Cyclingnews Fitness Q&A - October 23, 2009

Tight Iliotibial Band

Since November of 2006 I have been dealing with a problem diagnosed by doctors and orthopedists as a tight Iliotibial Band. The tightness manifests itself on the outside of my right knee where the IT Band crosses the joint.

The problem began suddenly and within 5 weeks it was bad enough that riding was not possible and walking was very difficult. Doctors and others advised rest, which actually made the situation worse. After going to a number of doctors, including orthopedists, and physical therapists I am still unable to ride.

I did seem to be on the road to recovery after certain physical therapy exercises which sought to correct my tendency to put my knees inward as I pedal. I also found that walking for 30-60 minutes and then stretching the quadriceps and the hamstrings helped tremendously. Weight training also seems to improve flexibility in the legs.

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In January and February of 2009 I built up slowly to riding an hour without putting much pressure on the pedals... really just turning the cranks. After one particular ride in which the wind was a bit strong, I awoke the next morning with a very tight and painful Achilles Tendon. This prevented me from walking, which has in turn not helped my IT band tightness.

My question pertains to any experience or advice dealing with Achilles Tendon tightness, tight IT bands and position on the bike. Although each rider is different, do you have any suggestions as to fore/aft position of the saddle, cleat adjustment, Q-factor considerations, etc.?

In April of 2006 I bought a new bike and had my position changed a bit as I had been experiencing patellar tendinitis. Those who fit me on the bike, who are very experienced in this area, moved my position forward a fair amount, while compensating for saddle height, cleat position, etc.

Further information:

31 year old male
6'2" tall, 145 pounds
17 years of road cycling and racing
Position determined by qualified individuals
Average yearly mileage: 8,000-10,000 miles
Look pedals with red ARC cleats
Custom orthotics for both every day shoes (flexible) and cycling shoes (stiff)
Sidi Genius 5 narrow shoes

At 31 years of age I don't want to give up on this sport without a fight, so any advice or direction is most appreciated.
Rob

Steve Hogg says

Rob,

Was the Achilles tendon strain on the right side as well? Proceeding on the assumption that it is, something is certainly awry and if I work through the major possibilities, something should strike a chord with you.

Firstly, ITB issues on one side only resulting from cycling are almost always a consequence of challenges to the plain of movement of the hip at one end of the kinetic chain or the foot / ankle at the other. Let's start with the simple things first.

1. You mention that the ITB problem came on suddenly. Did anything change in the month or so preceding the onset of pain?

For instance, did you get new orthoses or have existing ones modified? Did you replace worn cleats or change pedal systems? Did you change your seat, handle bar stem or adjust the height of your bars? Did you increase your stretching or decrease your stretching in the month or two prior to onset of pain?

Did you have a fall or other big hit, on or off the bike?. Did you change your diet noticeably? Did you increase you alcohol intake noticeably. Did you strain any part of your back at all?

2. Next, have you checked the rotational angle of your cleats? If not, do so to eliminate inappropriate cleat angle as a cause. I know you were positioned by people you trust but cleat angle is not; with red Look cleats, there will be less chance of this being the cause than with systems with less rotational movement but check anyway.

Ride at reasonable load and stop pedaling with the right foot forward. Twist the heel towards the centre line and see whether there is available movement. If not, stop and adjust the cleat so that the nose of the cleat points further towards the centre line. If there is movement, repeat the pedal and coast sequence but this time twist the heel outwards.

If there is no movement, stop and adjust the nose of the cleat so that it points further out from the centre line. Once you have done this on the right leg, repeat the process on the left leg as sometimes problems on one side cause fall out on the opposite side.

3. Do you sit squarely on the seat? Have you checked? If not, mount your bike on a trainer and warm up thoroughly with your shirt off. Working reasonably hard, you will need an observer standing above and behind you on a chair. What your observer needs to note is whether you ride with either hip forward and whether you drop either hip noticeably on the pedal down stroke. Get back to me with the answers.

4. Does one leg feel like it is working harder or is less fluent than the other leg? If so, drop the seat 5mm and see if there is an improvement in equality of effort between legs? Does one leg fell like it is under-extending?. Let me know what happens with this.

5. How long have you been using your orthoses in your cycling shoes? About 50 percent of the time, a well-prescribed pair of orthoses (by which I mean that they solve walking/running issues) will cause problems in a cycling shoe. Have you tried riding without them? If so, what effect did that have on your ITB pain.Before you say yes, have you checked?

Set your bike up on an indoor trainer, ensuring that the bike is leveled between axle centres and warm up thoroughly. You will need to pedal stripped to the waist so that your spine is visible. Have an observer stand above and behind you

Give me the answers to those questions and we'll proceed futher.

Rob then responded

Yes, the Achilles Tendon injury was also on the right side.

1. Changes in the month preceding the injury:
Orthotics: No
Pedals: Yes - I put an older pair of Look pedals on my training bike
Position: The only change was in my position the previous April, moving me quite a bit forward and raising the stem a bit.
Stretching: No change
Fall: Yes - in January of 2006 I had a bad fall on the bike, landing on my right side and causing enough pain in my right hip to keep me off the bike for 6-7 weeks. No broken bones or torn soft tissue was found, but the pain was quite intense.
Diet: Only change is that I recall not hydrating nearly as much as in the past
Alcohol: No
Back strain: No

2. Rotational angle of cleats: I conducted the procedure you suggested. There is enough movement to allow each shoe to touch the crankarm. There is also available movement away from the centerline.

3. Squarely seated in the saddle: My observer could note no drop in either hip or movement forward, though he did note that I do sit off to the right a bit, as opposed to directly over the centerline.

4. Weaker leg: I have been off the bike for over a year, so I can only spin lightly at this point. In the past my right leg tended to be a bit weaker than my left leg. My right leg is also slightly shorter than my left leg.

5. I have been using my orthotics since 2000. They were designed by a physical therapist who is also an active cyclist/runner/triathlete. She gave me two pairs of orthotics: a flexible pair for every day shoes and a stiff pair for my cycling shoes.

The reason for the orthotics stems from the fact that I have flat feet. Last year when she observed me on the bike concerning my IT band, she noticed that I tended to pedal with my knees very much in towards the top tube. Keeping my knees out definitely helps, but the IT band is still tight afterwards. As of now I only try riding every other day without putting much pressure on the pedals for 15-20 minutes.

I have not tried riding without the orthotics.

Steve Hogg says

Rob,

A number of things stand out in your reply.

1. You mention the right leg being shorter. Are you using a shim to compensate for the difference in length? If you aren't, you should be. If you are asking the right leg to reach further under load than the left leg, sooner or later, some part of your body will protest.

If you have your right cleat further forward relative to foot in shoe than is the case with the left foot to compensate then change that and use a shim. My long experience is that differential cleat position to accommodate a leg length difference will cause injuries over time in too many people for it be a method that I have any faith in. If this is the case, then Achilles tendon strains are amongst the common fall out from this approach.

2. You mention that you use an older pair of Look pedals on your training bike. Does that mean that one pair are Look Keos and the other pair are Look Deltas? If that's the case, have you altered seat height on each bike to accommodate the differing overall heights that the cleat and pedal platforms sit above the pedal axle?

3. You say that you sit off centre to the right (short legged side). This may be the problem or part of the problem. If you aren't using a shim under the right cleat, do so as that will make it less likely that you sit off centre.

4. Your orthoses. Were the cycling pair prescribed after watching your ride a bike OR after watching you run or walk?
If the latter, my experience is that 50 percent of the time, one or both orthoses will be the problem. This is because an orthotic alters foot plant angle (eversion/inversion) and pelvic symmetry has an effect on footplant angle.

If you sit on a bike with your pelvis at much the same angle in the coronal plane as you stand, then it is likely that your orthoses aren't the problem. But if you don't, and about half don't, then the amount of correction in your orthoses is likely too much or not enough on one or both feet.

Assuming that I'm on the right track with this, the simplest way to check is to get some BFS in shoe wedges (not Specialized in shoe wedges) in the appropriate size for your shoes and experiment with both orientations; i.e thick side of wedge towards centreline and thick side of wedge away from centreline..

A reason for your problems could be as simple your right leg overextending or the lack of symmetry on seat required for you to reach the bottom of the stroke on the right side with the shorter right leg. It could be as complex as any combination or leg length difference, the effects of orthoses, differential cleat position on each side (if that is indeed the case), the combined effects of the ITB and Achilles tendon issues.

Problems like yours are generally easy to solve in person but can be a bit frustrating to solve via email. Go through what I've mentioned above and get back to me with what you find.

Discuss in the forum

Uneven femur issues

Hello Cyclingnews,

I don't want to over complicate my question so: what bike fit compensation is normally applied for an uneven femur (one being shorter than the other?)

With my standard setup I ended up with ITB issues on the left (shorter) leg and patella issues on the right. Can't quite get that seat height agreeable to both sides. I stacked my left shoe with a home made shim which seems to work quite well. However, I suspect that something like having an asymmetric cleat position - left back, right forward - might be more appropriate?

I am not certain of this, but I think that any physical issues resulting from this condition are not so evident when seated but are more damaging when climbing out of the saddle.

I would appreciate any advice you have on this.

About me:

Riding: B Grade Club Crits and Road Races for Northern Sydney CC;
Distance ridden: 250 to 300km per week (slacken off a little in the winter)
Height: 5'8
Weight: 79kg
Age: 40
What are you good at? Rollers and short power climbs
Bikes: Colnago Cristallo and TCR 1
Flexibility is good

Steve Hogg knows my physio Martin in North Sydney, he indicates that all other parts of me are pretty okay, and my hip has long compensated for the slightly shorter femur (I don't get any back, calf or other issues).

Can't think of any other relevant information. I will save up for a fit with Steve one day but I know from my chums who have been fitted with him that you need to have in the budget the replacement of shoes, pedals, stem, seat, bars etc. Thanks very much.

Andrew
Sydney, Australia

Steve Hogg says

Andrew,

A shim is my usual compensation for a shorter femur on one side. I don't subscribe to any rules of thumb like 'x discrepancy = y shim size' and prefer to take individual cases on their merits. It is not only the femur length difference that has to be considered when deciding how thick a shim to use.

Any issues with pelvic symmetry on bike, differing degrees of flexibility between left and right sides, differing foot sizes and so on have to be part of the picture. The right shim thickness is the one that allows both legs to feel as fluent an even as possible through the bottom of the pedal stroke without causing any problems over the top of the pedal stroke, both on and off the seat.

Some trial and error experimentation should give you a good result but a word of warning; don't bother with differential cleat position. It's a hugely overrated measure for mine and often creates additional problems. If you can't find suitable shim material contact me privately for shims.

Lastly, the extra parts you may be saving for; yeah, it's common to need equipment changes if being fitted but it's not common to need everything you mention in a single case.

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Safety concerns whilst commuting

Hi,

I have recently taken up cycling to work. I do about 30km (19 miles) 3-4 times a week in the city. I cycle in India, so some of the roads are pretty bumpy. I am a 31 year old male and am reasonably active. I am 5 feet 10 inches tall and weigh about 80kg.

Please let me know if there are any health hazards that I can be at risk of and whether it can be avoided by some practices.

Thanks,
Gokul

Scott Saifer says

Gokul,

Thanks for the great question. Congratulations on your commitment to cycle to work. 19 miles 3-4 days per week is enough that you will start to gain some fitness. There are definitely some health concerns with such a commitment. The following list is by no means exhaustive.

First, riding long distances on bumpy roads puts you at risk of injuries related to all that shaking. A bit of rough pavement is not a problem, but seriously bumping up and down can give you numb hands, a sore back or neck and other problems. Picking a bike that sucks up bumps with fatter tires at lower pressure is a good start. If you can add some suspension, that's even better. Have the bike fitted such that there's not much weight on your hands as you ride normally and that you are not so low that you crane your neck or stress your back.

Second, your biggest danger is of course collisions with other bikes and motor vehicles. Get a good helmet of course, but then make sure you can use your senses fully. Listen for vehicles from behind, don't use headphones, do get a helmet mounted mirror. Ride as if you are invisible. Most of the time when a car hits a bike, the driver says something like, "I never saw him. I didn't know he was there." Ride as if the drivers don't know you are there.

Third, I may have a misimpression of air quality in Indian cities, but if they are anything like China, you'd do well to wear an air filter mask or at least a gauze mask that will filter out large soot particles when you ride. Keeping those out of your lungs will help you avoid chest infections and possibly longer term effects. Ozone from car exhaust can also burn your lungs and leave you coughing and more susceptible to illness, and you can't really filter it out, so avoiding the busiest streets is a good idea, as if riding at times of day when there is less traffic.

Good luck!

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Bone density

Hi, good to see this feature is back.

I am a 55 year old cyclist that does around 200-300km per week with some weekend racing thrown in. I recently had some tests done and was diagnosed as having low bone density in my spine (osteoporosis) but a high bone density in my arms. All blood tests and testosterone levels etc were normal.

It appears that the loss of bone density is not through general leaching, low calcium etc as the arms are good. Also the loss of bone density is not the result of poor diet or a alcoholic lifestyle - though perhaps an excess of coffee.

My questions are:

1. Can this be reversed
2. Will continued cycling further reduce bone density
3. What are the best ways to increase bone density through behavior. (having a bad knee rules out jogging)
4. What are the best ways to increase bone density through diet

Finally, this seems to be a cycling-specific problem and it would be interesting if you could elaborate on preventative and recuperative options.

Jim
Sydney, Australia

Pamela Hinton says

Jim,

Your results illustrate the importance of having a bone density test that measures the bone mineral density (BMD) of the whole body and looks at different regions individually. There are some simpler tests that measure BMD of only one region, e.g., heel, and extrapolate the results to the entire skeleton.

But, as you can see, bone loss is not always uniform throughout the skeleton; it varies with the type of bone (cortical vs. trabecular) and the habitual loading exerted on a particular skeletal site. Cortical bone is the dense bone that makes up the outer shell bones and the shafts of the long bones (i.e., femur, tibula, humerus, etc.); trabecular bone is the less dense "spongy" bone that makes up a greater proportion of the vertebrae and the ends of the long bones. Trabecular is more metabolically active and, therefore, tends to be lost more readily in the face of inadequate nutrition, abnormal hormonal status, or lack of mechanical stress.

Skeletal sites that are "stressed" will respond by becoming stronger, so these sites will be somewhat protected against loss. For example, as you might imagine, runners tend to have high BMD of the legs and hip, but relatively lower BMD of the upper body.

Because we all lose bone as we age, it is unlikely that the loss can be "reversed." But, you can take precautions to slow the rate of loss. Cycling is a non-weight bearing activity, so it does not "stress" the skeleton sufficiently to induce an increase in bone in the spine.

Your bad knee will limit your behavioural options to some extent. Obviously, high-impact activities such as running, jumping, etc. may not be possible. In this case, you might opt for weight lifting a couple of times per week. Remember, only the bones that are loaded will be strengthened, so you will need to incorporate lifts that load the spine. Because you have osteoporosis, it is very important that you start with light weights and progress slowly.

Of course, you cannot add bone without the necessary raw materials, so nutrition also plays a key role. Be sure to consume adequate dietary protein, calcium and vitamin D (be especially vigilant about vitamin D during the winter when UV exposure is too low for adequate skin synthesis).

Kelby Bethards says

Jim,

Did you happen to get a bone density on you femur (or hip as it sometimes called on the test)? It is interesting to me that there is this much of a discrepancy between the 2 sites. What I mean, is that many times the result is the opposite. Lumber spine can give false results, but in the other direction (ie: spine may look ok, but the long bones are "thinning").

Advice that Pam gave is sound. Calcium with Vitamin D. I tell my patients with Osteoporosis to make sure they get 1500 mg of Calcium throughout the day. That being said, talk to your practitioner about your options. Sounds like the "right" things were tested (electrolytes, testosterone, etc). Although, this is a small subset of causes of osteoporosis in men.

We can actually increases in bone density with proper diet, medium impact (weight bearing) exercise and in some cases, medications.

As I can tell from your query, you have read a bit on your own about the topic. I would encourage you to follow the link below and read what you'd like on the condition. (Nope, I don't own stock in this company).

www.uptodate.com/patients - search on Osteopenia and Osteoporosis.

Discuss in the forum

Hip-knee pain correlation

Hi,

I am a new road cyclist, riding 15-20 miles 3-4 times per week for approximately two months. On a typical ride, I notice discomfort in my left knee at around the one hour mark. The location is in front, just below and right of my knee cap. The discomfort resolves almost immediately after riding.

Not sure if this is related, but my left hip has been evaluated by an Orthopedic surgeon and I have experienced significant degeneration of the hip cartilage. My left knee seems to rotate out/away from the bike at the top of the pedal stroke.

I am not having any other physical issues at this point, and would really like to resolve this knee problem before it worsens. I am experimenting with saddle height-fore/aft position, cleat position (Speedplay), etc . Any suggestions regarding how to resolve would be much appreciated.

Thanks,
Bennett

Dave Fleckenstein says

I have two points to consider with regards to your knee pain. Both relate to the fact that your knee is the "victim" of your "culprit" hip.

First - the hip has potent referral patterns into the knee. Referred pain means that an area of dysfunction and breakdown can yield pain in a different area. I have treated many patients who cited knee pain as their primary complaint, but had completely benign knee exams. Examination and testing of their hip did yield their knee pain.

The second and more likely scenario relates to the loss of motion that occurs with hip degeneration. Internal rotation at the hip decreases with degenerative changes. This correlates with your observation that your knee "seems to rotate out/away" at the top of your pedal stroke - you are moving into external rotation.

Put simply, your femur is moving into the position that it can move to with the least pain and perhaps is forced to do because of changes within the hip. Your knee pain is simply the victim of your hip. The knee is made to function primarily as a hinge joint, moving in flexion and extension. With your femur forced into external rotation because of your degenerative hip, the next link in the chain, your knee, has now become a U-joint with rotation occurring at the knee.

Structure such as the patellofemoral joint, plica, iliotibial band, and meniscus are all reactive to increased rotation through the knee joint. I would imagine that most of your pain is coming from your patellofemoral joint at this time.

Thus, the solution to your knee pain is to treat your hip. We effectively help patients deal with degenerative hip changes through joint mobilization and manipulation to increase capsular and soft tissue mobility, strengthening of the hip abductor and rotator muscles (particularly the gluteus medius), and specific flexibility training.

Additionally, I have found that bringing the saddle slightly forward and slightly higher reduces the amount of hip flexion at the top of the pedal stroke and gives the hip the best chance to move in a straight plane.

Discuss in the forum

Hernia surgery

Hello,

I have been scheduled for surgery on an umbilical hernia in early December, and am told that I will be required to rest for 4-6 weeks in order to allow the mend in my abdominal wall to stabilise sufficiently before putting any strain on it via training.

My question is simple - should I start my pre-base prep training regardless now, and start over again after the convalesence period or should I just simply wait until January to start my training? My targeted events for next year are not until mid-August to mid-September, so time is on my side.

Michael Callaghan
Vancouver, BC, Canada

Scott Saifer says

Michael,

You are lucky that your target events are late next year. You'll have plenty of time to train up after your recovery period to be strong for August. That being said, the fitter you are before the layoff, the higher peak you'll be able to reach in the next cycle.

You should definitely be active on the bike between now and your surgery, assuming the doctors have okayed riding with your hernia. What you do on the bike before the surgery doesn't matter quite so much. Keep the volume up consistent with what your body is ready for based on recent training.

If you've not done much recent training, start your aerobic base riding. If you're race fit currently, enjoy that as much as the weather allows. You'll have plenty of time to rest up during your convalescence, so there's less need than normal during base development to be careful about avoiding excessive intensity.

Discuss in the forum

The Cyclingnews Form & Fitness panel

Steve Hogg (www.cyclefitcentre.com) has owned and operated Pedal Pushers since 1986, a cycle shop specialising in rider positioning and custom bicycles. In that time he has positioned riders from all cycling disciplines and of all levels of ability with every concievable cycling problem. Clients range from recreational riders and riders with disabilities to World and National champions.

Scott Saifer (www.wenzelcoaching.com) is head coach, CEO of Wenzel Coaching.com and has been coaching cyclists professionally for 18 years. He combines a master's degree in Exercise Physiology with experience in 20 years of touring and racing and over 300 road, track and MTB races to deliver training plans and advice that are both rigorously scientific and compatible with the real world of bike racing.

Scott has helped clients to turn pro as well as to win medals at US Masters National and World Championship events. He has worked with hundreds of beginning riders and racers and particularly enjoys working with the special or challenging rider. Scott is co-author of Bike Racing 101 with Kendra Wenzel and his monthly column appears in ROAD Magazine.

Kelby Bethards, MD received a Bachelor of Science in Electrical Engineering from Iowa State University (1994) before obtaining an M.D. from the University of Iowa College of Medicine in 2000. Has been a racing cyclist 'on and off' for 20 years, and when time allows, he races Cat 3 and 35+. He is a team physician for two local Ft Collins, CO, teams, and currently works Family Practice in multiple settings: rural, urgent care, inpatient and the like.

Pam Hinton has a bachelor's degree in Molecular Biology and a doctoral degree in Nutritional Sciences, both from the University of Wisconsin-Madison. She did postdoctoral training at Cornell University and is now an associate professor of Nutrition and Exercise Physiology at the University of Missouri-Columbia where she studies the effects of energy balance on bone health. She has published on the effects of cycling and multi-day stage racing on bone density and turnover.

Pam was an All-American in track while at the UW. She started cycling competitively in 2003 and is a three-time Missouri State Road Champion.

David Fleckenstein, MPT, OCS (www.physiopt.com) is a physical therapist practicing in Eagle, ID and the president of Physiotherapy, PA, an outpatient orthopedic clinic focusing in orthopedics, spine, and sportsmedicine care.

His clients have included World and US champions, Olympic athletes and numerous professional athletes. He received his Masters degree in Physical Therapy from Emory University and is currently completing his doctorate at Regis University.

He is a board certified orthopedic specialist focusing in manual medicine and specific retraining of spine and joint stabilisation musculature. He is a former Cat I road racer and Expert mountain biker.

Carrie Cheadle, MA (www.carriecheadle.com) is a Sports Psychology consultant who has dedicated her career to helping athletes of all ages and abilities perform to their potential. Carrie specialises in working with cyclists, in disciplines ranging from track racing to mountain biking. She holds a bachelors degree in Psychology from Sonoma State University as well as a masters degree in Sport Psychology from John F. Kennedy University.

Dave Palese (www.davepalese.com) is a USA Cycling licensed coach and masters' class road racer with 16 years' race experience. He coaches racers and riders of all abilities from his home in southern Maine, USA, where he lives with his wife Sheryl, daughter Molly, and two cats, Miranda and Mu-Mu.

Dario Fredrick (www.wholeathlete.com) is an exercise physiologist and head coach for Whole Athlete™. He is a former category 1 & semi-pro MTB racer. Dario holds a masters degree in exercise science and a bachelors in sport psychology.