As a sports physical therapist, my traditional caseload is loaded with ACL tears, shoulder issues, and ankle sprains. I also tend to treat a large community of cyclists with a wide array of aches and pains. This population puts their body through a beating every time they hop on their bike for that day’s epic journey.
As a sports physical therapist, my traditional caseload is loaded with ACL tears, shoulder issues, and ankle sprains. I also tend to treat a large community of cyclists with a wide array of aches and pains. This population puts their body through a beating every time they hop on their bike for that day’s epic journey.
Cycling is a contact sport. If you don’t agree with that, sit down with a road cyclist who’s been forced into a ditch by an oblivious driver, or a mountain biker who’s had an untimely encounter with a rogue root on a trail they’ve traversed for years.
Beyond traumatic injuries, these athletes present with multiple moving joints that play either a big or small role in turning the crank towards the finish line. When not working in harmony, that enjoyable 50-mile ride can turn into a painful wince with every downstroke.
The Cyclist’s Angry Knee
About a year ago, I was treating a patient who I had previously treated for neck issues. His new complaint was left lateral knee pain as his rides were progressing. He had just been fitted on a new bike and was looking to up his mileage but was struggling to break the 20-mile mark due to the pain. I was fortunate to have a student working with me at the time who is a beast of a triathlete, and who had extensive experience doing professional bike fittings. We decided to have our patient bring in his bike and hook it up to our trainer in the clinic.
My initial physical assessment of the cyclist didn’t reveal a lot of obvious weaknesses that could be contributing to his pain, which is not uncommon in high-level athletes. Some minor things did stand out, mainly that his left leg was slightly shorter than his right. Through discussion, my student and I decided to crush our patient with 45-50 minutes’ worth of high-intensity exercises to simulate the fatigue he might have by mile 20 of a ride. He then mounted his trainer and was recorded riding for 10 minutes.
Like clockwork, he began to feel some lateral knee pain about four minutes into the ride. With our fancy iPads, we were able to slow down and really dissect his mechanics, which revealed a gradual increase in internal rotation and caving in of his left knee at the bottom of his pedal stroke. This inherently increases joint compression laterally. Boom! We have the source of his pain.
I immediately had the patient come off the bike and attempt a simple single-leg balance exercise, which he could not maintain due to pain. Was this because his left leg was slightly shorter, or more due to fatigue in his left glutes? This is something that wasn’t seen during his bike fitting, and possibly could’ve been missed had we not worn him out prior to having him pedal for us. This video gave us great information, but how do we fix it?
One Step Back, 30 Miles Forward
I’d like to say his pains were eased by giving him a heavy resistance TheraBand, doing three sets of 10 clamshells, and calling it a day. Sometimes this is the case, but the endurance required by the demands of cycling dictated a more detailed approach. Couldn’t we just adjust the setup of the bike to accommodate for his shorter leg? Absolutely! But let’s be honest, I didn’t go to school for nearly a decade to put a Band-Aid on something and leave the source of the problem untouched.
For two weeks, this patient was challenged with simple balance exercises, dynamic exercises to keep his knee from turning and caving in, and also complex exercises to challenge the overall stability of his entire leg. Through this time, a visual change was taking place, and it was evident we were on the right path. The patient was instructed to attempt a long ride and follow up in a few days. He followed all of our instructions to the letter, except the results were relayed back to us via text the following evening.
After a 30-mile ride, his knee pain was nonexistent and his morale had been restored. This might seem like a tiny victory, but if you’ve ever worked with an endurance athlete and had to give the “trust me, just take a few weeks off” speech, you know this was more like winning the Tour De France!
Is this common? Is every pain a cyclist feels while rolling down the road possibly an opportunity for a trained physical therapist to work their magic? I’d be lying if I didn’t say yes! We aren’t miracle workers, but I feel a good physical therapist is worth their weight in gold. Sometimes little aches and pains are written off as “normal,” but they shouldn’t have to be. These little aches and pains can snowball and eventually lead to an accumulation of dust on a beautiful bike as it hangs unused in the garage.
