ridethetown

Patellofemoral syndrome flare-up is ruining our first week of nice weather. What can I expect from here? Extended time off the bike? I've experienced this before when marathon training but fortunately never before with cycling. I'm guessing the low-impact nature of riding is working in my favor as opposed to running, while repetitive motion and muscle imbalance are working against me now.

From what I know my patella is tracking wrong (probably laterally) and I need to work on my abductors, external rotators, glutes, and VMO, roll, stretch. Anything else? How long till I can ride? Riding with pain? With ski season just winding down, my mileage has been sporadic and I was really just starting to ride consistently (still only 70-80 m/week).

Thanks

Machka 

How tight are your leg warmers or tights over your knee? If they are constricting the movement of your knee, get looser tights or adjust your leg warmers so they're baggy around the knee.

My sports Dr recommended "old fashioned" leg extensions and those did indeed seem to help.

Carbonfiberboy 

VMO work is usually helpful. I like 150°-180° leg extensions with heavy weight. On the bike, raise your saddle as high as is comfortable and ride easy for about 1/2 hour every day until the pain goes away. Then get a bike fit and gradually lower your saddle to where the fitter puts it.

79pmooney

I had to do some research. Patellofemoral syndrome is what used to be called chrondomalacia patella. I was diagnosed with it over 40 years by a bike racing orthopedic surgeon specializing in sports medicine. (After a race I dropped out of. The doc was a friend of the race promoter who knew I wasn't a quitter. No charge, and in the back of a cold van, March in New Hampshire.) It was many years before I saw all of what he told me and more before I ever saw it all in one place. Since I hadn't seen it all together yet, I decided to write my story and what that doc told me. Below is that story.Chrondomalacia patella. Yes, I can tell you a little about it. I was diagnosed in ’78 and given very good advice by the doctor (an orthopedic in sports medicine. He was also a novice bike racer, so he had more understanding of the cycling aspects of CP than most). I will do my best to pass on what he told me.

In CP, the kneecap is not aligned with the knee under it, hence there is chafing as the knee is moved. This causes wear, first to the cartilage, then to the bone under it. The wear accumulates with number of repetitions and pressure. At some point, the wear can cause permanent damage.

Some people are more prone to CP than others. It can be triggered by exercising in cold weather, exercising without adequate stretching of the hamstrings, i.e. touching your toes or less extreme stretches of the same tendons. It can be brought on by exercising without adequately strengthening the small quadriceps muscles just above the kneecap.

I brought on my CP by training to return my body to racing form after a very serious accident. (I was weak enough after my hospital stay that I was no match at 24 years old for any 7 yo.) The accident was in November, and I returned to riding miles in March. I did nothing to keep my knees especially warm and did no stretching exercises (rationalizing that since my leg never extended to anywhere near straight, there was no chance of injury, hence no need to stretch). I was wearing just full tights and thermal underwear under them in Boston. The temperature was probably not much above 30. The ride that started it was 100+ miles on my racing bike, my first outdoor ride on that bike. It had 175 cranks. My trainer, with fixed gear and very low BB, had 168’s. After the ride I had a dull pain in my mid to upper knee in front. That Saturday was the first race of the season. I was forced to drop out, my knees hurt so much.

After that race, the race promoter introduced me to an orthopedic surgeon who diagnosed me in the back of a cold van. He laid out for me then and in later phone calls a plan that I will pass on here.

He first stressed that I had to stretch my hamstrings, touch toes or lean forward against a wall or post with one leg back and straight and stretch that hamstring or sit and touch toes. I now prefer the lean forward method. Very specific and hard to hurt yourself. (I am now a 48 yo, I damage if I am not careful.)

Second, he had me sit on the floor and do leg raises. He had me raise one leg at a time and hold it several inches off the floor for a while (I don’t remember the time, but 15 secs should work. Important – while the leg is raised, tense up your quads big time and tense up those little quads just above and beside the kneecap. Feel for them and get to know them. It is those little guys that keep you kneecap aligned. If you are in riding shape, you can do this with say 5 pounds on your ankles, but the tensing up is much more important than the resistance.

Third, KEEP YOUR KNEES WARM WHEN YOU RIDE!! For me, this is critical. I wear these dumb looking “knee warmers” for most of my rides, always below 70 degrees, often under tights. Since keeping the hamstrings loose is important, I had to stretch the elastic. To keep them from falling down, I sewed on garters that I clip onto my shorts.

Fourth, back off riding until you have been doing these two things long enough to make a difference. Keep up the exercises and especially the stretches after you resume riding. Build up your riding slowly. The doctor stressed this to me and it has been very true. My ability to come into real form and resilience on the bike is limited more by my knees than by my lungs/muscles.

After rides, take aspirin or Ibuprofen to speed recovery. I personally think aspirin is better, that my knees recover more with it. I disagree with the ice. I have always felt that moving my knees when they are cold is causing the damage I am trying to avoid. Perhaps ice speeds recovery, but I feel it also continues the damage (at least in my knees).

Big gears are the enemy of CP knees. I love to climb hills standing. I love to ride hilly country on fix-gears. It is a fact of my life that I can only ride certain not-so-steep hills on my commuter and that I have to have and use a granny ring on my custom. It is a fact that there are days, weeks and months when I have to let whippersnappers blow by me on hills where I know I can humble them.

Lastly, what you did not want to hear, but again what the doctor told me. Get used to the idea of CP. If you are at all like me, it will be a fact of your cycling life for a long time. 23 years later for me and I am feeling my knees now because of a very easy ride I did in street clothes without knee warmers at noon today.

Sorry to be the bearer of bad news, but you can still do a lot of riding. I raced that season (I already knew it was my last) and have done 60,000 (?) miles since. I still commute, but only on alternate days. (But for the first 7 years with CP, I did not own a car and rode everywhere.)

I took the time to spell all this out because in the 23 years I have had CP, I have never seen all of this in one place. In fact, I have only heard about the importance of keeping the knees warm from that one doctor. That is the single most important aspect of the program for me. Thank you Dr. Kish, wherever you are. I will probably ultimately need those carbon fiber knees, but by following the regime, I figure I can wait until a) the product improves, b) the price comes down and c) I’m old enough that my cycling level will be within the abilities of those knees. I hope to delay another 10 years.

Since I wrote this a year plus ago, my physician has recommended that I take glucosamine. He was very specific, that I should take 3000 mg/day in the form of glucosamine sulfate or glucosamine hydroxide, but to avoid chrondroitin. This I did faithfully for 9 months. Between riding steadily starting two years ago and the glucosamine, my knees never felt better than they did last summer. I was passing whippersnappers uphill. Then my riding tapered off, I tapered down on the glucosamine and got sick so my riding and conditioning dropped. Thanksgiving I rode 50 miles with 2500’ of climbing on a cool day. My knees hurt. How many of those rules outlined above did I break?

Ben

79pmooney

+1 I bought knee warmers patterned after old-fashioned basketball knee pads may years ago. Went for my first ride, had to pull the straps hard to make my hamstrings and knees happy and they promptly fell down. Made "garter straps" with clips that I clipped into my shorts. They worked well. Now i use a better version, two layers of 300 weight Polar fleece, two lose elastics behind my knee and a velcro strap that runs through D-rings I sew into all my shorts and cycling briefs. (Until it hit 80F, I always wear them. Often with regular kneewarmers over them)

Ben

OBoile

I had this for a few years after I hurt my knee playing basketball and then not letting it heal properly. The thing that ultimately solved it for me was peterson step-ups.
The (now debunked) idea was that they would work your VMO specifically, but really, any leg extension exercise does this (you can't really work individual parts of your quads). The video posted is still following this faulty logic.

I think what they actually did was give me more stability in my hip which helped my knee to track properly. So it was a stability/tracking issue, it's just not the VMO that actually causes the issue. When I first started them, my (bad) knee was extremely wobbly and I couldn't complete more than one or two without losing my balance while my good leg was quite stable. Eventually, I got better and my knee got better at the same time. Now both knees are fine and have been for the last ~8 years. I still play basketball once or twice a week.

ridethetown

@79pmooney: Thanks for sharing your experience, it's good to hear stories of recovery and perseverance. I know from my history that it's about managing it and knowing how the body will respond. This is the first I've heard the virtues of warm knees and it's strange I've never had problems with cold before. Still seems like sound logic to me. Fortunately (because I hate covering my legs) we're coming into 80 degree weather now.
@Carbonfiberboy, @OBoile: Thanks, this is good validation of things I've learned from running. Though admittedly, the whole VMO link to PFPS has always confounded me because I've thought running and cycling to work both the VM and VL roughly equally. My understanding is that drilling the VMO was borne from the intention to get the knee to track more medially, however the underlying cause of PFPS is not really problems with the kneecap, but with the femur rotating medially under the kneecap. I've always done VMO work along with intensive focus on hip strength and rotation so keep wondering if the VM drills themselves are making a bit of difference. That said, I'll keep doing it because the combination has worked in the past.

In general, it's good to hear the message being more, "back off" rather than "stop riding." It's been three days now since my flare up started and the pain is much more intermittent than it was on Monday. I think I'll keep off the hills and try to get some easy miles in the small ring this weekend and see how it responds. Hopefully responding early enough will serve as a relatively harmless reminder of the need for maintaining strength and stability. I'm signed up for the Death Ride in July so think I'll back of my expectation to clear five passes. I see already I just got started too late.

Carbonfiberboy 

The old adage is "Pain in front of knee, raise saddle. Pain in back of knee, lower saddle." So the problem could have started because your saddle has been too low all along. Makes sense when one realizes that the greater the knee bend, the greater the down force on the kneecap. Thus spinning on the climbs or climbing standing are also good for the knees. One can also reduce force on the kneecap by smooth pedaling rather than hammering the downstroke.

ridethetown

Yes, I had my bike fit a few weeks back, realizing I had my saddle 1.5" too low! Years ago I'd had posterior knee pain, lowered my saddle then just got used to it. Then I stopped riding for a couple years, jumped back on without making any adjustments. Last weekend I hopped on my MTB, realizing of course my saddle was too low - like way too low. I raised it but still think I need to go further. That was the day after a pretty tough and hilly 40 on my gravel bike, so all the ingredients were there for a problem.

Carbonfiberboy 

Well that's sure good news for you. No future problems once that pain goes away, IMO. Just 1 cm low can cause problems.

ridethetown

So I'm back for my one-week update:

I've been testing my hypothesis that above all else, the hips are key to addressing my PFPS problems and so far the results have been excellent. My program has been very simple (so I can religiously keep it) - two or three times a day I will do side leg lifts, clams, mule kicks, and fire hydrants. I'll roll for about 15 minutes a few times a day. This is in addition to my usual light core work and yoga (power or barre) once or twice a week. I've mixed in some simple VMO work, but it has not been my primary focus, as I really think my VMO development is fine due to the barre yoga.

After three days completely off, I've been able to pick up more or less where I left off and ride pain-free. I've been able to do a hilly 20+ on the MTB and up to about 30 miles on road with no issues provided I keep up on the program. There's no doubt the bike fit has been crucial also, and probably even the leading factor in recovery so far. Needless to say, I've been surprised with how quickly I've responded to the exercises.