Knee issue even after surgery, help me cycle again pain free!

[Tonybob]

Hi chaps, obviously new here and would love some opinions / ideas on my knee problem.

Background ; very active, been cycling for 10 years (mountain bike & road bike), running & swimming for past 3 years, prior to this I did Judo for >6 years to a decent standard too. Currently 35 years old, 5'8" and 70 kg. Not sure if any further details are required! I'll try to keep it detailed but brief if possible.

So, last year (approx 9 months ago), out running, aiming to do 10K, my right knee became sore - mainly after the run, and stiff the day after, this went after a few days, these things come and go sometimes so I didn't think too much of it, however, out on bike a few days later, the pain came back, after an hour or so riding and this time it was pretty bad, directly underneath the knee cap, sharp pain. I also had a dull ache in the quad muscle on the inside of the leg, which also seemed to ache into the lower limb on this side too. Again, it went after a few days. Anyway, this went on for a few months and even after resting (swimming only), around December I tried the bike again, however 10 minutes in the pain returned. I eventually saw a consultant, MRI indicating moderately severe focal chondrosis of the medial femoral condyle. Basically, I had knee arthroscopy & debridement- the consultant (also the surgeon) said the cartilage loss isn't too bad, but some torn cartilage was removed - and overall he was happy with the 'clean up'.

I don't think he ever really understood the other problems I was also concerned about though - I have looked up lots of information and have detailed my personal observations; before the surgery, what feels like the sheath or tendons possibly ? at either side of the knee cap (actually running over the knee cap on the right; lateral condyle - possibly ITB?(worst) and something to the immediate left the knee cap - at the head of the quad muscle over the medial condyle) tends to 'ping' as if being rubbed when I raise my leg - although this is not painful, it gets very annoying especially since the left knee doesn't do it. My concern is prevention of the previous problem - yeah the debridement has rid me of the excruciating pain under the knee cap, the remaining symptoms are persisting.

A recent return to the bike does not fill me with confidence - I have ran since surgery and this seems fine, but the cycling - something is not comfortable, even a week after a 90 minute ride I can feel dull aches in the leg / knee.

I know it is impossible to give a detailed diagnosis over the internet, but it feels like everywhere I ask, this is a unique problem, which I don't believe it can be.

I've had a dodgy back for the past 3 years since I managed to give myself a herniated disc (or two) but kept that in check, and I do feel this problem could be manifesting itself from the back / hip area.

I have a fair bit of crepitus going on in the knees too, and it is very easy to wake up in a morning and straighten my leg out to achieve a nice 'pop / crack' of the knee cap while standing on it - this sees to be occurring more frequently too.

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[marj]

[QUOTE=Tonybob;63990]Hi chaps, obviously new here and would love some opinions / ideas on my knee problem.]


Hi. I recommend you have a physiotherapist check your flexibility, including the flexibility of the soft tissue on either side of your knee cap, check your patellar mobility and check how well your knee cap tracks on the bike. Ideally, you want to find someone you trust (possibly a Physio) to check the set up of your bike and also be mindful of spinning/cadence when cycling. If your cadence (RPM) is too low for extended periods of time this can cause strain and pain around your patellofemoral joint. Good luck. Let us know the outcome.

[Tonybob]

[QUOTE=marj;64010]

Hi chaps, obviously new here and would love some opinions / ideas on my knee problem.]


Hi. I recommend you have a physiotherapist check your flexibility, including the flexibility of the soft tissue on either side of your knee cap, check your patellar mobility and check how well your knee cap tracks on the bike. Ideally, you want to find someone you trust (possibly a Physio) to check the set up of your bike and also be mindful of spinning/cadence when cycling. If your cadence (RPM) is too low for extended periods of time this can cause strain and pain around your patellofemoral joint. Good luck. Let us know the outcome.

Thanks for the input, the MRI showed no problem on the patella tracking and the knee specialist checked this (albeit briefly but not on the bike). My cadence is generally high - I have trained to keep it high as possible at all times - 90 rpm.

I think I can only assume that minor adjustments I had made to the bike has given rise to this or at least contributed to it - I had adjusted the seat further forward than normal as well as having to replace the chainset, but the cranks are marginally longer at 175mm instead of previous 172.5mm, I also recall thinking that the 'q factor' was wider (feet on bike further apart) from the new crank. All this could have just started the problems - after reading my journal back, the problem emerged about 2 months after these adjustments were made too. I wouldn't have expected these to have caused such a problem, but if a few contributing factors merge then I think it is a real possibility that my riding style has caused 90% of this problem.

I went out on the bike over a week ago and I can still feel a dull ache in my knee, with only swimming in between this to date. I just know this problem will recur if I carry on.

[Dr Damien]

im going to have to agree with Marj here. Patella tracking is a rather complex motion, first of all its not possible to see how your patella tracks on an MRI. secondly, tracking of the patella is relative to the assessments being made...i.e, your patella can track properly but still not effectively, for instance it may be tipped superiorly, laterally inferiorly etc...so your consultant may have overlooked its alignment when he or she checked its tracking.
you have described areas of discomfort akin to the patellofemoral ligament mainly...meaning you are showing signs of an overuse of this tendon. The question is why? first of all the majority of your questions you have answered yourself, the adjustments on your bike sound like the would obscure the alignment of your patellofemoral joint anyways thus causing an overuse of this tendon.
maybe you should try to change the adjustments so that you have a better knee joint alignment. you do realise that you are of the age wherein tendon issues are most common...only because you start to lose your flexiblity often mainly as you approach the middle ages...
there are knee supports that relocate the patella, and there are taping techniques that do the same, maybe trying out all these measures will stop your symptoms from emerging however if they are showing now, it is likely that no matter hopw much physiotherapy you get in the short term, they will always continue to be an issue from time to time.
one of the things you have to worry about are the possibilities of future knee joint arthritis. the surgery you have done may have left your quads slightly weaker that normal...take time to gently exercise the quads in the interim.

[Tonybob]

Hi and many thanks for the input. I have since been to see a chiropractor and his opinion is that my pelvis appears to be tilting upwards somewhat on the right side (same side as knee problem). It gives the appearance of a shorter leg yet the measurements show they are the same. He also clearly pointed out that the quad muscle in my right leg is inferior to the left (vastus medialis obliquus) however this is my dominant leg and should be bigger - he said 15mm less (circumference). It has been like this before the surgery as I happen to have a photo to compare. He says the muscles in the back acting on the pelvis are tight. simple resistance tests show my hip extension laterally and posteriorly is weaker on this side too. I will continue with treatment and his recommendations to see what can be done.

[Dr Damien]

Dear TonyBOB

Sounds like a very reasonable approach to check muscle length and strength relationships that control the knee ...so good for you, lets know how it goes
best of luck

[Tonybob]

Hi Guys, hope those of you looking previously are still subscribed here!

Just sort of updating really and really hoping for some more input.

I'd been seeing a chiropractor since the last post every fortnight which eventually was extended to a couple of times in the past 5-6 months. There didn't seem to be much positive progress and I hadn't been out on my bike in the past 3 months except once this weekend which made me come back here. I've been working out in the gym, strengthening my leg muscles, basic stuff really, still running a bit but mainly on the treadmill, swimming too so staying very active. So, back to this weekend and although my knee wasn't hurting, the continuous motion of the pedalling brought on the 'tendon pop' which, every time I raised my leg, bending the knee joint, the outer tendon(?) seems to slip over something to cause it to pop back after the movement continues, so basically every pedal stroke gives this 'pop' - not noisy but this is what the chiropractor called it and said it would eventually go away - clearly it hasn't! It is the Vastus lateralis side and happens regardless of cycling, that just exacerbated it, obviously hard to describe in detail without being clued up on the technical terms..but if I press a finger against the knee cap, top left hand corner (11 o'clock) as you would look at it and bend, then it pops at the 90 degree point.

P1030597.JPG

Fortunately no pain has arisen from the bike ride (except my bum, since I've not rode for so long!), but this is a serious factor I believe in the overall knee problem. Hopefully you can see the arrow where the tendon pop is occurring, this pic was last MArch, about 2 weeks after surgery.

Any help / ideas would be welcomed..thanks for looking and thanks in advance for any replies. The chiroprator recommends I see him 4 times a years to get 'straightned out' from all my exercise, but every time I go I end up feeling worse for a few days! I can also twist and crunch my own spine, so paying for someone else to do it is a little annoying! I will no doubt see a local physio for their opinion, but wouldn't mind further input. This feels like a very unique problem but I know it can't be, there are too many people suffering with bad knees, someone must know how to help!!!!!

Thanks!

[finchr]

there are several possibilities, one of which you mentioned, the bike adjustments. one thing you said piqued my interest, and that is the pain on the outside after a run. The distal ITB shifts behind the knew as you bend your knee, particularly witg running and this can get very sore. The only problem is your pain looks superior to this.
When the knee bends or straightens the last 10 degrees the lateral aspect of the kneecap can hang up on the femur lateral condyle, causing a pop. Try to put pressure across your kneecap when on a stationary bike and assessee if it goes away, or take elastic tape from your area of pain across the inside of your kneecap and around and see if that makes a difference. Cause and effect goes a long way. You could leave your right leg on a step and step down with your left or squat, and see if the sound is reproduced. My suspicion is patellafemoral and with the correct è exercises and short term use of brace, you should be able to make it much better. You do look as if you have genu valgus from the picture ( knock knee) which can contribute to this, but so can flat feet, weak hip external rotators, etc. There is no absolute cause in all cases. The best way to DX is to find what makes it do what it does then find what makes it stop. Therein lies the diagnosis and treatment. That is what we therapists are for... to figure that out

[Tonybob]

I'm back! Well, had the misfortune to have to see the physio the other day since I appear to have got myself a pinched / trapped nerve in my neck! Major pain down the trapezius / delt area and neck! Apparently I've a very stiff neck msucle, but I reckon it was cause by doing heavy shrugs in the gym, with bad form.... and a delayed effect. Anyway, apart from that, I asked her opinion on my knee situation which I was going to do within the next month anyway! Basically, she thinks my knee isn't tracking correctly at all and my right leg overpronates somewhat. VMO is very weak and should have had rehab to get that sorted - only a year too late hey?! It's what I've been looking at recently, so going back again tomorrow for both neck & knee assessment and hope to gain something at least! Thanks for all the replies so far, more information in any form is worth it, I can apply your thoughts and see what fits! Any further advice is very welcome!

[finchr]

It sounded like patella problems. A sunrise view is the only stay that shows this. There are so many factors that control or contribute to the patella and none of them are conclusive in the literature.

The most common association seen in most study's is weak hip external rotators.
The VMO is a very tiny muscle, relatively speaking, and can not be activated preferentially over the outside vastus lateralis. There is a tiny patellofemoral ligament that is the primary restraint from the inside, or medial aspect of the knee.
If patella tracking is the problem then the therapist should be able to immediately change it by taping or using the appropriate brace then having you do what normally hurts and it shouldn't with the change the therapist ads. If that is the problem it is easily diagnosed that way and gives the way to start treating it.