A patient presents to my office with bilateral knee pain that is present after riding his road or mountain bike. He has recently purchased his road bike to add to his training and the problem occurs soon after that. Review of his past medical history is non contributory and family history is benign as it relates to his present condition. After finishing his history I proceed to examine him and his physical exam is normal as well as vital signs. He is in his 20's, physically fit and has been riding for several years. He has recently started training harder. Range of motion is full in all planes, his arches and gait is 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 began to palpate (touch) his patella tendon just below his knee cap when the patients says "that's it doc, that's tender" I continue to feel around his knee and find no other finding. Next step, he has brought his bike and shoes so I take a look at his cleats and they are way off. The patient is basically riding on his toes, which is not good and his right cleat is rotated internally way too much. I then examined his position on the trainer and took some measurements and dropped a plumb line and his saddle was to low as well as to far forward etc. I have no idea how he was making that bike move forward. The best part he got a "free" bike fit with the purchase of his new bike. Needless to say he needed a proper bike fitting and some treatment for what looks like patellar tendonitis.
So, what are the indications that you might have this problem? Well first, the pain is just below your knee cap on the tendon that attaches your patella to a bump at the top of the shin called the tibial tuberosity (fig1). It can be at any point along this tendon. You may also have difficulty walking up and down stairs or notice the pain when you step off a curb. You can get swelling but this is not common and could mean you have some rupture of the tendon or fracture that needs further evaluation. This can occur at the patella or at the tibial tuberosity. The pain can occur when after a hard ride.
Why and how does this happen? Well for one, pushing a large gear for extended periods of time or doing long and hard climbs that can be made even worse if you are pushing a large gear. In addition, one should take into account the fact that people tend to jump into hard efforts or extended amounts of saddle time before their body has a chance to adapt to the change. That's why we have the 10% rule to let your tendons, ligaments, and bones adapt. There are patients who have improper recovery, not enough sleep, poor nutrition, or lack of recovery rides. Of course the bike fit can be a problem if the saddle is to low or if your cleats are not positioned properly. Also too much float can cause your knees to have to do too much work in stabilizing the area and this can lead to an increased tensile pressure at the patella tendon. Also, watch what you are doing off the bike (ie; heavy squats, kneeling for long periods of time, playing basketball, and riding can overload the area).
Okay, back to the patient, I made some quick bike adjustments and sent him to a great bike fitter named Chris at "The Bike Doctor" in Waldorf Maryland who made a few more adjustments to his position. In addition, I began to give him some treatment and recommendations based on my idea of the six pillars of recovery.
1. Awareness of state: monitor your overall health
2. Rest: Sleep, Naps, down time
3. Play: Make sure you have time for friends and family etc. Don't burn yourself out
4. Nutrition: Food and supplements
5. Physical: Chiropractic, physical therapy and massage
6. Psychological: Positive mindset, visualization and sports psycology
In this case we will focus on the Physical components of what we did with this patient. We used kinesio-tape as seen in fig 2. Kinesio-tape is used to take some of the pressure off the tendon and also aids in speeding up the healing process. Next, I used a low level laser or cold class III laser that will not heat or destroy tissue, but in fact speed up the healing process. I also performed some soft tissue work on the tendon and muscles of the knee. I adjusted(manipulated)the knee and ankle joints to make sure we had proper alignment and functional biomechanics occurring at the knee and ankle. I had the patient take some time off the bike and then worked him back on staying away from the hills and low cadence. I also had him perform ice massage to the area 3 times a day for 5 minutes, which is much quicker and better than using an ice pack for this condition. We made some diet recommendations and added a supplement to help with recovery. We also ordered some x-rays to make sure that the patella was not degenerating and to rule out some other possible issues. Other tests a sports doctor may order are an MRI, CT, and/or Bone Scan to further evaluate the knee and other conditions such as structural deviations or tears to soft tissue.
Another aspect of knee conditions I would like to point out concerns many younger athletes. A condition called Osgood-Schlatter's disease, that occurs mostly in young athletes and adolescence, where they experience marked pain in the knees. A hallmark of this condition is pain right on the tibial tuberosity, which is the bump on the shin. If a young athlete continues to exhibit persistent pain in the knees, he/she should consult a doctor and be evaluated for Osgood-Schlatter's disease.
In conclusion, my suggestion would be to follow these rules and stay out of my office:
1. Proper bike fit
2. Follow the 10% Rule
3. Good nutrition, such as eating plenty of fruits and vegetables
4. Proper recovery
5. Get help early and see a good sports Doctor
As I have mentioned before, I have used two different patient scenarios and have unfolded their conditions into one for the purpose of this article. After the proper bike fitting, and the treatment of adjusting, the application of kinesio-tape for tissue stabilization, and laser therapy, the cyclist responded quite well. The adjustment to his bike gave him a quick recovery due to the decreased stress put on his knees. I also suggested that stretching be included in his treatment in order to stabilize and help maintain his biomechanics. This included stretching of the gluts/piriformis muscle, the quads, the hamstrings, and the iliotibial band (ITB band) with a foam roller, in a side lying position. It is important to maintain flexibility and strength while riding, which can prevent further injury. In conjunction with the proper nutrition and essential recovery, the bilateral knee pain diminished considerably and he was able to get back on the bike and resume his rides better, with proper form, and more importantly, with less pain.
1. Orthopaedic Testing; Gerarad, Janet A., Kleinfield, Steven L.; Churchhill Livngstone Inc.; 483-578.
2. Knee Pain and Disability; Caillet M.D., Rene; F.A. Davis Company; 3; 143-179
1. This picture shows the knee with a black marker indicating location of the patellar tendon.
2. This is an example of the applying of Kinesio-tape for patellar tendonitis.