Case Study: Chondromalacia Patella (Knee Pain)

April 20, 2016/ by Dr. Jody Gilligan

My left knee was a disaster on the bike. I remember it taking about an hour for it to handle any pressure on the down-stroke. So when a fellow cyclist comes in with this all-too-common complaint, I know I can help. Here’s an example of a case I had the opportunity to follow up on lately:

Case study

33 y/o female
Left knee pain. Most of the pain seems to come from behind the knee cap on the inside of the knee. Diagnosed as Chondromalacia Patella by her orthopedist.

MRI was negative for any major degenerative changes. Minimal changes in the articular cartilage were noted.

The woman was recommended to our office, for a bike fit, by a patient she met while training on her road bike on A1A (on vacation). She stated that she has had this issue since she started training for triathlons 2 years ago. At first it was only an annoyance that would go away after warming up. Over the past year it had started to worsen as her training volume increased. For the past 3 or 4 months the knee hurts when she goes to stand after sitting too long (around 30 mins). It didn’t bother her running but pushing off the wall, in the pool, is painful as well. She also has a history of low back pain and left hip pain, which she was not experiencing at the time of the examination.

Before visiting our office, she had been under the care of her orthopedist. She was prescribed NSAID’s, stretching exercises and leg strengthening exercises (focused on the strength of her VMO) with minimal improvement. It was then recommended that she take 4 weeks off from training, which she does not wish to try (yet). She also has regular (weekly) massages and practices yoga.

What We Did

A very thorough examination of everything pertinent to this bike fit. It would be useful to know if there is some sort of perpetuating-factor or structural-issue before this patient continues with any activity. I start with Structural Radiography of the lumbar spine and pelvis before moving on to neurological, orthopedic and functional testing. Here are some of the findings:

Limited Structural Exam Findings

·         Significant right thoracic shift/translation, right forward/anterior pelvic rotation

·         She displaced more weight on the right leg (+7lbs) when standing

·         Structural Radiography: A congenital Leg Length Discrepancy (LLD), right leg is 7mm shorter than the left leg resulting in a 18mm right thoracic translation/shift. L5 Grade 1 degenerative anterior spondylolisthesis with moderate loss of the L5 disc height. Hyperlordotic lumbar curvature. Bilateral CAM deformity of the femoral heads.

Functional Exam Findings

·         Significant restrictions in bilateral ankle dorsiflexion, loss of hip internal rotation on both sides, restricted posterior glide, hip flexion and external rotation on the right side and extremely restricted knee flexion with hip extension. Her quadriceps musculature would be best described as beef-jerky. There were several other muscle groups with similar characteristics.

·         Video Motion Analysis demonstrated that she was too high and way too far back. Every compensatory movement-pattern you would have expected, based on the LLD, was present.

How Did She Do It?

When you grow up with a significant LLD in our perfectly flat world, you will most likely develop some structural shifts in the spine and a few compensatory movement-patterns. She had just about everything I’d think of if you told me your right leg was shorter than your left. So I was amazed she felt ONLY one significant secondary condition/symptom. This is a great example of how tough our bodies are, until they aren’t…

Having equal leg-lengths on the bike removed a major perpetuator of the compensatory movement-pattern she was displaying. Positioning the saddle in the correct range allowed for an impressive movement-correction as well. You can say it “took pressure” off the knee, but it isn’t that simple. At best this would be a temporary patch until the deeper functional issues “caught up” to her.

These things don’t clear up on their own, overnight, and they can come back if you aren’t paying attention. That’s why the bulk of our time spent together was on teaching her how to take care of herself. The Corrective Bike Fit is a major investment in yourself. You aren’t going to pedal-mindlessly out of here. I expect you to understand that the fit itself, along with the enhancements made to provide structural asymmetry, are just the foundation to better movement.

You can translate that into greater comfort, speed, performance, etc.

So I was reminded of this case because she dropped by to say hi and purchase some foot-correctors while she was on vacation. She reported that her knee felt better right away and had not been an issue since the bike fit. She does her “homework” regularly and feels very empowered with the knowledge she invested in. 

Wiggins VS Froome TT Position

From @Cycletard

So what’s the difference between these two guys? No, it’s not just the 1:16 difference. They both have Osymetric rings. Almost same rigs. Same helmets. Same skin suites. It isn't the aero booties. Here's the clue...Look at their backs. Froome, on the right (if your head has been in the sand for the past 3 weeks), has a rounded back, he looks totally crunched up, compressed, about as aero as a cannonball…if anyone needs an ISM seat, it’s him. 

His pelvis is locked in an upright position and his pelvis/hips don’t give his spine any slack, so he has to bend his spine out of the neutral position to compensate. Maybe he also has a thoracic curvature that’s contributing and/or wicked short hamstrings, but man, he’s got to work on achieving a more neutral position with his spine.

Froome is less aero than he could be, his hip extensors are inhibited by his flexed spine and his breathing potential is limited. Plus the struggle to stay in that position, sure you get use to it, but there is a cost…all I can say is that there’s TONS OF ROOM FOR IMPROVEMENT…which is scary.  

Wiggins, on the other hand, looks totally relaxed, stretched out, long and low, with as close to a neutral spine as is practical. Look how flat is back is!  His hip mobility is awesome, plus he must have some great thoracic structure. His effort looked effortless because he wasn’t struggling with his position.

Guess who uses their hip-extensors better? Guess who can use their diaphragm better?  Obviously Wiggins…BUT…Guess who can IMPROVE more? That’s what I like to do for everyone I work with. If you settle for just a “fit”, you are selling yourself way short…Especially if you are serious about performance.

As you can see, a “fit” isn’t enough, nor is a trip to the wind-tunnel. That’s why I don’t just do fits. The Corrective Bike Fit is about restoring structural and functional symmetry to optimize the bio-mechanics of cycling. You need someone with the background and experience to see and show you these things. Froome will need some time to improve his position, but that’s all he needs. It’s not like someone like me, who needs to drop 15 lbs and gain 150 watts…and get 20 years younger!

ISM SEATS

I've been using them for several years now...here's the backstory..

Toilet seat sparks inventor's idea: MyFoxTAMPABAY.com

Osymetric USA Rings Rock!!!

Why bother developing a skill-set you don't need...as you do with round-rings. Osymetric USA's rings let you focus on pushing, NOT pulling...complimenting gait. I can go on and on...so watch the video. If you have any more questions...call/email me!

Corrective Bike Fit Basics

NOW is the Time to Change Your Position

After a long race season, most of us are still focusing on recovery while simultaneously making plans for 2011. Unless, of course, you plan to be at Country Walk next Thursday...after all, it is the world championships of South Florida.

Regardless, NOW, NOW, NOW!!!!! is the time to deal with issues you may have had, over the course of last season, related to your position on the bike. Not 3 weeks before your first ever Ironman...ok? NOW!!! Same goes with 3 days before State Road Race...yes, I get this EVERY year. 

It's not that I mind. The sooner the better. It's just that, THIS is the time of the year, when you are/should be, going easy. NOW it is much easier for your body to ADAPT to a new position. 

Even more importantly, which relates to the way the Corrective Bike Fit restores symmetry to your structure...NOW...it is much easier for your body to learn how to function optimally on the bike. 

It's not a simple matter of changing your saddle height, and off you go. Developing proper pedaling mechanics requires in most cases, several weeks of Corrective Stroke Drills. These Drills are designed specifically for the way you compensated for a Structural Abnormality related to the spine, pelvis or anatomical leg length...things you can ONLY see with Structural X-rays.

Think of the Corrective Stroke Drills as an eraser. You use them to erase bad-form, so you can lean good-form.

Corrective Stroke Drills don't only help prevent injury. I recommend them for the treatment of most of the SECONDARY conditions that are so common in cycling such as: low back pain, hip pain, knee pain, etc...

So, PLEASE, if you have an issue, and you are thinking about changing your position on the bike...take advantage of this window of opportunity.

CORRECTIVE BIKE FIT®

Restore Structural Symmetry to maximize your bio-mechanical efficiency with the CORRECTIVE BIKE FIT®

The Corrective Bike Fit is a by-product of the structural correction work I do with my patients. About 10 years ago, I realized that my patients who were bike racers or triathletes just couldn't correct their spine as well as everyone else. The thing I was missing was the bike fit AND positioning.

I did my homework, looking at all the different fit systems and realized that the dynamic fitting system, using video motion analysis, made the most sense. I want to fit my athletes to their bike when they are "under load" .  This means the bike is set up for racing, not lallygagging.

The other missing piece was how to correct the abnormal stroke that is always present with structural abnormalities like Short Leg Syndrome, Lumbar Scoliosis and a Torqued Pelvis.

I already had the information I needed from when I did the Short Leg Study during the Structural X-Ray examination.  All the compensations that the body develops to deal with abnormal structure, that are present whether you are standing, running or laying down are present on the bike as well.

The solution to optimizing an athletes stroke was right before my eyes. It is just a matter of knowing what is going on structurally, on the inside, to correct what was going on functionally.

CALL 561-826-7101

WHY WOULD YOU NEED ALL OF THIS JUST TO RIDE A BIKE???

 

Ok, there's riding a bike and then there's RIDING A BIKE! Pro cyclists and triathletes spend as much time on pedaling technique and bike fit as they do anything.  Besides achieving maximum spinal correction, athletes are especially interested in efficiency and power while PREVENTING injury or recovering from injury.

So your answer depends on how serious you are about your performance.

CALL 561-826-7101

SO YOU'RE GOING TO MEASURE MY INSEAM AND  MY FOREARM AND THAT'S IT?

That's one way to do it. This is how the fitters who follow a "static" model for bike fitting do it. I'm sure they do a great job at it.

What I'm interested in is what you are doing "under load"...but that's not where I start.

First: I am going to aline your feet with your ankle and knee BEFORE I x-ray you for a short leg and any other structural abnormalities in the lower spine or pelvis. This initial step will shows us if there is a PRIMARY CONDITION that can generate a variety of SECONDARY CONDITIONS that you may feel or display in the form of abnormal function on the bike.

Some of the most common SECONDARY CONDITIONS that may require your attention are:

Low Back Pain

Hip Pain

Numbness and Tingling

Herniated Disc

Degenerative Disc Disease

Degenerative Joint Disease

Decreased Range of Motion

Knee Pain

Cramping

TFL Syndrome

Neck Pain

Poor Power Production

Saddle Sores

Erectile Dysfunction

Second:  After any structural abnormalities are addressed then you will get on your bike in front of the video camera and we will document what you are doing right and wrong on the bike.  You will have to make a satisfactory number of efforts to establish how you compensate and determine the current fit of the bike.

Bike Fit Under Load

Third: We make necessary changes to the bike set-up and we test them, under load, until I am happy.

Finally:  Functional correction drills are necessary. I will monitor you in your new position, if change is necessary, and train you on how to clean up your stroke, to restore balance to the legs and pelvis while protecting, and in the case of patients, assisting in the correction of their spine.  I also enjoy working on aero -positioning as well, and this is built in.