Right-sided knee pain in a cyclist...due to his hip?

This 54-year-old pilot presented to our office with pain on the outside of his right knee while cycling with his wife who is currently training for the triple bypass. The discomfort comes on later in the ride and is largely lateral. He thought it may be due to a seat position so he raised his seat up but then shortly developed lower back discomfort. Lowered the seat back down and presents to the office today. He is currently on a 54 cm Pierello road bike with a straight top tube.

Physical exam revealed him to have moderately limited internal rotation of the right hip which was approximately 5 degrees external rotation; left side had approximately 5 degrees of internal rotation. There was no significant leg length discrepancy or internal tibial torsion. Musculature, save for the long extensors the toes tests 5/5 and strong. Hip extension is 0 degrees bilaterally 5 flexion approximately 120 degrees with tightness mostly in the iliopsoas and some in the rectus femoris. Knee stability tests are unremarkable. Some patellofemoral discomfort with compression on the right. Palpable tightness in the right IT band.

X-rays revealed degenerative changes at the inferior aspect of the right acetabulum with a small spur an osteophyte formation.

His seat height was set so that at bottom dead center with the seat tube he had a 30 degree bend in his knee. Seat fore and aft position placed the knee over pedal spindle behind central axis of the pedal. His pedal stroke, seen on the video, reveals moderate internal rotation and medial displacement of the knee on the right side.

So what is going on?

It’s all about how folks compensate. This gent has very limited internal rotation of the right hip. Due to the nature of cycling, he is REALLY TRYING to get his 1st MTP down to the pedal to generate power. This is not unusual among cyclists, which is why what you think should be happening in gait does not always transfer over to cycling. in doing so, he MUST rotate SOMETHING forward (in this case his pelvis) medially to create the internal rotation needed. From this scenario, you can see how the posturing would increase knee valve and offer a mechanical advantage to the vastus lateralis, causing patello femoral dysfunction and knee pain.

So we did we do?

  • Moved his seat forward so that a line drawn from between the patella and tibial tuberosity fell through the center axis of the pedal

  • Angled his cleat so that he is able to have a greater progression angle moving forward, bringing his knee more into the sagittal plane

  • Began working on the hip to increase internal rotation working on the gluteus minimus, vastus lateralis and biceps femoris as well as hip capsule and ilio/ischio/pubofemoral ligaments

Dr Ivo Waerlop, one of The Gait Guys

#kneepain #cycling #hipproblem #femoralretrotorsion #thegaitguys #torsion

The next time they have gait asymmetry, try changing out the insole...

or putting a textured one in there...or maybe putting a some sand or dirt in their shoe...

image credit: https://torange.biz

image credit: https://torange.biz

Textured insoles change (we like to think for the better) proprioceptive input and can improve balance and gait performance, both statically and dynamically. We have seen this in folks with parkinsons (1) as well as stroke (2), though it can be used in the elderly (3), in diabetes and neuropathy (4), as well as healthy individuals (5,6). Changes from postural stability, to changes in anterior/posterior sway, to medial/lateral sway, to step length and height, the research is there.

These results support the hypothesis that enhanced somatosensory feedback to the sensory system, both through the spinocerebellar and dorsal column pathways, as well as the vestibular system, results in an improved motor output (and most likely coordination) of gait.

  1. Qiu F, Cole MH, Davids KW, et al. Effects of textured insoles on balance in people with Parkinson's disease. PLoS One. 2013;8(12):e83309. Published 2013 Dec 12. doi:10.1371/journal.pone.00833

  2. Ma CC1, Rao N2, Muthukrishnan S3, Aruin AS4. A textured insole improves gait symmetry in individuals with stroke. Disabil Rehabil. 2017 Aug 7:1-5. doi: 10.1080/09638288.2017.1362477. [Epub ahead of print]

  3. Annino G1,2,3, Palazzo F2, Alwardat MS4, Manzi V5, Lebone P2, Tancredi V1,2,3, Sinibaldi Salimei P2,6,7, Caronti A2, Panzarino M2,3, Padua E2,3. Effects of long-term stimulation of textured insoles on postural control in health elderly. J Sports Med Phys Fitness. 2018 Apr;58(4):377-384. doi: 10.23736/S0022-4707.16.06705-0. Epub 2016 Sep 15.

  4. Paton J, Glasser S, Collings R, Marsden J. Getting the right balance: insole design alters the static balance of people with diabetes and neuropathy. J Foot Ankle Res. 2016;9:40. Published 2016 Oct 5. doi:10.1186/s13047-016-0172-3

  5. Steinberg N1, Tirosh O, Adams R, Karin J, Waddington G. Influence of Textured Insoles on Dynamic Postural Balance of Young Dancers. Med Probl Perform Art. 2017 Jun;32(2):63-70. doi: 10.21091/mppa.2017.2012.

  6. Collings R1, Paton J2, Chockalingam N3, Gorst T2, Marsden J2. Effects of the site and extent of plantar cutaneous stimulation on dynamic balance and muscle activity while walking. Foot (Edinb). 2015 Sep;25(3):159-63. doi: 10.1016/j.foot.2015.05.003. Epub 2015 May 11.

Podcast 90: The brain: A deeper look at gait and motor control

Show sponsors:
www.newbalancechicago.com


Other Gait Guys stuff

A. Server links to the podcast:

http://directory.libsyn.com/episode/index/id/3302518

http://traffic.libsyn.com/thegaitguys/pod_90f.mp3

http://thegaitguys.libsyn.com/90

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :
http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Our Book: Pedographs and Gait Analysis and Clinical Case Studies

electronic copies available here:

Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx


Show notes:

Researchers Identify Important Control Mechanisms for Walking
http://neurosciencenews.com/spinal-cord-activation-neurology-walking-1698/
 “Using statistical methods, we were able to identify a small number of basic patterns that underlie muscle activities in the legs and control periodic activation or deactivation of muscles to produce cyclical movements, such as those associated with walking

People watching: Different brain pathways responsible for person, movement recognition
http://medicalxpress.com/news/2015-01-people-brain-pathways-responsible-person.html
Each time you see a person that you know, your brain seemingly effortlessly and immediately recognizes that person by his or her face and body. Just as easily, your brain understands a person’s movements, allowing you to perform critical skills such as interpreting social cues, detecting threats and determining the difference between skipping and jumping.

Remapping the brian.
http://news360.com/article/273798702/#
Published in the Journal of Neuroscience, 

How Rotation gets you dorsiflexion: Easy solutions for ankle mobility
 http://thenominalist.wordpress.com/2014/12/16/how-rotation-gets-you-dorsiflexion-easy-solutions-for-ankle-mobility/

Wedges: http://www.footfoundation.com/

Its hard to change the neurology of engrained habits……..
Neuromuscular Exercise Post Partial Medial Meniscectomy: Randomized Controlled Trial.
Hall M1, Hinman RS, Wrigley TV, Roos EM, Hodges PW, Staples MP, Bennell KL.
Journal Med Sci Sports Exerc. 2014 Dec 23. [Epub ahead of print]

Doc Martins Boots: Tobias and Curtis
http://www.journeys.com/product.aspx?id=243165&green=157F2C73-F732-5ACF-AC09-89894E6EE1F1
Tobias and Curtis

Relationship between physical impairments and movement patterns during gait in patients with end-stage hip osteoarthritis
Joseph Zeni, Jr.1,2  et al
http://onlinelibrary.wiley.com/doi/10.1002/jor.22772/abstract;jsessionid=E0C246BA281C71A4124C03FEB608C474.f02t02

VAncouver Gait course: http://twinbridgesphysiotherapy.com/courses-events/foot-and-gait-course/

Welcome to rewind (Late) Friday. Sorry about the late entry, folks.

Along the vein of bike fit, to go with our lecture on onlinece.com this week, here is gentleman with right sided low back pain ONLY when ascending hills on his mountain bike. Can you figure out why?

*Stop, watch the video and think about it before we give you the answer… .

____________________________

This gentleman presented with low back pain, only on his mountain bike, only on long ascents.

He measures out with an 83 cm inseam which should put him on a 44 to 45.5 cm frame (measured via our method). His frame has a dropped top tube and measures 55 cm.

He has a knee bend angle of 20 degrees at bottom dead center. Knee is centered well over pedal axis.

His stem falls far in front of his line of sight with respect to his hub. Stem is a 100 mm stem with a 6 degree rise.

There is a 2" drop from the seat to the top of the handlebars.

He has an anatomically short Left leg (tibial)

Look at the tissue folds at the waist and amount of reach with each leg during the downstroke.

The frame, though he is a big dude (6’+), is too big and his stem is too long. He is stretched out too far over the top tube, causing him to have an even more rounded back (and less access to his glutes; glutes should rule the downstroke and abs the upstroke). This gets worse when he pushes back (on his seat) and settles in for a long uphill. Now throw in a leg length discrepancy and asymmetrical biomechanics.

Our recommendations: smaller frame (not going to happen) lower seat 5-7mm shorter stem (60-75mm) with greater than 15 degree rise lift in Left shoe

We ARE the Gait Guys, and we do bikes too!