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An Unusual Case of Saphenous Nerve Entrapment in a Collegiate-Aged Competitive Road Cyclist:

An Unusual Case of Saphenous Nerve Entrapment in a Collegiate-Aged Competitive Road Cyclist Libby Bergman PT, DPT, MTC Fellow in Training 6 December 2012

History:

History 21 year old competitive road cyclist Vague right knee pain onset September 2010 after changing to longer crank length and lowering saddle Pain began as “swelling” during state road race LEFS 80%

Examination:

Examination Structural inspection Right lower extremity shows rearfoot varus , significant medial bunion Single leg stance: calcaneal varus collapses PROM Classical Hip PROM Flexion IR ER Ext ( sidelying ) Right** 134 abn capsule EF 45 60 -8 Left 140 28 52 0

Examination:

Examination Passive Accessory AP medial unicondylar glide hypermobile , capsule laxity end feel Talus medial:lateral glide 2:1 Calcaneal arc glide ratio 1:1 Hip Inferior glide initially feels hypermobile (4/6), then restricted medially towards end of range Anterior hip glide 1/6, abnormal capsule end feel

Examination:

Examination (+) Thomas test for iliopsoas and rectus femoris (+) Craig’s test for retroversion Weak glute max and glute medius Significant impairment in TA firing Single leg squat Significant knee valgus , rearfoot pronation and tibial IR on the right Unable to elicit pain reproduction with palpation for tenderness

Clinical Impression:

Clinical Impression Patellofemoral pain syndrome caused by multiple kinetic chain impairments and, potentially, alteration in bike fit

Impairments:

Impairments 1. Right hip capsular tightness anterior and medial. 2. Decreased muscle length of rectus femoris and iliopsoas 3. Weakness in core and hip stabilizers evidenced in MMT and functionally in single leg squat 4. Laxity in anteromedial quadrant of the knee 5. Rearfoot laxity in talus medial glide causing excessive rearfoot pronation in single leg stance

Functional Limitation and Goals:

Functional Limitation and Goals Cannot ride longer than 30 minutes greater than 100 watts without onset of vague anterior knee pain and swelling Goal: Return to training 100-300 miles per week at normal training wattage and road racing on the collegiate circuit pain free

Interventions:

Interventions Medial wedge in heel of R shoe for laxities into IR/ pronation Instructed to ride every day <30 minutes, <100 watts to attempt to create provocation to further determine cause

Intervention:

Intervention Mobilization of anterior hip capsule and fascia NMR of glute max/med and hip flexors as extension ROM returned NMR for coordinated TA and hip flexor firing and deep hip rotator firing Home hip flexor stretching Began myofascial exploration at VMO, distal quad, sartorius superficially

Patient response:

Patient response Gained hip extension Improved hip capsular mobility SLR no longer painful, improved NM control NM control of TA/hip flexors improving Increased riding 40  90 minutes at endurance watts (~150-175) with medial/lateral knee ache “Cramping” and “sharp” pain has ceased Pain is now vague subpatellar “tingle/ache”

Find the Cause:

Find the Cause Attempted to elicit symptoms on bike/trainer in the clinic--- tightness reported at 10 minutes Detailed palpation post cycle with assessment of sartorius muscle length Prolonged palpation of Hunter’s Canal with and without quad set lead to one fleeting episode of pain reproduction that was never reproduced again Palpation of adductor magnus tendon reproduces sub/ prepatellar pain and paresthesia

Saphenous Nerve Entrapment :

Saphenous Nerve Entrapment Deep pressure and medial-lateral fascial play performed in 2 sessions to adductor magnus tendon Next week patient trained 11 hours pain free and is now racing collegiately without pain

Discussion:

Discussion How can the adductor magnus entrap the saphenous nerve? Compartment Syndrome? Vastoadductor Membrane?

Treating the Cyclist with Knee Pain:

Treating the Cyclist with Knee Pain Knee pain is one of the most common pathologies in cyclists Bike fit Improper training methods Anatomical factors Pelvis and foot are fixed therefore the knee is the fulcrum of the lower extremity Knee is most likely point for extra stresses to be absorbed

The Effect of The Core in Treating the Cyclist:

The Effect of The Core in Treating the Cyclist Adequate core strength and stability in all planes is critical to normal lower extremity alignment When the core is fatigued, cyclists demonstrate lower extremity compensation to maintain power output Greater frontal plane motion Greater knee valgus at top of pedal stroke Greater total sagittal plane knee and ankle motion due to “ ankling ” to increase power Amplifies other factors including muscle imbalances, training error and improper gear selection

References:

References Abt , JP, Smoliga , JM, Brick, MJ, Jolly, JT, Lephart , SM, Fu, F. Relationship bewteen cycling mechanics and core stability. Journal of Strength and Conditioning Research. 2007;21(4):1300-1304. Horn, JL, Pitsch , T, Salinas, F, Benninger , B. Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Regional Anesthesia and Pain Medicine. 2009; 34(5):486-489. Piva , SR, Fitzgerald, K, Irrgang , JJ, Jones, S, Hando, BR, Browder, DA, Childs JD. Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC Musculoskeletal Disorders . 2006;7(33). Tubbs, RS, Loukas , M, Shoja MM, Apaydin , N, Oakes, WJ, Salter EG. Anatomy and potential clinical significance of the vastoadductor membrane. Surg Radiol Anat . 2007; 29:569-573

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