Patellofemoral syndrome - what worked for you?

[CKinnard]

If you get a sore back just standing around, then it is very likely you have a compromised disc or two. Manual therapy cannot do a lot for it. It comes down to spinal joint mobility, strong core and extrinsic back muscles, good posture off the bike, and general lifestyle choices (diet, hydration, stress, sleep).

Definitely mess with your stem length (and height). It's important to get this right. I'd even suggest you shorten the stem and keep it elevated just to decrease any potential irritation of the spinal cord, until your legs are better.

Building glut strength can be done by riding hills more often out of the saddle. And doing quick step ups and slow step downs. Eventually move to doing single leg repeats. Gluts don't kick in much until you do fast high resistance hip extension movements. You would also benefit from build lower back extension strength, which uses gluts (back extensions on a frame).

pedal extenders are a good thing to experiment with, especially if you are taller/broader (say over 6ft1in)
Having your foot angled toe in will increase load through the inner knee.

Adductors contribute to the down stroke with heavier efforts, especially climbing. If they have been sore for some time, I'd suggest you get them massaged heavily, and stretch regularly for a month. A women's world champion track cyclist saw me last week after a few weeks training with the Canadian cycling team on the Gold Coast. Her adductors had been cramping a lot during the longer rides, hills, and heat. They were full of old scars and very very tender.

[Jumma]

My back doesn't get sore just standing around, it's more like if I have a day out n Sydney or something where I am standing and walking around four hours on end. Normally wearing thongs or flat shoes too, so probably little support. I think it may be from tight glutes.

Anyhow. Been to physio again and he checked stability of knees, joints etc. I am tight in the hips and need to maybe work on glute activation some more.

Next week I am going to take my bike in and set up on the trainer and we are going to do some analysis on the trainer to see what is actually happening under different loads, positions and cadences etc. This is a refreshing approach as i have seen a few physios so far and none have suggested this. So that's a good start and a refreshing approach rather than just the standard out of the book stretching, tightness, massage and release attitude.

He said we need to work on finding the reasons and weaknesses, why this is occurring, rather than applying standard run of the mill solutions. Pretty happy with the attitude and extra interest from him for a standard physio service and not a bike fitter. So this is a good start I guess.

He also said that I will likely need to reduce the cycling load and rest more to help the current injury to heal. I kind of knew this, though I struggle with it!! I have been trying to take it easy this week, however I have already ridden 160 km since Monday. Though I did have Tuesday off I have been avoiding seated climbs and doing all my smaller hill climbs out of the saddle (NO seated climbs at all). Most of these rides have been high cadence most of the time (around 95 to 110 rpm) which I find easy to do, so that is good. I have also been avoiding hills and also avoiding riding with people, groups I know are fast and will make me push myself in any way. My VMO has been feeling generally sore but seems to be more of a muscular of DOMS type soreness which settles within a day. I think I still need to drop the load some more though - if I am to be honest with myself!! It is so hard to go slow

I have a 90 mm 6 degrees stem on order, will be here next week. It was on special, around half price, a Pro 90 mm, has the white Pro logo, which wont fit in with my S-works all black stealth look, but, hey it is only a starting point, if it is all good I will get a matching S-works SL stem. That will put me a little lower than now, but about 30 mm closer and I may even be able to set the seat back 5 mm or so and see what affect that has - loading glutes up more.

I have been trying to really perceive or sense my glute activation on the bike now to see if they are firing and trying to consciously activate them. It is hard to define whether they are doing much or not. I am also doing some clam shell and one leg bridge exercises, two to three times a week to try and focus on them and activation. I hadn't really thought about the hill climbing out of saddle to strengthen the glutes. I do tend to naturally stand a lot on hills anyhow when I can, except for extended climbs where the HR just climbs too much out of the saddle to sustain it.

I am just over 6 ft in height, but I run the narrowest seats in S-works and Pro (Shimano) - I think it is 142 mm or something, so I have quite narrow hips or sit bones. i cant run wider seats otherwise I find my inner thighs can tend to rub sometimes. The pedal spacers, may be a future option, depending on what the bike analysis finds. My feet are a little toe out now!

I need to arrange a good massage as I have never had one other than what physios have provided, I think you are right about releasing the adductors with some heavy massage - it is going to hurt like hell I know. They are super tender to even roll.

Anyhow, I'll keep at it.

Cheers

James

[CKinnard]

I think the glut activation thing is highly overrated. It sounds like you are a leaner build, in which case your muscle type is more likely slow twitch rather than fast. This biases being a diesel and not a turbo sprinter. In this case, no matter how hard you train your gluts, they are not going to improve much.

If you physio has not assessed your lumbar spine in accord with what i suggested above, then imho their experience is limited.
Gluts are commonly compromised by low back issues.

Gluts are best trained with powerful full range movements, and very fast ballistic stuff. This is when they are more optimally recruited, and as you can imagine cycling does not put gluts through large range powerful contractions. A cadence of 90+rpm just doesn't allow it.

Besides, I thought your gluts had been looked at a lot in the past.

This physio sounds a bit naive if he intends to look for variations under different conditions. The largest variations occur only when you are very fatigued, like after 2-3 hour of hard riding. If you stay seated and increase resistance, you will note your knee medially deviate. This is evidence you are recruiting your adductors for the downstroke. Everyone does this. But it almost always means your cadence drops under 80.

[Jumma]

Hi

I have been doing some more research into the issues I am having with the soreness in adductor, VMO, around the knee (medial side mostly) and around the top of the attachment of the inner side of the calf to the knee area.

I came across some information on the adductor tract and the saphenous nerve and the symptoms of nerve entrapment or soreness around this nerve seem to make sense for part of my problem. It still does not really explain the VMO soreness as much, unless I have a couple of things going on i.e. VMO tendinitis and nerve issues also!!?

The location where the Saphenous nerve passes over and into the back of the calf, just below and to the left of my inner knee area is quite sore and I can reproduce the soreness by doing a big side stretch, stretching the adductor and calf inner side.

I also notice that the tract to the inner side of my leg is tender around there, where the Saphenous nerve runs through at the adductor location, further up my inner thigh from my knee.

I will investigate this one some more and maybe try to rule it out, if it is not part of the issue - maybe I am just clutching at straws.

I have also been thinking about the back issue you were talking about and am going to start doing some back exercises - lying face down on the floor and lifting arms and legs type stuff for upper and lower back as I noticed when I was asked to lay on the bench and lift my RHS leg as high as I could backwards, using glutes, hips, hamstrings that I got a slight back strain on the RHS lower back area. I will also ask the physio re this - the more information and questions I guess the better the knowledge to help assess and find a solution.

Oh! I have been trying to do ALL of my climbing out of the saddle, trying to position by body back a little and focusing on using the glutes more. Thinking about them as I am peddling and pushing higher gears as you have stated to help build the glutes on the bike.

I have also been focusing on pushing through my heels more when I walk up stairs, loading the glutes, and I find that helps with reducing soreness, the rear chain is activated more, rather than more quads.

Physio didnt actually say different conditions, I just assumed that, I think he just wants to assess what is happening in the sport and function I am using the muscles and biomechanics in and how it relates to my issues.

I am a lean build, I've always been lean but muscular, do not have a large upper body, but have broad (swimmers) shoulders. I am 6ft 1" height and around 82-83 kg, I get to around 79-80 kg when I am in race mode

James

[CKinnard]

Get your physio to assess your lumbar spine, firmly!

And also assess your sore knee, especially deeper palpation of the medial mensicus (anterior and posterior horns, and body).
This usually requires several variations of McMurray's Test and deep palpation when the knee is in the loose packed position.
And get the ACL and PCL firmly and repeatedly stressed.

If you haven't had it done yet, get the inner side of your thigh right down to the knee massaged (adductor muscles), then do the hamstrings and calf muscles.
The adductor massage will probably be quite painful