Training around, and recovering from runners knee

I need some knee advice. A few times over the past 6 months, and seeming getting more frequently, I get quite bad knee pain when cycling, specifically on the trainer. It’s both knees, normally worse in the right, and particularly bad and noticeable when doing anything sweet spot/ threshold for upwards of 3-4 minutes.

It feels like an intense painful heat that surrounds my kneecap. It happened yesterday whilst doing over unders, and otherwise I’m in good shape and well rested etc (4 days off the bike prior to that ride). After around half an hour, during the second set of over unders I had to break for 10-30 seconds during the efforts to allow the pain to dissipate. I also cut the ride short by 15 mins/ one set of intervals. Info here if you are interested: - TrainerRoad )

I have elbow joint pain/ problems which has been diagnosed as loose bodies/ cartilage (helpfully my dad is a chiropractor and cyclist!). https://www.shoulderdoc.co.uk/article/1309 However I can usually work around elbow pain, even if it’s more frequent or worse, but dread stopping cycling for so many reasons…

Having spoken to my dad about knee issues he suggested it’s likely ‘runners knee’ / chondromalacia. He suggests a period of rest, but as the title suggests, I’m wondering if there is a way I can train around this, whilst recovering.

I read a post Jonathan L posted about knee pain, and there is a lot of good info there, which I will be trying to stick to.

I’ll start icing my knees after rides, and popping ibuprofen (anti inflammatories) when needed. I’m happy to adapt rides, or work at lower intensities, but I darent stop cycling all together. It’s so important for my physical and mental health and well-being!

I’m wondering if anyone has been in this situation and has recovered whilst continuing to train? should I be going to the doctor’s to try and find a proper solution?

For reference: Male, 30yo, moderately active lifestyle plus cycling, largely healthy diet, LV TR plan, 3-4rides per week/ 3-5hours per week, been cycling for many years, training more seriously for around 18 months, bike fit is good (although not professional).

Really my goal is to get back to as close to 100% as possible, then continue training and getting faster as usual :+1:

Thanks
Tim

Hi Tim,

Disclaimer: While I am a junior doctor, I have neither examined your knee nor do I know your previous health status, so cannot make a certain diagnosis or perfectly adequate recommendations. I cannot take responsibility if you follow my advice and you try it at your own risk, everything I write below is what I would possibly recommend after careful examination and interviewing and might possibly help, also trying to explain a bit why I would do it this way. Other doctors might recommend different things and be right in doing so, as there are always different ways of approaching medical problems. This is not meant to replace seeing a professional in person who can examine and interview you and cannot replace physical therapy, just some thoughts on what I would possibly recommend. I will not take any liability if it doesn’t help or get worse.

I saw you found Jonathan’s thread for knee problems, which is great, a good idea is to try as many of the suggested solutions (especially regarding exercises and PT) recommended there one by one or maybe even several at a time until you find something that helps and then stick to that. It may take several weeks for the pain to go away even once you’re on the right track, so don’t give up too quickly.

Icing is good and does no harm (unless too cold and you get frostbite on your skin) and can also be done via ice cold showering of the legs/knees after training.
Ibuprofen will only relieve pain short term (and negatively impact any endurance progress if taken regularly) but will not fix the underlying problem if it is biomechanical of origin (which it often is in chondromalacia patellae). What you can try is taking one course of Ibuprofen up to 800mg and 3x a day for 7 days (depends on your bodyweight and other health status, unless you’re <60kg or have liver, kidney or stomach issues, 3x800mg taken with meals should be fine. If you have too much acidity / reflux / have had a stomach ulcer, shorten the course to 5 days and/or use Pantoprazol 40mg once a day in the evening during the course and for 2 days after the course of Ibu has finished). This will help reduce an acute flare / active inflammation to a minimum. This should not be done too regularly (aim is not to do it more than once at all) and is only intended to get rid of active inflammation so you can start your physical therapy. Also, complete abstinence from anything that elicits the pain during this course is necessary, otherwise you’re setting a new inflammatory stimulus and counteracting the medication. Taking Ibuprofen here and there will not help as long as the underlying issue is not resolved, as said.

Next up, I would check out your cadence: too low → not good for the knees, anything above 85 would be good, don’t go near anything below 70.
Underlying principle: too much tension in the quads transfers to the patellar ligament and pulls your kneecap onto the femur.
This extends to:
very high power intervals;
individual leg training;
anything else that puts a lot of strain on your patellar ligament repetitively.
Note: strength training (including squats) should be fine, as you’re not in for 85+ reps a minute but likely 25 in total. Maybe don’t squat too deep (i.e. below 90 degrees bend in the knees) and maybe not in the acute phase or while you’re on the ibuprofen course.

Next, cleat position and knee movement. While the bike fit may have been good in the past, something isn’t working with your biomechanics now if you’re getting pain from cycling.
Check out these:
knees tracking straight;
angle of your knee joint during max force production (i.e. at 3 o’clock in the downstroke) should not be too small/narrow (meaning get closer to 90 degrees bend in the knees rather than 30 degrees) → might have to move your cleats backwards on the shoes to move your feet forward;
saddle position might be too low or too high (again, influences knee joint angle);
cleat rotation (inward / outward rotation could cause this problem);
lateral offset of the pedals helps for some people, i.e. insert spacers that set your pedal bodies further away from the bottom bracket (this might also be asymmetrically wide left and right, meaning more spacers left than right or vice versa);

If none of this works, give yourself a timeframe to keep trying, for example 6 months. If you’re not back to normal then, see a specialist, try getting an x-ray of your kneecap to see if it’s weirdly shaped (that causes issues often) and/or an MRI to see if something else is wrong. In such cases (long-term problem keeping you from training or weird kneecap alignment), the last resort might be a cortisol shot into the knee joint, which sometimes works wonders (it works like the ibuprofen course, but on [literally] steroids), but should not be used too lightheartedly and might have to be done several times to take effect plus you need to keep doing your PT. This has to be done by a professional who has done this many times before.

Will say this: runner’s knee is a vague description that means many different diagnoses to different people. My understanding of runner’s knee is a tightness of the tensor fasciae latae and fascia lata (fascia on the outer side of your thigh) causing a stabbing pain on the outside of the knee due to inflammation of a bursa (a little “cushion” filled with gel to buffer any lateral friction there). Very different story. Short summary solution for this: Blackroll the side of your thigh, strengthen your lateral hip muscles / abductors with e.g. side planks and banded side steps (stretch band around the knees above the kneecap and walk sideways). It will go away if you do this and stay away as long as your lateral hip stabilizers are strong. Cycling doesn’t make them, running doesn’t make them, you need to train them. Those and your core are the two essential things you need to train outside of your endurance workouts to keep you healthy and training (especially if you do any running).

Bonus insights while I’m at it, that may help you and others:
Injuries and strain occur all the time. If you stop every time something hurts a little, you’ll die from a heart attack due to inactive lifestyle. If you never stop even if something hurts badly, you’ll need new joints due to osteoarthritis (not what you want, especially not knees). Knees are a very whiny and sometimes overly sensitive body part, they hurt all the time for sometimes no reason, but pay attention to them and if it’s longer than a few weeks or reproducible in certain circumstances then adress it quickly. I’m not saying train through all pain, but you’ll (have to) learn to differentiate between pain that you have to take serious and ‘discomfort’ that you can ignore.
Don’t skip PT exercises. Don’t skip strength training. Eat your 2 pieces of fruit and 3 pieces of vegetables EVERY SINGLE DAY. Pay attention to your form. Bike fitting is not a one-time set it and forget it.
Ibuprofen doesn’t fix any underlying problems, ever.
Find a good physical therapy or read up yourself and do your PT. Regularly. Forever. It will keep your body healthy enough for training, which will keep your cardiovascular system healthy enough not too die at 65 (and exercise also prevents cancer).
If you can’t run because you’re injured, try cycling (depending on the injury location). If you can’t cycle, swim. If you can’t swim, do strength training and go hiking/regular walks. If you can’t lightly strength train with bodyweight and walk properly, go see a specialist and get this fixed asap, something is seriously wrong. :slight_smile:

Added for anyone with this problem (chondromalacia patellae) who is a runner: increase your cadence, which will automatically make your steps smaller and your feet will land closer to your centre of gravity, which is a lot better for your knees. Science says which part of the foot you land with doesn’t matter for injury, but where your feet land in relation to your centre of mass does. Big steps → bad, small steps close to or right under centre of mass → good. Anything above a cadence of 85 works for ultra-endurance runners long-term (most are above 90), there are next to no long term successful long distance runners running anything below this cadence, which possibly tells you something about the longevity of those other runners’ knees who didn’t perform for decades. Or at least it’s a starting point and has no drawbacks. :wink:

Not being able to train as you want can be frustrating. Accept, that this will occur regularly and you will have to include prehab and rehab into your training plans. Depending on your luck in the genetic lottery it might be all the time or it might be once every couple of years. You can’t change the fact that this occurs, but you can change how you view this fact of life and what you do about it. Make a habit of staying positive and keep a mindset of “what can I learn from this, what is my body telling me”. It helps with the mental side of things. It’s a challenge you are ready to face and will solve, not the end of the world, even if it may take months or years.

Good luck!
Stefan

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Wow, @stesol thanks so much for your reply. I really appreciate your info and opinion, and your time to write it all out for me and others.

A lot of info for me to process, I’ll re-read it later and take notes.

You obviously very highly reccomend PT. By this do you mean yoga/ stretches, or something more specific? Obviously Jonathan reccomended some specific ones which I’ll look info. Also as a rule of thumb, how many times per week would you reccomend doing this?

Thanks again!

I’ve been dealing with chondromalacia for a few decades. Two rules I’ve developed over time: one, do not train if there is pain. Just don’t. Two, ramp up volume slowly over time. Listen to your knee(s), and as soon as there is pain, reduce the training load. Use ice after workouts/rides/runs if there is discomfort.

But don’t train if there’s significant pain. You will only make things worse.

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Hi,
Sure, no worries. Off work anyway, so giving some advice is the next best thing to working :wink:

With PT and how often, there is only this guideline: as often as is necessary to solve your problem and as often as you can fit into your day. The more often the better. Best would be twice a day initially. If you can find some exercises that you can insert into your routine that you do on a daily basis, that is worth gold for the long run, but in the initial phase, you might have to dedicate more than that and find a couple of exercises that you do every day or as an alternative do different exercises every day, but every day and try to include stretching, strenghtening and balance exercises every day.

What kind of PT for chondromalacia, general guideline from my guidebook says

exercises to strengthen the muscles around your knees

Since most people who get this are runners, most recommendations revolve around running. Amongst those would be anything that stabilizes the knee. Hence the recommendation to strengthen the muscles around your knees. This means strength training for your legs long term and coordination training short term: try something like standing on an unstable surface with one leg at a time and a slightly bent knee for a couple of minutes for each side.
e.g. on one of those hot water bags that people use to put on their stomach when they have cramps, fill it up half and half with water and air, if you have one of those around (be aware that they’re not made for that and might break and leak). otherwise something like this:

Problems with biomechanics often involve more than one part of the kinetic chain as a root cause, so it could be due to an instability anywhere down the chain. Stability/balance exercises are greatly undervalued imho and should be included. They activate a lot of muscles that you wouldn’t be able to target so specifically and functionally otherwise. Other than that: any strengthening exercises you find in Jonathan’s thread and that you like. His outline there is great, as said, just pick and mix from there.

As a general rule regards stretching: if it’s the tendon itself that’s affected, eccentric weight training is gold, much better than stretching, for example for stuff like achilles tendonitis. Since it’s not the tendon that’s affected with you, I’m not sure how much it will help but it is definitely worth a try, maybe your quads are shortened (although in most people they aren’t, due to a lot of sitting) and it helps. Maybe try the couch stretch that Jonathan outlines in his FAQ. Stretching alone won’t be the solution, but definitely incorporate it if you can, you’d want to stretch the quads. But don’t overdo it. Too much stretching might also just press the patella against your femur and might make things worse. As @rocourteau said, listen to your knees.

Yoga is always great, it incorporates long stretches under load and isometric strength training, which is always good and a great adjunct to any other strength training. Even more recommended since Yoga is also great for peace of mind.

Link to Jonathans post for anyone reading this who doesn’t know what we’re on about:

Let me know how you get on and as said, good luck!
Stefan

A couple more quotes from my source:

In a prospective case control study, a regime of quadriceps stretching decreased pain and improved function among patients with PFP, although these improvements did not correlate closely with the gains in quadriceps flexibility

Although published evidence is limited, it suggests that strengthening of the hip musculature reduces pain, improves function, and is better than knee strengthening alone

A comprehensive approach to treatment should systematically address potential deficiencies in the interrelated group of muscles and other structures involved in moving the lower body (ie, the lower body kinetic chain). These structures include: Hip abductors, Iliotibial band, Knee extensors (quadriceps), Knee flexors (hamstrings), Feet – Excessive or insufficient pronation, Core (ie, trunk) muscles. As PFP appears to be multifactorial, as yet unspecified subtypes of PFP may respond better to specific therapies

Limited evidence suggests that foot orthoses may be useful for symptom relief in some patients with PFP

Plus they specifically recommend squats / leg press and core stability work after the acute phase and say that the ibuprofen course can be extended up to 3 weeks. Personally I’d stick to 1-2 weeks tops. Other than that, they talk a lot about the whole lower kinetic chain needing attention and strengthening (so everything from the feet to the lower back).

Source: uptodate.com

Hope this helps a little in choosing your exercises.
#dontskiplegday :wink:
Stefan

@stesol is absolutely right about the importance of stretching and strengthening. In my (unfortunately long) experience, this is critical in the acute phases, and useful in a preventive mode. Modulation of training over seasons (slowly increasing duration and intensity, for example) is, also in my experience, the best preventive action. I can do a half-marathon training plan without any issue, but if I just walk out of the house one day and go run 21km, it’s a sure-fire way to get into problems.

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Thanks guys, some great advice and info!