Please cite this article in press as: ONeill BC, et al. Custom formed orthoses in cycling.

med orthoses in cycling. J Sci Med Sport (2011),

doi:10.1016/j.jsams.2011.04.002
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Journal of Science and Medicine in Sport xxx (2011) xxxxxx
Original research
Custom formed orthoses in cycling
Brendan C. ONeill
a,
, Kenneth Graham
b
, Mark Moresi
b
, Philip Perry
a
, Donald Kuah
a
a
Sydney Sports Medicine Centre, Sydney Olympic Park, Australia
b
New South Wales Institute of Sport, The NSW Institute of Sport, Sydney Olympic Park, Australia
Received 30 November 2010; received in revised form 30 March 2011; accepted 21 April 2011
Abstract
To assess the effects of currently used prescribed in-shoe custom foot orthoses (CFOs) on a number of biomechanical variables during
the power phase of cycling, including: hip adduction, knee abduction and tibial internal rotation. Before and after cross-over study recording
subjects biomechanical variables with and without their CFOs. Twelve competitive cyclists, currently using prescribed in-shoe CFOs,
performed two exercise bouts on a stationary trainer, with 3-dimensional data recorded on an 8 camera Vicon Mx system. 2-way ANOVA
statistical analysis of Null vs Orthotic condition, and left leg vs right leg. No systematic effects from the CFOs were seen. A trend towards
reduced tibial internal rotation range of movement was found (P<0.072). Signicant subject-specic effects from the CFOs were seen
(P<0.05). Three distinct patterns of knee movement were observed. All subjects had signicant left to right leg differences. CFOs do not
produce systematic effects on cycling biomechanics. Signicant subject-specic biomechanical effects can be produced by CFOs utilizing
rearfoot and/or forefoot wedges. An individualised approach to orthotic prescription, and attention to the forefootrearfoot relationship, is
recommended.
2011 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Keywords: Cycling; Orthotics; Biomechanics; Knee injury; Exercise
1. Introduction
Overuse knee injuries in cycling are one of the most
common complaints of cyclists.
13
There are several factors
which contribute to knee injuries in cyclists: extrinsic (bike
size and set-up, training load and type) and intrinsic (lower
limb alignment, lower limb biomechanics) risks, forming a
complex interplay which can result in knee pain.
1,2,4
Injury
causes loss of training and potentially poor performance. A
more linear cycling pattern is suggested to offer greater ef-
ciency, reducing injury risk
2,5
and improving performance.
6
The use of external wedges and orthotics have been shown
to alter the frontal plane motion of the knee,
7
tibial internal
rotation,
8,9
and affect muscle activation patterns during the
power phase of the cycle stroke.
8
Subject-specic responses
vary which limits the statistical signicance of these stud-

Corresponding author at: Anglesea Sports Medicine, 7 Thackeray St,

Hamilton, New Zealand.
E-mail address: drbo@xtra.co.nz (B.C. ONeill).
ies, but subjective improvements are consistently reported in
cyclists with knee pain.
9
Similar results have been found in
research with custom foot orthoses (CFOs) in runners, with
variable biomechanical effects despite signicant subjective
improvements.
1012
Recent evidence supports an immediate
and sustained effect from CFOs on lower limb mechanics
in running. In particular, alterations in rearfoot and forefoot
kinetics and kinematics, and tibial internal rotation through
the coupling effect of the subtalar joint, are reported.
1315
Francis
16
hypothesised that understanding the coupling
relationship at the subtalar joint is crucial in appreciating
overuse knee injury risk in cyclists. Tibial internal rotation is
required during ankle plantar exion of a locked foot, such as
in the power phase of cycling, with increased tibial rotation
required to accommodate any forefoot varus or rearfoot val-
gus malalignment.
16,17
Similar models have been proposed in
running.
13,18
Compensatory hip adduction helps dissipate tis-
sue tension at the knee, but increases knee abduction and the
Q angle, known risk factors for anterior knee pain.
1,2,5
This
malaligned syndrome for cyclists, subtalar pronation, tibial
1440-2440/$ see front matter 2011 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2011.04.002
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Table 1
Subject characteristics.
Sex Number Age (years) Height (cm) Weight (kg) Cycling (years)
Male 9 40 14.8 179.4 7.6 82.7 8 14 9.7
Female 3 29 4 169.7 7.3 63.6 7.5 8.3 3.1
internal rotation, knee abduction and hip adduction forcing
the knee closer to the bicycle, coincides with peak power
development at the knee, potentially increasing tissue stress
anddevelopment of overuse injury.
16,18,19
Baileyet al.
5
found
support for the injury mechanism proposed by Francis
16
in
their study on coronal plane knee movement, where cyclists
with current or previous knee injury displayed a more medi-
ally placed knee, with increased knee abduction, during the
power phase of the pedal cycle. Evidence exists for exter-
nal wedging and in-shoe orthotics being capable of altering
lower limb mechanics in cyclists,
79
and thus potentially lim-
iting injury risk, but no research to date found by the authors
has assessed cyclists already using in-shoe orthotics for their
effects on lower limb mechanics.
The aimof our study is to determine if and howCFOs cur-
rently used by cyclists alter the mechanics of the lower limb
during the power phase of the pedal stroke, including: hip
adduction; knee abduction; range (degrees) of tibial rotation;
and relative knee position to the bike from top dead centre
to bottom dead centre. Our research seeks to address previ-
ous studies limitations by analyzing both left and right legs
over ten consecutive revolutions in cyclists currently using
CFOs specic for cycling, and comparing that to cycling
without their CFOs. This differs from previous research in
this area, where orthotics and/or wedges were provided for
the cyclists for the research period, with no knowledge if the
cyclists continued using the supports following the research
period.
79
2. Methods
Twelve competitive cyclists (nine males and three
females) were recruited from local cycling clubs in Syd-
ney, Australia. All subjects were required to be injury free,
and used podiatric prescribed CFOs specically for cycling.
Subject characteristics are shown in Table 1. All subjects pro-
vided written consent to undertake the research at the New
South Wales Institute of Sport after ethics approval from the
Australian Institute of Sport (AIS) Ethics Committee. The
participants underwent a medical screen by a medical practi-
tioner, to ensure cardiovascular tness and safety to perform
exercise to 85% of estimated HRmax (220 minus age). A
musculoskeletal screen was undertaken to ensure subjects
were free of injury. Foot type and CFO type were assessed
by an experienced sports podiatrist.
The subjects had standard Vicon (ViconPeak, Oxford
Metrics, Oxford, UK) anthropometric data recorded (height,
weight, leg length, knee width, and ankle width). Reective
skin markers were applied to the lower limb, torso and upper
limb, in accordance with the Vicon Plug-in-Gait marker set,
plus additional markers over the medial maleolus, medial
epicondyle, and tibial tuberosity (45 in total). A standing
static recording was made. The subjects own bicycle was
set up on to a stationary trainer (Tacx Satori magnetic trainer
Tacx, Wassenaar, The Netherlands) in the centre of the
eight camera Vicon Mx system. Reective markers were
applied to the bicycle and recorded for use in analysing
knee trajectories relative to the bike. Camera checks were
performed and black-out taping to reective areas of the bicy-
cle/trainer/subject applied. The exercise protocol (see below)
was performed, with and without the subjects own CFOs,
and 3D data recorded on the Vicon Mx system at a sampling
rate of 500 Hz.
The exercise protocol consisted of a warm-up period of
5 min, then two 5 min seated cycling efforts at 85% of pre-
dicted HRmax at a cadence and resistance set by the subject
to replicate an interval training session. One session was with
the orthotics (Ortho) andone was without (Null). Adata block
of 30 s was recorded at the end of each 5 min effort. This
protocol was accepted by the AIS Ethics Committee.
The 3D data collected on the Vicon Mx system were
coded and digitised using the plug-in-gait model. The follow-
ing data was recorded during the power phase of the pedal
cycle: maximum hip adduction (degrees), maximum knee
abduction angle (degrees), total range of motion of tibial rota-
tion (degrees), and coronal plane knee movement throughout
the power phase half of the pedal cycle including the most
extreme medial and lateral knee positions (mm) relative to
the bicycle. The data was analysed by a 2-way ANOVA pro-
cedure (Systat 13 statistical package, SYSTAT SOFTWARE
Inc. Chicago, USA) analysedfor groupandindividual effects.
Included factors were leg (right vs left) and orthotic (Null or
Orthotic). For all analyses signicance was set at P<0.05.
3. Results
No signicant differences were found between the Null
(N) and Ortho (Y) conditions in the variables measured when
analysed as a group. A trend for reduction of tibial internal
rotation motion was found (P=0.072; Fig. 1).
When analysed individually, statistically signicant
effects were observed between the Null and Ortho con-
ditions (Table 2). There were no signicant differences
found between sub-groups of subjects (FPI score >6 vs FPI
score 6). Effects of orthotic type (plastic vs PVA) and cor-
rective type (rearfoot varus wedge vs forefoot varus wedge vs
P
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Table 2
Individualised subject data and results.
Subject FPI CFO type CFO reason Subjective effect Biomechanical effects (signicance of P<0.05)
Hip ADD Tibial IR Tibial IR Med knee
1. +9 Carbon bre casted full Anterior knee pain Resolved knee pain Decreased Nil Increased Increased
RFVal RF Var wedge Poor knee tracking Improved knee tracking
FFVar FF Var wedge Improved foot stability
2. +7 PVA molded full Great toe pain/bunion Resolved toe pain Increased Decreased Nil Decreased
RFVal RFVar wedge Improved knee tracking
FFVar FFVar wedge
3. +6 Plastic casted full Forefoot pain Resolved pain Nil Nil Decreased Increased
RFVal RFVar wedge Improved foot stability
FFVar Metatarsal domes
4. +4 Plastic casted 3/4 Anterior knee pain Resolved knee pain Increased Decreased Nil Increased
RFVal RF Var wedge Poor knee tracking Improved knee tracking
FFVal
5. +2 PVA molded full Medial knee pain Improved knee pain Increased Nil Increased Nil
FFVar RFVar wedge
FF Var wedge
6. +8 Plastic casted full Forefoot pains Resolved pains Decreased Increased Decreased Increased
RFVar RF Var wedge Less leg fatigue
FFVar FF Var wedge Increased leg speed
7. +9 Plastic casted full Thigh pain Improved thigh pains Nil Increased Decreased Increased
RFVal RF Var wedge Low back pain Improved back pain
FFVar Improved foot stability
8. +4 Plastic casted full Anterior knee pain Resolved knee pain Increased Decreased Decreased Decreased
RFVal RFVar wedge Improved pedal efciency
FF Var wedge
9. +6 Plastic casted 3/4 Anterior knee pain Resolved knee pain Decreased Decreased Decreased Increased
RFVal RF Var wedge
10. +6 Plastic casted full Anterior knee pain Improved knee pain Nil Decreased Decreased Decreased
RFVal RFVar wedge Knee surgery
FFVar FFVar wedge
11. +3 PVA accommodative full Forefoot pain Improved forefoot pain Decreased Decreased Nil Nil
FFVar FFVar wedge
12. +10 PVA molded full Bilateral medial knee pain Resolved knee pain Nil Increased Nil Nil
RFVal RF Var wedge Improved leg power
FFVar FF 1st MTP cutout
ABD, abduction; ADD, abduction; FF, forefoot; Med, medial; MTP, metatarsophalangeal; PVA, polyvinyl acetate; FR, rearfoot; VAL, valgus; VAR, varus.
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Fig. 1. Group effect of Ortho condition (Y) on tibial internal rotation range
of motion (value =degrees) (P=0.072).
combined rearfoot/forefoot varus wedge) were not calculated
due to low numbers and the observed variability (Table 2).
Casted plastic orthoses with a rearfoot wedge consistently
reduced tibial internal rotation movement (6 out of 8 subjects)
and increased the knee-to-bike distance (6 out of 8). Forefoot
wedging predominantly reduced knee abduction angle (4 out
of 7). Clinically, all those reporting previous anterior knee
pain improved from an orthotic with a rearfoot varus wedge,
or rearfoot/forefoot varus wedge combination (7 out of 7).
Notably, half the group had a signicantly reduced knee
abduction angle and range of tibial internal rotation (Table 2),
and a signicant increase in the maximum medial knee posi-
tion(i.e. knee further awayfromthe bicycle at the most medial
point) (See Supplementary Figs. 13).
Three distinct patterns of frontal plane knee mechanics
during the power phase of the pedal stroke were seen, which
were independent of the Null or Ortho conditions. The rst
and most commonly seen pattern depicts the knee moving
from a lateral to medial position relative to the bicycle. The
second pattern depicts the knee moving frommedial to lateral
during the power phase. The third pattern of knee coronal
plane movement seen was an unexpected and unique nding,
with the right knee moving from lateral to medial, while the
left knee moved from medial to lateral, during the power
phase.
All subjects had signicant differences between left and
right legs across all variables measured.
4. Discussion
The rst important nding of this study was the absence
of signicant systematic effect by the CFOs for any of
the parameters measured. There were signicant individ-
ual effects by the CFOs, which are described later in the
discussion. The absence of any group effect on cycling
biomechanics may be related to the small subject numbers,
non-uniformity of the CFOs and foot posture, and the subject-
specic responses to the CFOs reported in similar previous
research.
7,9
The structure of the CFOs showed consider-
able variability, being made from a range of materials (EVA,
plastic and carbon bre), having variations in postings (rear-
foot only, forefoot only, or combined rear and forefoot), and
ranging in biomechanical effect when assessed in a weight
bearing position (no observed correction, appropriate cor-
rection, overcorrection). Foot posture also varied between
subjects, in particular the degree of over-pronation and fore-
foot varus, so CFO variability was expected. Although this
makes interpretation of the results difcult, we felt it was
important to assess what CFOs cyclists were currently using,
and what, if any, biomechanical effect they were having.
A trend was observed (P=0.072) for a reduction in the
range of tibial internal rotation with the orthotic condition
(Fig. 1). CFOs have been shown to reduce tibial rotation
in runners,
14,20
supporting the coupling theory of subtalar
joint overpronation and tibial internal rotation, as proposed
by Nawoczenski et al.
21
A similar coupling model has been
proposed in cyclists.
16
Francis
16
hypothesised that horizon-
tal movement of the knee in the frontal plane during the knee
extensor moment of the power phase of the pedal stroke,
was a result of coupling of the subtalar and ankle joints.
Specically, subtalar joint overpronation, with resulting tib-
ial internal rotation and obligatory hip adduction, places the
knee in a more medial position relative to the bicycle, pro-
ducing an increased Q angle of the knee. Given that the
peak knee extensor moment occurs at 8090 degrees after
top dead centre, which coincides as the point of maximum
medial knee position for most cyclists, large torsional and
valgus stress is applied to the knee.
5,18,19
Repeat application
of this stress over many thousands of cycles place the knee
at risk of overuse injury.
1,2
Ball and Afheldt
13
suggest that
control of tibial rotation may be the most signicant factor
in maintaining proper supination/pronation mechanics. Our
evidence shows that CFOs can reduce tibial internal rotation
in cycling. Subsequent decreases in torsional and/or valgus
stress at the knee is likely to improve both knee joint and
patellofemoral joint mechanics, thus reducing the risk of knee
injury.
A second nding of this study is the variability of the
effect seen in response to the orthotics. This parallels previous
research on the effects of orthotics, both in cycling and run-
ning, where a consistent and systematic biomechanical effect
from the orthoses has not been found.
7,9,20
Subsequently,
alternative mechanisms for the effects of CFOs have been
proposed, including alteration of the muscle length/tension
characteristics, and/or a proprioceptive role, assisting a pre-
ferred or more efcient movement pattern.
11,13,24
A number of authors have recommended using an
individualised approach to the prescription of orthotics
to accommodate this subject-specic response.
11,12,22
Vicenzino,
22
has proposed a treatment direction test (TDT)
as a means to improve success with orthotic prescription,9
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focusing on individualised prescription, re-testing, and alter-
ations to the orthotics dependent upon the outcome measures
used (e.g. motion quality; pain quantity). In our study, all
subjects showed a signicant individualised effect of the
orthotics on one or more of the variables investigated. The
most frequent biomechanical effects were: a reduction in
knee abduction angle, a more laterally displaced knee dur-
ing the power phase, and a reduced tibial internal rotation
range of motion. These results support the coupling theory
proposed by Francis,
16
with the orthoses reducing hip, knee
and tibial rotation angles, thus promoting linear knee motion
in the frontal plane. Additionally, all subjects reported sub-
jective improvements in cycling technique (feels smoother,
better knee tracking) and/or power development (less leg
fatigue, more stable through the down-stroke) while using
their CFOs, in addition to the improvements in various mus-
culoskeletal pains. Similar subjective improvements have
been found in previous research.
11,15
The third nding of this study is that three distinct patterns
of frontal plane knee mechanics during the power phase of
the pedal stroke were seen, which were independent of the
Null or Ortho conditions. The most common pattern in this
study supports that proposed by Francis
16
and seen by Bailey
et al.,
5
with the knee passing froma lateral to medial position
with respect to the bicycle, during the power phase of the
pedaling action. The next most common pattern is a reversal
of the previous pattern, with the knee tracking from a medial
to lateral position during the power phase. The last pattern
seen, and a novel nding, was a mix of the two above patterns
with the right leg tracking from lateral to medial and the left
leg from medial to lateral, during the power phase of the
pedaling cycle. This pattern was seen in two cyclists only, and
interestingly both of these cyclists were predominantly track
cyclists. It is tempting to suggest that track cycling, which is
raced anti-clockwise requiring the bike to be heavily leaned
to the left, has resulted in the development of an asymmetrical
cycling technique.
Another important nding is the consistent differences
seen between left and right legs, independent of the Null or
Ortho conditions. The right leg was signicantly (P<0.05)
more laterally displaced during the power phase. The right
legalsohadsignicantly(P<0.05) less tibial internal rotation
range of motion, but interestingly had greater maximal hip
adduction, suggesting kinetic chain compensations to allow
greater hip adduction while maintaining a more lateral knee
position. These results are consistent with the asymmetry
seen within subjects and the variability seen between sub-
jects found by Smak et al.
23
on their research into power
production in cyclists. Sanderson et al.
7
also found within-
subject asymmetries between left and right legs, this time
in response to external foot wedging. This subject-specic
variability and asymmetry raises the need for caution when
extrapolating results from research using single lower limb
models.
The current study is limited by the small number of sub-
jects, and the variability of both foot posture and CFOs
between subjects. For these reasons it is difcult to provide
any guidance stronger than recommendations for practition-
ers involved with prescription or modication of CFOs for
cyclists with lower limb problems. All subjects had a sub-
jective improvement to their cycling action, similar to that
reported from previous cycling and running studies on CFO
efcacy.
3,12,13
In this study, rearfoot only and combined rear-
foot and forefoot varus wedges produced signicant changes
in the measured biomechanical variables, in addition to their
subjective improvements (Table 2). Specic response to an
orthotic with a forefoot only varus wedge improved local
foot pain while also improving hip adduction and knee
abduction angles. Signicant changes were achieved with
both PVA and plastic orthoses. Importantly, this knowledge
allows the treating clinician to condently trial PVA orthotic
bases with postings tailored to the individuals needs, a
cheaper and potentially better t for the conned cycling
shoe. Casted plastic orthotics and appropriate wedging con-
sistently reduced tibial rotation and increased knee-to-bike
distance, potential causes for anterior knee pain.
Recommendations centre on an individualised approach
to orthotic intervention, with ongoing revision of outcomes
as suggested by Vicenzino.
22
Our results suggest that anterior
knee pain will likely benet from a rearfoot varus wedge in
over pronating cyclists. Attention should also be paid to the
forefootrearfoot relationship, in particular the use of a fore-
foot varus wedge, given the evidence supporting cycling as a
forefoot loadingsport withmost force transmittedthroughthe
rst ray,
25
and the preponderance of forefoot varus malalign-
ments in the general population.
26
Forefoot varus wedges and
other forefoot supports (e.g. metatarsal dome) can improve
cycling biomechanics and/or effect subjective improvements,
as shown in this study.
This current study highlights a number of areas for pos-
sible future investigation, particularly the effect of CFOs on
tibial internal rotation and the possible asymmetry of track
cyclists as seen in our two track cyclists. Larger subject num-
bers, and more uniformity in both the CFOs and foot type of
the subject, would aid in assessing the group effect of CFOs
on cycling biomechanics.
5. Conclusion
Cycling is a complex and dynamic activity, with highly
subject-specic patterns of movement and responses to inter-
ventions. CFOs currently used by cyclists do not have
a systematic effect on cycling biomechanics. CFOs can
signicantly affect subject-specic parameters of cycling
biomechanics, including tibial internal rotation and knee
position during the power phase of the pedal cycle. The
subject-specic responses to orthotic intervention may reect
different preferred movement patterns, incorporating aspects
of the alternative paradigms proposed for orthotic efcacy
e.g. improved neuromotor control through alterations in
proprioceptive or muscle-tension characteristics. CFO and
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foot posture variability may impact on the subject-specic
responses seen. An individualised approach to orthotic
prescription is suggested, with forefoot correction or accom-
modation in addition to rearfoot control, as cycling is
predominantly a forefoot loading sport.
Practical implications
In-shoe custom tted orthotics (CFO) can signicantly
alter the biomechanics of an individual during seated
cycling.
An individualised approach to orthotic prescription is rec-
ommended, with review and alteration of the orthotic
according to the clinical results.
Cycling is a forefoot loading sport, and attention to the
forefootrear foot relationship, with appropriate correc-
tion, is recommended.
Disclosures
None.
Acknowledgements
I would like to acknowledge the support I have received
from the Sydney Sports Medicine Centre and the New South
Wales Institute of Sport. No nancial assistance was given
for this project.
Appendix A. Supplementary data
Supplementary data associated with this arti-
cle can be found, in the online version, at
doi:10.1016/j.jsams.2011.04.002.
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