Part 1. Shoulder pain.
With three plus years into this fitting thing, five years into coaching, and 21 years into my physical therapy career, problem solving is part of my DNA. Through several fitting programs, with Trek, Retül, FIST, Bikefit, and others, I have learned many things. I am a more competent bike mechanic, I have more options to maneuver bike parts into different positions, I have a boat-load of fancy electronic gadgets, measuring devices and alignment tools to use. I have a nice space in a new shop, and enjoy spending my (very limited) free time working with athletes and bikes in the sometimes challenging search for a better bike fit.
One thing that these bike-fit certification courses cannot teach however, especially to students, is to analyze these fits with the mind of a physical therapist, and not a wrench. Paul Swift and Kit Vogel are making good efforts in that regard, and have a fit course for medical professionals, but I would venture further, and say that physical therapists are, or have the potential to be, the best bike fitters. Working with athletes who happen to be patients, gives us incredible insight into the mechanics of the musculoskeletal system of each individual, which can thoroughly change the bike fit. Last night after work, was a “tweak” to a tri-fit that I had done earlier in the year.
Triathlete, (and PT colleague) Susan is a competitive triathlon age-grouper, and was complaining of left anterior shoulder pain in her TT/aero position. In summary:
Main complaint: anterior left shoulder pain, upper Bicipital / anterior Deltoid region, 1-2’ into ride.
Injury history: SIJ dysfunction, intermittent, Tibialis posterior tendinitis. Currently under control.
Flexibility: High, global hypermobility
Power: good, improving in early season.
Muscular endurance: Fair, in upper body, Good in lower body.
Fit position: 35° knee angle, 89° shoulder-elbow angle, trunk-shoulder angle 85°, back angle 28°
Review of fit looked good, but Susan felt that her elbow position needed “something”. She has fiddled with her elbow pad position and by widening them 1cm, had released some of the tension in the shoulder.
Theory of “vertical loading” would indicate that she needed to get the shoulder elbow angle to 90° or thereabouts, thus allowing more of the upper body weight (remember, low muscular endurance) to be borne by the skeletal system, reducing load on the “holding” demand of the muscles. However, in this position, Susan’s, globally hypermobile shoulder was sinking into the sub-acromial space, potentially impinging on the Long head of the Biceps.
The solution resulted from the following tweaks:
Bar-ends tilted up 10 degrees, left one initially, then both matching angle (some riders will be happy with an asymmetrical set-up, this one decidedly not!). This produced left triceps ache but the anterior shoulder pain was much less evident, coming on after 10 minutes at power instead of 2 minutes.
Elbow pads moved in internal rotation to allow miniscule flare out of the elbows.
Right bar end and pad moved 2mm laterally to match left (was set up asymmetrically by bike shop after installation of new Di2 shifters)
Bar ends moved forward 7mm, giving a more open elbow angle. Shoulder pain at bay totally, and triceps ache eliminated.
A two-hour process later, I have a pain-free happy athlete, who managed a three-hour TT position ride the next morning with minimal focal discomfort. By conventional bike-fitting theories, she would have remained in a right angle position at the shoulder and elbow, with excessive compression of her sub-acromial space. Her final position was as follows: 35° knee angle, 109° shoulder-elbow angle, 95° shoulder trunk angle, 28° back angle. My theory is that moving into a more open position, however subtle, increased the muscular activity in the shoulder girdle area, but within the constraints of S’s muscular endurance. Moving the right bar to match the left (correcting the bike-shop asymmetry) allowed more equal loading, however small a balance shift, I think this was important. As she progresses through the season, we will tweak this further, dropping spacers 5mm then 10mm, and dropping the stem from 25° closer to 7°. Her thoraco-lumbar and hip mobility can handle it, her core strength will be able to handle it with some time and work, and her upper body, with practice, training and exercise, will easily be able to handle this more aero position. Her power production is better here in this lower position, but she needs to ease into this position, over the season. These minor, but important comfort adjustments will be a stepping-stone in getting her there. (some dry-needling to the biceps should finish off the issue..)
While I have worked with many great bike-fitters who come from a shop or bike-racing background, I truly believe that knowing this patient-athlete’s body from a PT perspective, coupled with deep anatomy and kinesiology knowledge, can create a more thoughtful, more complete fitter. As I continue through this season, I will keep you posted on some of these PT fit aspects and I hope you find them both interesting and helpful.
As always, I am available at firstname.lastname@example.org for Q+A.