Knee injury advice, chondromalacia patellae

[DRZRM]

So I just came from my doc, and will start PT later in the week, but I figured I'd ask you all, as I assume somebody will have experience with this injury.

So I've had significant knee pain, some swelling on the inside of my left knee (so to the right side of my left knee cap) and soreness, as well as general soreness at the back of my knee, mostly rear inside, so the right. Had X-ray and then MRI and they found an unrelated hemotoma (bone bruise) from me walking into a low pole about a month ago (dummy) and what he described as my kneecap being pulled to the left by overdeveloped thigh muscles that caused the sort of pain I'm experiencing (chondromalacia patellae). Said PT should sort it where I'd do selective strengthening of the inner portion of the quadriceps muscle to normalize the tracking of the patella. Ice and inflammatory meds help, and I've been using a neoprene brace.

My doc knows I bike, but he doesn't have real sports medicine background. Anyone with experience with this injury? How long will the PT take to work? Can I continue riding in the meantime, or should I be resting it? I'm sure PT will know what to do, but anything I should know in the meantime? Good stretches?

Thanks

[XXtwindad]

So I just came from my doc, and will start PT later in the week, but I figured I'd ask you all, as I assume somebody will have experience with this injury.

So I've had significant knee pain, some swelling on the inside of my left knee (so to the right side of my left knee cap) and soreness, as well as general soreness at the back of my knee, mostly rear inside, so the right. Had X-ray and then MRI and they found an unrelated hemotoma (bone bruise) from me walking into a low pole about a month ago (dummy) and what he described as my kneecap being pulled to the left by overdeveloped thigh muscles that caused the sort of pain I'm experiencing (chondromalacia patellae). Said PT should sort it where I'd do selective strengthening of the inner portion of the quadriceps muscle to normalize the tracking of the patella. Ice and inflammatory meds help, and I've been using a neoprene brace.

My doc knows I bike, but he doesn't have real sports medicine background. Anyone with experience with this injury? How long will the PT take to work? Can I continue riding in the meantime, or should I be resting it? I'm sure PT will know what to do, but anything I should know in the meantime? Good stretches?

Thanks

Well, it COULD be that you've overdeveloped your anterior chain (quads etc) at the expense of your posterior chain (hamstrings, glutes etc...) That could result in something known as "synergistic dominance" which could manifest in muscle imbalance.

https://uprighthealth.com/what-is-synergistic-dominance/

I'd recommend (as a PT) a regimen of foam rolling, "bridges" (to strengthen your glutes/hamstrings) and wall squats. BUT, you would be unwise to solicit advice solely from this forum and not seek a professional opinion from someone who's observed you in person.

[DRZRM]

Thanks. I'm seeing a PT at the end of the week, I'm mostly asking about recovery time and if I'll be off the bike during recovery. Don't worry, I'm not trying to avoid professional evaluation, just figured I'd ask here rather than going down the WebMD timesuck vortex.

Well, it COULD be that you've overdeveloped your anterior chain (quads etc) at the expense of your posterior chain (hamstrings, glutes etc...) That could result in something known as "synergistic dominance" which could manifest in muscle imbalance.

https://uprighthealth.com/what-is-synergistic-dominance/

I'd recommend (as a PT) a regimen of foam rolling, "bridges" (to strengthen your glutes/hamstrings) and wall squats. BUT, you would be unwise to solicit advice solely from this forum and not seek a professional opinion from someone who's observed you in person.

[m_sasso]

Your key, "selective strengthening of the inner portion of the quadriceps muscle to normalize the tracking of the patella"

Dependent on your rate of adaption, +6 weeks.

[John H.]

In addition to all of the PT you are doing I suggest foam rolling. Roll out the front, middle quad, IT bands and hamstrings. 2x per day. Start softly and gradually- Especially on IT.

2nd- Look at bike. Especially saddle height and setback, shoes, cleats, pedals and insoles.
A saddle in the wrong spot can flat up knees. Same for cleats in worn position, or set up too narrow. Do you wear supportive insoles? If not, you may need to get some. Try over the counter like Specialized 1st.
And pedals- A pedal with too much float or uncontrolled float can be a problem. Like Speedplay or Eggbeaters. You have the ability to pronate and also the small muscles have to work harder to keep everything straight.

I am working through a knee issue- Moving back to SPD SL pedals with fixed cleats has helped me-

[Alan]

You can get over this fairly quickly by doing the PT very religiously maybe even 3x per day. Anti-inflammatory drugs can help you get over this as well. Other posters have explained this fairly well. You could try riding easy on a trainer w PT approval to do something. Hills are not a good thing for you now.

You should improve quickly but every case is unique.

I got over this quickly, way faster than other injuries such as tendinitis.

Alan

[benb]

Foam rolling for sure..

I have had it in my right knee, more than once. It gradually got worse the first 10 years I was riding. It wasn't constantly there but it was always a risk. It started with getting patellar tendonitis, later the imbalances led me to several injuries to the kneecap that got me the chrondowhatever diagnosis.

I have been fine for another 10 years now once I PTed it properly and got my bike fit nailed down. (Some of it was cleat fit too, my legs are not quite symmetrical in operation.)

A significant amount of the imbalance was from riding my bike for years with bad fit, specifically saddle too low, but it really required nailing down the setback and cleat position too. Cycling seems to require things to be just right with fit to keep all the muscles evenly developed.

I still regularly use the foam roller and I work a bunch of the stability exercises into my off-season routine but it's never really come back once I fixed some of the issues. That knee has been rock solid ever since. It went from being my "bad knee" to my "good knee".

I was mostly in my 20s when this was an issue. The big wake up call injury was when I was 33, I'm going to be 43 this year. So I wouldn't worry about age too much here.

My PT was like 8 weeks. It was a lot of work, and I had to keep it up for a long time on my own to really get back to 100% but once I did it's always been better than it was before. I don't do super heavy squats but I squat regularly and can go below parallel no problem. The only thing I ever seem to notice is when the weather gets cold that knee seems to have a harder time staying warm.

BTW I got a total snake oil talk from the first ortho I went to. "You must have surgery". "You cannot PT this without surgery". "Without surgery you should never squat or bend your knee under force > 90 degrees again."

2nd Doctor = "Nope, totally wrong, just go to PT." 2nd doctor was right AFAICT.

[homagesilkhope]

Me, too. I've just come through a bout, happens once every few years, usually this time of year when re-starting after a winter break, always in the left knee. Appeared this time on a long, cold ride two weeks ago and I'm happy to say - just like the last time (three years ago), I'm on the other side of it in pretty short order. A bit each of rest, foam rolling, strengthening, stretching.

Discovered this guy's site three years ago and was so grateful then for the insight and help (especially since in the past I'd typically wind up taking a full month to six weeks off the bike to let the pain/disorder "resolve"): https://www.fix-knee-pain.com. He's refined the website since my last bout so that instead of presenting all of his advice at once, he'll send you an email everyday for a week giving you one new thing to do each day. And if you're like me, by the end of the week your pain will be gone. Woohoo!

FWIW, he's never included any kind of sales pitch. Maybe I'll get one next week since he's got my email address now, but so far, nothing.

[benb]

Once you've gotten it bad enough for it to be scary IMO the PT is well worth the money.

If you handed me all the exercises would I have necessarily done everything right to get to the same place?

I don't necessarily think so. Some of the stretching involved kind of requires someone else to help you, and some of the rehab exercises required cable pull machines, etc.. that had lower weights than what you find at the gym. There was some other specialized stuff too.

[Geemalar]

Close to 20 years ago. Most painful knee issue I've ever experienced.........I would be walking along and all of a sudden would just drop from the pain in my knee. I would wait a few minutes, start walking carefully, and everything would seem normal..........until the next time it would occur. Completely intermittent occurrences.

I went through the whole PT routine, and strengthened the area surrounding the knee that was causing the issue. At the time I thought PT was just a band aid until something drastically had to be done. Couldn't have been more wrong. Following the PT I was able to strengthen the knee area, and here we are. I get occasional light knee pain from overexerting the area, but nothing like when it was at it's worst.

Just follow the doctors instructions and you should be fine.......

As far as continuing riding, best you ask the doctor......I can tell you I had some slight meniscus damage in my other knee about 5 years ago. I was told to lay off the bike for 4-6 weeks. A week after my doctors visit, and to much criticism from my wife, I was back at it. Started easy, worked my way up, by 3 weeks later everything seemed back to normal. Probably not the smartest thing to do, but I was fortunate in that it all worked out.

[2LeftCleats]

May need to look at bike fit, including seat height and set back in addition to all the above.

[DRZRM]

Thanks all, the advice to check my fit is helpful. good. I'm pretty confident with my road and gravel bike fit, but this time of year most of my hours are on my HT 29er with my dogs, or my Fat Bike in the snow, and I'm constantly switching shoes and pedals depending on how cold out it is. The Five-Tens on flats have a different stack height than my Lake winter boots with XT pedals, and when its really cold and I switch to big ass winter boots on flats, that even further off. Even switching from my Sidis to my winter Lakes on the gravel bike messes with my stack height. I rarely put in really long miles, so I have not really worried about the fit, and I don't think my "fit" on my fat bike was anything more than putting the saddle the right distance from the bottom bracket, and ball-parking the handlebars from the seat.

Thanks for the advice, I'm optimistic about a quick recovery.

[thwart]

So I just came from my doc, and will start PT later in the week, but I figured I'd ask you all, as I assume somebody will have experience with this injury.

So I've had significant knee pain, some swelling on the inside of my left knee (so to the right side of my left knee cap) and soreness, as well as general soreness at the back of my knee, mostly rear inside, so the right. Had X-ray and then MRI and they found an unrelated hemotoma (bone bruise) from me walking into a low pole about a month ago (dummy) and what he described as my kneecap being pulled to the left by overdeveloped thigh muscles that caused the sort of pain I'm experiencing (chondromalacia patellae). Said PT should sort it where I'd do selective strengthening of the inner portion of the quadriceps muscle to normalize the tracking of the patella. Ice and inflammatory meds help, and I've been using a neoprene brace.

My doc knows I bike, but he doesn't have real sports medicine background. Anyone with experience with this injury? How long will the PT take to work? Can I continue riding in the meantime, or should I be resting it? I'm sure PT will know what to do, but anything I should know in the meantime? Good stretches?

Thanks
Only you know the timeframe here, but it may be that this acute injury tipped you over into some significant and obvious knee pain.

A lot of cyclists walk a fine line on patellofemoral issues (like yours truly) and an acute injury can push the problem into overdrive.

Everyone's experience and recovery from this is different (duh) but you've had some good advice here.

[mastaliu]

It has been said, but I will repeat it: foam roller. Focus on closed chain exercises that are careful with your knees. Be patient, take time and move slowly with your recovery.

Be careful with the diagnosis of chondromalacia patellae. That describes the condition, but its source can vary and be difficult to diagnose and treat. There is often a focus on strengthening the quads but it can be hamstrings and especially the hips that need work.

[Spoker]

Quad- hip strength, but also quad length is a factor. Stretch the quad frequently and intensively.
Agree with the "pedal with too much float" suggestion.

[ctcyclistbob]

I've had good luck over the years with these (I've used Mueller and Cho-pat brands):

[Plum Hill]

Is there any reading material on too much pedal float?

[DRZRM]

What are these called? What should I search under?

I've had good luck over the years with these (I've used Mueller and Cho-pat brands):

[akelman]

Look for a "patella strap." Or a "jumper's knee strap."

[ctcyclistbob]

What are these called? What should I search under?

Mueller:
https://www.muellersportsmed.com/jumper-s-knee-strap.html

Cho-pat:
https://medi-dyne.com/products/cho-pat-original-knee-strap?variant=11016024817707&currency=USD&keyword_session_id=vt~adwords|kt~|mt~|ta~393189442 775&_vsrefdom=wordstream&gclid=EAIaIQobChMI5MnT5LSp5wIVl5OzCh1KFwu2EAQYAyAB EgLQj_D_BwE

These and various brands are also available from Amazon and others. As Ari suggested search for "patella strap" or "jumper's knee strap."

Good luck!

[11.4]

I had major chondromalacia problems of my own which I completely eradicated, and then took the lessons I'd learned to about twenty years' worth of riders with similar problems. Everyone is different, but here are some of the ways to approach the problem.

First of all, recognize that most PTs are NOT serious cyclists and don't understand leg development in cyclist or how you've built latent leg strength (and also certain issues like latent muscle shortening). With that in mind, start very lightly on your own regimen, focusing on both rebuilding flexibility and also on selective strength enhancement. Imperative is to roll your glutes well, because they can pick up tension both from cycling generally and from coping with your injury. Your knee won't heal properly if you don't regain flexibility.

Second, do religious weight work. Start with a single kettlebell and do squats. Make them full squats (thighs parallel to the ground) and start lightly enough that you don't feel hurt afterwards. Remember you've already got a lot of latent strength and you just need to retrain the muscles around your knee joint. You don't need to go into heavy lifting, though I recovered enough to take a couple state age-categorized titles in powerlifting. You can do it.

Third, help out your knees. You may have had a good position, but after an injury it isn't going to be the same. Flexibility, muscle tension and elongation, and so on are all changes in how your body fits your bike. For starters I'd suggest raising your bars a centimeter or so to ease up on your hamstrings and consider shortening your cranks by 5-10 mm. Also slide your saddle back 5-10 mm and potentially down by the same amount. Again, remember you don't have the same flexibility after an injury and you want to help that along with these changes.

Fixed cleats can help you manage your recovery -- you will likely rotate your feet in a bit more and push your knees out more, but don't want to throw in excessive float. Align your feet with fixed cleats and your knees will find their own more-natural place. That will help restore healthy tracking to your knees.

Don't be afraid of taking some naprosyn every day -- it'll prevent pain or swelling from disturbing your knee position and your recovery efforts.

It may take a little while to get back on your bike in a normal fashion, but getting on your bike on a smart trainer with low load is a great way to transition.

Keep your legs warm -- leg warmers always and lots of warmup before you work out.

The PT will help structure your workout. I will mention I've commonly run into PTs who have knee extension stations rather than sleds or similar machines, so they tend to have you do knee extensions (calf hanging off a table and straightening the knee with load against the ankle). Those are bad for cyclists -- they can induce more extreme problems with your joint when it isn't aligned to begin with. Low-weight squats are much better. A big part of the business for many PTs requires quick responses to recovery but doesn't require recovery to real athletic prowess.

Be very reluctant to accept surgery for chondromalacia. It doesn't work all that well. Do consider stem cell therapy -- it can be very effective on this problem. And remember that the damage itself is very slow to repair or won't ever recover, so you are committing to a lifetime of training because otherwise your problem will exacerbate and leave you facing a knee replacement or an enduring handicap.

[velomateo]

I had arthroscopic surgery on both knees for chondromalicia almost thirty years ago. I’m sure that there have been changes in they way doctors approach this now, but it worked well for me. Video of the surgery showed that I had large flaps of cartilage, that the doctor groomed with laser.
One thing that I believe was very beneficial was PT before and after surgery. I had a really good PT guy, that got me on a stationary early and worked to get my muscles to “fire” in the correct order. Total time till when I felt well enough to start regular rides again, was about a year... and that was when I was young and healed a lot quicker.
Good luck

[DRZRM]

Thanks for all the advice ya'll, things are improving...though not as quickly as I hoped. For riding the dogs around the neighborhood, raising my seat and using lower gears seems to help, but most days, it seems like walking is the most aggravating thing I do. I'm not doing any long rides or climbing until I feel fully recovered. My PTist supports many of the exercises you all have suggested, and added a bunch of others. Hopefully I can ride in the spring.