A %& all riders rep%rted knee pain 6 An%ther stud(3$ %& '%re than 7$$ recreati%nal c(clists indicated that al'%st !2A %& all riders e4perienced %*eruse knee pain 0hile 'a+%r pr%.le's such as &ractures, disl%cati%ns, and li)a'ent ruptures usuall( %ccur %nl( a&ter 'a+%r trau'a, %*eruse in+uries are 'uch '%re c%''%n 0hen e*aluatin) knee pain and c(clin)-related %*eruse in+uries, i'p%rtant c%nsiderati%ns include .ic(cle &it, trainin) distance and intensit(, and anat%'ic &act%rs such as le)-len)th discrepanc(, 'uscle i'.alance, and in&le4i.ilit( :ta.le 3; >,@,33
TAB#E $% Ca&ses of Knee Pain in Bicycling Factor Anato(y Le)-len)th discrepanc( 0ide pel*is Pes planus and<%r pr%nati%n #nternal ti.ial r%tati%n Muscle /eakness %& -uadriceps, ha'strin)s, hip &le4%rs, )luteus Le) in&le4i.ilit( Bi)e Fit Saddle t%% hi)h Possi'le es&lt

#T, stretch %n sh%rter le), p%steri%r knee stress Lateral knee stress :increased B an)le; Medial knee pain Patellar 'alali)n'ent 2ati)ue-induced alterati%ns in pedalin) techni-ue that trans&er stress t% %ther parts %& the kinetic chain #T, s(ndr%'e

Saddle t%% l%/ Saddle t%% &ar &%r/ard Saddle t%% &ar .ack

Crank ar's t%% l%n)

#nternall( r%tated cleats C4ternall( r%tated cleats Training "apid increase in distance %r intensit(

?nee e4tensi%n that irritates the #T,, stress %n .iceps tend%n, patell%&e'%ral l%adin), hips stressed .( r%ckin) /hile pedalin), p%steri%r knee pain Stress %n patellar and -uadriceps tend%ns Stress %n anteri%r knee &r%' pedalin) in h(per&le4ed p%siti%n #T, stretch &r%' e4cessi*e &%r/ard reach &%r pedal, stress %n .iceps tend%n #ncreased &%rces %n the entire knee; patellar tend%n and -uadriceps tend%n are '%st a&&ected Patellar tendin%sis, ti.ial r%tati%n stress %n anteri%r knee Medial knee stress

Muscle ti)htness, 'icr%trau'a

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C4cessi*e hill /%rk :%n .ike; Pushin) hi)h )ear rati% =ill runnin) :%n &%%t; Deep le) s-uats #T, D ili%ti.ial .and

Cartila)in%us .reakd%/n, ch%ndr%'alacia Medial knee stress Medial knee stress :uphill;, ti)ht -uadriceps :d%/nhill; #ncreased stress %n entire knee

Bicycle Anato(y ,ic(cles c%nsist %& a &ra'e, handle.ars, .rakes, /heels, pedals, )ears, and %ther c%'p%nents :&i)ure 3; The ke( part is the &ra'e, 'ade %& 'etal %r 'etal all%(s such as titaniu', alu'inu', steel, %r car.%n 2ra'es can .e th%u)ht %& as t/% trian)les The &r%nt trian)le c%nsists %& the t%p tu.e, the seat tu.e, and the d%/n tu.e The chainsta(, seatsta(, and seat tu.e c%'p%se the rear trian)le =andlin) and 'aneu*era.ilit( can .e a&&ected .( the an)les /ithin each %& these trian)les "acin) .ic(cles ha*e a '%re upri)ht )e%'etr(, /ith steeper an)les &%r increased 'aneu*era.ilit( T%urin) .ic(cles are '%re sta.le, /ith a &latter )e%'etr( &%r c%'&%rt 2ra'e si8e is deter'ined .( the seat tu.e di'ensi%n in centi'eters, 'easured &r%' the center %& the .%tt%' .racket t% the center %& the t%p tu.e %r &r%' the t%p %& the .%tt%' .racket t% the t%p %& the t%p tu.e The t%p tu.e len)th a&&ects the reach %& the rider and is als% an i'p%rtant 'easure'ent &%r pr%per &ra'e &it The crank ar', chain rin), chain, )ears, and derailleurs 'ake up the dri*e train and trans&er hu'an ener)( t% 'echanical ener)( The pedal str%ke can .e th%u)ht %& as a c%ntinu%us circular '%*e'ent, /ith the ulti'ate )%al %& spinnin) the pedals in a s'%%th, circular '%ti%n Eearin) is a 'eth%d %& %*erc%'in) resistance that all%/s the c(clist t% pedal c%'&%rta.l( at a uni&%r' cadence t% i'pr%*e pedalin) e&&icienc( =i)her )ears result in hi)her resistance, and l%/er )earin) pr%*ides less resistance The sh%e-pedal inter&ace is *ital t% ener)( trans&er Sti&&-s%led c(clin) sh%es clip directl( int% the pedals, linkin) the rider directl( t% the .ic(cle Bicycling Bio(ec*anics One c%'plete circular '%*e'ent %& the pedals ar%und the .%tt%' .racket is %ne t/%phase pedal c(cle #n the p%/er phase, the c(clist pushes d%/n %n the pedal and trans&ers the )reatest a'%unt %& ener)( t% '%*e the .ic(cle &%r/ard The p%/er phase .e)ins /ith the pedal in the 32-%1cl%ck p%siti%n and ends /ith the pedal at the 9%1cl%ck p%siti%n The p%/er phase is &%ll%/ed .( the rec%*er( phase, /hich pr%)resses &r%' 9-%1cl%ck .ack t% the 32-%1cl%ck p%siti%n Durin) the pedal c(cle, the knee )%es thr%u)h appr%4i'atel( >7F %& '%ti%n The knee .e)ins the p%/er phase &le4ed a.%ut 33$F and e4tends t% a.%ut 37F %& &le4i%n The -uadriceps 'uscle pr%*ides '%st %& the &%rce, /ith input &r%' the ha'strin) and )luteal 'uscles 0hile the knee e4tends, it als% adducts .ecause %& the n%r'al *al)us an)ulati%n %& the distal &e'%ral c%nd(les relati*e t% the &e'%ral sha&t and &%%t '%ti%n durin) the p%/er phase This '%ti%n leads t% 'edial translati%n %& the knee durin) the pedal str%ke /hile the knee e4tends Additi%nall(, the &%%t pr%nates durin) the p%/er phase, causin) an internal r%tati%n %& the ti.ia that increases stress %n the 'edial knee Als%, an increased B an)le, seen in &e'ales, 'a( &urther stress the 'edial +%int Durin) the rec%*er( phase %& the pedal str%ke, the knee &le4es and '%*es laterall( /hile the ti.ia e4ternall( r%tates t% read( the le) &%r the p%/er phase %& the ne4t pedal c(cle

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,i%'echanic a.n%r'alities 'a( arise &r%' anat%'ic as /ell as &uncti%nal &act%rs Muscular in&le4i.ilit( is a leadin) c%ntri.ut%r t% in+ur( M%st c(clists1 -uadriceps and ha'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 and are 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 %n the knee #nappr%priate saddle hei)ht %r i'pr%perl( ali)ned sh%e cleats trans'it increased repetiti*e &%rces thr%u)h the knee, /ith a )reater likelih%%d %& in+ur( 32 Anterior Knee Pain Patients &re-uentl( rep%rt anteri%r knee pain that 'a( .e related t% repetiti*e stress %r t% in&la''ati%n #n &act, anteri%r knee pain is the '%st c%''%n reas%n .ic(clists seek ph(sician care 33 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 .ursitis 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 tissues Patell%&e'%ral pain s(ndr%'e is an earl( indicati%n %& cartila)e s%&tenin) that can pr%)ress t% &rank cartila)in%us da'a)e :ch%ndr%'alacia; Patell%&e'%ral pain s(ndr%'e is t(picall( an %&&ice dia)n%sis, /hile ch%ndr%'alacia is a sur)ical %r radi%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' 3!,37 Patients )enerall( rep%rt that anteri%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); Patell%&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 %& their patella and descri.e the pain as .ein) directl( under the patella, rather than %n the 'edial %r lateral side 32 The pain, s%'eti'es se*ere, %&ten %ccurs a&ter c(clin), rather than durin) the ride C*ondro(alacia+ characteri8ed .( pain %r crepitati%n in the retr%patellar area, is descri.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 C4cessi*e patellar shear &%rces %*er the &e'%ral c%nd(les and patellar )r%%*e /ith 'alali)n'ent %& the patella 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%n int% 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%/ an acute trau'atic e*ent .ut is usuall( caused .( repetiti*e stress, /ith p%%r .ike &it as a c%''%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 /ith i'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 2%cal s/ellin) ar%und the patellar tend%n /ith palpa.le crepitus 'a( .e seen Prepatellar '&rsitis+ less c%''%n in c(clin), sh%uld .e suspected /hen s/ellin) and tenderness 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 The saddle 'a( .e t%% l%/, t%% &ar &%r/ard, %r .%th, causin) e4cessi*e patell%&e'%ral l%adin) thr%u)h%ut the pedal c(cle 0hen the saddle is l%/, the knee &uncti%ns in h(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 2l%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.ial r%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 is e4tended Medial knee pain results /hen increased stress &r%' i'pr%per saddle hei)ht, saddle &%re-and-a&t p%siti%n, %r cleat p%siti%n :t%es p%inted t%% &ar %ut/ard; increases 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 knee pain Medial knee pain %&ten is caused .( pes anserine .ursitis %r 'edi%patellar plica s(ndr%'e Pes anserine '&rsitis is identi&ied .( insidi%us-%nset pain %*er the 'edial pr%4i'al ti.ial 'etaph(sis appr%4i'atel( 2 t% ! c' .el%/ the +%int line 39 Direct trau'a %r repeated &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 pes anserine .ursa usuall( pr%duce pain The p%pliteal an)le sh%uld .e 'easured and ti)htness treated /ith ha'strin)-stretchin) e4ercises !ediopatellar plica syndro(e causes pain %*er the 'edial retinaculu' A plica is a s(n%*ial septu' re'nant &r%' the e'.r(%l%)ic knee Medial plica %ccurs in up t% 3$A %& the p%pulati%n 3> 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 cause irritati%n and a snappin) sensati%n The c(clist /h% has plica s('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%'atic plica in*%l*es ad+ustin) the saddle &it and cleat p%siti%n t% reduce &%rces %n the anteri%r knee A l%cal anesthetic 'a( .e in+ected directl( int% the plica t% )i*e te'p%rar( relie& Orth%pedic re&erral sh%uld .e 'ade i& s('pt%'s persist l%n)er than

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9 '%nths #ateral Knee Pain Anat%'ic &act%rs and i'pr%per .ike &it are i'p%rtant c%nsiderati%ns /hen e*aluatin) c(clists /h% rep%rt lateral knee pain Ilioti'ial 'and syndro(e% The #T, is a thick, &i.r%us .and that runs %n the %utside %& the le) &r%' the hip t% the knee #T, s(ndr%'e is caused .( in&la''ati%n %& the intraarticular s(n%*iu' %r #T, &ascia /hen the ti)ht #T, repeatedl( ru.s %*er the lateral c%nd(le as it '%*es p%steri%rl( /ith &le4i%n and anteri%rl( /ith e4tensi%n Ti)ht, in&le4i.le le) 'uscles 'a( /%rsen the c%nditi%n C(clists /h% ha*e #T, s(ndr%'e e4perience sharp %r sta..in) lateral knee pain and 'a( rep%rt decreased pedalin) p%/er .ecause %& pain The '%st %.*i%us s%urces %& #T, irritati%n are anat%'ic a.n%r'alities and i'pr%per .ic(cle &it C4cess internal ti.ial r%tati%n, either anat%'ic %r caused .( i'pr%per cleat p%siti%n, places si)ni&icant stress %n the distal #T, as it cr%sses the lateral &e'%ral epic%nd(le Varus knee ali)n'ent %r e4cess pr%nati%n /ill increase the stretch %n the #T, Si'ilarl(, le)-len)th discrepancies cause di&&icult(, .ecause %nl( %ne le) is c%rrectl( &itted t% the pedal, pr%ducin) e4cessi*e #T, stretch %n the sh%rter le) Saddle p%siti%n can als% .e a c%ntri.utin) &act%r A saddle that is t%% hi)h results in knee e4tensi%n )reater than 37$F that can irritate the distal #T, Saddles that are t%% &ar .ack cause e4cessi*e &%r/ard reach &%r the pedal, als% stretchin) the #T, Posterior Knee Pain P%steri%r knee c%'plaints in c(clin) are rare M%st %&ten the( are attri.uted t% .iceps tendin%sis %r, less &re-uentl(, 'edial ha'strin) tendin%sis C(clists /h% ha*e .iceps tendin%sis rep%rt insidi%us %nset %& p%int tenderness at the tendin%us attach'ent %& the .iceps &e'%ris /here it inserts %n the &i.ular head > Saddles that are t%% hi)h %r t%% &ar .ack can stress the .iceps tend%n C4cessi*e internal r%tati%n %& the cleats /ill als% increase stress Varus ali)n'ent %& the knees %r le)-len)th discrepancies 'a( als% c%ntri.ute t% p%steri%r knee pain #& the saddle hei)ht is set &%r the l%n)er le), the sh%rter le) /ill .e &%rced t% stretch &arther /ith each pedal str%ke, increasin) p%steri%r knee stress Addressing Pain #nitial 'ana)e'ent &%ll%/in) an %*eruse in+ur( sh%uld &%ll%/ the P"#CCMM acr%n(' :pr%tecti%n, rest, ice, c%'pressi%n, ele*ati%n, '%dalities, and 'edicati%ns; 7 t% help c%ntr%l in&la''ati%n and all%/ the tissue t% heal Decreasin) in&la''ati%n and pain helps increase ran)e %& '%ti%n, all%/s earl( reha.ilitati%n, and speeds return t% c%'petiti%n Once healin) and reha.ilitati*e e4ercise ha*e rest%red da'a)ed tissues t% n%r'al stren)th, patients /ill need &urther trainin) t% achie*e the supern%r'al endurance and p%/er re-uired &%r the de'ands %& sp%rts 0ith tendin%sis, relati*e tend%n unl%adin) is critical &%r treat'ent success
9

5nl%adin)

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'a( .e acc%'plished .( c%rrectin) anat%'ic, &uncti%nal, %r e-uip'ent related err%rs Bicycle ad-&st(ent% M%st .ic(cle sh%ps /ill e*aluate and ad+ust .ike &it &%r the pri'ar( rider at a reas%na.le c%st The -ualit( %& .ike &its can .e -uite *aria.le, and l%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 #& the saddle is t%% l%/, t%% 'uch stress is placed %n the knee &r%' the patellar and -uadriceps tend%ns #& the saddle is t%% hi)h, pain 'a( de*el%p .ehind the knee Pr%per saddle hei)ht can .e deter'ined in se*eral di&&erent /a(s The easiest /a( is t% all%/ %ne pedal t% dr%p t% the 9-%1cl%ck p%siti%n and %.ser*e the an)le %& &le4i%n in the knee +%int There sh%uld .e a 27F t% 3$F &le4i%n in the knee /hen the pedal is at the .%tt%'-'%st p%int > An%ther 'eth%d is t% 'easure the insea' :in c'; and 'ultipl( .( $ @@3 t% )et the c%rrect distance &r%' the t%p %& the saddle t% the center %& the .%tt%' .racket 3@ #& the hips r%ck .ack and &%rth /hen pedalin), the saddle is t%% hi)h; l%/er the saddle 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 pain Saddles 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 a h(per&le4ed p%siti%n, increasin) the &%rce %n the anteri%r knee Saddle p%siti%n can .e e*aluated /ith the plu'. .%. techni-ue Seated /ith the pedal in the 3-%1cl%ck p%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%sses the %utside %& the knee C4cessi*e e4ternal r%tati%n /ill cause 'edial knee stress Cleats sh%uld .e p%siti%ned &%re %r a&t s% that the .all %& the &%%t is directl( %*er the a4le %& 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% knee and 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 knee Cust%'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 a c%'.inati%n %& 'echanical c%ntr%l and .i%&eed.ack 36 %r the clinical &uncti%ns %& '%ti%n c%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 %& a c%'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%/ 3 t% 2 /eeks %& trainin) t% return t% pre*i%us &%r' 23,22
TAB#E .% eco((ended Progra( for et&rn to Cycling After In-&ry

#engt* of e*a'ilitation Multipl( the durati%n %& the la(%&& :in /eeks; .( 3 :&%r less se*ere in+uries; %r 2 :&%r '%re se*ere in+uries; t% esti'ate h%/ 'an( /eeks it /ill take t% return t% prein+ur( trainin) le*el C4a'pleH La(%&& &%r a '%re se*ere in+ur( :2 /k 'issed; I 2 D ! /k %& reduced trainin) Stages for a /0 to 102) e*a'ilitation Sta)e 3 :3-2 /k;H Cas( rides /ith%ut &ati)ue %r pain Sta)e 2 :3-2 /k;H Cndurance pace /%rk at 7$A t% >7A %& e&&%rt and distance %& prein+ur( /%rk%uts Sta)e 3 :3 /k;H M%derate-intensit( /%rk until the c(clist can c%'plete &ull prein+ur( distance Sta)e ! :3 /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 and address pre*i%us %*eruse in+uries The c(clist sh%uld .e c%unseled a.%ut increasin) acti*it( usin) the G3$A ruleG--increasin) distance and intensit( .( 3$A each /eek durin) earl(- seas%n and .uild-up peri%ds 23 Athletes /h% ha*e a hist%r( %& %*eruse in+uries sh%uld .e e4a'ined &%r /eakness and &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%ut stretchin) r%utine is i'p%rtant &%r c%ntinu%us pain-&ree 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; 2le4i.ilit( %& the -uadriceps 'a( .e assessed .( per&%r'in) Cl(1s test and c%'parin) the a'%unt %& passi*e knee &le4i%n in each le) =a'strin) &le4i.ilit( can .e e*aluated usin) the p%pliteal an)le %r the sitand-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, such as -uad sets 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) 2inall(, patients per&%r' eccentricall( resisted knee &le4i%n and e4tensi%n /ith /ei)hts 27 2le4i.ilit( &%cusin) %n the -uadriceps, 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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&itness, ph(sicians /ill n% d%u.t see '%re patients /h% ha*e knee pain related t% .ic(clin) ,( learnin) a &e/ si'ple .ike &ittin) techni-ues, ph(sicians can treat and pre*ent 'an( c%''%n pr%.le's %& this p%pular acti*it( The opinions or assertions presented here are the private views of the author and are not to be construed as official or as reflecting the views of the US Department of the Army or Department of Defense.
eferences 3 2 3 ! 7 9 > @ 6 3$ 33 32 33 3! 37 39 3> 3@ 36 2$ 23 22 23 5S Depart'ent %& Transp%rtati%nH ,ureau %& Transp%rtati%n StatisticsH ,ic(cle use a'%n) adult 5S residents O'niStats 2$$2;2:9;H3-3 ,a-uie P, ,rukner PH #n+uries presentin) t% an Australian sp%rts 'edicine centreH a 32'%nth stud( Clin K Sp%rt Med 366>;>:3;H2@-33 ,r%d( DMH "unnin) in+uries Clin S('p 36@$;32:!;H3-39 Macint(re KE, Ll%(d-S'ith D"H O*eruse runnin) in+uries, in "enstrL' PA :ed;H Sp%rts #n+uriesH ,asic Principles %& Pre*enti%n and Care ,%st%n, ,lack/ell Scienti&ic Pu.licati%ns, 3663, pp 336-39$ O1C%nn%r 2E, =%/ard TM, 2ieseler CM, et alH Mana)in) %*eruse in+uriesH a s(ste'atic appr%ach Ph(s Sp%rts'ed 366>;27:7;H@@-63 C%%k KL, ?han ?M, Ma&&ulli N, et alH O*eruse tendin%sis, n%t tendinitis Ph(s Sp%rts'ed 2$$$;2@:9;H33-!9 =%l'es KC, Pruitt AL, 0halen NKH L%/er e4tre'it( %*eruse in .ic(clin) Clin Sp%rts Med 366!;33:3;H3@>-2$7 C%nti-0(neken A"H ,ic(clin) in+uries Ph(s Med "eha.il Clin N A' 3666;3$:3;H9>->9 Dannen.er) AL, Needle S, Mullad( D, et alH Predict%rs %& in+ur( a'%n) 393@ riders in a recreati%nal l%n)-distance .ic(cle t%urH C(cle Acr%ss Mar(land A' K Sp%rts Med 3669;2!:9;H>!>->73 0il.er CA, =%lland EK, Madis%n "C, et alH An epide'i%l%)ical anal(sis %& %*eruse in+uries a'%n) recreati%nal c(clists #nt K Sp%rts Med 3667;39:3;H2$3-2$9 ,r%/n EH #n+ur( pre*enti%n and 'ana)e'ent, in Keukendrup AC :ed;H =i)h Per&%r'ance C(clin) Cha'pai)n, #L, =u'an ?inetics, 2$$2, pp 22>-237 Sanner 0=, O1=all%ran 0DH The .i%'echanics, eti%l%)(, and treat'ent %& c(clin) in+uries K A' P%diatr Med Ass%c 2$$$;6$:>;H37!-3>9 Ere)%r "K, 0heeler K,H ,i%'echanical &act%rs ass%ciated /ith sh%e<pedal inter&acesH i'plicati%ns &%r in+ur( Sp%rts Med 366!;3>:2;H33>-333 Melli%n M,H ,ic(clin), in Melli%n M, :ed;H Tea' Ph(sician1s =and.%%k Philadelphia, =anle( M ,el&us, 2$$2, pp 72->$ 2rederics%n MH Patell%&e'%ral pain s(ndr%'e, in O1C%nn%r 2E, 0ilder "P, Nirschl " :eds;H Te4t.%%k %& "unnin) Medicine Ne/ J%rk Cit(, McEra/-=ill, 2$$3, pp 396-3>6 ?ruse "0H C*aluati%n %& knee in+uries, in Lille)ard 0A, ,utcher KD, "ucker ?S :eds;H =and.%%k %& Sp%rts MedicineH A S('pt%'-Oriented Appr%ach, ed 2 ,%st%n, ,utter/%rth-=eine'ann, 3666, pp 233-2!6 Theut PC, 2ulkers%n KPH Anteri%r knee pain and patellar su.lu4ati%n in the adult, in DeLee KC, Dre8 D :eds;, Orth%paedic Sp%rts Medicine, ed 2, *%l 2 Philadelphia, Saunders, 2$$3, p 3>>2 Le'%nd E, E%rdis ?H Ere) LeM%nd1s C%'plete ,%%k %& ,ic(clin) Ne/ J%rk Cit(, Peri)ee ,%%ks, 366$, pp 33@-3!7 Na/%c8enski DA, Salt8'an CL, C%%k TMH The e&&ect %& &%%t structure %n the threedi'ensi%nal kine'atic c%uplin) .eha*i%r %& the le) and rear &%%t Ph(s Ther 366@;>@:!;H!$!-!39 Su.%tnick S#H 2%%t %rth%tics, in O1C%nn%r 2E, 0ilder "P, Nirschl " :eds;H Te4t.%%k %& "unnin) Medicine Ne/ J%rk Cit(, McEra/-=ill, 2$$3, pp 769 0en8el ?H ,ack &r%' 8er%H /hen returnin) &r%' in+ur(, take it sl%/ Vel% Ne/s 2$$3;32:3$;H!! M%%re K=, Crnst EPH Therapeutic e4ercise, in O1C%nn%r 2E, 0ilder "P, Nirschl " :eds;H Te4t.%%k %& "unnin) Medicine Ne/ J%rk Cit(, McEra/-=ill, 2$$3, pp 7>9-7>> O1Neill D,, Micheli LKH O*eruse in+uries in the (%un) athlete Clin Sp%rts Med

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36@@;>:3;H763-93$ 2! Ma)ee DKH Orth%pedic Ph(sical Assess'ent Philadelphia, 0, Saunders, 366>, pp !@2!@7 27 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, 3666, pp !>2-!@3

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 2%rt ,el*%ir, Vir)inia Dr St Pierre is an assistant pr%&ess%r %& sur)er( at the 5ni&%r'ed Ser*ices 5ni*ersit( %& =ealth Sciences in ,ethesda, Mar(land, and ass%ciate direct%r at Nirschl Orth%paedic and Sp%rts Medicine in Arlin)t%n, Vir)inia Address correspondence to CPT Chad Asplund, MD, 7993 Marshall "d, 2%rt ,el*%ir, VA 22$9$; e-'ail t% chad asplundNus ar'( 'il

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