Knee injuries are common and SO frustrating! Please share what you’ve done to fix them in this thread.
DISCLAIMER: This post is LONG, but it’s meant to be a resource on what is working for me and a place for discussion on what is working for other folks. Cyclists and “knee problems” are as common a pair as shoes and socks, yet they are highly individual and in every scenario, an individual approach needs to be taken. What I am sharing in this post is what is currently working for me. I am not suggesting you do these exercises, and instead suggest you work with a knowledgable PT who has helped many cyclists through similar issues. In other words, this is not medical advice in any way, and please consult your doctor before undertaking any treatment.
Knee Injury History
This is a lengthy post, but I’ll keep this part short. I’ve battled with “knee issues” of one kind or another for the last 3 years. Over that time I have worked with eleven different Doctors, orthopedic specialists, physical therapists, coaches, and trainers to be pain free on the bike. Every one of them has pointed out something helpful, and in almost every case I had temporary relief.
In terms of diagnoses, I’ve had:
- IT Band Syndrome
- IT Band Friction
- IT Band Tightness
- Patellar tendonitis
- Runner’s Knee
- Chronic Inflammation Syndrome
- Musuclar imbalances
- Tight hips
- Lack of flexibility
- Inactive glutes
- Neuromuscular blockage/interference
- Ineffective hip control
- Hip impingements
- Ankle impingements
I’m sure there are others I’m forgetting. In other words, everybody will have a different opinion what is wrong with you, and they are probably right. Even if you are pain free, there is endless room for improvement in terms of biomechanical efficiency on and off the bike.
The tricky part comes in when you latch onto a diagnosis and think there is only one thing that needs a simple fix, then you’ll be on your way. The painful truth is we are all different, and although it may be frustrating and seem unfair that you deal with chronic injury while others don’t, it’s simply the cards you’ve been dealt. You get to work extra hard for normalcy, but I reckon that struggle will make you a better person and more dedicated athlete, so there are perks
There is low hanging fruit like a proper bike fit and proper pedaling technique, and I’m sure a fitter will be upset at me for this, but I am going to leave those two components at the following: Pedaling technique is individual, but if you are an outlier (extreme toe pointer or extreme heel dropper, habitually ride at a <70rpm or >110rpm cadence, inability to have your knees track straight) then you should address it. Bike fit is also very individual, but you will find commonalities across a range of proper fits. I don’t have any good bike fitters to recommend, but try to find one who has good reviews from athletes that are similar to you (discipline, experience level, etc.). Finding a good fitter is a tough and expensive process, but as silly as this sounds, I find Competitive Cyclist’s Bike Fit Calculator to be a great tool for a starting point.
Treatments/adjustments I have done:
- Compression (I’ve tried all sorts of braces with little to no improvement)
- Stretching posterior chain (lower back, glutes, hamstrings, lower leg)
- Stretching quadriceps and anterior hips
- Plyometrics (Great way to build durability, but tough to do when already injured)
- Hiking and walking
- Foam rolling
- Dry needling
- Manual Therapy
- ITB Flossing
- Countless exercises to strengthen glutes and hips
- Cortizone shots (Just a bandaid, and in some cases an illegal one depending on your organizing body and competition level)
- Diagnostic MRI
- Medicinal anti-inflammatory regime (Another bandaid with very detrimental side effects)
- Homeopathic anti-inflammatory regime
- Plant-based diet
- Low carb diet
• Low sugar diet
- Gluten free diet
- Cleat adjustment (shims, fore/aft, left/right)
- Pedal choice
- Bike fit adjustment
- Using rollers instead of trainer
- Cadence adjustment
- Pedaling technique adjustment
- Reduction in high intensity training (No causation in my case with intensity and inflammation)
- Reduction in low intensity / high volume training (Same as the previous point)
- Changed time of day that I train
- Neuromuscular repatterning ( I used the Halo Neuroscience product for three months, but found no improvement)
Feel free to ask questions on the above, but from that list, this is what I have found most helpful / am currently doing:
What's working right now
(If inflammation arises, you simply have to respect it. Don’t pedal through it)
Stretching posterior chain
(See more on this below)
Stretching quadriceps and anterior hips
(See more on this below)
(Very beneficial at building control and stability. I don’t attend a yoga class, but regularly incorporate movements into my routine. See more on this below)
Hiking and walking
(I’ve noticed a direct correlation between improved control in the pedal stroke and increased dog walking and hiking)
(I roll my quadriceps hamstrings, glutes, lower leg and feet every day. I don’t go crazy with it, but a 15-minute session is part of my every day routine when I wake up)
(I have a monthly appointment with a PT that specializes in Manual Therapy. The goal is to diagnose any major imbalances or impingements in my body and reset everything back to “straight and balanced”. It’s expensive, but I find it irreplaceable)
(Helped me initiate the process of regaining control and proper recruitment patterns with my glutes)
Countless exercises to strengthen glutes and hips
(I feel like I’ve done darn near everything with this, but I’m always surprised by new movements. Dr. Jay Dicharry from Rebound Physical Therapy in Bend, OR provided me with the current routine that I find more beneficial than any other routine I’ve used. See below for images and descriptions of each movement.)
Homeopathic anti-inflammatory regime
_(I take in a high amount of foods that are rich in anti-oxidants. Berries, turmeric, red/black beans, cranbarries, artichoke, apples, etc.)
“Low sugar diet”
(I’ve noticed a correlation between periods of inflammation and binging on sweets. Why can’t chocolate chip cookies be more healthy!!?? )
Cleat adjustment (shims, fore/aft, left/right)
(I’ve tried everything here. Only thing out of the norm that I have is that the cleat tends to be about 1cm toward my heel from center. Otherwise, I’ve found no correlation between a cleat adjustment and change inflammation. YMMV.)
(A big help was getting custom Surefoot insoles for my shoes. Helped me control knee tracking in the pedal stroke)
(The custom float of Speedplay Zeros is hugely beneficial on the road, and I dislike Crankbrothers on the dirt. The float always has some degree of resistance, and then the cleats, shoes or pedals wear, the pedaling platform becomes unstable. I like SPD-style cleats since they offer more “free” float and a stable platform)
Bike fit adjustment
(Only correlation I’ve found here is that most bikes put me too far behind the saddle and that correlates with an increase in pain. This is getting better as brands are steepening seat tube angles and getting rid of setback seatposts)
Using rollers instead of trainer
(Rollers have taught me to be extremely disciplined with my technique, and I had become a bit sloppy over the years with my bike locked in place. You can cultivate the same discipline on the trainer, but the rollers force it upon you )
(On dirt I usually average 85-90RPM, on road 95-100RPM, and this hasn’t changed. What has changed is my focus on being proficient outside of those ranges. I do plenty of cadence drills.)
Pedaling technique adjustment
(I am very conscious of glute activation when pedaling. It’s not that my glutes are what is pressing my pedals, but I should feel my glutes engaging in order to stabilize the pedal stroke and let my quads put more focus on just making watts.)
(I use the time I do my stretching/mobility routine to get into a very focused and clear headspace. I’ll use controlled breathing techniques with a mantra to make everything beside my connection to what my body is mechanically doing melt away. I do the same when training. I’ve found this to be key in establishing a feedback loop with my body so that I don’t get sloppy without noticing.)
Disclaimer: All of this will likely change over time, and I’m sure I’ll have new struggles pop up over time. That’s how this works
My current routine comes from Jay Dicharry of Rebound Physical Therapy in Bend, OR. I can’t recommend him and his office enough. They work with elite and professional athletes from all over the world, and Jay is a cyclist himself. He knows what he is doing.
The routine I am sharing here is what he prescribed for me. I am certain it would change for each person that visits him, so once again, please refer to a professional. I’m only sharing this due to the sheer number of requests I’ve gotten for it.
Part 1: Open Blocks
Before I started to build things back up, I had to clear any blocks out.
My talus tends to drift forward in relation to my tibia, and this stops my knee from being able to track correctly. To address this I place a high resistance band in the bend of my ankle with as much tension as the band supports, then bend my knee forward while keeping my heel on the ground and resisting pronation of the foot.
Hip Internal Rotation
Even though you may think internal and external rotation of your hip has little to do with a pedal stroke since your leg is supposed to track straight, hip stiffness above the knee forces it to twist as it bends. What this looks like when I ride is the classic “hatchet and cut”, meaning my knee flares out at the top of the stroke, and in and the bottom of the stroke.
An approachable method to clear up this block is the 90/90/90 self mob. It’s called that because your knee, hips and knee are all at 90º angles on the ground. Start from a seated position, then let your right leg roll outward so the knee touches the ground. Then bend that knee to 90º. Now roll your left leg inward so the knee touches the ground, and position that leg so you have a 90º angle in your hips and the left knee. Your legs will resemble the Triskelion featured on the flag of the Isle of Man.
Once you get into this position, make sure your torso is position upright, then rotate your torso toward your left leg until you feel tightness in the groin and hip joint. Your left hand will be between your left heel and your glute, and if your can, your right hand will be just inside your right knee. This is really uncomfortable for some, and it feels more like something is genuinely wrong more than just a normal stretch. Take your time easing into this one.
At that point you are ready to actually start working. In this position, try to think of pressing your left knee downward into the ground for a couple seconds while keeping your left heel on the ground. You’ll do this almost entirely through glute activation. Then think of pressing your left ankle down into the ground for a couple of seconds while keeping your left knee on the ground. I alternate this pattern 30 times, then switch legs, then repeat that set three times.
The rectus femoris is a deep muscle in the thigh that is really hard to target with standard quad stretches and even foam rolling. A short rectus causes excess tension on the knee cap, and that is less than desirable.
The Couch Stretch is a variation of a lying quad stretch. The difference is you want to be on a surface that allows the leg that isn’t being stretched to drop down and allow that knee to bend at a 90º angle (or as close to it as possible. Use a band to get the stretch, and spend a significant amount of time here. Time is what will really make this effective.
Part 2: Stability
It’s funny that we have to focus on making the knee track properly sometimes, because it should just automatically track straight. These are exercises I am doing to help increase stability.
Pigeon Pose Hip Extension
This is a great way to isolate glute activation, and a good way to get in some stretching while you’re at it.
For an explanation on Pigeon Pose, see the image below. Keep the toes of your back foot on the ground, and only extend your back leg backward as far as you can while still maintaining contact with your kneecap and toes to the ground. Your back knee will be slightly bent. Once you are in this position, using only your glutes, left the back knee off the ground.
This one is extremely hard, and not because of it being physically strenuous. It’s an exercise that once again isolates the glutes, but even more than the previous exercise. It takes a lot of neuromuscular control and it will feel awkward at first, but persistence will make it better.
Assume the position you see in the image below (on all 4s with 90º angles in shoulders, hips and knees). From this position and while keeping your knees bent in their current position, left your left leg up so that you make a straight line from your shoulder to your knee on your left side. Your foot should be flat with the base pointing to the ceiling.
It’s very easy to let your back cave in this position and allow your belly button to get closer to the floor, but work to maintain a neutral spine. Any movement you do from here on out should have zero effect on the position of the rest of your body. If you want, put a foam roller on it’s end under your left knee to serve as a warning point when you are dropping your knee. You can do the same for your belly and chest if you really want to stay strict.
Once you are in this position with neutral spine, it’s time to have your left foot make a rainbow. Imagine standing behind you and the left foot has a paintbrush in it. The following movement would cause that paintbrush to paint an arc.
The way to do this is to imagine your femur is a rotating spindle that can’t be moved off of its axis. While maintaining this position, rotate the left femur (without letting your knee flare out, drop or rise) so your left foot gently arcs medially until you can’t hold position, then retrace that path and go as far laterally as possible until you can’t hold that position. The lateral rotation in this case feels almost impossible for some, but you’ll get better at it with time. Add ankle weights to drop deeper into your range of motion.
Banded Hip Twist
(Heads up, we shot this one incorrectly. You should be standing on your left leg, not your right. You can tell which side is correct because you should feel resistance when opening up laterally rather than medially.)
For this and the remaining exercises, keep in mind that “rotational spindle” concept we talked about on the last exercise.
This one is simple. Anchor a resistance band to something in front of you, bring it around your left hip and hold it in your right hand while putting your right hand on your right hip. Then stand on your left leg and while keeping your hips, torso and shoulders aligned, imagine your body’s rotational spindle is your left leg and rotate slowly inward and outward. You’ll feel a lot of glute engagement when rotating outward.
Supine Hip Rotation in Half-Bridge
Another great one for isolating glute activation. Get into a bridge position, making sure your hips are high enough to maintain a straight line from your shoulders to your hips and finishing at your knees. From this position, extend your left leg skyward, keeping your left femur parallel with your right. You goal should be for this movement and any subsequent movement to not affect your position in any way.
At this point, consider your rotational spindle your right leg and rotate your hips around this axis. This one feels awkward at first, but keep at it.
Tippy Bird Twist
If your familiar with Yoga, assume a Warrior III pose but place your hands on your hips. Maintain this position despite all further movement.
From this position, Rotate your body outward and inward. This requires a ton of balance and it is really hard. Stick with it.
Banded Hip / Jack
Stand in an upright position with your feet comfortably place under your shoulders, hands on your hips, and a band around your knees with another band around your ankles. Their size should give you immediate tension if you were to widen your stance, and the knee band will have less tension than the ankle band.
In this position, balance on one leg and move it backward at a 45º angle, making sure to move only as far as you can control. This is a great one for more glute isolation.
You can make this one extra tricky by standing on a bosu or some sort of balance-challenging device.
Part 2: Quad Control
Standing Knee Extension
Put a large swiss ball against a wall and put the backside of your knee against it in such a position that without compressing the ball, your knee is bent. In this position, straighten your knee fully.
This one really puts a lot of emphasis on balancing out workloads across your quadriceps, which is something we are really bad at as cyclists.
This is similar to a single leg squat, but the focus is not on getting into a deep squat. Instead, the focus is complete control of the leg you are standing on.
This is a three part squat, with the first squat seeing your free leg go forward, the second squat seeing it go outward, and the third squat seeing it go backward. Your goal with this will be to keep your upper body in a similar position across all three squats. Remember, just go as deep/far as you are able to control.
Rock ‘N’ Roll Squats
Start in a standing position on a soft floor, carefully, and in one fluid movement, crouch down and roll backward onto your back before reversing the movement to get up to your feet and jump. Using momentum is good, and this all happens in one fluid motion. Your goal should be to move through this fluidly without needing to reposition feet or knees in order to get the strength/fluidity you need.
SummaryOnce again, I have not clue if this is what will help you, but it has helped me. More specifically, getting many opinions and working through a lot of different professionals has led me to this point. I still have subtle twinges every once in a while, and tightness in my muscles and joints persists, but this is what I've learned in this process of managing the issue.
I think it would help if other people shared what they have done to alleviate or remove knee pain and regain control of the legs in the pedal stroke. Please share your insights below, and share this with anybody you know who is having these issues. Let’s make this the best thread for knee problems for cyclists!