medicine of cycling foot anatomy & foot-pedal interface · foot anatomy & foot-pedal...
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©BIKEFIT.com
Foot Anatomy & Foot-Pedal
Interface
Clint Laird, DPMFAAPSM, FACFAS
Reaction Sports Medicine,
Director.
Medicine of Cycling
Medicine of Cycling
Lower Extremity Anatomy Review:
Normal Anatomy
Abnormal Anatomy
Orthotic Devices
Shoe/Pedal Interface:
5 Cleat Adjustments
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Normal Anatomy
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Bones of the foot
26 normally occurring
40 accessory ossiclesof the foot
33 joints
106 ligaments
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Anterior Tendons of the Leg
Tibialis Anterior
Extensor HallucisLongus
Extensor DigitorumLongus
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Lateral Tendons of the Leg
Peroneus Longus
Peroneus Brevis
Peroneus Tertius*
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2
Medial Leg Tendons
Tibialis Posterior
Flexor HallucisLongus
Flexor DigitorumLongus
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Posterior Leg Tendons
Achilles Tendon (medial and lateral heads of the gastrocnemius and the soleus)
Plantaris
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Nerves of the Foot
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Abnormal Anatomy
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Tendonopathies
Tibialis Anterior Tendonitis
Shoe gear irritation
Direct trauma
Compartment syndrome (rare)
Saddle too high
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Tendonopathies
Posterior TibialTendonitis
Flat foot
Age
Running/Triathletes
Saddle too low
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Tendonopathies
Peroneal Tendonitis
Rear foot varus
Saddle too high
Ankle sprain
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Neuroma
Inflammation of the insulation around a nerve.
Causes: biomechanical, trauma, improper shoegear and repeated stress.
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Neuroma
Typically between 3rd
and 4th metatarsal heads (Morton’s Neuroma).
Can be between any of the metatarsal heads.
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Neuroma
Heuter’s Neuroma- 1st
and 2nd webspace
Hauser’s Neuroma-2nd & 3rd
Morton’s Neuroma-3rd & 4th
Islen’s Neuroma- 4th
& 5th
Joplin’s- medial hallux
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Neuroma affects Webspace
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Nerve Compression
Deep Peroneal Nerve
High Arched foot type
Low volume shoes
Overtightening shoes
Spurring at the 2nd
Metatarsal-Cuneiform joint (common).
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Varus Definition
Position of the rearfoot or the forefoot relative to the weight-bearing surface that is inverted.
Towards the midline of the body.
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Valgus Definition
Position of the rearfoot or the forefoot relative to the weight-bearing surface that is everted.
Away from the midline of the body
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Rearfoot Varus vs. Valgus
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Forefoot Varus & Valgus
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Cycling orthotics
Must be thin (2mm suborthalon or carbon fiber)
Allow for minimal correction due to depth of shoes.
Minimal rearfootcontrol and forefoot correction.
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Is there a need for custom?
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The Question…
What is the BESTfoot
position for a
cyclist?25
The Answer…
The BEST foot position creates…
MAXIMAL biomechanical efficiency for lower extremity joints/tissue
while
MINIMIZING risk of injury…
for that SPECIFIC CYCLIST26
4% Less than 10% of people/cyclists have a neutral foot
(Cornwall, 2000; Agosta 2001; Whitney, 2003)
Break-down (Garbolosa et al., 1994)
87% = FF varus 9% = FF valgus
Plantar flexed first ray? 4% = Neutral FF:RF relationship
Plantar flexed first ray?
Pedals are made for flat-footed connection. (Millslagle et al., 2004)
Therefore, conventional pedals only “fit” 4% of the cycling population. (Millslagle et al., 2004)
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Leg Architecture: Everyone is UNIQUE!
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What is “normal?”What is “efficient?”
Inefficient Efficient30
©©
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Peak Force = Ball of Big Toe(Sanderson & Cavanaugh, 1987)
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Cleat Fore-Aft Range
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Methods: Cleat Fore-Aft
Primary Goal Ball of big toe over or slightly in front of the
pedal spindle for MAXIMAL FORCE TRANSFER
↑ Stiffness = ↑ Fore-Aft Range
Move cleat Foot FORWARD (anterior) = Cleat BACK Foot BACK (posterior) = Cleat FORWARD
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Setting up front view
Reference Points Second toe (2nd ray) Tibial tuberosity
Lasers – self leveling One for each leg
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Medial-lateral cleat position
What would you change? WHY?38
Methods: Cleat/Foot Medial-Lateral
Primary Goal: Bring foot under knee
Move cleat Foot OUT = Cleat IN Foot IN = Cleat OUT
(Boyd, Neptune, Hull, 1997; Ruby & Hull, 1993)39
Side-to-Side
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Cleat Medial = Foot Lateral Cleat Lateral = Foot Medial
1/2”
1/8” Longer Spindle
1/4” Longer
1mm Washer & 20mm Spacer &/Or Multiple Spindle Lengths
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Pedal Brands Speedplay®
5 widths
Keywin®
6 widths
Shimano®
2 widths
Lateral Knee: Before & After
AfterBefore42
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V-twin Before Spacer & After Spacer
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Valgus Forces&
Cycling
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Causes of Excessive Valgus Forces
Morphological Structure of the cyclist
Neuromuscular PMH
Bike & Foot-Pedal Interface
***Genetics!***
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Solutions: Excessive Valgus Forces
External/Foot-Pedal Interface OTC shoe inserts Custom orthotics Wedges
Cleat Wedges ITS (In The Shoe) Fore Foot & Rear Foot
Internal/Body HEP Manual RX Etc…
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Effects of Severe Valgus Forces (Ruby, Hull, Kirby, Jenkins 1992; Sanner & O’Halloran, 2000; Powers, 2012)
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Forefoot Varus: BikeFit Recommendations
Correcting for FF Varus** 0-2°
No Wedges
3-7° 1 Wedge
6-12° Up to 2 Wedges
12-20° Up to 3 Wedges
** Static Measurements
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Research demonstrates…
Use of cleat wedges increases power output. (Moran & McGlinn, 1995, Dinsdale & Williams, 2010)
Use of cleat wedges improves efficiency.(Sinéad FitzGibbon, doctoral candidate, RMUoHP Ph.D Orthopedics and Sports Physical Therapy).
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MFPI vs. BikeFit®
Recommendations
Modified Foot Posture Index
MILD 0-7 degrees
MODERATE 8-14 degrees
STRONG X > 15 degrees
“WHOPPING” ** 20+ degrees
BikeFit® Recommendations 0-2°
No Wedges
3-7° 1 Wedge
6-12° Up to 2 Wedges
12-20° Up to 3 Wedges
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Pressure area with & without varus wedge
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Posterior View
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Tiberio, 1998
Valgus Forces: Before & After
AfterBefore54
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Cycling: Minimal Variation
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Rigid
Neutral/Flat
Custom or Accommodative Inserts?
Primary Goals: Force redistribution Capture the midtarsals
Custom Orthotics: CYCLING
Cycling orthotics RUNNING
Running orthotics
Accommodative: MAJORITY of cyclists SuperFeet® Heat Moldable
“semi-custom”
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Rotation vs Float(Ruby & Hull, 1993; Wolchok, Hull, Howell, 1998)
Primary Goal: Reduce frictional torsion between tibia & femur
Float = motion of the cleat in the pedal
Rotation = position of the cleat
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Cleat Rotation
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Rotational Adjustment
TOE-OUT Rotate front of cleat IN
EX: Tibial External Torsion
TOE-IN Rotate front of cleat
OUT EX: Tibial Internal
Torsion
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STRAIGHT TOED-OUT
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“Heel IN”
Ideal Cleat Position
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Leg Length Differences
Structural Measurable difference between length of
R & L femurs &/or tibias
Functional Lumbar spine/pelvic obliquity rotation
Asymmetry: COMMON
Symmetry: UNCOMMON
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Leg Length Difference ?
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LLD or Pelvic Obliquity?
How does this affect the legs?
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LLD or Pelvic Obliquity?
How does this affect the legs? Right knee tracks
MEDIALLY (BDS)
Left knee tracks LATERALLY (TUS)
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Standing AP X-Ray
L > R Structural LLD
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Gold Standard: Standing Scanogram
Full-length x-ray Feet Lumbar Spine
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(Jackson & Porter 2012)
Standing AP X-ray
“…& the MD cried…
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Leg Length Difference
Verify presence of a STRUCTURAL LLD
Start correction at 25-50% LLD: x > 12 mm…
Correction up to within 5 mm of total LLD
Sole lift, LL shim cycling & daily shoes
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When Do We Stop?
STOP WHEN...
Your level of knowledge has been met.
Noted improvement in efficiency of cyclist yet discomfort/pain still present.
You’re little voice tells you to...
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Clinical Differential Diagnosis (Two Classic Cycling “Pains”)
Medial knee pain
Numbness in ball of foot
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Clinical Differential Diagnosis (Two Classic Cycling “Pains”)
Medial knee pain Patello-femoral pain Medial meniscal pathology Knee arthritis (OA)
Knee joint Patella
Hip arthritis (OA) Referred pain
Numbness in ball of foot Metatarsalgia Neuroma Low back injury at nerve root
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Clinicians & Bike Fitters
Advocacy creates allies.
Referring out bolsters your credibility.
There is always more to learn.
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Thank You!
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