Sorry I took a while to get back to you.
Hip flexor exercises with stretch bands worked wonders for me.
This list covers most of the ones I have used: https://www.prevention.com/fitness/workouts/g29485708/resistance-band-exercises-for-legs/
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Interesting regarding riding with pain. I’m still riding, but have dropped volume a lot. From 6-7 hr per week down to 2 hours per week for the last 3 weeks, zero positive effect. Which is interesting. It’s good to hear that it’s ok to ride with a tolerable level of discomfort.
I’m still sorting out the why behind my tendinosis, I just saw a highly regarded fitter. Going in thinking my fit was off, it wasn’t, he actually complimented me on how I had my bike set up. However, he could visibly see lateral pull on the knee when pedaling. Ok…
…”Let’s look at your feet and shoes.”
I’m in Giro VR90 2-bolt SPD shoes. He immediately commented on how narrow they were for my foot shape and noted that I’m incapable of spreading my force through the entire foot bed, and most of the pressure is on the lateral side of the shoe. He was more eloquent in his diagnosis, but bottom line: This is causing all sorts of issues.
He also noted that Giro shoes have a very limited cleat placement range and said he wanted mine to get even further back. They are already in the rear most position.
I took his direction and bought a pair of S-Works shoes and immediately noticed they fit a lot nicer. My feet have more room, and I can get the cleats much further back…effectively taking more of the knee out of the pedal stroke.
Oh, and he mentioned my right glute feels inhibited. Commenting that I’m all quads on my right side. Likely a result of cleat position and fit of shoe.
On the rehab front…
Lots of quad, adductor, abductor and hip flexor work now. Slow squats. Heavy banded knee extensions with a long isometric hood. Isometric split squats. 
All this to say, I’m a bit frustrated that I haven’t improved at all over the last 16 weeks.
Look at how much further back the cleat is in comparison!
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Did the fit help at all in terms of pain?
We didn’t even touch the fit, the fit looked good from his POV. Focusing on footwear, cleat placement, glute recruitment.
Kinda wish it was just a fit thing!
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What I type here is my opinion, not fact - I am not a bike fitter.
PAtellar tendinopathy is more of an overuse issue rather than a fit issue per-se. General patellofemoral pain is a fit issue (pain around the kneecap, behind it, inferior to it, but not specific to the tendon).
There is NO way someone could see inhibition. The only way to truly measure it is with a valid strength assessment with force production measurement, then place electrical stimulation pads - turn up the juice and see how much stronger the force production is with the stim and then look at the ratio of strength without stim superimposed and with it. You can’t see it. There are other proxies - but these aren’t good and are usually present with people with back pain.
What I say now is not medical advice for you, just what I see/do in my practice. When you’ve had issues this long, and you’ve been doing the proper resistance training and limited riding/offending activity - there are some pain science things you can try like noxious stimulation. Basically the brain aspect to pain - not the peripheral mechanisms causing it (DM me for more info, don’t need to bore everyone here). This is something I do with my patients who have more chronic tendon pain issues (along with the regular PT stuff).
Also, if it has been a long time, might be worth a referral to a sports med doc (non operative) who does things like Tenex procedures, PRP, etc… but these tend to be out of pocket - but I have patients with recalcitrant tendon pain who do benefit - but this is of last resort.
Sounds like your PT is having you do appropriate work/rehab - so just things to consider.
Again, my opinion and clinical experience
Please do post here.
I am following that thread closely as well
There is both a peripheral (think skin for example) and central (brain) aspect to pain.
Your skin, muscle, bone has sensors that detect pain or pressure and relay it to the brain via nerves.
The thought is that when pain becomes chronic in nature the processing of the pain in the brain changes. Meaning that less of a painful stimuli is needed to cause the brain to think “oh hey here is pain”. They can test this in a lab with pain or heat threshold testing. How much pressure can a piece of tissue (think tendon) take until the person says to stop pushing the instrument.
So the idea is that if you introduce a new painful stimulus (in the case with tendon pain, noxious/painful electric stimulation) it can attempt to change the threshold at which the brain will think there is pain. Basically the brain thinks “oh, what I thought was pain isn’t pain, THIS is pain”. And then hopefully the sensitivity changes back to a more normal amount. This is usually done in conjunction with normal rehab. Not instead of it (resistance training for the muscle controlling the tendon)
TLDR; pain is weird and we don’t even know a tenth of what’s actually going on in the brain with it.
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Never heard about that, that’s fascinating! Thanks
Coming up on a year at the end of March when I started noticing some very subtle soreness in my right knee patellar tendon. I am still experiencing pain during loaded knee flexion, but have been able to ride pain free since early December. I have been doing a lot of lower body strengthening with a focus on the heavy compound lifts hitting the hips, glutes and hamstrings and then a lot of single leg quad strengthening exercises. Reverse lunges, step ups/downs, split squats, and isometrics. All of which has been prescribed by a PT.
While I can now ride pain free…I’m still having noticeable “pain” every single day with things as simple as standing up from a chair.
This has been a real headache, err knee ache. And I’m now noticing an onset of soreness on the other knee in the same location (tibial tuberosity). I’m riding the bike about 1-3 hrs per week, which is 1/3rd my typical volume at this time of year. Fitter likes my fit.
I’m at a loss.
Did you ever completely stop riding for at least 6-8 weeks?
I’ve been good since November, doing clam shells, monster walking, hip thrusts, and lately walking backwards on a treadmill gradually ramping up to 5 min at 1.6 mph on a 15% grade. Plus…and maybe the most important…staying at 250-300 tss/wk. not sure if this is true improvement or just part of the waxing and waning of the problem. But that’s where I’m at.
Joe
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No, I never just stopped riding. To me that is a bad idea, as long as the rides aren’t/weren’t over a 3/10 on the pain scale. During late summer early autumn I went through a stretch where I stopped because it was too painful. I have been fluctuating between 50-150 TSS/wk for the last 9 weeks, only 4 or 5 sessions that were high intensity (2min VO2) and those were not problematic. In fact, I can ride pain free since early December. Before that it would be sore for the first 15-20 min and then warm up.
That’s good to hear. I was feeling really good between mid-December and mid-January, felt like I was 90%, then within the last week or two I have felt gradually worse. No coincidence with an increase in anything, I have actually had reduced volume over that period.
I have learned that tendon and ligament injuries can be extremely fussy and slow to heal and never linear in recovery progress.
Wishing you the best!
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Just read some of the literature bcs a friend is suffering with this issue. Cessation of biking and heavy weights with slow movement were my main takeaways.
You are not recovered. What do you have to lose for a chance to get rid of this malaise?
Good Luck
You should provide a link to that literature. I have worked with multiple PTs, and none of them have ever suggested cessation of activity, unless it is causing significant pain or there is an increase in pain afterwards.
As I mentioned, I can ride pain free and pain does not increase after riding. Why would I stop? What if the root cause of pain wasn’t bike related, but something else?
The hard part is understanding what the root cause is and then developing a strategy for slow, but gradual loading.
The goal is to cycle. If I can do it pain free I don’t see any logic in cessation of that activity.
Sorry, I just had a bunch of tabs open, you understand that is a lot of work to recreate. But it shouldn’t be to hard to find. Also, cessation of biking was also the medical advice my friend got independently.
I guess I’m a bit confused when you say that you can ride pain free but still have pain in other activities. Don’t you think there’s a link?. Anyways, I imagine this is frustrating and I feel for anybody facing this issues. Good Luck!