Undiagnosed Knee Issue - Advice?

Training
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Hi Folks. So I have been reading Jonathon’s lengthy post around this issue which as you’d expect, has lots of good info and certainly things I am going to try.

That said, it would be nice to hear anyone’s willing advice for what they would do in my circumstances.

I should note I am not looking for a diagnosis of a knee issue and I know that rightfully, this forum is wary of offering such unqualified advice. More so, what would you guys do next in this situation.

Bit of background on the issue, I was moving some items at work back in Feb 24 (items as in, a low trolley that has no handles, is on 50mm castors and weighs 400kg) that require sliding around the floor. Awkward positioning means a kind of tyre pull position but pushing instead. Felt a pain in my right knee going from flexion to extension.

That pain that was more or less constant for a week went away but since then, the same knee and occasionally the left has given me re-occuring pains. Initially I could not re-create them and still to this day can not fully predict when they will occur, but I have noticed a pattern of the pain coming when going from easy low power to sudden high power and/or low cadence work. Basically high torque applications when my knee goes from flexion to extension.

Also worth noting I changed turbo trainer around a month after the injury and got a new commuting bike for cycling to work (Extra 2.5hrs in the saddle per week)

Since then I have had a bike fit done on my road bike & TT bike but not my commuter or indoor. The indoor is setup as close to the road as I can get (it has a 4mm wider Q-Factor) and commuter bike has the saddle set right but everything else is as it was intended by Scott except for the crank which ive changed to a 1x CUES which again has a wider Q-Factor than my roadie.

Tried to ignore the issue for more or less 18 month before it has started becoming more frequent, like a pain towards the front of the knee. A dull ache that when it occurs is bad enough to influence power output but dissipates a few seconds later. Once irritated it will also be painful going up and downstairs or easier to annoy whilst on the bike.

Went to work place Physio who suggested it could be Patella tendinitis and I was referred to a specialist in Orthopaedic knee issues. A very short consultation later I was booked in for an MRI and 6 weeks after that a follow up which was last night. The outcome of that was that there is nothing structurally wrong with my knee and no indications of patella tendinitis, but that knees just “sometimes hurt when doing exercise”

This feels like a bit of a cop out.

Whilst waiting for the MRI results consultation, I have following a program by our Physio which has eccentric workouts in our gym. Leg extensions, Single leg extensions, Hamstring curls, Seated leg press & calf extensions. All on 3x10 with weights slowly rising as I find whatever my 10RM is (I never normally goto the gym). Whilst I have noticed my legs feeling stronger, the pain seems to reoccur at the same rate so not sure if that is helping.

So the question then is in this situation, what would you do next ? The physio’s plan was on the assumption it would patella tendinitis which it doesnt seem to be. So I could go back to him, or to ask to see other specialists etc?

Genuinely dont know how to progress from here

Thanks in advance

-edit-

Should add, loading is currently around 280-320TSS per week of TR workouts or Zwift TT’s

Plus 2.5 hours of Z2/Z3 commuting, plus the Gym sessions which tend to last around 30min each 3 times a week.

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It’s probably a strength or muscle imbalance issue, and the answer is probably PT or an ongoing strength routine. This stuff doesn’t fix stuff fast though - probably minimum 3 months, and I know of people and issues where it’s taken 6 or more.

What would I do? A 6 month rehab program (look up KneesOverToesGuy on Instagram/Facebook/Youtube or do one month here to get all his exercises and then cancel https://www.atgonlinecoaching.com/ )

And, I’d have the fit checked on the bikes I haven’t to try and eliminate those variables.

Basically, older you get, these “rehab” programs just become permanent if you want to be functional and doing the things you like to do.

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Cheers, I’ll look into those.

I was expecting a rehab PT program to be honest, never really thought it would be surgery or medication or anything like that so that way forward would suit my expectations.

Obviously there is a finite amount of time til next seasons TT’s restart but that gives me a good 6 months to get a crack at it.

Fit wise, I think i’ll look at the geometry of the commuter over the weekend. Ive never been bothered as its only 15mins each way but as it adds up to 2.5hrs, I guess it could have an impact.

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Another thing to consider - if something hurts or is inflamed, you should also consider taking some time off to let it get better. If you haven’t taken an off-season break, you might consider 1-2 weeks off the bike and then working back into it slowly.

If something’s aggravated and you keep aggravating it, it won’t get better.

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Where’s the pain exactly? Above? Below? directly underneath the patella?

The fact that unlike a lot of us on here with current or former knee troubles you had an “event” so to speak that brought up the issue gives me a little bit of pause about how to move forward on this. If you can get any more opinions that might be prudent. Not every doctor can graduate top of their class and even good ones can miss stuff. But there’s also a non-zero chance that the injury changed something about your pedal stroke and brought up something that you had been getting away with for quite some time so who knows. My dad was a former professional brass player and accidentally got bapped in the lip once. It caused him to change where he put his mouthpiece and found out that part didn’t really work and wouldn’t have known without the injury.

As for addressing it I’d say look up the more recent knee issue posts on chondromalasia (i searched patella). There’s a couple posts there. I want to say Jonathon’s thread got extra long and the more recent ones are a bit more to the point. With that in mind I’ll give the short version and echo what’s been said: Check you fit professionally. Even if nothing or barely anything changes it’s good to have a trained set of eyes on you and your pedal stroke. You might also find going forward you’re more sensitive to position changes. Welcome to the club!

After that it’s stretch (the hips) and strengthen (the VMO and glutes, med and min specifically). Also ice your knees after workouts to bring down inflammation and just add comfort. Also gives you a chance to just sit still a bit which is nice.

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Long personal experience post…tldr; the only thing that works for me is rest

I have had bad knees since my early 20s when I was in the military running hills in boots. It came and went for a few decades, but hit me really hard in my 40s, to the point where there was no running, no grinding strength or hard stomps on the bike, and no Z4+ erg mode. (For me, erg mode makes my knees hurt more than resistance).

In my mid-50s, I decided to bring strength and flexibility work back into my life, and almost immediately re-injured one of my knees. I went to sports doctors, physiotherapy, Doctors Google, Forum, and Reddit, and none of it helped. The one thing I haven’t tried is PRP, simply because it’s very expensive and requires extended recovery time, so I decided to try the recovery without the PRP. What finally helped was stopping all intensity and mostly just walking and lightly spinning for a few months. I used the opportunity to drop some weight too.

After that, I reintroduced some light running and cycling until I was certain it wasn’t going to all come crashing back down. I’m still super weary of doing anything too hard and pay close attention to how things feel at all times. I’ve given up on doing strength work or stomps. Any time I feel sharp pain, I know it’s time to back WAY off for a few days. At this point, I just want to be able to ride/run.

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I used to say, when asked, inside the knee but after much discussion with the physio here that changed to front of the knee, directly under.

The event could have certainly changed things for me leg wise, although the previous 5 years before that when I was doing running & cycling, I had been plagued on my right side (injured side) with tight calves, Plantar fasciitis and occasionally, race ending knee pain when running. To the extent I now rarely ever run, especially training wise. I’ll do the odd 5k, 10k or HM but only to 4:30-5:30/km ish pace depending on distance and not try to go any faster. Usually for charities etc

Much to my bike fitters annoyance, even now I ride with my toes super pointed down. Usually suggesting saddle is to high however even if lowered, I still pedal with toes pointed down. Could be tightness or injury related but pedalling flat footed feels super strange to me. I have to concentrate 100% to achieve it and at FTP or above, Ive got no chance.

Doctor wise, Im lucky to have free private medical care through work and the consultant I saw was supremely qualified in the operation of the knee. Likely over-qualified to the point it felt like he couldnt care less. But then I have found consultants are often like that & either way, he could still be wrong.

Likewise for the Bike fitter, Im lucky to live nearby a former Team GB head physio who luckily is also one of 7 IBFI level 4 fitters in the UK (and a great bloke to) so I trust his judgement in terms of the bike fits he’s done but the turbo and commuter are obvious potential areas of concern.

I will try icing though as thats something I have avoided so far, but stretching and gym wise, even if they are not helping directly, I am enjoying the time spent in there. And at 40 years old, its probably about time for me to get started in there.

I can absolutely see how you could injure yourself gym wise. Doing seated leg presses there have been a few occasions where I have thought/felt, If I just push through from this position & weight, the knee is aching just applying pressure on the pad, let alone the actual lift.

Following my initial consultation, given it had been getting slowly worse, I did give myself around 4 weeks of no racing, no Z4 or higher etc and in all honesty it did help.

Whether that is because of the injury healing, or me simply over-doing it for what my fitness/knees can handle… I am not sure.

What is PRP out of curiosity?

Thanks for the replies all

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Used Google AI for below:

PRP, or platelet-rich plasma, is a medical treatment that uses a concentration of a patient’s own platelets to accelerate healing in injured areas. To create it, a blood sample is drawn from the patient and spun in a centrifuge to separate the components, resulting in a plasma with a much higher concentration of platelets and growth factors than the original blood. This concentrated PRP is then injected into the site of injury to stimulate tissue repair. [1, 2, 3, 4]

What PRP is and how it works

  • Platelets: These are small cell fragments in your blood that help with clotting but also contain hundreds of growth factors crucial for healing injuries and rebuilding tissue. [3, 4]

  • Concentration: By concentrating these platelets, the PRP solution has a much higher concentration of growth factors than what is normally found in blood. [3]

  • Treatment process: A small amount of blood is drawn and then processed in a centrifuge to isolate the platelet-rich plasma. This concentrated solution is then injected directly into the damaged area, such as a joint, tendon, or muscle. [1, 2, 3]

  • Goal: The goal is to kick-start the body’s natural healing processes to repair damaged tissue. [1, 4]

Uses of PRP

  • Treats injuries like joint, tendon, muscle, and ligament injuries.

  • Helps manage chronic pain from conditions like osteoarthritis.

  • Can be used for issues in the skin or scalp. [2, 3, 5]

What to expect after a PRP injection

  • Post-injection care: A doctor may recommend avoiding anti-inflammatory medication and limiting activity for several weeks to allow the healing process to work properly. [6]

  • Recovery: Patients may experience soreness at the injection site for a few days. [2, 6]

  • Timeline: Relief and recovery vary depending on the severity of the condition and may require multiple injections, often followed by physical therapy. [1, 5]

AI responses may include mistakes.

[1] https://www.massgeneralbrigham.org/en/patient-care/services-and-specialties/sports-medicine/programs/regenerative-medicine/platelet-rich-plasma-therapy

[2] https://www.pennmedicine.org/treatments/prp-injections

[3] https://med.uth.edu/radiology/subspecialties/msk/patient-resources/platelet-rich-plasma-injection-prp/

[4] https://www.youtube.com/watch?v=zQuSVXQG9-U

[5] https://www.emoryhealthcare.org/centers-programs/orthopedic-spine-center/treatments/platelet-rich-plasma-therapy

[6] https://nyulangone.org/care-services/center-for-regenerative-orthopedic-medicine/platelet-rich-plasma-injections-in-regenerative-orthopedic-medicine

Not all images can be exported from Search.

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Damn you have some great access. Can’t say I’m not a tad jealous. As you said maybe some concern they’re so good they don’t take the common rabble seriously but here’s hoping that’s not the case. Maybe a bit of squeaky wheel action might yield enough looks for them to finally have an “ah ha” moment. Especially if it doesn’t cost out of pocket.

This definitely sounds like something. I don’t think I mentioned in my previous knee stuff posts that my issues started in my left then moved to my right as I compensated. The fact that your right side has so many “interesting things” going on does suggest a place to look. The phrase I’ve seen come up time and time again is “the knees are always the victim” so as to say it’s something up or down the chain that expresses itself with knee issues. I’ve always been a fan of fancy insoles for my high arches but my “ah ha” moment of relief came with cleat adjustment. I’m pretty sure I mentioned in previous “fixed myself” knee posts that if you’re clipless try throwing flat pedals on there and using regular sporty shoes for a bit and see if you can put your foot in a position that provides some relief. This might also help with your toe pointing troubles as it might not let you do that (also might be fine but just look bad, we’re all different). That might provide some insights whether your cleats should be in the same spot on both shoes or if there’s something to compensate for. Who knows, maybe you’re a candidate for varus wedges or cleat height spacers. I’d prefer to do this on the trainer rather than the road so you can really concentrate on the motion and sensations without having to worry about getting to work and keeping your eyes on the road.

Definitely time to have a more wholistic approach to your fitness if you don’t do much strength work, especially if you enjoy it. You’re not old at 40 as I’m only 41 but strength work is something that pays dividends all over the place, especially when you do actually get “old.” Cycling is great for carido and making the legs tired but it’s so narrow in scope that it neglects so many other things that need tending hence all the overuse injuries. Not to mention just having some general strength can prevent other silly injuries. I haven’t thrown out my back in years. Might suggest working on the lower core a lot as well as that can support your pedal stroke (had many a high power/sprinty workout where my lower core felt just as tired as my legs if not more so). I do mostly body weight work with some kettle bells and bar bells here and there, all at home and all in about 20 minutes twice a week. Also did a fair amount of single leg/favoring leg stuff as I have/had a decent L/R power imbalance (still working on it, probably also why my left knee blew up first). If you’re left only or using trainer power it might be a good excuse to pick up a pair of assiomas or whatever true dual sided power meter suits your fancy/budget. You might learn something and at least you’ll have the data whether it’s useful or not. As legendary cycling physio and forum jerk once said on here: “Friends don’t let friends use single sided power meters.”

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Quality stuff there bud, thanks for the advice.

Trying some flats to see where my feet lies naturally versus clip-ins is something I hadn’t thought of and wont cost anything to try :slight_smile:

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Just a warning to provide the other side of the coin. People always recommend doing strength work because it “helps prevent injuries”. I can assure you I’ve had plenty of injuries BECAUSE OF strength work. Even with stuff like kettlebells and dumbbells. I’m not recommending everyone avoid strength work, but for some of us, It’s not the “preventative cure to aging injuries” that a lot of people sell it as.

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Agreed. Proper form and not over-doing it plays a big part in preventing injury while trying to “prevent injury” but sometimes it doesn’t take much, momentary lapse in concentration and form, to get that little tweak that you feel for weeks afterwards. Still, to my mind better from that than nothing at all. Likewise it doesn’t take much to be better than nothing. I feel like people think gym work and start thinking “i gotta stack plates and do hard shit” which I feel skews towards injury without close attention to form. Also just the availability of so much to hurt yourself with for better and worse. I’ve never hurt myself doing body weight, only caused some soreness that yielded a “damn, that feels weird” only to have it go away upon repeating the exercise the next session/week.

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Which is exacerbated by all of the “you have to lift low reps to failure” talk that is currently en vogue.

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Yea I can see how gym work could become problematic rather than a solution. I tend to get back or intercostal pains easily from lifting heavy boxes, unusual movements etc anyway so I was wary going into the gym.

To be honest my main issue with starting any new gym work and the myriad of guides online to starting out with gym work rarely discuss how I am meant to safely find out my Max RMs for any given rep.

e.g. in this case it was 3x10 prescribed, but I have no idea on each movement type what my 10RM is. Its taken weeks of trial and error starting on the side of caution to get where I think I am almost there.

Seated leg press as an example where it also depends on the range of motion through my knees. On seat position 7 (out of 10 so a fairly obtuse angle) I have been doing 195kg (59kg bodyweight & the machine only goes to 195kg), yet when increasing the ROM Ive had to drop down to 115kg as the initial lift feels like it could do damage if it was any higher. Or im just scared to because of that :man_shrugging:

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A few years back I did an event and developed pain inside the front of my left knee. Climb for about 1 hour then 3 peaks separated by short 1 minute down hills 20% gradients. Down the road a fellow rider made the comment that he could not believe he was only able to go 6.5 mph over those peaks. It took a few days to develop the pain. It took 6 months of spinning ( no out of saddle work) for it to go away. Did not get a doctors opinion as I was still able to ride. I’m old so you may get over your injury quicker.
Good luck

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Touch wood the last serious knee pain I’ve had was back in 2007. The physio explained it well and the prescribed exercises kept it at bay but actually missed the permanent solution. That was picked up in a buke fit 6 years later, a leg length discrepancy. Back in 2007 my right thigh was a lot bigger than my left thigh. The left thigh became tight and pulled the right patella out of alignment, so it was no longer running smoothly, and it was rubbing against the bone. That rub suddenly felt like a jagged knife straight into my kneecap when I tried to pedal. As I was saying physio prescribed stretches kept it at bay for 5-6 years but whenever I eased back on them, I could feel the left thigh becoming taught. Then I had a bike fit and it all made sense my right leg was identifies as being a few mm shorter. So it was having to do more work hence the right thigh being visibly larger than the left thigh, which was triggering things exactly how the physio described. Since shimming the right foot, I’ve got away with being less rigorous about stretching :crossed_fingers:

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Yeah - definitely don’t do this for anything rehab related.

Rehab work is usually 10-12 reps that can be completed with correct form EVERY time, probably at least 2-4 reps in reserve.

But with that said, finding the right exercises (e.g. not deadlifts and squats) and doing them regularly and correctly can be a big help.

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LLD is an interesting one as for 4 year after a bike fit where the guy spotted my right toe pointing down and assumed i was reaching due to a LLD. So i ran with a full pack of cleat shims until my latest bike fit where after proper checks, it turns out there was no LLD lol

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I feel that is where I am at now. 10 reps is certainly making itself known but I could push two more out if I had to. Squats is an interesting one though as along side the movements mentioned (inc seated leg press which is similar to a squat?) Ive been told to do single legged slant board squats daily.

This is from my workplace Physio though. My bike fitter (and also specialist physio from December if I can convince my insurer to pay the man) reckons that is a 1980s esq solution and things have moved on since but doesnt want to recommend anything movement wise until hes had a proper assessment himself rather than just a bike fit… which I get to be fair.

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The thing about squats and deadlifts - with the heavier weight and compound movement, there’s a higher chance for injury, That’s why it’s good to be careful with them and I wouldn’t recommend them if rehab is the focus. You very much have to have your back and core, as well as even shoulders ready for them too.

Seated leg press is different in concept because your upper body isn’t involved and you’re isolating the leg. Maybe not as good as a total body / compound movement, but probably better from a rehab perspective if you’re worried about injury.

Single Leg Slant Board Squats probably depends on how you’re doing them. They’re probably lighter weight, if not just straight bodyweight, so don’t carry the injury risk of a Squat (Barbell Back Squat)

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