Training & Nutrition - patellofemoral syndrome aka runner's knee

Anyone else have this?

A cycling buddy has had this for about a year, and it's totally destroyed his fitness (i.e., he now weighs 340 lbs, no joke).

Now I've got it.

After a hammerfest last month I developed pain, stiffness. Continued for a month, took time off, finally went to Dr., who yesterday diagnosed me with patelletc. syndrome.

He recommended physical therapy. Most websites I've visited recommend, as therapy, light cycling. Uhh...duh...that's how I got came down with it. That and heavy cycling.

Anyhow, I've been doing some hammy, ass, quad and itb stretching, some strengthening exercises, but I'm not sure if it's any good.

Personal testimonies? Cures?

Perhaps it's something fairly simple like cleat alignment. What shoes & cleats are you using ? For how long ? Did you get a cleat fitting or just trial & error ? How's your seat height ? Too high or low ?

It used to be called chondromalacia. It's not a diagnosis, it's a doctor's way of b.s.ing you.
From Wikipedia:
"As noted above, 'chondromalacia' and 'patello femoral syndrome' are not diagnoses, as they do not help explain the source of pain."

I had a bad case once, went to a orthopod who measured my knees and advised me to never run, hike, or cycle again. Instead, I raised my saddle a little, changed my gym workout, and increased my mileage.

So, #1, go to a bike fit professional, not just the guy at your LBS. Someone with training in cycling physiology.

If #1 is impossible, try #2: raise your saddle until, with lower crank aligned with seat tube, your heel on the pedal and knee locked, the heel doesn't quite touch the pedal. Then KOPS: move your saddle fore-and-aft until you have knee over pedal spindle, when the pedals are horizontal. Start with that.

Next, do light cycling. No hills. Zone 1. High cadence - 90 or better. Try really hard to pedal perfect circles. If you don't have a computer with cadence, buy one. They're cheap. If you can't ride outside and stay in zone 1, try rollers or trainer. In fact, what the heck, buy the rollers. You don't want to weigh 340, right? Start with 30 minutes and gradually increase it. Take ibuprofen if you need to. I've taken 600 mg 3 time/day with good result. Don't ride harder unless you are pain free, then increase it very gradually.

Get a gym membership if you don't have one. Start working out. Stay off the treadmill. Never run. Never use the knee curl or knee extension machine. For your legs, only do barbell squats and leg sled. Very light weights. Don't bend your knee more than it bends on the bike. Start with one set of 30 and gradually, over a year's time, work up to 3 sets of 30 of 7-10 multi-joint exercises, done in a circuit, gradually increasing the weight until the 3rd set is quite difficult. This is right out of Friel. But don't go on to lifting heavier weights, at least for 2-3 years.

That worked for me. I still have occasional knee twinges, but probably everyone does. I'm 99.9% knee pain free, can even backpack with 65 lbs. My uneducated opinion is that this syndrome arises from inadequate muscular support for the patella, coupled with knee exercise which causes the patella to rub unfairly on the knee joint, largely because it is not correctly supported.

Apologies for any orthopods on here who know what they are doing.

I would recommend getting the physical therapy evaluation. I had a different knee problem (torn patellar tendon) which would just not heal. I continued biking on it and eventually my 2 quads got very uneven.

Anyway therapy has really helped, mostly I attribute it to the light strengthening exercises. Most of them are various types of leg lifts. It can really provide a lot of relief if you keep up on the strength.

I know some people don't like to go to therapy because it is time consuming, but even just going a couple times and getting the exercises and making sure you do them right is a huge help. Key is consistently performing them.

raise your saddle until, with lower crank aligned with seat tube, your heel on the pedal and knee locked, the heel doesn't quite touch the pedal.

Shoe on or off? I've never heard which is the "official" version. (I always assumed off.)

Shoe on or off? I've never heard which is the "official" version. (I always assumed off.)Shoe on. Some say it should just touch, some say a 4mm gap. I go with "just touch", but PFS sufferers might need the saddle slightly higher, at least until they get better. If you go with "just touch" then it makes a difference whether you wear MTB shoes or not. I do, so my saddle is a bit higher, maybe includes that 4mm gap.

On fit:
I use speedplay pedals for road and crankbrothers for commuting on fixed g. Early on, when i first had pain, I fiddled with seat and cleat alignment--didn't seem to make a difference; probably should get a fitting, homebrew.

Thing is, I haven't heard from anyone who improved after a fitting.

That said, I'm going to follow carbonfiberboy's fit advice, maybe ask my special lady friend for a fit for St. Pat's Day or whatever.

On physical therapy
My insurance won't cover therapy because it's not deemed "medically necessary." I may go once anyhow, just to get an idea.

On self therapy
Thanks for the alignment and therapy advice, carbonfiberboy. Exactly what I was looking for.

2 Follow up ?s:
1) Do you think isotonic exercises are better than isometrics? I've been doing some isometrics, but it feels a little pitiful, you know? Here I am able to squat a reasonable amount (300 lbs) and I'm doing granny flexes, squeezing a ball between my knees and, you know, things I see done in golden years water aerobics classes.

2) Do you stretch?

My knee problem came on after increasing my running mileage. In my case it was a pronation issue and my muscles over compensating. I was alternating days of running and cycling while training for a triathlon. After resting for a few days and running again the problems didn't go away. I googled everthing I could about runners knee and spoke with my doctor. I ended up taking three months off, buying "support shoes" for running and adjusting the cleat position on my biking shoes.

When I started in again I focused completely on form while running and biking and worried about getting my fitness level back later. I do some light warm ups before going full tilt and still pay close attention to fit and form. So far no recurring injury.

Some good advice above. For me rest and attention to form has paid off well.

Hope i can explain this without showing you. A large part of the problem in ITB, chondromalacia and everything else knee related in cycling, running is muscle imbalance. Some are too strong, of too tight. When you continue to use a very tight musce it causes friction somewhere. In the quads the patellar squeezes down on the under lying bursa, and bone causing chondromalacia. Or lots of pain in the knee cap with grinding, etc. Keep the quad stretched. If your tensor fascia lata (TFL)is too tight, which if you hammer on a bike or run long or hard, it IS!! The TFL causes ITB(iliotibial band syndrom) this can cause pain at the outside edge(Lateral) knee, and can pull the knee cap off track ,so more knee cap pain, or vague hip pain. The TFL originates under the top of of your pelvis( just below your belt) If you dig in with your thumb just 1-2 inches under the pelvis straight down from the arm pit or an inch forward(dig in deep) you should give a mild scream of pain. It will be sore . Dig around a little. Push and hold the most painful spot 10 secs, then repeat. Now lay on your side on a bed or couch, bring your top leg up towards your nose, keep that knee straight and force it towards the floor and towrads your head at the same time.. hold 10 secs, repeat 4-5 times. Try not to cry. This is the number 1 problem in serious cyclists. In my opinion.... Dadof7, the chiropractor.

On fit:
I use speedplay pedals for road and crankbrothers for commuting on fixed g. Early on, when i first had pain, I fiddled with seat and cleat alignment--didn't seem to make a difference; probably should get a fitting, homebrew.

Thing is, I haven't heard from anyone who improved after a fitting.

That said, I'm going to follow carbonfiberboy's fit advice, maybe ask my special lady friend for a fit for St. Pat's Day or whatever.

On physical therapy
My insurance won't cover therapy because it's not deemed "medically necessary." I may go once anyhow, just to get an idea.

On self therapy
Thanks for the alignment and therapy advice, carbonfiberboy. Exactly what I was looking for.

2 Follow up ?s:
1) Do you think isotonic exercises are better than isometrics? I've been doing some isometrics, but it feels a little pitiful, you know? Here I am able to squat a reasonable amount (300 lbs) and I'm doing granny flexes, squeezing a ball between my knees and, you know, things I see done in golden years water aerobics classes.

2) Do you stretch?Ahhhh, Eeeek, Arrggghhh, Owwww, no, please, please not a fixed gear! (Rough translation of knee tissue under stress). Actually, f.g. is OK as long as you can maintain a comfortable 90 cadence all the time. Although, s.s. would be better for you. And a geared bike better yet. So if you have hills on your commute, park the f.g. until you're just fine again.

I mean a bike fit from someone like this:
http://www.bikept.com/

I went through the very same issue last fall through this winter. Here is my thread about it. I hope you read it and benefit from it:

http://www.bikeforums.net/showthread.php?t=362664&highlight=

Well, I'm going for at least one session of therapy starting tomorrow, bostonroadee. I hope it's worth it.

The thing that's really aggravating about this is not being to get out just as the weather's getting nice, you know? I want to get out there and just hammer the hills and ride (it's getting really nice here in DC), but I'm sitting on the couch and stretching. Went out yesterday for thirty minutes, 90rpm cadence, 13 mph, and was passed by doods w/ beards on wood-fendered bikes.

They rang their little annoying bells as they dropped me, the *******s.

Well, I'm going for at least one session of therapy starting tomorrow, bostonroadee. I hope it's worth it.

The thing that's really aggravating about this is not being to get out just as the weather's getting nice, you know? I want to get out there and just hammer the hills and ride (it's getting really nice here in DC), but I'm sitting on the couch and stretching. Went out yesterday for thirty minutes, 90rpm cadence, 13 mph, and was passed by doods w/ beards on wood-fendered bikes.

They rang their little annoying bells as they dropped me, the *******s.

I hear you, I hear you, I hear you, Calvini. I spent a while off my bike, or riding really softly. Ever so frustrating. I hope the PT is a good one and gives you good news and good exercises!

If it's any solace, being patient and following the advice of my PT has me feeling better. Progress was constant, but also took a while. However, I was able to be on the bike most of the time.

I had issues with knee pain in Jr. High. Orthodoc told me basically it was insufficient muscle strength around the patella, allowing the patella to move and get irritated underneath (as someone else here alluded to). His recommended was leg lifts (with straight leg) to help strengthen the muscles around the patella). You could also try a patella strap to see if it is helps (thin strap with velcro, wrap around your knee right below the patella). It isolates it from moving around so much. Probably in drug stores, or check at a running store. Common issue for runners.

Rumor has it that the reason cyclists develop this is because we only build up 3 of our 4 quad muscles and that pulls the knee a little bit out of alignment. The cure, I was told, is to exercise that forth quad (vastus medialus(?), the inner one) by doing leg press, squats, or even leg extensions. Leg extensions have helped me.

Check out this article: http://www.cptips.com/knee.htm

Another lesser known cause of patellofemoral syndrome are tights. If your tights are too constricting over the knee, and you ride long distances with those constricting tights, you'll have patellofemoral pain too. My tights need to be a bit on the baggy side.

Well, I'm going for at least one session of therapy starting tomorrow, bostonroadee. I hope it's worth it.

The thing that's really aggravating about this is not being to get out just as the weather's getting nice, you know? I want to get out there and just hammer the hills and ride (it's getting really nice here in DC), but I'm sitting on the couch and stretching. Went out yesterday for thirty minutes, 90rpm cadence, 13 mph, and was passed by doods w/ beards on wood-fendered bikes.

They rang their little annoying bells as they dropped me, the *******s.

Good luck with the PT. It will probably take at least a couple weeks min for it to really help. The upside though is if you keep up with the exercises it can really help.

I hear you about wanting to get out and ride (I'm in DC too), I'm stuck at home a week and a half post op on ankle surgery and won't be able to walk let alone ride for at least a month or so.

Good luck

I'm no Dr But.....:)

Firstly, I reckon there's a bit confusion out there in 'cycling world' between patellofemoral syndrome abd 'basic' chondromalacia. Patellofemoral syndrome, as far as I understand, is the problem caused by a lateral maltracking of the knee cap (it usually gets pulled outward, due to overtight/strong vastus medialis and IT band, relative to a weak vastus medialis), and the other chondromalacia is a 'lazy' tracking of the knee cap.

The way my physiotherapist explained 'standard' chondromalacia to me, is that during normal quad contraction, the rectus femoris quickly 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 gets buggered up, and the rectus femoris doesn't pull the knee cap up quick enough, therefore causing the grinding of the knee cap on the femur, and the subsequent wear, inflamation and pain.

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, but a 3rd physiotherapist diagnosed chondromalacia, and it was gone in about 4 days after doing straight-legged kicking exercises with very light weights.

http://vmartin.bigpondhosting.com/photos/chondro.jpg
Only 5 or 10lbs was enough for me, although even less than 5 pounds might be enough. If I ever have to do them these days, I use an old rollerbalde with only 2.5 pounds attached to the bottom.

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

As far as patellofemoral syndrome and patella tendonitis goes, there are a trillion websites out there with stacks of good info

As others have suggested, other typical causes of anterior knee discomfort are low saddle, and/or cranks that are too long, and/or super-tight quads.

I'm no Dr But.....:)

Firstly, I reckon there's a bit confusion out there in 'cycling world' between patellofemoral syndrome abd 'basic' chondromalacia. Patellofemoral syndrome, as far as I understand, is the problem caused by a lateral maltracking of the knee cap (it usually gets pulled outward, due to overtight/strong vastus medialis and IT band, relative to a weak vastus medialis), and the other chondromalacia is a 'lazy' tracking of the knee cap.

The way my physiotherapist explained 'standard' chondromalacia to me, is that during normal quad contraction, the rectus femoris quickly 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 gets buggered up, and the rectus femoris doesn't pull the knee cap up quick enough, therefore causing the grinding of the knee cap on the femur, and the subsequent wear, inflamation and pain.

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, but a 3rd physiotherapist diagnosed chondromalacia, and it was gone in about 4 days after doing straight-legged kicking exercises with very light weights.

http://vmartin.bigpondhosting.com/photos/chondro.jpg
Only 5 or 10lbs was enough for me, although even less than 5 pounds might be enough. If I ever have to do them these days, I use an old rollerbalde with only 2.5 pounds attached to the bottom.

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

As far as patellofemoral syndrome and patella tendonitis goes, there are a trillion websites out there with stacks of good info

As others have suggested, other typical causes of anterior knee discomfort are low saddle, and/or cranks that are too long, and/or super-tight quads.

This is all excellent info. I was in PT for chondromalacia, and icing, basic stretching and some other simple exercises cleared it up quickly. Some of the exercises were non-obvious, though, like standing on one leg with the knee slightly bent. This was to get all the muscles in the quad to fire. The exercise was made more challenging by doing it with the eyes closed, and eventually, while standing on one of those instability platform thingys.

Also, there was IT band rolling on one of those hard foam rollers. Ouch!

Also leg lifts with ankle weights, and calf stretches. Good luck!

Thanks, all recovered pfs sufferers, for giving me hope. A friend of mine who's had this for two years told me yesterday "you're going to suffer from this the rest of your life," which wasn't exactly encouraging.

One session of therapy hasn't led to any noticable difference.

I'm hearing pretty much uniformly that muscular imbalance causes pfs. But it seems like this imbalance can involve nearly every muscle from the chest down.

My pt has been working on my hammies, which he says are tight. He also says my itb is tight. Oh, and my glutes, and gastocs. (Actual words: "hmmm...you're tight, weak, and imbalanced.")

I'm going to continue to work on my flexibility and strength, rolling on the IT band foam thing--and I'll incorporate 351Ausie's straight legged lift routine.

Also, I notice a pop every time I straighten my knee out in front (parallel to the ground while I'm standing). This may be due to weak or apathetic vastus medialus--as I write this I'm balancing on one leg to get wake the dang thing up.

Not to keep plucking the same string or anything, but that wasn't a bike fit coach/physical trainer. That's what you need. Websites aren't going to fix this. You need an expert watching you pedal.

Calvini, I'm with CarbonFiberBoy in that a physical therapist did good things for me -- but was only half the deal in my recovery. (Your friend might not be right about recovery; each body and injury is different. I'd say I'm about 85-90% recovered, after five months of constant care-taking -- but that included lots of riding in my case.)

The other half of the deal (at least) was an expert fit by a very accomplished expert in a highly reputed local store. It didn't cost much (I just did the leg/pedal fitting to save money over the entire fitting cost, which included reach to the bars and all the upper body stuff). It did, however, include custom cleat adjustment. I *immediately* started feeling better after rides -- like, the next day.

As far as foam rollers go, I *highly* recommend them -- and here is a post about a roller technique I found on the Web that was very, very helpful to me. Use it on any muscles giving you trouble, but especially the ITB:

http://www.bikeforums.net/showpost.php?p=5965203&postcount=12

Best of luck getting strong and flexible again!

I've had issues with my right IT band in the past, usually when riding in cold weather, not enough warm up/cool down and not enough stretching (especially IT band specific stretches). I haven't had the IT band issues or knee problems since it has warmed up, however... now I'm getting some vague hip pain on my right side (subsequently the same side I was having IT band problems). I found that moving the saddle BACK helped with the IT band but now my hip gets a little achy from time to time. My hips are not rocking in the saddle at higher cadences. This is not a chronic problem yet or something that keeps me off the bike (it is sporadic... probably related to volume (which increased over the last 30-45 days), how much climbing and higher instensity workouts). Moving the saddle back has activated my hamstrings and glutes whereas before I barely noticed I was using either, even when standing. This took some of the strain off my quads but I'm afraid "my" IT band problem has now turned into "my" hip problem... heh.

I never really tried the roller technique on my IT band. I did do HARD and deep tissue massage there and several IT band specific stretches and it all seemed to help. Since I've moved my seat back I've really noticed the "work" my hamstrings and glutes are doing and my quads don't seem quite as sore. This has made my hamstrings tighter and I've really tried to stay on top of staying flexible (especially my hamstrings).

Any suggestions or comments?

Any suggestions or comments?

ZXi, you're not too specific about where and what the hip pain is -- and I'm not a doctor anyway -- so my general thoughts would be a) is the pain really pain, or just your body adjusting to new muscle-stress. After 45 days, not sure if that would be the case, esp. if you're really stretching, warming up, cooling down.

Hate to be a broken record, but I've said it so many times elsewhere, I might as well again: If you're over 35 or even thereabouts and the pain continues despite your best efforts, I believe in fitting technicians and a really good PT. Young bodies can bounce back from continued abuse, slightly older ones (I'm 44) take much, much longer, if at all.

It's nothing too extreme and you're probably right. My glutes and hamstrings are getting used *alot* more and this could be my glutes and not my hip (although it definately feels like my hip). I'll give it some more time and see. Like I said, this doesn't seem to be a chronic problem and I just started doing alot of climbing with my new on bike position.

I'm 39.

It's nothing too extreme and you're probably right. My glutes and hamstrings are getting used *alot* more and this could be my glutes and not my hip (although it definately feels like my hip). I'll give it some more time and see. Like I said, this doesn't seem to be a chronic problem and I just started doing alot of climbing with my new on bike position.

I'm 39.

If I were in your shoes, I would look up some specific stretches for the affected areas, be real diligent about warming up and stretching them before and after workouts, and then, after a month or so, if the pain is still there, I would see the fitting/PT experts. There are young 39s and old 39s, but in general, at our age level, you don't want to ride too long with a recurring pain. Like I said -- if it should set in, it could take forever to fix, or might not ever be quite the same.

My 2 cents. YMMV. :)

I've been to my fifth physical therapy session now. I haven't really been on the bike (except for the trainer in the pt's office).

I bought and use a foam roller on my itb (painful, yep) every day, I've done narrow squats, exercises to strengthen my vasuc medialis, I've stretched every muscle in my lower body. I bought $35 inserts for my shoes. I haven't had a bike fitting, but I haven't even ridden my bike in two months, so that's irrelevant. And I'm still in a fair amount of pain and unable to ride.

I wonder if, instead of undergoing therapy, I would have been better off doing nothing. According to this article (http://www.nytimes.com/2008/03/13/health/nutrition/13Best.html?ref=health)in the NYTimes, stretching hasn't been shown to do much good.

I guess this is more evidence that everyone responds differently to treatment, and that treatment, not diagnosis, is the real challenge of healing up.

Screw it. I'm going to water aerobics.

Really sorry to hear things aren't improving, Calvini. I wish you the very best as you heal up. I bet you will. Sorry our suggestions weren't more useful!

Calvini, I'm really sorry to hear about the troubles you are having. It sucks. I know. I spent 8wks off the bike last year during the main part of the cycling season (.5 of May, all of June, .5 of July). I still have naggin issues with my knee and have recently strained my calf and/or hamstring by changing my saddle height and a mtn ride all in the same weekend.

I'm back to stretching the hammies/calves 3-5x a day and using the foam roller. Damn, that thing hurts!!! But, even though I'm still just a tad sore, I'm back riding. I'm not taking time off the bike right now. Not unless someone is pointing a gun to my head. Maybe this winter I'll take time off (prolly not:rolleyes:)

I'm pretty much to the point of 'screw it' too, but I will back off a bit and hit the stretches/roller more when I feel it bothering me a bit more than it does right now. BTW, even with the recent problems I've had - I have 90 miles in so far this week, will put in another 35 tomorrow and a metric on Saturday...just do as I say, not as I do:D.

<<>>
I guess this is more evidence that everyone responds differently to treatment, and that treatment, not diagnosis, is the real challenge of healing up.

Screw it. I'm going to water aerobics.I always prefer diagnosis to precede treatment. Otherwise, treatment is going to be trial and error. OTOH, it's only been three weeks since your first post. How many years had you been riding previously to coming down with this ailment and how much/week?

Have you tried glucosamine? If not, try taking 500mg three times a day. If that's going to work you should notice a difference in a month.

I agree that stretching is probably not going to do much.

Have you tried ibuprofen, and if so, how much for how long?

i did maybe a 25-mile ride with calvini yesterday, and 20 miles on saturday. the knee was bothering him some, but he's still faster than me...

all good stuff, with all of the above information when you do ride,spin,spin,spin. Easy gears take your time I found this helps more than anything and it really lessens the pressure within the knee area.

I have a constant problem with my right knee,osteo-arthritis,though I really enjoy hammering in the big gears I am re-teaching myself to spin @ higher cadence,seems to be working as there is less pain from riding.

I went out with qualia, and my knee was bothering me for 45 min, mostly zone 1 and 2 riding. But we went really slow, no hills. I stopped, stretched for twenty minutes, hammys quads, itb, and calves. Hopped on the bike, and wadyaknow, the knee felt great for the rest of the ride!

Perhaps my pessimism from the previous post was premature. Newfound faith in stretching, goofy little pt exercises to build medialis and itb flexibility! Foam tubes rule! Advice of bostonroadie and carbonfibreboy!

In response to carbonfiberboy:
I've looked at other threads on glucosamine and concluded (maybe wrongly) that I'd rather spend my money on PT. But gluc worked for you?

To answer your questions:
Riding for: 1 year.
Not taking gluc.
Taken ibuprof on occasion--it helps some, but seems more like a palliative than a true solution.

Anyhow, I'm pretty happy at getting my hr up to 150 for the first time in two months, and the thought that I might have a while on two wheels before I'm relegated to the warm pool.

Glucosamine is really cheap. Look for it in a Trader Joes. It worked for me. I take 500mg every day now. But it doesn't work for everyone. If it works for you, it's magic.

Ibuprofen can be a solution if the problem is swelling from an irritation. By making the swelling go down, it makes the irritation go away. So the way to use it is to use a lot, say 600mg three times/day, for a week or two. Then stop it completely. If the pain is gone, it's gone. Otherwise it didn't work. Simple, eh? And cheap. And no damage from short term consumption like that.

Now don't start hammering again! Spin and give it time.