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May 17, 2024

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the difference that one degree can make when performing adjusts to a cyclist's bike fit.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog

If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

MATT KOESTER
Okay, we are live on Instagram and live on Facebook. Good morning, everybody. Welcome to another episode of the PT on Ice daily show. I am your host today, Dr. Matthew Keister. I am an elite faculty in the endurance athlete division with a specialty in bike fitting. So today I definitely am excited to step in and have a conversation about one of my favorite aspects of bike fitting. And that is the really nitty gritty small details that we love and we talk about every course and we get really into the weeds on. But I think sometimes to the outsider can be a little confusing. Before I step into that realm, though, I do want to take a second and highlight a few upcoming courses. This weekend, Jason London, my co-faculty, is going to be in Minnetonka, Minnesota. That course is pretty darn full. If there was any spots left to grab, it's probably the last second to do it, and they might not even be available. The next course we've got is in Bellingham, Washington. That is June 1st and 2nd. That course is sold out, and we're currently building out a wait list. We're also working on setting up a second course offering for that in the fall right now, but there's more details to come on that. And then we have another course set up. Next one coming in is July 27th and 28th in Parker, Colorado. That is going to be an awesome course. Just an easy place to get to in Denver. Always good to ride around there and get some time outside in the mountains. So super stoked for that one as well. That's it. That's it for the upcoming courses right now that I wanted to talk through.

THE DIFFERENCE OF ONE DEGREE WITH BIKE FITTING
Let's get into the title of today. I called it one degree away and I think When we think about like one degree, first of all, the margin of error for that with our measurements is often really, really hard to overcome. It can be incredibly hard to take a look at somebody and say, I'm going to make a one degree change on this and think that that's going to be clinically significant or meaningful to their pain or their experience. It gets a little bit different when we talk about bike fitting, though. When we talk about bike fitting, we're often using a little bit more precise measurements. We're using laser levels. We're using digital electronic levels, things that give us really specific data. And then when we think about the other part of bike fitting, when we make that adjustment to whatever componentry it is on the bike, and I'm going to talk through two specific cases in a moment, but whether it's the pedals or it's the seat, when we go to make adjustments there, that adjustment, while small at the instrument, one, two degrees, has upstream effects or downstream effects that are pretty pronounced when you extrapolate that one degree as it gets further and further away from the axis in which you made the change. So I think sometimes that's the missing piece when we try to have conversations about making a one degree change or a two degree change to something really small. So I mentioned we're gonna go through two different cases and I think the first one is the one that is oftentimes the trickiest when we're actually at the course. We spend a ton of time in the course talking about the art of trying to improve somebody's pedal stroke so that their legs are driving more up and down like pistons and less with dynamic changes or aberrant motions that are in the frontal plane. So knee valgus or going more into abduction. We try to kind of eliminate those things because any power that isn't going straight down the pedals is wasted. So one of the ways that we typically will make a change to get somebody into a better position or consistently riding in a better position is we'll add shims to their shoes. The shim is like, I mean, think about it the way like you would shim anything. It's a, it's a little wedge. It's thicker on one side than it is on the other. And it goes right underneath the shoe or sometimes inside the shoe. We can put that on the medial aspect of the foot. If we want to push that knee out a little bit into more abduction and stop a little, stop some of that abduction or potentially dynamic valgus. We can also, for the individual who rides with their knees pushed out a little bit, We may have to solve other things around the hip and the low back, but for that individual, we can also shim laterally and drive the knee in some to create some stability and drive them into the more neutral up and down position. Every single time that we break out one of these wedges though, they seem like, how could that thing make the change? It is one degree or it's one and a half degrees. And I think that's where things get lost a little bit. It's not the one degree made at the foot that makes the impact. It's what that one degree does when you extrapolate that 12, 18 inches up through somebody's shin bone. When you take it up through all that to the knee, we see some changes. And I grabbed this old-fashioned measuring tool. I had to pull it out of the dirt to get it here. But if we have our goniometer, we have it set up, and I make at the bottom, from a perfect 180, if I make a one degree change and I push that thing over. Down here, that is almost a non-measurable, hard to even see that change happen. But when we get up here towards the top, it's pretty crazy how that one degree change, just in this amount of space, moved us out probably four to five millimeters. Or for those who like freedom units, that's more in the quarter inch range. Many people's tibias are not this length. They'll think even further, take that out even more. All of a sudden now that person whose knee was riding like a half inch or a little bit more outside of what we'd want in a neutral position, as one degree change down here might have a dramatic shift at the knee. So it's really cool when you actually see it. And every time we put it, we put one underneath the client's shoe as fit as ourselves. I think we're constantly amazed. that we put that thing in and we're like, well, we'll see how this goes. And then it's amazing how much different it is and the patient can feel it too. They'll be like, yeah, that feels really good. My foot feels really supported. And you're like, okay, that one degree really did it, did it great. Another really key case for this, there's been research done by Andy Pruitt, who's kind of the godfather of bike fitting. He's done a ton of the leg work for the style of fitting that we do nowadays. When he was early on in his career and he started to really put a lot of content out for this and put a lot of effort and research behind it, he got partnered with Specialized. They're one of the largest bike brands in the country and they wanted him to help create what they considered their body geometry line. The body geometry line was essentially a best attempt to create the best contact points on the bike possible. So that's the cleats, or the feet, so the shoes, the seat, and the handlebars, or like the grips. So they put a ton of effort into their shoes. What they found after just time and time again testing folks, they found that everybody benefited from some level of a medial shim in the shoe. So they were like, over and over and over again, if everybody's benefiting from this and we're getting less adduction and a more piston-like vertical motion, why don't we just build this into the shoes? At this point, they actually do. Specialized, with all of their shoes, the Torch is one of their most, like their flagship and most consistently sold shoes, is baked in with a three degree medial shim to take up some of that flexibility in the foot so that the power we're putting down isn't lost in these aberrant motions, it's more direct into the pedal and it's nice and sturdy. So, that's one of the main changes that came out of the research from Andy Pruitt and Specialized. And I think it just kind of goes to that point of, we know how impactful a degree can be. The person who's dealing with knee pain that is definitely coming from these constant, shifty, aberrant motions, we start to clean that up. We start to get a cleaner picture of what's going on. That all starts with a one degree change. Now, I think the interesting one and the more pronounced version of this is actually at the seat, though. So we're not talking about now adding components or putting new things onto somebody's bike. We are talking about just making an adjustment to tip or tilt the seat. If we bring the nose down, which is a pretty common change for a lot of riders, it makes pretty pronounced changes in low back pain as well as some of the perineal pressures. So you can imagine that if this was the front of my seat and it's tipped up, there's going to create a lot of excess pressure in the perineum. This is a great conversation for any of our pelvic physical therapists to step into because the ramifications of sustained pressure in those areas is definitely in their ballpark and certainly outside of mine, especially if I make the changes and it doesn't quite get what I want. However, when we bring that seat down to try and fix those problems, we want it level or potentially slightly nose down. It's usually like one to two degrees. The reason we want that one to two degrees nose down is because what it allows the person to do is achieve a more relative anterior tilt. They're able to get out of this posteriorly locked lumbar flexion and roll a little bit forward and get into a little bit more favorable position to take stress off the low back when they're riding. This is a space where you go to make your adjustment and you put a electronic level on their seat with a nice level platform on top, and you might make a tiny little adjustment, one degree down. And in that moment, the client is sitting there going like, why did I come in here for this? That was the tiniest little adjustment I've ever seen. And then they hop back on and it's incredible how much better they feel. And the reason for that is the same thing that I already explained at the knee. When we're talking about a one degree change at the axis where you make the change, it has a lot of ramifications upstream. So I'm gonna use my Sangoniometer example. If I look at a one degree change, so let's just say I wanted to get somebody's shoulders more upright, get their back out of some flexion. I make a one degree change nose down. At this point, I've got my quarter inch, maybe a little bit more at this point. Think about somebody's torso being almost double this. and then consider the fact that we might have made a two degree change. I've already got a half inch here. By the time I get to the shoulders, I've probably got a full inch or more change. And that's just a rough estimate, assuming that the person's body was a super rigid straight line. Think about the fact that we have this chain link of vertebrae going up. If you can reduce stress up each one as it goes, you actually can get even more range of motion out of that. So it's pretty profound when you take somebody from a locked out lumbar spine position make a one degree change to something that's sitting right underneath their pelvis. It allows their pelvis to get into a one degree better position, but what it does up the chain is pretty incredible. You'll have somebody immediately go, Oh, that feels so much better. Like I don't feel that pressure underneath my butt anymore. That was really giving me numbness. Oh, I already don't feel that tension on my back. I don't, I feel like I can like get myself upright a little bit. I can get myself into a more neutral position and neutral coming in air quotes there. Cause it's a little bit different. Um, like we're not actually in lumbar spine neutral, but they get closer to it. And that can be the thing, getting out of that fully locked out position, getting into a slightly more neutral position is something that happens with a one degree change. So when we're talking to these folks and we're talking about the adjustments we want to make, it can almost sound really unexciting when we do our wrap up. We're saying, hey Sally, when you came in today, we made some adjustments to the bike. The first one we did is on your shoes, we actually added a shim to them. I put a one degree shim in there. And then when we went to the seat and we made our adjustments, we made a one degree change nose down and we actually slid it forward two millimeters. Those things don't sound really exciting when you say them out loud, but when you start to put together what those things are doing throughout the chain, throughout the whole body, bike fitting ends up becoming one of these things where we can make a very minute change now and have immediate, immediate reductions in pain, immediate improvements in performance, immediate changes in posture and positions and access to those positions. So getting into the nitty gritty, getting into the details, knowing that if you're going to make a one degree change or a two degree change, that it's going to have even bigger effects, talks even more to how important it is that we're accurate with those changes. If you are really, really interested in learning about making those changes, how to keep them accurate, how to make sure that we're not Throwing something else out of whack while we make one adjustment, I highly suggest you join us on the road. The BikeFit course is probably one of the most unorthodox courses in all of ice. It is the most niched down, it's just a bunch of people who love riding bikes and love tooling on bikes. And it's also folks who have absolutely no experience turning wrenches. People who come in who's first time using a torque wrench is in the course and we love that. It's a beautiful thing to have in the clinic and this is one of the main reasons why. It's those tiny adjustments that give us access to positions that we never would have had access to otherwise or would not have been able to fix even if we'd spent a ton of time in rehab when we could have just made the one degree change. Thanks y'all. Appreciate ya.

OUTRO
Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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