Quick Case: Cyclist with Bilateral Knee Pain | Modern Manual Therapy Blog

Quick Case: Cyclist with Bilateral Knee Pain

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

flexion        FN
extension    DN
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
Treatment included
  • 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
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...


  1. Dear Dr E, I really enjoy your youtube clips and your blogs. They are all practical and clear. I am a graduate from the UK and I notice that there's a difference in terms of assessment between the US and UK. Could you educate me on your interpretation of dysfunctional ankle DF on your above client?

  2. How do you suggest to
    measure tibial IR?

  3. Katherine, please check out this post's picture, look from above when a patient is sitting 90-90, the feet should both externally rotate and interally rotate 10 degrees.


  4. Hi Yun, not sure it has anything to do with US and UK training. I measure using the test that is referenced in the SFMA, half kneel ankle dorsiflexion. It is a proven reliable method of assessment.


  5. Yun, I think you'll find today's post helpful as well. Check it out and you are very welcome!