Patella pain - position help (with video)

thomasmorris · February 2014

Background:
I've been road biking since November 2012, start racing last year and am now starting my second season as 2nd cat. I never had any knee issues all last year doing 14,000k. Here's my strava account for riding history: http://app.strava.com/athletes/458344

Around Christmas i felt slight pain behind the knee cap in my left knee, took a week easy and it started to feel OK, so I started training hard the second week of Jan (making an effort to do some proper interval training this year rather than just riding around). It then flared up again after a hard ride in mid January. So I put my saddle up 3 mm and back 1cm.

I then raced the weekend before last and it flared up really bad. Took a day off and put my saddle up another couple of mm and carried on training last week, but then my first big race of the season was cancelled last weekend so I've decided to take a break to sort out this problem.

Video of position:
All round view: http://youtu.be/uDDLcnYXAh0
Front view with black tape for knee tracking: http://youtu.be/XjjxrXQT3pE

Going forward:
I'm icing the knee every day this week and taking a complete break from riding. I'm now stretching my hip flexors and doing VMO strengthening exercises both of which should address imbalances affecting patella tracking.

Currently, I can't bend my knee to stretch my quads without pain, but hopefully as I reduce swelling I will be able to do this also.

I've already but my saddle up 5mm. Anyone got any thoughts on my position?

neal1984 · February 2014

I've currently got exactly the same problem with my right knee. My physio told me to stretch my hip flexors and quads quite aggressively for 2 to 3 weeks and he is confident that this will solve the issue.

In the mean time I have also been to see the bike whisperer for a proper bike fitting and they made some adjustments to my set up to help ease the situation (especially my cleat position and reach on the bike). My main concern is that when I'm stretching my quads it does seem to aggravate the knee slightly so it seems to have a negative effect.

I will carry on following the stretching program as it's only been 8 days but I'm just so impatient as I want to get back out on my bike but I also have a weeks skiing booked from the 1st of March which is a bit of a concern.

ai_1 · February 2014

I can't help much on the saddle position side of things but had you changed anything since last season? If you think foot position or leg alignment could be a factor I would highly recommend switching to Speedplay Zeros if you don't already use them. They give loads of adjustable resistance free float which may remove one potential cause. I switched to these 2 years ago largely due to knee problems and I love them.

Remarkable · February 2014

I had a similar problem. Specialized insoles helped to correct my collapsing foot arch, which was the root cause. Make sure to foam roll your quads as well on a daily basis. Getting a bike fit might be a good idea in the near future to prevent any recurrences or other problems.

cheschcat · February 2014

Looks like your knee is tracking inward on the down stroke, I was doing the same last year before my bike fit. Try adjusting your cleat towards the inside of your shoe, in effect widening your stance, this should keep the knee tracking straighter. Strengthening the VMO and stretching IT band might also help.

ugo.santalucia · February 2014

I have had patella problems on and off for a few years... a few thoughts

1) Long tights contribute as the stretchy fabric presses against the patella... I have cut holes around the knees and solved the problem

2) I still get it on long rides with very steep climbs... I try to avoid silly rides... 1.5-2 Km of climbing is my limit now and I no longer do the big 20% monsters

Bikerinthesand · February 2014

My ten penneth, from what I see you right leg dominant so your left leg basically has to take and make the best of what remains after your right side has made itself comfortable.
My advice would be to return your saddle to it's previous position and get some proper insoles that offer a lot more support to your left instep - I see the left knee is having to cant out to maintain your foot position so you will find yourself unable to "lean" fully on your foot.

http://www.hargrovescycles.co.uk/specia ... tAod1j8ASw

They will feel strange to start with I warn you.

BTW Steve Hogg has quite a bit of literature on this.

https://www.stevehoggbikefitting.com/bi ... h-support/

Hope this helps

thomasmorris · February 2014

Thanks for all the useful advice.

Remarkable wrote:

Specialized insoles helped to correct my collapsing foot arch

Bikerinthesand wrote:

get some proper insoles that offer a lot more support to your left instep - I see the left knee is having to cant out to maintain your foot position

I have e-sole with my bontrager mtb shoes. I could try these in my road shoes (Northwave) to support my arch (I have high arches). I'll give it a go tonight, just gently and film the tracking to see the change (if any).

cheschcat wrote:

Looks like your knee is tracking inward on the down stroke... Try adjusting your cleat towards the inside of your shoe, in effect widening your stance, this should keep the knee tracking straighter.

I have my cleats all the way over at the moment so my shoe just clear the pedal (minimum q-factor). Widening my stance is not something I had considered, but will try and see if it changes the knee tracking.

ugo.santalucia wrote:

1) Long tights contribute as the stretchy fabric presses against the patella... I have cut holes around the knees and solved the problem

Interesting... I've been weary in the past of getting cold knees and so keep them covered most of the time. However, it started well into the winter and I didn't get it last year, so I hope I can go without cutting holes.

Remarkable wrote:

Getting a bike fit might be a good idea in the near future to prevent any recurrences or other problems.

Yes, after I've gone through a few home remedies and given it some rest, if it persists I will go straight to a proper bike fit.

ugo.santalucia · February 2014

thomasmorris wrote:

Interesting... I've been weary in the past of getting cold knees and so keep them covered most of the time. However, it started well into the winter and I didn't get it last year, so I hope I can go without cutting holes.

As the remedy is often ice and rest, I'd say getting cold knees might actually help reducing or preventing altogether the inflammation.

I have been lucky to find something that works for me... I have friends who have battled with it and gone through endless sessions with physios and bike fitters with no real result

ollie51 · February 2014

1) Widen your Q factor. So cleats further in to the insides of your feet, partic on your left leg.
2) Reduce the drop, you look like you don't have the glute flexibility to tolerate that amount of drop, that or your core stability needs work. Probably both (cyclist tend to have bad core strength)
3) looks like you have some forefoot collapse, soles and wedges may well be necessary.
4) I'd be tempted to reduce stem length by at least a cm.
5) saddle looks too low.

Basically get a bike fit.

thomasmorris · February 2014

Alternations http://youtu.be/LqSnJdQc5kU

ollie51 wrote:

1) Widen your Q factor. So cleats further in to the insides of your feet, partic on your left leg.
2) Reduce the drop, you look like you don't have the glute flexibility to tolerate that amount of drop, that or your core stability needs work. Probably both (cyclist tend to have bad core strength)
3) looks like you have some forefoot collapse, soles and wedges may well be necessary.
4) I'd be tempted to reduce stem length by at least a cm.
5) saddle looks too low.

Thanks for that critique. I initially had an 90mm stem (based on calcualted reach from body measurements), but it felt much to0 short, so I went to a 120... which coupled with the drop I had before produces to much reach. I've gone up 5 mm at the front.

In the video I raised saddle by 5mm and it still doesn't feel like I'm over stretched at the bottom of the stroke, but is a 1 cm higher than when I first go the knee pain. I've made some adjustments and filmed each change. Light isn't very good, but it looks a small improvement.

Widen Q factor and put in supportive insoles is done. It felt slightly better, especially insoles, but I might need a insole with still greater arch support. We'll see once I've rested my knee properly.

I agree a bike fit would be best, and if I get a return of the pain after this rest period, I'll go for sure.

As for now, ice, leg stretches and VMO strengthening, then back on the bike in the new position and see how it goes.

xavierdisley · February 2014

Don't widen your Q Factor!!! That will likely create knee instability:

http://www.ncbi.nlm.nih.gov/pubmed/24392768

Try setting your cleat slightly more toe in for your left leg, but rest it first.

Xav

ollie51 · February 2014

thomasmorris wrote:

I agree a bike fit would be best, and if I get a return of the pain after this rest period, I'll go for sure.

As for now, ice, leg stretches and VMO strengthening, then back on the bike in the new position and see how it goes.

No, no, no. Bike fits are to prevent pain, not to stop it once it has happened because you are probably already broken in some way, that's what physios and and strength and conditioning coaches are for.

ollie51 · February 2014

xavierdisley wrote:

Don't widen your Q Factor!!! That will likely create knee instability:

http://www.ncbi.nlm.nih.gov/pubmed/24392768

Try setting your cleat slightly more toe in for your left leg, but rest it first.

Xav

Narrow Q factor works for a group of ten in a study, ergo one individual should narrow their Q factor.

Sorry, but no.

xavierdisley · February 2014

Sigh.

http://www.ncbi.nlm.nih.gov/pubmed/22612455

I have more studies on the way as well. What evidence do you have that widening Q Factor (over standard road cranks) is beneficial?

Xav

thomasmorris · February 2014

xavierdisley wrote:

Don't widen your Q Factor!!! That will likely create knee instability

Yes, that's what i've read in some cases. In the end, I could only move my cleat in by about 1.5-2mm (shimano doesn't have much adjust-ability with my shoe). Before my shoe was slightly rubbing on the crank, and now it's not, with a little bit of daylight between the shoe and crank.

I've screen shot all the changing positions to measure the position of my knee at top and bottom of the stroke and the q-factor change made no difference. The biggest difference to lateral movement seemed to be moving the saddle up, which brought my knee in at the top of the stroke by about 1cm, and seems to have removed the slight jerk of the knee moving out and then inwards over the top of the pedal stroke (that you can see in my earlier videos).

Anyway, it's impossible to tell long term comfort from just a few turns of the crank, and leave my knee to heal then re-evaluate once I can do longer / harder rides again.

ollie51 · February 2014

xavierdisley wrote:

Sigh.

http://www.ncbi.nlm.nih.gov/pubmed/22612455

I have more studies on the way as well. What evidence do you have that widening Q Factor (over standard road cranks) is beneficial?

Xav

Every individual has an optimal Q factor. Looking at the video (although v difficult to tell) it seemed to appear that the OP could benefit from moving his cleats to increase Q factor (q factor may be the wrong term here) a couple of mm. Although I'd address the the apparent forefoot collapse first to see if that's the case. I am not suggesting he chucks some mtb cranks on.

These studies ignore the individual needs of the given athlete, they are therefore relatively irrelevant to a single individual. If all bike fits were done to what suits the control group in a study, hideous, hideous things would occur. Studies show that a 30 (or thereabouts) degree knee angle at the bottom of the pedal stroke is optimal, but not everyone should ride at that knee angle, because in some cases, their individual needs mean that it is not optimal.

xavierdisley · February 2014

I've done countless hours of work with individuals' Q Factor, both kinematically and metabolically. I would not recommend increasing it in this case, looking at that video and understanding that it's with an experienced rider accustomed to <150mm cranks (he's currently on 147mm Q Factor).

Xav

ollie51 · February 2014

xavierdisley wrote:

I've done countless hours of work with individuals' Q Factor, both kinematically and metabolically. I would not recommend increasing it in this case, looking at that video and understanding that it's with an experienced rider accustomed to <150mm cranks (he's currently on 147mm Q Factor).

Xav

But you accept that it's not always right to narrow Q factor?

ollie51 · February 2014

To the OP.

The cause of improper knee tracking can be multi-faceted and difficult to ascertain. If you solve it with a feedback from a forum based upon a video, you'll have been very lucky. Please get someone professional to look at it.

xavierdisley · February 2014

ollie51 wrote:

But you accept that it's not always right to narrow Q factor?

In this case, he shouldn't - which is what I originally said :? . What evidence do you have that he should widen it?

Xav

ollie51 · February 2014

xavierdisley wrote:

ollie51 wrote:

But you accept that it's not always right to narrow Q factor?

In this case, he shouldn't - which is what I originally said :? . What evidence do you have that he should widen it?

Xav

You argument was that he should narrow his Q factor. The initial evidence you gave for this was study based on ten trained males. That is of course illogical. As it presupposes that the optimal Q factor for everyone must be like the ten trained males in the study. If, from assessing him physiologically as an individual, and then observing him in how he interacts with his bike, indicators suggest he would benefit from a narrower Q factor, and he does indeed benefit from the change, bio-mechanically, then Q factor should probably be narrowed. Studies don't really come into it. When deciding on the Q factor of your new crank for racing cyclists, it would be highly relevant, of course.

My argument is not necessarily that he should widen it, merely that he should do whatever is optimal for him as an individual (which is why I have reiterated he should go and see a bike fitter). My observation (which is of course very limited) from the video is that a slightly wider q factor would be more optimal, ipso facto he should widen it.

All we can do here is at best, guess, spuriously. That's all it can be, you have a video. You cannot asses the athlete and view the effect of a given change. It appeared from the video that the knee and the ankle did not track in-line, and that the knee would move outwards at more than one stage in the pedal stroke. Many things can cause this, too narrow Q factor is one of them, hence my suggestion. Although I think the OP may find his left ITB is tighter than his right (again, a spurious guess).

matt_n-2 · March 2014

ugo.santalucia wrote:

I have had patella problems on and off for a few years... a few thoughts

1) Long tights contribute as the stretchy fabric presses against the patella... I have cut holes around the knees and solved the problem

Interesting to read that as this is one of my theories too, I seem to suffer more over winter when riding in my tights.

My current pair are nearing the end of their life and the stiching over the knees is coming away anyway so I'll give this a go I think.

I'm currently working my way through Core Advantage and building up my Vastus Medialis too as these tend to get neglected when cycling and become weak.

I seem to suffer a bit with 'movie' knee too, i.e. discomfot when sitting for long periods (sitting all day at work doesn't help me!) as it puts pressure on the patella.

Patella pain - position help (with video)

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