TRIA Orthopaedic Center Your Cycling Blog

Depending on the stability of our joints, and the ligaments and cartilage enveloping said joints, noises might occur during a variety of exercises. Relatively impact-free, cycling can elicit some clicking or popping in the knee joints when harder efforts (read: gears) are performed, as well as when the knees are fully extended in the pedal stroke when standing up and out of the saddle to climb or bridge a gap. The real question is: should we be worried about that sound or sensation?

For the answer, we asked asked Dr. Fernando Pena, M.D., an orthopaedic surgeon with the TRIA Orthopaedic Center, whose specialties include foot and ankle issues, reconstruction, and sports medicine. Here’s what he thinks about the uncommon sounds and feelings of harder efforts or climbing out of the saddle:

For the most part, clicks, clonks and pops of any joint, as long as they are pain free, should not be a reason for concern. If the noises are associated with some pain or locking, then you should be evaluated by a physician or physical therapist. When it comes to the knee, you could have a torn meniscus (internal cartilage of the joint) that is getting caught or pinched when you bend the knee.  The definitive solution/answer to a problem like this would be to have an arthroscopic (small incisions and looking inside the joint with a little camera and instruments) intervention of the knee.

The only painful noises not to be concerned about are the ones coming from the front of the knee under the kneecap. Cycling, by design, is one of the healthiest sports for the knee cap joint. Appropriate seat height adjustment is critical to help eliminate knee noises and mild discomfort of the front of the knee.

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We here at the TRIA Orthopaedic/Nature Valley Grand Prix blog like a lot of things. Two of them are constants: good weather and a nice bike ride. Every day, we’re getting more and more sunlight, leaving us with more time after work each day to hop on our bike and ride until the street lights come on. It’s this time of year that brings out the kid in us, as we traverse on roads we know and try out the roads less taken. Bob McEnaney, a certified USCF and USAT coach, and owner of Total Cycling Performance, has these tips to prepare your steed for the roads ahead:

Funny things seem to happen to our bikes from the time we put them away in the fall until we bring them back out in the spring. What we remember as a finely tuned and fully operational bike is all of a sudden filled with funny noises, poor shifting and in serious need of maintenance.

Assuming you don’t have any major issues with your bike (especially safety-related) these few simple tasks should be enough to get you out on the road. BUT, your bike should still be overhauled, or at least tuned up, prior to embarking on any major rides or events. Good luck, and GET OUT AND RIDE!

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During our rides, the heat tends to get to us. Sometimes, it’s an environmental issue. Other times, it’s the bottom of our feet that get hot, but it may or may not be due to the ambient temperature. It could be another issue altogether.

For this answer, we asked again asked Dr. Fernando Pena, M.D., an orthopaedic surgeon with the TRIA Orthopaedic Center, whose specialties include foot and ankle issues, reconstruction, and sports medicine. Here’s what he thinks about the cycling “hot spots:”

The commonly known “hot spots” are foot blisters or at a minimum, early stages of a blister. The reason why a blister takes place is because of the separation between the different layers of the skin. The separation creates damage to the skin and fluid leaks into it by loosing the ability to contain or seal the water inside our body.

The reasons to create that type of damage are many but for the most part all of them follow the same principle; having the skin moving back and forth against the shoe instead of being static. The skin on our feet is very mobile. You can put your finger on it and move the skin almost on any direction while your finger is on it. If from previous injuries or surgeries a scar is developed, the skin will be scarred down to the bone and therefore the ability of the skin to move back and forth is more limited.

Given proper time and a well planned progressive increase in activities, a blister will transform into a callus and remain as such until the activity is stopped. Calluses don’t represent any increased damage to the skin by themselves, but they may still be painful.

A good fitting shoe is mandatory to prevent this type of injuries. If the same spot continues being a problem, try to protect the painful spot by applying some protection to the area (foam or felt donuts) that you can hold in place with athletic tape.

If the “hot spots” are over the bottom of the foot, likely you will need some type of shoe insert to make the pressure over the ball of your foot more even and decrease the increased stress over that portion of the skin.

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As the season progresses, so do our aches and pains. When we begin powering up our training volume, new pains tend to rear their ugly heads until they becomes unbearable. One of those that is typical of increased mileage is knee pain. No stranger to the cycling world, pain around the knees can subdue even the most experienced cyclist.

With the increase in pain comes the increase in blame. Many riders feel that it could be a variety of imperfections within the equipment, but the answer is usually within the riders themselves. This week’s answer comes from Cindy Schlafmann, PT, SCS, ATC, who just happens to be an Ironman triathlete in her spare time.

Typically, early in the season, cyclists start doing too much too soon and fail follow “The 10% Rule.” The recommended increase is no more than 10% per week. Often, the cause of knee pain is pushing too hard of gears and using more quadriceps (front of the leg) power rather than a more balance pedal stroke, which would use the pull of the hamstrings (back of the leg) and gluteal (butt) muscles.

Focus on a smooth circle during the entire pedal stroke rather than on just the push down. You can think of trying to scrape mud off the bottom of your shoe on the stroke between 9 o’clock and 3 o’clock if you think of the pedal stroke as a clock.

It would be recommended to keep the gearing lower and focus on higher cadence of >90 RPM(revolutions per minute), as well. Including hill repeats too quickly at the beginning of the season can also put increased strain on the knees if your strength is not yet there.

Another cause may be improper bike fit with the seat being possibly too low, which would cause more strain on the front part of your knee. I also recommend working on strengthening your core including lower abdominals, gluteal and hip muscles to help with balance throughout the trunk and legs.

We appreciate the help that Cindy has lent us in this week’s post. Stay tuned for more helpful information from the sports medicine specialists at TRIA Orthopaedic!

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Today, we have another hot-button issue for our TRIA surgeons and sports medicine specialists to chew on: to clip in or not to clip in.

We all tried out the toe-strap and gym shoe combination when we first began cycling.

They were easy and you could wear your normal gym shoes. It made riding and commuting a breeze!

If you’re one of the lucky (and coordinated) few who went straight to the clip-less pedal option, then you more than likely fell at many an intersection or stop sign before you mastered the art of rotating your heels in the opposite direction to free yourself from the binding below.

Why the options? Is one more efficient than the other? It’s an obvious technological advancement, but can it aid both biomechanically and physiologically? For this answer, we asked Dr. Fernando Pena, M.D., an orthopaedic surgeon, whose specialties include foot and ankle issues, reconstruction, and sports medicine. Here’s what he thinks about toe clips and clip-less pedals:

The recreational rider will do well with pedal cages and gym shoes. There will be very little benefit to the financial investment of going to clip-on pedals and shoes. Just make sure they both (shoes and cages) fit you well. A comfortable shoe to go walking may not feel that comfortable after a while of pedaling, as the forces across the ball of your foot are higher. If the shoe is not wide enough, you may experience some numbness of the foot. Be careful with not taking chances for an accident. In case of a need for a rapid dismount, the cages may keep you from separating from the bicycle quick enough and you may suffer more injuries than you anticipated based on the speed at the time of the crash.

If you are planning to move it one level up, clips are always beneficial. The most obvious one is that they allow you to use your hamstrings, back of your thigh muscles, to carry up the pedal, so you fire your quads on the way down and your hamstrings on the way up for that pedal. Another added benefit is to keep your feet straight instead of pointing in or out. That will decrease the chances for any knee cap problems (pain, swelling, tendinitis) once the mileage is increased. The only clear down side is the financial investment. If you use orthotics (shoe inserts) make sure you will be able to fit them into your riding shoes. You may even need to go for an specific pair just for your riding shoes, given their unique width. Similarly, dismounting from a bike with clips, takes time and practice to do it safely and quickly. Be careful those few first times out…

We hope you enjoyed Dr. Pena’s response! It took us all a while to figure out how to clip in and out and still stay upright, so don’t fret! All it takes is an empty parking lot, some spare time, and a lot of patience!

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As cyclists, we often experience pains that seem to come out of nowhere. Since the majority of us are not sports medicine or orthopaedic experts, we typically will either ride with the pain or stop riding altogether. Neither does any good for our cycling psyche, but, as untrained medical professionals, our options seem limited.

We are proud to offer the devoted readers a forum for these specific issues. Today, we’ll get the ball rolling with one popular question that plagues cyclists of all ages and skill levels. In the future, feel free to leave a comment and ask a question that we can answer here on the blog.

Our first question deals with lower back pain (LBP) and long-distance rides. So often, on rides longer than twenty miles, we experience some lower back pain. It’s troubling, but most of us can’t figure out why it’s there or where it’s coming from.

Thankfully, we have a TRIA Orthopaedic surgeon on board to answer this question, as well as all our questions in the future. For this particular question, Marc Swiontkowski, M.D. has provided us an answer to the question that has plagued us all, at one time or another, during our cycling career. Here’s what Dr. Swiontkowski has to say:

The way to avoid LBP on longer distance rides has several components. The first is to make sure you are set up on your bike correctly. A frame that fits accompanied by appropriate seat height adjustment, correct crank arm lengths, a well fit stem (the part that the handle bars attach to) with an aero bar extension will provide the best biomechanical situation for your back. Your local bike shop can help you be sure that your fittings and equipment are correct for you. Frequent rotation of hand positions around the handlebars and aero extensions will help take the strain off the back as well. Finally, standing out of the saddle for 60 seconds or so, 4-5 times an hour will help your back from becoming sore. Nothing can substitute for training miles though, and an available hot tub after the ride will fix what ails you.

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It’s heresy to include criteriums (short circuit races) in a pro stage race. It’s just not done. Yet the Nature Valley Grand Prix has the top ranking on the USA Cycling National Racing Calendar despite using criteriums for three of the six stages.

What gives? How can a race get the top ranking when it breaks the rules?

The Nature Valley Grand Prix is the NASCAR of bicycle racing. Most pro stage races follow the European model, which emphasizes road races that start in one city, finish in another and a spectator’s race experience can last for less than a minute. Here they come and there they go.

Well, this ain’t Europe and people in the US of A want a show.

Since criteriums are held on a short course (usually less than a mile), spectators can see the start of the race, they see the pack of racers whiz by every minute or so, they can walk the course to see different aspects of the race and they can be there for the finish. And because the course is short, it can be surrounded by a party with a bike race in the middle.

Even people who aren’t into bike racing have a blast.

And our road races are nontraditional as well. They’re the long distance endurance events that road races are supposed to be, but they finish with multiple laps of a short circuit to provide the spectator experience that’s the hallmark of the Nature Valley Grand Prix. So they’re really road races that finish with a criterium. The best of both worlds.

When you rewrite the rules, the real test of success is whether the insiders buy in. The professional teams attend in force because they need the crowds and media coverage to give value to their sponsors. And USA Cycling, the sport’s governing body, must buy it because they’ve given the Nature Valley Grand Prix the top ranking and invite the promoter to their symposia every year to share our radical ideas with others.

And, most importantly, the public loves the format and vote with their feet. The crowds are huge and enthusiastic and non-fans who come to one race come back for others, except that they come back as true believers.

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Strength Training
Dr. Josh Sandell
Spine and Sports Institute

The risk of injury is an ever-present aspect of cycling, but almost every great performance follows a long period of relatively uninterrupted training. Though many athletes believe either that an injury is just a normal part of training or an unfortunate random event, the frequency of injuries may be dramatically reduced by an injury prevention program that develops strength, flexibility, and elasticity in tissues that are at high risk for injuries. Use this program to prepare your body fully for the high-volume/high-intensity training that will come later in the season.

Strength Training

Strength training is a critical aspect of injury prevention, affecting the connective tissues and the muscles. Since cycling actions occur primarily in a single plane, the tissues that act in that plane become disproportionately strong while those that act side-to-side atrophy.

Programs developed only for performance enhancement usually neglect tissues that act laterally, therefore increasing the risk of injury. Several muscles that are neglected in strength training programs are the hip abductors, hip adductors, and the ankle dorsiflexors. When performing the weight training exercises, use relatively heavy weights and slow movements. Keep the duration of each set between 40 and 60 seconds.

Strength training can be accomplished by simply using your own body weight with the use of physio balls and balance trainers. These exercises should be performed slow and controlled with the use of rotational movement and frontal plane movements.

We’ll have some more information down the road about ability-appropriate workouts geared toward both the recreational and the racing cyclist, so stay tuned!

GET ON YOUR BIKES AND RIDE!

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Injury Prevention 101 – Flexibility
By Dr. Josh Sandell
Spine and Sports Institute

Flexibility

The Australian triathlon team was screened in November 2003 prior to the World Championships in New Zealand, and found two main predisposing factors to injury: thoracic spine stiffness and tight hip flexors.

This pattern is extremely common in cyclists. Cycling training is one potential cause of thoracic stiffness because of the time spent in the time-trial position. If good spinal posture is not maintained on the bike, the thoracic spine can become excessively hunched when the cyclist becomes fatigued. If this posture is not corrected and the mid-spine is not regularly stretched, stiffness can develop and a drop in cycling performance may follow as a result of the athlete adopting a less efficient aerodynamic position.

The thoracic spine’s mobility can be improved with lying on your back over a physioball or lying on one’s back with a towel on the floor.

Tight hip flexors are a major injury risk factor and are a common problem because of the length of time cyclists spend with the hip bent in the time-trial position while cycling. Low back injuries, hamstring strains, hip flexor strains and lower limb overuse injuries can be linked to tight hip flexors. Hip flexor and quadriceps stretching are essential to prevent this pattern from developing.

The muscle groups should be stretched daily, before and after activity (especially after cycling). Stretches should be held for approximately 30 seconds to one minute without bouncing, performed gently and slowly to the point of tension but never pain.
While an effective stretching program may reduce injuries, many athletes look to stretching as the answer to injuries. Athletes do become injured because of over flexibility. Be consistent with your stretching, but don’t go to extremes and don’t look to it as the injury cure-all.

Our next post will deal with strength training and injury prevention

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We’ve see the unfortunate news: Lance wrecked his way out of the Vuelta a Castilla y León.

Even though he’s a professional, this is a very common injury amongst all cyclists. From racers to weekend warriors, we’ve all seen, heard, or felt the pain that a broken collarbone brings forth. As athletes, injuries are commonplace, but when our upper body is restricted, how soon can we be back on the road?

Helge Riepenhof, a doctor for Team Columbia-Highroad who has studied injuries in cyclists, said a broken collarbone was the second-most-common injury in the peloton. Skin lesions top the list.

He said riders often hung onto the handlebars during a crash, in hopes of staying upright, and ended up falling on their shoulders. The collarbones break because they are the weakest bone in the shoulder area, he said.

Dr. Jonathon Braman provided us with additional insight on these pesky injuries:

Jonathan P. Braman, M.D – TRIA Orthopedic Center

Broken collarbones or “clavicles” are a frequent result of falls, especially involving cycling. Most breaks can be managed without needing surgery, by placing the arm in a sling for a period of time then gradually getting the strength and motion back over time.

Sometimes, however, they do not heal in a sling. This can be especially troubling for cyclists as the collarbone absorbs much of the stress during long rides.

One reason why some breaks don’t heal is if during the first part of healing, too much motion occurs. This can cause the broken bone to fail to grow back together.

New studies looking at how people do after breaking their collarbones has shown that some broken collarbones should be operated on at the start. As a result, it is best to see a shoulder surgeon with any broken collarbone.

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