Need advice- knee pain starting months after bike fit

Triathlon Forum
1

Hi - I’m a lurker finally coming out to ask a question… I’d love to hear from anyone else who had knee pain on their bike even after it was fitted and how you fixed it, or anyone else who thinks they can tell from my story what should be changed so that I don’t have to stay in the flats. Sorry for the length- just trying to answer the questions that always seem to be asked in these kind of posts :slight_smile:

The problem- starting to (re-) develop knee pain while on the bike which of my best guess is more due to non-ideal gearing of the bike rather than some saddle switches I’ve been making. A few weeks after I got my new bike (back in Feb), I did get a professional fit, which made most everything that didn’t feel ‘right’ in the first few rides feel much better.

Until a week ago, I don’t remember having any knee pain while riding this new bike(meaning any pains must have been really minor), just an occasional small ache after a hard or long ride. But I did have saddle discomfort so finally last week went in to LBS to try WSD saddles. Each time a new saddle is put on, they recheck the measurement so that the saddle still has the setback from my orig fit. And sitting on the bike, it feels exactly the same fit-wise, just so much more comfortable sitting in the saddle for long periods of time. On short (20-30 mile) rides with trying out new saddles, the knee feels fine. Last weekend I did a longer, hillier (in number and steepness- meaning my cadence is ~40) route than usual and started to feel some pain in the middle of my knee right beneath the kneecap (or the very bottom of the kneecap), during the ride. A non-hilly ride last week felt fine as well. Then yesterday within the first 10 miles of a hilly 45 miler, my knee started hurting A LOT. Continued to hurt at that one point really badly during the next few hours of climbs and still lingered even while pedaling on the downhills at times. Always seemed to be this same spot just at bottom of kneecap, and just slightly to inside of leg, size is approx nickel’s diam. And commuting a few miles this morning on a hybrid bike brought some of the pain back again.

Until my climbing ability improves so that my cadence is higher- what do I do? Is there any chance that if the saddle was off by maybe 1/2cm that it could cause this much pain? And even before I got my bike fit (and the saddle was changed from ~2.x to 5.x setback), I pushed myself way back on the saddle when riding so it seems like it’s just a coincidence that my knee has started hurting with the change of saddle. I have a 12-25 in the back and 53-39 in the front. Do you think just changing the rear cassette to have a 27 would make enough of a difference? Thanks in advance for any advice you can offer.

2

Yes, getting a 27 or larger granny gear should help. I got a much larger cassette and it has helped my knees. A cadence of 40 is pretty low for someone with knee problems.

After my first professional fit my knees still hurt (though in different places) and I got a second fit from a different person. The second fit was quite a bit different from the first and also helped a bit.

You might also try climbing out of the saddle more. It’s not ideal, but might help your knees.

Good luck.

3

If you are spinning 40 with a 39x25 then you need a smaller front ring and a larger one on the rear. That makes my knees and achilles ache just thinking about it. Gaining two teeth on the rear will perhaps get you from 40 to 50-60, but even that is very low. When I did big gear workouts last year I did them at 55-60 rpm and even then I had to be careful not to overdo it.

A cassette will cost you $40-80 for Ultegra or cheaper; a nashbar compact crank is not a bad idea either. If you go larger than 25 teeth you may also need a new derailleur to handle the size.

A low seat won’t help either. Combine that with 40rpm and you will be injured in no time. If you can’t afford equipment changes then I recommend you stay on the flat until you can.

Chad

4

Exactly where my knee was hurting, and after doing lots of big hills over weeks.

May, get a compact crank, 50/34 and a read 12/27. No reason to burn your knees up. As Dev has posted, on big hills you want to be doing lets say 80 rpm, not 40.

Dave

5

Sounds like you’re developing patellar tendonitis. The patellar tendon (it’s really a ligament) attaches from the bottom of your kneecap (aka patella) to your shinbone (Tibia or Fibia, I forget which is which.) It’s a short, stubby piece of tissue that holds your kneecap in place as your quads contract. On the top of your kneecap four tendons attach from each of the muscles in your quadriceps. When those muscles in your quads get tight, they pull up on your patella. And since there’s four of those tendons to one patellar tendon, it’s the patellar tendon that gets stretched, inflamed, and in pain. Runners often experience the “pain walking down the stairs” syndrome several hours after a run. Same cause/effect. You feel it right below your kneecap, and it’s probably worse after you’ve had a chance to cool down. The way you describe your rides, particularly your hill climbs, you’re probably working your quads well beyond their capacity to recover. They get tight, create tension on the patellar tendon, and that causes pain.

Treatment ideas: reduce the inflamation with ice and/or advil. Loosen the quad muscles with a good, deep tissue sports massage or at the very least a session with a foam roller or TP Massage “Quad Baller”. (And take a nice warm bath as a temporary measure – quite nice for loosening the muscles.)

Long term solutions: don’t push your muscles so far beyond their capacity. Ramp up volume & intensity more slowly to give your body time to adapt. As others have posted, get gearing that’s more appropriate for your strength level at this point in your cycling career relative to the hills you have to climb.

Lee Silverman
JackRabbit Sports
New York City

6

I changed my cleats. I use Look pedals and was using the gray colored cleats. They restricted the float. I switched to the red ones that have a greater float and my knee pain went away.

7

Thanks everyone for your replies. I really appreciate them, even though it unfortunatley sounds very much like I’m going to have to make an even larger investment in my new bike than I thought I’d have to.

It’s certainly been frustrating on my hilly rides, watching even other people going up the hills at the same slow speed as me spinning their legs so much faster than me! I certainly miss the triple chainring I had on my first road bike (unfortunately too large a size entry-level Felt), and I was fairly worried once I decided on buying the new bike (Giant TCR C2- mostly Ultegra 10sp) a few months ago since it would only have the double. But of course all my friends said I would just “get stronger” and “it would be good” for me, so I couldn’t get much advice on any pre-emptive changes (even though many of those friends know I’ve had lots of aches/pains in knees in past years-very unlucky biomechanics but at least fixed running issues a few years ago…). Sometimes I have felt a little bit stronger on the Giant since I’ve been forced to stand on some hills (never ever stood on hills with my triple) and so am getting up a bit quicker, but I can’t climb 2+ miles standing. So even if my cadence might be 60/70 for a little bit, I obviously tire out soon after and just try to hang on…

I guess it sounds like I’ll definitely be needing to invest in a change in gearing. I’m assuming that my saddle height hasn’t changed too much just putting on a different saddle, but I’ll definitely check to see if it should be raised a little if my new saddle is flatter than the original. As for changing to Look pedals- I had heard the recommendation of changing to no float if I had IT band problems but not for front of knee. Anyone else hear of a change in pedals helping my type of problem? I’d obviously prefer the cheaper option of changing the cassette (or pedals), but as I was afraid, it seems like it really wouldn’t make that much of a difference.

In which case I probably need to bite the bullet and buy a different front chainring since I just signed up for a late summer 1/2 Ironman. So I’m assuming I would go with a different compact- should I go 50-34 in front and then assume 25 in back will be more than enough? Thanks again everyone.

8

Lee- If I’m icing, stretching, and using ‘the stick’ these past few days but still have a bit of pain, will I be doing myself more harm/ prolonging the inflammation if I keep doing some flat bike rides this week? I think I can get used to the aching on a short easy ride, but if it’s just going to make things worse then I’ll try to take a few more days off from riding. Thanks.

9

For PT, the biggest factor in recovery is to rest the joint, meaning no more hill climbing, especially at only 40 RPM!!. You have to ice after every run, bike etc., preferably 3 times a day for 15 minutes, warm-up throughly, and stretch like you have never stretched before. As silverman stated, when you are tight everything pulls on the soft tissue, and tendons of the knee. I found that extensive stretching of my hamstring and quads along with lots of time on the foam roller(if you don’t have one, buy one, its the best preventive maintenance tool around) helped alleviate the beginnings of a full blown problem I was experiencing at the end of last season. To adequately stretch your quads you need a table, high bed, or some other flat surface that comes up to your hips. You then lie on your stomach on the table with one foot on the floor and the other leg on the table, grab your ankle and pull your leg toward your back, the table keeps your hips from rocking and you get a stretch that is 10x as deep as the regular old standing quad stretch. To deepen even further you can slide your foot on the floor forward. You will be amazed how tight you really are after doing this, but over time this stretch will loosen you up quite a bit. Do each leg 3 times and hold for 30 secs. Do after a good warm-up and as part of your post workout.

Also, make sure your shoes are not flat when running, and you shouldn’t be doing any weight lifting that stresses the joint–leg extensions for example. If your knee really hurts going up and down stairs its probably time to go a Physical Therapist.

10

Did you change your cleats when you got your new bike? If so, then I think Rowdy might be onto something with regard to a possible solution or even the root problem. If you changed your cleats when you got the new bike, then each pedal stroke might be slightly twisting your knee. You might want to try to re-align it correctly. Or, if you need the extra wiggle room, then go with a cleat that provides that. Rowdy: I had no idea that red v. gray meant anything. Whatever the case, your hill workouts might be exacerbating the mis-alignment problem, although it would probably manifest itself even without the recent stress, albeit over a longer time period.

11

i had similar pain, right below the patella (though mine was a tiny bit medial). Turned out my seat was too far forward, and my saddle was angled down (so i would slip even more forward). once i got it right, i was fine. Also, remember that just because you paid the guy to fit you doesnt mean it was a good fit. At the very least, during the fit you might have sat more back than you normally do, which would make the fitter push the seat forward.

12

Check on another post that I did last week on a similar knee pain issue. My guesses are (in order of likelihood):

  1. Your seat is too low.
  2. Your hamstrings are too tight.
  3. The nose of your seat is tilted slightly down (requires you to “push back” to keep seated stable).
  4. You are pointing your toes down in the stroke.

Any of the above, or a combination of the above, will cause patellar tendonitis. I suffered badly from this last year and my solution was to fix all 4 of the above. The seat height was the biggest issue, but the others are definitely things to check. Pedaling at 60rpm is also a good way to hurt your patellar tendon, but you already knew that. :slight_smile:

BTW-Red is the highest float, grey is half the float of red. I can’t remember the exact numbers but I’d recommend the red ones.

13

If I understand correctly the stretch you’re explaining, it sounds like during this stretch you will have your knee bent as much as possible(?). I’ve actually been avoiding doing that type of stretch (the usual standing one, or laying on back and bending knee so that foot/ankle is by hip) because I remember hearing/reading that bending the knee so much just to stretch the quad can cause more damage to the knee. It seems like there’s just so much conflicting research out there about what type of stretching should be done. And I think a physical therapist from a few years ago also cautioned me about some of those stretches. Although she also suggested some strengthening exercises that would make my knee start to hurt again even if it’d felt ok until that session, so who knows maybe I should find another physical therapist!

I definitely agree though with everyone who says that I’m tight- there’s no question about that. I’ve unfortunately cut down on post-workout stretching sometimes just to fit the workout and shower in. I’ll try the stretch that you’ve mentioned etocaj, and also start to actually use the big foam roller I got last month.

14

If I’m icing, stretching, and using ‘the stick’ these past few days but still have a bit of pain, will I be doing myself more harm/ prolonging the inflammation if I keep doing some flat bike rides this week?

That’s a $64,000 question – “how much can I exercise while I’m injured so that I maintain my fitness and allow myself to heal at the same time?” Impossible to answer well in an internet forum because there’s no way anyone can know enough about your history and how you react to each workout. But I am a big proponent of using a muscle as a method of helping it heal, as long as your use doesn’t exacerbate the injury.

If you decide to exercise while recovering, remember that:

1)You’re only as strong as your weakest link. If you’ve got a great aerobic system and your knees are shot, you still can’t run.

1a)Speaking of which, now might be a great time to work on your swimming if you need work in that area. Or to take a Pilates class if you need core strength conditioning.

2)Your emphasis is on the recovery part of recovering while exercising. You’re trying to maintain, not gain, fitness in the rest of your body while you gain fitness in the weak/injured part of your body (your knees & quads) by healing the injury.

3)In your case, you’re probably OK doing relatively short bouts that keep you well below your maximum force. I.e., do a lot of spinning. If you have an indoor trainer, use that and stay in an easy gear, keep your cadence above 90, and go for 20 minutes or so and see how your knees feel the next day. If that’s OK, ride for longer. Short Slow Distance runs are probably also OK, but again check in with your knees the next day and see how you feel.

4)A little bit of aching and creaking is probably normal and not to worry about. Sharp pain is bad. Pain while you’re exercising is generally bad. You have to learn the difference between good pain and bad pain, and until you’re confident that you know the difference, assume that most pain is bad – especially while you’re exercising. (Except lactic acid buildup during a hard workout – that’s good pain, but you probably shouldn’t be doing anything that intense outside the pool right now.)

5)Do a nice long warmup before any exercise, and stretch afterwards. The warmup and the stretching are as important as the workout itself.

Lee Silverman
JackRabbit Sports
New York City

15

So I just got back from the LBS and the first plan of attack, before I put money down for any new parts, will be to get my fit checked by a guy there- thankfully was able to make an appt for tomorrow morning. I do very much trust the last fit I got because it was from a well-known guy at a special sports med center that does a lot of work with cyclists. But before I put down 300+ bucks for a compact double and whatever other changes that would require, it seems a very smart idea just to make sure on those aspects you and others have mentioned, such as the seat being too low, or maybe my cleat position needing to be changed again.

Regarding (2), flexibility wise, I can easily touch my toes, nose to knees, all that- I’m assuming that means my hamstrings aren’t too tight? But unfortunately my IT band/hip flexor have been fairly tight the past few years (but with the Giant I never get the sharp hip flexor pain that I used to get on the Felt- that’s good right :slight_smile: ?). None of this is helped by my right kneecap being rotated in slightly (this is one of the biomech probs my physical therapist pointed out) compared to the left knee… And I think that even working on my stretching, as others have pointed out my cadence will still be stuck below 60 on most hills and I might have no choice but to plunk more money down on my bike. As for (4) when I’m spinning quickly, I have to constantly remind myself to not point my toes down in the stroke. If I forget and have my toes pointed for too long while I’m spinning easily, could that still contribute to pain? I think when climbing hills my feet are pretty flexed because I’m concentrating so much on getting as much power as I can.

Thanks again for your advice. I’ll let you guys know tomorrow what happens after a re-check of the bike fit.

16

Flexibility wise, I can easily touch my toes, nose to knees, all that- I’m assuming that means my hamstrings aren’t too tight?

I can put my hands on the floor on request. But I have VERY tight hamstrings and a weak, hypermobile lower back. Not a good combination for riding in an aero position.

Try lying down on the floor on your back, put your pelvis in a neutral position and HOLD it there, then while keeping one leg straight try to lift it to 90 degrees. (Very few people can make it to 90.) Don’t let your pelvis rotate to follow your leg. That’ll give you a better sense of how flexible your hamstrings are.

Lee

17

"To adequately stretch your quads you need a table, high bed, or some other flat surface that comes up to your hips. You then lie on your stomach on the table with one foot on the floor and the other leg on the table, grab your ankle and pull your leg toward your back, the table keeps your hips from rocking and you get a stretch that is 10x as deep as the regular old standing quad stretch. To deepen even further you can slide your foot on the floor forward. You will be amazed how tight you really are after doing this, but over time this stretch will loosen you up quite a bit. "

This stretch is money, and it is quite painful (in a good way). I was recently to the point, after 1.5 years of knee pain from cycling, of giving up on cycling. This stretch has been huge at bringing me back.

One ammendment is just to start the stretch off by simply leaving the leg on the table straight, while pushing the foot on the floor forward - this hits the hip flexor, and also the hamstring. Then, proceed as described above.

These stretches got me about 80% of the way back and continue to keep me healthy, the other 20% was accomplished using a new pedal setup.

18

Flexibility wise, I can easily touch my toes, nose to knees, all that- I’m assuming that means my hamstrings aren’t too tight?

I can put my hands on the floor on request. But I have VERY tight hamstrings and a weak, hypermobile lower back. Not a good combination for riding in an aero position.

Bingo. I could also easily place my palms flat on the floor on request. It definitely impresses people but it doesn’t really show that your hamstrings are suitably loose. Try two things:

  1. Sit partially sideways leaning left in an office chair, lift your right leg over the armrest and rest the center of your hamstring on the arm. By rotating your hips closer/further from the arm you can do a pretty good muscle stretch by pressing down somewhat with one arm on top of your quad. It looks goofy but you can do it at work easily.
  2. Sit on the floor flat-legged as though you were going to do toe-touches. Put a tennis ball under one hamstring and basically roll around to various locations with the tennis ball. Don’t put your whole body weight on the ball initially. Chances are this will hurt…a lot. Sometimes it’s only a very small area of the hamstring that is bound up, sometimes it’s my whole hamstring.

Those are the two excersizes that I do to make sure I am not excessively tight. It’s worked pretty well so far!

19

Lee- Trying that flexibility test- lying flat on my back (and assuming my pelvis is staying in place) and with one leg remaining flat on the ground, I can actually easily bring either leg up to 90 degrees (it’s the former gymnast in me since I used to have someone push my leg past 135 all the time). While I’m more flexible than the general population who never had to perform splits :wink: and backbends, I know that I’m tighter on my right side than the left- the side that always has more pains, and the side that has a kneecap slightly rotated inward. I’ll be adding some more of everyone’s suggested stretches to try to even things out some more…

20

Went to LBS that I’d talked to yesterday and had my bike fit looked at again: as some of you helpful ST’ers had suggested, the changing of the saddle indeed made some minor changes to the prior fit. I showed the new fitter the fit measurements that I’d gotten before and he noted that the saddle should be raised a little bit to even be at the prior number.

I explained to him all my history of past pains from running with bad shoes/ biking on previously horrible fitting bike etc and how I’ve been pretty pain free for the past 6 months except for recently on this new bike. He did the measuring angles/watching me pedal etc. and suggested (and then made) the following changes- raise the saddle a little bit, push the saddle back even a little bit more, and also replaced my speedplay cleats (so TriFloyd- it looks like even though I hadn’t changed the cleats in years, it was something that I needed to do after all). He explained that the wearing of the cleats allowed more lateral play than would normally be there with new cleats- plus the old shim in the right shoe had apparently worn down so much that both shoes looked to be at the same angle now. So a new 2 degree shim got put in there with the new cleats. He didn’t think that different pedals would help since I don’t have the pain on the side of the leg…

I’m crossing my fingers that these minor changes can help, but he agreed that the fit looked pretty good- nothing major to change… and that I’d just have to see if it worked… because otherwise, especially with what sounds like my biomechanical issues that make me prone to problems with the patellar tendon rubbing badly, it would be more likely that I’d have to do something mechanial to the bike vs just fitting me more to the bike. So the plan is- hoping for the best- do some flats this wknd/ next week if I’m feeling better and then following week try to get out to just do hill repeats so I could stop if it starts to hurt. And then would immediately return to bike store to get the gearing changed to compact crank probably 50/34…

He also mentioned that he could find out from someone else about a recommended specialist/therapist who explain how to strengthen the VMO and whatever else to help the patellar tendon tracking, someone who specifically helps runners/ cyclists…Unfortunately the doctor a few years ago who said that my large Q angle/ rotated inward kneecap and flat feet just would mean I’d always have to deal with patellar tendon rubbing, makes me not too optimistic that strengthening could solve all the problems. But I’d certainly be willing to give the strengthening exercises a try again if anyone has some recommendations that don’t need equipment!