patellofemoral syndrome pain

[Onix]

Hello all,

So, I have been battling feet/knee problems for the past several years. I just went to an ortho and was given the "patellofemoral syndrome" diagnosis. (Commonly called runner's knee). Basically, my knee tracks incorrectly (tendency to roll out), causing irritation, pain upon bending, straightening, stairs, etc. Popping, hyperextension, cracking etc. (Lucky me!)


I have been in physical therapy for 1.5 months. Am will continue with it. I was told I can still ride my bike (hallelujia!), but not as long, and not when it is painful.

In the past, I only had walking pain, not biking pain. But, now I am having some biking pain/swelling/irritation.

I ice, heat, take ibuprofen, take it easy, wear a brace etc.

But, anyone have this experience with patellofemoral pain/cycling? Any cycling specific things you found to be helpful? Any additional cycling stretches I can do to help with cycling pain? Any thoughts at all?

Thanks as always to each of yoU!

[Pedal Wench]

Same thing here. I'm an ultra-cyclist -- my pain starts after about 150-200 miles... It got really bad towards the end of a 400K and I had to quit, but I'm back to back-to-back centuries and I just did a 216-mile ride, with minimal pain - I iced like crazy the day after.

What is your PT doing?

I'm doing IT band stuff with the foam roller, but I think the most important thing was an analysis of my pedal stroke. He discovered that I tended to swing out my knee slightly at the top of my stroke, and probably was really bad as I got further into the long-distance rides. So, I'm working on keeping my knees close to the top tube.

Any tips and exercises that you're doing that seem to help?

[OakLeaf]

Make sure your crankarms aren't too long for you and that your cleats are perfectly aligned (even if they have tons of float). Has your PT analyzed your pedal stroke, and/or has your fitter measured your knees' flexion at the top of your stroke? What about your walking/running gait?

Years and years ago when I still had 170 mm cranks, stretching before a ride would normally keep my PFD from flaring up. I'd just kneel barefoot, *ss on my heels, for 2-3 minutes.

If your PT isn't working with your feet, if I were you I'd at least raise the subject - foot strengthening exercises, orthotics, something as simple as a pad under the first metatarsals if you have Morton's foot (which depending on whom you ask might be pretty common)?

[Cataboo]

I have patellofemoral pain in my right knee... I did physical therapy for it for a couple months in 2001? I haven't kept up my exercises like I should, so certain things do flare my knee up.... skiing, going down hill hiking, etc.

For the most part cycling doesn't flare up my patellofemoral knee, provided that I have my seat at the right height, I use 165mm cranks, and I use speedplay frog cleats.

Has your physical therapist taught you how to tape your knee cap in place and counterbalance your improper tracking? That worked really well for me when I was having constant patellofemoral pain.

[Becky]

I have it in my left knee. It originally started as an overuse injury from cycling. It seems like a tight IT Band goes hand in hand with my PFS. Stretching makes a big difference. The Stretch Book by Jim and Phil Wharton has some great ideas about active isolated stretching and targeted stretches for different conditions and sports. I've recently started using one of those foam rollers and attribute my recent knee pain-free century to regular massage with the roller. Previously, a ride half that length would have had my knee flaring.

I've also had good results with varus wedges in my shoes. They seemed to prevent my knees from rolling inwards towards the top tube when I pedal and, as an added bonus, I clench my toes less.

Of course, ice and Vitamin I help too!

Good luck figuring this out. The scientist in me would try one thing at a time, and see what makes the difference for you.

[KnottedYet]

I have been battling feet/knee problems for the past several years. I just went to an ortho and was given the "patellofemoral syndrome" diagnosis. (Commonly called runner's knee). Basically, my knee tracks incorrectly (tendency to roll out), causing irritation, pain upon bending, straightening, stairs, etc. Popping, hyperextension, cracking etc. (Lucky me!)

Girl hips. Medial wedging, massive core strengthening, pelvic posture correction, and teaching yourself NOT to lock your knees are big juicy goodies for dealing with this particular problem.

Iliotibial bands get tight for a reason. Often in women they are trying to control rotation of the femur. Eliminate the reason, and you'll help eliminate the imbalance that caused the problem.

I worked with an ATC who called it "Dumb-Butt Syndrome." The external rotators of the hip (under the butt cheeks) go on vacation in a lot of women, allowing all kinds of trouble to occur. Since the knee is just a hinge, it often squeals when forced to deal with the rotation force sent down the femur by a woman's "dumb butt".

Stand in front of a mirror, in your normal posture. Next unlock your knees and squeeze your butt cheeks HARD. If you see your kneecaps roll away from each other and you suddenly look/feel a little bowlegged in comparison, then there is a good chance you need to do some core and hip work. Ask your PT for some guidance on this.

(BTW, knee caps will look like they have a tendency to roll out when actually the tibia and femur are rolling IN underneath them)

[Onix]

Thank you all for your feedback!

OKay...lets see if I can answer all of the comments questions...

1. Feet: I have seen a podiatrist. They diagnosed me with nerve neuromas in the ball of my feet. And, gave me shots in my feet to try to calm them. This has worked about 80%. (thank goodness!) Feet are largely addressed. Occasionally though, I get numbness/pain in the ball of my feet (like I used to when I was walking) when I am peddling. Despite the fact that I really try to focus on not only the pedal push down, but the stroke up/having heel down---this continues to be a problem sometimes

2. As for perfectly aligned pedals/cleats...do you have any advice on this? I use light action speed plays. (My first, and only cleats/clip pedals). They are free floating. However, sometimes I wish the position could move further back on my foot (they're as far back as they go)...but...I'm not really sure where they are supposed to be. It seems to all be guess work? Any positions you have found particularly helpful for knee pain?

3. Cranks: How do you know what the right length is for you??

4. My PT has never seen me on a bike. How did you guys find PTs that know a lot about cycling? I have been fit on my bike. So, presumably, the seat height is good. The fitter also noticed that I rolled my knee out a bit with my stroke, which I have been trying to correct. He also noticed that I rock my hips a lot when I ride, despite having the right saddle height. Go figure.

5. I do need to learn taping. The J brace I have is good, but it is cumbersome, and makes it difficult to keep my knee bent for any length of time (thus making wearing it anywhere when I won't be constantly walking pretty much impossible).

6. As far as running gait---I don't even have a running gait at this point. I can't run. I can't even walk right. I'm trying to re-learn how to do that. I have done so many adjustments subtly to try to ease pain, that I have majorly screwed myself up.

7. I need to learn to not lock my knees. I am trying. It is hard.

8. Things I'm doing with my PT: muscle strengthening exercises for the muscles above the knee/inside the knee. Apparently, these are not muscles you develop with cycling. (And, since I haven't been able to walk more than about 15 minutes without intense pain, and I definitely can't run anymore---I was way lopsided. So, lots of half-leg lifts, balance exercises, stability exercises, etc. I can be more detailed about these muscle exercises if desired.


Thank you all again, as always for your feedback! (and taking time to read my lengthy, rambly posts!

[lo123]

2. As for perfectly aligned pedals/cleats...do you have any advice on this? I use light action speed plays. (My first, and only cleats/clip pedals). They are free floating. However, sometimes I wish the position could move further back on my foot (they're as far back as they go)...but...I'm not really sure where they are supposed to be. It seems to all be guess work? Any positions you have found particularly helpful for knee pain?

My LBS does a separate cleat fitting session for $50. It made a HUGE difference in my hip/knee/ITB issues.

He also noticed that I rock my hips a lot when I ride, despite having the right saddle height. Go figure.

Same here--though it's only my bad hip. My fitter suggested getting on the trainer and focusing on a smooth full stroke to counteract my natural tendency to mash. I've tried to think about this on some road rides, but I can't concentrate on smooth strokes and the road at the same time without being a road hazard .

[Onix]

Good to know. I will check into the cleat fitting.

And, I think it is a good idea for me to get on the trainer more at home to monitor my stroke.

Thank you all for the good advice.

Lacy

[OakLeaf]

Crankarm length for me was just, 22 years ago I read somewhere that I should have 165s, so when I built up my race bike, that's what I put on. The difference from the 170s on my touring bike was obvious right away, and I never had another cycling-related knee flareup.

It has as much to do with your tibia/femur ratio (which can't be measured very accurately without an X-ray) as it does with the length of your whole leg, but a good fitter should check the angle of your knee at the top and the bottom of your pedal stroke. Set the seat height based on the angle at the bottom, then choose cranks short enough that your knees aren't excessively flexed at the top.

An added bonus is that it's much easier to spin smoothly with shorter cranks.

My knees feel it right away when my cleats are off by even a little bit, so that's one thing I don't need a fitter for. I wonder, if you feel your cleats are too far forward though, if the problem isn't actually that your seat is too far forward? Unless you have VERY long toes (and mine are pretty darn long), there should be enough adjustment to let you get the cleat under the ball of your foot. But maybe your knee is actually forward of the pedal spindle (which would also cause excessive flexion), and that's what you're feeling?

[Wahine]

There are a ton of issues here. First I have to say +1 to everything in Knottedyet's post.

1. Feet: I have seen a podiatrist. They diagnosed me with nerve neuromas in the ball of my feet. And, gave me shots in my feet to try to calm them. This has worked about 80%. (thank goodness!) Feet are largely addressed. Occasionally though, I get numbness/pain in the ball of my feet (like I used to when I was walking) when I am peddling. Despite the fact that I really try to focus on not only the pedal push down, but the stroke up/having heel down---this continues to be a problem sometimes

Are you using orthotics when you ride? Chances are you need them if you have these types of foot issues. You may not need a custom orthotic but Specialized makes and orthotic with a forefoot wedge and a metatarsal button that might work.

2. As for perfectly aligned pedals/cleats...do you have any advice on this? I use light action speed plays. (My first, and only cleats/clip pedals). They are free floating. However, sometimes I wish the position could move further back on my foot (they're as far back as they go)...but...I'm not really sure where they are supposed to be. It seems to all be guess work? Any positions you have found particularly helpful for knee pain?

I know that a lot of people out there swear by speedplays but I have to say that in your case they are probably contributing to your problem. If not your knee pain then they can make your foot pain worse. I often recommend a Look or Time style pedal to people with forefoot neuroma/pain and yes, you want the cleats positioned farther back on the shoe. Ideally the knuckle that joins your baby toe to your foot should be in line with your pedal axle when you are clipped in.

4. My PT has never seen me on a bike. How did you guys find PTs that know a lot about cycling? I have been fit on my bike. So, presumably, the seat height is good. The fitter also noticed that I rolled my knee out a bit with my stroke, which I have been trying to correct. He also noticed that I rock my hips a lot when I ride, despite having the right saddle height. Go figure.

You may be able to find a PT that does bike fitting. I do and so does Knott. But we're in the PNW... I have no idea where you are. I would ask around at PT clinics for a PT that does fitting, ask at the bike shops and any local teams you might know of.

8. Things I'm doing with my PT: muscle strengthening exercises for the muscles above the knee/inside the knee. Apparently, these are not muscles you develop with cycling. (And, since I haven't been able to walk more than about 15 minutes without intense pain, and I definitely can't run anymore---I was way lopsided. So, lots of half-leg lifts, balance exercises, stability exercises, etc. I can be more detailed about these muscle exercises if desired.

This all sounds pretty good except the bit about not working your muscle on the inside of the knee while riding. If you are riding well (good pedal stroke and painfree) it's actually a very good exercise to develop this muscle. If your pedaling is compromised by form issues, muscle imbalances or pain then it's not so good, but it's not bad either.

I always recommend a lot of hip stretches, foam roller work and stability exercises for the core and hips with these problems. You might want to ask your PT about these things if they are not already being addressed.


Hope that helps.

[Onix]

I know that a lot of people out there swear by speedplays but I have to say that in your case they are probably contributing to your problem. If not your knee pain then they can make your foot pain worse. I often recommend a Look or Time style pedal to people with forefoot neuroma/pain and yes, you want the cleats positioned farther back on the shoe. Ideally the knuckle that joins your baby toe to your foot should be in line with your pedal axle when you are clipped in.

Wahine,
Why do you say that speedplays might be contributing to the foot/knee pain? Because they float??

[Wahine]

Not because they float but because they might be irritating your metatarsal area. If your foot isn't happy you will change your pedal stroke to compensate and that might put more pressure on your knee. Speedplays seem to irritate the metatarsal area more than other pedals with a larger base to push off of, like Time and Look pedals. Having said that, more float is not always better. Some people actually do better with less float as long as the cleat position is properly aligned.