If you’re a keen cyclist, runner or mountaineer then your knees are a ticking time bomb. You’ll forget they’re there until one day they begin to hurt. What happens then? You carry on and ignore them, stop doing what you enjoy, or you do something about it. If you’re a Scot, “knee bother” doesn’t sound too bad, but for everyone else it’s a right royal pain. Here’s the first of two posts on how I solved my knee injury.
If this were a TV drama the music at this point would be really dramatic and melancholic, probably self-indulgently so. I live in Manchester, UK, so suggest you put on The Smiths’ I know it’s over to read this bit.
About 18 months ago I had some knee pain in one leg. It came on slowly, a dull nagging ache under the kneecap which occasionally presented lower down my shin, and it wasn’t long before the knee ached all the time. I mean all the time: sat at my desk, standing up, walking about, driving… whatever. Running and cycling for fun were impossible (why would you want to go out to do a knee-intensive exercise if just wandering about aches, and you know it makes it worse?).
I went from doing about 10 hours of aerobic exercise a week to 0.
I did some crying, saw four different physios all over the country, spent hours reading books and watching Youtube to try and solve the problem, and spent literally hundreds of hours doing physio exercises. On more than one occasion I didn’t think I’d ever run or ride a bike pain-free again and started looking into knee replacement surgeries, which at age 30 is pretty depressing, and it’s the longest period in my life where I’ve felt down.
I’ve had plenty of injuries in the past from broken bones to snapped ligaments but this was the hardest to deal with because there seemed to be no way to fix it.
But, wind forwards a few months and I seem to be on the road to recovery. I’m just back from a 10 mile fell run, I rode 60 miles on my bike yesterday, and my knee hasn’t ached in weeks. If you’re suffering from knee pain I understand how frustrating it is – it can be a total nightmare – but in the majority of cases there will be a solution, so don’t lose hope. Replace The Smiths with something with some tally-ho.
This isn’t the sort of post I usually write, but it’s something I feel pretty passionately about. However, I have no medical qualifications and no medical training. Any advice presented here is what worked for me; it might not work for you. I did a lot of research myself but I’m not an expert and I’m only going to cover one of the million different types of knee pain. If your knees hurt then you should see a doctor or a physio, preferably a specialist, and if you’re still struggling then you might be desperate enough to read my thoughts on it. For anyone reading this who does have a medical background, I am sorry for the doubtless mistakes in my descriptions of physiology – this is how I think of it and hopefully it’s not that far off the truth. For the physios who’ve helped me, thank you very much.
The knee is a slave joint: it does what muscles tell it to do. That means unless you have structural problems with your knees (ligament damage, etc.) then the pain in your knee is probably not because of your knee but it’s because something else isn’t working correctly. Those things are likely to be your glutes, hips, thighs, ankles, or feet. So, to fix your knee you probably need to fix a muscle or two somewhere else, and that will align the knee better or make the patella (kneecap) move more smoothly, etc..
Patellafemoral pain is what I had. It was pain under the kneecap felt in the front of the knee and sometimes slightly lower down in the pes anserine bursa (a meeting point for bits of your hamstrings and adductors (inner thighs)). It was never really painful, it was just a dull throb, maybe 3 out of 10 on the pain scale, but it was constant. It moved about a bit too, never quite in the same place and seemingly not linked directly to activity level. It was worse if I kept my leg in one place for a while (e.g. driving, watching tv, sat on a plane) or if I did repetitive knee-based exercise, such as road running or cycling. Running downhill made it much worse; hiking downhill was okay but only with a lot of weight on trekking poles. The pain originates from the kneecap being pulled out of its groove and grinding a bit on the side of the knee.
Advice for improving patellofemoral pain in everyday life
First thing is to try and work out what makes it worse and stop doing it. When driving, cruise control might be a massive help, and avoid driving straight after exercise as it’ll cause your legs to stiffen up. Move around whenever you can and avoid getting stuck at your desk. Bend your legs regularly. Do regular gentle stretching. Try to forget about it and don’t let it get you down. It will, but don’t worry about it. Some part of the injury might be psychosomatic and once you notice it the pain won’t go away. Instead, distract yourself doing something else. Don’t go mad and try to do a massive bike ride, but do some light exercise. I found rock climbing helped me because it moves your knee lots, has no impacts (hopefully) and increases strength. Yoga, also, was very beneficial. Write a knee pain diary to track what helps and what doesn’t.
Get clued up yourself. Visit various physios and do what they say, but ultimately you have to fix it, so being knowledgeable will help.
Books, online articles and Youtube are amazing resources. The internet has made knowledge transfer so much easier and there’s no excuse not to learn stuff.
If you’re frustrated enough by your knee pain that you are reading this guff then by now you will know that your knee isn’t fixing itself: without you doing something different why would it get better? The most important thing, then, is to do some physio exercises which will encourage it to improve. My next post on this will go through these things.
Advice for cyclists
You’re a cyclist and your knee has been hurting for ages. This is not good; you are probably going insane. The first thing is to work out whether it’s the bike or you, or both. ‘Get a bike fit’ is what people might say but in my experience bike fits are pretty hit and miss, and coming out of a bike fit with a saddle 30mm higher than what you’re used to is a sure fire way to injure anyone, and it was a factor in why I got injured in the first place. Instead, unless you’re really desperate for a one-stop-fix, slowly tweak stuff yourself and see if it helps. Some things to try:
- Seat height. ‘Raise the seat to rid pain in the front of the knee’ is the classic advice. I bet you’ve tried that. I bet your seat is now too high. If you have a seat that’s too high your hips will rock and your knees will be ‘windswept’ to make up for it. That will not be good for you. Check to ensure your legs both track in the same position relative to the top tube; if they don’t, or if you notice uneven pressure on your saddle, lower your saddle.
- Seat fore/aft. ‘Put your seat backwards to remove knee pain’ is more classic advice. Maybe, but only to a point. Don’t make yourself overreach, but if you’ve knee pain you probably don’t want a setup with your knee at the top of the pedal stroke tracking way forwards.
- Shorter cranks might help. I went from 175mm to 172.5mm on one of my bikes and it might have helped. Not sure, but it certainly didn’t make it worse.
- Move the cleats backwards. Cleats that are too far forward make the knee angle at the top of the pedal stroke more extreme and increases the length of your lever which increases ‘wobble’. You might lose 5 watts. Who cares, if you’re pain free? I moved mine back 5mm on all my shoes and it helped a lot. Try cleats with more float if you like, but that might not help. It didn’t help me.
- Make certain your cleats aren’t worn out. If you ever ride SPDs then replace the cleats and replace the pedals. The pedals’ bearings might be fine but if the contact surfaces are shot then your foot wobbles all over the place. That’s a sure-fire way to wreck your knees. That was the best £20 I spent in my rehab.
- Multiple bikes. If you’re lucky enough to have multiple bikes and/or shoes then ride with one bike and one set of shoes for a while. That removes loads of complicated scenarios like ‘ooh was it this bike that hurt me?’ stuff. I had to ride my prize Bianchi through one of the coldest winters in recent years because it removed the complexity of wondering which bike was causing what pain.
- If you’re taking measurements of your bikes at home with a tape measure and then transferring those numbers between bikes then realise the limitations with this: it’s not very accurate. If your pro-level bike fit is set up whereby a saddle going up a few more mm throws out your hips then that’s madness: be more conservative with your bike fit.
- Reduce the intensity of your riding. I didn’t use the big ring for 9 months, which I can tell you now is really frustrating, but it removes the temptation to grind or to put down big power and make your knee hurt. Ride at 90-100 rpm and don’t sprint out from traffic lights.
- Keep riding your bike; don’t stop altogether. But, don’t go mad and do a century with a painful knee.
- Watch the Bikefitadvisor channel on Youtube. John is an absolute legend and some of the stuff in his videos really helped me. It’s an exceptional resource.
- Do the physio exercises. Accept that it might not be the bike and it might be you: this might take you months to come to terms with but it is really important.
- Accept that you will lose a lot of fitness, but it’s better to come back pain-free than repeatedly get injured after a couple of weeks. My FTP dropped from about 310 W to about 200 W. Despite being really slow, coming back to the bike feels amazing.
Advice for runners
I’m not really a proper runner but I miss it if I can’t do it when I want to. Mentally, knee pain for runners is just as bad as for cyclists, but try to keep yourself occupied with other things that you can do.
- Try running on different surfaces. Running on the road is very repetitive and running off road might be that much better.
- Avoid blasting down hills. Walk down them if it makes it feel better.
- Don’t run up hills fast. Steady is okay but I found that running up them hard made my knee hurt.
- Are your shoes worn out? Wear shoes that work with your style of running.
- Try to keep running, but pare down the intensity and the length of the runs.
- Do the physio exercises. Accept that it might not be running that’s doing it – it might just be you that’s broken and you need to fix yourself. That is hard to accept. This was the key to me getting better.
Advice for hikers and mountaineers
Carrying big packs up and down hills hurts loads of people’s knees and it’s a constant gripe among hikers. I found my knee pain was never too bad while hiking, even on really big days, but I always used trekking poles and have been walking up hills as long as I can remember: if I can’t do that anymore then I must be really buggered! I found big days out in Scotland last winter extremely beneficial for various reasons: they stopped me going insane because I was doing some exercise; they made me feel worthwhile and that I could still do stuff; and they made my legs stronger.
A physio joked that prescribing his knee patients ten hour days on Ben Nevis with a 15 kg pack might not go down too well, but it helped me.
Most hikers and mountaineers aren’t out every week. If you’ve not climbed a mountain for six months then try to hike every day for a week is it any wonder your knees ache? You wouldn’t try to run 100 km in a week having not run in six months: don’t do the same thing with hiking. Build up slowly and do other exercises when you’re not in the hills to maintain fitness. Also, do the physio exercises: they really do work. They’re coming up in the next blog post. Stay tuned.