Knee cap pain

[silentC]

I came back from a short ride this morning with a very sore right knee, just behind the knee cap. It has been giving me trouble for a couple of weeks now, but only when I stand up from a squat. It is a sharp pain right behind the knee cap. It hasn't been giving me any trouble on the bike at all. This morning I felt a bit of a twinge when I was going up a slight incline. I was almost going to abandon the ride but the rest of the guys came along just then, so I stupidly joined them. I rode half way with them and then turned back, which I always do because I need to get to work. I only rode about 35km/700m at a moderate 26kph average pace. Anyway it was pretty much OK until about the last 5km and then it started to get really sore. So I've obviously buggered it.

The first thing people want to suggest is bike fit. Saddle too low. I'm pretty sure it is not. I worked out a saddle height with a bike fit guy a couple of years ago and have stuck to that. I have done about 7,000km on this bike with that saddle height and this is the first time I've had any knee pain. So I'm really not sure if I injured it off the bike and it's not getting better, or if I have gradually injured it on the bike and it has decided now is the time to flare up. If I did it off the bike, I really have no idea what caused it. Probably old age I suppose. A few weeks ago I was painting skirting, so a lot of kneeling/squatting. My knees don't like it, so maybe it was that.

I'm supposed to be riding tomorrow, just another short one about 50km/500m. I'm wondering if I should stay off the bike for a while. I didn't think that riding moderately would agitate an injury like that but I guess it is telling me something. One of the guys suggested dropping the seat but that seemed counter-intuitive to me. But saddle height is the only thing I can think of?

[rodneycc]

Yeah I reckon its the kneeling/squatting that has done it. I'm forever buggering my body up doing stuff around the house. I'd take it easy for the next week on the bike and if it starts to hurt - stop! Its not worth doing more damage. Your best friend might be Voltaren Emulgel. I live on the stuff nowdays with a dab here and there. Otherwise RICE - (Rest, Ice, Compression, Elevation).

[Calvin27]

I had similar symptoms. Have full strength in the knee but a bit of pain during loaded movement, no pain at all when cycling except during high loads. I rested and it would come and go. After 3 months of rest and stuffing around with every physio, ultrasound, medical practitioner and their dog, I bit the bullet and got an ultrasound. Best money I ever spent. Diagnosed the issue straight away no uncertainty (the ultrasounds are hilariously unreliable).

So turns out it was a bakers cyst. The surgeon said it was probably due to a really minor tear or equivalent during a stressful event (I can still remember that monster ride to be honest!). These things lead to the bakers cysts which are annoying but got he all clear to keep at it and consider surgical removal if it was too irritagting. The issue was considered non structural so as long as i could bear the discomfort my knee was still good. I opted to drain the fluid and a course of cortisone did the job. It rearely flares now and only if I overcook it but I don't mind because it is an indicator if I am pushing myself too hard.

Anyway the short advice, rest, and if it hangs around get an MRI.

[danny the boy]

Ive had the same symptoms, spent 3 months seeing a physio who just drained my extra's cover by rubbing my ITB and achieved nothing. I then had another bike fit which found my KOPS was way too far forward but since the pain was only on one knee I'm skeptical this had anything to do with it but I paid him for advice so I'll stick with it. The fitter also picked up a slight technique issue that I was dragging that leg through the top of the stroke rather than pushing down, which when I think about maybe correct. I only get the sharp pain when really trying to put effort in on that side whilst seated, which occurs more on the dirt than road. So i've spent a fair bit of money and TBH dont think anything is any better so next year when my health cover resets think I'll be taking Calvin's advice.

[silentC]

Yeah have got ice on it now and since I have a desk job, rest is easy.

I think the KOPS position is OK, I checked it last year. If it's pedalling that's causing it, it's probably my technique. I have a tendency to lift my heels.

Guess I'll just see how it goes. Hopefully it's just a strain injury from the painting that I have stirred up and it's not related to cycling per se.

[Calvin27]

Yeah have got ice on it now and since I have a desk job, rest is easy.

Desk job is the worst for it. Hams get real tight and causes all sorts of stuff. I have a few serious cyclists at work and they even go so far as to rotate the mouse use between left and right hand frequently.

For myself, I forgot to mention tat the orthopeadic surgeon mentioned that muscle imbalance is usually the first inital cause of these problems the wear and damage only happens long after the imbalance has occurred. So Now the problem is a lot more mild and managable through a lot of stretching and maintenance. Google pialtes/yoga for cyclists. It has helped me ride more and stay inury free.

Ive had the same symptoms, spent 3 months seeing a physio who just drained my extra's cover by rubbing my ITB and achieved nothing. /quote]

Haha I was down $400 worthh of physio, 3 ultrasounds, $500 in othropeadic surgeon consultations, $120 of cortisone and $300 bike fit (although this was somewhat useful anyway). The MRi, at $600 (per knee) was cheap in comparison.

[NASHIE]

I had similar pain every time i climbed stairs, stood from a squat etc and in the end got diagnosed with a torn meniscus from MRI scan approx 18 ago. Actually the results page was full of other wear and tear to the joint but i think thats all being the wrong side of 40. Decided not to have surgery and just made sure i didn't do anything that caused pain, that mainly being squatting and climbing ladders. Kept riding but no out the seat hill stuff, just made sure i was spinning with no pain. Long story-short 18 months on and the knee is the best its felt in 20yrs. Back in the hills, sprinting etc but do limit squatting and other twisting motions. The main one being the twisting movement you make on your right knee getting into the drivers seat. Hard to explain but try to step, heal and toe around rather than twist on your soul i.e. try to limit strain in the joint.

[silentC]

Desk job is the worst for it

Generally true but at least it means keeping the weight off my knee doesn't require much variation of the daily activity...

[enduro2]

How did you end up with your knee injury?

I had similar pain some years back which ended up as what's linked below.

http://www.healthline.com/health/chondr ... #Overview1

Hope it got fixed up for you. For me, I just needed a lot of stretching the right muscles. I was already very flexible but my muscles were not balanced causing unbalanced.

[silentC]

I just got back from the physio as it happens.

In my case, it seems to stem from a broken ankle that I sustained 20 years ago. Basically my right hip is weaker than the left and so everything else is compensating for it, which has brought on the knee pain and some other niggling back issues on my right side. He thinks it flared up the way it did after all the painting etc because I don't squat/kneel properly (as a result of above).

There is no evidence of cartilage or tendon damage thankfully. He seems to think some strengthening exercises will fix it. So I'll see how that goes.

I might go for a gentle roll tomorrow morning with the men's shed (what we call the easy Wednesday ride).

[Leaf T]

It may have been said already but stretching especially the ITB is an easy place to start. Hold it for a good 30 seconds and repeat as often as you can. Definitely helps for me. Physio told me it's tight muscles pulling the knee cap off it's ideal tracking. She said it can also be due to lower back tightness. It's all connected and relies on each other to work properly apparently.

[vander]

I know this is old but there is some misinformation happening in the thread and, as a physio, I cant watch it.

Firstly SilentC hope the knee is going ok. Any more recent updates?

If it is pain behind the knee cap and by the sounds of it (always hard to say without properly assessing you) it sounds like what we call patellofemoral pain syndrome. This is an overuse injury and is no real long term damage but can be tricky to get in control. You need relative rest from the painful activities (or modify these activities preferentially) while you work on the things that may contribute to it. The rest may be enough for some people.

Ok I am going to address some things in no particular order.

You cant stretch the ITB it has been studied a fair few times it is connective tissue and doesnt stretch. You can stretch muscles that attach to it (TFL and gluts for example). There is a theory that you can break up some possible adhesions it can develop with your lateral quad by rolling it. I am not sure I believe this or are you just rolling your lateral quad?

Tight muscles pulling the kneecap off to the side has been 90% proven to be wrong. Instead what happens is because of the rotation of your femur (thigh bone) your kneecap moves relative to that so it more came from the hip than the thigh. However there is research to show strengthening the quads (generally not one more than the other) can help with the pain. The knee is often the victim joint of things happening above and below (the knee has a single plane of movement as opposed to the ankle and hip)

With respect to the ankle, plenty of evidence if you lack appropriate amounts of dorsiflexion (how much your toes come towards your head at the ankle) then this can contribute to knee pain (possibly something to work on). Also these injuries can create 'muscle imbalances' or just make one side generally weaker than the other so if overloaded more prone to injury.

"Chondromalacia" is very much a 1980-1990s term and is very much out of fashion at the moment. Its definition of cartilage damage, arthritis etc actually isnt found in many knees (seems to be more of an irritation rather than lots of damage) and it makes people think it cannot be fixed easily where it often can. I have seen people with extreme damage to the area who have got better quite quickly with a few simple exercises and some biomechanical changes. Structural stuff often does not = pain plenty of pain free people which on scans look terrible and people in pain whos scans look clear. Pain is more complicated than that.

Nashie with your MRI scan showing meniscal tears etc. Yes certainly happens as people start to age. Think of it as wrinkles. It just happens and is often pain free. It may have been related to your pain or may not hard to tell from what you said but generally as you did changing a few things and a bit of strengthening and the body is back to 100% the body is meant to be moved. There is an interesting study for these non-acute meniscal tears where they did surgery and a mock surgery (little cuts but no actual surgery) they both had the same rehab. The mock surgery was no different to the real surgery at follow up.

Bike set up can change the knee pain even if its in an OK position you can change things to help offload it in the short term to keep you riding. The other part of this is pedaling technique there is a few changes people can often make here. I saw a rider who had knee pain for 2 years had seen a bunch of physios etc his bike fit was ok (one minor change) but changed his pedalling technique and gave him a few simple exercises and monitored his load and he was pain free in about a week. Had one flare up when he did too much but 12months later he has forgotten about it.

For dannytheboy yep ITB is not the answer here at all. Hope your knee is feeling better, unfortunately MRI wont really help either but I will get onto that in a sec. If the physio didnt work its likely you are seeing the wrong one.

Onto MRI, as I mentioned earlier often not the answer. Structure often does not = pain. Especially in the case of a bakers cyst. It is often just an indication that something else is going on in the knee and is just a sac of inflammation. Surgeons often remove it saying that will fix things then it is back in not very long at all. If you MRI things you will often find something there but there is nothing saying that is actually causing the pain (sometimes it is though which is where the confusion comes in) MRIs are expensive and mostly are useful in acute injuries (a fall etc), in chronic injuries they are rarely advised.

For Calvin - Its almost impossible to tear meniscus riding a bit unless you fall off so if you had a tear causing the bakers cyst it wasnt from a long ride. Cortisone in the knee could have done one of many things and is an ok short term fix (although they are going away form it in a lot of cases as it can affect tendon and bone strength) however it isnt a long term fix need to actually do something different to achieve a long term fix.

Rest and MRI advice goes against everything in the medical world at the moment. Complete rest just makes things weaker generally and therefore more likely to have issues. MRI I have touched on a few times but slowly slowly people are getting more against scanning everything (which was the way not long ago).

Lastly dropping the saddle would likely be a bad idea in this case so you were right to go against that. However tough to say without looking at your fit (there is the odd case where it may be needed). As has been mentioned going and seeing the right physio or medical professional is often the answer. Unfortunately like every profession there is better and worse ones out there. If you cant see the way forward with the one you currently have or they dont explain things well enough try someone else. Although sometimes they may not have as quick short term responses because they are looking for long term gains but you can always ask them questions to see what they are trying to do.

Hopefully some of this is informative.

[silentC]

Hey, thanks for the detailed reply.

Currently still working through the problem but it is getting better.

Physio's current thinking is that it is related to a combination of the lack of dorsiflexion in the right foot and some weakness in the hip (which is possibly caused by the ankle issue). Using that gauge against the wall I only had 4cm on the right foot, much more on the left. Have been working on that and I can get it out to 5cm fairly easily now.

What happens is that because of the lack of dorsiflexion, I turn my right foot outwards duck style to get more movement, which causes the ankle to roll and the knee to track inwards. All the bending and squatting I was doing while painting etc has caused a strain injury because basically my knee and ankle are not working properly together.

So I am concentrating on keeping the foot straight and getting the knee to track over the instep. It's OK on the bike, because everything is more or less locked in position, I just need to keep an eye on my knee tracking and make sure it is relatively straight and not moving side to side.

At the moment, I'm not getting much pain but I have only been doing shorter rides. I feel a bit of pressure behind the kneecap and sometimes a burning sensation off to the side, but this goes away once it warms up. After riding it is a bit sore in the area just above the kneecap.

Otherwise, physio seems to think that some hip strengthening exercises combined with a bit of lengthening work on the hip and ankle should get it all working OK. I just have to remember to do it...