Sometimes, you just need to add a little pressure….

Cyclists are no different than runners; often when the effort is increased (or the conditions reproduced), the compensation (or problem) comes out.

Take a good look at this video of a cyclist that presented with right sided knee pain (patello femoral) that begins at about mile 20, especially after a strong climb (approx 1000 feet of vertical over 6 miles through winding terrain).

The first 7 seconds of him are in the middle chain ring, basically “spinning” ; the last portion of the video are of him in a smaller (harder) gear with much greater effort.

Keep in mind, he has a bilateral forefoot varus, internal tibial torsion, L > R and a right anatomically short leg of approximately 5mm. His left cycling insole is posted with a 3mm forefoot valgus post and he has a 3mm sole lift in the right shoe.

Can you see as his effort is increased how he leans to the right at the top of his pedal stroke of the right foot and his right knee moves toward the center bar more on the downstroke? Go ahead, stop it a few time and step through it frame by frame.  The left knee moves inward toward the center bar during the power stroke from the forefoot valgus post.

So what did we do?

·      Worked on pedal stroke. We gave him drills for gluteal (max and medius) engagement on the down stroke (12 o’clock to 6 o’clock) to assist in controlling the excessive internal spin of the right leg. Simple palpation of the muscle that is supposed to be acting is a great start.

·      Did manual facilitation of the glutes and showed him how to do the same

·      Worked on abdominal engagement during the upstroke (the abs should initiate the movement from 6 o’clock to 12 o’clock)

·      Manually stimulated the external oblique’s

·      Placed a (temporary, hopefully) 5mm varus wedge in his right shoe to slow the internal spin of the right lower extremity

·      Taught him about the foot tripod and appropriate engagement of the long extensors; gave him the standing tripod and lift/spread/reach exercise (again to tame internal spin and maintain arch integrity)

Much of what you have been learning (for as long as you have been following us) can be applied not only to gait, but to whenever the foot contacts anything else.

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