Cyclingnews Fitness Q&A - October 14, 2009

Left knee pain

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.

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Bennett

Steve Hogg says

Bennett,

Your problem may have a simple solution. The key is when you say "My left knee seems to rotate out/away from the bike at the top of the pedal stroke" which in turn means that it has to move towards the centre line of the bike on the down stroke. When there's pain where you are experiencing it is common with this out on the way up; in on the way down, type of knee movement.

So why is the knee tracking like this?

There are a couple of possibilities. In no particular order they are:

1. The damage you have done to the cartilage of the left hip. Is that the left hip alone that has degeneration of the cartilage?

If it is, are their arthritic changes in the left hip joint?

If there are, that may be the reason for the compromised knee tracking and that pain you experience. The larger question is why are you experiencing cartilage degeneration in the left hip alone (if this is indeed the case)?

Whatever the answer to that is, and it will be some sort of underlying left / right asymmetry, with a functionally or measurably shorter right leg being a strong candidate, will provide the likely explanation for your problem.

2. That the cartilage damage plays no part in this. If so, the reason for your wayward knee tracking is likely to be that you are dropping and/or rotating forward your right hip.

Picture this: right hip drops and moves forward on right side pedal down stroke. As a consequence, the left knee has to move outward relative to the left hip which is being dragged towards the centre line on the left side pedal upstroke. Then as right pedal rises after bottom dead centre, the pelvis rebounds towards the centre line and the left knee moves back towards the centre line placing a sideways load on the knee.

This is very common and has a multitude of potential causes. It could be:

a. Functionally or measurably shorter right leg - Solution - shim up the right cleat
b. Hypertonic right psoas - Solution - see a good physio and have them perform a psoas release and check for psoas trigger points and treat them if they are present.
c. Seat height that is too high. If the seat is too high, the majority of riders will autonomically choose a side to 'protect' and a side to 'sacrifice'. My experience in these matters is that 90 - 95% of riders will 'sacrifice' the left side and protect the right side and that there is no correlation with handedness / footedness etc.
d. A right side in need of correction. My research indicates that something like 99% of riders need some sort of compensation for kinetic chain misalignments and that there is a greater need for this on the right side than the left side. What I'm saying is that again, you may be protecting a right side problem and compensating for it by damaging the left side.
e. Any combination of those things.

Overall, the left hip cartilage damage worries me. If you are new to cycling, then the hip damage didn't happen because you are riding a bike. I have seen the sort of thing you describe, both the hip cartilage damage and the pedaling technique that loads the left knee, on a number of people who have had a short right leg so that needs to be checked out. I'd suggest an X ray or similar - here's something from a hand out I give customers:

Consider seeing a health professional for a referral for a standing, load bearing X-ray with both knees locked and with the relative height of the femoral heads noted. You will need a front on shot and a side on shot so as to determine whether both halves of the pelvis are in the same plane.

The reason for having it taken that way is I get a bit sick of seeing X rays that show no meaningful difference in bone length but the rider will have a collapsed arch or similar foot issue on one side that creates a functional leg length difference. Let me know what the relative height of the femoral heads is and I may need to advise further.

Keeping up with the pack

I was wondering how I can work on being able to keep the pace with my local fast group ride. I'm not a big gear pusher: I'm 5'5", 145 lbs soaking wet, I prefer spinning up climbs.

My problem, among many, is that I can't stay with the group for the whole one hour ride - a circular, 5km mostly flat loop. They average about 40km/h and there are some fellows with quite the belly who hold on but not me.

I have a good base - I do at least six hilly centuries a year and ride in between.

John L
Pasadena, CA, USA

Scott Saifer says

John,

There are three essential characteristics for success in keeping up with a flat group ride:

1) You have to have the base fitness.

Studies vary a bit on the exact number, but generally say that the power to maintain a given speed is reduced about 30 percent when you draft a big group compared to doing the same speed alone. The exact reduction depends on how well you draft and how big you are compared to the people you follow.

As a little guy, you should be able to tuck in well behind other riders. To be able to ride with a group at 40km/h (25mph), you have to be able to hold about 36.5km/h (22.8mph) for the same amount of time, riding by yourself. If you can't do that, nothing else will help you.

2) You have to have some speed and some ability to recover from efforts above the average pace. The best way to get those is to ride with the group and do your best to hang on.

3) You have to have drafting and pack handling skills.

Especially as a smaller guy who probably doesn't make the same power as the bigger riders, you need to be able to get protection from the wind at all times. That means, among other things, that when the pack turns, you move to the protected side as you come out of the corner, you draft a half-wheel or so behind the people in front of you and you understand that the draft is rarely exactly behind the rider in front.

If you do a lot of riding but don't keep up with people who ride as much as you do, take a look at your ride quality: Any time you are 'training' even though you are already tired, you are doing junk miles. When you are making good speed for your effort and feeling strong, you are really training.

More knee pain

I have a question about back of the knee pain. I have some pain in my left knee. The pain is in the outside rear of the joint and seems to be near the point where the tendon from the hamstring attaches to the tibia. It does not feel like the pain is within the joint itself.

The pain seems worst when the joint is in maximum flexion. It is more of a nagging pain then an acute pain. When I walk and run it is not noticeable until the knee flexion approaches 90 degrees. What are the likely causes of something like this? I have so far thought that my cleat placement was good but now I have my doubts. I use Speedplay X-2 pedals which have a lot of float.

Thanks,

Dave Walker

Steve Hogg says

Dave,

In my experience, pain in the location you mention is almost always the result of over extending on the left leg while concurrently dropping the right hip on the right side pedal stroke and not rebounding quite to centre for the left side pedal stroke. so the left leg overextends and works through a less than ideal plane. The only problem with what I've just said is that almost always, the pain is worst at greatest extension of that leg whereas yours is at maximum flexion.

Set your bike up on an indoor trainer; take your jersey off and warm up thoroughly. You will need an observer standing above and behind you. What I need to know is, while you are working reasonably hard on the bike -

1. Which hip sits further forward than the other?
2. Which hip do your drop?
3. Do you feel more powerful on one leg than the other?
4. Do your feel more weight on one hand than the other?
5. With hands on brake hoods, which elbow is more locked than the other?

Dave Walker responded

Thanks for the quick reply. I'll try to answer your questions. I had my wife watch me on the trainer last night.

1) It was not obvious that either hip was forward of the other. She said that they looked about the same.
2) It appears that my left hip (the leg with the knee pain) drops at the bottom of the pedal stroke. The right look fairly stable.
3) My right leg definitely feels more powerful than the ailing left. It feels more 'connected' to the pedal. The left almost feels like it loses contact with the pedal at the bottom of the stroke while the right always feels solid. It almost feels like my left knee completely locks at the bottom of the stroke.

The right doesn't feel that way. The left also feels like the cleat is too far back and there is a lot of foot ahead of the pedal axle compared to the right foot. Measurements of the foot and cleat positions do not substantiate this feeling. Everything measures even on both feet.

4) The weighting on my hands and my elbows feel and look pretty even. There might be slightly more pressure on the left hand but I am not sure.
5) I paid more attention to where the pain occurs in the pedal stroke. It is more or less the entire downstroke. It is not really that much worse in one place or another.

Based on what I just answered I am wondering if my left leg is shorter than my right? How would you tell for sure? What would you do about it?

Steve Hogg says

Assuming that your wife's answer to 1. is correct, the most likely reason is that your left leg is shorter. This may be bone length, it may be that you are significantly tighter on the left side, making the left leg 'functionally' shorter.

You are either pointing your toes down on the left side or externally rotating the left hip (turning left heel inward). Either or a combination of both would account for what you perceive.

It's possible that your left leg is shorter than your right - the way to tell is through a CT scan. Given the inherent inaccuracy of 'guesstimating' leg length, as well as the functional asymmetries we all possess in varying degrees, it doesn't matter whether you have a leg length difference or not.

What matters is that you sit as squarely on the seat as possible (and if what your wife has noted is correct, an inability to sit squarely is not the problem) and have both legs reaching through the bottom of the pedal stroke with similar or equal facility, while concurrently not causing problems at the top of the pedal stroke.

Any measure that moves you towards that goal is positive. I would suggest that you shim your left cleat. Based on what you have said, I would suggest 5mm as a starting point but wouldn't be surprised if you need more. You can make one yourself, or alternately, purchase ready-made ones. If the latter and you are in the US, contact bikefit.com.

If you are elsewhere, let me know and I will point you in the right direction. My experience is that something like 71 percent of riders need a cleat shimmed on one or the other leg, as a short, medium or long-term measure.

Dave Walker responded

Thanks again for the reply. I ordered some shims. One comment you made brought up another question. You said: 'You are either pointing your toes down on the left side or externally rotating the left hip (turning left heel inward).' One thing I have noticed over the years is that when I ride my feet have always been angled toes out and heels in.

In fact, I have to locate my cleats all the way to the crank side of my shoes (toes out as far as possible) to give enough heel clearance to not hit the chainstays with my heels.

In street shoes I also tend to walk toes out and wear the outside corner of the heel on all my shoes. According to my mother when I was a baby my feet turned somewhat outward and I had to wear a brace for a while to straighten them out. Can this be contributing to my problem? It there a way to compensate for it?

Steve Hogg says

The simple answer is that you are tight in the external rotators of the hips. The larger question is why.

This may be developmental or even congenital problem occurring anywhere from the feet upwards. What you need to do is find a good structural health professional; preferably with some podiatric knowledge or experience, have them assess you and tell you why.

Once armed with info, you can then plan a regime to change how you function to whatever degree is achievable, relative to the time you are prepared to devote to it.

If all else fails, find a good yoga class or similar.

Guidelines to weight loss

What is the best nutrition strategy for losing 5-7 lbs while maintaining my energy levels for a typical 30-50 mile competitive ride, and not over eat afterwards, yet still recover for the next day?

I am not sure if this data is relevent, but since you often ask specifics, here goes: I am 53 years young, 6'0", 173 lbs, (I was 165 lbs in school), 48 resting heart rate/172 maximum heart rate. I would like to think that about 165 lbs is still a sustainable weight now; I just haven't found out how to get there.

Overall I am competitive with some Cat 3 & 4 racers I ride with. But my side profile tells the truth of the larger belly area than my chest. I would appreciate any suggestions on how to accomplish reducing intake while still maintaining energy.

My general practice has been to eat something like half a wholewheat bagel with jelly shortly before the ride, and then consume one or two gels, a litre of sports drink, and about 3/4 litres of water during the ride. Weight before and after is well within a pound.

I notice on some shorter 20-30 mile rides using just water that I feel sluggish. Maybe that is to be expected and I need to keep doing that alone vs trying to engage the fast guys on those days. Comments welcome.

Thanks so much,

Brent

Pam Hinton says

Brent,

In your question, you hint at the challenge that losing weight during the competitive season presents. It is very difficult to put your body in negative energy balance and still perform optimally. The key to success in this situation is patience!

In addition, based on my experience, you will be much more successful at losing weight if you focus more on your training and less on 'dieting'.

To lose weight, as you know, you have to create an energy deficit. A negative energy balance of 500 kcal per day will result in the loss of about one pound per week. If you lose weight too rapidly (more than two pounds per week), then you risk losing muscle mass, which you obviously want to avoid.

Another pitfall that people often encounter is limiting their carbohydrate intake before or during a ride, believing that carbohydrate restriction will increase fat loss. However, carbohydrate is essential for high-intensity exercise. If your muscles are depleted of glycogen (storage form of glucose) during a competitive ride, you will not have the proper fuel source available to sustain a high-intensity effort.

The suggested carbohydrate intake during a ride that lasts longer than 90 minutes is 30-60 grams per hour. In addition, assuming that you train most days of the week, you need a regular supply of carbohydrate to maintain your muscle glycogen stores. A reasonable carbohydrate intake is 50-60 percent of total energy intake, which for a daily intake of 3,000 kcal would be 375-450 grams of carbohydrate.

Recovery is also enhanced by carbohydrate ingestion immediately following a long, hard effort - approximately 60 grams per hour for the first couple of hours post-ride should do the trick.

Thus, rather than limit yourself to drinking only water during your rides, I suggest you focus on your regular diet. Making one or two small changes can result in significant weight loss if you are patient and maintain the changes over time.

Moreover, these small changes aren't likely to have a negative impact on your training. You want to limit your intake of foods that have a high energy density, i.e., a lot of kcals per volume, and that are low in other nutrients (vitamins and minerals).

A good example of this type of food, are added fats, e.g., butter on bread, dressing on salad, etc. I am by no means suggesting that you eliminate these foods from your diet. Rather, simply decrease the amount that you consume. For example, by using one tablespoon of salad dressing instead of two, you cut out 100 kcal. This a very small decrease in your overall daily energy intake, but over the course of 4-5 weeks would result in a loss of one pound of body fat.

Another common source of 'empty calories' is beverages. Soda, fruit drinks, and beer have about 150-200 calories per 12 ounce can and most of that energy comes from simple sugar (or alcohol). You could easily reduce your energy intake by replacing these beverages with water or a low-calorie alternative.

Don't lose sight of your ultimate objective - which is to enjoy riding with the group - as you try to drop a few pounds. Good luck!

Consistent calf pain

I recently seem to have become afflicted with constantly sore calves, both during and after riding at most intensities.
I'm a 37 year old male who rides on average at least 200km a week and am currently training for a 200km alpine-style climbing endurance event.

During an average week, I concentrate on no more than one aspect of my riding at any time (such as climbing or speed exercises for example), with the exception of a long endurance ride at the end of each week which I increase by about 10 percent in distance each week. I am up to about 110 kilometres now and it has been since my last long ride that this soreness has persisted (some two to three weeks ago).

I take special care to have at least one rest day each week, and a rest or easy week every fourth week with no long ride. I stretch warm each day, space regular low intensity rides between high effort days, and haven't had any soreness issues from poor fitting or sizing in the past with one exception.

I am currently only on my second pair of cycling shoes since I started riding some three years ago. My first pair as it turned out were way too small, but the cleat position felt perfect towards the rear of the ball of my foot. Upon buying my second pair of properly sized shoes, I found that I could not adjust the cleat position far enough back to mimic the position I was used to.

I initially experienced some calf soreness as as I suppose my muscles adjusted to pedaling in a slightly different position than they were accustomed to, but this was only temporary and completely disappeared after maybe three weeks. I am also doing twice the miles since the new shoes. That initial soreness however is the same sensation as what I am now experiencing.

Could position be a factor where it hasn't really been in the past? Or should I look elsewhere such as nutrition? I am still learning when it comes to feeding my muscles both on and off the bike. I also moved my rest week forward one week immediately after the last long ride.

Damien Tydd

Steve Hogg says

While there are a number of reasons and combinations of reasons that can cause the symptoms you describe, by far the most common is a cleat position that is too far forward. You mention that your current shoes don't allow the same degree of rearward cleat movement as your previous poorly fitting shoes. You don't mention what brand, model or size of shoe you have or what pedal system you use.

The easiest solution is to change to Speedplay pedals in conjunction with Speedplay part no. 13330 which is a pair of altenative baseplates that allow adjustment of the cleats anywhere from 5 mm further forward to 14 mm further back than the standard baseplates.

I would be surprised if changing to Speedplays with the 13330's doesn't resolve the problem.

Damien Tydd responded

Thanks for the reply. I did forget to mention the shoe set up I was currently using (Shimano PDR540 pedals on Vittoria Raider shoes).

I was actually unaware of the possibility or existence of alternative set ups that allowed for extra adjustment, thinking the common range of adjustment on offer was something you just had to deal with. I have so far fluked my ride positioning, and after almost 4000km I don't seem to develop any unusual soreness or discomfort anywhere else except for the calves, so many thanks for the tip.

Steve Hogg says

Damien,

Vittoria shoes... That is likely your problem. My relatively little involvement with Vittoria shoes over the last couple of years suggests that their cleat mounting holes are way to forward.

If the shoes fit well and you wish to keep them, the Speedplay option with part no 13330 will improve matters a lot. Failing that, look for a pair of shoes that fit well with more rearward cleat mounting holes. At the moment Specialized and DMT are probably the best in that regard.

If you have a wide foot, don't go for a larger size to gain width as this will move the cleat mounting holes further forward as measured from the heel. Both Shimano and Sidi make shoes in extra width sizing.