Knee Pain and Pronation

[Randybaker99]

I am in Base3 and in mid April I started to ramp up the hours/miles per week. By the time I got to about 120+ per week (I did ramp up somewhat gradually, but I haven't ridden at this volume for about 12+ years), I started experiencing sharp pain on the outside of my right knee during pedalling, on a 30 mile ride, and it has returned in subsequent rides after about 15 miles, getting worse every time. I took a 7 day break, and then did a 30 mile ride that was the worst yet. All this riding was 90+ RPM cadence. (OK, so I finally got a clue and stopped riding 30 miles at a time, till I can figure this out!)

Before I go further, let me say that I already have an appointment with the Orthopedic specialist on Monday, but in the meantime I am wondering what the root cause of this problem are. Here are my theories in decending order of likelyhood:

1) I seem to have some mild pronation and perhaps the increased mileage is bringing this problem to the fore, and maybe related to my new SPD-SL pedals, though the cleats were professionally fit.

2) Tendinitis in the tendon(s) of the calf. When I got off the bike it was hard to reproduce the pain, except when climbing stairs and certain knee rotations. This may have been caused by experimenting with pedal stroke.

3) Increasing mileage too fast. I think I was increasing beyond the 15% per week recommendation. Tell me it's not so!

My question is has anyone experienced any of these scenario? Does it make any sense? Should I just stop thinking about this until I see an expert? My issue is I want to get back on track quickly, so I am looking to bottom out on the problem quickly!

 

[Jhikers]

"I STARTED EXPERIENCING SHARP PAIN ON THE OUTSIDE OF MY RIGHT KNEE"


Is the pain above or below the knee?


I tend to think this is more a Quadricep or ITB related pain - I suggest you read through the all the posts at:
http://www.cyclingforums.com/t86579.html

However, the best way to get something 'diagnosed' is to go to a Physio and let them see, feel and assess the area.



"1) I seem to have some mild pronation and perhaps the increased mileage is bringing this problem to the fore, and maybe related to my new SPD-SL pedals, though the cleats were professionally fit. "

"Professionally fit" - I would use this phrase quite loosely, only because I know of professionals who don't even put their own cleats on.

A professional is someone who does something consistently, has great experience and knowledge. Sure a professional athlete can help to an extent - but YOU know your body the best, you use it everyday - so change the cleat position - ride, repeat. When all feels the best - you've got it. You don't want to feel pressure, or tightening of muscles on either side of your knee while pedalling.

I know that if I look down while pedalling and see the inside-edge of my shoe at the heel more than 1cm away from the centre of the crank - when the foot I am looking at is 'forward' and the crank is horizontal - I know my cleat position is out and the inside-bottom of my knee is gonna need a lot of massage work afterwards. Not only that - but I can feel the area tightening whilst pedalling.




"2) Tendinitis in the tendon(s) of the calf. When I got off the bike it was hard to reproduce the pain, except when climbing stairs and certain knee rotations. This may have been caused by experimenting with pedal stroke."

Climbing stairs - lots of QUAD in that.


"3) Increasing mileage too fast. I think I was increasing beyond the 15% per week recommendation. Tell me it's not so!"

15%?! I would recommend 10...
Yes, this may be a factor in your injury - the reason your muscles are jamming is because you are STRAINING them - using them past their strength and trained limits.

Again - read the posts in the link above

Jhikers

 

[Randybaker99]

Originally posted by Jhikers
"I STARTED EXPERIENCING SHARP PAIN ON THE OUTSIDE OF MY RIGHT KNEE"


Is the pain above or below the knee?

Below the knee. I think it is a ligament that crosses the IT Band, across the upper the Tibia.

I tend to think this is more a Quadricep or ITB related pain - I suggest you read through the all the posts at:
http://www.cyclingforums.com/t86579.html

However, the best way to get something 'diagnosed' is to go to a Physio and let them see, feel and assess the area.

Did that today, and the orthopedic surgeon suspects that I inflamed a ligament that crosses the IT Band, but I can't remember its name.

"1) I seem to have some mild pronation and perhaps the increased mileage is bringing this problem to the fore, and maybe related to my new SPD-SL pedals, though the cleats were professionally fit. "

"Professionally fit" - I would use this phrase quite loosely, only because I know of professionals who don't even put their own cleats on.

A professional is someone who does something consistently, has great experience and knowledge. Sure a professional athlete can help to an extent - but YOU know your body the best, you use it everyday - so change the cleat position - ride, repeat. When all feels the best - you've got it. You don't want to feel pressure, or tightening of muscles on either side of your knee while pedalling.

Right, what I mean is the guy was competent and the cleat seems to be dialed in correctly.

I know that if I look down while pedalling and see the inside-edge of my shoe at the heel more than 1cm away from the centre of the crank - when the foot I am looking at is 'forward' and the crank is horizontal - I know my cleat position is out and the inside-bottom of my knee is gonna need a lot of massage work afterwards. Not only that - but I can feel the area tightening whilst pedalling.




"2) Tendinitis in the tendon(s) of the calf. When I got off the bike it was hard to reproduce the pain, except when climbing stairs and certain knee rotations. This may have been caused by experimenting with pedal stroke."

Climbing stairs - lots of QUAD in that.

But I have no Quad pain. It is all below, under and behind the outside of the knee.

"3) Increasing mileage too fast. I think I was increasing beyond the 15% per week recommendation. Tell me it's not so!"

15%?! I would recommend 10...
Yes, this may be a factor in your injury - the reason your muscles are jamming is because you are STRAINING them - using them past their strength and trained limits.

Right, that is the likely cause, coupled with some experiments using my calf muscles on the downstroke - not going to do that anymore!

Again - read the posts in the link above

I did and they are very helpful - thanks!

 

[Jhikers]

Look at where these muscles attach to the bone (outside-under the knee)
http://www.rad.washington.edu/atlas2/bicepsfemlong.html
http://www.rad.washington.edu/atlas2/bicepsfemshort.html
they are both part of the 4 muscles making up the hamstrings:


You can see it is "... all below, under and behind the outside of the knee."


If it is in the calf region, it will be either:
http://www.rad.washington.edu/atlas2/peroneuslongus.html
or
http://www.rad.washington.edu/atlas2/tibialisposterior.html
or
http://www.rad.washington.edu/atlas2/soleus.html



Why do you get the pain?

The belly of a muscle tightens as it is strained - this ends up pulling the tendons, which are the lighter coloured bits that attach to the bone, and these in-turn pull on the bone... causing pain around the joint. That is why PAIN is most commonly experienced around joints...

The best way to help ease the pain - if it is in fact the outer-hamstrings, is to:

- Sit on the edge of a desk/ledge with your legs dangling over the side

- Have the very edge of the desk within about 6cm / 3 inches of the back of your knee.

- Now slightly rotate the leg outwards and then lean on your leg / knee with your arm and body - putting weight into it.

- You will feel a fair bit of pain there, but let it sink in - unjamming your muscle - trying to switch the muscle 'off' so that it will let the edge of the ledge sink into it.

When you can do this - the muscle will be in a lot better shape thean it was, like in the other exercises you have read about.



I RECOMMEND:
Another great way for you to help this - is to kneel, knees and feet together, with a broom handle right up behind both knee-caps - between the tendons of the 'bottom' of the hammys and 'top' of the calves, that you can see in the above pictures.
This will help knock off both areas - it will be VERY painful - but bit by bit you will be able to kneel lower and lower - until your bottom is touching your ankles.

This is best done IMMEDIATELY after a ride - when your muscles are at their warmest and 'juiciest'.

 

[Randybaker99]

Originally posted by Jhikers
Look at where these muscles attach to the bone (outside-under the knee)
http://www.rad.washington.edu/atlas2/bicepsfemlong.html
http://www.rad.washington.edu/atlas2/bicepsfemshort.html
they are both part of the 4 muscles making up the hamstrings:


You can see it is "... all below, under and behind the outside of the knee."

Great web site! Thanks!

I RECOMMEND:
Another great way for you to help this - is to kneel, knees and feet together, with a broom handle right up behind both knee-caps - between the tendons of the 'bottom' of the hammys and 'top' of the calves, that you can see in the above pictures.
This will help knock off both areas - it will be VERY painful - but bit by bit you will be able to kneel lower and lower - until your bottom is touching your ankles.

This is best done IMMEDIATELY after a ride - when your muscles are at their warmest and 'juiciest'.

I agree that stretching is key - I was not taking the time to stretch properly before and after and I think that was part of the problem. I can't really do your broom stick stretch though, as I have a reconstructed ACL in my other knee and it is not as elastic as the original - if I stretch it too far it will become too loose! I am pretty close to bottom-touching-ankles but shouldn't be trying to go all the way.

I rode 15 miles today and the knee was great, so I think mostly I just overdid it. I will be sticking to the shorter rides for a while.

 

[Postie]

Originally posted by Randybaker99
Below the knee. I think it is a ligament that crosses the IT Band, across the upper the Tibia.


Did that today, and the orthopedic surgeon suspects that I inflamed a ligament that crosses the IT Band, but I can't remember its name.


Right, what I mean is the guy was competent and the cleat seems to be dialed in correctly.


But I have no Quad pain. It is all below, under and behind the outside of the knee.


Right, that is the likely cause, coupled with some experiments using my calf muscles on the downstroke - not going to do that anymore!


I did and they are very helpful - thanks!

Hi RandyBaker99.

The one thing about what you've done is introduce three variables into your cycling at one time.

1) New Pedals
2) New Stroke Method
3) New Training

This is a bad idea. All three of these things can cause different kinds of injury of which the knee would be one of the most probable. An inflamed tendon (which is what I would have guessed was the problem based on what you described) isn't the end of the world. However a tendon issue that isn't taken seriously can foul your entire season. Ensure you give it some rest and build back slowly.

Regarding the three things you've introduced;

1) Pedals are tricky. Cleat position is critical. To give a guesstimate of what position they should be in, go to a counter or desk top where, when you're sitting, your feet can't touch the ground. Sit with your kneecaps about a foot apart (whatever is comfortable) and let your legs dangle completely naturally. Look down at your feet and see how they are pointing. That is your natural foot position. Your cleats should be adjusted so that the most neutral position has your feet pointed exactly the same way. Some people go so far as to say you should video tape your feet as they dangle and don't look down because some people will subconsciously adjust their feet to point in the direction they "think" they should point.

At the end of the day, even a well-adjusted cleat won't entirely help if you've picked the wrong pedal. Some people simply need non-centering float (ie, no springs to return you back to neutral).

Ensure you have a lot of miles behind you before you play with stroke or training so that you can be confident the pedal is working.

2) Finding new stroke methods is fun and a great way to learn new tricks. Your legs, however, should stay in a fairly natural position. Some people put their legs really close to the head tube to maximize aerodynamics. If it works for you, that’s fine. If you find this puts torsion on your knees/legs/hips, adjust to a more natural position. If you have your knees facing outwards so you can really mash the pedals, then shift down, pedal faster, and become a better rider. The plus is you get increased fitness and stay much more injury free.

3) Training amounts are tricky. For an athlete that is training considerably for better fitness, 10% should be the upper limit. Clearly, at the pro level they'd never increase training by 10% during mid season. It would be WAY too much. The same holds true at the other end of the spectrum for people that are trying to gain fitness without a strict program. If someone has been riding 30 minutes in the start of a season, 10% is only increasing to 33 minutes. Hence there's nothing wrong with going for a considerably longer ride. Clearly some of this is just common sense.

However one thing that is completely obvious but not always properly pondered is that training hurts you. You are doing your body harm every time you train. The improvement comes in the rest that follows as your body becomes stronger then it was before. As a joke the couch potato would say they must be really strong then. But clearly, you need the breakdown for the body to come back stronger after the rest. I think pondering this fact can help people remember that rest is ALL of as important as the workout. Over-training can make you weaker and it's definitely one of the most common ways of becoming injured.

 

[Randybaker99]

Originally posted by Postie
Hi RandyBaker99.

The one thing about what you've done is introduce three variables into your cycling at one time.

1) New Pedals
2) New Stroke Method
3) New Training

This is a bad idea. All three of these things can cause different kinds of injury of which the knee would be one of the most probable. An inflamed tendon (which is what I would have guessed was the problem based on what you described) isn't the end of the world. However a tendon issue that isn't taken seriously can foul your entire season. Ensure you give it some rest and build back slowly.

So true. I am taking this to heart and slowing down the pace of change. It is even worse than you know, I actually have a new bike attached to the new pedals...

2) Finding new stroke methods is fun and a great way to learn new tricks. Your legs, however, should stay in a fairly natural position. Some people put their legs really close to the head tube to maximize aerodynamics. If it works for you, that’s fine. If you find this puts torsion on your knees/legs/hips, adjust to a more natural position. If you have your knees facing outwards so you can really mash the pedals, then shift down, pedal faster, and become a better rider. The plus is you get increased fitness and stay much more injury free.

I am sticking to simple strokes that feel natural. I am also noticing that if I am not paying attention, my knee is moving in a figure 8 - not good! I have an appointment with the LBS to see if shoe inserts (arch support) might be in order. Attention to detail...

3) Training amounts are tricky. For an athlete that is training considerably for better fitness, 10% should be the upper limit. Clearly, at the pro level they'd never increase training by 10% during mid season. It would be WAY too much. The same holds true at the other end of the spectrum for people that are trying to gain fitness without a strict program. If someone has been riding 30 minutes in the start of a season, 10% is only increasing to 33 minutes. Hence there's nothing wrong with going for a considerably longer ride. Clearly some of this is just common sense.

This is something that I am taking seriously, I think that in the past when my riding was more casual, I could ignore all this, but as I start following an actual training plan, it is much more important to pay attention to. Also, at 42, my body isn't quite as resilient as it once was.

Thanks for taking the time to make your points. It is very helpful.

 

[mtk]

had the same thing happen to me last year. exact same pain as you describe and mine was pedal related. i had switched to a new pedal and about two weeks later i got these knee issues. my doctor (one of the best sports specialists in dallas) suggested going back to my old pedals as a test first and - voila - pain went away within days.
problem was that i had changed to a pedal that didn't give me as much float and my cleats were not set up properly. happens more often than you think. i would give this a try first.

mk

 

[Randybaker99]

Originally posted by mtk
had the same thing happen to me last year. exact same pain as you describe and mine was pedal related. i had switched to a new pedal and about two weeks later i got these knee issues. my doctor (one of the best sports specialists in dallas) suggested going back to my old pedals as a test first and - voila - pain went away within days.
problem was that i had changed to a pedal that didn't give me as much float and my cleats were not set up properly. happens more often than you think. i would give this a try first.

mk

Yes, food for thought. Trying my old pedals again is definitely on my list, but I thought I would look into some shoe inserts first. The funny thing is my old pedals are $40 Nashbar Tourmalets and the new ones are $140 Shimano SPD-SL's. Both seem to have sufficient float.

To your point, one thing I need to keep reminding myself is - don't try to use logic, just test, test, test.

 

[mspriggs]

Originally posted by Randybaker99
Yes, food for thought. Trying my old pedals again is definitely on my list, but I thought I would look into some shoe inserts first. The funny thing is my old pedals are $40 Nashbar Tourmalets and the new ones are $140 Shimano SPD-SL's. Both seem to have sufficient float.

To your point, one thing I need to keep reminding myself is - don't try to use logic, just test, test, test.

one thing i would check is saddle fore/aft position.
i had this exact pain at the beginning of the season. i was in the process of dialing in a new bike, so when the pain went away, i wasn't quite sure which change had made a difference. a few weeks ago i purchased a new saddle, and the pain came back. i quickly realized that i had set the seat too far back. moving it up a bit (along with a little rest) was the cure. something to consider in your testing.
best of luck...

 

[Randybaker99]

Originally posted by mspriggs
one thing i would check is saddle fore/aft position.
i had this exact pain at the beginning of the season. i was in the process of dialing in a new bike, so when the pain went away, i wasn't quite sure which change had made a difference. a few weeks ago i purchased a new saddle, and the pain came back. i quickly realized that i had set the seat too far back. moving it up a bit (along with a little rest) was the cure. something to consider in your testing.
best of luck...

mspriggs, you are psychic! I just came back from the LBS where I had a pedal/cleat refit. The guy who helped me this time around moved the seat forward a bit, saying that i could be straining to push back into the seat.

He made a few other suggestions and adjustments, and I brought some shoes inserts which provide a lot of arch support.

Now, I am hoping I am ready to get back on track in time for the good weather!

Thanks for all the helpful info, everyone!

 

[davidbod]

Originally posted by Randybaker99
mspriggs, you are psychic! I just came back from the LBS where I had a pedal/cleat refit. The guy who helped me this time around moved the seat forward a bit, saying that i could be straining to push back into the seat.

He made a few other suggestions and adjustments, and I brought some shoes inserts which provide a lot of arch support.

Now, I am hoping I am ready to get back on track in time for the good weather!

Thanks for all the helpful info, everyone!

Sounds like you have figured this out. I had the exact same problem about a year and a half ago. And it was a saddle too high that caused it. I discovered in the end that my right leg with the problem is shorter than my left and the saddle height was just right for one leg and a tad too high for the other. I used some cleat shims to adjust out the leg length difference and all is better now. It took me almost a year to get back to where my knee is 100% though. No real pain just the knee feeling weak on longer rides, but after a year it is 100% back to normal.

Good luck,
David

 

[Randybaker99]

Originally posted by davidbod
Sounds like you have figured this out. I had the exact same problem about a year and a half ago. And it was a saddle too high that caused it. I discovered in the end that my right leg with the problem is shorter than my left and the saddle height was just right for one leg and a tad too high for the other. I used some cleat shims to adjust out the leg length difference and all is better now. It took me almost a year to get back to where my knee is 100% though. No real pain just the knee feeling weak on longer rides, but after a year it is 100% back to normal.

Good luck,
David

This is interesting to hear. I did some hard riding this AM, and was still getting some twinges in my knee and I started to wonder if my seat was too *LOW*. After 10 miles I brought the seat up about a 1/4 inch and I immediately felt a difference. I rode another 15 miles and I was no longer feeling anything in that knee. Success!

I had dropped the seat considerably from my last bike (maybe 1 or 1 1/2 inches) - it was really too high, I was doing some hip rocking and also my toes were somewhat extended in order to complete the downstroke. So much for do-it-yourself fittings! This new bike was fitted from a "Fit Kit" - so much for accepting those measurements as absolutes!

Next steps:

1) a few more rides to confirm the improved knee situation
2) explore the possibility of raising the seat another 1/4 inch - which might also require a slight forward adjustment of the seat.
3) another vist to the LBS to get a second opinion and perhaps confirm the fore/aft seat position (have you ever tried to drop a plumb line on your own knee? I can't do it)
4) Look into whether I have a leg length assymetry - David, how did you actually make this discovery?

Also, thanks again to everyone who contributed to the boatloads of helpful and useful advice - it has really helped me along the path to finding a solution.

 

[Postie]

Originally posted by Randybaker99
This is interesting to hear. I did some hard riding this AM, and was still getting some twinges in my knee and I started to wonder if my seat was too *LOW*. After 10 miles I brought the seat up about a 1/4 inch and I immediately felt a difference. I rode another 15 miles and I was no longer feeling anything in that knee. Success!

I had dropped the seat considerably from my last bike (maybe 1 or 1 1/2 inches) - it was really too high, I was doing some hip rocking and also my toes were somewhat extended in order to complete the downstroke. So much for do-it-yourself fittings! This new bike was fitted from a "Fit Kit" - so much for accepting those measurements as absolutes!

Next steps:

1) a few more rides to confirm the improved knee situation
2) explore the possibility of raising the seat another 1/4 inch - which might also require a slight forward adjustment of the seat.
3) another vist to the LBS to get a second opinion and perhaps confirm the fore/aft seat position (have you ever tried to drop a plumb line on your own knee? I can't do it)
4) Look into whether I have a leg length assymetry - David, how did you actually make this discovery?

Also, thanks again to everyone who contributed to the boatloads of helpful and useful advice - it has really helped me along the path to finding a solution.

Great to hear RandyBaker99!

Having the seat two low can be really hard on the knees, however I too have had issues when the seat is too high. If a person has put a lot of miles at one height, it can be really hard on the tendons, etc to start working with a dramatic change in seat height. The 1/4 inch increments are exactly the amount that is recommended to play with at a time. When fine-tuning people do just a millimeter or two at a time.

To keep from hindering your success, I just wanted to suggest that if you do continue playing with your seat height, ensure you adjust your fore/aft properly. Knee strain often increases if you knee moves forward of the pedal axle.

The plumb line isn't too hard. The toughest part is finding the spot that you'd naturally be positioned in your seat. For that reason people usually say to have your bike on a trainer, pedal for a few minutes, and do the test as soon as you stop pedaling. Then you should be in your natural cycling position. However there's nothing wrong with leaning against a wall, ensuring your bike is as straight up as possible (don't fall over with those clipless pedals ), and drop the line with a weight on the end.

I'm glad to hear things are looking good. Hopefully now you can enjoy that snappy new bike.

 

[davidbod]

To measure for a leg length discrepancy this is what I did, you'll need a helper:

Standing stright upright with no shoes on have a helper measure from the floor to top of your shin bone. You can find this just below and to the outside of the knee. This will give you a measure of your lower leg.

Again standing upright no shoes have a helper measure from your hip bone to the top of your shin bone. This gives a measure of your upper leg.

If you have more than a 1/4 inch difference in either of these you should consider adjusting for it. If it is in the lower leg you adjust it by shimming under the cleat or by adding a shoe insert. You only want to adjust half of the total difference out. The idea here being your body has already had a lifetime to adjust to the difference so don't dial it all out. if the difference is in the upper leg then the way you adjust for it is by moving the longer leg's cleat forward on the pedal and the shorter leg's cleat back relative to the pedal. Again only half the difference total so this would be 1/4 the difference on each side.

If you have a lower leg difference the shoe inserts would work well for you since this is also how you can correct for pronation with an angled footbed.

Keep at it. You'll get there eventually.