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.

Objective:

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

ROM

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

Lumbar

flexion FN

extension DN

sidegliding FN bilaterally

Thoracic

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

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...