lateral tracking of the patella - talk to me about knees, cranks and PE

[nikki]

My knees
The latest pronouncement about my knee pain is that it's caused by lateral tracking of the patella - kneecap drifting outboard and grinding on my femur.

Likely contributing causes: suboptimal genes; dropped arch and excess pronation; slightly tight iliotibial band and weak vastus medialis oblique. Whilst the left knee has been the focus of the attention for the last five years (not that focussed, it would seem), the right is showing signs of deterioration and pain too.

I'm awaiting an MRI to find out how bad the damage is on the left and inform conversations about surgical repair. The consultant has given me stern words about losing weight and not doing activities that undo any work by surgeons or physios. (I'm currently seeing a physio, but he's the 3rd due to department rotations and I think they've all mostly giving up on me - hopefully this latest news can spur things on a bit.)

PE
The banned activity list is a bit vague at the moment. When asked, the consultant said "kneeling" and "climbing stairs" (attic-flat-related ). When asked about cycling he said on the flat was okay, but if it got hilly enough that I had to get out of the saddle then that was bad (hospital-where-I-get-my-physio-treatement-at-the-top-of-a-bastard-hill-related ).

Q1) Can anyone tell me why honking's bad in this context? Is it a geometry thing or a size of force thing?

He also talked about how doing the wrong activity once could undo several weeks' worth of physio. Something about switching muscles off.

Q2) Whut?

I don't have another physio appointment until Thursday next week, so I've Googled and am self-medicating with exercises along the lines of this:


Q3) Discuss.

Ow. Just generally ow!
I can't take ibuprofen because of stomach damage, but do resort to ice every so often. Knees are hard to ice with iceblocks (the camping ones) though, and the bag-of-peas substitute I've got just doesn't seem to hold any coolth.

TENS got a brief mention on the Wiltshire tour.

Q4) Has anyone any experience of TENS for relief of knee pain...
Q4b) ...or of getting TENS treatment from the NHS - any chance they'll lend me a machine?

On the bike
I'm a short-arse; it's probably time to try shorter cranks.
I'm just over 5' and the current cranks on my runaround hybrid and my tourer both look like they're 170mm.

I've googled enough to think I should be aiming for something in the region of 160 - 165mm  ...and also that there are loads of different sums that claim to tell me what crank length I should have, so I reckon I should just try and see what happens.

I've not had any dealings with cranks up until now. Halp!

Here's what I've currently got on the hybrid (photos sensibly taken in daylight):







Here's what I've currently got on the tourer (photos a bit crappy - sorry)





Q5) What tools am I going to need? (does the spidery bit on the right hand crank come off too, or is it a separate component?)
Q6) What are the keywords I'm looking for when searching for replacement cranks?
Q7) Has anyone got any suitable cranks of target length that I could try out for a bit, please?

I'm also making a conscious effort to use lower gears and have raised the seat on the hybrid as much as I dare.
Q8) Is there anything else (low budget) I can try?

Q9) This post is plenty long enough now, isn't it?

[Hot Flatus]

I had this.  I used to have to tape my kneecap when going for long walks.  I don't seem to get it anymore. I think it was exacerbated by having saddle too far forward and too high.  I did some exercises to strengthen the VMO muscle too.

[Ian H]

Is this the same thing I had in a minor way, caused by an imbalance of the thigh muscles, pulling the patella off track?  My physio, apart from specific exercises (which I can't recall), recommended walking off-road – pebble beaches were mentioned. 
I'd say beware of NHS physios. My experience is that they are far more negative and less pro-active, than private, dedicated sports physios.

[nikki]

Hmmm, I'll add taping to the list of things to ask the physio about.

Is this the same thing I had in a minor way, caused by an imbalance of the thigh muscles, pulling the patella off track?

He reckoned that's part of the problem, but that I'm also generally predisposed to it too 'cos of the way I'm put together.

(Oh! Walking downhill is frowned upon too, apparently.)

I think Kim/barakta mentioned a sports physio at the uni - holding that in reserve depending on how the NHS step up!

[Hot Flatus]

Taping just stops the patella moving sideways, it won't cure the cause.  I used to do step ups on the stairs.

[Pedal Castro]

I had this, as said upthread NHS physios were  no use at all. I cured it in the end by stretching. The physio gave the leg strengthening exercises which had no effect so I thought laterally and came up with longer muscles as an alternative. It was magical, a 30s quad stretch (each leg) once a day for about a week and then whenever I feel a twinge.

[Hot Flatus]

I think that might be what cured me. I did loads of ITB stretches at the time.

[toontra]

Sorry to hear the negative NHS physio comments.  I've recently had a similar problem (problems caused by incorrect knee tracking - but mine inward) effectively treated with several sessions at my local NHS physio centre and by following their treatment plan rigorously.  For me the answer was slow one-legged squats concentrating on the knee tracking, as well as half-balance-ball work, but they tried lots of other stuff as well.

[hellymedic]

In general:
Try not to straighten your knee against large loads.
Use the lowest gear possible.
Take care going down stairs and put as much weight as you can through your arms on a handrail.
Do straight leg raises with weights (eg rice bag) on your ankles. Do these lying down. Just raise your foot a few inches off the floor, hold, repeat
Sit with knee extended when your doing little. See how long you can keep that knee straight.
Do not straighten your knee against resistance....

[redshift]

Knees. 
I put one through a window when I was 13, and tore the MCL of the other one in 2001.  For context I also have a dud sacroiliac joint on the right hand side, and since March there's something going on under my left trapezius that's either nerve damage or something nasty in the cervical spine department.  Either way, I'm under orders from both the doc and the physio.  Mostly not to lift anything weighing more than 5kg. 
Disclaimer: Nothing that works for me is relevant to you, but...

The VMO exercise that concentrates on the last 5 degrees or so of the knee extension is worth doing.
Generally I've been told to keep force through the knee constrained such that the knee joint line remains behind the ball of the foot whilst it's under load.  This does actually seem to correspond to the canonical 'knee-over-pedal-spindle' that is mentioned in cycling literature, and one of the reasons I had a bike fit done by Paul Hewitt - the bike is never a problem. It makes walking up the studio stairs interesting, as they are pitched a little differently and require concentration.  Keeping the lower leg/foot in line with the upper is also good - I tore my MCL because the thigh and lower leg weren't aligned when I put the leg under stress.

I kneel (carefully, barefoot) and perform basic aikido or iaido exercises: particularly moving from seiza to toes tucked under and then rising smoothly.  I find these help, but that's mainly about hip power and stability, which all helps.  If I kneel at work in my steel toecaps, because I can't get my toes into the correct position I kneel on the scar on my right knee.  This is mostly numb except for the point I invariably land on if I kneel in my toecaps.  This is like having a nail driven under the kneecap.  Ouch.

Other exercises I've found useful are 'horse stance' (kiba dachi) and 'awkward chair' (utkatasana) from karate and yoga respectively, but like I said I have more back-related issues than knee-related.
The biggest benefit I've had recently was actually from throwing the desk away at work and moving to a completely upright workstation.  This has taught me much more about proprioception and posture than a whole series of lectures or textbooks.  I'm slowly unclenching my lower back, with the result that in the upper back my trapezius is also unknotting around the nerve that's irritated.

The idea of 'switching muscles off' seems to be related.  I was discussing with my physio why standing was having such an effect, and she pointed out the the brain's very good at editing unused pathways.  She suggested that sitting down for long periods (writing software at a desk, for example) means that the brain simply disposes of many routines related to balance and posture, as they are no longer priorities.  Moving to an upright posture and needing to balance reinstates the requirement for those routines.  That and the Doc's '5kg' limit make me think they're talking about retraining lots of little posture-related muscles, and exercising the larger ones gets in the way.  It's possible that's what your consultant meant.  It could also be bollocks, but what I'm doing works for me.

TENS works for me, but I've mainly used it on my back.  I've never tried it on the knee, simply because the MCL is long past the point where it hurts.  If I could use it to drain the fluid, on the other hand...

I'm 5'3 and use 165mm cranks (Stronglight) but could probably go shorter, I just haven't felt the need.  Like I said, the bike fit is good.  However, I'm still on square taper bottom bracket, and the stuff in your photos is newer and needs analysis by someone more familiar with up-to-date Shimano gear than me.

Low gears, high cadence are usually considered better for knees, and on the trike I used to try not to drop below about 85-90 rpm.  I was fitter then, though!

[BrianI]

Must be something in the air, with all these gammy knees in yacf at the moment!

Hope everyone who is sair of knee, is less sair of knee soon!   

[barakta]

Kim has the tool for crank swapping, you're welcome to borrow/visit/fettle.  She may also contribute about KneesTM when she's not in nosignal land.

Physios are weird, I've had good and bad on NHS. My hand physio has been SUPERB but some of the OTs in that same dept were meh (modelling splints off their own hands when mine is biomechanically different for example).

[nikki]

Must be something in the air, with all these gammy knees in yacf at the moment!

Hope everyone who is sair of knee, is less sair of knee soon!   

*nods*

(Also, it took some self restraint to not say "well, it's gubbed", when he asked me what was wrong) 

Redshift: oof! That's a lot of aches and pains! 

Disclaimer: Nothing that works for me is relevant to you, but...

Ah, but it might help getting my brain tracking laterally, and that could be useful!
Probably the working position thing is relevant!

Helly: thanks - noted

Toontra, Flaatuus, Pedal Castro: I've been doing various squat variants since the Spring. On seeing them, this new physio declared my squats to be immaculate! (There have been a lot of squats!) Also static quads, clam stretches, long lever leg raises... I'm guessing that if there's a muscle imbalance some of these might have made things worse, though.

ITB only really came up in the last session - he did some deep tissue massage and I acquired a foam roller shortly afterwards and have been trying to work things a bit looser. I was looking at some stretches earlier today and think I've found a few that I can add onto the list, too.

Taping just stops the patella moving sideways, it won't cure the cause.

Understood - given that I still need to move about and work on the weight loss thing, it might have its place in the arsenal of tools.

[nikki]

Kim has the tool for crank swapping

:: not surprised face :: Thanks!

[BrianI]

(Also, it took some self restraint to not say "well, it's gubbed", when he asked me what was wrong) 

 

Toontra, Flaatuus, Pedal Castro: I've been doing various squat variants since the Spring. On seeing them, this new physio declared my squats to be immaculate! (There have been a lot of squats!) Also static quads, clam stretches, long lever leg raises... I'm guessing that if there's a muscle imbalance some of these might have made things worse, though.

In my case squats are a Bad Thing according to physio, so just limited to leg raises, which I've been guilty of not doing much of....     

[hellymedic]

I would imagine squats might be unwise for nikki too.

Did I advise against straightening the knee against resistance?
Twice?

[nikki]

Where do we think swimming might come on the spectrum of no resistance <--> resistance?

My spidey sense is that it'd be a good non-impact exercise to help with mobility and the weight loss and strengthening hip muscles, but perhaps a bit too much knee-work whilst there's the imbalance. (I tend towards breaststroke.)

[Ningishzidda]

How long ( in years ) have you been riding a bike, and how many steep hills have you ridden up?

[toontra]

I would imagine squats might be unwise for nikki too.

Did I advise against straightening the knee against resistance?
Twice?

Absolutely.  I wouldn't dream of giving someone medical advice.  I was just saying what had worked for me (with a different problem), and also putting in a word of support for the NHS physios who treated me.

[DaveE128]

I had pains that as far as I remember were also caused by patella tracking issues, which were due to a muscle imbalance (relative weakness of the vastus medialis oblique AFAICR), probably as a result of cycling. it was so painful that the muscles around my hip would spasm and cause hip pain as well.

I saw an NHS physio who gave me two exercises to do. One involved moving up and down with one foot on a step while keeping various positions carefully controlled, the other was straightening the leg while sat on the floor with a rolled up towel or similar under the knee. Both involved doing the last bit of extension (that you don't do on the bike). I don't think that there is much resistance involved in either exercise as the weight of the lower leg is all for one of them, and the other, although lifting body weight, the leverage is massive. I wouldn't suggest trying to do the exercises without being instructed by a medical professional so that you do them right, so I have haven't tried to describe them in detail. Googling exercises to strengthen the VMO finds many different variations and none that are exactly the same as what I was given.

These two exercises sorted the problem rapidly for me. Every now and again the issue comes back slightly and I remember that I should be doing the exercises regularly. I do them and it goes away again.

I find the issue reccurs more often after doing more mountain biking, probably due to riding with a slightly lower saddle. Still no issues if I remember to do the exercises occasionally though.

No complaints about the NHS physio I saw! Didn't even have to wait many weeks for an appointment. This was about 10 years ago though.

Oh, and about changing the cranks:

With the ones on your hybrid, I'm not sure, but it looks like the chainrings are permanently fixed to the cranks, so you need to by a whole new chainset (also called a crankset sometimes). With the ones on your tourer, in theory you can buy just cranks but in practice it is easier to source (and often cheaper) a complete chainset. However, if your chain is significantly worn, changing the chainrings will cause the chain to slip when you push hard on the pedals, which is quite unnerving and potentially even dangerous. (see http://sheldonbrown.com/chains.html for explanation. I have experience this!) If your chain is significantly worn, you'll probably want to change the chain, chainrings and cassette at the same time (£££!) or with your tourer cranks, buy the exact same ones in a different length (model number will be on them somewhere, but they might not be easily available any more, depending on how old they are - maybe try ebay for used?) and swap your current chainrings onto the new cranks.

Tools and procedure wise, I suggest you check out Park Tool's excellent website: http://www.parktool.com/blog/repair-help/how-to-remove-and-install-a-crank

[Kim]

FWIW, I found that clipless pedals made a massive difference to my patella tracking issues while cycling.  To the point that it's not really a problem in day to day life^[1], as long as I keep putting the miles in and don't try to push heroic gears.  The catch is working out exactly what cleat position you need to keep the knee straight, which probably involves either bike-fit voodoo, or a whole lot of trial-and-error that will exacerbate the problem.  It would also involve the non-trivial problem of shoes.

I've got a set of 160mm XD2 cranks (and some appropriate chainrings) currently lying around not doing anything after failed Brompton gearing experiments.  The catch is that they're a 110mm BCD double, so it's limited to a 33t smallest ring, which will limit the bottom end somewhat.  (Reconfiguring your shifters to work with a double shouldn't be a problem.)

http://www.physiokinetic.co.uk/ are the local sports physios.  They know a thing or two about knees and have sympathy for student budgets.  Seeing them for an assessment probably wouldn't be a waste of time.  They're also handy in that you can usually get an appointment with someone fairly quickly, in the event of acute gubbedness.


_{[1] This is a lie.  My day to day life involves using a bicycle instead of walking for distances of more than about a mile, specifically to avoid knee problems.}

[nikki]

How long ( in years ) have you been riding a bike, and how many steep hills have you ridden up?

About 3. I self-censor for what I* call hills (Clent, Dufton, Day 3 of the Wiltshire Tour) - knee pain, innit.


Calibrating with what the consultant regards as being a hill is on the to-do list.

Absolutely.  I wouldn't dream of giving someone medical advice.

Don't worry - usual forum filters in place and I consider all this initial research and brainstorming rather than Things That Are Definitely Appropriate and Will Work.

The NHS in its current state hasn't work particularly well for me over the last few years, but I'm still mightily grateful it's there.

I saw an NHS physio who gave me two exercises to do. One involved moving up and down with one foot on a step while keeping various positions carefully controlled, the other was straightening the leg while sat on the floor with a rolled up towel or similar under the knee.

They both sound very familiar from the last 9 months!

Oh, and about changing the cranks:

With the ones on your hybrid, I'm not sure, but it looks like the chainrings are permanently fixed to the cranks, so you need to by a whole new chainset (also called a crankset sometimes). With the ones on your tourer, in theory you can buy just cranks but in practice it is easier to source (and often cheaper) a complete chainset. However, if your chain is significantly worn, changing the chainrings will cause the chain to slip when you push hard on the pedals, which is quite unnerving and potentially even dangerous. (see http://sheldonbrown.com/chains.html for explanation. I have experience this!) If your chain is significantly worn, you'll probably want to change the chain, chainrings and cassette at the same time (£££!) or with your tourer cranks, buy the exact same ones in a different length (model number will be on them somewhere, but they might not be easily available any more, depending on how old they are - maybe try ebay for used?) and swap your current chainrings onto the new cranks.

Tools and procedure wise, I suggest you check out Park Tool's excellent website: http://www.parktool.com/blog/repair-help/how-to-remove-and-install-a-crank

Thanks! I had feared having to buy a new chainset as part of the process 
I think I've got some spare chains stashed away somewhere, though.

Ooh! Thanks for the Park Tool link - I'd Sheldon'd, but forgotten about them. Looks like the identification stuff will help me get a grasp of what's involved and what I might have.

FWIW, I found that clipless pedals made a massive difference to my patella tracking issues while cycling.

*shudder* I still have the image of my sister's wrist come to mind any time that gets suggested.
I know, I know...

Budget constraints probably postpone the pedals/fit decision for now, anyway. Cranks I think I'll have to research, but hopefully I can consider them a worthwhile investment

Will maybe chat to you about the cranks, but I'm hesitant about changing up several elements of the system - too many variables to be able to judge the effect of the cranks, perhaps?

Thanks for the physio link
*clicks*

[ian]

I had problems a couple of years ago and I stopped using clipless pedals. Probably a good thing if you get them perfect, but they're likely exacerbate otherwise. To be honest, knees are guaranteed to cause problems as we age, so some aches and pains are to be expected. I did the physio and the exercises and it mostly went away other than occasional soreness. I stretch a bit, but if I overdo it, that tends to make my patella free-range. I did also start to spin the pedals rather than grind, I always used to be a bit of pedal masher, now I aim for a gear lower and up the cadence. Also check seat height so you're not over-extending your legs. I also have to kick with less vigour when doing breast stroke, that seemed to cause issues, so now I try for a smoother motion.

I replaced the cranks/chainset on my commutified BSO – OK, I attempted – with a basic Shimano Acera set. I think they cost about £23 quid for the entire kaboodle including chainrings. I say attempted because my bottom bracket disagreed with sizes which meant the front mech couldn't negotiate properly. At which point I dumped it with my local LBS and they fitted a new bottom bracket, and fitted an entire new drive train for about £40 labour.

[Kim]

FWIW, I found that clipless pedals made a massive difference to my patella tracking issues while cycling.

*shudder* I still have the image of my sister's wrist come to mind any time that gets suggested.
I know, I know...

I'd be more concerned about exacerbating problems with badly-fitting shoes or poorly aligned cleats TBH.  Everyone^[1] falls off once, but it's usually just pride that gets injured.  Usually.

And if you're particularly unlucky, the unclipping motion itself can be problematic.

Will maybe chat to you about the cranks, but I'm hesitant about changing up several elements of the system - too many variables to be able to judge the effect of the cranks, perhaps?

Indeed.

Probably worth you having an experimental ride on my Brompton (160mm cranks, sensible gearing, nikki-friendly seatpost adjustment) as a quick and easy way to see how the difference feels^[2], but that's changing an awful lot of variables to conclude much about knees.  Similarly, barakta's trike (152.5mm cranks, but that's got basically nothing in common with what you're used to riding).

http://www.spacycles.co.uk/products.php?plid=m2b0s109p0 is the go-to place for affordable short (160/165) cranksets.  They seem to be having stock issues, thobut.  Shorter than 160mm is where it gets tricky (unless you only want a single chainring, as per most kids' bikes).

_{[1] Exclusive tricycleists don't count.
[2] If you think "Oh, my legs don't feel like they're flapping about!" then that's a pretty good indication that your usual cranks are Too Long.}

[nikki]

At which point I dumped it with my local LBS and they fitted a new bottom bracket, and fitted an entire new drive train for about £40 labour.

My LBS-owner passed me the other day and said I should pop in for a chat (he's moved to new premises). He may yet get this dumped on him!

Probably worth you having an experimental ride on my Brompton (160mm cranks, sensible gearing, nikki-friendly seatpost adjustment) as a quick and easy way to see how the difference feels.

Yeah, go on then; will email...