Hello everyone

I have a chronic knee problem that I would very much like to solve. I will try to keep the story brief, but there are kind of a lot of details. I put headings to make it a bit more manageable. Thanks for reading!

THE BACKSTORY
Almost 3 years ago, my friend and I started a long tour from Portugal to China. Everything was great until the very last bit of the trip, when my rim split in a remote area of China, and my wheel became unrideable. I took a bus to a nearby town, but no one had a 26" wheel, and ultimately I was off the bike for about 9 or 10 days while running around acquiring a new wheel.

The second day back on the bike, I developed a slight pain on the inside of my knee, slightly under the knee cap. On that long of a tour, I had seen many random pains come to all parts of my leg. They had all lingered for a day or an afternoon, then gone away. This one didn't seem special at first. However, the next day it was still there, so we rested an extra day or two, then tried to ride again. The pain came back immediately, and became progressively more painful over the next two days. At that point, the riding was pretty easy, but even flats or pedaling downhill was painful. Walking was fine, however, and even fairly strenuous hiking caused me no pain, but as soon as I started pushing the pedals the pain would come back immediately.

At that point, it was clear that it was something serious. I took another bus to a town some days riding ahead, waited for my friend to catch up, then we took a long 4 or 5 day rest. The pain seemed to go away, but as soon as I started riding, back it came. That was the end of my cycling-section of the trip. It was too painful to ride, and I was worried about permanently damaging my knee if I forced myself to do it (I was very close to the end, and reaaaaally wanted to finish it). I traveled for a week or two on buses while my friend completed our planned route, then we met up in Hong Kong.

RIDING HABITS AT TIME OF INJURY
We averaged about 100 km a day, but this is a very rough average... longest day was 183 km, shortest was less than 20. Rode in all kinds of weather, from snowstorms to 48 degrees C, but at the time of injury, we had been in large mountains with long climbs and cold weather. I have read that cold weather climbs are not good for cartilage. At that point, we'd ridden about 15,000 km over 8 months, so maybe it was just an overuse injury that had been building for a while. Or maybe that 10 day break from riding, followed by jumping right back into it at full throttle was a factor. More generally, I liked to ride hard and fast, almost always climbed faster than my friend (who is a much better cyclist than me), and typically rode in the highest gear I could comfortably handle. I enjoy that style of riding, but obviously this had an effect, and in the future I will learn the value of SPINNING, so you don't need to worry about that. I was riding with clipless pedals for the whole trip.

INITIAL DIAGNOSIS
In Hong Kong, I had an MRI done, which revealed inflamed and somewhat irregular (rough) cartilage under the kneecap. No cracks, no broken pieces, no bone-on-bone contact. The doctor said to stay off it for a month or two, then slowly start riding again, and things should be okay. I believe it was officially diagnosed as chondromalacia of the patella, and that does indeed seem to match my symptoms fairly well. I saw that doctor almost exactly 2 years ago, in early December of 2011. I stayed off the bike for about 6 weeks, then took a 50-60k ride (on a poorly fitted rental bike.... maybe not the best idea but I was on the road away from my bike, and the seriousness of the injury wasn't totally clear to me at that point), and the pain started to come back, albeit very mildly, and I decided to wait another month or so. By then, I had decided to settle in Thailand for a while, where I still am today.

THE PAIN ITSELF
In the beginning, I would get a lot of pain after sitting with a bent leg for a while. Straightening it was painful. That doesn't happen so much anymore, at least not to the same degree. I often feel some pain in my knee after any kind of sporty activity (including swimming), and even sometimes just kinda randomly. Sometimes the kneecap will make a "pop," particularly when I'm walking up or down stairs. I've noticed that if I'm hungover it will get a bit sore.

The pain hasn't really hurt very much since I stopped riding two years ago, but I'm sure it would if I continued to stress it. It starts as just kind of a pressure, changing into a mild sharp pain. It's in a very specific point on the side of me knee, so I can feel it quite distinctly, and identify it as the same problem as before. Right now, it's more of an annoyance than anything else, but I have no doubt that the mild sharp pain would turn into a quite painful sharp pain if I were to continue with whatever activity is causing it.

ATTEMPTED TREATMENT THUS FAR
In these last 2 years, I have tried a number of things to solve the problem. At first, I did the RICE stuff, took anti-inflammatories, and then had my failed attempt to get back on the bike. That pattern of waiting a month or two, then unsuccessfully trying to ride again continued for over a year, at which point I kind of gave up. I haven't ridden at all for months. (A terrible shame, indeed, there's some great riding around northern Thailand).

I've also tried two times to do a particular exercise that is supposed to strengthen particular quad muscles to pull the kneecap back into alignment, but both times, the exercise began to give me pain after a couple weeks, so I stopped. (the exercise was sitting against a wall, turning my foot to face outward and pulling it back a bit, then lifting the leg 6-8 inches off the ground). I've tried swimming and yoga. Recently I've started running now and again, which I know is obviously bad for my knee, but honestly I was going a bit out of my mind without being able to really exercise, and it was really necessary for my sanity at the time. I have also made sure my bike is properly fitted, and have tried riding without clipping in at all (i.e. just wearing regular shoes).

I saw a specialist, and he had a bunch of options, none of which sounded terribly promising, and were expensive, and he seemed quite wishy-washy about what I should do. I always had this hope that just resting it would eventually permit my leg to heal by itself, but it hasn't happened. At this point, I'd be happy to put some money into some treatment, if I can find something that's likely to help.


CURRENT PLAN/TREATMENTS
I could probably continue to ride around town sometimes, but never very far, and definitely not touring. I still hope to do quite a bit more touring if I can, for decades to come, really... it is really the best way to travel. So I'd really like to fix this problem once and for all, or at the very least, learn to manage it to the point where I can do long bike tours again. I'm looking for a physical therapist in town now, and will start another few weeks of RICE and exercises/stretches, but this won't the first time I've been down that road, and I'm really not sure it'll work out. I'm considering getting another MRI done, although the symptoms have really not changed much in two years. IT seems like the only reaons to get another one would be to see if they made a poor diagnosis the first time. I still have the old pictures though, I might just show them to a new doctor.

Honestly, it has been pretty frustrating... these are few things I can really do, I've tried a number of them and they haven't seemed to have had any effect. I feel lazy and negligent just sitting around waiting for it to go away, but every time I resolve to tackle the problem head-on, it seems like there's not much I can do.

I don't really know the best course of action at this point, but I 'd really like to solve this problem ASAP. I'll be leaving Thailand in a few months. My plan had been to leave on a bike. I'd still really like to do that. I have considered the possibility that I will never be able to tour again, but I hope that is not true.

I'm hoping that daily anti-inflammatories for a few weeks, plus really diligent RICE, plus the right exercises/stretches will hopefully realign the kneecap and let the inflammation go down enough to the point where I can slowly start building up my riding habits again, spinning of course, and making sure my bike is fitted properly in all ways.

Does that sound reasonable? Has anyone experienced a similarly persistent knee problem? What should I do? Any and all advice is appreciated. Thanks to everyone!!

JAco