Last week I saw a PT who is also a high level cyclist with bilateral knee pain. Her eval was as follows.
Subjective: Pt reports cycling daily, trains with a coach. Off season was Sept-Dec, had onset of pain in B medial and inferior pole of patella. Now felt along patellar and quad tendons. At first blamed it on Yoga, hero's pose (full WB knee flexion, lying back). Cross training was yoga, light cycling time. Now believes her resistance training caused the knee pain since she went heavier; mainly performs squats, single leg press, step ups. Stopped working out in end Dec, all of Jan. Her pain subsided, however, at first workout, immediately felt bilateral knee pain return. Currently Sx worse with working out or certain yoga poses. Better with rest.
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension
Cervical flex DN, all others FN
Shoulder LRF and MRE B FN
MSR Left DN Right FN
hip IR Left DN Right FN
hip ER Left FN Right FN
ankle df Left DN mod Right DN mod
tibial lateral glide Left DN sev Right DN mod
tibial IR Left DN sev Right DN sev
sidegliding FN bilaterally
Rotation Left DN, min Right FN
A few things stood out about this case
- knee pain onset was during off season
- off season involves resistance training with varied closed chain exercises
- her daily cycling does not cause knee pain during the season
- a severe limitation of L > R tibial IR and ankle dorsflexion is most likely contributing to her knee pain during cross training
- IASTM to lateral upper and lower leg patterns
- functional mobilization tibial IR in half knee ankle dorsiflexion
- talocrural lateral glide with patient active hip abduction
After treament, the patient reported an "awareness" and feeling much more mobility and free in her WB function. Her tibial IR improved by about 5 degrees (was 0), and half knee ankle dorsiflexion went from knee 4 inches away from the wall to 1.5 inches bilaterally. She was instructed on
- self tibial IR function mobilization 5-7 times/daily
- self talocrural tibial lateral glide reset 5-7 times/daily
- to continue holding off from resistance training until her ankle/tibial mobility is restored to FN
Follow up is in 1 week where I will address her minimal loss of left hip IR/flexion and thoracic rotation. I anticipate following up 2 weeks after that for a bit more manual to address any remaining asymmetries if any and then allow her to ramp up her resistance training.
Keeping it Eclectic...