Cycling after TKR

Kinesio tape actually curbs kneecap grind

So I finally got around to trying some kinesiology tape to try to alleviate the grinding sensation coming from my natural left kneecap. For me, it actually helps. It's a bit of a hassle, but worth the effort on longer rides.

I had a total knee replacement (TKR) of my left knee in the fall of 2009. My recovery went great and I'm still able to ride my bike strong, but one nagging consequence of the TKR is that there is a grinding sensation and noise when I ride my bike, especially during the first 15 to 20 minutes of riding, and during seated climbing efforts when I'm putting down more power. It rarely hurts, but it's not pleasant, so I thought I'd give this tape a try, since I had heard it helps keep a joint well aligned and functioning more smoothly.

According to my orthopedic surgeon, the grinding (the medical term is "patellar crepitus," which I've written about here before) is most likely related to the underside of my natural kneecap rubbing against the artificial joint. He had told me that as long as it doesn't cause pain or starts accelerating the wearing down of the joint, it's best to leave it alone. If it got worse, I was told, we could consider taking out my natural kneecap and inserting an artificial one. Of course, I wasn't about to do anything that invasive for what amounts to a nuisance, so I've learned to live with it. Then I started finding out more about this tape, seeing it on athletes including cyclists, and hearing about how it helps protect joints.

The bottomline for me is that it reduces the grinding sensation by about half. The downside: it's a bit of a hassle to use. 

First off, you have to shave your knee area and part of your leg, so that's a bother for a recreational cyclist like me who doesn't leg shave. Once that stubble comes back in, the tape doesn't stick as well unless you keep it shaved. So I'm going around with just my left knee region shaved--kind of odd looking, but a time saver.

I also found that to get the tape to stick well, you need clean, oil-free, dry skin. I'm using alcohol-treated medical prep pads to wipe down my knee prior to tape application and that really makes a difference in getting the tape to stick. I'm sure it's not great for my skin to use those pads, but we're talking here about the battle-scarred skin of 53-year-old man who has had three knee surgeries, not the silky skin of a 20-year-old model, so I just use the prep pads and maybe apply some lotion after I remove the tape. In the picture here (it's a "selfie" so it's an odd angle) you can see how I arrange the tape, which is pretty close to how I've seen it on instructions. There are many how to videos on You Tube.

Another drawback to this sort of tape is that it's relatively expensive. I'm using a more moderately priced brand called "KT" that I picked up at a local CVS pharmacy using a 20 percent off coupon, so I paid just a tad over $10 for a box of KT pre-cut strips. There are more expensive brands that I plan to try, but the KT is working for me as long as I prepare my skin properly, so I'll finish off the second box before giving some SpiderTech a shot. If I apply it carefully, I find that the KT can withstand a sweaty, long ride and one shower, and still be worn the remainder of the day, but if I sleep with it on, it comes partially undone along the edges.

I'm sure I'm probably not doing this tape in the best possible way. Some fellow riders have told me I need to go for the SpiderTech brand. An expert might tell me I need to see a specialist to learn how to apply the tape. Others might say my application isn't terrible, but is a bit off, and they may be right, because a few days ago, I noticed a picture of young cycling star Andrew Talansky from the Tour de France that shows his knee taped somewhat differently, and he probably had a masseuse or expert to help him. I even had a fellow rider kid me that I'm trying to look "pro." But for now, what matters most to me is that the tape significantly reduces the grinding I experience.

The crepitus is by no means gone. The grinding sensation is reduced by about half. My theory is the taping sort of "lifts" the kneecap a bit and helps it track better during cycling, thus reducing the grinding, while also giving support to the surrounding muscles. I have no scientific proof for this--no digital "grindometer" data to share, but I know my knee, and it feels better with the tape on. So I think I'll keep using this sort of tape for longer rides, experiment with new taping and application techniques/advice, and not worry about the expense. Even if I spend $200 a year on tape, I figure that's a pretty cheap price to pay for better comfort day to day, and possibly, more longevity for my TKR.

 

 

Two years out from TKR, joint is solid

Next week, it will be two years since the total knee replacement (TKR) on my left knee. I'm glad to report it's holding up well, as confirmed by a visit with my doctor Sept. 28.

He took an X-ray, and the joint is looking solid, as you can sort of see from the picture I snapped while the X-ray was up on a computer screen. Basically, there should be an even gap visible between the top and the bottom halfs of the joint. In fact, the look of the X-ray hasn't changed much since my last X-ray in July of last year. Nice even gap, with no significant change versus my x-Rays from last July. So that's the good news: my artificial joint is looking rock solid. I put about 4,000 miles on my road bike this season, including three century rides and a couple of 100 kilometer rides. No swelling or pain after these long efforts, and I also did plenty of hiking, walking, and some stream wading/fishing. So the knee is holding up well to my active life-style.

Now the not so good news: I discussed the clicking and popping noise and discomfort coming from my kneecap area, and my surgeon (Michael Schaubelt of Aurora Baycare in Green Bay) says that's going to stay with me.

The condition--which I've mentioned in earlier posts--is called patellar crepitus. My natural kneecap was left in during the TKR, and as my doctor explains it, the condition is due to the inside of my kneecap rubbing against the artificial joint and basically "losing the battle." As there is only minor painful sensations in my case (especially when I bend the knee under higher loads or stress), there is nothing that can be done at this point.

My doctor says if it gets worse, to come see him. The only lasting way to get rid of the popping would be another knee surgery to remove my kneecap and put in an artificial one, but for the foreseeable future, I'd rather put up with some limited noise and discomfort than have another operation. Note: during the course of the summer, the patellar crepitus stablized and actually seem to get a bit better. Funny how putting the mileage in on my road bike always seems to make me feel better.

We briefly discussed the use of kinesiology tape (like SpiderTech brand) to make my kneecap track better or somehow create better "lift" between the cap and the joint under high stress flexion. My doctor didn't think such taping would help much, but said it might be worth a try. Has anyone out there used kinesio taping to alliviate patellar crepitus popping/clicking problems? If so, let me know. In the meantime, I'll try experimenting with it.

 

A bit creeped out by my knee's patellar crepitus

Well into my second year after total knee replacement (TKR) surgery on my left knee, I'm doing well, except for grinding, popping, and a bit of pain coming from under the knee cap area at times. I've found that there is a term for this sort of noise--it's called patellar crepitus.

According to an article I found on the Orthosupersite, "crepitus is caused by the same conditions responsible for patellar clunk: frank catching of a synovial nodule in the intercondylar box during knee extension." The way I think about it is that there is some bad bits floating around under my kneecap that catch and cause some grinding and occasional pain.

I plan to talk to my surgeon about it next month when I see him for a checkup and x-ray. The crepitus first became noticable early last summer, about seven months after the surgery. It's been getting steadily worse, even though my knee feels stronger than ever. The crepitus doesn't keep me from cycling hard, but I've quit doing squats in the gym, because when I tried doing squats with free weights last fall that seemed to make the crepitus worse. On the bike, it's most pronounced when I first start riding, and also when going uphill seated but putting out a lot of power under lower RPMs. On flats at cruising speed, it's not an issue. When I walk it's not an issue, but if I do a deep knee bend I experience some crepitus.

I'll do some more posts about this condition soon. My basic outlook, however, is that I'm still happy I had the surgery. I was hoping my knee would be less noisy post-TKR, but overall, my knee condition and ability to do off-the-bike activities like standing and walking is so dramatically improved versus my pre-TKR condition that I'm OK with a bit of crepitus. For sure, I'll do another "crepitus" post after talking to my surgeon. Maybe there is something that can be done about it, such as special taping or bracing.

 

 

Year after TRK, lessons learned, Part II

As written about in my last post, it's been a year since my total knee replacement (TKR), and I'm sharing my top lessons learned. Here is the second half of those tips:

6. Get refit on your bike. In my case, my left leg ended up being much straighter than it was before the surgery. This can be fairly common among TKR patients, because the "bone-on-bone" condition many of us suffer through prior to surgery wears away of the bone on one side or another of the joint. About three years before TKR, I had a bike fit specialist set me up with some shims to try to bring a more even pedalling motion to my arthritic leg. At the start of the 2009 cycling season, I had another cleat fitting after I moved to Green Bay that resulted in a further modification my shim set up. After my TKR, I started pedalling using no shims, but after several weeks, went back to my local bike shop (the Bike Hub) so that the fitter could take another look. We ended up using less shimming, slanted toward the other side, and moved my seat position a hair higher. After riding the roads in the spring, I took out one shim, and that has resulted in a good pedalling motion. However, I should probably go back again for a final look, as I feel my motion may be a bit off. A professional bike fitter can spot little imbalances that even an experienced cyclist won't notice on his or her own motion.

7. Don't be surprised if your artificial knee is noisy. When cycling, my artificial left knee still makes a lot of noise, but it doesn't hurt when it makes noise. Before TKR, my left knee also made a lot of noise while cycling, and, it also hurt sometimes under harder efforts. I was sort of hoping my new knee would be less noisy, but overall, I'm not disappointed. It functions well both on and off the bike, and I've come to the realization that it isn't going to feel like the type of normal, natural knee I had as a very young man. After all, my first knee injury was in 1976, and I had two knee surgeries before my TKR.

8. Be ready for setbacks. For me, after a successful summer of riding and a great outing in my first post-TKR century in early September, I had a painful "clunk" from my patella (kneecap) area a few days after doing the century. I attribute it to overuse, since right after the century, I went stream fishing for a couple of days, and then was lifting and portaging a canoe. Thank God, the clunk went away and hasn't come back. It also took a very long time for my swelling to completely subside--close to eight months. In short, be patient, and don't get discouraged by setbacks. Instead, be positive--your condition will improve with time.

9. Pushing your limits is a good thing. By late winter, it was warm enough to ride outdoors again, and despite trying to take it easy on the bike, I couldn't help testing the new joint by trying to pedal out of the saddle now and then. When I first did this, I could feel a little twinge of pain, similar to the pain I felt when trying to lift heavier weights on the quad extension machine. Whenever I felt a twinge, I would ease up. But right after those little twinges, my knee actually felt better--looser, stronger, and not as creaky. How far you can push it is the tricky thing to figure out. Most people going through TKR know their knees pretty well, and can sense when they can go harder. It's my belief that some harder efforts on the bike or using progressively heavier weights in the gym are the best way to really break up and pump out the last of that lingering inflamation.

10. Get off the bike and start enjoying other activities. In the last year or two before I had the TKR, cycling was the only activity I could do on a high level without much pain. I could only walk about a mile or so without my knee swelling up. Standing in line at stores, at a conference gathering, or farmer's market, or that sort of "milling around" event, was out if the question if it involved more than a few minutes of standing. Now I can hike eight or 10 miles without pain, enjoy walking in the outdoors, (like I did at Yellowstone--see video), or wade a stream fishing for several hours. 

I love the bike. It's been a savior for me these last several years and as the cornerstone of my TKR recovery, but now that I can do more of other things, I am.

 

Year after TKR: lessons learned, Part 1

As mentioned, October 7th was the annniversary of the total knee replacement (TKR) of my left knee. I've been thinking about how to sum up some of the things I've learned during my recovery, and thought I'd compose list, because that's what journalists do when we can't think of anything better:

1. Cycling is the perfect form of physical therapy for TKR recovery. It pushes range of motion (ROM), strengthens muscles, and helps loosen and pump inflamation out of your knee. On Oct. 30, 2009, roughly three weeks after my surgery, I was able to pedal a bike using a 360 degress motion. Some TKR patients get back to cycling a tad more quickly, but I had limited ROM those first few weeks, because I tend to swell a lot after a big surgery like TKR. Of course since then, I've used cycling as my main means of recovery and strengthening from the surgery. By May, I was able to ride a 60 mile ride with some friends, and by September, I completed a full century in good form (for me, anyway, which I about 6 hours on the bike).

2. Prepare to start slow with the cycling. For me, this meant setting up a cruiser bike with platform pedals on my indoor stationary trainer, and putting the seat up considerably higher than normal, which in effect makes it easier to revolve the pedals without bending your knee as much (I've read it takes a 110 degree bend, but it can be done at a 100 degree bend if you cheat on form and bow your leg out slightly or keep your ankle up a bit at first). The platform pedals also make for less stress on a still swollen and painful knee. Don't worry, you'll be back on your road bike or "normal" bike soon, but I would advise setting yourself up with something easy to ride with comfy seat and platform pedals, at least for the first week or so of being back on the stationary bike.

3. Take advantage of physical therapy sessions and do all the ROM stretches, leg lifts, and other tricks your PT folks suggest. It's amazing what they have in a good PT clinic--sort of a combination of a health club crossed with semi-torture devices reminiscent of pictures of the Spanish Inquistion. They will whip your ROM back into shape for sure! In short, just because you are a cyclist, don't think that cycling is the best and only way to recover. I found ROM stretches, leg lifts, and quad flexes with a light ankle weight to be extremely important to my early recovery. My insurance only paid for physical therapy through late December, so roughly about 8-9 weeks, going three times a week, as I recall. I had some hefty copay on it, but it was well worth it.

4. Keep up with the ROM stretching and weight lifting after formal physical therapy ends. After my PT wound down, I joined the local YMCA so I could keep up with leg lifting machines and the use of an elliptical trainer. When the outdoor cycling season began again in late winter/early spring, I kept up with the leg lifting, even though it probably made me slower on the bike because my muscles were in near constant recovery mode. But I knew I needed to target the rebuilding of muscles, and that the leg press, quad extension, and hamstring curl machines would help. I stayed with fairly light weights at first, but kept it up regularly until early summer. By summer, I curtailed the leg lifting because I was cycling more than enough to get a good workout for my legs. However, through summer, I worked my calf muscles with weights at least once a week. Over the years, the valgus deformation of my left leg has caused my left calf muscle to atrophy, and I wanted to build that back. Only now is that left calf getting back to the tone it had 15 to 20 years ago.

5. Be patient with your return to high-paced, hard cycling. By late spring, I was feeling pretty good pedalling my road bike, but I didn't have the sort of high-end power needed to keep up with fast riders. I was keeping to shorter distances (less than 100 kilometers), and not doing any sprint work or climbing out of the saddle. In fact, when I did try to climb out of the saddle, it hurt a little bit, though it felt good to test the limits of what I could, and hurt less with each test. As the summer wore on, I felt better on the harder efforts. Maybe others could come back more quickly to their cycling peak, but I would advise that if you race or do fast club rides, don't plan on being able to go balls out for many months after the surgery. In fact, I would recommend taking a full season off from competitive cycling, allowing your new joint to slowly strengthen and lose all swelling, which my surgeon says can take up to a full year. Steadily work your way back to faster riding, perhaps targeting an event about a year after the surgery as your "comeback" event.

One year after surgery, great progress seen

On October 7th, it will be the anniversary of the total knee replacement (TKR) surgery on my left knee. I'll be recapping what I've learned during the past year in some upcoming posts, but I wanted to share these pics of my knees.

I took the first picture just a few days before the surgery. I had been cycling quite a bit that summer, since cycling was about the only activity I could really do without pain and swelling. The thing that stands out in this picture is the severe outward slant or "valgus" deformation of my left leg. My knee had grown very arthritic over the last 15 years, stemming from old sports injuries and removal of cartilage when I was a young man. I didn't help that during my 30s and early 40s, I got away from regular exercise and gained a lot of weight, which probably accelerated the need to have the surgery last year at age 49.

In the second picture, you can see the condition of my knee on October 5, 2010. Obviously, it's much straighter. For comparison sake, I even wore the same old camping shorts I wore the year before. My apologies on the black socks. 

Not only is the leg straighter, it's as strong as it was the year before. In 2009, I was able to ride a six-hour century, and did so again in September of 2010. The muscle strength is back to where it was, though I think that now that my leg is straighter, I'm beginning to improve my muscle strength and tone beyond where it was before the TKR. Most importantly, my knee is functionally much better off the bike, restoring my ability to engage in activities like hikes and stream fishing that I had to give up or curtail before the surgery.

I'll be blogging more soon about what the past year has taught me about cycling-focused TKR rehab, but as they say, a picture tells 1,000 words.

X-rays show knee holding up fine to bike-focused rehab

On July 8, I had a followup visit with my surgeon that showed my knee is holding up perfectly some nine months after my total knee replacement (TKR) surgery. You can see for yourself a picture of the X-ray from the visit, which I snapped with my camera off a PC screen.

As my doctor, Michael Schnaubelt of Aurora Baycare clinic explained, the X-Ray looked fine for both of the key things he looks at: 1) no tilting or slanted wear between the bottom and top halves of the joint; and 2) no dark spots (an infection indicator) above the artificial part where it interfaces with bone.

Naturally, I was pleased the knee x-rays looked fine. It's feeling real good, even with the fairly intensive regimen of cycling and light weight lifting I've been on. I continue to get some grinding noise when I do certain things, so I was concerned this grinding might be related to some strange wear & tear on the knee. More on that grinding in another post, but the x-ray evidence, the way I feel, and the doctor's exam all indicate the knee is doing great.

I did get the chance to ask Dr. Schnaubelt about whether avid cycling--even riding 100 mile centuries--is OK. He said the occasional century ride would not concern him, "but if you are riding 100 miles four or five times a week, I would be concerned." Well, I don't think we have anything to worry about here. I'm an avid cyclist, but I have neither the time or inclination to do that much cycling.

Schnaubelt related a story about a rowing coach who had a hip replacement, but wore it out in just six months of very intensive rowing. His point, I think, is that artificial joints can wear out ahead of schedule if you go ballistic. My doctor doesn't want me doing any running, but says cycling, hiking, and swimming are all excellent activities.

With Baby Boomers like me turning to joint replacement surgery at a relatively young age and still wanting to maintain an very active lifestyle, I'm sure this question of how active can you be without frying the new joint will be debated. The conventional wisdom seems to be to stay away from high impact sports, but I came across news of a recent study that indicates higher impact sports might not be all that bad for premature wear & tear. I'm not going to push things myself. I might shoot a game of horse with the neighbor kids, but I'm not going to get back on a basketball court or try running a 10K.

I'd like to hear other opinions or experiences on whether intensive sports, even high-impact, are all that bad on artificial joints.

Working on range of motion after TKR

In trying to build back atrophied muscles and regain muscle endurance after total knee replacement (TKR) surgery, it can be easy to forget about range of motion (ROM) once you reach a certain level of flexibility. To be able to do things like walk down steps or pedal a bike, I've read that you need to be able to bend the knee joint about 110 degrees backward.

I'm now about eight months out from TKR on my left knee, and achieved that 110 degree ROM a few months back. Since then, I've had the tendency to forget about pushing my ROM, since my knee joint bends just fine for most activities. But that's a big mistake in terms of rehabilitating the knee for a fuller, more active life. I'm finding that the more ROM I have, the more normal the joint feels, and the more power and snap I have to my leg. So I've placed a renewed focus on ROM in hopes of getting my ROM back to where it was before the surgery, and perhaps even beyond that.

One step was to purchase a goniometer to measure the maximum bend in my artificial knee joint. The video below explains this device. I'm also doing some stretches. The most useful ones for me include:

1. Lie face down on bed, pad, or carpeted floor, and bend your heel back toward your glutes. You can hook your other foot around the back of the leg/foot you are bending to gain more leverage, but ideally, have someone help you push your foot back to gain more flex in the joint. This can hurt, so the person helping you should exert steady pressure, rather than a jerking motion. If you start pounding on the floor for mercy like an old fashioned TV wrestler, then perhaps you are overdoing it. Once it gets to the maximum bend you can tolerate, hold it there for few seconds.
2. Simply sitting back on a chair or bench, tuck one knee in and pull back on the shin with your hands to achieve a good bend. You can also use the back of your ankle on the bent leg to pull back with added pressure. I find this stretch works great in a whirlpool, especially after the warm water heats up the joint. Once again, don't jerk back, apply steady, strong pressure, and then hold for a couple of seconds.
3. Try doing a deep knee bend while holding onto a chair or railing, and crouch till you reach the maximum flex. A variation on this is to do a controlled lunge/knee bend into a set of steps, putting the foot for the knee you are working two or three steps up, and keeping your other on the floor or landing.
4. I'm Catholic, and I found that while kneeling in the Church pew, if I keep the balls/soles of my shoes on the floor, then let my weight sink back until my rear end rests on the front edge of the pew, I get an excellent flex in my knee joint. This was difficult when I first tried it at the start of Lent, but was easier by Easter. I felt a bit guilty at first about using a church pew as a physical therapy device, but I was praying for quick recovery anyway, so I figure it's OK, as long as I'm still paying attention to the Mass.

Those are a few stretches that have worked for me. Please keep in mind that I'm not a physical therapist, or in the case of the pew-stretch, not a theologian, so it's best to consult an expert for the best stretches for you.

My bigger point is that ROM is something that needs to be kept after, even after you've achieved a base, functional level. Right now, I'm close to a 122 degree bend, which is where I was at before the TKR last October 7. As I review the video of the "Goni" self measurement, it seems I didn't have it aligned quite properly, so perhaps I was a bit shy of 122. But I'm damn close, which is great. I need to keep working at this while the joint is still healing and adjusting to the surgery. A few more months from now, it may be too late to gain additional ROM!

Second follow-up with surgeon

Today, I had my second post-op visit with my orthopedic surgeon, Dr. Michael Schnaubelt of Aurora Baycare Orthopedic Center. As you can see from the video clip excerpt, the feedback was that I'm doing fine, with the swelling coming down and my muscle tone coming back.

My general pain is pretty much gone except when doing certain movements, so we spent most of the visit discussing a small clicking pop and pain I've been feeling while using the leg curl machine at the local YMCA.

Another concern we discussed was infection, which is serious concern wth total knee replacement. Dr. Schnaubelt says the biggest infection concern is in the 3 months right after the surgery, but that a light antibiotic regimen is a good idea anytime I have any surgical procedure or even a teeth cleaning. The surgery part I knew, but not the part about the teeth cleaning.

I was glad to hear I'm progressing nicely, and that the swelling should be gone in another couple of months. Also, measurement on the bend of my knee was 120 degrees today. We're hoping to get that to 125 or so by my sixth month followup.

Getting refit on the bike

Yesterday, I got refit at my local bike shop to see if my positioning or cleats needed any adjustments before I started using my indoor trainer in earnest as part of my knee rehab. My pedal stroke and tendencies have changed quite a bit after the surgery, so some adjustments were needed.

I've had a couple of different bikes set up on the trainer since the total knee surgery, but I wanted to set it up with my primary road bike for the winter. The first bike I had on the trainer was a hybrid with big, flat "platform" pedals and a comfy seat, but as my range of motion has improved, I'm ready to put my road bike on there. With my road bike, I use a Speedplay clipless pedal system which secures my shoes to the pedals, and since the alignment of my left leg is now a whole lot straighter than before (see pic of "old" knee at right), I wanted to get my positioning looked at again before riding this bike.  So I stopped by The Bike Hub in DePere, Wis., recently and set up an appointment with co-owner Rebecca, who is the shop's bike fitter. DePere is just 3 miles down the road from my house in Green Bay. The shop has a great location right off the Fox River trail.

For three years prior to my surgery, I've been using cleat shims to compensate for the valgus deformation of my arthritic left leg. Basically, a cleat shim (see pic of one these products at left) compensates for misalignment in your pedal stroke and in the way that your foot/shoe applies force to the pedal. These shims come in various slants depending on what needs to be corrected. I see that you can buy cleat shims online, but I wouldn't recommend it unless you are trained in bike fitting. Adding shims should be done as part of a bike fitting or cleat-fitting session with an expert bike fitter.

Pre-surgery, I tended to bow out my left leg quite a bit when pedaling, and the shims I had been using reduced that tendency. My right leg and pedal stroke have always been very good, with no shimming needed. Last spring after I moved to Green Bay, I had Rebecca at The Bike Hub review my cleat fit and cleat shims, and we made some changes then that got me through last spring and summer with no significant knee pain from cycling.

Since my knee is much straighter now, the first step was to remove the old cleat shims in between Speedplay cleats and bike shoes. Rebecca first did some measuring and assessments, including a look at the way my feet naturally hang. Then I got on a stationary trainer to examine my pedaling motion. Rebecca even used a laser light positioned a few feet in front of the bike to see how my knee was tracking while pedaling. This revealed that I needed some shimming, but slanted toward the other side because my stroke now had a slight tendency to move inward toward the bike frame's top tube. My range of motion remains pretty limited, which probably effects my ability to pedal a consistently smooth up/down stroke, so we agreed it's probably a good idea to take another look in a few months. For now, the pedaling motion feels fine and looks pretty good after this initial refit.

I'm definately planning on getting a fuller refit in about three months after my swelling goes away. It would be a good time to upgrade my pedals to a newer Speedplay model that allows for more adjustment in what's called "float." Unlimited "float" felt good with my old arthritic knee, but if the new knee feels strong and really solid in three months, I'd like to be able to limit the float to get a more efficient pedaling stroke.

I'm thinking most any avid cyclist with knee problems already knows about the benefits of a good, professional bike fitting. To anyone unfamiliar with what a bike fitting can do, take a look at this article from the Nov. 19, 2008 New York Times. Bike fittings can seem sort of expensive, but they are well worth it to avoid injury and increase your comfort level during and after rides. I think bike fitting is even more important when recovering from knee surgery, back surgery, or any injury that impacts your cycling motion, especially if you're on a clipless pedal system. Anyway, I'm all set up to pedal away with confidence. I just have to remind myself to take it easy (lighter spinning) on the bike, and in no way neglect the other types of strengthening and range of motion exercises in need to perform to rehab the knee properly.