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Mountain Biking FAQ
Section - 4G. Knee Pain

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J Wesley Prince []
Below is the reply I sent to Tom regarding his knee pain. Thought you might
want to consider it as FAQ material for anterior knee pain.

Sorry for the late reply. I am way behind on the list and still trying to
catch up. Anterior knee pain is generally thrown into a catch-all category
described as patello-femoral syndrome. A precise description of where the
pain is located, what makes it better and what makes it worse would be
helpful. I will make my best guess without the benefit of an exam. Just from
the most likely diagnosis is patellar tendonitis. Often brought about by a
sudden increase in training (or a difficult race with mucho gear pushing?).
It is usually quite benign and easy to treat. I hope it is much better now
but if not, let me know. For the benefit of yourself and others I will
outline a treatment / rehab regimen for this disorder:

1. The pain is your body's way of telling you something is wrong. Therefore,
the most important thing is to stop (if you are racing, consider stopping
the race or at least go into spin mode and stop the gear pushing). A severe
pain means "stop now or you will be sorry!"  A DNF sucks but so does
Arthroplasty and subsequent rehab.

2. Ice the knee for no more than 20 min (E-mail me if you need an
explanation for why longer is NOT better when it comes to icing injuries).
Do this as frequently as possible during the next 48 hrs allowing 1-2 hrs
between treatments. Avoid walking up stairs and hills and much walking
period if possible. If there is swelling you can wrap the knee but keeping
it elevated (higher than the heart or you are not really elevating it) is
the preferred method. Obviously if you have to go to work, wrapping will
have to do. 

3. NSAIDS like aspirin, ibuprofen, naproxyn (Alleve) are the mainstay of
treating musculoskeletal injury. Different substances work better on
different people. Ibuprofen works as well as all those very expensive Rx
brands and is dirt cheap to boot. For an acute injury, 10 days of 1600-2400
mg per day is need. These are not headache doses, but are need for injury
inflammation. Divide into three doses and take it with food. If you have
trouble with stomach acidity (ulcers, gastritis) you may cause a bad flare
up so avoid these meds (tylenol is fine for pain but is useless as an
anti-inflammatory). If you have kidney disease also avoid these meds.

4. When you are pain free in normal walking start to easy spin on the wind
trainer or a nice flat area in a low gear. Just turn the pedals over for
15-20 minutes or so the first day. Stop if you have pain. Ice the knee after
the ride as above for a couple of ice cycles. Progress your riding as
tolerated, maintaining a pain free workout. If you continue to have pain
with minimal effort and have done what you were supposed to do (as above)
it's time to see the orthopedist (a sports medicine specialist if possible).

5. Cycling overdevelops the middle and lateral groups of the quadriceps
muscles and virtually ignores the vastus medialis. This is because the
medialis is resposible for the final 10-20 degrees of extension of the knee
as well as keeping the patella from tracking too far laterally. To protect
the knee you should not be extending beyond 15-20 degrees shy of full
extension in your stroke. You can palpate this muscle on yourself. Feel that
little bulge above the knee on the inside as you extend your knee. It
doesn't get hard until almost fully extended (unlike the other groups more
lateral). You can strengthen this muscle to help keep the patella on track
by doing straight leg raises with progressive ankle weights. This will help
to ensure midline tracking of the patella as you cycle and hopefully prevent
later injuries. Anyone with patellofemoral syndrome type pains should be
augmenting their vastus medialis. It almost always helps!

6. You must be fit-kitted unless you are using clips and straps without
cleats. If you use cleats, take a moto-tool and hour-glass them. If you use
power-grips, time to go to clipless. It you are clipless, make sure you have
rotational freedom. The new shimano pedals work well as well as Onza (for
rotational freedom, not for action). Bee-bops, speedplay and others also
have good freedom. Ritchey's have pseudo-freedom that is not smooth and in
my opinion worthless in this regard. Back in early Sept I posted a how-to on
adding rotational freedom to shimano 737's. If you are interested, let me
know and I will try to dig it up and forward it (a moto-tool is required). I
personally believe that everyone should have at least 7-10 degrees of float
and some absolutely require it. This is easily ascertained while going
through the fit kit procedure. If the bars float back an forth as you pedal,
you set the cleat in the middle of the float and tell the person they need
pedals with float. The more they waver, the more float is needed.  Ignoring
this will most likely send you to the orthopedist somewhere down the road.

N.B. (note well) The information provided above is provided without the
benefit of a physical exam. The Physical Exam along with X rays and other
studies are sometimes very important for arriving at the proper diagnosis.
While anterior knee pain is usually quite benign, there can be serious
etiologies for the pain which demand medical / surgical intervention. Severe
or prolonged  pain, marked swelling about the knee, a locking of the knee,
any instability of the knee, the inability to bear usual weight on the knee,
and a knee which worsens or does not improve within 1-2 days of conservative
therapy needs a prompt medical evaluation. In addition, any popping heard or
felt at the time of the injury needs prompt medical evaluation.

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