# Patellofemoral Pain Syndrome



## dovid (Apr 1, 2003)

hi guys,

had pain in my left knee that came and went for about a year. after a trip to a clinic today that specializes in sports injuries i was diagnosed with patellofemoral syndrome. a course of physical therapy was prescribed and i'll try to start that as soon as possible. anybody else have experience with this problem? did you ride through it? i really don't want to stop riding... the doc told me it's fine to ride but to avoid hills, which basically means stop riding. also the doc confirmed what i thought all along that my left leg is a little shorter than my right leg. about a .5cm difference which no doubt contributed to the left knee problem. any moral support is welcome and would be appreciated


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## unterhausen (Jul 22, 2008)

they didn't tell me the fancy name that was wrong with my knee, but basically said my muscles weren't strong enough to keep my kneecap in the right place. I started swimming and my knee is back to tolerable levels of pain. I could never keep up the stuff they had me doing at PT. Doing those exercises always seemed to hurt more than they helped anyway As a side benefit, since the only thing that kept me from doing triathlons was swimming, learning how to swim distances is something I've always wanted to do.


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## dovid (Apr 1, 2003)

thanks for the reply. how old are you? if you don't mind me asking. i'm 25 and my left knee has been aching for about a year with a noticeable increase three weeks ago. i haven't been riding at all due to the fear of worsening the injury. do you ride with the pain? did you ride while you were doing PT? thanks.


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## CleavesF (Dec 31, 2007)

Ahahahahha! I have the same thing. I'm off the bike currently. 

Whenever you exercise, always use a knee brace. I'm on it for a month until my next checkup. I still run and spin though. 

My doc told me that it can be there forever, or be gone, or come and go. I know what you and I are wishing for!


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## v7rockista (Jul 8, 2008)

Yeah well its a syndrome so it stays with you. I am a therapist and I prescribe biking to my patients. And then after all the exercises are done, I give them a cold pack. You can do the same. I actually had some pain on my knee when I started riding but when I'm on the bike, I don't have it. There was a time that I can hardly stand much less walk with my left knee but the bike was so friendly to me. Like its very gentle on my knee. I'd say, stretch first really really well before you ride then after your ride, ice your knee. And stay HYDRATED


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## bigmig19 (Jun 27, 2008)

Raise the saddle as much as reasonable (they probably already told you that). They automatically tell you, no hills...this doesnt always exacerbate the problem though. The therapy usually helps but only if you do it religiously. By the way, limb length differences are a definite cause of foot and knee problems, unfortunately I believe you said your painful knee was the SHORTER leg. The opposite is what we expect. Long leg usually has all the problems due to compensations. Nonetheless, put a .5cm heel lift in the short shoe. Having said all that, most people do end up 'managing' PTFD as oppose to curing it and do so very successfully.


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## Jrmccain (Apr 11, 2007)

I've had the same issue for a number of years. It stemmed from a broken ankle when I was 8 (I'm 41). After the cast I continued to limp ever so slightly favoring the weak side. This became habit and caused my right leg to be noticeably weaker/smaller than my left. 
It wasn't until I was 35+ that it started to really give me problems. I had to stop running long distances (12+) and have since stopped running all together. I've tried the therapy exercises and braces but they never seemed to do any real good, I think the damage was done and rotational motions were set.
Since riding, (+1.5 yrs.), I have not experienced any problems with my knees. The only issue came about when I tried to push gears that were a little too tall and placed a lot of stress on them (I felt soreness afterwards). I have noticed a considerable increase in knee stability since taking on a riding regimen (100-175 miles a week). 
I hope to some day take running up again, all this riding has really piqued my interest in trying to do a tri.


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## dovid (Apr 1, 2003)

*hmmm...*

i'm seeing some conflicting ways of treating this problem. from doing a quick search on patellofemoral syndrome it seems that some people abandon cycling until the condition improves and the other group rides as part of their therapy. this is a little confusing. however, i don't think my condition stems purely from cycling. from September until March i didn't ride at all, but did walk and hike a lot. i remember clearly in the middle of January going down a steep mountain and my left knee was giving me trouble. the pain wasn't too bad and i took it as normal... now i have the same problem only it's a little more painful. to make things worse i bought new Sidi 5.5. Carbon Composites and haven't even had the chance to ride with them


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## v7rockista (Jul 8, 2008)

Walking and running causes great pressure on knees even if you walk in a pavement or a treadmill. For my patients, the last thing that I give is a treadmill. Its always the bike first and some exercises closely resembling pedaling. And this syndrome will not really cure completely. The pain can be manageable only. But if your body is so used to being active and exercising, depriving it of its activity will cause more problems like tightness, weakness and pain in some other parts of your anatomy. If you walk, make sure that your shoes will accommodate the difference in your leg length. Also choose shoes that have good cushioning to absorb the impact when you walk. Continue to ride. But like what BIGMIG19 said, raise the seat as much as possible to remove the pressure on your knees and transfer it to your hip.


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## YuriB (Mar 24, 2005)

YMMV but I was diagnosed before a big week long ride so I kept riding for a bit but after the ride was over I took a self-imposed 3-4 weeks off the bike.
Strengthening the "auxilliary" muscles that stabilize the knee, and ASTYM on my IT band seems to have done the trick.
I still have issues on occasion but if I get back to the exercises and work my IT band with a foam roller it seems to resolve the pain.
The real key for me was finding the right PT people. If you're in AZ I highly recommend Endurance Rehab.


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## PigmyRacer (Oct 3, 2007)

YuriB said:


> YMMV but I was diagnosed before a big week long ride so I kept riding for a bit but after the ride was over I took a self-imposed 3-4 weeks off the bike.
> Strengthening the "auxilliary" muscles that stabilize the knee, and ASTYM on my IT band seems to have done the trick.
> I still have issues on occasion but if I get back to the exercises and work my IT band with a foam roller it seems to resolve the pain.
> The real key for me was finding the right PT people. If you're in AZ I highly recommend Endurance Rehab.


Thats really the key. Just taking time off isn't going to help the majority of knee problems long term. Patellar tracking and IT band problems in particular, but a dozen other knee injuries, are related to an imbalance in ligamentous strength. Knees require complete balance and uniformity in order to function properly without injury. The only way to correct an imbalance is to strengthen weak ligaments, resting isn't going to help much with that.


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## bigmig19 (Jun 27, 2008)

Just to clear up one thing: you might be told to stop cycling TEMPORARILY, just like any acute problem (PTFD is chronic but can flare) until you get it under control, but ultimately you are fortunate that cycling is your bag, because it is probably the best exercise for your problem (maybe swimming).


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## Slow Eddie (Jun 28, 2004)

PigmyRacer said:


> Thats really the key. Just taking time off isn't going to help the majority of knee problems long term. Patellar tracking and IT band problems in particular, but a dozen other knee injuries, are related to an imbalance in ligamentous strength. Knees require complete balance and uniformity in order to function properly without injury. The only way to correct an imbalance is to strengthen weak ligaments, resting isn't going to help much with that.


1.) Ligaments connect bone to bone. There is no contractile tissue in a ligament, so there is nothing to strengthen. I agree that muscle imbalance can often be implicated in PFPS (patellofemoral pain syndrome).

2.) Your PT should check as a matter of course, but part of your tracking issues may be related to a tight iliotibial band. A suprising number of my PFPS patients (I'm a PT as well) have some associated IT band tightness. The ITB attaches to the lateral retinaculum of the patella, which, if tight, can exert a lateral force on the kneecap during knee flexion, causing lateral tracking and patellofemoral pain.

3.) Get a bike fit from someone who knows what they're doing. It couldn't hurt.


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## thirstyman (May 6, 2007)

shorter left leg here too. found to be femer or hip difference (not below the knee) by about a cm. I had the same PFPS pain last year as you but in my long leg. stretched the ITB and strengthened the inside quad muscle. seat as high as comfrotable. absolutely no pain whatsoever now but it takes constant stretching to make sure it stays that way. Also I have begun using an 1/8" shim on my left pedal cleat as a first step to equalize my leg length. over 200 miles per week this summer and the legs feel great.


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## CleavesF (Dec 31, 2007)

v7rockista said:


> Yeah well its a syndrome so it stays with you. I am a therapist and I prescribe biking to my patients.


So you're superseding my doctor with your expertise?

Considering the actual cause isn't even set or agreed upon, it's hard to say you'll have something for life considering the medical world can't even agree on it's initial causation.


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## v7rockista (Jul 8, 2008)

CleavesF said:


> So you're superseding my doctor with your expertise?
> 
> I am not. Doctors vary in their approach. We work closely with the doctors of our patients to get the most out of their treatments. If the doctor says no bike then no bike. But most of the time, they don't say anything about no bike so we give bike as an exercise since it the gentlest form of exercise outside of the pool. There are conservative doctors who says don't do it and some aggressive ones who says go for it.


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## kcdoc (Dec 30, 2007)

dont worry, dovid, you will ride again. PFPS is a pretty common problem. It has a number of causative factors that all basically can feed into the essential problem itself--- poor tracking of the patella in the femoral groove. The factors include: tight hamstrings, tight lateral attachments to the patella, a weak vastus medialis (medial quad), tight gastrocsoleus (calf muscles), tight ITB, increased foot pronation, increased internal hip rotation, increased Q angle, etc... You can see that there are alot of potential causes for it. Typically the best approach to treating is first finding out what the actual causative factor is, then addressing that. Usually it is due to thight muscles/ITB combined with a weak vastus medialis, Best approach is stretching of the ITB and hamstrings, combined with strengthening of the VMO. Combining a taping protocol for the kneecap is sometimes done and is based on who your therapist is. Running should be out, as should hammering on the bike. Soft pedaling is not a problem. I agree, you need to check your bike fit and make sure you arent creating too much internal angulation at the knee when riding. That can cause the patella to move lateraly in the femoral groove and create inflammation/pain. So, basically....stretch, strengthen, make sure your mechanics are looked at and corrected if needed, and soft pedaling is okay. 

My wife had it years ago. She is a runner and is now running pain free (has been for a number of years now) 5-6 miles in hills. It can certainly be treated effectively.


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## dovid (Apr 1, 2003)

thanks for the support guys! i do have to go for a bike fitting. it's something i have overlooked partially due to the cost and partially because of an ego. does anybody know any excellent fitting places that can survey my pedaling mechanics in NYC? i was planning to order a new bike this winter, so if anybody knows of bike shops that can also give me a measurement sheet for a custom frame in NYC area that would be super.


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## PigmyRacer (Oct 3, 2007)

Fast Eddie said:


> 1.) Ligaments connect bone to bone. There is no contractile tissue in a ligament, so there is nothing to strengthen. I agree that muscle imbalance can often be implicated in PFPS (patellofemoral pain syndrome).


That is a good point, my mistake.


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## Slow Eddie (Jun 28, 2004)

dovid said:


> thanks for the support guys! i do have to go for a bike fitting. it's something i have overlooked partially due to the cost and partially because of an ego. does anybody know any excellent fitting places that can survey my pedaling mechanics in NYC? i was planning to order a new bike this winter, so if anybody knows of bike shops that can also give me a measurement sheet for a custom frame in NYC area that would be super.


Cadence comes to mind, as does signature cycles.

And I will take this opportunity to shamelessly plug the shop I used to wrench for, Fit Werx. A bit of a journey for you, but there are plenty of NYC cyclists who have made the trip.


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## jmrachek (Jul 28, 2007)

As a therapist, there are several reasons you can get patellofemoral syndrome most likely the causes are a weak VMO (part of your quads) and a tight IT band. Sometimes you can have a patellar tilt which can contribute as well. Keep stretching and strengthening. For the love of god, never, ever let a doctor talk you into a lateral release surgery (the cut the retaniculum on the lateral side of the knee to "adjust" for faulty tracking. In my 12+ years of practice I have never seen one work and they basically ruin your knee. just my 2 cents.


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## Slow Eddie (Jun 28, 2004)

jmrachek said:


> For the love of god, never, ever let a doctor talk you into a lateral release surgery (the cut the retaniculum on the lateral side of the knee to "adjust" for faulty tracking. In my 12+ years of practice I have never seen one work and they basically ruin your knee. just my 2 cents.


Word.


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## bigmig19 (Jun 27, 2008)

I agree surgey is very rare and should be a dead last resort. BUT, they do work sometimes. The literature supports that. Still a last resort though. Just dont want you to lose hope. Nearly 100% of patients get functional improvement without surgery concentrating on basically what KCDoc outlined. While being dogmatic for decades, "isolated" strengthening of the VMO (your quad just inside of your patella) is more or less considered virtually impossible. However, anecdotally the exercises one does to stregthen the VMO help anyway (probably due to overall strength increase around the patella) so the exercises are not a waste of time overall.


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## jcolley (Jul 11, 2007)

I had a knee injury 15yrs ago that resulted in my discharge from the US Air Force with a diagnosis of Patellafemoral Pain w/ a possible Lateral Meniscus tear in my right knee.

After undergoing "exploratory" orthroscopic surgery to determine if the meniscus was actually torn and having some of both the medial and lateral meniscus taken out, I was told that the majority of the pain I was having in my knee had nothing to do with that.

I had a patella tracking problem in which as I bend my knee, the patella would move laterally off to the outside. While he was "under the hood", the surgeon slightly cut the lateral tendon which connects to the patella to relieve some of the pull it exerted.

I was given a very specific brace which was designed to correct lateral tracking problems. The doc and PTs told me that "any old knee brace" wouldn't do the trick and could in fact make problems worse.

In addition, I was taught various stretches, one of which I realize now was specifically for the iliotibial band. They actually used electrical stimulation to attempt to strengthen the inner quad (VMO I believe) to help "pull" the patella back to the center.

I have had knee pain for years when running, etc. and I have always thought that cycling would give me problems since I started a year and a half ago, but so far, no problems at all.

I have correct minor pains here and there by mucking around with my bike fit and think I have something that works for me.

I will definitely be seeking out a reputable fitter toward the end of the year.

I would be very leery of just wearing a brace whenever riding or doing anything unless that brace has been specifically prescribed for your condition, but that's just me.

I have never been an athletic person, but I went from hating/not doing exercise due to knee pain to taking up cycling and completing a 10hr 34min double century in a year and a half in my mid 30s. 

I wouldn't say you'd never be able to cycle again...:thumbsup:


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## jcolley (Jul 11, 2007)

edited...duplicate post


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## MT Road (Sep 26, 2004)

Let me “chime in” here..

I had PFS really bad actually when I was 18 I started Racing bikes at about 15 and was a big runner. Running during HS and so on, basically my Left knee hurt so bad it made me limp after many doctor visits I was diagnosed with PFS – I was told all kinds of things and at my young age I believed them all. I stopped all exercise as they told me at the time that the exercise (Riding and Running) gave me this issue.

I did PT for over a year and took pain meds, I was miserable and still had knee pain as well as I gained about 20 Lbs. One day I said I was not going to go through my life not doing what I loved to do so I broke out the shoes and the bike, I started slow, quit PT, and stopped taking Meds. In about 6 months I was starting to feel better when I was 22 I did my first full length Tri and was back at racing (Mostly MTB)

I am 37 now and still sometimes have pain but I average around 300 hours per year of riding (this year already over 2,000 miles) run weekly and swim once a week. Mostly I am pain free in that knee, it hurts when I DO NOT exercise. (Like on Vacations, or long 1 – 2 week work trips) I am not a doctor so you really need to find one you trust but for me I worked through it albeit I took a full year off I think I could have done a reduced schedule and worked on my legs. DO go to the gym I make sure I do weekly leg work and this seem to help (and makes you a stronger rider)

I guess the moral I want to leave is – you can be OK find a good sports doc but try to find one who understands your goals. My current Family Doc is a Tri Guy and he NEVER tells me to stop he always offers ways for me to train and heal and I value this relationship..

Good luck and it will get better but you will also have it forever (at least I do)

C


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## Body (Mar 12, 2012)

kcdoc said:


> dont worry, dovid, you will ride again. PFPS is a pretty common problem. It has a number of causative factors that all basically can feed into the essential problem itself--- poor tracking of the patella in the femoral groove. The factors include: tight hamstrings, tight lateral attachments to the patella, a weak vastus medialis (medial quad), tight gastrocsoleus (calf muscles), tight ITB, increased foot pronation, increased internal hip rotation, increased Q angle, etc... You can see that there are alot of potential causes for it. Typically the best approach to treating is first finding out what the actual causative factor is, then addressing that. Usually it is due to thight muscles/ITB combined with a weak vastus medialis, Best approach is stretching of the ITB and hamstrings, combined with strengthening of the VMO. Combining a taping protocol for the kneecap is sometimes done and is based on who your therapist is. Running should be out, as should hammering on the bike. Soft pedaling is not a problem. I agree, you need to check your bike fit and make sure you arent creating too much internal angulation at the knee when riding. That can cause the patella to move lateraly in the femoral groove and create inflammation/pain. So, basically....stretch, strengthen, make sure your mechanics are looked at and corrected if needed, and soft pedaling is okay.
> 
> My wife had it years ago. She is a runner and is now running pain free (has been for a number of years now) 5-6 miles in hills. It can certainly be treated effectively.


I wanna give this topic a new shot.
I have patellofemoral on my left knee and when I compare my left leg with my right knee than my left leg is more flexible than the right. I dont understand.
Would like to hear knew experiences if possible
Thanks


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## JustTooBig (Aug 11, 2005)

Body said:


> I wanna give this topic a new shot.
> I have patellofemoral on my left knee and when I compare my left leg with my right knee than my left leg is more flexible than the right. I dont understand.
> Would like to hear knew experiences if possible
> Thanks


It would probably be to your advantage to start a new thread (and the TRAINING sub-forum is probably a better bet than General), this is a 5-1/2 yr old thread, and a lot of the posters aren't here much anymore.


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