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  1. #1
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    Help me diagnose my knee problems!

    Last year I started getting a pain in my right knee while riding. A bit of history, I've suffered from obvious iliotibial band syndrome in my left knee for a few years while hiking or running, but not while riding. Last summer I did the Copper Triangle (80 miles, 6,000 feet gain) and felt great. I also hiked a 14er around then. A few weeks later on a short ride I started getting a significant pain in my right knee. I continued training and I think it kind of came and went, I don't remember being particularly concerned about it. Well, being in Denver I didn't train properly for El Tour de Tucson but did it anyway. My lungs felt fine but about 3/4 of the way through the pain became very significant on my right knee. The next few days were hard walking, especially down stairs. I went on a few rides the following week, had to cut the first one short and the second one just hurt.

    I pretty much rested over winter, I rode an exercise bike about once a week and started getting some pain after 20 or 30 minutes but stopped after that and didn't think of it much. Well, the first ride of this season was quite painful. Now I can't really ride more than a few miles before it hurts. It's an odd pain though, it's not exactly like the ITBS in the left side. It seems to hurt in a few places, alternating between them. The side of the knee hurts, around the fibula head. The back of the knee hurts around the popliteal muscle. It also hurts some down the biceps femoris and maybe the peroneal nerver. Then eventually I get IT band pain too, right where it attaches at the femoral epicondyle and running up the IT band a little bit. I have pain around the fibula head doing other exercising on my feet. I also get pain when I straighten my knee, my PT noticed it tends to go more towards hyperextension than the left side. When I swam kicking with straight legs it hurt to straighten my knee after that. The pain on the bike comes when I'm most extended under power (no my saddle is not too high). If I REALLY lower my saddle it doesn't seem to hurt but I'm scared to ride significant portions of time like that because I imagine I could mess things up.

    What the PT and bike fitter (Todd Carver with Retul) have noticed:
    1. PT - She thinks it has to do with a tibia that won't rotate fully (my right foot sticks out...but it's always done that) and maybe a frozen fibula. Lately she's been mobilizing that and having me strengthen the popliteal muscle. I can't rotate my foot inward without keeping my arch high and dropping the outside of the foot. But, as I said, I've always had that and so far no relief. She's also tried taping the fibula forward and backward and taping the tibia back at the foot. But none of that seem to work. Whole host of other things I won't mention.
    2. Retul Fit - Todd noticed my right knee wobbles a lot. He put in green superfeet and angled my forefoot out quite a bit. That fixed the wobble but, to be honest it still hurts, maybe more. He also noted my saddle was really low and raised it some. The more he raised it the more it hurt, he noticed I pointed my toes more to "protect" the injury. I had a low saddle to help with the pain, raising it just makes it worse.


    Other than above here is what I've tried : I've been to multiple doctors and physical therapists (recently about half a dozen physical therapy sessions). I've tried foam rolling, extremely deep tissue massage (said he's never seen anyone take an IT band massage pain like me...I really want to get better), anti-inflammatory gel and pills, stretching, IT band straps, tennis ball massage, lengthening contractions on the hamstring, lowering my saddle, raising my saddle, cortisone shot (although he did it in the joint, not the tissue on the side of the knee), pedal extenders, rotating the cleats so my shoes point out, and an MRI in both knees (negative).

    I hate to give up cycling. The left side I'm considering surgery for the ITBS. I don't even know for sure what's wrong with the right side though so I don't know that going in and scoping is a good idea.
    2010 CAAD9-1

  2. #2
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    it sounds like you are doing everything right (at least everything that generally gets suggested in these threads).

    hate to say it, but you may want to keep trying new docs (who treats the pros/olympic athletes? who do top cyclists see/recommend?)...keep getting referrals and recommendations from folks here with experience, from docs that you respect, etc.

    in my experience with other health conditions, persistence in finding the doc that "gets" your exact condition can take a lot of time. you may have to travel (mayo clinic, clevelan clinic, johns hopkins), but if it works out, it will be worth it.

  3. #3
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    Quote Originally Posted by motorthings View Post
    it sounds like you are doing everything right (at least everything that generally gets suggested in these threads).

    hate to say it, but you may want to keep trying new docs (who treats the pros/olympic athletes? who do top cyclists see/recommend?)...keep getting referrals and recommendations from folks here with experience, from docs that you respect, etc.

    in my experience with other health conditions, persistence in finding the doc that "gets" your exact condition can take a lot of time. you may have to travel (mayo clinic, clevelan clinic, johns hopkins), but if it works out, it will be worth it.
    What he said.
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  4. #4
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    Thanks guys. I think you're right. I don't know what I expect at this point, if there is a standard approach I've tried it. I guess it's time to broaden the search.
    2010 CAAD9-1

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    Osteoarthritis? How old are you?

    Like motorthings said, find an orthopedic doctor who treats athletes.

  6. #6
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    When I first started reading I had a number of suggestions, then I kept reading and it sounds like you have tried them all. From my experience (me knees are extremely fussy) different insoles have a significant effect, so the fact you have tried superfeet and found no relief makes me wonder if it would be worth triying others such as the blue specialized insoles. I went through 4 before I found some that worked for me.

    Another thing That might be worth a try is different shoes. I find for some reason (dont really know why) no amount of adjustment and messing around will get rid of the knee pain I get wearing sidi shoes. I think its becasue they are just a little narrow for me. IME good knees start with good feet. It took a year for me to try different shoes and my problems (IT band pain mostly) went away fairly quick.

    Dispite the above, it sounds like you have tried a lot already so its possible this has nothing to do with the equipemt you are using or the fit on the bike so I think you are doing the right thing in seeking all the advice you can.

    Good luck and dont give up, it took me 3 years to nail my probelems but i got there in the end
    Last edited by lazerzxr; 05-05-12 at 02:31 AM.

  7. #7
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    I'm 34 and I don't believe it's osteoarthritis. Unless I'm mistaken that IS one thing that should show up on x-rays and it didn't.

    Thanks for the idea about the insoles and shoes. So far I've tried the green superfeet and the black superfeet. I also tried some lateral wedge insoles as I've read that can help IT band pain (which I'm thinking less and less that that's the cause). As far as shoes I've tried a few but mostly just two brands, two different Shimano shoes and a few of the cheapo Sette brand shoes.

    Anyway, I appreciate the comments. I'm not trying to be difficult, it's just that I've already tried a lot. I'm thinking more and more it's not IT band pain. One big hint is I get back knee pain when I extend all the way on the bike under load.
    2010 CAAD9-1

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    I am a PT in the Denver area, and have a couple of suggestions. First you mention all kinds of stretching/soft tissue work that doesn't seem to be helping. Have you also been doing strengthening? Is your PT picking up on any muscle imbalance? I don't give much credence to a weak popliteus. It sounds like extension is the main problem. Try this, find a position/activity that will bring on almost immediate pain. Use this as your "control" variable so to speak. Now, sitting on a table or high chair, (feet off the floor) fully extend your knee with a really hard contraction, hold for about 5 seconds and repeat 10-20 times. If your pain increases with each rep then stop, if there is no change or it gets better keep going. There is no magic number to do, and being that you have had this for a long time, the "ideal" number of reps may be high. Anyway, do a bunch, then repeat the "test" that produced pain to begin with and notice if there is a difference. In general I have seen repeated extension help more often than Flexion, but if extension does not work, try repeated end range flexion. End range in both direction means getting to the end of the joints natural range of motion. I should add, that your PT can also help in this area. If the extension seems to give a benefit but not fully take the pain away, ask your PT to do extension mobs with overpressure. If they don't know what that means find a different PT.
    Last edited by denvertrout; 05-05-12 at 08:38 AM.

  9. #9
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    Quote Originally Posted by denvertrout View Post
    I am a PT in the Denver area, and have a couple of suggestions. First you mention all kinds of stretching/soft tissue work that doesn't seem to be helping. Have you also been doing strengthening? Is your PT picking up on any muscle imbalance? I don't give much credence to a weak popliteus. It sounds like extension is the main problem. Try this, find a position/activity that will bring on almost immediate pain. Use this as your "control" variable so to speak. Now, sitting on a table or high chair, (feet off the floor) fully extend your knee with a really hard contraction, hold for about 5 seconds and repeat 10-20 times. If your pain increases with each rep then stop, if there is no change or it gets better keep going. There is no magic number to do, and being that you have had this for a long time, the "ideal" number of reps may be high. Anyway, do a bunch, then repeat the "test" that produced pain to begin with and notice if there is a difference. In general I have seen repeated extension help more often than Flexion, but if extension does not work, try repeated end range flexion. End range in both direction means getting to the end of the joints natural range of motion. I should add, that your PT can also help in this area. If the extension seems to give a benefit but not fully take the pain away, ask your PT to do extension mobs with overpressure. If they don't know what that means find a different PT.
    Thanks so much. I've PM'ed you with some other questions. She did check for some muscle imbalances. She had me do one leg squats and noticed I was a bit wobbly (but I had my runner wife do the same thing and she was very wobbly, with no issues or injuries). So first we tried strengthening the hips. That didn't seem to do anything. I've also done the lengthening contraction exercises on the hamstring. She had me lay on my stomach and move the foot from fully extended toward my butt and I had poor control on the right side (it's hard comparing sides though because I've had severe, recalcitrant IT band issues in my left side when hiking or running). She did some other strength tests but I can't recall at the moment.

    One of the difficulties is that the pain doesn't start right away. I suppose I could ride for a while to the point where it starts hurting then do what you mentioned? As I mentioned I noticed that after swimming and kicking with a locked knee I had pain for the rest of the day whenever I fully extended my knee. The PT noticed the right one tends more towards hyperextension.

    The other problem is the pain is somewhat variable. It starts hurting in the back when I put pressure on the bottom of the downstroke. Then it comes up around the fibula head. Then it hits the IT band. I think in that order but not 100% sure.

    I'll try your suggestions, much appreciated.
    2010 CAAD9-1

  10. #10
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    PM'ed you. Try that exercise for a couple days. Hundreds of reps not 3 sets of 10 Then go back to whatever aggravates it the most. If it helps you will know immediately, pain will be less. If it didn't you have lost nothing but time, switch directions and do repeated flexion.

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  12. #12
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    Quote Originally Posted by soulbike View Post
    Thanks, I saw that site recently. But, to be honest, there are a couple of problems. One of my issues with this injury (injuries if you consider both knees) is there is an over-abundance of information, much of it bad or irrelevant but some good. I have no idea on that site what actually to do. There was one video describing what my right knee looks like (IT band pain, foot turned out, not much tibial rotation, tried everything else, etc.) but then he didn't make any recommendations, just showed the problem. Later on in the comments he made a few recommendations but it was like it was talking a different language, some of which didn't give a clear answer on a google search even (mulligan knee mobs comes to mind). But I'll keep looking and try to filter the wheat from the chaff. I'm finding a bit more on knee mobs now the second time I searched.
    Last edited by cooleric1234; 05-06-12 at 02:35 PM.
    2010 CAAD9-1

  13. #13
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    Any change with the knee after that exercise? Mulligan mobs are really not all that different than what I am suggesting. Just adding some overpressure with a PT and paying a lot of money to do that.

  14. #14
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    Thanks for following up. This week I was on travel and I tried to do that exercise as much as I could. First of all, I have a question. I was extending my knee all the way, and THEN contracting hard and holding. After a little searching I wonder if I should have been contracting as I extend my knee and just keep holding it the whole time?

    I'm not totally sure but I think it helped. I used the recumbent exercise bike in the hotel twice and the pain came on later than previously and wasn't as severe. It's not fully apples to apples though (recumbent bike vs. my bike setup). With today's weather in Denver I don't think I'll ride but I'll at least get on the trainer in the next couple of days and see.

    This pain is frustrating as it's kind of amorphous. This time I started feeling pain around the front of the knee under and to both sides of the patella, which is totally contrary to the usual pain. That seemed to subside with time though and the biceps femoris started hurting some, which is more in-line with the previous complaint. I've always been able to bend my knee and get it to grind and then pop and then it's good for a while, but that doesn't produce pain. Nothing showed up on the MRI but I imagine something is going on with that (a lot of basketball and volleyball in younger years).

    So perhaps I'll ask the PT about overpressure. I worry about her doing that, she noticed that my right knee tended to hyper-extend more and she told me to AVOID extending it as far, so I'm doubtful that she'll be willing to try it. I would like to keep doing it and get on the bike again and be able to say that it definitely helped and use that as evidence to her.

    Thanks so much for your input and help.
    2010 CAAD9-1

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    Pm'd you. Had to send it in 3 messages as it was too long. Hope it makes sense still.

    You can't extend your knee from a sitting position without contracting the muscle, keep doing it. The hard/full contraction is at the end. It sounds like you are doing it right. Add the overpressure with your PT. You are just taking a joint through a normal range of motion, your knee happens to hyperextend a bit, normal for you. I also mentioned trying to tape the patella with some kinesio tape. May help with the ITB. I think you likely have 2 different things going on.

    Get on the bike again, if you haven't already and see what happens. What are you doing for strengthening?

  16. #16
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    Quote Originally Posted by cooleric1234 View Post
    I'm 34 and I don't believe it's osteoarthritis. Unless I'm mistaken that IS one thing that should show up on x-rays and it didn't.

    Thanks for the idea about the insoles and shoes. So far I've tried the green superfeet and the black superfeet. I also tried some lateral wedge insoles as I've read that can help IT band pain (which I'm thinking less and less that that's the cause). As far as shoes I've tried a few but mostly just two brands, two different Shimano shoes and a few of the cheapo Sette brand shoes.

    Anyway, I appreciate the comments. I'm not trying to be difficult, it's just that I've already tried a lot. I'm thinking more and more it's not IT band pain. One big hint is I get back knee pain when I extend all the way on the bike under load.
    My 65 year old knees started to give me grief not too long ago- pain under the patela- and a fellow cyclist recommended BCQ:

    http://www.amazon.com/Vital-Nutrient...7138162&sr=8-1.

    I'm not a huge supplements fan, but damned if this stuff didn't work. May have messed up my stomach for a couple of days, though (not sure if it was the BCQ or something else). I'm taking 2 caps, 2x a day, between meals.

    And I'm not affiliated in any way with either Vital Nutrients or Amazon.

  17. #17
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    Since you seem to be looking at all the right venue, I will just throw in few more perspective.
    1) It could be that your body is overcompensating for issue on your left side...
    2) What kind of pedal system are you using? Try platform for short? Compared to using clipless, this will get rid of any potential issues you might have with foot angle, cleat position, etc. Also, it's definitely something cheap (or even free) to try out. Maybe using your most comfortable tennis shoes with platform to see if it changes dynamics. (could be partial solution to #1 too)

  18. #18
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    Quote Originally Posted by bored117 View Post
    Since you seem to be looking at all the right venue, I will just throw in few more perspective.
    1) It could be that your body is overcompensating for issue on your left side...
    2) What kind of pedal system are you using? Try platform for short? Compared to using clipless, this will get rid of any potential issues you might have with foot angle, cleat position, etc. Also, it's definitely something cheap (or even free) to try out. Maybe using your most comfortable tennis shoes with platform to see if it changes dynamics. (could be partial solution to #1 too)
    Interesting, that could be true with the left side, not sure what to do about that but it's a good possible "out of the box" thought. Regarding the platforms, that's also a good idea and why I don't think it's a bike fit issue, at least at this point. Over winter and while on travel I rode a few different exercise bikes, some recumbent and some not. The pain was still there. As mentioned previously my right foot tends out a little, when I keep it that way on an exercise bike the pain tends to be a little less, or onset a little later, but it's still present.

    Getting a cortisone shot directly in the knee joint should have helped if it were anything around the meniscus or that area. That leads me to believe it really is a soft tissue issue on the side or back of the knee or a biomechanical issue.
    2010 CAAD9-1

  19. #19
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    Quote Originally Posted by hawiken View Post
    My 65 year old knees started to give me grief not too long ago- pain under the patela- and a fellow cyclist recommended BCQ:

    http://www.amazon.com/Vital-Nutrient...7138162&sr=8-1.

    I'm not a huge supplements fan, but damned if this stuff didn't work. May have messed up my stomach for a couple of days, though (not sure if it was the BCQ or something else). I'm taking 2 caps, 2x a day, between meals.

    And I'm not affiliated in any way with either Vital Nutrients or Amazon.
    Thanks. I'm usually against holistic approaches and prefer to see the science but I'm so demoralized that I'll try just about anything now. Haven't quite got to the point of using magnets but who knows, another year or two of this and maybe I'll engage in some voodoo just to see if it works. I'll give it a shot.
    2010 CAAD9-1

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    i didn't have a good handle on a bunch of back/knee issues till a doc did a series of x-rays of my hips to my feet to measure skeletal leg length discrepancy of 6mm. functional leg length discrepancy is totally different from skeletal, and are treated differently.

    i'd recommend the same thing, as it will help rule out or confirm an important possible causal issue. a 5mm shim in my walking shoes, and a cleat shim for my cycling shoes has made a HUGE difference for me.

  21. #21
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    Quote Originally Posted by cooleric1234 View Post
    Thanks. I'm usually against holistic approaches and prefer to see the science but I'm so demoralized that I'll try just about anything now. Haven't quite got to the point of using magnets but who knows, another year or two of this and maybe I'll engage in some voodoo just to see if it works. I'll give it a shot.
    Don't forget Acupuncture on top of rest Worked great for me when I sprained my ankle on speeding up healing. Something this prolonged might take more effort to heal up though even if they can fix it.

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