Orthotics - where is the value?

Last week I met with Anthony who called the office looking for someone to fine tune his bike position as he kept experiencing knee pain in spite of a previous bike fit. Interestingly enough is that he recently got a new set of orthotics and was instructed to do so for his cycling shoes every year.....to address his knee pain. On his last visit to the doctor's office, the saddle height was changed (+5mm), however the 9 year old issue of knee pain still persisted. I was skeptical about tackling this fit because he had been to a Bay Area doctor that helps many cyclists with the fit issues and he had seen by one of the Bay Area's most experienced fitters (and most expensive) both of whom could not solve his issue. Furthermore this bike fitter also taught at Serotta's SICI ... the pressure was on!



As you can see in the photo knee over tow alignment was completely off and neither the doctor nor the previous fitter measured his feet with the FFMD (http://bikefit.com/docs/FFMD.pdf ) or a similar tool! Once I saw his initial position on the bike I knew I had my work cut-out for me.
With a 17 degree and 9 degree (L/R) varus measurement and one knee tracking to the inside and the other outside of the toe line I was glad I had my Speedplay pedal kit available. His tracking was so bad on the right leg that the laser did not even come close to the patella and his knee was not stable at all throughout the pedal stroke. In addition Anthony displayed lot of inward heel rotation which had forced him to install 20mm pedal extenders a few years back. Lastly Anthony rides Specialized BG shoes which should help with their varus built into the sole ...
After close to 2.5 hours of work these are the major changes made to Anthony's fit:
Right Shoe: 2 ITS wedges, 4 cleat wedges, removed the 20mm pedal spacer and set him up with a + 1/4 pedal and moved the foot as far in as possible.
Left Shoe: 2 cleat wedges, a 3mm leg length shim and -1/8 pedal.
Seat position: brought seat forward about 8mm
Hoods: moved R & L hood inward about 10 degrees.
Handlebar: moved handlebar up a few degrees so the hoods/bar created a straight line/contact area for a more neutral wrist position!
Since Anthony was going to go for a ride the following day I gave him a few pointers in the event he would experience some discomfort with the extreme (but necessary) changes made. We are not always sure how the nervous and muscular systems will respond.

Here is what he had to say after the first ride:
"The bike fit is amazing. My bike has never felt this comfortable under me. I had no knee pain. It's the first time in a long while that my speed was entirely dictated by leg fatigue, instead of in part by knee pain. Thank you so much for an excellent fit.
My buddy and I did about 33 miles around Old La Honda, Skyline, and Page Mill. Came up to about 3400 feet of climbing. We pushed pretty hard."
The moral of the story is threefold: never be afraid to tackle a bikefit that was previously done by published experts in the field, never assume that an orthodic is the correct way for someone to adjust fit issues and use as many wedges as needed to get the tracking under control.
I have also realized that many BG shoes I have fitted in the last few months do not appear to have the varus tilt that is claimed. I am still wedging the BG shoes as if they were just plain neutral shoes; maybe their manufacturing tolerances are off because I certainly cannot explain the need for some many wedges on a shoes that supposedly is built to account for 1.5mm of varus tilt.
During my follow-up visit this week we will attempt to remove the custom orthodics and ride with the cycling specific SuperFeet ... Stay tuned!
TOTAL WEDGES USED: 8
Andrew