serpico7

I've been experiencing pain in my right knee, in the area where the VMO (vastus medialis oblique) connects to the knee. Went to see an orthopedist, and he pointed out that my right VMO is smaller than my left VMO, and when flexed, feels less firm to the touch than the left VMO. So this may be causing a tracking problem, with the vastus lateralis overpowering the VMO. Also, my right quad is less flexible than my left quad. So I'm supposed to perform VMO strengthening exercises and stretch quads/hamstrings.

So with that background info, I want to ask forum members about bike fit. I've got my saddle raised about as far as I can go without rocking my hips (raising to this level seems to have helped). I've also got it set back probably an inch or so behind the KOPS (knee over pedal spindle) position (not sure that this has had much effect either way).

1. Is a rearward saddle helpful for those experiencing this type of pain?

2. Cleat positioning - the only adjustment I've made here was to slide the cleats forward a little bit so that my foot is further back on the pedal, with the balls of my feet over the pedal spindle. But no lateral or rotational adjusment. I'm using Speedplay Frogs, so lots of float. In which direction should I try a lateral adjustment? Cleats inward (which would bring my feet further away from the bike, and, I suppose, reduce the Q angle)? Or cleats outward, bringing my feet closer to the bike (and increasing the Q angle)?

Any other adjustments I should try?

Machka 

I struggle with Patello Femoral Syndrome from time to time, and I've discovered three things ...

1) Doing other leg muscle building exercises is very important. As you've discovered, cycling develops some of the quad muscles but not all of them, and that can throw the tracking off. Therefore, I walk, run, and weightlift in addition to my cycling.

2) If I'm having patello femoral pain, I need to raise my saddle a little bit. You've raised yours, so that's good. You might also read through this article: https://www.cptips.com/knee.htm

3) If I wear tights, I have patello femoral problems. It's not bad when I'm doing short rides, but tights on a long ride are just not a good thing. I have tried several different types of tights and have made sure that the ones I wear are loose over the knee, but none are perfect. I much prefer riding in shorts, but Canadian weather doesn't offer me that opportunity very often. For me to totally eradicate my patello femoral problems, I think I'll have to move to a warmer climate.

watchman

I'm currently in the same boat as you. My PT is focusing on working on the muscle imbalance, my vastus medialus is pretty weak and I tend to produce alot of my power on the upstroke with my hamstrings. I can't do any bike riding at all! 30 seconds of pedaling and my knee is hurting, thankfully I can still run with not so much pain (I have a marathon in 19 days).
The statement about a too low seat makes some sense to me, prior to my knee going out, I had been doing alot of mtn biking and run my seat a bit low (for the downhills).
I'll be interested to hear what treatments work for you

serpico7

Actually, I think studies have shown that cyclists produce very little power on the upstroke, but your focus on the hamstrings may help smooth out your stroke. I also "feel" like I engage my hamstrings a lot.

Are both your VMO muscles weak or just one? As I mentioned, my left VMO is noticeably larger and firmer than my right VMO, so I think I must have had some trauma (years ago) to the VMO or tendon on the right leg that has ******** its development.

Funny how are symptoms are similar but still quite different. I can bike 50+ miles, as long as I keep the cadence high and stand a lot on climbs. But I couldn't run a 1/4 mile without pain.

OCRider2000

I was diagnosed with 2nd and third degree Chrondomalacia back in 1987. Back then my orthopedist wanted to do a lateral release to address "tracking issues" etc, Etc. I passed on this procedure. Stayed off the bike for 2 years then was able to resume cycling pain free. I was doing pretty good up until a year ago when I started having problems again. Up until then I never did any leg stretching as a part of cycling. I was thinking my knees had finally given up on me when I decided to try regular leg stretching . To my joy my pain went away. I can't help but attribute stretching with getting me back on the bike again, pain free. I have a standard stretching routine that includes hamstrings and calfs. It takes me about 15 minutes before and after every single ride. When I started my stretching routine I was doing it like 5 times a day. Now I only do it before and after I ride. I make sure I'm warmed up before stretching. Also I don't ride early in the AM anymore, I make sure my muscles are fully warmed up. As far as position. I had my cleats professionally mounted (RAD) lots of float (Look). I also am way rear of the spindles 3cm + rear. Also, I'm super careful about mileage, intensity and hills. I don't do crazy hills at all any more and I am very very careful about increasing the length and intensity of rides after any time off the bike. Other than when I'm just tooling around I make sure to keep my cadence at 90-95 rpm.

531Aussie

I'm not even sure if there's confusion between chromalacia, PFS, and patella tenonitis, because the pain is in the same area. Many sources say that PFS and chrondomalacia are the same thing, yet some of the symptoms and treatment are sometime different. PFS is is described as a misalignment, partly due to VMO/lateralis imbalance; but chrondomalacia is sometimes described as lazy tracking, due to weak rectus femoris, as I describe below.

I must admit my chrondomalacia experience was very fortunate, and probably not severe, but this is my standard chrondo post from an old thread:


I had some chondromalacia about 15 years ago, and after 2 physiotherapists misdiagnosed it as patella tendonitis, the subsequent rest, stretching and icing for a month did nothing. A 3rd physiotherapist diagnosed chondromalacia, and it was gone in about 4 days after doing straight-legged kicking exercises with light weights.

Only 5 or 10lbs was enough for me.

The way my physiotherapist explained it to me is that during normal quad contraction the rectus femoris pulls the knee cap up and out of the way of the end on the femur, but when fatigue, overuse, or imabalances develop -- or whatever -- the firing order of the quads stuffs up, and the rectus femoris doesn't pull the knee cap up quick enough, therefore causing the grinding on the femur and the subsequent pain.

The straight-leg exercise somewhat islolates the middle quads (rectus femoris and vastus intermedius) and corrects the tone imbalance. The leg doesn't have to be dead straight, just so long as the dominant movement is hip flexion, and not knee extension.

https://www.bikeforums.net/showthread.php?t=172208

'nother

Nothing to add on cleat positioning, etc.; won't hurt to see someone who does bike fitting but honestly I think people put too much stock in that. There are just some people who are going to have knee problems no matter what they try.

Keeping flexible and balanced seems to be helpful. So work on your alternate-muscle strengthening exercises and stretch, a lot. Personally I find just a simple quad stretch provides instant relief but I try to hit the hamstrings and calves, also piriformis as often as I can.

From experience I can also suggest the use of a foam roller. Roll out your IT bands, quads, whatever's tight. It might help, and it won't hurt.

Good luck, knee pain sucks.

orcanova

I had Patella Femural maltracking over a decade ago so my input is rather limited except to ditto what others have said. It is from a strength imbalance in the quads and they put me on a PT schedule using a cybex machine which gave resistance training all the way through leg extentsions and leg curls. I think those two exercizes in a gym should make it go away.

As far as cleat positioning, I since switched to Speedplay X pedals and never looked back. The free float the pedals allow I believe (just my opinion) allow my feet to fall in their natural position (I am a bit duck-footed) and minimize my own biomechanical imperfections. Both my road bikes have a bit of scuffing on my crank arms (particularly the right) where my heel brushes the cranks. I don't think pedals with more fixed and limited float would allow that much leeway that I think I need.

I believe the pedals help me stay more injury free over the long haul (again, just my personal belief). You may want to give them a try...and at least give you a little piece of mind.