Hey there,
I felt I need to share my story about my chronic knee pain that tortured me the past three years on and off the bike. Hopefully this serves as motivation for others that suffer from chronic knee pain without a clear diagnosis, or even prevent others from running into this trap blindfolded.
How it started
I’m riding bicycles ever since, but am relatively fresh to road bikes, started three years ago. While I had some OK-ish fitness, I never followed structured training plans in the past, but also never had issues with powerful bursts up the hill, fixed cleats and all the things considered to cause injuries.
Then I switched to road bikes, started training with power and got obsessed with pushing my FTP until I started to have weird sensations in my knee. I ignored them for a couple of months, tried exercises and altered the fit of my bike according to obvious suggestions on the internet.
I had all sorts of knee pain changing on a daily basis. Sometimes medial pain, sometimes lateral pain, mostly anterior pain around the knee cap. Sometimes just the left leg, sometimes just the right, sometimes both. Instead of resting, I kept riding and tweaking my bike for an entire season, until the pain eventually became so severe that I had stop any sort of sports.
What I tried during these years
I went to a orthopedist which sent me to the hospital for some x-rays and MRIs, telling me that my knees look fine without major wear and tear, except both sided second decree meniscus laison, which should not be the cause of my pain. After visiting him four times, I was told to get used to it - there is nothing he can do. The pain was so bad that I wasn’t able to squat down to pick stuff up from the floor, walk stairs up or down, or even drive my car for prolonged periods of time. And when I drove to work, the first 5 minutes of walking after getting out of my car felt really unstable, just like I am about to learn to walk again. So I tried to rest my knees a couple more months with no significant improvement whatsoever.
Then I went to a physical therapist, who got x-rays of my hip done, finding that I have a very unflexible and misaligned hip as well as very weak glutes. I went through half a year of therapy, again without improvements. By that time I had pain for 1,5 years and almost accepted my fate of never having fully functional knees again. I continued the stretches and exercises he gave me for another 6 months, but nothing changed. After two years of constant pain on and off the bike, I had week long periods of pain, followed by 1-2 days with no pain. However, as soon as I started to get on my bike, riding without any resistance, the pain returned for a couple of days.
Of course I also stumbled upon Jonathans great knee pain thread here on the forum and tried some stuff. While it didn’t directly work for me to fix my initial issues, I strongly advice to have a read. (Tons of great information and exercises in there.)
The missing piece of the puzzle
I got the feeling that the pain is caused by the movement of my knees rather than the force introduced by training. I waited until I had a pain free period and blew the dust off my running shoes to go for a run. And I had no increased pain the following days. But when I did other repetitive movements, the pain returned for a couple of days. The problem was that even if I did rest for longer periods, the pain returned, so I still had no proof whether these situations were lucky coincidences or not.
So I pulled myself together and looked for another specialist, waited a few months for an appointment, got some more x-rays and another MRI done. It took a while, but he found the causes for all the pain spots I experienced. This also explains why I had so many different sensations of pain:
The proper diagnose
Plica syndrome - I got some tissue left in the medial sections of my knee joints that can cause issues for some people.
Hip misalignment - Causing weak glutes and a weird walking style. While it never caused pain in the past, it seems like it contributed to my knees not recovering after destroying them on the bike.
Flat feet - Causing my knees to bend inwards and misalign.
Bad overall flexibility - Causing excessive pressure on my knee cap on and off the bike.
Weak VMOs - Causing my knee cap to not track properly in the designated channel of my femur bone. It pulls my knee cap laterally, also playing a role in the constant inflammation of my knees.
Patella Femoral Pain Syndrome - Pain on the front of the knee and around the knee cap. May come along with a clicky patella, instable knees. This is more to be considered the result of all the issues mentioned above.
A bad bike fit - (But I’m talking about this later, because by the time I felt the pain, the fit seemed right. Only after gainin flexibility again I noticed that the fit was totally off).
What actually helped
Strength training: The doc told me that I should strengthen my quads, especially the VMOs, but as soon as I did these exercises, the pain became worse again. And this was the first culprit: These exercises put stress on your joints, but you gotta do them gently to slowly fight the patella maltracking. If your knees are otherwise healthy, you have to go through a bit of pain before it eventually gets better, but you have to escape this nasty vicious cycle first. Another key factor is that by having chronic pain, you start to develop some protective attitude, causing muscular imbalances that further hinder your injury from healing.
Stretching and Yoga: Doing Yoga teached me that my flexibility was still really bad, especially my calves and hamstrings were super tight. (Thanks to my desk job as software engineer, I guess). Now that I reached normal (but not good) levels of flexibility, I am almost pain free. While I do stretches daily, I noticed that some proper Yoga sessions have a bigger impact in my range of motion. For example I did some static hamstring stretches, standing and “touching” my feet, but doing yoga for two weeks made me come closer to actually reaching the ground than doing half a year of static stretching. For me personally yoga provides faster results in terms of increased flexibility.
Height adjustable office table: This one sounds a bit weird, but this was a game changer for my recovery. As I mentioned, I work as a software engineer and spent half my day sitting. All the strength training and stretching I did for a year did improve the situation a little, but it was when I got an height adjustable office desk for work where I made the final necessary improvements. Using this table for some weeks allowed me to finally stand up from a chair without pain. I noticed that I also got rid of the pain when walking up or down the stairs entirely.
Being relatively pain free doing normal movements again allowed me to massively ramp up my stretching and strength training to fight against my PFPS and the patella maltracking, seeing even bigger improvements.
Getting my walking style fixed
So walking around with pain in the knees made me adapt an even weirder walking style where I hit the ground with the balls of my feet first. It took some orthotics and a couple of weeks, but I almost walk normally again. Occassionally I fall back into bad habits, but actively remind me to walk with my heels again - Doing so, I immediately feel all my leg and hip muscles properly engaging all of a sudden.
Getting an e-bike
This one was kinda nice as well since it allowed me to stay a little active, but avoid mashing the gears uphills. As soon as I felt weird sensations, i just increased the power of the support motor. It also made me notice how much I prefer a wider stance compared to my road bike. Riding the e-bike was very beneficial since it allowed me to have some movement and train some stabilizer muscles when riding through the forest, while avoiding hard efforts, especially on hills.
Adjusting my bike fit
So after two years of failures, success slowly kept creeping in and I hooked my dust collecting road bike up to the smart trainer. Now that I am close to normal flexibility, immediately noticed my seat being way too high, whereas I didn’t change since I stopped road cycling 1,5 years ago. I was a massive toe dropper and after stretching my posterior chain properly, my feet were flat while pedalling. To compensate for this change I had to lower my seat 40 mm until I regained control of the bottom of the pedal stroke.
I also added 16 mm pedal spacers to my power meter pedals to have a wider stance width - which also adds some space between my heels and my cranks. (Especially since I’m a little duck footed). I’m a relatively short guy, but got a wide pelvis, and also when standing or doing squats, my feet are relatively wide apart. Increasing the stance width on the road bike feels better for me.
The issue I had was that I am ussing Assioma Duos and you need special pedal extenders with a hole in the center so you can use an 8 mm allan key to attach/detach them. 3 years ago when the pain started to creeped up, I wasn’t able to find extensions with a hole in the center. Now there seems to be tons of them. (Side note for those interested: many brands offer 16 and 20 mm extensions, but only the 16 mm ones fit the 8 mm allan key for the Assiomas. The center hole on the 20 mm extensions are often narrower to preserve the rigidity of the extension and avoid them to break.)
Getting proper cycling shoes
I have very wide feet and one of the biggest mistakes I made was buying bigger shoes to fit my width. The result being the cleat screws being too far in the front. Even when adjusting the cleats all the way back, the pedal axle still ended up 3-4 millimeters in front of my big toe joint.
My issue was that I always had Shimano shoes and they also offer “wide” models, which are not really wide at all. Despite having size 42 feet, I ended up getting a “wide” Shimano shoe sized 44 to feel comfortable. After that I upgraded to Specialized Torch 3.0 which also ended up being size 44. I liked the quality of both and really enjoy the carbon sole of the Torch 3.0, but the integrated forefoot varus correction is something that threw me off.
I went for another brand that offers a lot of different widths and got a size 42 shoe that actually fits to my wide feet. The result is that the cleats now sit where they should be. Had to adjust the saddle a little to compensate for the new cleat position, but I immediately feel way more control on the bottom of the pedal stroke and my knees feel much more stable. Though I have to say that I’m possibly still months away from returning to structured training. For now I am prioritizing strength training and stretching, just doing gentle spins on the bike if at all.
What I learned from this injury the hard way
- If you start to feel pain while cycling: REST and find the cause. I am sure that if I had paused my training early enough to recover, I would maybe have ended with 2 months off the bike rather than two years.
- Flexibility is important and I will never neglect it again. (Check out Jonathans knee pain thread!)
- Strength training for supporting muscles to reduce the risk of injury is now part of my daily routine. (Again: Check out Jonathans knee pain thread!)
- If you can, find a specialist to perform a proper bike fit (I don’t have these offers where I live, but I’d spend the money any day)
- Be patient: It took me literally years of stretching and exercising, but it does work.
- Escape the vicious cycle in case of PFPS, but talk to a doctor first. Doing the exercises made the pain worse in the beginning, but it was the only way to build muscles to get my legs back in shape. However, talk to a doctor first - this approach worked for me because all the MRIs and x-rays showed that basically my knees are healthy and I don’t suffer from meniscus tears or arthritis.
- Don’t give up: I almost sold my road bike and got used to the thought of never being able to properly do sports again. There were times in which I was very depressed and lacked motivation to find the cause, but it is worth it. Imagine the loss of life quality due to constant pain while performing normal daily tasks like standing up from a chair or taking some stairs… Just keep going - it is worth it.
Alright, if anyone actually took the time to read all of this and suffers from similar chronic pain issues: I hope this encourages you to keep going. It’s definitely worth the effort. Just imagine I had listened to the first specialist I visited two years ago, who told me that I should get used to the pain and live with it…
Stay healthy and keep riding!
Cheers