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Addressing Pain

Addressing Pain
Initial management following an overuse injury should follow the PRICEMM acronym to help control inflammation and allow the tissue to heal.

Protection
Rest
Ice
Compression
Elevation
Modalities
Medications

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.

Soft tissue therapy—sustained myofascial tension of the distal iliotibial band (Bruckner & Khan – 2002)

Mobilizing the patella. With the patient in a side-lying position, the patella is mobilized in a medial direction. This can be combined with massage therapy to the lateral structures (e.g., transverse gliding, friction (Bruckner & Khan – 2002)

The above glides performed strongly in side lying ARE the gold standard in treatment and patients having undergone the above regime will jump off the bed after half an hour or so describing a knee the ‘feels much better oiled’.

Unloading the patella to reduce the retightening effect and address causative factors may be accomplished by correcting anatomic, functional, or equipment related errors.

Bicycle adjustment

Most bicycle shops will evaluate and adjust bike fit for the primary rider at a reasonable cost. The quality of bike fits can be quite variable, and local bike clubs should be able to provide references.

A simple saddle height adjustment may ease the forces placed on the knee. If the saddle is too low, too much stress is placed on the knee from the patellar and quadriceps tendons particularly during prolonged seated climbing, so common in European sportives such as the Etape du Tour of Marmotte. If the saddle is too high, pain may develop behind the knee. Proper saddle height can be determined in several different ways, however, the method I personally find most useful and reproducible is the method pioneered by Greg Lemond and Cyril Guimard in the mid eighties.

This method is to measure the inseam (in cm) and multiply by 0.883 to get the correct distance from the top of the saddle to the centre of the bottom bracket. Please see below for full description;

Lemond G, Gordis K: Greg LeMond’s Complete Book of Bicycling. New York City, Perigee Books, 1990, pp 118-145

I find this methodology produces a seat height towards the higher end of the spectrum but provides the most effective mechanical relief for patellofemoral pain syndrome.

Saddle fore-and-aft positions and shoe cleat position may also contribute to knee pain.

Saddles that are too far back cause the cyclist to reach for the pedal and stretch the ITB, resulting in knee pain. Saddles that are too far forward will force pedalling in a hyperflexed position, increasing the force on the anterior knee. Saddle position can be evaluated with the plumb bob technique. Seated with the pedal in the 3-o’clock position, a plumb hung from the most anterior portion of the knee should intersect the ball of the foot and the axle of the pedal.

Cleats that are internally rotated too far may increase stress on the ITB as it crosses the outside of the knee. Excessive external rotation will cause medial knee stress. Cleats should be positioned fore or aft so that the ball of the foot is directly over the axle of the pedal. Rotational cleat position can be evaluated with a bike shop “fit kit” or rotational adjustment device – this is more important for cleats with less than 5° of float. Most new road cleats allow greater degrees of float to protect the knees.

Correcting anatomic problems

Individual cyclist anatomy may contribute to knee and hip pain. Cyclists with leg-length discrepancies may develop knee pain, because only one side is correctly fitted to the bicycle.

Cyclists with flat feet may be more prone to excessive pronation (internal rotation) of the leg, causing greater stress on the ITB at the knee, as well as on the medial knee. Customized orthoses from a podiatrist specialising in cycling mechanics may correct the alignment of the knee and decrease or prevent medial or lateral rotational stress on the connective tissue in the ankle, knee, or hip, thus reducing pain.

Orthoses may influence the pattern of leg movement through a combination of mechanical control and biofeedback or the clinical functions of motion control, pressure relief, and redistribution of forces.

Cyclists require a different type of orthoses than runners; cycling orthoses are longer and provide additional metatarsal support. Pedal shims or shoe lifts may help correct malalignment or leg-length discrepancies.

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