Knee pain with hill climbing

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  Mar 20, 2007 7:40 PM GMT

  I'm 6'4", have a 60cm frame that I got professionally fitted for me, so I'm pretty sure all the geometry is correct. Yesterday I started sprinting up and down Stratford road in Austin which is just 2 miles of up-and-down, short, steep (maybe 8-14% grade) hills, trying the HIIT thing, trying to keep my heart rate high through the sprint.
  
  First of all, it's actually quite hard for me to keep my heart rate pegged because I can't seem to work hard enough on the flats and especially downhills to maintain 170 bpm, which is the threshold where I feel like I'm going to explode. I was trying to stay over that, and at least on the uphills I mostly got there, or at least the mid-160s. It'd probably be better on one solid 2 mile uphill, but I don't really have one of those near my house.
  
  Okay, sorry, on to my real question: on my second 4-mile interval I noticed my right knee was aching. It wasn't really pain, but more of a pronounced, acute heat on the front of the joint right above the kneecap.
  
  I think that was coming from climbing the hills while seated, where some were steep enough that even in my granny gear, it was a pretty low-cadence, high-torque pedal stroke, and so I was putting a lot of pressure on the joint when the kneecap was out in front of the foot, which my yoga teachers routinely condemn as very bad for the knee.
  
  I switched to more standing-climbing on anything remotely steep, but that actually made it harder to get my heart rate high, since that makes it a lot of muscular work and less high-speed aerobics.
  
  I think my front granny gear could be significantly smaller (I rented a bike in SF a couple weeks ago and was stunned to find how low the lowest gear ratios were, it blew my bike away,) but other than that, does anyone have any form advice on preventing knee pain while cycling?

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  Mar 21, 2007 10:30 AM GMT

  It sounds like you a form of anterior knee pain syndrome, but that comes in 4 flavors, or a combination of more than one. Further, you were not very clear about the location and pattern of the symptoms. “Above” the knee cap meaning superior/proximal part of the knee part or inferior/distal part near the patellar tendon? Is the pain only with descending? Does it feel unstable? Any clicking or locking? Or is there snapping/popping?
  
  Anterior Knee Pain Syndrome are:
  1. Patellar mal tracking, subluxation, pathological positioning. Does the knee cap travel in a pathological path during knee motion because of laxity or poor tension ratio of various parts of the retinaculum tissue? It is too high riding (superficial retinaculum)? Is it tilted (deep retinaculum?)
  2. Patellar condrosis. The cartilage surface of the knee cap is wearing down, Sort of like patellar arthritis. This can happen without any patellar mal tracking, subluxation. Vice versa, having a lax patellar that subluxes does not mean you are at the confrosis stage either.
  3. Patellar tendonitis with patellar bursitis. The patellar tendon is irritated. It can be caused by poor quad conditioning (too tight), mal tracking, micro trauma, poor mechanical loading of the tendon. Your yoga teach was referring to excessive knee flexion with decreased hip flexion ration (the quad crosses 2 joints). This loads the knee distally and very stressful on the patellar and patellar tendon.
  4. Plica Syndrome. The inner surface of the knee joint capsule have small creases and with repeated micro trauma or acute trauma, these creaseses can get inflamed and thickend to the point of forming bands. These intra aarticular bands can snap over the knee condyle joints or get impinged inbetween the patellar and femeral condyles. This condition is most often misdiagnosed because the symptoms of snapping and popping correlates with meniscual tears and patellar subluxation.
  
  If you have more questions, you can email me. Be aware when you shop for doctors. Only a seasoned sports ortho doctor who treat knees as a specialty would likely able to treat you with the best results. And there are even more BAD

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  Apr 03, 2007 4:33 AM GMT

  as a triathlon coach. be careful when you train in the hills, especially if you are not conditioned. you have to build a base 8-12 weeks of areobic training. your target HR seems kind of high. My anaerobic thershold is 165 on the bike. Remember that when you train on HR, that the target HR is just a "cap", if you don't reach it, it's OK. Techique for climbing is important, keeping your cadence at 65 RPM is as low as you want to go. sitting is the best, especially for long climbs (ie. 2miles). good luck, ride the flats for a week and easy gears, spin 90 cadence.

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  Apr 11, 2007 10:14 PM GMT

  Thanks for the responses, guys!
  
  Sorry, yeah, I could have been clearer. Anterior on the knee and proximal to the patella.
  
  The knee joint doesn't feel unstable, and the pain is a consistent dull ache, and -- once it has started -- it becomes worse as I load the knee during extension, from what I can tell.
  
  I think there are other aches I'm feeling as a result of compensating for this, but they are minor; this is the major one. Furthermore, it is not acute, it's more like a radiant heat in that area, and feels simultaneously both relatively superficial -- which would lead me to suspect minor inflammation of the quadriceps tendon (sorry, I've been erroneously calling it the patellar tendon, not realizing that only describes the tissue distal from the patella) -- but also relatively deep. It's hard to be entirely sure but it seems that I've felt some of this ache/heat on a line across the knee where the femur and tibia come into contact. Again, it's not so localized that I can be sure I'm not just imagining that kind of precision, though.
  
  There is no clicking, no locking, no snapping, no popping in the joint. If I sit, hold my leg up, and alternately flex and extend the knee, right as I reach full extension (with the leg muscles engaged, doing the work) I can hear a very soft "crinkling" noise in the knee joint.
  
  I have good flexibility in my upper and lower leg musculature; my hamstrings have enough length that in a standing forward bend I can put my palms on the ground, and my quadriceps have enough length I can get reasonably far down into the yoga pose called Supta Virasana; see:
  
  http://yogajournal.com/poses/790_1.cfm
  
  Not quite like the model there; I can't get my hips to extend fully, but well past 90 degrees, certainly. So I'd be surprised if this was from muscular tightness.
  
  I believe the patella is tracking well, but I could be wrong. Certainly, it does not feel unstable, nor does it seem floaty, it's not moving side-to-side.
  
  I went and got my bike re-fit -- I'd had it fit in January and had the stem shortened and seat adjusted to take work out of the lower back and arms when riding very long distances, but I asked them to undo that and put it back, since now my knee is hurting. He actually said the seat was a bit too high, which suggests the knee was extending too far, which could maybe have been causing the pain. I read about pinched fat pads, and while it sounds like the pain from that is generally distal to the patella, it sounds similar in nature.
  
  My yoga teacher also just remarked that it could be general compressive aches from poor mechanical loading if my bike wasn't fit quite right.
  
  I've ridden 18 miles on it today with the new fit (it was hailing over the weekend, so I missed out on riding! Ugh!) and it seems, so far, improved. We'll see as I bike more.

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  Apr 11, 2007 10:20 PM GMT

  USTri: I'm going on my lactate threshold, here, which seems (based on the perceptual measurements, "have someone stand next to you and tell you when you can't carry a conversation comfortably") is right around 175 or so (it appears the term there is LT2, the point where I can only sustain it for a few minutes at a time), and so I'm riding to push myself up close to that and hold it for a while, so it remains aerobic but is really working me into a lather.
  
  I've been training again in earnest for a few months, now, 100 miles a week kind of thing, so I think my tissue's in reasonable shape.
  
  Furthermore, I had this same knee pain not even sprinting up hills, but recently in a 70-mile ride I did where stronger riders than I were pushing my limit a bit, I was averaging more like 160bpm consistently while riding, but there wasn't much climbing, not a ton of heavy loading on the knees. That led me to suspect just a poor bike fit, which was going to cause me aches commensurate with longer rides no matter what.
  
  We'll see. Thanks again for the thoughts, guys.

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  Apr 11, 2007 11:49 PM GMT

  Still riding at your HR 160 is not aerobic, you are right on the edge red lineing sort to speak. what is your cadance as well? aerobic would be 150 or under, use it as cap not a target, 130 to 150 would be your range. keep a cadence of 100-85 on the flats and ride the hills 65 or more. plus get the postion of your cleats looked at.

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  Apr 18, 2007 1:42 PM GMT

  Atxclimber
  
  The yoga position you referred to only stretches the distal portion of the quad, near the knee. The quad crosses 2 joints, the hip and the knee. Full flexibility of the quad requiresbotht he hip to be extended (legs going behind trunk) and knees flexed. It is called a Thomas test position. Furthermore, if your legs deviates in hip adduction in this position (legs spread open,) that would also mean not just quad tightness but also ITB band tightness. A lot of runner with IT tightness also have proportionally weaker hip abductors and weak quad VMOs.
  
  The cracking you hear with knee ext is most likely your patelalr and not the meniscus or any other structures of the knee. It sounds like condrosis or the cartilage wear under the patellar. The ony other structures taht can make such sound is a torn meniscus, but that would be very painful and can lock up, and medial shlf plica thickening, but taht is more like a snap than crackel.. It only takes a small amount of mal patellar maltracking to produce this. And this may NOT be the source of your pain. The location of your pain sounds like pataller tendonitis or inferior pat pad and bursa infallmation.
  
  You need to check your whole quad flexibility, ITB tighness, VMO and hip abductor strength ratio...

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  Apr 18, 2007 1:48 PM GMT

  Also, do you have patallar alta? To high riding patelalr? That would put your patellar tendon (some call it patellar ligament or distal quad tendon, all the same thing...) in a poor biomechanical position to act as a sessmoid bone increasing lever and producing torque for knee extension. Depending on the hip flexion and knee flexion ratio, patellar alta, instad of producing torque, can just load the tendon with great increasing non rotory shearing force, causing irritation.

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  Apr 18, 2007 1:54 PM GMT

  Also try biking with hihger seat, this way the ratio of flexion between hip and knee at any one time is dirfted towards lowered knee flexion, decreaing loading of the patellar tendon.
  
  In another word, higher seat prevents you to flex your knee too much when you push...

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  Apr 18, 2007 9:13 PM GMT

  NYC: That's awesome info, thanks. As for the yoga pose, if you flex the knee fully and extend the hip fully, lying back on the ground with the heels by the hips, doesn't that stretch the quad fully? short of extending the hips past 180 degrees, but that's uncommon, I thought.
  
  As for the cracking noise, it's very soft, just a kind of crinkling, and I just assumed it was some random inflamed tissue getting squeezed or whatever. I'm getting an MRI this Friday so I'll see if there's any serious cartilage damage, but I finally made it in to my sports doctor and he palpated the joint, inspected it, did as much as he could short of the MRI and said he doesn't think we'll see any long-term damage, and that it's just general inflammation and swelling from overuse, and that while I should obviously pay attention to my biking form, he doesn't think I'm doing anything terribly wrong.
  
  When I had my bike re-fit, the fitter dropped the seat just a touch, in fact. I'm almost thinking my knee was extending a bit too much on the downstroke, pinching a fat pad or bursa or something and causing the inflammation.
  
  But then I went riding Saturday and Sunday, only did 25 miles Saturday and 60 Sunday, and my knee's been really grumpy for the past couple days. Just general soreness, nothing acute, and doctor says I should be fine to ride the MS150 this weekend ("You'll be hurting afterwards," he said, "but you won't be doing permanent damage -- ice it and take some NSAIDs.") I'm trying to get some Celebrex out of him for the ride. We'll see.
  
  My lower legs bow outwards a little bit, and so I think my knees are just biomechanically kind of crummy, but hearing my doctor say all the ligaments are quite intact and he didn't hear any concerning noises or feel any unusual flexibility was reassuring. He said if there had been major cartilage loss or flap tears, we'd have been able to tell.
  
  In paying more attention to my biking form, I noticed I've been, uh, pronating is the word, I guess, collapsing into my inner arch as I pedal, which hasn't been distributing the weight over the joint very well. When I was more careful about that, the tendinitis-like heat and localized ache went down, and instead I get this inside-the-joint soreness that feels more like general overuse swelling. I guess that's progress, kind of. :)
  
  Now I'll just hope the MRI comes back all clear. :)
  
  Thanks again for all your information. Slowly, I'm learning...

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  Apr 18, 2007 9:44 PM GMT

  MRI's will see most soft tissue but not the ideal for some conditions. To view patellar condrosis, the best way is X ray but in the Merchant or Sun Rise view. This is because traitional AP & lateral, full flexion, and weight bearing views does not see the under side of patellar clearly due to super imposing of image. Merchant view is taken with the knee in flexion, and the X ray is taken on top of the knee cap, veiwing into the contact space between patellar and femeral condyles. This way, you not only see the surface of the underside of the patellar, but also how itrides onthe femeral condyles (passive mal positioning?)
  
  Furthermore, a lot of radiaologists misinterpret thickening of plica as normal. make sure a very experienced ortho sports radiaologists reads your film.
  
  And the pose you described is not so clear to me... It is best to use precise medial terms to describe positions. Thomas testing position is with one hip flexed fully with the knee up your chest while the other one hip in extension and knee flexion. This is done so the entire pelvic structure is in flexion, leaving the stretched leghanging with just the hip flexors and quad. One modified way to do this is like a one leg loundge with the other knee on the floor, rock forward so the hip with the knee on the floor is in extension, then flex the same knee on the floor even further by getting thefoot towards your buttocks..
  
  What you are also describing sounds like you have ankle/foot issues. Pronated foot also promotes knock knees, or genu valgus. You also mentioned you turn out your feet? That can be tibial rotation. Pronated feet with genu vlagum and external tibial rotation puts stress on the medial collateral ligament. Unless you see an ortho MD, most physicians do not understand to test the MCL in various degress of knee flexion. It shoudl be tested in full knee ext up to 40 deg of knee flexion. The reason is because the MCL is actualy in slack when knee is in full extension, and more tight in knee fkexion af about 40 deg because it has to bedn witht he curvature of hte knee flexion while being bound down by retinabulum fibers.
  
  Hope that helps.

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  Apr 18, 2007 10:31 PM GMT

  Wait your legs bow out aliitle meaning genu varus not valgus? Meaing the opposite of knock knee? That changes EVERYTHING...

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  Apr 18, 2007 10:56 PM GMT

  ATX- I think the seat to pedal ratio has alot to do with why people injure their knees cycling..
  mike

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  Apr 18, 2007 10:58 PM GMT

  That is why I recommended trying higher seat...

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  Apr 19, 2007 8:47 PM GMT

  Yes, the opposite of knock knee. When I stand up with the inner borders of my feet touching, my knees do not touch. The top of my tibia, where it meets the femur at the knee, curves, so the inside of the shin -- where you get shin splints -- is concave, bows away from the midline of my body.

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  Apr 19, 2007 8:52 PM GMT

  To be clear, my knees are only about 1" apart when I stand with feet together. My legs don't bow dramatically; you can't tell if I'm wearing pants, and even wearing shorts, you'd have to look closely. It's a very slight curve to the tibia. My femurs are normal.

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  Apr 20, 2007 4:50 AM GMT

  ATX
  
  So. you have genu varus. Now do you hyper extend your knees? That would be called genu recurvatum. If you do, also check for ACL laxity. Now, your feet are pronated? meaning the arch is flat? Your heels also slides outwards...?

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  Apr 21, 2007 4:24 PM GMT

  Nah, I don't hyperextend, and the knee ligaments feel solid (it makes my skin crawl when my doctor palpates my knee, the various twisting and jerking to feel whether the ligaments have any give, but he said they're all solid.)
  
  Because my tibia has a curve -- or anyway this is my theory -- the weight isn't coming down vertically, but rather in along the tibia, which puts the weight down into the arch. For the longest time in my life I had flat feet and just never knew. Now I'm much more diligent about keeping my arches raised and balancing the weight over the rest of the sole of the foot and all those details. One benefit there is that my calves are always well-developed just from walking around!
  
  Had an MRI yesterday, and I'll know results this coming week. My expectation is it'll show the cartilage and ligaments and bursae and everything are all fine, and it's just been overuse injuries and swelling exacerbated by not riding with perfect form. We'll see, though.
  
  Thanks for all the advice on here.

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  Apr 23, 2007 3:15 PM GMT

  ATX..
  
  Your legs are not the common type.. Most pronated/flat feet come with genu valgus not genu varus.
  
  The way you describe your knee and tibia structures, I would not be suprised if your MRI comes back positive for increased signals in the medial meniscus. It may not be a bucket handel or oblique tear extending to articular srufaces, but it may just be some degernation.
  
  But ortho surgeons would not do anything if that is the case anyway. They would only shave off parts of the offending menisucs torn parts if the tear shape, size, and location warrents it. Because once you take some meniscus away, since it is a cartilage, it wont grow back, and taking off too much wil lead to early onset of osteo arthritis as your MCl will be somewhat lax after loosing some menisucs materail. We currently do not ahve a great implant material for meniscus. Artificial implant materials are never the right combination of strength, pliability, and slippery quality. Previous attempts of cadever menisucs implants ended up with inconsistant and unpredicatable outcome, as the cartilage material has to be cleaned by freeze dry, and the removal of water content makes the tissue degrade.

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  Apr 23, 2007 11:38 PM GMT

  The crank position at 12 oclock is where it matters. Make sure your knee is not flexed beyong 90 deg at this position. Greater than 90 deg knee flexion will laod the knee anteriorly into the patellar tendon.
  
  You may also need cutome made orthotics for your shoes for you to pedal correctly with the right motion. Pronating feet will not only tilt the tibia, but also rotate it. Rotation of tibia on femur in knee flexion is essentially the same as the mechanical test for torn meniscus, the McMurry Test. This motion will wear out your meniscus.
  
  You wold probably need the posting instead of cushioning kind of orthotics, where it is a bit rigid.

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  Apr 26, 2007 9:40 PM GMT

  Alright, MRI results back. Omitting the full analysis, here's the final impression:
  
  ==============
  No evidence of meniscal tear
  
  The cruciate and collateral ligaments are intact.
  
  Small joint effusion, with mild lateral subluxation of the patella. In addition, there is a mild patella alta.
  
  Proximal popliteus tendon strain, with mild prepatellar bursitis versus a residual soft tissue contusion.
  
  Mild chondromalacia at the medial and lateral patellar facets, without significant marrow edema.
  ==============
  
  Yeah, so basically, my joint is swollen, some bursitis, some effusion, and yeah, my patella rides a little bit higher than normal. The subluxation, though, and the chondromalacia, I'm pretty sure were both just caused by my heel being turned inwards a bit too much while biking -- naturally if I torque the tibia externally while flexing the knee, the patella can't track correctly.
  
  I definitely didn't feel much sensation near the popliteal tendon, but again, given that it was undoubtedly being stretched by the lower leg rotation (from the improper heel position) during flexion and extension of the knee I guess that's not too shocking.
  
  They didn't really spot anything on the quadriceps tendon, which is where I'm currently feeling some discomfort. Then again, I guess the bursitis and effusion are going to increase friction just about everywhere inside the joint.
  
  My doctor did observe that the genu varum puts additional strain on the knee but also the ankle, and wrote me a scrip for physical therapy. I'm going to these guys, in Austin, and I'm actually fairly excited. I've spoken to them on the phone a few times and they sound really enthusiastic about working with athletes, and, well, *I'm* pretty enthusiastic about continuing to cycle without tearing my knees apart, so it seems like a good match. :)

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  Apr 26, 2007 10:32 PM GMT

  Glade to see that y ou have no meniscual issues!
  
  I was about right. I mentioned patellar condrosis (condromalacia) and patellar mal tracking, bursitsi, and patellar alta. I am still sure you ahve patellar tendonitis. Patellar bursitis and tendonitis tend to come as a pair. Your effusion of the patelalr tendon was probably not enough to be picked up by the MRI (MRI pcils up water or fat.) The only one I did not predict was popliteal tendon irritation.
  
  And your theory external rotation of tibia probably have indirect effect on the popliteal tendonitis, but how the popliteofibular complex intreacts with the screw home mechanism is quite complex and there likely are many other factors to the popliteal muscle tendonitis.
  
  Did youfind out if itis the fibular side or the tibial side popliteal tenond irritated?
  
  Popliteal muscle check the screw hom mechanism, the externakl rotation of tibia at the last 20 to 30 deg of knee extension, where there is not only rolling motion but also anterior glide in addition to external rotation of tibia. Uncontrolled external rotation of tibia tugs on the popliteal. If your popliteal is completely torn, your tibia would externally rotate during all motions of knee ext/flex, especially at end range flexion.
  
  I have to run but I will come back to this for those who are interested in preventing knee injuries!

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  Apr 26, 2007 10:57 PM GMT

  Proximal would be tibial side, right? I guess "medial" would be the better term. I can't keep it all straight. All it says in the full report is "proximal popliteus tendon strain."
  
  Oh yeah, I noticed that he also refers to "mild intrasubstance hyperintense signal within the posterior horn of the medial meniscus" -- albeit with no tear -- and then doesn't mention it in the later summary, but basically, I bruised my meniscus on the medial side, too. That's pretty consistent with the sensations I was feeling.
  
  Again, thanks for all your feedback on this. It's been a huge learning experience.
  
  After sitting in my doctor's office for, you know, a half hour or however long they keep me waiting, and playing with the resin-cast model knee joints with the rubberized tendons and ligaments and stuff, I have a much better mental model of the knee. I was really surprised, when I just sat down and probed at my knee as I flexed and extended my leg, how well I can palpate it by myself -- I can really feel exactly where the patella tracks, feel the cartilaginous surface of the femus and tibia when I flex the knee all the way, and can trivially feel the collateral ligaments. Certainly all the major muscle groups and tendons are easily palpated. I guess feeling the cruciate ligaments would be pretty tricky, as would some of the more subtle tendons.
  
  The less mysterious my joints seem to me, the easier it is to keep them healthy, which is nice.

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  Apr 26, 2007 11:14 PM GMT

  Becareful about the model knee joints as the parts DO NOT move the way an actual joint moves! This is the # 1mistake with the interns I teach. They coem to me and move the joint and assume it is what you see, it is NOT... You don't get the interactions of the soft tissues, contractile ones, fibrous ones bounding in difrent directions, etc. There is only rolling on the model, no gliding, no rotation, no moving axis..
  
  YES increase signal is degeneration of meniscus. So I was completely right! You DO have meniscus issues!
  
  I will post some more later..

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  Apr 26, 2007 11:20 PM GMT

  Proximal for the popliteal is the lateral superior side, not the medial side. but proximal is not a good term to describe the orientation of popliteal as it is oblique but more horizontal than vertical... That is why it checks rotation more than aiding flexion/extension.

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