Nuffield Health Educational Seminars

Cycling Knee InjuriesChester Race Course!29 March 2014

Vladimir Bobic MD FRCSEd!Consultant Orthopaedic Knee Surgeon!

Chester Knee Clinic!@ The Grosvenor Hospital Chester!www.kneeclinic.info!@ChesterKnee

Chester Knee Clinic wwwkneeclinic.info @ChesterKnee

Chester Knee Clinicwww.kneeclinic.info

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.

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

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.

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!

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.!

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.

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.

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.)

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

Professional Bike Fit

Seat angle and longitudinal position

Seat height

Crank length

Handlebar height

Handlebar reach

Chester Knee Clinic

Chester Knee Clinic

Source: www.specialized.com

Correct footware: alignment, cleat position, etc.

Knee Replacement and Cycling:

Limited knee flexion is a problem.

! What is the solution? ! Change: !

• seat height, • crank length, • “sliding” cleats?

❖ 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.

Saddle Height

Saddle too high

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

Saddle Position

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

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

Causes of Cycling Knee Pain:

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

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.

!

❖ “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.”

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.

Patella Tracking Issues

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

Patella maltracking, cartilage damage and BME

Irreversible PFJ damage: patellar and trochlear cartilage damage with subchondral patellar changes (bone marrow oedema)

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.

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

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

Articular Cartilage Repair: Surgical Options

ACI (BioPoly)OATS

MicrofractureChondroplasty

Microfracture

MFC Microfracture site after 5 years

Autologous Osteochondral Grafting (OATS)

ACI (ChondroCelect) Open Implantation

Source: www.geistlich.com

PD fat sat

LPF CCI Graft Hypertrophy 12/12

PD

CKC Chester UK

Mesenchymal Stem Cells (MSCs)

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

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.

Rehabilitation of Cycling Knee Injuries

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

… and don’t do stupid things:

The isle of Coll, 26 April 2008

Guess what happened next!

Thank You

Le Tour 2014 : Grand Départ Leeds 5 July (J-97) L’Angleterre passe au jaune!