Spring Knee

Original Editor - Puja Gaikwad

Top Contributors - Puja Gaikwad and Lucinda hampton  

Introduction

Biking-Up hills

Cycling is great exercise and a wonderful way to explore your local area and bike trails. But too much too soon without enough preparation can lead to a soft tissue injury known as 'Spring Knee'.[1]

Spinger Knee:

  • Overload injury more likely to occur when ramping up outdoor riding in early spring after undertraining in winter.[2] eg 'mashing' up hills or through tough efforts utilizing big equipment to get fit after a reduction in biking activity over winter.
  • Cause: A Sudden increase in activity, either by a rapid increase in load, mileage, or intensity in an attempt at last-minute fitness gains.[3] This could be an effect of both the training intensity and the duration.
  • Both situations can give rise to knee pain.
  • This type of soft tissue injury occurs because the new recruitment pattern may not be optimal, and at 5,400 pedal revolutions per hour, it adds up, leading to neurological reprogramming, muscle imbalance, and, ultimately, causing an overuse injury.[2] (see Cycling Biomechanics)
  • see also Cyclists Knee

Knee Anatomy

Knee anatomy.png

The knee joint is fundamental in providing pedaling power on the bike. The torque applied through the downward segment of the pedal stroke is the highest area of force production, achieved through a combination of hip and knee extension.[4][5] The extension of the knee is a result of contracting the quadriceps muscles in the front of the thigh, which crosses the front of the knee joint and pulls against the lower leg. Since the quadriceps make up the largest muscle group (especially in cyclists) the knee joint deals with much of the overload during cycling.[6][7]

Causes

  • Riders increasing the amount of riding volume and or intensity dramatically over a short period of time.
  • Inadequate training and physical conditioning
  • High intensity, harder rides, climbing, or riding with a low cadence all of these can put a lot of strain on the knee.[8]

Contributing Factors

Cyclist racer.jpg

Some of the contributing factors in developing this type of knee pain in cyclists involves:

  • Incorrect Bike Fit
  • Training Errors: Include heavy training loads and high mileage (beyond what the body is conditioned to do), or a rapid increase in training duration or intensity, particularly hill work.[9]
  • Gearing and Cadence: Pushing hard gears at low revolutions put a high load through the patella, whereas lower gears at a high cadence (85-90rpm) will put less load through the Patellofemoral joint with each stroke.[10]
  • Pedaling Mechanics: Inside drift (internal rotation) of the knee, especially during the push-down phase, can be due to weakness or fatigue of the gluteus medius or vastus medialis oblique muscle. This increases the lateral forces on the patella.[5]
  • Muscle Tightness: Most cyclists’ quadriceps and hamstrings will be tight with prolonged riding due to the repeated contraction and shortening of these muscle groups.[11] The inflexibility of the quadriceps, hamstrings, or Iliotibial band (ITB) can limit the range of motion around the knee and are likely to increase the forces on the knee.
  • Weak Lower Limb Muscles: May lead to fatigue-induced alterations in pedaling technique, which will also alter the forces on the knee. As muscles fatigue, their ability to take load reduces, increasing forces through the joint.
[12]

Signs & Symptoms

This is marked by a sharp pain at the top of the patella. Cyclists generally report that the pain is worse when the knee is loaded for example when climbing or descending stairs, during prolonged sitting or squatting, when climbing hills, or pushing high gears.[13]

Management

  • Reduce/manage the training load[14]: To treat and prevent “Spring knee”, cyclists need to alter the amount of load going through the patella and surrounding tissues. An easy option is to avoid using external chainring when cyclist first increases their mileage in spring. Stay on the inner chainring as much as possible to keep cadence high and resistance low. HIGH CADENCE, LOW RESISTANCE IS THE KEY TO HEALTHY KNEE. This, in turn, will decrease the forces and stress put through the articular structures of the knee.[13]
  • The primary objective when experiencing knee discomfort is to customize biking to decrease the loading and stress on the knee joint. A comprehensive bike fit is essential, looking at the three points of contact that are saddle, handlebars, and foot/pedal. Also, specific modifications can be made to mitigate knee pain including the saddle (height, fore/aft, tilt, type), shoe (insoles, wedges, size, width, heel support), cleat (position, float), crank length, and handlebars (reach, height, angle, levers) all need to be addressed,[8] and finding the right balance between comfort, efficiency to minimize the injury risk.[15][16]
  • Modification/loading design can be utilized to efficiently handle knee pain. Spring knee is also sometimes associated with over-gearing, so it’s often a good idea to use smaller gears until regular training is back on track and Progressively increase load as discomfort decreases.
  • Gradually build up strength and endurance: Exercises geared towards cyclists that strengthen the knees is the best way to stop knee pain for good. Quadriceps, Gluteus medius, Hip Flexor, and Core all play vital roles in improving overall lower limb strength.[17]

Preventive Measures

  • Slowly increase the amount of cycling and strength training. For example, begin with easy pedaling, without intensity or hills, over a short distance every second day. A general rule of thumb is to increase the distance or load by 8-10 % each week.[18] They might start at 30 minutes per ride and increase by 10 minutes per week per ride. Once progress to one hour of easy riding on flat ground then cyclists can tackle a harder or longer ride on the weekends.
  • Pay attention to biomechanics: Improper technique is also a major factor especially in endurance sports that feature highly repetitive motions. If a cyclist has a poor bike fit and they ride for an hour at 85 rpm with 5,100 pedaling revolutions in a position that is potentially increasing strain on the tendons of the knee, hip, and ankle joint. Therefore, proper biomechanics are fundamental to minimizing the risk of injury.[19]
  • Perfect Pedaling: It is actually a better practice to pedal in a lower gear, as the stress on joints is significantly less. Also, It is important to pedal in a circular motion, balancing between the right and left leg. Most beginners pedal with an ovular motion which creates an imbalance of stress on each leg.[8]
  • Pre-ride warmup: A proper warm-up may last 10-20 minutes depending on the length and intensity of the training session.[20]
  • Regularly perform strength and conditioning training at the same time as returning to cycling. Generalized stretching and a foam roller around the quadriceps and gluteal muscles can help to control soreness and thereby helps in faster recovery.
  • Include sufficient rest: our body is amazing at adapting to training stress and even adapting to changes in biomechanics. But adaptation takes time and recovery. Ideally, athletes must include at least one day of complete rest after 7-10 days of training.
[21]

Return to Biking

A very important step upon returning to active training is to make sure cyclists are reconditioning their bodies to operate with proper biomechanics. This can be done by taking a step back in the intensity of training so that they can focus on technique for a while, and then start increasing training load by 5-8% per week for the first 2-3 weeks of training for a successful return to cycling.[9]

References

  1. Clarsen B, Krosshaug T, Bahr R. Overuse injuries in professional road cyclists. The American journal of sports medicine. 2010 Dec;38(12):2494-501.
  2. 2.0 2.1 Silberman MR. Bicycling injuries. Current sports medicine reports. 2013 Sep 1;12(5):337-45.
  3. Guanziroli N, Billières J, Menetrey J. Cycling Injuries. InInjury and Health Risk Management in Sports 2020 (pp. 605-614). Springer, Berlin, Heidelberg.
  4. Burnie LA. The effects of strength training on intermuscular coordination during maximal cycling (Doctoral dissertation, Sheffield Hallam University)
  5. 5.0 5.1 Langer P. Cycling. InAthletic Footwear and Orthoses in Sports Medicine 2010 (pp. 193-213). Springer, New York, NY.
  6. Bini RR, Hume PA. Effects of workload and pedaling cadence on knee forces in competitive cyclists. Sports biomechanics. 2013 Jun 1;12(2):93-107.
  7. Ruby P, Hull ML, Kirby KA, Jenkins DW. The effect of lower-limb anatomy on knee loads during seated cycling. Journal of biomechanics. 1992 Oct 1;25(10):1195-207.
  8. 8.0 8.1 8.2 Wanich T, Hodgkins C, Columbier JA, Muraski E, Kennedy JG. Cycling injuries of the lower extremity. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2007 Dec 1;15(12):748-56.
  9. 9.0 9.1 Cosca D, Navazio F. Common problems in endurance athletes. American family physician. 2007 Jul 15;76(2):237-44.
  10. Lepers R, Millet GY, Maffiuletti NA. Effect of cycling cadence on contractile and neural properties of knee extensors. Medicine and science in sports and exercise. 2001 Nov 1;33(11):1882-8.
  11. Bini RR, Bini AF. Potential factors associated with knee pain in cyclists: a systematic review. Open access journal of sports medicine. 2018;9:99.
  12. Cycling Knee Pain Explained Available from https://www.youtube.com/watch?v=FhncCmz3ZvM&list=LLaDrvwvYgVKMo_1Zy-JMnpg&index=416
  13. 13.0 13.1 Schwellnus MP, Derman EW. Common injuries in cycling: Prevention, diagnosis, and management. South African Family Practice. 2005 Aug 1;47(7):14-9.
  14. Silberman MR. Bicycling injuries. Current sports medicine reports. 2013 Sep 1;12(5):337-45.
  15. Silberman MR, Webner D, Collina S, Shiple BJ. Road bicycle fit. Clinical Journal of Sport Medicine. 2005 Jul 1;15(4):271-6.
  16. Thompson MJ, Rivara FP. Bicycle-related injuries. American Family Physician. 2001 May 15;63(10):2007.
  17. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2005 Sep 1;13(5):316-25.
  18. Asplund C, St Pierre P. Knee pain and bicycling: fitting concepts for clinicians. The Physician and sportsmedicine. 2004 Apr 1;32(4):23-30.
  19. Caporaso T, Palomba A, Grazioso S, Panariello D, Di Gironimo G, Gimigliano F, Iolascon G, Lanzotti A. Development of site-specific biomechanical indices for estimating injury risk in cycling. In2020 IEEE International Symposium on Medical Measurements and Applications (MeMeA) 2020 Jun 1 (pp. 1-5). IEEE.
  20. Atkinson G, Todd C, Reilly T, Waterhouse J. Diurnal variation in cycling performance: influence of warm-up. Journal of sports sciences. 2005 Mar 1;23(3):321-9.
  21. How to Eliminate Knee Pain when Cycling Available from https://www.youtube.com/watch?v=-RPI7ZXDVvs