Dreaded Knee Pain

[philip]

After a couple of big weeks (though not that much bigger than normal) of hard training, my right knee started to feel a bit of pain when on the bike. It was sore for a few days (only when riding) then I had one day off the bike and raced the next. It was fine during the race and riding home, but the next day on my short commute it was very bad again. That was Monday, I decided to give it a few days rest so didn't ride at all tue/wed/thu but went out again this morning for an easy 35km loop to work, it didn't feel painful but didn't feel quite right either. On my commute home I could feel the pain again. Very frustrating after taking 3 days totally off the bike! It isn't painful at all when off the bike/walking around. On Monday when it was at its worst I could reproduce the pain when sitting down in a chair with my knee at 90 degrees and pushing down on my foot.

The pain is coming from the left side of my right knee cap:



I haven't changed the setup or anything on my bike, everything has been the same as it has always been for the past couple of years.

Does anyone know what this is/have they had it before, what did you do to resolve it?

[Nobody]

Do I have this problem? Yes.
Have I cured it? No.
Can my opinion be trusted? No.

Now we've established a few things:
Have you ever measured yourself for different leg lengths?
If you place your heels on the pedals and pedal backwards slowly with rigid hips, does one leg feel longer than the other?
Do you over-pronate when you walk?
Do you use long cranks?
Ever had a bike fit?

Things that have helped me are lowering saddle height, shorter cranks, wedges and a 3mm leg length plate.


Probably worth having a look at the links below, although I don't agree with rotating a cleat to fix a problem on the second BR article, as the linked video below totally disagrees with it. Cleat rotation made my problem worse.
http://www.stevehoggbikefitting.com/bik ... knee-pain/" onclick="window.open(this.href);return false;
http://www.bikeradar.com/fitness/articl ... nce-17010/" onclick="window.open(this.href);return false;
http://www.bikeradar.com/fitness/articl ... t-2-17445/" onclick="window.open(this.href);return false;
http://www.youtube.com/watch?v=oxNznrlRXGU" onclick="window.open(this.href);return false;

Hopefully someone will answer that actually has the answer to benefit us both.

[winstonw]

the following is not exhaustive or overly accurate. it's just a very rough guide to identify more so where your pain is originating.

1. with leg straight, push a finger firmly along th left margin of your right knee cap. make sure you drive your finger in under the knee cap.
2. bend your knee 90 degrees, then use a finger to press firmly around the end of the femoral condyle left of the knee cap, looking for the pain.
3. now bend your knee as far as you can, and press your finger firmly into the joint space between the femur and tibia, to the left of the knee cap.

- if the pain is mainly from 1, that indicates you have patellofemoral joint medial margin issues, possibly from maltracking. in this case, you may need a biomechanically skilled bike fitter to sort out shims and wedges.

- if the pain is coming from 2, then its possible you have a chip of cartilage off the end of the femoral condyle, or have just bruised the cartilage.

- if the pain is coming from 3, then it's most likely a medial meniscus anterior horn contusion or small tear +/- meniscal cyst. again, shims and wedges may be necessary.

[philip]

Thanks for the replies guys

Have you ever measured yourself for different leg lengths?

No. I'm fairly sure my right leg is shorter than my left but have never actually measured it and I haven't had a problem before.

If you place your heels on the pedals and pedal backwards slowly with rigid hips, does one leg feel longer than the other?

Haven't tried this yet but I'll give it a go.

Do you over-pronate when you walk?

No idea!

Do you use long cranks?

No, I'm 185cm and use 172.5 cranks

Ever had a bike fit?

No. I've been riding for the past 2-3 years on the exact same setup, normally do about 300km/week.

Hopefully someone will answer that actually has the answer to benefit us both.

Thanks, I'll check the links out. I tried to do some research before my first post but didn't understand any of the jargon used (I know nothing about anatomy, especially of the knee)

winstonw, I tried doing the 3 different methods of finding the pain and couldn't find it anywhere. So far I've really only felt the pain when cycling, although something in my knee does feel a bit "funny" (sorry, best I can do!) at other times. I don't know if other people get this, but sometimes when you feel like your knee needs to release pressure or something and you give your leg a shake and your knee cracks (like cracking knuckles) and it feels normal again? Sort of feels like that all the time at the moment.

Anyway, I think I'll give it a rest for a bit longer this time, I'll give it another week off the bike and see how it goes. If it still hurts after that I'll go see a dr or two (one for my knee and one for my mind if I have to stay off the bike any longer!)

[Nobody]

No. I'm fairly sure my right leg is shorter than my left but have never actually measured it and I haven't had a problem before.

Thanks for the answers.
Check your normal shoe wear. If the right shoe is worn more than the left, that can be a sign. As you can see from the pic of my shoes, my right leg is shorter than my left.
Never having the problem before doesn't mean a lot as I didn't when I was young either. We are all getting older.

Do you over-pronate when you walk?

No idea!

Most people do to some degree. If I understand it correctly, it means your ankle will rotate inward slightly when you walk. It determines if/what wedges you may need. But you won't need to know about it if you go to a fitter.

Ever had a bike fit?

No. I've been riding for the past 2-3 years on the exact same setup, normally do about 300km/week.

Probably a good time to get one then as you'll be able to feel the difference if it works.

I tried to do some research before my first post but didn't understand any of the jargon used (I know nothing about anatomy, especially of the knee)

It just takes time to get acquainted with the medical terms. You could always google the terms.

I don't know if other people get this, but sometimes when you feel like your knee needs to release pressure or something and you give your leg a shake and your knee cracks (like cracking knuckles) and it feels normal again? Sort of feels like that all the time at the moment.

Yep, I've got the same. Maybe try doing some leg/back/hip stretches, especially calf muscle stretches. I find it helps. Also it might be worth your while to lower your saddle height by 5mm for your next ride. If you have the same as me, you should notice a slight improvement.

[philip]

So after a week off I decided to try riding to work (only 8km) yesterday to see how it was. After about 1km I could feel the pain again. To say I was frustrated is the understatement of the century! I was really hoping that much time off would fix it up. Met up with some of my mates who recommended trying some voltaren so I went straight to the chemist and got both the gel and the pills. Got to work and booked an appointment with a physio a mate recommended for that same afternoon.

On the way home via the physio I was taking it very easy but it definitely felt better than the ride to work. Whether that was the voltaren or because I was taking it super easy, I'm not sure.

After describing the situation to the physio he said "I can tell you straight away what that is" but got me to do a few tests to see why it was happening. Basically it came down to my right side being a lot tighter/knee doing funny things (points inwards slightly, when I stand on my right leg and do a one legged squat it tracks inwards instead of straight like my left) which cause the kneecap to not track properly. Short term he's given me a bunch of stretches to do (ITB, glutes/hammies) and also tape up the knee to pull the kneecap to the left so that the tight ITB doesn't pull it to the right. Longer term will be building up strength/core to try and even out that side. He said the leg length difference was quite small and we'll try these things first before seeing if I need to use shims or somesuch.

As to the cause, not too sure. I did have an OTB stack a bit over a month ago where I got a bit of soft tissue damage in my upper back (between shoulder blades), he said that may have caused some misalignment in lower back/hips but hard to know. One thing I totally forgot to mention to him is that I also started doing some daily situps/pushups about a month ago too. I hadn't thought of this as a correlation at all so it didn't even enter my mind, I'll mention that in my next visit.

He told me to keep commuting to work for now, that way we'll know if it's getting better. I rode in this morning and it definitely felt better than yesterday but with the tape on my knee I found it hard to tell for sure as I'm not used to the tape and that was distracting me a bit.

[nescius]

I know when I get knee pain it's time to break out the foam roller. I rarely get sore knees but when I do it is always after I increase volume and intensity without adding extra stretching/foam roller. The crits started here a couple of weeks ago, plus I'm training for Tour of Bright, and sure enough this week I've had a sore right knee, I spent 30 minutes on the roller this morning and it was agony which tells me that things were way too tight. I have always managed to resolve the pain by using various self massage techniques, I should have started some preventative stretching and massage before my knee got sore but apparently I am a slow learner.

[philip]

I should have started some preventative stretching and massage before my knee got sore

Yeah do this! I've always been the same because I've never had any problems before. I very occasionally did a small amount of stretching after a hard ride to try and help with recovery but obviously not enough!

[moosterbounce]

I had exactly the same as you Phillip. Listen to the physio and strengthen the glutes. If he hasn't used it already, ask the physio to use rock tape or similar instead of the rigid strapping tape. Promotes blood flow, stays on longer, less painful, and better looking.

Be warned though...I did as I was told and found I "over strengthened" my left side and had the the same thing happen on the right as I was not out of whack. It's very common apparently. Perhaps do the exercises prescribed on both legs just in case?

[Dr_Mutley]

"Strengthening" this and that, albeit probably beneficial holistically in the long run, is unlikely fix this acute problem. To get more accurate responses, a couple of short videos of your pedal stroke on the bike is probably quite beneficial.

Your acute issue is likely to be a 100% bike fit/setup issue... Reading and understanding the basics via the links above is a good place to start as the causes for your pain is so vast that's spurious suggestions are unlikely to help without further info...

But here's a spurious suggestion. Place 2 varus wedges under each cleat, move them to the most rearward position on the shoe u can, and to the most inward position on the shoe (ie widest stance attainable).... Try that and see if that minimises the pain. If it does but causes issues elsewhere, then migrate the cleat position back towards your original position in a stepwise fashion. Worth a try

[Nobody]

But here's a spurious suggestion. Place 2 varus wedges under each cleat, move them to the most rearward position on the shoe u can, and to the most inward position on the shoe (ie widest stance attainable).... Try that and see if that minimises the pain. If it does but causes issues elsewhere, then migrate the cleat position back towards your original position in a stepwise fashion. Worth a try

Thanks for the suggestion.

I understand the wedges and cleat to rear as that's what I have, but I'm lost on the wider Q as I thought I was supposed to move the shoes closer together (narrower Q) as per direction from the second BR link. Maybe it's wrong as it seems that way for cleat rotation.



Oh well, I might do some more reading and maybe try moving the shoes out as well. My knees aren't too bad since got the tighter road shoes with the wedges and shim. But still early days...

[Dr_Mutley]

With regards to the above recommendations, I've just based them on the most common cleat issues u see in "average" subjects... How much they can be transferred to your situation is difficult to predict obviously sight unseen. Maybe my subject population isn't representative as a whole, but I most commonly see riders who have too narrow a stance width, who over pronate, with saddles too high, trying to emulate the pros

With too narrow stance widths (for the lack of a better term), it depends on the degree of cleat rotation and pronation whether u experience medial or lateral pain. I recognise however lateral pain, such as ITB issues are more common, but not exclusive. A better way of visualising the concept is, if your knees track outside the pedal/cleat interface then lateral knee pain is more likely. If your knees track too far inwards then medial pain is more prevalent. This can be changed however by a myriad of other factors...

Mark your original position and then have some trial and error rides... Just remember though, if your moving your cleats rearward a fair way, u will likely need to drop your saddle height a bit to compensate.

[Nobody]

I most commonly see riders who have too narrow a stance width, who over pronate, with saddles too high, trying to emulate the pros

Yes, like most I over pronate. Saddle height is only 106.8% of the shortest inner leg measurement, with the cleats all the way back. Philip and I both have medial pain on the right.

Thanks for the explanation. Time to get a video for my own assessment.

[Dr_Mutley]

Well if u over pronate then that's the first easy step to fix... Supportive arch insoles and some cleat or rearfoot varus wedges, and see how that changes things...

[Nobody]

Yes, that looks like the next step. Thanks again.

I got my son to take some video of me on the trainer today. Both in front and behind, on both sides with light and heavy load and normal cadence. Although the camera angles weren't very straight, it appears my right knee tracks inward as the pedal goes down with heavy load. At least I now have a clue of what's happening. Ankles look straight at the back so wedges appear to be working.

I'll probably try to get some more accurate video tomorrow.

[Baalzamon]

Also if your knee cap has been tracking incorrectly for a while, this is what happened to me. Doing body attack running and BANG left knee goes. Swelled up on the outside of the knee, get an arthroscope and no damage. Year down the track doing boot camp knee goes bang again running. Saw a different doc due to my regular being off on holidays, sent me off for another arthroscope no damage, knee still swollen on the outside. Then sent me off to a specialist and had a MRI which found the damage. Osteoarthritis in the inside of my knee, I had just caught it and the spot where it was actually referred the swelling to the outside, go figure...

What could be happening to you is your arch collapsing when riding if you have an arch, as others said get insoles. I've got Vaysli heat modable insoles for my shoes.

[rdp_au]

I would second the suggestion to a get a proper bike fit. I too suffered from medial pain in my right knee for a long time. I saw a couple of highly recommended sports physios who suggested taping the knee, and various strengthening exercises. These worked for a while, but the pain would return.

Early this year I was able to see Steve Hogg who does a very no holds barred assessment and bike fit. His words, after he had finished his battery of tests were, "Functionally, you are a mess.." He did some adjustments to my position on the bike, adjusted my cleat position, and very carefully fine tuned a set of insoles for both shoes. This, plus the stretches and exercises he suggested have meant I've been pain free for eight months.

It was an expensive exercise, but it worked.

[vander]

I like how you have all gone down the over-pronation/medial wedging option even though this is very much going out of fashion as far as what to do goes.

@nobody, that tracking of the knee is (as far as the research I have looked at which is extensive) a major issue. The dynamic adduction of the knee relative to the hip causes adduction and internal rotation of the femur, increasing the Q-angle and decreasing contact area thus greatly affecting the the patellofemoral joint stress. The issue with wedging in regards to this is although a medial wedge does decrease your static Q angle, it does not affect your change in Q angle (based on the limited evidence so far), that is, your knee is slightly less adducted but as you pedal (in the majority of participants) it still adducts through the pedal cycle just as much.

As far as your foot collapsing/arch going in/over pronating that I am hearing. This is all quite normal, it is normal to pronate and a lack of pronation is not good and can cause issues on its own. The current studies show that wedging or providing medial support does not translate up the chain as well as once thought in most people they adjust at the ankle and the resultant effects to the knee are not as desired. Also its affect on muscle forces during cycling are only recently being examined and a lack of pronation can lead to increased use of your lateral quadriceps which may infact worsen the issue.

With Phillip you may have had some underlying issue however your body had adjusted to your training load (you had done it over a long period of time) however the increase in the training load may have caused you to tip over the physiological limit for damage. I would say listen to your current physio and see how that goes, as off the bike treatment is often effective. With regards to bike fit there are a few things that your can do, such as raising the saddle height, if the saddle is set to length-based measures it often falls above the recommended knee angles at BDC, this will both increase the forces at the knee and has also been shown to increase the amount of adduction during the pedal stroke. Saddle height is one of the few that has had some research on it but other options include, setting your saddle further backwards, rotating your cleats (to your natural tibial rotation angle or slightly internally rotated). Also in some cases medial wedging may work, in others lateral wedging works, they have not discovered a pattern for which sort of wedging to use based on the presentation. One thing that hasnt been well researched is technique, but trying to pedal with your knee tracking straight up and down and not inwards and outwards may be extremely beneficial. Resist the urge to move the cleats back on the shoes as this increased the work the quads and gluts do and takes work off the calves which may not be beneficial in this case.

It is currently in the inflammatory stage you need to settle it down by taking it easy (dont have to be off the bike but need to take it easy on it) and stretching ice etc will help. Once the pain is settled then you can slowly go about building your riding back up, and fixing the strength etc imbalances.

[vander]

Well if u over pronate then that's the first easy step to fix... Supportive arch insoles and some cleat or rearfoot varus wedges, and see how that changes things...

Rearfoot wedges in cycling are not useful as they are not the weightbearing part of the foot, unlike walking.

[philip]

It was an expensive exercise, but it worked.

Yeah the cost of it is what's making me wait and see if I can fix it myself (with the help of a physio though). I'm looking at other bike fit options, Blair at The Body Mechanic seems to get good reviews too (not sure about cost). Not sure about the specialized BG fit. Both of them are close to me.

I don't have a trainer/rollers so can't video myself, might see if I can borrow one from a mate. I have noticed that my right knee is quite close to the top tube, occasionally rubs it.

[Dr_Mutley]

Well if u over pronate then that's the first easy step to fix... Supportive arch insoles and some cleat or rearfoot varus wedges, and see how that changes things...

Rearfoot wedges in cycling are not useful as they are not the weightbearing part of the foot, unlike walking.

True to a degree, but also not always the case...

Any wedging is to primarily influence rear foot posture. How u do it is individual to the person your fitting, but in some, heel wedging works far better than cleat wedging... Trial them all, use what works, and don't use what doesn't...

If think this paragraph sums up the principle from SH...

http://www.stevehoggbikefitting.com/bik ... 2-wedging/" onclick="window.open(this.href);return false;

"In a cycling shoe what is being corrected in the great majority of cases,indirectly via a cleat wedge or in shoe forefoot wedge; or directly via a heel wedge is rear foot varus. The forefoot wedge, whether under cleat or inside the shoe corrects the rear foot because the heel is not fixed to the ground. The important thing here is that if you try to correct rear foot varus by using forefoot wedges in normal walking gait when the heel is fixed on the ground, the midfoot will pronate around its long axis and damage joints by jamming them together. This is not the case with varus wedges in cycle shoes or underneath a cleat as the heel is not fixed to the ground and is more or less in an open kinetic chain. However, it would be preferable when using an in shoe forefoot wedge to add a rear foot wedge as well, especially if there is a large amount of Tibial varum"

[Nobody]

What could be happening to you is your arch collapsing when riding if you have an arch, as others said get insoles. I've got Vaysli heat modable insoles for my shoes.

You could be right. I've ordered some G8 2600 insoles to see if they help. I checked my arches to find my right foot is slightly lower than my left.

I like how you have all gone down the over-pronation/medial wedging option even though this is very much going out of fashion as far as what to do goes.

@nobody, that tracking of the knee is (as far as the research I have looked at which is extensive) a major issue. The dynamic adduction of the knee relative to the hip causes adduction and internal rotation of the femur, increasing the Q-angle and decreasing contact area thus greatly affecting the the patellofemoral joint stress. The issue with wedging in regards to this is although a medial wedge does decrease your static Q angle, it does not affect your change in Q angle (based on the limited evidence so far), that is, your knee is slightly less adducted but as you pedal (in the majority of participants) it still adducts through the pedal cycle just as much.

As far as your foot collapsing/arch going in/over pronating that I am hearing. This is all quite normal, it is normal to pronate and a lack of pronation is not good and can cause issues on its own. The current studies show that wedging or providing medial support does not translate up the chain as well as once thought in most people they adjust at the ankle and the resultant effects to the knee are not as desired. Also its affect on muscle forces during cycling are only recently being examined and a lack of pronation can lead to increased use of your lateral quadriceps which may infact worsen the issue.

Thanks for the comment. As far as I can tell, the knee only tracks about and inch or so inward. If the insoles don't help - which from your comment, they may not - I may have little choice other than to get a bike fitter to tell me where it's all going wrong. I'd rather do it myself, not just because of the cost, but because it's more of an adventure (for want of a better term) and I'll learn more along the way. Plus the pain is rare on the bike, but appears the next day. It also doesn't seem anywhere near what Philip is experiencing. Just irritating/worrying at times.

[philip]

On my last couple of rides I've been paying a bit more attention to what my right leg/foot is doing and have a couple of ideas. Also my knee pain doesn't seem to be there now, definitely not the pain I was feeling previously anyway - but something in my knee still doesn't feel quite right. Hard to pinpoint what it is, it's just a sort of uncomfortable feeling (like what it feels like when you feel a joint needs to "crack"). Only doing short commutes a the moment.

Anyway, I think there's two things going on - one is that my foot is angled out a bit (as in heel is a little closer to the bike that toes) and the other is that my right knee is tracking inwards slightly (coming close to the top tube). I tried trying to lift the inside of my right foot (mainly by only putting pressure on the outside while pedalling) and that seemed to straighten it out. So I think I need the same sort of thing that it looks like Nobody has on his right shoe especially - to lift up the inside of my foot. Does this sound reasonable? Where does one get those wedges? Did you make them yourself? Off to do some searching...

[Nobody]

Anyway, I think there's two things going on - one is that my foot is angled out a bit (as in heel is a little closer to the bike that toes) and the other is that my right knee is tracking inwards slightly (coming close to the top tube). I tried trying to lift the inside of my right foot (mainly by only putting pressure on the outside while pedalling) and that seemed to straighten it out. So I think I need the same sort of thing that it looks like Nobody has on his right shoe especially - to lift up the inside of my foot. Does this sound reasonable? Where does one get those wedges? Did you make them yourself? Off to do some searching...

I have the same things you describe and using the outside of the foot also helps my problem. As to where to get the bits, Steve Hogg has them online or there is a US site.
http://www.stevehoggbikefitting.com/sto ... -products/" onclick="window.open(this.href);return false;
http://www.bikefit.com/default.aspx" onclick="window.open(this.href);return false;

A couple of tips in fitting are:
- It's important to fit the new cleat bolts to the correct length. Best way to do this is to measure in comparison with the standard bolts, taking into account the extra height at each bolt. They supply bolts, but some may need to be cut to length. Bolts need to be at least 2 turns into the nut for enough strength. (Sorry if this seems basic, but I don't know how experienced you are at such things).
- Make sure you keep periodically tightening the bolts after install, as the stack will settle considerably.

[philip]

As to where to get the bits, Steve Hogg has them online or there is a US site.

Great, thanks for that. I'm seeing my physio this afternoon so will discuss these things with him and see what he says about it before changing anything.