Chester Knee Clinic and Nuffield Health The Grosvenor Hospital Chester Educational Seminars. St David's Park Hotel, 23 April 2016

1. Nuffield Health Educational Seminars
Cycling Knee
Problems and Injuries
St David’s Park Hotel, Ewloe
23 April 2016
Prof Vladimir Bobic MD FRCSEd
Consultant Orthopaedic Knee Surgeon
Chester Knee Clinic
at the Grosvenor Hospital Chester
www.kneeclinic.info
@ChesterKnee

2. Le Tour 2014 : Grand Départ Leeds 5 July
L’Angleterre passe au jaune!

3. Cycling Revolution: Design Museum London 2005/2016

4. Cycling is Many Different Things to Many People

5. Cycling Revolution … or just slow Evolution?

6. Chester Knee Clinic www.kneeclinic.info office@kneeclinic.info @ChesterKnee

7. Chester Knee Clinic
www.kneeclinic.info

8. Controversy About Helmets:
Chester Knee Clinic
Cyclists are vulnerable road users. Compared
with car occupants, bicyclists are more than
twice as likely to be fatally injured per
person trip and up to 10 times more likely to
be injured per kilometre travelled
… it is certainly true that in many countries,
such as Denmark and the Netherlands,
cyclists have low injury rates, even though
rates of cycling are high and almost no
cyclists wear helmets.
… this seems to be achieved through
interventions such as good infrastructure and
stronger legislation to protect cyclists and a
culture of cycling as a popular, routine, non-
sporty, non-risky behaviour.

9. Controversy About Cycling Helmets:
• “Helmets are absolutely crucial to
bicycle safety”. More than 75 percent of
all biking deaths are caused by head
injuries. If all cyclists wore helmets,
perhaps half of these deaths and injuries,
especially in children, could be avoided.
• The BMA has recommended that cycle
helmets should be worn by pedal
cyclists but the evidence in support of
this recommendation is at best slim
and does not give the whole picture
relating to head injury and cycle helmets.
• However, most experienced trauma
surgeons believe that cycle helmets
give only very limited head protection.
• Studies in Australia have shown that they
give only marginal prevention of mild
head injury and no effect on severe
head injury, or death.
www.cyclehelmets.org/index.html

10. Cycling Helmets
• Always wear a helmet when cycling
• Remember: a good fit is very important
• New generations of helmets offer much better “wrap-around” protection
• Do not reuse if damaged in a fall - buy a new one.

11. Try to Avoid Concussion …
• The older you get, the harder it is to recover from a concussion.
• Just one head injury can quadruple a risk of developing Parkinson's disease.
• Symptoms started an average of 20 years after the incident!

12. Cycling Knee Problems and Injuries
❖ Although cycling is considered a knee-sparing exercise because it does not
require impact with the ground, the repetitive motion of pedalling can lead
to a variety of overuse knee injuries.
❖ The majority of cycling knee injuries are indeed caused by overuse, which
leads to cumulative tissue microtrauma and consequent symptoms.
❖ Cyclists of every ability level are at risk: riding too hard, too soon and too far
is the usual recipe for numerous knee problems.
❖ In one recreational long-distance bicycling tour, 65% of all riders reported
knee pain.
❖ Another study of more than 500 recreational cyclists indicated that almost
42% of all riders experienced overuse knee pain.

13. Common Cycling Knee Problems:
• Riding too hard, too soon. Don't get impatient. It's going to be a long season
and there's plenty of time to get in the proper progression of efforts. Successful
cycling is a matter of listening to your body. When you see cyclists burning out,
hurting themselves and just not progressing past a certain point you can be fairly
certain that it is because they are not paying enough attention to what their
bodies are saying.
• Too many miles. The human body is not a machine. It cannot take all the miles
we sometimes feel compelled to ride without time to grow and adapt. Keep this in
mind whenever you feel like increasing average weekly mileage by more than
forty miles over two or three weeks and you should have no problems.
• Low cadences and excessive crank length. Save those big ring climbs and
big gear sprints for later in the season. This is the time of year to develop fast
twitch muscle fibers. That means spin, spin, spin. You don't have to spin all the
time but the effort put into small gear sprints and high rpm climbing now will pay
off later in the season. Mountain bikers need to be especially careful of low rpms.
This means that even full time MTB competitors should do most of their training
on a road bike.
• Improper position on the bike. Unfortunately, some bicycle salespeople in this
country have no idea how to properly set saddle height. The most common error
being to set it too low. This is very conducive to developing knee problems
because of excessive bend at the knee when the pedal is at, and just past top
dead centre.

16. Cycling Knee Problems and Injuries
❖ When evaluating knee pain it is very important to consider:
❖ Cyclist’s and bicycle anatomy
❖ Seasonal variations (early cycling season)
❖ Training distance and intensity …
❖ … and numerous human anatomical factors such as:
❖ Inflexibility
❖ Muscle imbalance
❖ Patellofemoral malalignment
❖ Leg-length discrepancy: if the difference is up to 10 mm you can
correct it by putting spacers under one cleat. If one leg is shorter by
more than 10 mm you should try a shorter crank arm on the short leg
side.

17. Bike Fit
Chester Knee Clinic
❖ GB Team Injury Audit
over the course of 2 years:
❖ Riders who did not get
injured … were less
sensitive to positional
changes, including
changes to other
equipment set-up (pedals,
cycling shoes, etc.)

18. Five Ways to Reduce Your Risk of Overuse Injury on the Bike

19. Professional Bike Fit
Seat angle and
longitudinal position
Seat height
Crank length
Handlebar height
Handlebar reach

20. Chester Knee Clinic

21. Chester Knee Clinic

22. Source: www.specialized.com
Correct footware: alignment, cleat position, etc.

23. Knee Replacement and Cycling:
Limited knee flexion is a
problem.
What is the solution?
Change:
• seat height,
• crank length,
• “sliding” cleats?

24. ❖ Andy Pruitt, director of the Boulder Center for Sports Medicine and fit expert of many superstars, said: “Crank length formulas using femoral length or leg
length are fine,” he says. “But if your style is mashing, use longer cranks, and if you are a spinner, shorten them a bit. Mountain bike cranks should be a bit
longer for that moment to get you over a rock. Use 2.5mm or 5mm longer for purely time trial usage, and vice versa for the track.” Pruitt warns that,
although one study showed that everybody was faster with a super-long crank over short distances, you can hurt yourself if you do not stick to
proportionality.
❖ “If you use cranks too long for your legs, the compressive and shear forces in the knee joints go up
exponentially.”
❖ Generally using shorter cranks keeps pedal speed up and knee stress down. Too long crank arms increase forces
on the entire knee, but patellar and quadriceps tendons are most affected.

25. Saddle Height
Saddle too high

26. Saddle Height
Correct saddle height
Also, do not forget the saddle angle: it should be level or
very slightly nose up, no more than 2mm at the nose

27. Saddle Position
Source: Callaghan MJ et al.: Lower body problems and injury in cycling. Journal
of Bodywork and Movement Therapies (2005) 9, 226–236

30. Source: Asplund C, et al. Knee Pain and Bicycling. The Physician and Sportsmedicine, April 2004.
Causes of Cycling Knee Pain:

35. Patello-femoral Pain Syndrome
• The PFPS is the most frequent
complaint in running and cycling
• Excessive pressure across the
patellofemoral joint is caused by hill
climbing, riding in high gears, and a
too-slow cadence
• It is an early indication of cartilage
softening that can progress to structural
damage of PFJ articulating surfaces and
subchondral bone, associated with more
severe pain and grating sensation.
• Patellofemoral joint problems frequently
differ between cyclists and runners -
cyclists will point to the centre of
the patella and describe the pain as
being directly under the patella, rather
than on the medial or lateral side.
• Quadriceps and patella tendinosis
are often associated with chronic PFPS

36. Patella and Quadriceps Tendinosis
❖ We should adopt the term "patellar tendinopathy" or tendinosis rather than the
misnomer tendinitis when referring to patellar tendon overuse injury.
❖ The key pathology is tendinosis - collagen degeneration and its sequelae.
❖ A patient who presents with patellar tendinopathy for the first time may require 2 to
3 months to recover. A patient who has a long-standing injury may require 4
to 6 months to return to competition pain free and without recurrence.
❖ Imaging has not been shown to be a useful guide to the choice of management or
prognosis.
❖ Relative tendon unloading is critical for treatment success. This can be achieved
by activity modification and by biomechanical correction.
❖ Progressive strengthening graduating to eccentric exercises are the
treatment of choice.
❖ Surgery has been considered the treatment of last resort for tendinopathies.
❖ Return to full competitive sport after successful patellar tendon surgery takes 6 to
12 months.
❖ Only 60% to 75% of patients are able to return to former levels of sporting activity.

37. ❖ “Tiger Woods has said that PRP
put his golf career back on track
after a series of knee injuries.
❖ Rafael Nadal has also used it
although there have been fears that
it moves sport dangerously close to
blood doping.”

38. PRP for Patellar Tendinopathy
Chester Knee Clinic
❖ A combination of eccentric
exercises and US-guided
leukocyte-rich PRP
injection with dry needling
of the tendon accelerate
the recovery from patellar
tendinopathy …
❖ …but the apparent benefit
of PRP dissipates over
time.

39. Patella Tracking Issues
Patella maltracking, including ELPS, is often
the main source of chronic PFJ problems
and accelerated osteochondral wear and
tear.

40. Patella maltracking, cartilage damage and BME
Irreversible PFJ damage: patellar and trochlear cartilage damage with subchondral
patellar changes (bone marrow oedema)

42. Quantitative MRI (qMRI) and in vivo
deformational behaviour of articular cartilage
• One of the great advantages of
MRI, in comparison with histology,
is that consecutive slices are
contiguous and spatially aligned so
that 3D parameter can be
obtained.
• These parameters include
cartilage volume, thickness,
surface and curvature.
• Current findings suggest that
human cartilage deforms very
little in vivo during
physiological activities and
recovers from deformation
within 90 min after loading, but
physical training status does not
seem to affect in vivo
deformational behaviour.
Eckstein F, Hudelmaier M, Putz R: The effects of
exercise on human articular cartilage. J Anat 2006
(Anatomical Society of Great Britain and Ireland);
208: 491-512.

44. Eckstein F, et al:
The effects of exercise on human
articular cartilage.
J Anat 2006; 208: 491-512.
Quantitative MRI (qMRI)
and in vivo
deformational behaviour
of articular cartilage

45. Surgical Options for Lateral Patella Tilt: Electrothermal Lateral Release
(only if everything else fails)

46. Articular Cartilage Repair: Surgical Options
ACI (BioPoly)OATS
Microfracture
Chondroplasty

47. Microfracture

48. MFC Microfracture site after 5 years

49. Autologous Osteochondral Grafting (OATS)

50. ACI (ChondroCelect) Open Implantation
Source: www.geistlich.com

51. PD fat sat
LPF CCI Graft Hypertrophy 12/12
PD
CKC Chester UK

52. Mesenchymal Stem
Cells (MSCs)

54. Ilio-tibial Syndrome
• The ITBS is the second most frequent
complaint in running and cycling (the “other”
knee problem), with an incidence as high as
12% of all overuse injuries.
• Though recognizing the sharp, burning pain
close to the lateral femoral condyle of the
ITBS isn't difficult, treating the condition can
be a challenge because underlying myofascial
restrictions can significantly contribute to the
patient's pain and disability.
• Sometimes this is accompanied by a
snapping sensation and a positive Ober’s
and Thomas tests.
• The aetiology is thought to be due to
repetitive friction of the distal iliotibial band
posterior fibres against the lateral femoral
condyle (the impingement zone) that is
particularly susceptible at 30 degrees of
knee flexion. This is just within the usual
range of knee motion for a cyclist of 30 to
110 degrees
• A myriad of reasons have been proposed to
explain why cyclists are prone to this
condition that can be summed up as
improper cycle fit

55. Rehabilitation of Cycling Knee Injuries
Source: Asplund C, et al. Knee Pain and Bicycling. The Physician and Sportsmedicine, April 2004.

56. Indoor Cycle Trainers
• The UK weather is not an excuse for giving up on
cycling. If you have a bit of space at home, and a
few pennies for a decent cycle turbo trainer or a
roller, or both, you can continue to cycle, workout,
build endurance, gain confidence, loose weight,
etc. Indoor cycle training is not something reserved
for winter months and bad weather. Rather, it is
the most effective and rewarding exercise to do
when conditions and circumstances will not allow
you to get outside and ride a bike.
• Basically, if you want fitness training get a cycle
trainer but if you want technical training get
rollers.
• Rollers are less boring than cycle trainers, are
nearly silent to operate and cause less tyre wear,
but require a great deal more concentration than
cycle trainers.
• Rollers are hands down the best way to maintain
bike-handling skills and a fluid pedal stroke.

57. How to Ride Hills
• UK climbs are seldom long and steep (like
Stelvio) but there are many tough ones
around.
• How can you train for steep hills? Well,
the best way is to ride them frequently.
• Before you attempt any hill training, make
sure that you are fit to do so.
• Power to weight ratio plays a huge part in
how successful you are on steep hills, but
your ability to tolerate the accumulation of
lactate in your muscles is also significant.
• Upper body strength and your core play a
bigger role in muscling your way up steep
hills than they normally do on the flat.
• Think about your gearing before you
need to shift.
• On really steep hills, when you’re out of
the saddle, use your upper body to help
apply weight to the pedals.
• Try alternating between being in and out
the saddle.

58. The (Huge) Importance of Nutrition

59. Great Exercise but …

60. Great Exercise but …

61. Great Exercise but …

63. Thank You

64. … and don’t do stupid things:
The isle of Coll, 26 April 2008
Guess what happened next!