I need help figuring this one out. Rider is experiencing pain on the outside part of her knee. She has quite a bit of inward knee movement throughout her pedal stroke. She pronates moderately. We has shimmed with varus wedge and used superfeet orthotics to stabilize the arch. Knee tracking is visually improved with still some inward movement with 3 varus wedges. We have moved up and down the saddle height range from 145 to 153 degrees without much change or reduction in knee pain. Cleat width seems to be correct. The only ‘fix’ to her knee discomfort seems to be her pointing her toe downward throughout the pedal stroke. I can’t really think of what this is doing aside from effectively lowering her saddle height on the left side. Specifically her discomfort seems to be lateral of her patella tendon on the bottom of her kneecap.
Thoughts on what is causing the issue? BTW, she is using a pair of Look Keo with 4.5 degree float cleat. We have checked cleat rotation and she seems to be comfortably within the float range without any noticeable outward or inward patellar rotation throughout the pedal stroke.
sounds interesting…can you be more specific about the location of the pain? near the patella, or ‘back’ towards the back of the joint? At/above/below the level of the tibial plateau?
At what point of the clockface of the pedal movement does the pain begin or peak - top of stroke or at full extension?
Hi, I don’t know exactly where you take the different points for mesuring the angle but this is typical from a woman with a saddle too high.
A man generally suffer first at the back of the knee because they have less laxity on the joint.
What tool do you use for mesuring ?
I’m using goniometer. We have gradually adjusted height throughout the spectrum between 145 degree to 153 degree. Nothing seems to be working that well, even with more knee flexion. As best I can tell pain is coming from the lower anchor point of the IT band. Thoughts?
It really sounds like a cleat/float issue. I know that you’ve checked this, but it might be worth revisiting. Be sure to check at different effort levels. In most cases, Look cleats can be checked from behind the bike and watching the amount of cleat on either side of the pedal body. Good luck!
I would consider moving that foot out a little more to see how it feels.
By the way does one hip dip/move more than the other?
If the discomfort is outer but toward the front - move foot out and rotate toe out
If discomfort is outer but toward the rear - move foot out and rotate heel out.
Why do you think you can solve her pain with a fit?
If tissue is damages or inflamed you can do everything in the book without making a difference.
Get her off the bike and into rehab, then re-approach the fit.
The only reason I thought it may be fit related was because she can pedal toe down with nearly zero ankling and almost fully alleviate her discomfort. But when she pedals with appropriate heel drop and ankling the pain persists. Generally I would have thought that it would have been a leg extension issue as her toe down pedaling would effectively lengthen her leg length. But she was not complaining of any biceps femoris tendonitis when ankling appropriately so I had assumed saddle height was correct. I suppose too high of a saddle could cause excessive rubbing on the IT band and the lateral bursa, but pain would be higher up the leg if that were the case. It seems odd that the discomfort seems to be localized at the anchor point of her IT band…
Not sure this would be considered odd. Based on the little bit of information provided this sounds fairly common. Regardless if off the bike support is needed (may be a good idea) the bike still needs to be addressed.
Off the bike care only works if the bike is also adjusted. Otherwise it just keeps coming back.
I had a client the other day with a similar problem, a masters road racer who complained of pain in the same spot. He had a ton of fore foot varus and was taking good advantage of the float his speedplay pedals allowed for. Through cleat adjustment, cleat shims and also in the shoe shims I was able to drastically reduce the amount of tibial rotation and lateral movements of the knee. He e mailed me when he got home (a 12 mile ride from my studio) to tell me that he had no pain whatsoever for the first time in a few years.
I experienced knee pain in one leg when my float was insufficient - not enough heel out. In actual fact I had mounted one of the cleats slightly rotated in relation to the the other, I doubt there was more than 2deg difference between the left & right. Cleats were 6deg float.
Have you checked for a leg length discrepancy? If what you’re describing is true then it’s possible the “bad” leg is presenting as short when on the bike due to a hip or pelvic displacement. I do agree with a couple of other posters that she needs to rest the joint and get the inflammation down before expecting instant relief, but with relief coming through raising her heel I’m wondering if her leg may be a touch short.
The other possibility is that by raising the heel she is engaging stabilizer muscles that are helping the knee track on a better plane. Can you quantify knee tracking with a level foot and a flexed foot?
Have you considered looking at her Q angle and if she has a muscle imbalance in her quads? By toeing down she is changing muscle activation in her upper leg. If she has a large Q factor it could over develop parts of the quad resulting in pain on the outside of the knee due to muscle imbalances.
a few things, a goniometer is notoriously inaccurate, since people can not replicate the force, foot angle etc when they stop. You should get a motion capture system. Kinovea is a great freeware for this purpose. If you need evidence, Prof Will Peveler has published a paper on this very subject, KNEE AND ANKLE ANGLES FROM RESTING MEASURES TO ACTIVE PEDALING (partial title) . If the foot does not have enough arch support as super feet do not have adjustable arch support this may still be a problem. I suggest trying an orthotic with adjustable arch support as well as metatarsal support there are a few out there, one that is generally easier to get is the Giro super Feet. Make sure they can feel the arch support as mildly intrusive if not they do not have enough support. Have you tried fore foot, heal and cleat wedging or combinations? Often one will work better than the other, or a combo since too much in the toe box can be a problem. Finally it is very likely if all the rest is OK they may have flexibility/ muscle imbalance issues and they need to work on that problem to solve the bike fit. More often than not, the problem is not the bike but their muscular issues that cause knee pain. A great book for this is Tom Danielson’s core advantage. There is a section that talks specifically to knee pain and how it is related to core issues. Finally are they sitting square on the saddle, is their hip dropping on the right side (very common and often due to tight hip flexors). Again stretching and core exercise such as yoga can go a long way to solve this problem.
These are a few suggestions, you might also consider reading info on Steve Hogg’s site there is a wealth of info that might speak to the problem there as well.
Not in capable hands.
I guess that can be said of any tool, it is the hands of the crafts person that does the work not the tool! however in this case the likelihood that the subject maintains the actual angles they have while pedalling under stress is unlikely and as long as the goniometer user accommodates for that unknown then, like anything, it depends. Poor use of motion capture and analysis can be the same but the best way to know is to look at a series of images at the same location, then you can assess if the measurement is the same or different from one time to a few revolutions further on or back. This is the strength of that tool, you can put up the measured angle tool fixed upon the landmarks and let the video move forward or back and see how it changes, it should not. As well if you recorded the power from the trainer you know how much stress the rider was using since too little or too much can change things. So it is not one tool but the group and your ability to interpret and assess that does the job. However people who have used both dynamic motion capture and static goniometer on the same subject will tell you they do not give the same results. As I noted Dr Peveler has written a peer reviewed journal article on just that.
Bottom line- it is the person and their skill, not the tool that does the bike fitting. There are very competent fitter who can do so with no measurement of this sort(knee angle).
So you honestly believe trying to draw a line on a freeware computer program with a uncalibrated camera is more accurate then a trained bicycle fitter using a Goniometer?
I use the Body Geometry Fit Data to watch the pedal stroke, look at ankle position, set the rider and measure by palpating the GT, LFC, LM then measure.
I can imagine being off around maybe 2-5 degrees but using http://www.kinovea.org/ I can’t imagine you would get anywhere near as as close.
I do agree with you that a talented fitter is the most accurate tool. But i believe you need to use the camera, data, flexibility analysis, goniometer, and experience to have a good fit.
I just get rubbed weird when people make such rash statements on this forum.
So you honestly believe trying to draw a line on a freeware computer program with a uncalibrated camera is more accurate then a trained bicycle fitter using a Goniometer?
I use the Body Geometry Fit Data to watch the pedal stroke, look at ankle position, set the rider and measure by palpating the GT, LFC, LM then measure.
I can imagine being off around maybe 2-5 degrees but using http://www.kinovea.org/ I can’t imagine you would get anywhere near as as close.
I do agree with you that a talented fitter is the most accurate tool. But i believe you need to use the camera, data, flexibility analysis, goniometer, and experience to have a good fit.
I just get rubbed weird when people make such rash statements on this forum.
sorry to rub you wrong… however it is not the fitter who may be unable to get the right angles but the client may not be able to hold the position they had under a moderate amount of stress. Beyond what I am saying you can argue as well with this article: A KINEMATIC COMPARISON OF ALTERATIONS TO
KNEE AND ANKLE ANGLES FROM RESTING MEASURES TO ACTIVE PEDALING DURING A GRADED Exercise PROTOCOL WILLARD W. PEVELER, BRANDY SHEW,SAMANTHA JOHNSON,AND THOMAS G. PALMER published in Journal of Strength and Conditioning Research. What they say is a goniometer is a starting point but dynamic observations are important and that it has more to do with the subject than the operator.