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

What a wonderful thread!

I am privileged to live close to one of the world’s top surgeons who sees professional athletes and recently went with the US Olympic team to Kyoto. Last year he diagnosed me with Plica and recommended surgery. See posts above for a great description of what that entails: a fairly quick recovery with standard exercises and treatment. Instead, my insurance company denied coverage and I could not get the procedure done. I was livid at the time, but it forced me to find my own treatment. So far it has turned out well.

Since then I take great care with my diet to include anti-inflammatories with most meals, including turmeric in almost everything I eat. I add ginger, cayenne pepper, black pepper, and EVOO when it will add flavor, i.e., not just for the medicinal properties. I eat spinach and almonds with lunch/dinner when I am working from home. I am working on adding more fruits.

My go-to exercises which strengthen cycling muscles without pressuring the knees include straight leg raises and calf raises. More ideas are in this link. I tried squats a few weeks ago and my knees became inflamed, so I won’t do those again for a long time. I also don’t ride for more than one hour on consecutive days.

Thus far I am thrilled that I’ve been able to ride without pain since making numerous small changes that all added up to a big difference. Hoping that others can also develop a plan that helps to manage knee problems and lets you enjoy cycling.

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Very interesting! Great to hear that you have had good results without surgery. I ended up getting my Plica removed, and everything has been great since. The recovery definitely took a little longer than I would have liked, but I was back on the bike in a few months. Since recovering I have not had any flair ups, and have been able to stay more consistent than my knee previously allowed.

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My ongoing minor knee issues continue to break my brain. For a year now I have had intermittent bouts of pain in my left kneecap, mainly when climbing and descending stairs. Seems like classic “runners knee.” Here’s the thing: not only do I not feel pain on the bike, but relatively big/hard rides actually make it GO AWAY, sometimes for days. It’ll feel a little fragile/stiff/weak for the first hour or so, then by the end it feels completely normal, and I have no pain for the next day or two. It is as if riding is both causing and helping my symptoms. My best guess is that a certain dose of riding brings about inflammation that actually masks the pain, but I really have no idea. For awhile I was dialing training way back during flair ups, but lately I have just been training through; it doesn’t seem to make a difference. My main question is: am I living dangerously continuing to train as long as it doesn’t hurt while riding, even if it does continue to bother me (sometimes considerably) in day-to-day living? @stesol you had a very thoughtful response in another thread, hope you don’t mind the tag…

@Jonathan have you ever had issues with an MCL? I went for a (stupid little) 20 minute run a week ago and BAM, sprained my MCL. Was having a great string of consistent weeks (for me) and now I’ve been off a week and its really irritating me. Been taping it daily and doing banded exercises for it to get rehab going, but even going up and down stairs is a chore. At least I know there’s hope, lol.

This describes what I’ve been going through the last couple months. Have no clue what it is. For me, the pain is in my top inner knee area. I’ve had a professional bike fit late last year and have both trained indoors and rode outdoors with this fit without any known problems until these last couple months. The pain usually lingers for the rest of the day and by the next day, it’s usually gone.

I actually don’t experience any pain on the trainer (standard Kickr Gen2), though I’m on LV and my workouts are 60-90 minutes. I only experience pain on outdoor rides around mile 15-20. My hypothesis is that out of the saddle efforts could be the reason and my form isn’t good, which just exacerbates it.

The weird thing is that the issue pretty much “went away”. I had a century/fondo ride last weekend. By mile 15-20 the pain kicked in. After more miles, the pain went away and by the end I didn’t feel anything at all.

I went out on a outdoor ride today and the pain never popped up, despite a lot of hard and out of the saddle efforts.

I’ve not yet gone to a doctor or specialist for a diagnosis yet, but I’m going to schedule something this week.

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The simple answer is you won’t know what’s going on unless you have diagnostics

Just piling on here, what a great thread.

I’ve been dealing with patellafemoral pain my whole life. Mostly pain under the top part of my kneecap. At it’s worst, I wake up with a searing pain after straightening my knee, or sitting on a plane is excruciating without straightening.

Seems to pop up more when I’m training more and especially indoor on the trainer. Also more frustrating because I’m making progress training. PT has always worked but I’m very impatient, and that’s why it keeps coming back (for a month or so, a couple times a year.) Things that have worked for me:

At first notice, Ice for 15 mins, 4 times a day.
A lot of ibuprofen for a few days (600 Mg every 6 hours)
PT exercises:
Foam rolling (my IT band is like beef jerky)
Glute bridges
Single leg deadlift
Quad/glute/hamstring stretches
Lunges (but not to the point of pain)
Step downs
Banded clamshells and sumo walk
Pigeon pose and/or “4” stretch

Good luck everyone!

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One other thing, although I don’t have a weak VMO, I learned that the more I can engage it in the pedal stroke, the better my patella tracks, and the less pain. It’s natural to back off using it because it seems like it will CAUSE pain, but then I end up dumping into my hip, which starts to hurt, and my knee then aches (especially at the top of climbs, when VMO is not engaged as much).

Upon noticing the recurrence of my knee pain (diagnosed PFPS/chondromalacia by a sports orthopedic years ago) I immediately cut back on the volume and intensity - was doing sweet spot high volume base. Did 30 min of easy endurance, then 45 the next day, then a few days of an hour… then added a little tempo, then a short sweet spot ride etc. Have not returned to the 2 hour sweet spot rides in SSHVB yet. During these rides I stopped and foam rolled if I felt twinges.

I generally adhered to the PT principle of stretching what hurts and strengthening everything else around it, especially strengthening the opposing muscles like the hamstrings and glutes.

I did the following:

  • Foam roll before and after riding and sometimes during. Progressed to flexing my knee as I foam rolled, sort of pinning the muscle on the roller and then flexing so it really stretches - lots of youtube videos on this. Focused most of the rolling on the outer thigh muscle, especially right above the knee.
  • Clamshells, hip flexion while laying on back with one leg straight and the other leg bent and the straight leg rotated just lightly outward, hip abduction while laying on side, RDLs without weight, and good mornings without weight. Did good mornings and RDLs before riding to get some activation. Added resistance to these after I was able to do the movements controlled and easily. Was surprised at how terrible my clamshells and hip flexion was. Strengthening Exercises To Help Stop Kneecap Pain (Patellofemoral Pain Syndrome) - YouTube
  • TAPING - this was the single biggest thing i did this time that i think made a huge difference. I did not tape during rides but sometimes had it on all day and night (eventually irritated my skin so wouldn’t do at night). This gave me a break from the pain cycle which in the past is what really did me in. I personally believe that the more you feel pain from PFPS, the worse your pain will get. The tape gives you a break from that so your nerves can stop escalating the pain response. How To Tape & Stop Kneecap Pain (Patellofemoral Pain Syndrome) - YouTube I didn’t do the first layer of tape, just a couple pieces of leukotape giong from the outside of the patella to the inside of the knee so that the tape pulls the patella inward.
  • ICE after every ride and sometimes throughout the day if pain is persisting. Used it at night too the first couple of days. I did not use any medication.

I worked for a few years in a PT sports medicine clinic and also went to a PT multiple times for knee pain in the past so I know I’m doing stretches, exercises, and taping correctly. Of course would recommend going to PT if you are unfamiliar with how to do these things the right way. But I know from experience that if you’re an athlete it can be hard to get the right level of care at a PT and helps to learn your own body and know what to do at home.

I also have previously had bike fits and had not changed a single thing in my fit when the recurrence started. I learned years ago to not change too many things at once on the fit but of course you should get a bike fit if you’re having pain and haven’t gotten one.

I hope to do more of the longer sweet spot rides again but will not push through any pain.

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Over the Christmas period I increased my volume significantly and gave myself PFPS (mainly dull pain for a period after sitting with a bent knee, and after cycling).

Consensus seems to be that 6 weeks is a typical recovery period and indeed that seems to be the case for me. I’ve completely stopped cycling and it has started to feel much better in the sixth week.

I’m left with occasional mild soreness when seated and some clicky-ness.

Does anybody have any experience restarting cycling after similar injuries (PFPS with insidious onset through overuse rather than a chronic issue)? I’m tempted to hop back on the trainer and try 30 mins of zone 1 but worried about setting my recovery back.

During your 6 weeks off the bike, did you do any strength work for your knee? If not, based on my experience you should start that immediately.

The key thing to realize is that during your 6-weeks off the bike your FTP has dropped, and if you haven’t been doing strength exercises for your knee you’ve also lost a lot of leg strength and knee stability. So go easier than you think is easy when starting back on the bike, and keep the sessions short - less than 45 minutes. Ease your way back and listen to what your knees are telling you you can handle

Yes, exercises as prescribed by a PT. That said, the exercises were cookie cutter “anterior knee pain” exercises and all felt extremely easy.

As part of my ongoing plan I want to do some more load bearing exercises in the gym, such as leg presses, but starting very lightly.

Getting slightly off topic from my original question, but mentioning it in case it is useful for others, one thing that coincided with my knee feeling better was performing stretching exercises focused on my hip. Very hard to say if it was the cause as it was also around the time one might expect the knee to start feeling better. But worth trying for others with similar symptoms to me (insidious onset through overuse, “cinema” sign, not much previous history of knee pain or known structural issues).

Just had the same thing happening to me during Christmas break.

What made it worse: load-bearing strength training (such as leg press), sitting, walking.
What made it better: stretching the posterior chain, lying down.

It took me 6 weeks to realize that once the culprit was eliminated (in my case, a cleat that was too worn out), cycling had no impact whether bad or good on it.

On the other side, load-bearing exercices with knee flexion have made the recovery significantly longer : the pain only started to subside when I stopped going to the gym.

N=1 ofc.

(I’m not saying that a good strength training regimen is useless for healthy knees, but once you’ve got PFPS you shouldn’t load them until the pain is gone).

My update: While taping, foam rolling, clamshells, etc., all helped me feel better, and I definitely had some hip weakness going on, the thing that has really made me feel better is switching from sweet spot to polarized. I was doing SSHVB1. I think if I was going to do a sweet spot plan again I would work up to it much more gradually. I’ve been riding very consistently for 7 years or so, 12-15 hour weeks, often more, rarely < 10. I felt better almost immediately with polarized and don’t have to tape or foam roll or anything. Been at it for a few weeks, feel great, knee ache is all gone.

It is PFPS/chondromalacia (diagnosed via orthopedic dr and MRI). I have never found that stopping cycling makes a difference. Apparently dropping sweet spot - yes. It was still bothering me on z1-2 rides until I dropped my other sweet spot rides. Shorter, high intensity is fine. I’ve done 4x8 at 105% 1-2x a week for the past few weeks.

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My recent experience: knees over toes guy’s regime seems to be helping my longstanding PFPS. Alternating every other day with glute strengthening - banded clams, single leg bridge, etc. Couldn’t cycle without sharp pain above my kneecap last week; just stepped off the turbo after 30 mins z2/3. Fighting the urge to smash it as it’s been so long since I could ride without knee pain, but I know I have a long road ahead of me so need to be patient!

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I am experiencing knee pain on the inner edge of the left knee cap, which comes on after 30 mins-ish of cycling, and lasts for days at a time, it also aches if I sit for periods of time and the patella almost feels bruised.

I have a long history of cycling and structured training and have been relatively injury free until last year when I had problems with the right knee, which fixed itself a few months ago, a week or two before the left knee became troublesome.

I’ve had a bikefit in the past, and custom insoles for cycling, as well as experimented with forefoot varus wedging.

I experienced almost exactly what you’re describing. After seeing a sports PT we concluded that I had severe weakness in gluteus minimus and max of the affected side as well as overall adductor weakness. It took a good 12 weeks of glute-focused strength training with good progressive overload to finally get the pain to subside. I also did A LOT of mobility work that consisted of foam rolling the quadriceps and calves. We continued short and controlled bike rides so long as pain wasn’t worse during or following. The goal is to ride, do not remove that component unless it’s further aggravating.

Many folks make the mistake of focusing on trying to correct where the pain is coming from and ignore the other muscles along the chain. If your knee hurts, it’s usually not because you have an issue with your knee.

Work on your glutes via bridges, banded monster walks, deadlifts and things that don’t load the knee first. Then start slowly incorporating depth controlled step ups and step downs and test how it feels on the knee. Know that some pain is ok, and actually good and necessary to illicit adaptation. But keep it around a 3/10 max.

Follow up with questions if you have them, here to help.

^^^ this for me too. Seven years ago I started actively cycling, and would experience knee issues from time to time. Solved them by strengthening the posterior chain and glutes. Weak glutes and posterior chain is common among desk workers.

This is great, thanks. I’ll definitely incorporate more of this stuff into my gym work, interestingly when the knee is in early stages of hurting, riding out the saddle seemed to relieve a bit of pain, but only for a short period before it starts completely hurting and I have to unclip that side completely.

I have followed the Glute doping protocol in past, and believe I have sufficient glute med strength and have reasonable single leg stability, will continue to activate pre-ride.

Currently it consists of Bulgarian split squats, Single leg RDLs, Squats, Calf raise, hamstring curl and misc core.

It’s aggravated by most knee flexion exercises, regardless of whether i’m pushing hard, including sitting. I have a feeling it could be Prepatellar Bursitis, and have been told by my Acupunturist of that.

I’m going to continue taking Ibuprofen in hopes to reduce the inflammation over the patella. I’ve got an appointment with a physio in a few weeks and will have a look at my bikefit in hopes to recruit more of the posterior chain as I am very quad dominant.

I found this useful article on the old Bike+ site years ago, its subsequently morphed over to Bike Radar and they may have updated it. Touch wood since fitters have lowered my saddle I’ve had nothing as bad as my knee pain (ITB problems) of 2006 and fitting a cleat shim in 2013 (another fit) seems to have sorted it altogether. Between 2006 and 2013 I had been managing it with stretching.

Cycling knee pain explained: how to stop cycling knee pain. Causes and solutions identified - BikeRadar

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