[FAQ] How to Fix Knee Injuries for Cyclists (Knee Pain)

:joy::rofl::joy::rofl::joy::rofl::joy::smiley:

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An alternative short Rectus stretch that I find much easier to spend significant amount of time in.

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I do that one every day. :+1:

I have been battling knee injuries since as long as I can remember. First it started with my left knee in high school when I ran cross-country and my left knee would “catch” or it would feel like pressure building up. It was bothersome enough that I would sometimes have to stop to “pop” my knee to release the pressure. I can also remember doing this when I played baseball, specifically standing on first base and getting the sign to steal from the head coach.

Fast forward about 4 years later to 1999, I was attempting to ride across the country over my summer break from college. I had done a fair amount of training to prepare for this, but I did not have any knee pain during my training. Once I started riding around 75-100 miles a day the on trip back east from San Francisco I started having seriously bad knee pain behind the patella. I ended up flying home from Phoenix and saw my doctor who sent me to physical therapy. Since then I’ve been through physical therapy 3 more times (4 times total: 1999, 2003, 2005, and 2016). My first professional bike fit in 2005 kept the knee pain manageable for about a decade.

About 3 years ago my current primary care doc (who is also a cyclist) ordered an MRI of my knee. Those results showed a slight amount of damage to the articular cartilage behind the patella, but nothing major. More importantly it showed that my patella was tracking high and too far laterally. Perhaps because of quadriceps muscles and an IT band that are too tight. I went through physical therapy again (4th time) for about 3 months.

Each subsequent time that I’ve gone through physical therapy they’ve focused on something different. I guess as technology improves and our knowledge of orthopedic injuries expands, the physical therapists and techniques get better. Seems like I’ve had more luck with each subsequent physical therapy experience. The latest session in 2016 focused a lot on glute strength and single leg exercises, as well as graston scraping and dry needling of my lateral lower leg. A lot of the same exercises that Jonathan posted above are similar, or the same as, what I was prescribed in '16. Some additional exercises I performed were TRX single leg squats, TRX single leg side squats, goblet squats, single leg dead lifts, single leg hip bridges, couch stretch (same as the pic above for the short rectus stretch), and lots of foam rolling of the hamstrings, quads, ITB, glutes, calves, and shins.

I did not have any issues in 2018 with my right knee (although I did develop tendinitis in my left knee that was an issue the entire year, and I think a lot of that was related to being 40 and trying to do too much too soon with my strength training program in the off season). I took a couple of weeks off after my cyclocross season ended on December 10th, but I mostly stayed active from the 10th through the 20th, and only sat on the couch for about a week post vasectomy on December 20th. Jumped back on the bike a couple of times for about 30 minutes prior to my team’s annual New Year’s Day Ride. Opted to only do 35 miles instead of some of the longer route options, but about 28 miles into the ride I started noticing right knee pain again. By the time I finished the ride my right knee was extremely sore and I could barely bend it (no visible swelling though, and there never has been any visible swelling).

Point is, this is something I’ve dealt with for almost 20 years now. Unfortunately, it’s never going to magically disappear. I’m going to have to be more diligent about stretching, doing glute exercises, single leg drills, and NOT ramping up my mileage too quickly. I think the fact that I did not do more than 2 or 3 rides over 2 hours during my entire cyclocross season was a partial factor in the pain I experienced on NYD. I rode for 2.5 hours with my team at a “chill pace”, and that was enough to do it. Also, I’ve noticed that when my knee does not hurt I eventually get lazy with doing my PT exercises, and then the pain returns.

But to summarize, my pain is due to a patella tracking problem. And making sure that I’m loose and flexible as well as having a strong core, and strong glutes. I’m going to try a few of the things listed here though, including the Surefoot custom insoles and some of the various exercises that Jonathan listed above.

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Update from my last post regarding my plica syndrome knee surgery.

Here is how my routine went from 2 weeks post op to 8 weeks post op - (ride for ~1hr = knee hurts, take the next day off, ice, ibuprofen) . I was certain that I was bike on the bike quicker with my first surgery, and looked back at my strava to see how it went. I was back on the bike around week 6 with little to no pain. “That’s it, I’m doomed.” I’ll never be able to pedal pain free again… I’ll have to find another physical activity that doesn’t involve any sort of bending at the knee!

Here we are, 9 weeks post op - No pain, no more icing, 3 hours rides outdoors doesn’t bother my knee. I’m finally back to training, and overall super relieved that my life isn’t over.

I feel bad reading about people with lingering knee injuries, since mine was such an easy fix. Hopefully that someone reading this will think about their pain, how I’m describing it, and think “that’s what I have!” and follow my steps. I know every injury is personal, but Plica syndrome is real, and it can be fixed through arthroscopic surgery.

Description of my knee pain in the past: pain while pedaling, mostly as the top of the pedal stroke, on the medial (inside) side of my kneecap. It would flare up with the harder efforts, ice and ibuprofen would help, but not much. It got progressively worse. When I would bend my knee, it would “catch” and be very difficult to bend my knee completely from the pain.

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Question: For those of you working on glute strength to help with knee pain: Do you actively try to engage the glutes when riding or any other activity that causes your problem?

I’m in PT now and doing tons of glute exercises. I do try to actively engage my glutes during activity but I’m not sure if it really helps. It definitely doesn’t seem to hurt so I keep doing it.

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Squats and Foam roller helped me! I was told by a physio I had weak hips and bad balance.

I see I already responded to this.

I know I should swim more, that’s what really keeps my patellas tracking. But it’s cold in there.

Ironically my knee problems led me back to cycling, as running would cause my knees to hurt for days and days. And while cycling was easier, climbing rides and hard group rides would sometimes cause knee issues to flare up and keep me off the bike for the better part of a week. My quest for getting faster on the bike led me to the gym, where no amount leg work was tolerated by my knees and just led to more setbacks on the bike.

The final straw was my wife’s joking about how I wouldn’t put things away on the bottom kitchen shelves, right about the time I started listening to the podcast ~9 months ago. I really appreciate your willingness to discuss this on the podcast, like so many other topics you guys bring forward and discuss. And so I credit TR and you Jonathan in particular with the extra shot of motivation needed to commit to fixing the problem.

From talking with PTs, it was clear that both flat feet and 20 years of working from home and all that sitting were part of the problem. Tom Danielson’s “Core Advantage” book also helped explain how knee issues can stem from weak glutes among other things.

To remediate / rehab I’ve done a slow progression to rebuild core/glute strength, while working on proper hip hinging mechanics so that someday I would be able to work on leg strength in the gym. As a result, within the last month I’ve finally been able to incorporate (low weight) deadlifts and squats into my 2-3x/week strength training. As my routine evolves, I’m going to try incorporating some of the exercises you’ve listed. Thanks again!

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I’ve searched the internet and got lots of opinions.

But I want some personal experience on how to solve knee pain. I mostly get the pain after riding, occasionally during the end of workouts. It’s on the inside of my knee towards the top.

First my legs feel heavy then the pain begins. Usually escalating during the day.

Hi Jonathan!

I have exactly what you have: chondromalacia + patellar (dont remember the exact name).

Basically I started cycling, because doctor advice me was the best therapy when opposing to surgery (i used to be a squash player ).

What works and makes me pain free:

  • 3mm higher the seatpost to what the bike fit states (or in the higher range possible by the bike fit).

  • More cadence- less force.

  • Erg mode makes worse the problem and when do workouts in erg mode I start to feel pain again. So: I try to put it under resistance , with manual resistance ).

  • When it starts to hurt: glutamine + chondroitin powder once a day. (my doctor recommended using it only when there is pain and for a couple of days).

Hope it helps!

Was diagnoed with light symptoms related to patellofemoral pain syndrome by my phyiso 3,5 weeks ago. I’d been riding for a few weeks before that with a slight sensation at/behind the left knee cap, but no pain. Then suddenly after a hard 1,5 hour ride I had trouble the next day. Took some rest after this and went straight to my phyisio, and he said I had gotten on top of it early which was a good thing. I had pain when going down stairs and getting up from office chair the first few days after the first painful ride. I’ve pretty much been symptome free for a week now, but i’m a little worried about going too hard too soon.

Anyone with experience regarding this? How long until you’re in the clear? My physio meant that this came from overuse, therefore cutting back on mileage for a while was the best solution. He’s been needling my quads once a week, and I’ve been using a foam roller at home (quads, hamstrings, ITB) almost daily.

Replying to my last post, see above.

Since then I’m still symptome free in daily life, and I’ve upped the mileage slowly without any pain of the bike. In terms of intensity I’ve been doing 2-3 SS workouts on the trainer each week, as well as a couple of 1-3 hour endurance rides outside. No problems to be fair, which is good.

However, I feel like there is still “something there”. As I said, not had any pain, but maybe once in each workout I will get a small sensation in the knee for a couple of seconds. I might be overthinking this, but we all know how it is psychologically coming back from an injury, you are afraid of causing it to flare up again.

To summarize: I feel like I’m doing the recovery by the book, as in getting symptome free and then upping mileage/intensity as long as no pain or symptomes. However, what should I read from these minor pain free “sensations” I get in the knee?

November 2017 is when I gave myself a decent case of pattellofemoral syndrome thanks to a saddle position that was too low and too forward. And my cleat position wasn’t helping either but I found out about that much later. I let it languish for about 3-4 months with poor self diagnosis of other things and trying internet stuff based on that until I finally went to my primary care and got a proper diagnosis. After that things improved but weren’t perfect. I more or less rode through all of this because most of the interneting I did said cycling was often a treatment for this syndrome. I had addressed my saddle position issue but thing weren’t really improving like I had hoped. Finally in late June of 2018 a week before the fancy bike fit I had scheduled to try and fix my position and stem the knee pain entirely I decided to move my cleats forward and holy crap that put me on the track to being “fixed.” I had my fit seemingly well dialed but just in case I went to it anyway and for $150 got confirmation that I did the right things with my cleats and why that helped my knees. And he moved my saddle back less .5 cm. For $150. Oy.

So that’s the story. What I did to help fix myself by the recommendation of my primary care was strengthen the supporting muscles. Strengthening the VMO and the outside of the leg (don’t know the fancy name for that) with help from the packet that the doc gave me and some more internet research. This helped support the patella properly and get it to track in the right spot thus reducing the irritation, inflammation and pain. Also stretching my IT band seemed to help get things back on track. McConnell taping provided the most immediate relief and allowed me to ride a bit more comfortably for a while but was not a cure and didn’t work forever though I do highly recommend it. An exercise I really liked that I think helped a bunch was step downs, which are basically really low key pistol squats when it comes down to it. I do those and a bunch of other stuff during my body weight strength routine to keep all the supporting muscles strong that cycling alone doesn’t touch.

I consider myself 90-95% cured at this point. From what I’ve read it’s called a syndrome for a reason. Once you have it, it can come back at any time if not kept after. Around the time I finally figured things out, like late July into August 2018 I was still getting twinges that would spring up and go away over the course of a workout, but nothing that lasted longer than the workout. Getting into the fall and then into starting a training plan in November I was aware of it but barely thinking about it since things had progressed so well. Now in June of 2019 I mostly don’t think about it anymore unless I’m noticing that my knees don’t hurt. I occasionally get an ache where the knee meets the quadricep during sustained hard efforts like the race I did last weekend but I think that mostly comes from high amounts of fatigue. But it’s going to be diligence in strengthening/stretching routines to keep things in balance that will keep the pain of riding in its proper places and away from the knees.

As they say, results may vary but this is what worked for me and hopefully continues to do so. A phrase that I heard that sticks with me that I think Dr. Andy Pruitt said(or at least I heard it from him): “The knees are the victim.”

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I just posted my long ass blurb from my experience. It took me far more time to get it diagnosed and just as long or longer to see improvement and then lack of symptoms. I never saw a physio but my primary care knew what he was doing and the rest I just interneted.

In my internet educated n=1 experience I’d say seek out what caused the knee pain and make sure you have addressed the many possible reasons before assuming you’re in the clear. Strengthening/stretching stabilizer muscles to keep your patella tracking properly (strengthen the VMO, stretch/roll to loosen the ITB) and making sure your bike fit isn’t causing you any harm. If that’s all been accounted for I’d say keep at it and know you’re on the road to recovery. Damage has been done to the cartilage behind your patella and the irritation is there so you will feel “something” here and there while it heals. Some sensation or pain here and there is no huge reason to freak out, but be aware of it and make sure the sensation is getting less and not more. During my recovery I had finite pain just during workouts that would move around and come and go but over time has pretty much gone away. Maybe I was somewhat fortunate in my idiocy in letting things get really bad because then I knew for sure when things were causing less pain and I was actually solving the issue. Finding the proper cleat positioning for me was a real “Ah ha!” moment. Good luck and be diligent.

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Wow, thanks for your comprehensive input. Really helpful!

In terms of cause to the injury, my physio meant overuse. Specifically my left quads. I’ve been training consistently for a while now, so I’m not totally convinced that this is the sole cause. However, I had been doing a lot of 1-2 hour hard rides outdoors in the weeks prior to this injury flaring up for the first time. I suspect this triggered it, and I will cut back on these sort of efforts in the future and focus more on structured intervals and endurance rides when riding outdoors.

I’ve made some adjustments to my seat height (slightly raised) and setback (pushed slightly back). Haven’t thought much about this before. but I think this has helped without affecting my power. In terms of cleat position I can’t see anything wrong to be fair. Using 6 degree cleats and made sure that the spindle is right underneath the ball of my foot. Also been studying how my knee is tracking and I can’t see anything wrong there. What was wrong with your cleat position in the first place?

Thanks you all

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I hope it’s helpful. Each of our experiences will be different and what worked/works for me might not for others, but it’s always worth a try. Patellafemoral is of course an overuse injury but I glean that something must be amiss for it to occur otherwise I bet we’d hear about it way more from the pro peleton. Sometimes it can be caused by too much intensity too quickly. For some this can occur early in the training season doing too much, too intense, too soon which may be your case but check your calendar and look for correlation to see if that’s there. Mine was that and a bad position. And to think it happened at the beginning of SSB 1.

As far as knee tracking that may be something to look at but might not be the cause. There are plenty of people doing silly things with their knees while riding and have no knee problems where as I paid as much attention to “juggling that soccer ball” or having them act like pistons and still had issues. I’m guessing the motion could be perfect but if an overly tight IT band is pulling your knee cap out of position and a weak VMO is letting it do so, problems will occur regardless. Foam rolling and stretching is part of my evening ritual.

As for my cleats, it was part of the journey. It started with saddle position. Everything said address the knee over spindle position first. After I did this I got my saddle setback position pretty dern close. I also raised my saddle but something still wasn’t quite right. For some reason when I started using clipless peddles I decided to put my cleat position as far back as possible for my crank brothers. No clue why, this was back in 2012 and I was purely recreational/commuter then. I should mention that this doesn’t cause everyone issues, in fact I read that RAAM riders and long distance touring riders will move their cleats back as far as possible to help with hot foot, even drilling holes further back than their shoes are built for. But I digress, during that time I’m guessing it didn’t cause any issues because I was maintaining a certain level of use and it wasn’t all that intense. That and in similar fashion I also put my saddle as far back as possible, but that was mostly so I could easily fit my under seat bag with my rear rack. After reading about cleat position also having some effect on knee pain I decided to mess with it. First suggestion was to ride with flat pedals till the pain goes away because being locked in with little float can cause issues. So I pretty much did that and discovered there was little to no pain when I pedaled closer to or on the ball of my foot. I then moved the cleat and it was like holy crap that’s it. Upon going to the bike fit, when I told the fitter this he said because I was able to elongate my leg better thanks to the better foot position. It improved my knee angle and moved the strain further up the chain into the quads and glutes and away from the knee. And though I spoke somewhat disparagingly about paying for the fit, in retrospect I think it was still worth it to get that confirmation from a highly trained eye that had probably helped people in a similar situation. If you haven’t gotten a fancy fit I would still recommend it. Not one of those $75 saddle height jobbers but a dynamic fit, whether motion capture or spending up for retül. Ask around or internet it a bit for your area for someone reputable with a lot of experience. If you’re in the northeast I can make recommendations. But in lieu of said fancy fit using a plum bob to figure out your knee over spindle position and large mirror to the side of your trainer set up so you can observe your leg extension and knee angle can give you some insight into how you’re doing. If you’re curious how to check these things feel free to ask but I’ll save that for another post if at all. Andy Pruitt’s “complete medical guide for cyclists” and Phil Burt’s “bike fit” have a bunch of good information on this topic as well.

One thing I forgot to mention in my original post that has become part of my post ride ritual is icing my knees. This was recommended by my primary care and I think it’s been helping a bunch. It’s just become such a habit that when I did it after my ride today it reminded me oh yea people might find this useful. Basically after workouts/hard rides most of the time I’ll mix up a whey protein recovery drank, put my legs up on the couch or ottoman and put a CVS reusable cold pack over each knee. I take them off when they get uncomfortable or I get bored of reading news on my phone. It helps reduce inflammation and irritation brought on by the workout and gives me a good reason to sit still and put my legs up after a ride.

Please pardon the verbosity, I tend to go on and on about stuff that has bothered me at some point. The cleat position may have been the ah ha moment but it was the holistic approach with strengthening/stretching/rolling/icing and bike fit that really put things back the way they should be.

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I need some help here. I have been dealing with a stubborn IT band issue for well over a year now. (I’m a 40-year old recreational cyclist and spin instructor .) Pain at my lateral knee as well as my hip. I feel like I could have written Jonathan’s post. I’ve seen several doctors- sports Med and ortho, MRI (showed greater trochanteric bursitis in the hip, and inflammation at the lateral knee) done months and months of PT with two different therapists, dry needling, cortisone shots at both hip and knee, massage, ice, heat, foam rolling, hip and glute work, core work, professional bike fit,etc. I feel like I’ve tried everything. And nothing is working. I DNS’d my two goal rides this spring and summer. :sob: I’m at the point where I feel like I may have to quit biking altogether.

I currently teach two cycling classes per week, and that’s it. No TR since about January. No riding outside. I think I need to take some time completely off the bike, but how long? My PT seems to think that won’t help. Do I keep doing all the hip and core strengthening exercises in the meantime? Anyone have any ideas at all? I’m taking a biking week in Vermont in October, and I really want to go. It’s a bucket-list trip for me. I’m so tired of being in pain and being unable to do the things I want to do. I’ll try anything at this point. Any ideas?

You didn’t mention static stretches but I’ll assume you’ve tried those. I’m a big fan just as a nightly ritual for relaxation. A half hour of foam rolling and stretches. I don’t need any white papers to tell me whether it works or not, I just like it. @Nate_Pearson had a way of releasing the ITB that he described a while back that I’ve found useful when that thing was causing me trouble. Hopefully he could make a little video of him going through the motions of that because I could use a refresher as well.

My big question is did your bike fits address your stance width?(I’ll throw in that when I got my fancy fit I don’t remember him walking around behind me to check stance width but then again I didn’t mention any ITB issues, just anterior and medial knee pain) And are you using clipless pedals? If so what kind and how much float? Both books I mentioned in my above post talked about stance width being a culprit in causing ITB problems, in general too narrow causing the tightness. I remember Jonathon saying he addressed his Q factor by widening it as part of his epic quest to solve his knee issues. If you’re not using clipless pedals then disregard this part. But I’d suggest pulling off your clipless pedals and throwing some flats on there and riding with sneakers. This way you can ride without your feet being forced into a certain position and you can feel and observe what they would like to do naturally that doesn’t hurt. After that try to recreate that position with your cleats and pedals. Likewise just standing comfortably with your feet apart and observing where they naturally fall is a start and whether they toe inward or outward. Then try to apply that to your stance but adjusting your cleats inward or outward and angling them accordingly. If your setup won’t alloy your feet to get wide enough there are washers that can be put between your pedals and crank arms or some companies make pedals with longer spindles. Jonathon also swears by custom orthotics which if you have any arch support issues going on may cause trouble up the chain. You might not need to go as far as he does but I just use the Specialized body geometry insoles that I got fitted for at my LBS and those have been working just fine. After you address your stance problems stick with your PT routines until your ITB finally relaxes, and maybe beyond just as precautionary maintenance. If the above has been addressed then I apologize for not being able to contribute more since that’s all I could come up with. Good luck!