Knee Pain in Cycling – Don’t let it ruin your big day!!

Introduction:

Just to introduce myself, my name is Rob Harris. My profession is as an elite sports physiotherapist and along with Jeff Ross, I am one of the founding partners of the Harris & Ross Sports & Spinal Physiotherapists chain of sports physiotherapy Centres located across the North West.

My background however is as an elite cyclist and triathlete competing in both sports at the highest levels at various stages during my career.

Interestingly I got into physiotherapy following a severe bout of knee pain induced by cycling in too larger gears which almost kept me out of my place with New Zealand at the World Cycling Championships of that year. Following this I have always had an interest in cycling related knee pain.

Following my experience in private practise, in which patellofemoral or knee cap related pain is one of the most common conditions we treat, I was astounded on one particularly brutal day, riding the Passo del Mortirolo, on the back of the enormous Passo del Gavia in Italy last year, just how many cyclists on a climb like this littered the side of the road wincing in pain, bending and straightening their knees, their big day and possibly their season in tatters because of an entirely preventable but inherently poorly understood condition!

This article is written largely in the hope of explaining the condition, its causes and hopefully as a means of helping prevent its onset well before it strikes halfway up a road in the middle of nowhere in Northern Italy, or ruins your big day out at the Etape du Tour this year!

Patellofemoral Pain:

Several studies in athletes besides our previously mentioned experiences at Harris & Ross have demonstrated that knee injuries, including anterior knee pain and patellofemoral pain syndrome, are the most common overuse injuries evaluated in sports medicine centres across the world.
Further to this, it is well documented that knee pain is the most common lower-extremity overuse problem in cyclists. In one recreational long-distance bicycling tour, 65% of all riders reported knee pain.. Another reputable study of more than 500 recreational cyclists indicated that almost 42% of all riders experienced overuse knee pain. While major problems such as fractures, dislocations, and ligament ruptures usually occur only after major trauma, overuse injuries are much more common.
Injuries such as this may also be related to improper bicycle fit or equipment, poor technique, or inappropriate training patterns. Cycling is very repetitive; during only 1 hour of cycling, a rider may average up to 5,000 pedal revolutions. The smallest amount of misalignment, whether anatomic or equipment related, can lead to dysfunction, impaired performance, and pain.

The Patellofemoral Joint:

Patellofemoral pain syndrome, also called retro patellar pain syndrome, refers to anterior knee pain emanating from the patellofemoral joint and supporting soft tissues. The patellofemoral joint being the articulation between the kneecap and the femur or thigh bone.

In overuse cases, the cause of the damage is usually repetitive rubbing of part of the cartilage of the under surface of the knee cap against the underlying thigh bone. In a healthy knee the movement of the Patella across the knee is a gliding, smooth movement. In individuals with Patellofemoral pain syndrome, the knee cap rubs against the part of the joint behind it, resulting in inflammation, degeneration and pain. This can be for a number of reasons, but is usually due to the position of the patella itself.
The most common feature of patellofemoral pain is patella mal-tracking. The patella most commonly runs too laterally (to the outside) in the groove. This problem is most regularly caused by muscle imbalances, where the lateral quadriceps muscles and other tissues such as the retinaculum are too tight and the vastus medialis oblique muscle is weak.

To put all of this in English, basically the function of the knee cap is to enhance the lever arm over which the quadriceps can better impart their force into moving the lower aspect of the leg. The knee cap should ‘float above’ the groove in the femur to allow this to happen in a pain free way. It is held in place to allow this float by a medial contraction of the Vastus Medialis Oblique (VMO) muscle, or that big tear drop shaped muscle that is prominent on the inside of the thigh, and a lateral contraction of the gluteal muscles acting on the Illio-tibial band (ITB) that runs from these gluteals in your buttock, down the outside of the thigh and inserts into the outside of the knee cap.

Their contraction should be balanced and occur in a synchronised manner merely locking the kneecap in place.

The flaw with this is several fold in cycling:

• Problem one is that cycling naturally tightens and strengthens the glutes and therefore ITB, thus resulting in a greater lateral component of pull.


• Problem two is that despite what many people would naturally believe, cycling does not, as effectively as it would seem, strengthen the VMO as much as it strengthens other quadriceps muscles thus resulting in a reduced medial pull.


• Problem three is that any slight biomechanical flaw in technique or load directly effects and tightens the lateral structures producing more lateral pull.


• Problem four is that any even mild knee pain results in an inhibiting effect of the VMO thus reducing the medial component of pull further and thus increasing pain further.

The upshot of all of this is that any given cyclist faces an ongoing battle to maintain correct patella alignment and thus prevent knee cap pain. Should you then get knee cap pain the inhibiting effect on the VMO produces an ever increasing downward spiral!

Thus the battle against this pain and its onset must start before training even commences. A pre training bike set up to identify and reduce mechanical disadvantages, a correctly managed training build up to prevent over load pain and an ongoing stretching plan to alleviate and slow down the inevitable tightening of lateral structures, unfortunately normal in the loading pattern of cycling!

Causes & Factors to be Corrected:

Patellofemoral pain syndrome is related to a combination of factors involving malalignment of the knee extensor mechanism. Patients generally report that anterior knee pain is worse when the knee is loaded (e.g., when climbing or descending stairs, during prolonged sitting or squatting). Patellofemoral joint problems frequently differ between cyclists and runners—many cyclists will point to the centre of their patella and describe the pain as being directly under the patella, rather than on the medial or lateral side. The pain, sometimes severe, often initially occurs after cycling, rather than during the ride but as this progresses eventually overflows into the next ride or when under extreme racing loads occurs more severely than ever as seen on the dreaded Mortirolo

When evaluating a cyclist who has anterior knee pain, the physiotherapist must first inspect the bicycle fit. The saddle may be too low, too far forward, or both, causing excessive patellofemoral loading throughout the pedal cycle. When the saddle is low, the knee functions in hyper flexion, increasing compression of the patella on the femur.

Improper shoe cleat position or float may force the rider to pedal with poor biomechanics, increasing patellar forces. Float is the motion of the cleat on the body of the pedal and is usually measured in degrees of internal or external angulation (i.e., 9° of float means that the foot may rotate 9° inward or outward relative to the pedal body). Cleats with excessive internal or external rotation may cause exaggerated tibial rotation, placing more stress on the anterior knee.

Training errors are leading causes of overuse knee injuries. Holmes et al showed that heavy training loads and high mileage contribute substantially to knee injuries. Likewise, a rapid increase in training distance or intensity, seen in the early cycling season, also leads to overuse injuries.

When evaluating knee pain and cycling-related overuse injuries, important considerations include bicycle fit, training distance and intensity, and anatomic factors such as leg-length discrepancy, muscle imbalance, and inflexibility.

Addressing Pain

Initial management following an overuse injury should follow the PRICEMM acronym (protection, rest, ice, compression, elevation, modalities, and medications) to help control inflammation and allow the tissue to heal. Decreasing inflammation and pain helps increase range of motion, allows early rehabilitation, and speeds return to competition. Once healing and rehabilitative exercise have restored damaged tissues to normal strength, patients will need further training to achieve the supernormal endurance and power required for the demands of sports.
With tendinosis, relative tendon unloading is critical for treatment success.

Treatment from a good, and particularly a sports specialist, physiotherapist is an extremely effective means of reducing patellofemoral pain. Because of the mechanical nature of the problem electrotherapy modalities simply won’t touch the pain, however, thorough manual treatment incorporating DEEP soft tissue therapy to the Glutes, ITB (as shown) and Quadriceps, culminating in STRONG medial glides as shown below to stretch the lateral retinacula and thus ‘re-align’ the patella itself will prove remarkable beneficial.