As others have said, the pain could be caused by a host of things, and consulting with a knowledgeable physiotherapist is probably the smart thing to do.
Worked very well for me and it is still my go to remedy for these sort of niggles. NB, this movement is not necessarily helpful if the cause of pain is not simple patellar overload but related to posture, bike position, posterior chain function, core stability etc.
The other thing I changed was saddle height. I’m a tall rider, and have over the years gradually dropped it from 845mm to 805-810.
I wasn’t diagnosed with anything, but after a range of screening tests and some manipulation of my patella he deduced it to tightness of the medial retinaculum likely caused by over-worked medial quadriceps and serious weakness of my left lateral hip/glute and hamstring muscles.
He said there was a remarkable difference in lateral hip/glute strength between my dominant and non-dominant sides. On top of that a lot of compensation happening.
The plan is a bunch of glute strengthening exercises (nothing that loads the knee though as that initiates discomfort) and mobility work of the patella as well as the medial quads and associated fascia and ligaments.
I never knew about the two trigger points in the VMO, but I certainly have found them. OUCH. Such an interesting thing though in the way that pressing on them actually refers pulling sensation to and around the patella.
At this point riding a bike is second to recovery, I fully realize that I’m likely going to lose A LOT of fitness as a result of this, but I’m really hoping that I can maintain some low-intensity riding. If not for fitness, but for sanity.
I’m almost two weeks into my rehabilitation program and knee pain still persists with movements like squats, lunges and step downs. Especially when the quad is emphasized and the shin angle is increased. Im even getting pain in the night when I sleep, and sitting with a bent knee is uncomfortable.
However, if I maintain a vertical shin angle and focus on loading through the hips I’m able to do single leg work and squats to a controlled depth.
So for now the program is built around a lot of glute bridging, RDLs, controlled-depth squats, and banded glute/hip work.
This has been slow going and Im still not able to cycle w/o a level of discomfort around the patella.
PT doesn’t seem to think this is a patellar or quadriceps tendon issue and also doesn’t think it’s arthritis, but more an issue with muscles imbalances and over-word medial quads. Possible some tight fascia on the medial side of knee as well.
I am currently going through the exact same situation OP! Diagnosed with PFP-S likely due to overuse. Only difference between us is that in addition to being a cyclist, I am also a soccer player. I am on my second PT session and i am hopeful that the stretching and strengthening exercises will help get rid of the pain. But I have been told that I shouldn’t expect an instant fix so likely looking at 1-2 months.
I had X-rays done last week and they showed no arthritis, however they did find calcification at the connection point of my quadriceps tendon and patella. That’s interesting, but not necessarily a contributor to my knee pain.
My team still is ruling this as PFPS and we are progressing the glute and hip work to focus on strengthening the lateral side and overall posterior chain. Not a ton of quadriceps work at this point.
Things I can do today that I couldn’t 3 week ago:
Ride my bike for 90 minutes with no pain. Still a little soreness when I pedal standing out of the saddle.
This has been a slow progress, but I’m hopeful. It’s so odd how I can now cycle with no pain, but something as simple as going downstairs can trigger pain.
Training-wise I’m a good 8 weeks behind plan, and my FTP has decreased from 325-330w to 290-300, and so has my desire to ride. I’m intentionally taking it slow, and prioritizing strength training over cycling.
I don’t know if you have the opportunity, but snowboarding helped me with some beginning tendon pain (quad side). Somehow, the angle and tension was extremely beneficial. Good luck.
A bit of an update: after going through 8 weeks of PT, I’m now on my own and continuing to focus on posterior chain strength and even a bit of work on the quads. I’m getting better. I can ride w/o pain and push as many watts as possible pain free. I still have a little soreness from time to time under the patella (especially if I sit with bent knees for prolonged periods), but it’s much better than it was.
What I’ve learned.
These things take time. I think 12-16 weeks is a good baseline as long as you’re doing your PT work.
If you’re a cyclist (or runner) and don’t strength train, chances are your glutes and hamstrings are vastly underdeveloped (alarmingly so for me)
Foam rolling consistently can make an impact on tight and over-worked muscles. For me the trouble spots were the medial quadriceps
Prioritize strength-training. Save the bike for later. This has been hard, I’m looking back at 2021 and during this time my fitness and workout schedule were in a much different (better) place on the bike, but I’ve had to accept that in 2022 my season is getting a late start due to and off-season injury
Here have been the staple exercises in my program:
Single-leg touchdown/step down “squat”. This really isn’t a squat as much as it’s a controlled eccentric with a real focus on hip hinging. You should feel this in the glutes/hips, more than the quads. Got this from Squat University.
2. Lateral banded walks. Really hitting the glute minimus and medius. I like to do these almost daily. For max engagement put the band around the feet towards the front. I like to do 3-4 sets of 10 each side. This will burn.
KB/DB single leg Romanian Dead Lifts. Start with less weight than you think you can do and focus on good form and balance. If you’re not feeling it in the glutes/hams focus on pushing up through the floor. Not lifting up with your back. I like to hold the weight in the opposite hand of the working leg. This will really test balance. These take some getting used to.
Glute Bridges. These are a so-so for me. I never really feel like I’m fully engage my glutes. Some people love these, but for me I find the above exercises to be superior.
Good mornings. Another underrated exercise that I overlooked. These are excellent for training the hamstrings and increasing engagement and range of motion. Don’t go crazy with the weight when you start.
As my body started responding to the workouts, and I could feel myself getting stronger (took about 3-4 weeks) I started to increase sets/reps/weight and eventually started incorporating some bi-lateral work. Squats (really hurt my knee at first), and then Romanian dead lifts, and conventional deadlifts.
Rehabbing a knee injury is a fine line between doing too little work and too much work. Just like training on the bike you need to progressively overload the injured knee. If you do too little you won’t actually initiate the rebuilding phase, but if you do too much you could just prolong the injury. This was a difficult thing to figure out, sometimes I felt like I was doing more harm than good with my protocol (injured knee would hurt during exercises, pain wasn’t going away), however, what really helped me know was that if my knee wasn’t worse immediately after or the following day I knew that I wasn’t over working it. All of my PT’s wanted me to be in that 2-3 / 10 RPE/pain scale. And lastly, I cannot overstate how important patience and consistency is. Do the work, do not skip days unless you feel worse. And, accepting that these injuries will take more than 2-4 weeks to fix is crucial.
This was a good resource for me along with my PT work:
Yes. My knee is back to normal. No post ride pain or on bike pain to speak of. I have tried my best to maintain some consistent level of glute work.
It’s mainly a lot of lower weight higher (15-20) rep stuff now just to keep things engaged. Heavier lifting will happen again this fall through winter.
The not so funny thing is that I’m now having an issue with my other knee! Feeling post ride soreness where the bottom part of my patellar tendon inserts into my tibia. It’s mimicking Osgood Schlatter’s. Not fun.
I thought I had sorted out my knee problems but they are back in a bad way. Sounds like I am dealing with something very similar to you and taking a similar approach (not focusing on the bike at all. I’ve been completely off for over a month just working on PT and strength).
Can I ask, did you have patellar tracking issues as well toward the end of your recovery? My kneecap is still really clicking and snapping when I extend my leg—not really painful but very obvious and not anywhere close to my healthy knee. I feel like I’ve made progress with my strength in the glutes and VMO but I am hesitant to reintroduce cycling when these tracking issues are still so apparent.
