Tentative steps

About three weeks ago I took a couple of gentle weekend rides, with only a few slight clicks and creaks coming from the recovering knee. SuperGran said that I’d probably be very aware of anything odd going on down there for a while and that it was probably nothing to worry about. She’s a wise lady is SuperGran.

I might have tackled the commute that week, but I wanted to test it one or two more times. A few busy weekends passed without the chance to get out for another spin. Then for some reason I was extra grumpy yesterday morning, so MLSP threw me out of the house telling me to get on the bike and not come back until I could be cheerful.

So off I went, along my usual commute route. Barely the fainest pang or crick was felt in the left knee. Everything was going OK, so I continued along to tackle my nemesis: the little roller coaster dip under MacRobertsons Bridge. This is where it all fell apart last time.

The deadly dipper: city side of MacRobertsons Bridge

I cruised through with considerably more glee than would be normal and healthy in someone reaching the top of such a pathetically small incline. But when you’re in recovery mode, you take ‘em where you can get ‘em. I was pleased to find that I did it much easier than the kid and his dad who were following along behind me—it looked like it nearly killed them.

That was enough, so I turned around and headed for home—cheerful would be an understatement.

Caution to the wind

No more excuses then—this meant I was fit enough to have another go at getting in to work.

Having missed most of winter, I did feel like a bit of a slacker as I blundered around the house this morning trying to find stray gloves and the other bits and pieces I needed to tackle the chilly conditions. When I’m in my commuting routine, I find that Monday mornings tend to involve retrieving bike gear from wherever the hell it’s become dispersed over the weekend. Today the dispersal was multiplied by three months…

Not unexpectedly, I completely failed to make an early start.

But eventually I was away. Every little hill was a test, as I anxiously waited for something to go “twang” and pain to return.

Yes, it really felt this good...

It didn’t.

I made it.

And my goodness, it’s a beautiful day, isn’t it? (If you were on the Gardiners Creek or Yarra Trails this morning and some grinning idiot burbled “Hello” at you, that was probably me.)

It was a slow ride and I was spectacularly late to the salt mine, but I didn’t care: the theme from “Rocky” was playing in my head as I walked in the door.

Now, I just need to decide whether I should ride home tonight, or should I follow MLSP‘s advice to take it easy and catch the train…

Super-Gran measured the ride at 19km—far enough to get me thinking about returning to the commute! So I gave it a few days, to be sure there were no nasty after effects, and decided to have a go at the commute this morning. I’ll admit to being as excited as a kid on Christmas Eve last night.

I laugh in the face of your so-called “gale warning”!

Others might have considered a weather forecast that includes gale warnings as pretty unfavourable, but in my world it was a perfect day for a ride. I trundled along, sending silent praises to just about everyone from Karl von Drais to Tullio Campagnolo, John Boyd Dunlop to…umm, whoever it was who invented bike mud guards. Anyone and everyone who has ever had a hand in developing and making these beautiful, elegant machines. What the heck, I even felt good toward the jokers who invented STI gears! Yes, it was indeed a beautiful morning.

But it’s funny how your mood can change in a flash, isn’t it? For as I rolled under MacRobertsons Bridge and tackled one of the few inclines on my route, it was all over. In the space of a few minutes I went from not a twinge to “Oooh —! That really —ing hurts!” From the warm glow of happiness to cold, hard despair. My knee may well have been OK for a leisurely trundle along the (almost completely flat) Rosstown Rail Trail on an unloaded bike, but it turns out that it wasn’t ready for a commute on a loaded bike.

And I wasn’t even pushing things—I was taking it really, really easy. Seriously annoyed, I can tell you.

Here’s my Big Lesson for the Week: when recovering, don’t rush your return. Bleeding obvious really, but I don’t think I’m the first or the last to fall for this mistake.

New insight

We used to gently tease the ol’ Retired Marathoner whenever (frequent) injuries kept him from his jogging routine. I’m not sure who first said that it was like he was having withdrawal symptoms, but I’m gaining a whole new insight into it. It really happens—and it turns out that I’m not alone:

Depressed mood and fatigue are commonly observed in individuals deprived of usual exercise activities, and the increase in fatigue may be partially mediated by reduced fitness levels. These findings may explain mood changes in response to short-term exercise withdrawal such as injuries and recovery from medical procedures that do not require full bedrest.

So steer clear people. For your own safety, steer well clear.

(However if you come with sympathy and support, you will be grudgingly tolerated…)

There were two main things I wanted:

Sound advice about cycling and knee injury

Something a bit more substantial than ‘just jump on a bike—it’s low impact so it’s good for your knees’, because my own experience shows that’s not necessarily the case

Sound advice on how I can help my knee recover

I’m thinking that maybe a sensible regime of exercise might be the go here

I found two titles: Knee Pain: The Self-Help Guide, published in 2000 by John Garrett, MD and Bob Reznik, MBA (MBA?!? Do the business schools cover anatomy and physiology these days?) and The Knee Crisis Handbook, published in 2003 by Brian Halpern, MD with Laura Tucker.

Self-help guide

Never really a fanatic for self-help guides, I warily poked inside Garrett and Reznik’s book for what they had to say about cycling. In the chapter on “How to prevent knee pain”:

Another way to stay in shape is to bike, either outside or inside on a stationary bike. Because you are seated, you are removing the bone on bone impact caused by running.

The downside of biking, however, is the movement required typically involves a fuller range of motion than other sports.

And that’s about the extent of it. Not altogether forthcoming about making sure the bike fits. But the point about the extra range of motion is well made: unless you’re running up stairs, you’ll generally put your knees through a greater angle of bend on a bike than on foot. And that’s something I reckon cyclists don’t often think about.

What about their recommended exercises? In the same chapter is a section on “Exercises that make the knee injury-resistant”. Most of these seem to involve squats and otherwise loading the bent knee—and that’s something that’s no longer an option for this little black duck.

True, my knees are probably more pathological than normal at the moment, so how about the entire chapter on “Exercises to relieve knee pain”? That sounds more like my speed. Mostly these look good: plenty of unloaded knee extensions and flexions, leg lifts, ankle rotations, and muscle stretches. (And unlike with the more aggressive exercises in the other chapter, there is only a light-handed attempt to flog their SpοrtCοrd®—something that you could easily substitute with an old bike inner tube and a bit of ingenuity.)

Overall it seems like a pretty comprehensive book on its topic, but for me its coverage of cycling aspects is slender at best (which is odd, considering it includes no less than five photos of cyclists, making it the most illustrated sport in the book). I am also distinctly nervous about the “injury-resistant” exercises they recommend—my experience is that repeatedly loading the bent knee can actually cause injury.

Crisis? What crisis?

So to Halpern’s book, where in the chapter “Play it safer: a activity-by-activity general knee health guide” I read:

Most cycling injuries are the result of overuse. Think about it—if you’re cycling between 60 and 100 revolutions per minute, then your knee is performing the same task between 3,600 and 6,000 times an hour! That’s a great deal of repetitve stress on the knee.

I seem to have heard that somewhere before, and I find it reassuring.

In terms of “protecting yourself”, Dr Halpern makes a series of reasonably detailed recommendations under the following headings.

On proper equipment:

• Make sure you bike is the right fit [yes! yes! yes!]

• Use proper footwear

• Correct leg-length differences

On training:

• Don’t do too much too soon

• Don’t build too fast

• Don’t ride in too low a gear

• Maintain proper technique

• Quit when you’re tired

• Strengthen your inner leg

When compared to the previous book, this is much better coverage of doing right thing by your knees while riding.

Halpern’s recommended exercises are similar to those of Garrett and Reznik—I suppose there aren’t too many different ways the knee can be bended and stretched—but Halpern definitely has fewer that involve loading the bent knee. He also gives a specific caution on squats:

It’s true about all exercises, but especially of squats: proper mechanics lead to results, poor mechanics lead to injury. I’m here to tell you that a properly executed squat is one of the safest exercises out there, and if you can remember to [follow my technique], you’ll be in good shape.

And I’m here to tell you that an improperly executed squat can lead to excruciating pain and debility. So, if you don’t mind Doc, I’ll just give them a miss altogether.

Other than the squats and a small selection of exercises with gymnasium equipment, his selection exercises is easy to perform and requires no equipment more exotic than a towel.

Conclusion

Although I favour Halpern’s book, it’s really unfair for me to “review” either because I only really dipped into them. The sections on knee anatomy and common maladies that affect the knee appear (on a quick skim) to be pretty comprehensive in both books. I must say that in Garrett and Reznik’s book the anatomical illustrations are more generously-sized and lusciously detailed (including a wonderfully squirm-inducing diagram of an arthroscopy). This book also makes better use of photos and diagnostic imaging. And their self-diagnosis flow chart is more extensive than Halpern’s too.

But for his sensible advice on cycling, his caution on squats, and his good selection of gentle exercises, it’s mostly Halpern’s advice that I’ll be following.

Now if you don’t mind, this old granny has to go and take some glucosamine (about which both books are cautiously positive).

Knee pain is the most common lower-extremity overuse problem in cyclists. In one recreational long-distance bicycling tour, 65% of all riders reported knee pain. Another study of more than 500 recreational cyclists indicated that almost 42% of all riders experienced overuse knee pain. While major problems such as fractures, dislocations, and ligament ruptures usually occur only after major trauma, overuse injuries are much more common.

Which is not at all surprising when you consider that:

Cycling is very repetitive; during 1 hour of cycling, a rider may average up to 5,000 pedal revolutions. The smallest amount of malalignment, whether anatomic or equipment related, can lead to dysfunction, impaired performance, and pain.

Or as Dr Will Peveler and co. put it in the Journal of Exercise Physiology:

Cyclists usually keep their pedal strokes around 90 rev/min or greater while riding. Many rides, as well as races, last greater than 4 hours. This repetitive motion can lead to overuse injuries in cycling. Mellion recommends that overuse injuries in cycling should not only be treated with rest and rehabilitation, but also with adjustments to bike setup. Patellar tendonitis is a common overuse injury in cyclists and is usually associated with a low saddle height. A saddle that is too low can cause over-compression of the knee, resulting in anterior knee pain.

Feeling low

Statements like this in both papers (and in some other reading) put more credence on my hunch: that my seat has slipped down a bit in recent times.

According to the Peveler team, there are four methods for determining the correct height of a bike seat:

Hamley

The distance from pedal axle to the top of the seat should be 109% of the rider’s inseam measurement

LeMond

The distance from the centre of the bottom bracket to the top of the seat should be 88.3% of the rider’s inseam measurement

See Greg LeMond’s Complete Book of Bicycling

The ol’ heel-toe

Sitting level on the seat, the rider can just touch the pedal with their heel with the leg fully extended

Holmes

At the bottom of the stroke, the knee should be bend 25-35% from straight (which appears to be backed-up by some pretty sound biomechanics)

See Smart Cycling: Successful Training and Racing for Riders of All Levels and Maximum Performance: Sports Medicine for Endurance Athletes

Peveler’s paper set out to see if these four methods for setting seat height actually agree, and they found that the Hamley and LeMond formulas often do. However, they also found that the heel-toe method more often gets the rider into the 25-30° sweet spot, although the range of angles this method produces is pretty wide.

Running the tape measure

While they recommend the Holmes method, we don’t all have a goniometer-wielding biomechanist on hand to measure our knee angles, so for me it would have to be one of the other methods.

I’ve always used the heel-toe method and I’ve never had any problems before. Other than that, it puzzles me how you can set seat height without taking into account the crank length, so I leaned more towards the Hamley formula than LeMond’s. When I did my sums LeMond said my seat was 2cm too low and Hamley said it was a wild 5cm too low. And a check of the heel-toe length showed that my seat height had slipped a bit without my noticing—about 2cm, as it turned out (I know, I know—I shouldn’t have let that happen). I don’t quite know how, but for me on this particular bike the LeMond formula is pretty effective, so full credit to the TdF champ and his coach—they obviously knows whereof they speak.

I took my newly LeMond-ised bike out for a spin this afternoon, and it definitely felt better with only the odd twinge from the knee to remind me that, yes, I have actually injured myself. But several hours later, the verdict seems to be that the bike is fixed but the same cannot be said for my knee. And given that I have been doing harm to myself over what must be several weeks since I foolishly allowed my seat to slip, I guess I shouldn’t expect it to come good in an instant. I hope recovery won’t take too long, but I can’t say that I’m turning cartwheels of delight this evening. (I’m even considering going [shudder] swimming just to try to keep some muscle tone.)

I don’t know how or when. I haven’t (knowingly) changed anything in my riding setup and I certainly haven’t been overdoing it lately. It happened a bit over a week ago when I noticed a bit of a niggle down in the knee joint as I was trundling home. I didn’t think too much of it—it would be fine by morning, surely.

Wrong

The next morning I started out well, but I wasn’t far from home when things went downhill fast. I was getting severe discomfort on every down stroke, to the point that I was effectively pedalling with my good leg only. And the sore knee still hurt as it turned around.

By some good/bad/indifferent fortune I came down sick that same day, so I left the treadly shackled to a post at work and took the train home. And I continued to ride the train for several days after that—joy of joys.

By the end of the week I’d shaken off the lurgy and with nary a twinge from the knee I was fit enough to ride again. Or so I thought. Despite the extended rest, the knee pain came back almost immediately.

Consultation

So I took my problem to the family physioterrorist over the weekend, in any exchange that went a little like this:

Me

I need some advice.

Phyiso

(Knowing look) Oh, yeah? What’s wrong?

Me

Well, Friday week ago I was riding to work and I got some really nasty knee joint pain.

Physio

Does it happen any other time?

Me

Not really. I notice it sometimes when I pull my feet back to stand up from a chair. Other than that, it’s just cycling that does it. I wasn’t riding most of last week because I was sick, so I thought that would be good recovery time, but when I rode the bike home last night it started again.

Physio

Hmm, could be overwrought hyperflexion of the interstitial gristle*.

* It’s possible these were not the exact words used.

Me

So, what can I do about it?

Physio

Well, a bit of cycling is usually pretty good for that.

Me

Aaaarrgggh!

Cruelty

Several years ago, during a period of madness, I was a gym regular. This ended with a crippling knee injury that left me barely able to walk for months (and climbing stairs was nothing short of excruciating). It’s recovered pretty well, but since then that knee has always been the dodgy one—it’s the creaky, crunchy one. The cruellest thing about the current injury is that it’s in the other knee.

So it’s look like I might have dual dodgy knees—oh, how jolly!

Hmm, I think I’d better check my seat height…