Knee injury comeback

Hi all,
I’ve had a knee injury ( likely patella femoral syndrome) which came on during a long ride in October. I’ve seen two physiotherapists, my Gp, and had an MRI scan. I’m also due to see at orthopaedic knee specialist in march.
After lots of physio/strength training, rest, and applying ice, I’m not experiencing and pain day to day.
Riding wise, I’m cautiously building back up, as advised by physio.
I can ride Z1 for around 20 mins no problem. Physiotherapist advised extending this each week. Theoretically I could do this forever.
At what stage should I start raising the intensity to z2 and above? Does anyone have any general guidelines?
Thanks

PH

Can’t help you with the training advise, but was wondering what your crank length is and if you ever experienced with shorter ones?

I also have a history of patella issues when strength training and cycling. But they’ve completely disappeared since in switched from 175 to 165 cranks. Read of many people having the same experience when making this change.

Thanks for reply.
I had a four hour long bike fit on Friday. Seat was lowered fractionally, new insoles in shoes, new shoes, eats further back and wedges to correct angling in of knee and instable ankles. He floated the idea of 165mm cranks (I currently run 170), I tried it on the rig and it felt good. I can’t remember the exact logic behind it, but the changes made already to my fit will bring significant relief to my knees, and we can try different cranks later. I’d already spent £800 at this stage on a bike fit and new shoes so I wasn’t too keen on buying a new crankset if it was only going to bring marginal benefit. Maybe I go back to my fitter and try it.

The best guidance for raising your intensity would come from the physiotherapist but from my experience as a patient I would think he or she would recommend 6-8 weeks of this Z1 overall with the time gradually increasing from the 20 minutes you are doing to 45 minutes. At that point you could maybe start doing the final 5 minutes at Z2 for a week and then each week thereafter keep increasing the Z2 time by 5 minutes while reducing the Z1 by 5 minutes until you are doing the entire 45 minutes at Z2. Being fully healed takes time and is well worth it.

You are probably ready for some Z2 now.

I am currently returning from a knee injury (too much details to explain here), but the common approach that you and I are taking is one of caution including a gradual increase in cycling after appropriate rest.

In addition to adding some Z2 work on the bike (gradually adding it), non-flexion based leg strength training is very useful. If you have access to a gym and a cable machine, this would be done using ankle straps and doing forward, backward, left and right directional work. If you don’t have access to a gym, then elastic bands of increasing resistance that you attach to a bedpost (or other sturdy post) could work (albeit, less effectively). This specific strength training will strengthen all of the supporting muscles and therefore the muscles directly around the knee won’t have to work as hard as you are increasing your cycling efforts. Perhaps your physiotherapist has given you these exercises? If so, I’d suggest keeping at it.

Thanks a lot. I’m certainly going to take it very steady in the next few weeks, starting with Dans (I just managed the full 30 mins today, so that is a win). Over the next couple of weeks I plan to build up to Lazy mountain -2. Then start adding in some z2, as you suggested.
After that, if I can get to do a full pettit, four times a week, I’ll start introducing some sweet spot.
It doesn’t look like I’ll get cat2 (UK) this year, as originally planned. But I’d delay that for a year or two to just be riding healthily again.

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My first physio was poor, she had me over working too soon on the bike and I felt she was just trying to clean me out. The second, this time non private physio (free, on the NHS in UK) was very good. She took the approach of ice regularly, take it very steady on the bike to start, and get lifting weights instead of bodyweight exercises, to get better adaptation. She gave me a plan, which includes lots of band work (monster walks, clamshells, and a type of bridge), and some heavier weighted stuff; step ups, split squats (going slowly on the way down), and deadlifts. I also do a bit of upper body as I’m already there. I experience no pain at all doing step ups with 15kg dumbells in my hands (3x12) yet cycling still hurts :man_shrugging: I don’t get it!
I also had a bike fit re-done for both my bikes on friday, at one of the best fitters in the UK. My old fit wasn’t great, my feet weren’t supported adequately which caused my knees to roll inwards. Now I have some insoles and a load of wedges, as well as new shoes.
One positive for my longer term goals is at least I am now adapting to strength training, something I always gave up on during normal cycling training.
I hope your knee issues are getting better bobmac. What caused yours? Mine came on suddenly as I overtook a car at changing lights. A few powerful pedals strokes. I thought it would pass but it didnt.

I suffered knee pain for a long time, which stopped me from running, and I obtained no successful help from doctors and PTs, and then solved it in a couple of weeks with the joint-mobility exercises from Becoming a Supple Leopard by Dr. Starrett. That book has since solved all my joint issues that have come up in training. And I apply it regularly since muscle growth will give tight muscles in recovery for many of us, which will eventually lead to these joint issues.

I can now ride my bike with a poor fit and not have joint pain. This will still cause a weird sensation in the movement of the knee’s joint capsule (it gets very slack anteriorly in extension), and I don’t want to bike like that, but it doesn’t cause pain. Dr. Starrett was on a TrainerRoad podcast, and made it clear that we should make our bodies fit the bike — not ask the bike to fit us, and his approach has worked well for me (within limits). For example, many people swap their handlebars, or get a bike fit, to deal with tennis elbow — I instead eliminated the tennis elbow.

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I obviously don’t know your details well enough, but my intuition is that you should have been off all knee bending exercises during this period, and likely even now. Despite not experiencing pain during these exercises (squats, steps ups, deadlifts, etc.), that doesn’t mean that there isn’t inflammation there that may be causing pain during cycling. My non-professional advice (but experience based) would be to knock off doing these exercises for a few weeks until you have eliminated this potential underlying issue before continuing to chase expensive equipment/fit solutions.

Thanks. Complete cartilage loss of the medial facet of the patella.

FWIW: Although the source of our issues might be different, my orthopedic surgeon (who is also a Cat 2 cyclist) had me eliminate the strength exercises that involved bending during recovery. In my case, it was to allow the bones that had been [micro]fractured to heal. But it seems to me it would have the same effect on inflammation if that is the source of your pain during cycling.

Thanks again Bobmac. I’m due to see an orthopaedic knee specialist in late March, if things aren’t improving much by then I’ll be sure to tell him.
Are you seeing good progress with your approach?

It’s too early to give a full report. However . . .

I was off the bike for most of 4 months doing lots of gym (upper body, core and the leg work I mentioned) and using the elliptical for aerobic (including doing intervals). I recently got permission to get on the bike outdoors and begin gradually upping the wattage.

So far, so good (i.e. no knee pain; power gradually increasing). However, there is still no cartilage (it doesn’t regenerate). So next step is exploring a few different procedures that exclude knee replacement. So the ultimate answer will come after I go down one of those paths and am [hopefully] able to resume hard training and all out efforts.

ps. I’d advise you to make sure that your orthopedic specialist really understands the forces and mechanics of cycling. The first supposedly top notch specialist I saw basically gave me lousy advice for those reasons.

Big up to movements targeting hip extension and abduction. Not an expert or professional here, but my understanding is that most knee pain athletes typically have weak and or less than optimally functioning hips. Ankle function might also be worth checking, tight calves impairing dorsiflexion, for instance.

It is probably a good idea to be conservative in flexing the knee and espescially under load, but eventually you have to flex and extend it, under load, and ultimately also ride a bike.

One option that might be worth exploring to strengthen the patellar tendon and remedy pain, preferably under the guidance of a professional, are eccentric squats. They come in a variety of guises, and a basic googling will probably land you with incline board eccentric squats. They might be worth trying. But in my experience there are better options. Namely, there is a very cheap device called “Russian belt” or “Tirante musculador ruf” in Spanish that I myself have used with success in rehabilitating my knee injuries. In short, using it to perform eccentric squats will allow you put considerable torque onto the knee joint, quads and the patellar tendon in the phase where the muscle contracts while being lengthened. The physio I worked with recommended this device and movement it and I have been very happy.

The movement I mean is being performed here: https://youtu.be/XyZDvaImgao

I myself have used a very pronouncedly eccentric rhythm : going down in 4-6sec and going up 1sec. Usually did 4x10-15 reps. It is actually a tough movement when done slowly, so not very conservative after we had established that it did not make things worse. Also started riding rather soon.

This movement is sometimes referred to as Spanish squat because it apparently has been quite popular with spanish footballers. There are quite a few resources online. One upside is that the eccentric squat has been shown to have an analgesic effect on the injured tissues, ie rit educes pain, so this might be used to create a window for performing movements that otherwise hurt. I have not done this, though. But the pain relief is good in its own right. It was counter intuitive, but it worked exactly like that with me: eccentrically applying force to the knee helped.

Finally, this is a review that one might also find helpful, as it discusses remedies, timeframes, progress and so on related to patellar injuries. It also mentions eccentric Spanish squats: https://www.researchgate.net/publication/282046406_Patellar_Tendinopathy_Clinical_Diagnosis_Load_Management_and_Advice_for_Challenging_Case_Presentations

Also a short paper specifically on the movement I mentioned: https://www.researchgate.net/publication/336903268_A_biomechanical_investigation_of_a_Spanish_squat_The_effect_of_trunk_inclination_on_quadriceps_activation

Best of luck and be smart.

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That’s great, thanks for the information. In amazed how much info people on this forum have :slight_smile:

Same here, did not have any issues for 7 Months riding a lot 500 to max 900TSS . Then tarted strenght training this Jan. 2 weeks ago slight issues with knee pain. I did Figure out it is one exercise i do in the gym that i think is the problem, funny a friend gave me the hint when he did complain about knee pain whenever he does that particular machine… Just did google it it is the Milon Leg Curl…

But i guess at some point i give 165 cranks a shot…

I think there is mention of leg extension machines on this forum not being good for the knees. The entire physical therapy staff where I go is against this type of machine in general. In discussions I have had with them the only way they will agree to its use is with a much smaller range of motion and not with heavy loading.

Basically the starting position is with about a 15 degree bend at the knee. The loading only about 30 lbs. Even so they prefer I not use the machine at all.

Hmm, what about Back Squads and Deadlifts? This is what i plan to do now for legs and skip the Leg extension/Leg Curl machines or just do them very very low weight

Thanks Ridill. I love a dealift. One benefit of my knee injury is i’ve got over the hump of strength training. I was only deadlifting 25kg 3x12 when I started, I’m now doing 60kg. If/when I’m back on the bike, hopefully I’m over the awkward achy transition period.

I created a similar thread last night asking for help about my knee injury. I’ve deleted it as the advice here has been super helpful and I didn’t want to double up on threads.

May I ask you guys, if the advice would be the same if the injury was caused from walking into my bed frame and bashing just below my knee cap. I.e. it’s not an overuse injury or down to a poor bike fit?

The low level pain has been there for a month and I don’t think it’s improving. There is some slight inflammation. Apparently tendonitis doesn’t often include swelling. There’s a very light pain during cycling just above the knee, but if I cycle hard, the next day the tendon below my knee becomes painful going up and down stairs and standing from sitting. Sometimes it hurts when I’m lying on my side at night. I took my kids out on my cargo bike along a muddy canal path and couldn’t walk the next day, so I know hard efforts are out.

I’m just about to buy a Russian band online. I bought the inclined board two weeks ago, but keep flip flopping between thinking it’s best to rest my knee and starting recovery exercises.

I’m pretty sure stretching is working well. Quad and hamstring stretches.

Having suffered from knee injuries a lot may have made me very cautious, but with that said, the things you list (a trauma to the tendons around the knee, enduring pain during and post exercise, pain in the everyday life & at night) would imho suggest a consultation with a professional. Maybe a general practitioner doctor, but at least a physio who has experience working with leg injuries in athletes.

Thanks for the advice. I phoned the GP a couple of days ago and have an appointment booked for the 23rd March. It’s the first date they could do on a Monday, which is the day I have off work. I cycled to work yesterday and the swelling was worse this morning, so I’m going to give cycling a rest for a bit. I might phone the non-emergency NHS phone line on Saturday and they might be able to book in a same-day weekend appointment at the community hospital. The pain isn’t too bad, so I’m hoping it’s nothing serious.

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