Topics: Plica Syndrome, Technical aspects of criteriums, RE: Foot discomfort, Hamstring Soreness, How much to spend on Bike fit, Returning from respiratory infections
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I am an avid cyclist living in Malaysia. In November 2009 I developed a small pain in my left knee. The pain started (or at least this is when I began noticing it) during a fairly long ride of 160km. The pain was isolated to about a "dime size" point on the medial side - basically right where the quad connects with the knee. The pain was more debilitating than anything. When I would stand the leg felt powerless and like it would almost give out. I rested for a few weeks and tried the bike again. However I had no luck, after about 10 km I had the small pain and the leg felt weak.
I went to what is considered the best orthopedic sports medicine facility here and the doctor did an evaluation, X-ray, and MRI. He concluded that it was Plica Syndrome. He also commented due to the inflammation my knee cap was rotated towards the outside of the knee.
He understood that I am an athlete and need this joint to perform. Since I had virtually no pain or discomfort off the bike he suggested physio first. I did about 2-3 months of physio and was off the bike Nov - Aug. (Not fun!) But I had hoped that time would help. I didn't start riding again until Aug 2010 and have continued until now with my training becoming more serious lately.
Now the discomfort/unusual feeling is back and has been progressing. I do not have the pain yet, but I can feel there is something not quite right. When I get off the bike and bend the knee joint I can feel a "snapping" sensation of a tendon - not painful, but unusual. You can also visibly see (when I squat a little) my left knee cap is rotated towards the outside as compared to the right knee cap. The longest ride has only been 70km and I am afraid to push it any further.
The doctor said that the next step would be arthroscopic surgery to remove the plica and do a lateral resection (I think that is what it's called) to put the knee cap back in the right spot.
My questions are: How common is Plica in cyclists? Is this most likely my condition from the symptoms I explained? Why now? (I have been riding for many years, how come all of a sudden) Could this have developed from a fit issue? Why not the right knee than? How successful is the surgery and what is your advice? Anything else that comes to your mind that I could try?
Thanks for everything!
Steve Hogg says:
I can't answer all of your question and I'm hoping Dave or Kelby will weigh in with the medical view of your problem in addition to this. What interests me about your question is that you mention that this pain and discomfort is only apparent when you ride and that it affects the left knee only.
Here's what may be part of the picture. The plica can vary in it's location and there is individual variance so this may be an accident of birth in your case. However, that the left knee only is affected and that only cycling irritates this may mean (I say cautiously) that is is related to your bike fit. My experience is that left knee problems are far more common on a bike than right knee problems. The reason for this is that when a riders position is subject to any challenge they will not compensate symmetrically. What I call a challenge is any factor that reduces the riders stability or symmetry on a bike.
To take the simple example of a seat height set too high. It is a rare rider who will sit symmetrically on the seat and equally overextend both legs. What happens in the vast majority of cases is that without conscious thought, the rider will automatically drop one hip and reduced the leg extension of the 'favoured' leg. Of course, doing so further extends the already overextended leg on the other side and often challenges the plane of movement of the knee on the other side. What makes this interesting to me, is that probably 90% or a touch more, when presented with a simple challenge like this, will drop the right hip, reducing leg extension on that side while further increasing the extension of the already overextended left leg. This happen whether the rider is right side dominant or left side dominant, meaning that at some level most riders have a Right Side Bias. Have a look at that link, particularly the video clips.
What I'm suggesting is that perhaps you are doing something similar which results in loading of the left medial knee. If in any doubt, have someone shoot some similar footage of you and see what you are doing pelvically on your bike.
When I mention seat height, that is only one potential challenge. There are many others and usually with overlapping consequences. For example, have a look at two things when you get a chance. Firstly, strip the waist in front of a mirror and and run your thumbs down from your ribcage until they contact the top of your pelvis on each side. Is there a noticeable difference in height between each side of the pelvis. If my fit clients over the last umpteen years are anything to go by, there is a 95% chance that the answer is yes. If so, you need to find a physio or similar who can determine whether there is a measurable or functional leg length difference. Your issue on the bike (assuming it is only a bike related issue) could be as simple as one leg being shorter than the other.
There are a stack of other possibilities but that's enough to check out for now while waiting for Kelby or Dave to give you more info about the medical side. Let me know what you find.
Technical aspects of criterium racing
I would like to talk about training for criterium race. I’m 24 years old amateur racer; 188cm and weigh 71 kg. I generally train around 12-17 hours a week and have about 25 race days per year. In hilly races and time trials - I’m good. But something about criterium racing is hard for me.
Typical criterium racing in my country is around 50 laps of a 1km circuit. Average speed is between 42-47km/h and I tend to not have the power in my legs for the sprint or even to not over exert myself in the tempo of the race.
How can I adjust my training for criterium racing?
Scott Saifer says:
If you are good in mountains and time trials then you already have aerobic power. There are two places you might look for improvement. Most likely is bike handing. If you are using your brakes more than once every few laps, not counting courses with hairpin or other tight turns, you need to get past that. That can mean learning to watch holes rather than wheels, learning to open a little gap before turns and then roll into that gap when the rider in front slows or several other things. If there is wind, you need to learn to plan which side of the field to exit the corners on at each corner, and then get there.
If you are really an excellent bike handler then of course there's training to deal with above LT intensity. There the question can be willingness to suffer appropriately or to generate those higher power levels. If it's really a question of generating the higher power, then efforts of intensity and duration similar to the surges of a race are what you need.
Anyway, give us a bit more info and I'll try to give some more specific advice.
Bike handling is definitely one of the problems. In my last criterium I started at the front of the race by the end of the first lap I was at the back. I think the other problem is that I’m an amateur and the guys I race against are professionals.
Scott Saifer says:
Without watching you race or having a more detailed description of how you managed to move back through the pack, I can't say for sure what you need to work on so I'll just give three bits of advice that will apply to someone reading this even if they do not apply to you.
1) When you feel threatened by someone easing in on you from the side, rather than backing off, pedal a little harder to close the gap they are trying to move into. Of course you have to do it before they get partway into it.
2) When you feel crowded, put your elbows out. Each rider has an amount of personal space they need to be comfortable. If the guy next to you is happy with a few inches less than you, he's willing to ride closer to you than you are comfortable riding next to him. You are tempted to make yourself small in order to not be too close to him, but when you pull your elbows in, that gives him permission to come closer. Put your elbows out and you push his comfort zone away from you and claim your space.
3) Ride with others as often as you can without sacrificing the intensity control on your training rides. Race or do hard group rides once or twice per week, and try to find at least a few riders whose pace is similar to yours with whom to practice close riding, drafting, bumping, trading pushes and so on.
RE: Foot discomfort in warmer weather
Thanks for the thoughtful and timely reply. I intersperse my responses between your questions below.
Before moving onto likely causes, when you say "balls of feet", do you mean the base knuckle of the big toe only on each side OR the base knuckles of all toes or multiple toes?
Certainly on the left foot and to a lesser extent on the right foot, the pain is more concentrated at the base of the big toe's knuckle. That said, the sensations that I described extend across all of my base knuckles and eventually much of the balls of my feet.
1. Not enough foot over the pedal. If your last fit positioned your cleats so that the ball of the foot is over the pedal axle, the stress that this can place on the plantar fascia can load the metatarsal heads (base knuckles of toes) and compress the joints enough to pressure the nerves in that area and cause numbness and pain. Let me know what your relative cleat position is. Have a look at this for info on how to determine what your cleat position is and to rectify if need be.
As best I could, I made some of the measurements described on your webpages, but the numbers seems to be a bit contradictory. On my right foot I measured the 1st MTP joint at 203 mm from the wall and the 5th MTP joint at 176 mm from the wall. On my left foot I measured the 1st MTP joint at 199 mm from the wall and the 5th MTP joint at 177 mm from the wall. On my right shoe I measured the distance of the pedal axle behind my 1st MTP joint at 8 or 9 mm. On my left shoe I measured the distance of the pedal axle behind my 1st MTP joint at 15 mm. I have my cleats set up so that the left one is about 5 mm farther back on the shoe than is the right cleat. I established these cleat positions largely by feel when riding. I should note that, although the right cleat is farther forward, it feels better positioned---slightly farther back---under my foot, while the left cleat sometimes feels too far forward under my foot. This has proved true for all of the cycling shoes that I have ever used.
2. You mention that your shoes aren't tight. Does that also mean that there is little feeling of lateral compression of the forefoot?
Is the toe a little tight at either the 1st MTP joint (base of big toe) or 5th MTP joint (base of small toe)?
Right, my current shoes are not tight in the sense that there is plenty of vertical room in the toe box. I would not say that the shoes are tight laterally, either at the 1st or 5th MTP joints, but there is certainly no wiggle room in the lateral direction there. My previous shoes were definitely tight at the 5th MTP joint and perhaps somewhat tight at the 1st MPT joint, so I specifically sought out shoes wide enough to accommodate my wide forefoot.
3.If your seat is too high, problems like this can occur with susceptible people. See this or this for more info. When subject to any challenge to their position, like too high a seat height, the rider will almost always compensate for that challenge asymmetrically. In this case the most common response is to drop or roll the right hip forward. That increases the distance that the left leg has to reach. I mention this possibility because you not that the discomfort is more severe on the left side.
I will have to get back to you on this point. I live in the Sacramento Valley, and I have yet to find a chance to get to a hill long enough to try your seat height test. If I had to guess, though, then I would say that my seat could be slightly too high but probably not by very much.
4. Could you possibly be doing your shoes up too tightly across the top of the instep and not allowing for foot expansion that sometimes take place in hotter weather. Before saying "No", have you experimented with backing the tension off the middle of the foot with your old shoes. I know this isn't possible with the BOA system of your current shoes.
I might be tightening up my shoes too much across the top of the instep prior to starting riding as I prefer a fairly snug feel, but I do not tighten them initially so much such that they feel tight. With my previous shoes undoing the Velcro straps across the middle of the foot did little to alleviate the pain as I recall.
5. I've left this to near last because there is a small possibility that the wedging is in the wrong direction. I mention this last because it is very uncommon for wedges to need to be thick side of wedge facing away from the centre line of the bike. Also, I need to know what brand of wedges you are using and where they are placed, inside or outside the shoe.
I am using Big Meat Speedplay shaped wedges sandwiched between my Speedplay cleats and a thin steel plate (of the same shape as the cleats) protecting the carbon soles. My right shoe has two such wedges, and my left shoes has one such wedge. The wedges do have their thick side facing the bicycle. The thick side of each wedge is about 1 mm high.
6. Is your second toe longer than your big toe?
Very slightly longer on the right, not longer on the left.
7. Read this and tell me whether the arch support you have is equivalent to Level 2 or not?
I do believe that my shoes provide level 2 arch support: when I first started using the Lakes, the arch support seemed notably more robust than in any of more previous shoes, but I got accustomed to the support after only a few rides. Now I wish that my regular shoes had as much support.
Thanks again for your help.
Steve Hogg says:
Thanks for the detail, it helps. You say, "I should note that, although the right cleat is farther forward, it feels better positioned---slightly farther back---under my foot, while the left cleat sometimes feels too far forward under my foot. This has proved true for all of the cycling shoes that I have ever used."
I hear much the same from time to time. I'll tell you what is almost certainly happening.
You are overextending the left leg. That is why a more rearward cleat position feels more forward because you are reaching too far. In fact the more rearward cleat position is counterproductive as it causes you to extend the left leg even more. The question is why are you overextending the left leg. The common possibilities in order of likelihood are:
1. Your seat is too high. Probably quite a bit too high. When this happens, almost no one will sit reasonably squarely and equally or near equally overextend both legs. They will asymmetrically attempt to compensate by hanging one way or twisting forward on one side. For 90 something percent, it is the right side that the rider will hang towards or twist towards and the left leg will be forced into overextension. If your left foot ever feels like it wanders around on the pedal a bit, whereas the right feels planted more solidly on the pedal, then the possibility of what I am saying being correct is high. If this strikes chord with you in any way, drop your seat 10mm and reassess. If better but not better enough, drop some more. I have found people with the same self description as your quote above can need a seat height drop of 12 - 35mm before they can reach the pedals fluently on both side and sit squarely or more squarely on the seat. Assuming of course that that is the reason or a large part of the reason for the problem.
2. That you are not necessarily sitting too high but that you twist your pelvis forward on the right side markedly or drop it markedly, either of which causes the left leg to overextend. That doesn't explain the incidence of pain on both sides though or why the pain occurs only in hot weather. The only way you will verify whether this possibility is the case is to mount your bike on a trainer, strip to the waist and have an observer stand above or behind you while you pedal under load. See this link for video clips showing cues that your observer should be looking for.
3. That either 1. or 2. are happening, with the additional impact of less than ideal arch support of cant of the foot on both sides. I don't know how high your arches are but would suggest that you try a pair of eSoles Supportive insoles. They have modular arch support in 4 different heights (with a 5th highest option available separately) as well as 2 different heights of metatarsal lifts in each kit. See this link here for instructions on how best to use them. The combination of arch support and and metatarsal lifts will likely improve or resolve your situation. If it improves but doesn't totally fix, then almost certainly the cant of your foot on the pedals needs to change. See this link for info on that.
I'm 30 years old and I've been riding for several years. This is my first year racing. I typically ride 3 strong group rides per week (30-40miles, average speeds in the mid 20s, maxing out in mid 30s). This year I have progressively been adjusting my bike fit to get into a more aggressive riding position for racing. I feel very comfortable while riding and have only one pain that may be related to my fit. I get some pain in my right hamstring.
Since I live in Florida I don't spend much time out of the saddle, typically I'm down in the drops and a pushing large gears for a good portion of each ride. My seat is low enough that my legs do not fully extend so I don't think I'm overextending. In recent weeks I have made intentional effort to ride at a higher cadence and it seems to help some but I still get that slight pain randomly throughout the ride. The pain doesn't lead to cramping and I don't ever get the pain in my left hamstring. Do you have any idea what may be causing this or suggestions on how to prevent it? Would stretching more throughout the week help?
Steve Hogg says:
You don't mention this hamstring niggle being present before "adjusting my bike fit to get into a more aggressive riding position". If it wasn't, the simple answer is to raise your bars OR to drop your seat either of which will relieve pressure on the troublesome right hamstring.
The less simple answer is this -
By a more "aggressive position" I assume you mean you have lifted your seat, dropped your bars or some combination of both. The increased forward lean of your torso that caused by the changes to your position is causing more stress on your right hamstring as the hamstrings are being stretched out more to help allow the lower torso position which is what I assume you mean by "more aggressive riding position" (though I'm not sure what aggression has to do with it). Why the right hamstring and not the left?
Any number of reasons is the answer. It could be a functionally (tighter hip / lower back) or measurably shorter right leg; it could be that a compensatory mechanism you are using for the challenge to your position caused by the lower torso is causing you to load the right side more than the left and so on. You may have already had a difference in range of movement of the hips on left and right sides and the lower torso position is enough to highlight that difference.
The background to this is that any challenge to your position (and I would define a challenge as any factor that lessens your stability or symmetry on a bike) will cause you to develop a pattern of compensation. All patterns of compensation evoked by a Challenge work by forcing the rider into a greater tendency to asymmetry.
The solution to your problem is to think about what you have changed, whether it be seat height, bar height or other parameters in combination. Back the changes off incrementally until your right hamstring niggle disappears. Then you will have the most "aggressive" position (sorry, I don't like the term because it doesn't describe what it means) you can ride with your current state of structural fitness and knowledge of how you function. If you improve either of those underlined phrases, it is likely that over time, you can reach the position you desire without problems.
Thanks for the information.
I do often experience tightness in my lower right back and realize now that it could be connected to the pain in my hamstring. One thing I will try (which i have been told can help with back alignment and back pain) is removing my wallet from my right rear pocket. Its usually pretty thick, unfortunately not because there is money in it though. Also, I'll try to refine my bike fit a bit more. Thanks again.
Steve Hogg says:
If the wallet is in the right rear pocket of the pants you wear to work etc, conceivably, that may play a part in the global picture of how you function. If you are talking about your wallet in your jersey pocket while cycling, then it is not a factor.
Do you stretch regularly?
If yes, you will already know if you have any real differences in range of motion between left and right sides. If not, it's a good habit to get into for pre hab (which is better than rehab) and the benefits of knowing several times a week where you are tight and where you are not. A good and inexpensive self help book is "Flexibility for Cyclists" available from here. It is worth getting the stretching strap as well unless you have one or something similar already.
Spending the right amount on a bike fit
I have always cycled recreationally and commuted etc but I am now trying to get a bit more serious about my cycling with the intention of doing some sportives or similar. I have never had a bike fitting but have played about with various positions myself, but haven't every found anything that works for me, which is causing a problem now I am trying to cycle for longer periods of time (more than an hour and a half). I know that I have a significant (3cm) leg length discrepancy which I have tried to correct, but it's crude at best. I am about to move to Australia.
As the bikes I do have will take 3 months to get there and I haven't really got a proper road bike I will be buying a new bike when I get over there. I intend on spending about AU$1200-1500 on the bike, which I appreciate isn't a lot compared to most others. I also want to get fitted to check I am buying a frame that suites me and is setup so I can enjoy it properly. While I could spend $680 getting a first class fit is this really justifiable i.e. 50% of the cost of the bike. If I were to spend that much I would need to be on the lower end of my range or even below. Others offer fits for free when you buy a bike, but I fully expect them to be a lot less thorough and probably insufficient to consider cleat positioning etc, which I think will be important with my leg length discrepancy. Is there a maximum percentage of a bike spend that you think it is worth spending on a bike fit or should I go for the lower spec bike with a top notch fit?
Scott Saifer says:
The goal of a bike fitting is of course to get you to a comfortable, powerful position in which you can ride injury free for many years. There's no reason that has to cost a lot, but it probably will. I'd suggest you start with the free fit that comes with your bike. If you feel great, keep that position. If not, see a mid-priced fitter. If that works, and there's a good chance it will, keep that position. If that doesn't do it, go for the high-zuit fit from someone who really knows what they're doing and has experience with special cases, not just your average, symmetrical riders. Given your large leg length discrepancy, you're probably going to need someone with a lot more experience than the bike-shop guy, though not necessarily the top-level, $680 fit.
I agree that it can seem crazy to pay half as much for the bike fit as for the bike, but I've had lots of people come in with $4000+ bikes that they really didn't like or enjoy riding due to various pains and handling issues, and with a few tweaks, they leave with a bike they love. A cheaper bike that really fits well is a lot more fun to ride than a great bike that doesn't fit, so I think you'd be on the right track if you set aside at least a few hundred for the fit.
When to begin training again after a respiratory infection
I'm sure you may have answered this one before but nearly 4 weeks ago I came down with the flu and then developed a pretty serious bronchitis that required anti biotics and anti virals to clear up. Though the bronchitis is mostly gone, I find that with even light exertion (160ish watts, 100-110bpm) I am still hacking and bringing up junk from my lungs.
The obvious answer, which I dont like considering it's June and I had really hoped to be racing today and not riding an hour in my little ring, is to ride really easy until everything is completely clear. I understand that infections like this have the potential to cause some serious long term damage to the lungs. I guess my question then is, am I wrong to be so concerned? Am I freaking out about this for nothing and should I just go out, race, and deal with it?
Scott Saifer says:
No, you are not freaking out unnecessarily. If you are bringing up junk from your lungs, don't race or do anything else harder than recovery riding. If you really are healthy, the coughing stuff up will be over in a few days and you won't have lost much. If the coughing stuff up doesn't clear up in a few more days, talk to the doctor again.
Kelly Bethards adds:
I second this and actually have been through it myself. After any lung sort of infection, I have seen it take up to 6 weeks to stop coughing. Your season is NOT lost, but you need to recover. If you do not recover fully, your season will be lost and worse off. Like Scott said, if you take it easy and get back to normal, good! If your cough isn't tapering away, you need to see your doctor again.