Before throwing money at equipment and fits etc I’d suggest giving your body a good once over to see if it’s working as it should be…
Sadly found this thread. Sharing what I’ve discovered in the hope it may help a few. Seems like a lot of it has been documented above. The most important thing is not to just think it’s a bike setup issue - it could be a problem with you - muscles imbalances, weaknesses etc.
OK a bit more detail:
Patellofermoral Syndrome has been bugging me for decades and I gave up on cycling. I saw an excellent Exercise Physiologist two years ago and he was able to get me back on the bike and doing events like a 3 day 300km + ride and a few 170/150km finds etc. He was expensive so I stopped seeing him and ramped my on bike training for a big event in March 2026. I was doing a bit of strength and mobility work but in hindsight… nowhere near enough. So my PFS has come back…
Here are his notes: Main focus for us has been:
hip mobility, specifically increasing hip extension, internal/external rotation
improving glute/hamstring strength to improve the tracking profile of the femur posteriorly during hip flexion
contralateral core strength
hip abductor strength to improve lumbo-pelvic alignment
external rotator strength to improve lower limb tracking profile.
Now here’s an interesting one for you all (at least, I don’t think I’ve heard of symptoms like this before). I was experimenting with a more forward seat position and a slightly more forward cleat position, and sure enough my knees got a little achy. One hard jump on the trainer made something pop in my left knee, but nothing else seemed to happen at the time, no new pain or weakness. After about a week in the new position the general dull pain wasn’t getting any better so I figured I should back off for a bit. The general knee aches went away and the right feels fine. The left hurts around the distal head of the vastus medialis, and it’s kind of a sharper/brighter pain, but only in very specific positions:
-Top of the pedal stroke, even at easy power output. Nowhere else in the pedal stroke. Somewhat alleviated by raising the seat, but I can only raise it so far. Further fit experiments to be conducted. Also noticeable in a deep squat or lunge.
-Near lockout (full extension) on a leg extension machine, but not near the bottom of the lift in flexion.
Notably, running and going down stairs seem just fine. Spanish squats and wall sits provoke some general dull knee pain but not really this specific ache. Obvious inference is some kind of VM strain–a couple torn fibers but not a full rupture–but then why does it hurt in deep flexion and not running or on stairs? And how to progress back to deep flexion?
I have a reasonable degree of general strength, run regularly, probably have a double bodyweight deadlift in me, do some band walks a few times a week, single leg deadlifts as a warmup, so I think the low hanging fruit is reasonably well addressed. No history of knee pain provoked by cycling; some generic runner’s knee type symptoms associated with running in the past, but hasn’t been an issue for a while, and MRI didn’t show anything interesting at the time.
MRI shows partial intrasubstance tearing in quadriceps tendon. Not at all certain about progress back to run, bike, or non-isometric strength work. Reverse Nordic curl isometrics seem to work pretty well (two-legged wall sits seem a bit light, one-legged wall sits are tough but don’t seem to make things any better, Spanish squats seem to actually make things worse.).