Help me with sudden onset knee pain

Anyone here ever rehabilitate a knee injury along the lines of patella femoral pain syndrome or “runners knee” and or patella or quadriceps tendonopathy, or chondromalacia?


Over the end of the summer into fall I noticed a little, talking minute tenderness on the inner edge of my left kneecap, but it never bothered me—just tender to the touch. Fast forward 2 months and I’m wrapping up a lower body strength session doing barbell lunges and WOW, ouch! So either it was that or a long slow build up. But I can’t tell if it was brought on by poor knee tracking or and overload of weight.

It’s weird, any knee over toes stuff really triggers the pain, so a forward lunge is not good, neither is going down the stairs, but I can go up stairs done and surprisingly do full range of motion double leg squats without pain. I can also ride the bike with no pain seated, but standing triggers some discomfort at the front bottom and medial edge of the knee cap. The tendons (quadriceps and patella) themselves have no pain.

So…I bought Dr. Aaron Horscheig’s book Rebuilding Milo and it seems like a great book to have, however, I’m having difficulty screening myself and uncovering what is likely causing my knee pain. I think it’s either an issue with load on the patella tendon or something to do with compression of the kneecap in the groove of the knee.

I’ve been implementing a range of exercises from the above mentioned book for the last 8 days and only get temporary relief from eccentrics, like wall sits. I know it’s still early days and this will be a long road ahead, but I’d like to nail it down.

Any advice or suggestions appreciated—I’m nearing the point where I may have to gamble on a local PT and hope for the best.

Pain descending stairs is classic runners knee…had it several times from running back in the day. You probably have strong quads so lack of strength is not the issue. Firstly stop lifting even exercises that don’t hurt as you will cause imbalances. Secondly it’s nearly always either the VMO or vastus lateralis becoming tight and pulling the tracking of the patella over the femur out of alignment. If the VL is tight (you often get tight trigger points above the knee on the lateral side which get sore) it pulls the kneecap out. If the VMO is weak (and you often get wasting of this small stabilizing quad muscle) on the medial side then it stops the knee tracking correctly from the other side and this muscle is often overpowered by the more powerful VL. For the VL you need foam rolling on the outer quad/IT band - plus maybe a bit of massage ball stuff to loosen it off. For the VMO its tough to sort it out but single leg shallow squats with a book under the heal isolates it for strengthening - you can massage it as well with a massage ball - in fact massage all around the kneecap helps. The VMO is tough as it only comes into play in the last 30 degrees of straightening the leg…but it stabilizes through the whole run stride/pedal stroke…I’m not a physio - but I have had this injury and done tons of research over the years…good luck :grinning:

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Thanks for your insight. I’ve noticed that my VMO seems to be more developed than the vastus lateralis, and that the VL is always significantly tighter and has way more trigger points, it’s incredible painful to foam roll, whereas I can roll out the VMO’s all day with little issue. In fact, the whole lateral side of both legs is very sensitive.

What’s confusing me is that I can do things like squat deep and do high step up with no pain, which seems to counter what I’ve read about pain associated with patellar tendinopathy.

Here’s what elicits some level of discomfort:
Descending stairs (can ascend or go up with no issue)
Knee over toes stuff
Single leg touchdowns/squats
Bike riding in a standing position

Things that don’t hurt:
Bilateral squats
Wall sits
Going up stairs
Step ups
Knee range of motion exercises
Knee flexion
Reverse Nordic curls
Bike riding in a seated position

It seems like it’s either a muscular imbalance that is causing poor tracking and thus pain associated with the cartilage under the kneecap or it’s actually some sort of tendinopathy.

I dont know how often x week and how heavy your strength training is, but it could also just be an overload issue being caused by a lot of training which is outing now.
Maybe back off on the gym work completely during your next recovery week and see if the pain becomes less. If so, reduce the loading a bit or the number of sessions.

In the past, I used to get this issue at the end of multiple blocks where gym and bike intensity both are quite high. Nowadays its either focus on strength or focus on bike intensity and reduce the volume of the other modality.

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Thanks, @Beneluxrider

My strength training “season” actually had just started 3 weeks prior so I was in the adaptation phase doing mostly un-weighted or very low weight strength work to prep for the actual work that was to come.

Funny enough, this injury happened during the first strength session after my adaptation month, and happened after doing reverse lunges with a barbell on my back which was loaded @ 2x the most recent weight I was doing during the adaptation phase. But @ 70lb 10 reps were around RPE of 8/10, so doable, not max. It was almost instantaneous upon finishing my last set of lunges. Weirdly, zero pain or issues DURING the lunges, but when I moved on to my next exercise it was immediately obvious that something was hurt.

When I look back I think I noticed a little soreness on the medial/inner edge of the kneecap during cross season. This season I started riding a single speed, and I’m wondering if that high torque, low cadence took it’s toll and along with possible muscular imbalance caused some mis-alignment of the knee and how it’s supposed to track.

Regarding a muscular imbalance, if someones Vastus Lateralis is under-recruited, and the VMO is doing most of the work, it would seem like the patella/kneecap would pull inward, and if the VMO was weak it would be pulled outward or laterally. I’m experiencing pain on the medial/inner bony edge of the actual patella, given that, I wonder which muscle–if it’s a muscular issue–is to blame. To clarify, pain is never directly under or above the patella.

What a frustrating derailment! I think a PT assessment is the obvious next step.

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Having been someone who found a very knowledgeable PT I really wouldnt hesitate to have a PT advise. You can always second guess what they say but it may lead you to a solution quicker.

Being your own doctor is typically not advisable.


PT managed my knee pain of about 13years ago. I had IT band issues. One side got so taught that it pulled the patella on the other side of centre. So instead of running smoothly it was rubbing against the bone. PT introduced stretches to loosen the taught side. But it, touchwood, it disappeared completely about 8 years ago when a bike fit lowered my saddle and shimmed a leg length discrepancy. In my non expert opinion and just going on my experience I’d reccomend a good bike fit @anthonylane particularly one who looks at cleat position, leg length and saddle height. Good luck!

Usually if the tracking is out due to a tight VL then the irritation is below the patella as the cartilage that is there to ensure smooth movement of the joint gets inflamed or worse case worn away - especially when we get old - that’s why you get that grating/clicking as you extend the leg.

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Go to a sport/orthopedic PT. This can not be diagnosed without a detailed movement exam.

Also, as /I have written before in other forums - THERE IS NO WAY TO ISOLATE THE VMO. This does not exist (without the use of muscle stimulation machine with the pads over the VMO). You can find many places on the internet that change certain exercises to “isolate” it. But you can’t - the research is strong that VMO strengthening is old science and has been debunked.

Most patellar tracking issues are not just VL tightness (which isn’t really a thing, you can have rectus femoris tightness), or weak VMO (which you say is developed). The patella is fixed below from the patellar tendon at the tibial tuberosity. The tracking dysfunction arises from hip weakness or motor control issues at the hip. Yes, there are isolated cases in which there is tightness of the patellar retinaculum, or medial patellofemoral ligament that can cause structural tracking issues but these are RARE - and you would 100% have pain during your pedal stroke, and with most movements that your knee is bending.

Eccentrics are useful for muscle strains/tendon issues - but you don’t have point tenderness over the quad tendon or the patellar tendon. My guess is eccentrics, descending stairs, knees over toes things bother you because your movement pattern is not optimal. Yes, there is probably some rectus femoris, hamstring, gastroc tightness, but these are contributing - not the isolated issues. Have someone watch you single leg squat, go down the stairs, and then do a detailed exam based off these findings. Have them check your feet and see if orthotics could help and change your ankle position - which also can affect patellar tracking.

No one on this forum can help anyone who complains of back pain, knee pain, etc… We are all special snowflakes - and what works for one persons issues won’t necessarily work for the other. I have so many patients who come in in MORE pain because they were doing back exercises they read on google which promote movement in the OPPOSITE directions that would help them!


I get similar pain in my left knee descending stairs. What’s weird is it fades after rides or runs, and during big training blocks it goes away completely, only to return at the tail end of my recovery week. Been following that pattern for six months now. I feel like it’s a good sign that training makes it feel better, but concerning that it’s always beneath the surface. Anyone else have this phenomenon where it only shows up when you reduce volume/intensity?

Fair point - especially about the VMO - maybe I just got lucky sorting my knee issues over the years with the DIY method :grinning:…that said PT are expensive these days and it’s an extra expense in the current climate so if I could sort it myself I always did - that said the professionals I saw were excellent and did help with various problems I have had in 35 years of Tri/running/TT so I’m certainly not against the nuclear option if my own attempts fail :grimacing:

I think trying yourself or doing research first is totally fine. Just recognize that when that isn’t working taking the next step is better than continuing down the google rabbit hole

I understand the expense part. Copays are getting absurd in the US but I try to work with people and space out appointments or just 1-2 and talk on email if that’s all they can afford. Being at a non profit helps with this. It’s the for profit places that judge their employees on tons of metrics where that model/style is more challenging


there are getting pretty absurd in the UK as well :grimacing:

Had pain like that, in similar situations. Started suddenly, and was wondering what caused it. Then remembered that I clipped one of the plastic stakes during a cross race. There was no visible bruising on my knee, but it went away after 2-3 weeks.
Just saying…

Hi, there are several factors creating the pain in your knee. If you have pain during cycling then (re)check your cleat and saddle positions to make sure they haven’t rotated/shifted. If you haven’t done so already - have a professional evaluate your bike fit. A reach too far, a saddle too low and/or forwards would be the first for culprits I would look at for overloading the quads (but I’m not fitter!).

Your quadriceps tendon is overloading and/or the patella is mistracking. Fire up the glutes (medius and maximus), stretch hip flexors, transverse and rectus abdominal is muscles will help control the pelvic tilt so get those strong.

Posterior Chain!!! Posterior Chain!!! Posterior Chain!!! Get it working and get it strong.

I went trough this same thing three years ago. I ignored all signs of trouble for about three months because I had a climb I was training for. In that time I had increased my training load while having a saddle that was too low and forward, and cleats that weren’t aligned correctly. My knee was a swollen mess by the end, and it took the best part of 6 months of specific training with one of my colleagues to sort this out, AND a proper bike fit to get confidence to ride the bike again.

Hopefully for you this sorts out before the next riding season.

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Thanks for all the replies. I fully understand that seeing a PT might be the best thing to do, however, I do enjoy the process of fixing myself. Based off extensive reading and a couple of screening movements I’m fairly certain that I have Patellarfemoral Pain Syndrome and/or “Runner’s Knee” or some sort of Patellar compression thing.

How you say?

I feel that this was a slow build up of over-loading the quads with 2x weekly strength training and maintaining 5-7 hours per week of cycling. I think I actually have an over worked VMO, and it’s pulling the patella out of alignment. Hence why there’s sensitivity on the medial edge of the patella and any classic quad-strengthening exercises seem to make it worse.


  • Started with very minor, but gradual soreness of medial and bottom medial patella
  • Started after incorporating strength training into my off season routine (strength 2x/week, bike 6hr/wk)
  • One strength session with an emphasis on lunges triggered an acute episode of intense pain
  • Many trigger points on the medial/inner quad, very painful to roll
  • Load doesn’t seem to make it worse. I can jump pain free—hence I don’t think it’s tendon related.

What makes it worse:

  • Prolonged sitting with knee flextion
  • Going down stairs
  • Going down hills or embankments
  • Doing any sort of single leg work that involves knee flexion where the tibia is not at a 90º angle
  • Romanian deadlifts (this really surprised me, but even the small amount of knee flexion followed by the act of pulling weight seems to do something that causes irritation)
  • Some knees-over-toes stuff
  • Sometimes walking
  • Sometimes cycling

What doesn’t make it worse or actually eliminates soreness/pain:

  • Foam rolling medial/inner quad (this almost makes the pain dissolve, it’s instantaneous and I can feel almost a release or some movement of the connective tissue around the patella…it’s satisfying, but painful to do)
  • Long and deep quad stretching
  • Going up stairs
  • Keeping leg straight
  • Standing
  • Some cycling
  • Isometrics
  • Body weight squats to full depth (might be a dominant side thing doing more work here though)
  • Sometimes I’m able to do reverse lunges with heavy emphasis on keeping my tibia straight and loading through the hip/glute, sometimes I feel knee irritation though.

I’m in the process of locating a PT. But, I’m kind of frustrated because I was really hoping I could deadlift and hit my posterior chain really heavily, but that seems to be out of the question right now. I’m also finding that all of the classic “recommended exercises” for PFPS or Runner’s Knee that involve any loading of the knee also irritate it. I’ve tried everything from Squat University and the The Prehab Guys as well as some other reputable DPT’s like Tim DeFrancesco, but everything seems to irritate it.

So far the only thing that helps is a ton of mobility work that involves the quads. In the meantime I’m doing a ton of banded hip work and glute bridges.

Sounds awful…! It’s not me who has the issues though - I was just giving my anecdotal advice on what worked for me in the past when I ran. Since I became a serious cyclist and cut my running back to 10 miles/week and the odd parkrun I haven’t had any knee issues…it was when I was running 60miles/week as a marathon runner that I got knee issues. :grimacing:

Sorry about that! Still getting used to the interface. My reply was intended for the thread starter. Nonetheless I’m thrilled that you’ve no longer got the knee issues. Pain Free is the way to live.

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Thanks for the insight. I’m doing some exploratory bike fitting of my own. I’ve never had fit issues that were clearly present, but I’ve never had a pro-fit.

I’ve raised the saddle up from 84cm to 85cm which has gotten my leg angle from 40° to 30° at the bottom. It felt good for the short time I was riding, but I will do a longer ride later today and see how it feels. I’m also a touch further back so hopefully that forces more glute engagement.

I do not want this to turn into a fit thread, but here’s photo of me in the new position.

A great way to fix your own problems is by following Kelly Starrett’s Supple Leopard book. I have solved many knee problems with it (my muscles get tight while training), along with many other joint issues. Without this book, I wouldn’t be cycling.

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