Optimizing the Use of Cleat Shimming in Chronic Knee Pain ...

Optimizing the Use of Cleat
Shimming in Chronic Knee Pain
Management among Road
Cyclists
Presented by:
Silvia Araujo, Arien Sirois, Emily Stock, D.Ch Candidates
The Michener Institute, Toronto, ON

Background
Ø Cycling has become a popular form of
recreation, competition, and commuting
(Callaghan, 2005)
Ø Clarsen et al. (2010) cite anterior and lateral
knee pain as the most common overuse injuries
to cause time lost from cycling, prompting the
need for identifying intrinsic and extrinsic risk
factors that dictate appropriate interventions
(Fig. 1)

Cycling and Knee Pain
Ø Due to the repetitive nature of cycling,
overuse injuries are commonly reported
among cyclists (Callaghan, 2005) with 36%
(Fig. 1) of these attributed to the knee
(Clarsen et al, 2010)

Background
Ø Chronic anterior knee pain is
most commonly caused by
patellofemoral pain syndrome
(PFPS) while chronic lateral
knee pain is largely indicative
of iliotibial band friction
syndrome (ITBS) (Dettori &
Norvell, 2006)

Cycling and Knee Pain
Ø Asplund et al. (2004) reported
that anatomic variations in lower
limb alignment, such as limb
length discrepancy, genu varum,
and excessive STJ pronation
(Farrell et al., 2003; Dettori et
al, 2006), often lead to the onset
of overuse injury, causing
dysfunction and pain
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Management Approaches
Ø Current approaches to managing knee pain in
cyclists include: modifications to the bike,
addressing training errors, adding removable
insoles, and cleat shimming in order to alter
foot position at the pedal interface (Burke,
2003)
Ø Dettori et al. (2006) and Asplund et al. (2004)
advocate that a proper bike fitting is essential
for every rider, as incorrect fit may increase
repetitive forces through the knee

Evidence for Shimming?
Ø The addition of varus wedging or shimming to
address intrinsic factors (i.e., LLD or forefoot
deformities) in order to treat overuse knee
injuries in cycling is cited by Burke (2003),
Sanner et al. (2000), and Asplund et al. (2004),
but is often anecdotal and not evidence-based
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Research Aim
Ø The aim of this research is to offer a clinical
approach in implementing cleat shimming to
minimize the impact of intrinsic forefoot
deformities on the knee
Ø Primary objective: To determine whether cleat
shimming can effectively reduce chronic knee pain
in cyclists
Ø Secondary objectives: To determine if lateral or
medial knee pain will benefit more from the use of
cleat shimming and correlate degree of deformity
to degree of pain relief

Hypothesis:
Custom-fitted cleat shims will lead to a
reduction in reported chronic knee pain
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Proposed Methodology
Ø Target population:
healthy road cyclists,
age 18-34, recruited
from local
community
Ø Subject eligibility
determined by
recruitment
questionnaire and
comprehensive
biomechanical
assessment
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Proposed Methodology
Pre-assessment Period:

Proposed Methodology

Proposed Methodology

Outcome measures
Ø Determined at weeks 4, 8, and 12
Ø Include:
Forefoot deformity values
Pain intensity
Degree of pain relief with inclusion of 100 point
VAS and VRS
Ø Secondary measures:
Subgroup analysis of lateral and medial knee pain
Degree of pain relief achieved in each subgroup

Statistical Analysis
Ø A visual analog scale (VAS) and verbal
rating scale (VRS) will be used to assess
pain intensity (Fig. 3) with the objective
aimed at determining the size of the VAS
and VRS decrease, indicating clinically
meaningful pain relief

appropriate score

Statistical Analysis
Ø Descriptive statistics will be computed as means ± SDs
for quantitative variables and percentages for
qualitative variables
Ø A paired, one-tailed T test will assess treatment
effectiveness from baseline on study outcomes
Ø Linear correlation coefficients will be used to assess
correlations pain relief among lateral and medial pain
Ø Means between groups at weeks 0 (baseline) and 12
(endpoint) will be compared using analysis of variance
(ANOVA)

Future Directions
1. If cleat shimming effectively
reduces chronic knee pain in the
participants, this intervention can
be incorporated into a standard,
evidence-based treatment protocol
for this target population

Future Directions
2. Further research incorporating
larger sample sizes, and a randomized
controlled approach will strengthen
the efficacy of the findings and
eliminate the current anecdotal
approach used in cleat shimming

Future Directions
3. This research can offer insight into
the optimal degree of wedging,
thereby promoting its clinical use and
applicability in the podiatric setting
for overuse knee pain in cyclists

Contacts
Silvia Araujo, HBSc, D.Ch Candidate,
saraujo423@michener.ca
Arien Sirois, HBSc, D.Ch Candidate,
asirois479@michener.ca
Emily Stock, HBSc, D.Ch Candidate,
estock402@michener.ca

References
Asplund, C., & St Pierre, P. (2004). Knee pain and bicycling. The
Physician and Sports Medicine, 32(4), 1-12.
Burke, E. (2003). High Tech Cycling.Illinois: Human Kinetics
Publishers.
Callaghan, M. (2005). Lower body problems and injury in cycling.
Journal of Bodywork and Movement Therapies 9(3), 226-236.
Clarsen, B., Krosshaug, T., & Bahr, R. (2010). Overuse injuries in
professional road cyclists. The American journal of sports
medicine, 38(12), 2494-2501.
Dettori,N.J., & Norvell, D.C. (2006). Non-traumatic bicycle
injuries. Sports Medicine, 36(1),7-18.
Farrell, K.C., Reisinger, K.D., & Tillman, M.D. (2003). Force and
repetition in cycling: possible implications for iliotibial band
friction syndrome. The Knee, 10(1), 103- 109.