kvs

I am a male in my mid 30s and have been experiencing knee pain in one knee when cycling for the past 8 months. I ride a gravel bike with SPD cleats, which is relatively new but did have it for a few months without any issues. After about 15-20 km I start to feel pain usually below or on the inside of the kneecap. Two separate physiotherapists and one sports doctor have all said it is patellofemoral syndrome caused by tight quads, weak glutes, muscle knots, etc. I was sent for knee x-rays, which were completely normal. I have been doing all of the prescribed strengthening exercises as well as foam rolling/stretching the quads and IT band for over half a year. Additionally, I had a professional bike fit which made the bike more comfortable but didn’t seem to help the knee pain. I have since been making my own adjustments to cleat positioning (moving cleats back).

After all of this, I have had almost no improvement and am getting increasingly frustrated since I feel like I’m running out of things to try.

One thing to note is that the pain usually goes away when riding out of the saddle up hill, which seems counter intuitive since more force is going through the legs.

Has anyone else experienced frustrating knee pain such as this? What would the next step be? Knee brace? A more expensive bike fit? Different bike?

Thanks in advance!

hcgaloi

I had exact same issue as yours and went through similar fixes. Anyway, I switched to Speedplay X-series pedals and used pedal extenders. Speedplay provides more free float than SPD, and the extenders gives more q-factor. They solved my knees pain problems.

Good lucks

MAK

I AM NOT A DOCTOR but when I had a similar problem, it was solved when I bought Specialized shoes. They have Body Geometry insoles that support forefoot varus (found in 87% of adults and not a problem, but simply how your foot tilts dangling at rest). I'm sure you can just try Specialized Body Geometry inserts to replace your current inserts. A second possible problem might be the saddle height, but the professional bike fitting should have remedied this. Information is from Andy Pruitt's Complete Medical Guide for Cyclists and my personal experience. Andy Pruitt just retired (I think), but he is very well respected with professionals from around the world traveling to him for fittings and consultations at his Boulder Center for Sports Medicine.

Good luck.

smashndash

Have you tried cleat wedges? Cheap and easy to test. One symptom of needing wedges is your knees brushing the top tube or having pain on the lateral (outside) side of your feet.

Prowler 

I had the same issue and, for me it was a weak VMO - vastus medialis oblique, or something like that. A pear shaped quad on the inner side of your thigh. Being weaker than other quads it allowed the knee cap to be pulled off center = pain. Patella tracking error. Simple but persistent exercises and changing how I climb stairs has "gone'd it away". Maybe read up on that via numerous websites.

I also ensured that that my saddle height was correct. I don't use clipless pedals. Outmoded toe clips and straps so my feet can move. I make sure my feet point straight ahead, not heels in.

jlockwood98

For gravel, you'd need to look at the Speedplay Frog or SYZR. I use the Frog for gravel and mountain bikes and it has unlimited, full float. That works for some knee issues, but not for others. With regard to Q-factor, I was able to get custom spindles on my Speedplay Zeros on my road bike, but was told they don't offer them for the Frog. Not sure about custom spindles for the SYZR, but they are supposed to have a good range of adjustable float.

motorthings

1. retul fit - find a good local fitter using Retul, with great references
2. stop rolling the IT bands - there is a lot of good info out there about what foam rolling the IT bands does, and how it often makes the problem worse (typically tight glutes are the issue, so roll those instead)
3. find a good rolfer - they can do amazing things to structurally realign your body and help address issues the fitter and you may find. i get rolfed every 2 weeks (prior to pandemic) and it is what keeps me going

that's what worked for me, good luck.

Fredo_Adagio

My knees are very particular about my cleat positioning. With SPD cleats, I have to have the nose of the cleat pointing slightly inboard. If the cleats point straight forward, my heels will be too far outboard and my knees will begin to feel sore.

I have also had knee problems when running. I have to have shoes with wide soles at the heel for good stability. I also need to do deep knee bends every morning. Strengthening the muscles around the knee joints is very important.

bluehills3149

During almost my entire 40's (9 whole years) I had chronic patella femoral syndrome. I saw over a dozen physios, surgeons and anyone else who promised relief. Sometimes I could ride 5 miles or so, other times 1 or 2 and it would flare up, reducing me to enough pain that I'd be limping for weeks. I got rid of all my bikes save my beater which I used gingerly to get around on short trips in my neighborhood but I was reluctantly coming to the conclusion that my cycling days were over.
But I saw one more physio who convinced me to stick with exercises for longer so I did no cycling (or long walks) for 3 months and twice daily did VMO building exercises and foam rolling and after that I slowing started riding again until 6months later I could ride again any distance and 3 years later I'm thinking of racing again.
However, this was my experience and reading the others here shows there are many ways that knees screw up but my advice is don't expect a quick solution and a professional is really the best person to listen to.
Also, try and find a physio who specializes in knees or athletes like runners and cyclists. Running and cycling clubs sometimes have a list of local physios or look at research papers on knee injuries and google the authors' names to see if they are local.

Paul Barnard

Would trying platform pedals for a few rides be useful?

noimagination

Good point (and also smashndash post immediately below MAK's post). Have you tried consulting a podiatrist? A good one can often help provide another perspective that might lead to a solution.

Sorry for your difficulty, I was lucky and my knee pain was resolved fairly quickly and easily by lowering my saddle and by working with a PT on increasing hamstring and calf flexibility and strength with exercises and stretching. My foot issues were separate, solved by an aftermarket OTC footbed for my shoes. I hope you find a solution.

JayKay3000

Just going to jump in with my own experience because I used to have a similar problem. I've never had a diagnosis of what mine is, but I know my bike is fit properly and is the right size. But sometimes the knees don't play ball.

If I get knee pain now which isn't all the time I can normally cure it by one or more of the following. Some of these may be placebo effects though so I'm no doctor and don't take my word for it.

> Making sure I'm properly hydrated. Sometimes the pain will go away by drinking more water.

> Easing into a ride, such as not using too hard of a gear too soon.

> Standing up / riding out of the pedals some of the time if there is pain preferably in a slightly harder gear and not too high cadence. Usually the pain will go away after a short amount of time doing this.

> Using flat pedals. This has allowed me to get my feet in a position where I'm comfortable to ride 100+km

> Not over-spinning to too high cadence when seated.

> Making sure my knees are warm as I get more pain if they get cold.

> Being careful how I sit or walk during normal activities.

> Making sure I have enough protein in my diet. (Could be a placebo effect)

> Making sure my foot / ankle goes through the full range of motion to make the muscles at the back of my leg are stretched.

> Do calf muscle exorcises as these will tighten up over time. If you can hardly put your feet on the floor when you squat that's a good sign they're over tight. Loosening them hurts though and can't be fixed over night.

One website suggests you may need to look into orthotic shoe implants, but I would try some other suggestions before jumping straight to this.

pbass

I was having similar knee pain a number of years ago. Conventional PT did nothing for me. I then saw a myofascial release therapist and she literally cured me in 2 visits. Turns out, in my case the problem was coming from "upstream". I had a very tight gluteus medius, which was in turn, pulling everything below it a little off--it was pulling my hip a little out of whack, and then down to my knee. Pain is apparently often originating from somewhere other than where you're feeling it the most. I now foam roll and use these little yoga/massage therapy balls to keept the gluteus medius loose and haven't hand an issue since.

Alan37

I used to have almost the same situation. First of all, I visited my doctor. He advised me some things ( including sports stuff) and also, recommended me to chance shoes I wear when I ride a bike. And don't know what exactly helped me, but now I feel almost no pain. But, it individual things, so it's better to visit a doctor to know for sure what is going on with your knees

Oneder

I used to run and gave it up due to knee pain. They will tell you a bunch of nonsense about strengthening one muscle over the other but the reality is that while this thing works for some grandma it is absolutely irrelevant to runners and weight lifters. You need to have lots of time to recover and ultimately running is just hard on your joints especially if you are a larger person. Cycling is much less bad on the joints but ultimately the same idea applies, you need lots of rest and to have plenty of collagen in the diet and as soon as you feel pain doing something you need to stop. When you feel pain it means you are doing damage, and any damage to your joints or tendons takes a long time to repair. I also use red light therapy for my shoulder after I separated my shoudler and tore every tendon and this helps a lot with the pain and recovery. Whenever I forget to do it or don't have time to do it in the morning I always feel pain again later in the afternoon.

teutoned

Dr. Tim Woo is the answer

https://socalbikept.com/

Barry2 

Hindsight 20/20, my left foot point outwards, if I stand on a tiled floor I can see it.
I went for a bike fit and it was the first thing the gent changed. He twisted the cleat on my left shoe.
Done, Cured, finished! No more knee pain.
I was so happy with the result I returned two weeks later to "thank $" him.
Bike fit was $300 and worth every single penny.

You had a fit, did they miss something?

Barry

Drew Eckhardt 

See a bike fitter.

Your saddle could be too low or positioned incorrectly fore/aft.

My right knee hurt on longer rides when my saddle was too low and aft.

The fitter also set me up with insoles to correct valus/vargus so my knees would run straighter and changed my cleat position.

See one with a good reputation that uses video.

lavalamp

legal thc/cbd oil?
artificial joint fluid injections?
lots of boring physio exercises helps

jay4usc

start using a foam roller and stretching before you ride.

Pop N Wood

Went through something similar. Started out as outer knee pain, than iliotibial band syndrome, than piriformis syndrome, psoras muscles, a whole Gray's anatomy of tight muscles. Tried all sorts of exercises, stretches, yoga, riding, not riding, heat, cold, chiropractors, different bike fits, cleat positions, saddle heights, platforms etc etc etc. Even tried a recumbent

Finally got an xray for an unrelated back injury and they discovered I need a new hip. No cartilage and one oversized bone spur.

I have an appointment with a surgeon in an hour.

Kapusta

Seems to me that trying flats for a few rides could answer some questions.

Try moving your foot around and see how it feels.

But don’t get cheap crappy ones, drop $50 and get something grippy with a large platform like Deity Deftrap, Kona Wha Wha 2 composite, etc.

vane171

This is what I was going to mention when seen this thread.

I think this was the cause of the burning like pain behind my patela on right knee that would develop on 15-20 mile rides. Over-spinning on light load, it also wouldn't bother me if standing uphills. In my case it went away after some months away from biking. Like now winter is coming, I'd take it as off season opportunity, maybe do some other activities that don't flex the knee that much.

It can happen that some irregularity behind the knee patela irritates it to the point it causes that burning pain, which I would guess is due to inflamed tendon or something.

63rickert

The doctor you want is a sports orthopedist. Which basically means they do not perform and are not insured for surgery. The board specialty began with doctors who observed they could get results with physical therapy only and believed surgery was overused. When surgery is required they will refer out very quickly.

Your doctor should inspire confidence immediately. Otherwise you don’t need him in your life. What he prescribes should make sense and give results. If all a doctor is good for is generating billing and stirring up confusion might as well spend the time getting a good massage. Or stay at home and soak in a nice hot bath tub.

Knees are tricky and heal slow. The mechanics of pedaling are not that well understood. My orthopedist is one of the founders of sports orthopedics and he doesn’t understand it that well. Once while visiting him about something else he observed that I always spoke of cycling as a boon and cure-all, while he had a waiting room full of patients who thought of bikes as torture machines. We walked over to where he had the stationary bicycle and he watched me pedal while asking endless good questions. Made an appointment for more pedaling and more questions the next week. Find the guy with that level of interest and there will be answers.

Rule of thumb says pain at front of knee saddle is too forward. Pain behind knee saddle is too back. Does rule of thumb sound right?

The story about no pain while standing is striking. If everything works well while standing we know the problem is nothing to do with feet, pedals, shoes, cleats. Those all remain the same and it works. In fact there is nothing structurally wrong with the knee. When seated something prevents the normal function that happens readily while standing. First guess is when seated you are crowded. Put the saddle back and you can stretch out a bit. Were it the opposite way, saddle too far back, you would simply slide forward to nose of saddle. And that one you would notice early.

My guess is that this is going to be a big adjustment to the seated position. Most likely direction is down and back. But depends on a lot of variables so can’t be sure. Try a big change. Carry tools and switch up a lot. Look for a place where it is all as natural and unavoidable as the posture you have when standing on the pedals. Don’t forget handlebar position.

Fitters are as good as they are. A lot of them would admit your case is at the limit of what they know, or sometimes they know. I would have more confidence in a fitter who asked lots of questions. And who could explain his insights. Some fitters just measure and calculate to a formula. You don’t need that guy.

Most people can ride a bike without pain and without having to think too much about it. Very few have structural problems that preclude cycling. But it is a technical hobby and once you go about it sideways the way back can become complex. Hope you find it.

jay4usc

have tried just using platform pedals? Try it for a month and see if alleviates any of your pain. Doesn’t hurt to try.