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

Could you be more specific where the pain is:
... How far below the kneecap? 1/4", 1", 2", etc...
-- How far inside the knee?

I had what I feared was knee problem, but turned out to be strained medial Quad... The pain was ''below the kneecap and inside' -- but it was about 3" below -- where the muscle attaches to the tibia...

I hope you figure out the issue and solve it so you can enjoy riding again.

I've had similar issue with my left knee(behind the cap) pain. It happened after i changed some parts on the bike and although i thought my position(fit) on the bike was optimal, my knee was telling me otherwise. I fiddled with everything, adjusted pretty much all the parts that were adjustable, and finally when i stopped using clip-less systems, the pain decreased. Its not completely gone, but at least i don't feel like my knee is rusted and can keep riding all day. I am going to get a professional bike fit this winter to prevent any future problems since I plan on riding 600K with the Randonneurs next year.

Some things to consider:
Age- the older we get, the longer it takes to heal, and some parts take a lot longer to heal than others.
After its all healed, you want to do the same thing you were doing before the problem, but you body is not at the same fitness level and you have to build back up. Be very patient and do not re-injure yourself. I've done this before thinking all is well, but then not so much.
Do you spin on the bike when you ride or do you mash it? I like to mash, but if i want to keep riding in my 60's, i better keep spinning, more so when riding loaded or climbing.
Another difference might be getting a 44/32/22 crank with 12-34 or even 12-36 to help those knees.

This is so far from my experience. Others might be more helpful. Whatever it is, don't give up. Life gives you lemons, make lemonade and share it with someone. I have learned a lot from this forum and still have a ton to absorb.

Good luck

You have one of the commonest cycling injuries, correctly diagnosed. As you say, the hard part is fixing it.

First thing is saddle height. Start by putting the heel of your cycling shoe on one pedal and rotating it down in line with the seat tube. Adjust your saddle until, with your knee completely locked out and not tilting your pelvis, your heel just barely touches the pedal. Repeat on the other side, since almost everyone has legs of different length. Take the highest setting and then raise the saddle another 5mm. Then try the treatment below, plus only riding the bike 1/2 hour at a time at a very low pedal effort. If it hurts, don't ride at all.
Here's what is presently known:
https://www.bikeforums.net/showthread...1#post16081392
and
https://www.bikeforums.net/showthread...1#post16073799

The pain is on the inside of my leg, focused right on the "point" of the kneecap. If you traced the circumference of the right knee cap with a straightened leg, it's the point that sticks out farthest to the left. On the side of the kneecap. The pain starts as a swelling/pressure sensation right under the kneecap at that point, then becomes more focused as sharp sensation right at that point, feeling almost like it's on the outside of the knee. As I recall, at the time of injury two years ago, the sharp pain seems to move progressively more under the kneecap as well, as I tried to ride on it a bit more, but always maintained this pinpoint sharp pain at that spot. I hope that's clear, i'ts a bit hard to put into words.

I guess I should make clear that by "under the kneecap" I mean inside my knee, not lower down on my leg towards the shin.

In answer to some other questions/clarifications...

-Bike fit. I had my bike fitted by a very experienced riding/touring friend of mine. The seat hieght was smack dap on the line where it was supposed to be...like down to the millimeter...

-It was also on this friend's advice that I stopped using clipless pedals and rode with just regular shoes. This had worked for his wife who was suffering from knee problems. I noticed no change.

-Crank length. I have not messed around with crank length. I'll look into it. Honestly, in spite of having done a rather long tour, I'm really not much of a biker, and have no idea about the relative effects of different crank lengths.... but I'll check it out.

- Spinning. I will definitely do my best to learn to love spinning in the future. I tried, almost a year ago, with my bike freshly fitted and my feet unclipped completely, to ride daily for about half an hour at low gears. The pain began to come back as normal after about 7-10 days.

I will check out those other threads when it's not 3 am. Thanks!

Thanks to everyone so far, I appreciate anything more I can get!

You don't want your "correct" fit. You want the modified fit with raised saddle. The purpose is to lessen strain on the kneecap temporarily. Clipless pedals vs. platforms makes little difference. If there's any difference, it's a benefit to use clipless because there's less focus on the downstroke. Or there's supposed to be less focus. Go back to the clipless. Learn to spin if you haven't. When I say pedal "at very low pedal effort," I mean never push down on the pedal. You should feel a cushion of air beneath your foot the whole time. If you don't know how to do that, now's a good time to learn.

So I checked out the other threads you mentioned, and ended up finding my way back to many sites and videos I'd seen before that offer exercises for chondromalacia of the patella. The thing is that I think I know what's wrong with my knee, but I can't find a way to fix it. I am trying the high kicks, but they feel very similar to the exercises I've done before. I tried two sustained attempts to do these leg-raises, for a few weeks each time, and both of them ended up causing me more pain. I'm worried the leg lifts will do that, too. How can i strengthen my VMO without causing my knee more pain? I don't know if it's because of incorrect technique or some other problem. I certainly do my best to maintain good form....

I'm taking anti-inflammatories now, and will do so daily for the next couple of weeks, as well as icing after even very mild exercise. I will try raising the seat when/assuming i start riding again in a few weeks, but that's not going to be all I have to do, as I still get this pain sometimes and haven't ridden more than a handful of times in the last 2+ years.

It could be that you need cleat wedges. You could try a pro fit with that in mind. I know a couple people who that helped.