Ramping up VO2 workouts causing knee pain again. Any suggestions?

Seeing a pattern here. Winter of 2021/22 once I was forced inside to the trainer, I successfully complete the SSB Mid Volume plan over December/January, and then moving into build, the Vo2 max TR workouts started to ramp up and I developed a knee injury that forced me off the bike for a few weeks. When I came back, I went back to base and, because I don’t race, just started riding outdoors and basically cut off most interval work but at a reasonably high volume of “Zone 2 ;)” (typically around 10 hours a week) and the knee didn’t bother me again.

I took a brief off-season and started back on the trainer again toward the end of December 2022. Again, I completed the SSB Mid Volume plan and felt good about my fitness improvement. I then did the first half of build and was still feeling good, but in the last couple of weeks the Vo2 max workouts have returned and my knee issues have cropped up again.

The timing of this recurrence is pretty obvious, but I’m not sure what to do about it. Is this a fit problem that only shows symptoms at high intensity? Is it just my body’s reaction to a sudden increase in intensity regardless of fit? If I let the injury heal and determine I can continue to train at the lower zones that have been okay for me, how can I safely introduce VO2 max work? Has anyone experienced anything like this before?

Typically, knee issues that relate to intensity develop because of overextension. In other words, your saddle is likely too high. A saddle that is too low may also cause knee pain because of the constant strain on the joint throughout the pedal stroke, but pain relating to underextension tends to appear regardless of intensity. Knee pain related to an increase in force production is often caused by overextension of the knee. While you can compensate for the excessive saddle height by shifting your weight and/or overextending your ankle during lower intensities, these compensations become increasingly hard to implement as power rises. Thus, your knee joint starts violently overextending under the high load, and subsequently, you experience knee pain.

You never mentioned where you experience the pain, but pain derived from overextension tends to reside in the front of the knee joint. Is this the case for you?

Give this excellent thread a read.

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@rhendering What cadence are you shooting for?

That sounds right. I would say the pain was in the front of the knee joint yes. It’s sort of generalized at this point and is hurting even off the bike now but this seems like the most likely cause. I’ve known I’m a toe pointer, but have seen mixed reviews on whether or not that’s an issue. I thought if I was able to perform it wasn’t an issue but maybe it does need to be addressed.

Typically I’m in the high-80s to low-90s range

That is an excellent thread. A lot of good advice in there. Maybe I should have responded there instead of creating a new thread. If a mod wants to move this into a reply there that would be great. I can also copy this post there and this can be deleted if that’s appropriate.

Probably worth experimenting with getting up towards 105 or 110 and seeing if that helps.

I had similar issues in the past, and yes, it does start to appear off the bike too. My guess is that your saddle is a lot higher than it should be. I also identified myself as a “toe pointer” until my saddle height was set correctly. You’re likely overextending your knee and compensating by pointing your toes. When I went through a proper fitting session, I ended up lowering my saddle about 25mm and shifting my cleats 10mm backwards. All of a sudden, I started activating my hamstrings and glutes properly and having control over the entire pedal stroke. As a result, I gained about 5-10% on my power at any given intensity without a higher RPE, and my knee pain went away.

I’ve had similar issues. What I decided to do to fix this:

  • I’m working virtually with a PT - Dr. Carol Passarelli - to address imbalances I’ve developed over the last several years. This has been really helpful with getting me to be more square on the bike, and not inflame my historical knee issues
  • Be very mindful with ramping up both volume and intensity

Are you using ERG? It might be the quality (to precise lack of) my suito in handling ERG but I found it would injure me on VO2 Max workouts. I use resistance mode now, as I did pre my TR use and touchwood there’s no injury. I’m also hoping that with no ERG as I was doing before I won’t be scared to increase my FTP.

I’m going to look into a bike fitter. I’ve seen one before but if this wasn’t caught, I guess I need to see a different one and figure it out for good. Wouldn’t mind another 5-10% lol.

This was another thought that I had. I am using ERG (Wahoo Kickr Core) and always have, but I have always found the sudden change in power demands sort of jarring. I’ve gotten used to it, but I did consider that could be a contributing factor

Keep in mind that if the bike fitter uses knee angle as a way to set saddle height, that may be problematic. Many people fall outside of the range in terms of joint angle at full extension of the pedal stroke. I, for instance, am 5’10 (178cm) with a saddle height of 70-71 cm, which is 2-2.5 cm lower than suggested by the 109% method or the Lemond method. Just make sure you actually feel entirely in control of the pedal stroke when you set saddle height. If you have been riding too high and pointing your toes (like I had for a long time), a proper saddle height will feel uncomfortably low to start with.

I had the exact same symptoms. I went for a new bike fit, that guy told me that the fitting was right that the problem was me for neglecting strength training and stretching/flexibility work… I went to a dr, get an MRI, everything was fine… Then I went to a PT told me that I had weak stabilization muscles and muscular imbalances, my core was miserable, he said something like “doing intensity on the bike without a good core and pelvic stability, is like shooting a shotgun from a kayak” (you know… The recoil… Bad idea) and that my knee was moving everywhere when I pushed too hard because lack of stability and that was the cause of the pain (for me).

I took a few recovery weeks (not completely off the bike but less load), started with the PT workouts, when I was better I gradually increased load and intensity and also I added strength training and flexibility to my training routine. The problem is gone.

May be you should go to a PT to get a proper evaluation and therapy.

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I just wanted to follow up on this because when I first started experiencing this I was searching everywhere for someone to say how they got better and while I’m not out of the woods yet, I am already so much improved, and I’m currently riding without pain and (for the most part) not feeling pain off the bike. So I want to share my experience and what I did.

First, I got a bike fit. I want to say, that this is the common recommendation to addressing pains and niggles and while I think it’s helpful, I don’t think it’s a panacea for addressing these sort of things. I am in a privileged position such that I can afford to see a nice bike fitter, and my thought process was that even if it’s not my fit that is causing these issues, correcting that first gives me the foundation to start making other interventions. They really didn’t change much for me. They moved my saddle higher slightly (maybe a cm or so). The most noticeable change they made was the adjustment to my cleats.

The second thing I did was take time off the bike. I took three weeks completely off the bike. No riding at all. I now think this was longer than I needed, but I had some travel obligations and things of that nature and instead of cramming in a workout or two in between trips, I just let myself rest.

Thirdly, I started a self-prescribed PT routine. I did see a doctor and get a referral to physical therapy, but the earliest they could see me was more than 6 weeks (I actually have my first appointment next week). In the meantime, I started stretching my hamstring, IT band, calves, etc. and foam rolling all of this as well. And I did some strengthening exercises for the muscles around the knee: wall sits, unweighted leg extensions, one-legged standing from seated.

When I returned to riding, I kept the intensity low. Just short z2 rides. I did this for about a week to 10 days and felt good. I thought the PT work must be working and maybe I was all healed. So I threw in a real workout and immediately had symptoms return. This was super discouraging. Back to the drawing board.

I did some more research and changed the focus of my self-prescribed PT work. I continued to do some of the stretching and strength exercises I was doing, but I then introduced more hip mobility and glute strengthening work. I think this is what really changed things for me. I had always heard the line “Your glutes should be firing” or whatever and just kind of shrugged it off. I assumed, if I needed the muscles to work on the bike, they would be working. I don’t have to tell my forearm to help my bicep when I’m doing curls, so my glutes must be doing something on the bike automatically. Wrong. I started focusing on actually using my glutes on the bike, which I achieved by opening up my hips. Just really making sure that my whole leg was involved in the pedal stroke starting from way back and up. Good God. I have been using TrainerRoad for 2+ years consistently, and I am pretty fit on the bike. When I started actually using my glutes, I was exhausted. I realized just how unconditioned I had left this muscle group. More hip work, more mobility, more glute activation exercises before and after riding. It feels like I am re-learning how to bike. It is so much more difficult and requires real concentration.

Again, I am not “healed.” I think these are things I will need to continue to work on (even if less frequently) for as long as I want to train. I also acknowledge that this won’t be the answer for everyone. But I seem to be improving now so there is hope.

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Can you describe what you mean here? Are you doing hip opener exercises or did you change your position on the bike or something else?

Yeah I think part of the reason that I felt that glute activation was a myth was how no one seemed to be able to say how they do this, but I’ll try:

My bike fit did raise my saddle so I am getting slightly more extension on the bottom of the pedal stroke, which I think might help with this, but generally I don’t credit a position change. I am doing hip opening exercises as part of my PT and mobility work, but when I’m on the bike the best way I can describe it is letting the top part of your leg (from knee to hip) move from the hip joint. I kind of focus on the glute muscles (literally just thinking about them helps), and I let this part of my leg drift forward from the hip and follow the natural arch made during the revolution with the glute contributing well on the downward portion as you feel your leg extend. It might just be mental thing, but I sort visualize it as a decoupling of my hips from side to side. I’m sorry if this isn’t helpful–it’s difficult to describe.