PRP Injections and Bike Fits (Knee pain update)

It's been about 6 weeks since my knee really started hurting bad this year. The pain originally started as IT Band Syndrome while doing the 24 Hours in the Sage - solo on my birthday in August of 2005. That set off a chain of pain and imbalance that morphed into posterior pain and Popliteus Tendinitis that completely derailed me in 2006 and much of 2007. After a relatively pain free season in 2008 it's back in the form of continual IT Band tightness and acute Patella Tendinitis just below my left knee cap. My experience over the past 3 years has taught me that my knee pain will probably never go away completely, but with proper treatment it can be managed enough to race competitively. Holding out hope that this is true I put together a plan to be able to race this year.

The first thing to do was visit Andy Pruitt of Boulder Center for Sports Medicine (BCFSM) to see how bad the Patella Tendinitis was. An ultrasound scan revealed a small growth on the my Patella tendon just below the left knee cap, probably due to misalignment and years of over use. A few measurements also confirmed what Bobby and Patrick have been telling me for months, that my left hip and pelvis are externally rotated the result and cause of more misalignment plus sculliosis in my spine. Andy suggested a PRP injection in my left knee to heal the tendinitis. PRP stands for Plasma-Rich Platelet injection. It is a relatively new tendinitis treatment that uses the patient's own blood as the main tool of healing. A small amount of the patient's blood is drawn and put in a centrifuge to separate red blood cells from protein rich platelets that are essential keys to the body's natural healing. A small amount of the platelet rich plasma is injected back into the injured area of the body to accelerate the healing process. The platelets stimulate stem cells into the area which rebuild the injured tissue. The recovery time is about two weeks and has been successful in 40-60 percent of stubborn tendinitis cases. More on PRP here, here, and here.

This expensive and experimental solution would be moot if I didn't also try to solve the cause of the tendinitis. To do that I scheduled a 3 dimensional medical bike fit with Andy at BCFSM and sought out world champion distance runner and expert physical therapist Mark Plaatjes. Ramin has had great success working with Mark and highly recommended him. I also backed off my training to shorter and lower intensity efforts and continued to get weekly body work.

Mark found that my left leg is 6mm longer than the right in the tibia. He suggested this was the cause of my hip rotation as my body tried to make up for the leg length difference by rotating my pelvis. The solution was a 3mm heel lift in my regular shoes and a shim in my cycling shoes to even my legs out. Mark also uses cross tissue frictional massage also known as Myofascial Massage on my patella and areas of my back that make me cry - literally! This breaks up the scar tissue and is similar to PRP in that it stimulates the body's natural healing methods. Incidentally, Mark let Molly come in the office on my first visit and while he was working on me she wiped her ass on the carpet right next to him. I was face down on the table and only heard him say is in his distinct South African accent; "I bring you in my house and you wipe your ass on my carpet!?" I was mortified, but he thought it was hilarious and we both had a good laugh.

The bike fit was next. I had a 3D bike fit at BCFSM in 2006, but it was after 3 months off the bike and done mainly on my road bike. Other than a few minor changes it didn't reveal much. This time things would be different, I had put in a solid 8 weeks of training and the main bike would be the Superfly. Before going to the fit studio Andy had another look at my alignment and ordered an x-ray to confirm the leg length issue. It showed an 8mm difference in the top of my hip bones causing my spine to depart the top of my pelvis at a 10 degree angle. In the studio Andy and his assistant Sean velcroed reflective foam balls to my back, hips, knees, ankles, and toes. I pedaled the Superfly on a trainer with moderate resistance inside an array of infrared cameras that took a 3D image of my movements, analyzed it, and plotted the results in 3 plains of motion. My leg length difference and pelvic rotation showed in the results. The side view showed that my right hip was extended forward and rotated with my leg. The front and top views showed that my right knee was not aligned over the top of my foot.

Before and After Views

The first fix was a wider saddle to stabilize my hips. The Fizik Gobi saddle I had been using was only 130mm wide. Sean measured my sit bones on a special foam pad and determined that I needed something at least 140mm wide. He recommended a Specialized Phenom saddle, size 143mm. He also moved my saddle forward and shimmed my right cleat which helped align my knee vertically. I pedaled for the camera again and the results showed much better vertical alignment and less rotation in my hips.

Top View

The two blue dots towards the bottom of the image are the balls on the back of my pelvis. You can see that on the before image they are not clean dots which shows hip rotation and instability. On the after image they are dots which shows good hip stabilization.

Side View

Note how the blue and green balls at the top left of the upper triangle are not in line on the before image which shows that my right hip was rotated forward. On the after image they are superimposed over each other. You can also see that this brought my knee plains in line, the red and black arcs.

Front View

Here you can see that my right knee (red line) is inside of my right foot (green line) on the before image. It is closer aligned on the after image.

Hip Rock and Vertical Alignment

Here are graphs of my hip rock and vertical alignment before and after the changes.

Moving my saddle forward revealed a more disturbing truth, that the Superfly is too small for me. In fact all of my bikes are the wrong size except for the Litespeed, which ironically hurts the most to ride. To get the Superfly close Sean recommended a longer stem, but the trade off is less agile steering. Riding on the trainer also showed a disturbing amount of forward / aft flex in the Bontrager Carbon Seatpost. Not wanting carbon splinters in my backside this would be replaced with the stem. I've never been a fan of Bontrager parts anyway so I opted for a Thomson aluminum stem and seatpost (both were lighter than the former). Here are the new bits and saddle.

New Bits and Saddle on the Superfly

As far as the rest of my bikes, the Ritchey Break-Away is too large and the HiFi is too small. The Superfly is close enough, but I haven't ridden it enough to know if I can live with the muted steering. The changes Sean and Andy made are pretty drastic and the two rides I've done so far felt like I was walking around with my shoes on backwards. After a 2:30 Switzerland Trail loop my seat height felt a little too high. This was confirmed by posterior knee, popliteus, and upper calve pain. That derailed me for entirety of last week. After a follow up visit, Sean moved the saddle slightly forward, but I was too scared to ride this week after how painful the Switzerland Trail ride was.

Today, I finished the last element of the plan and got my PRP injection. All I can say is there were a lot of needles involved and I didn't handle them well as it was early in the morning. Dr. Nichols and his pathologist were very informative and answered all of my questions in depth. The pathologist let me stay and watch blood and plasma separate in the centrifuge. Dr. Nichols encouraged me to watch the injection needle on the ultrasound screen, but the thick heavy gauge needle protruding through my patella tendon was too much. The whole procedure took less than an hour. I'm told it will be a 2 week immediate recovery time followed by up to 3 months of healing. I will be able to start riding easy as soon as this weekend and resume normal training by the end of the month.

Not training at the level I would like to has been frustrating, but I've tried to stay focused and keep out of the pit of despair. I have a great deal of fear that my knee will never heal enough to race at my potential. I try to balance that fear with gratitude that I couldn't have better resources and talent at my disposal. At times it feels like I have been swimming upstream, but such is life. Instead of grinding away the miles in rain, heat, and snow my tenacity is better placed in keeping on track and doing what I'm told. I'm a survivor and am confident that with discipline and some luck I'll be competitive for the Laramie Enduro on August 1st. Hopefully completing the last step of my plan today will be the light at the end of the tunnel.