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Let me tell you about my story first.

I am diagnosed to have PFPS (patella-femoral pain syndrome) about 10 years ago. Some specialists also told me that my kneecaps were tilted outwards. I kept riding few more years ignoring the pain and inflammation on my knees after the rides. Good thing was I wasn't having pain during the rides. I was starting to feel pain and discomfort on my knees following days after the ride. Finally it got really worse and at some point I was having pain even sitting on my office chair even though I stopped riding. I gave myself a long break; I didn't touch my bike at least two years. I walked a lot during this time and I think it helped my knees to heal a bit. I was riding my bike again to see how my knees are doing time to time; not more than an hour without pushing myself at all. Since last month I started to add some more mileage to my rides and reached 50 km distance on my last ride. Now I feel that my knees are starting to get upset again but I want to continue riding.

Is there anyone who's going through same problems as myself and want to share some tips to keep riding?

I'm 43 years old if it matters.

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    What is PFPS? Please spell it out, and even briefly describe/define it. Also, because this is medical related, it may get flagged to move to another exchange that is more attuned to the question. Yes, it does appear to be a cycling-specific issue and may fall into the grey area where it may be included here. Good luck in getting relief.
    – Ted Hohl
    May 7, 2023 at 17:26
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    You may the perfect candidate for an ebike, to assist with the function of pedalling.
    – Criggie
    May 7, 2023 at 19:14
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    Really cannot be answered as the first suggestion given you shot back with a variation of "Its not really riding". If you prefer to walk, then walk, or at least give us more about what you find important about cycling and be constructive about you responses.
    – mattnz
    May 8, 2023 at 4:01
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    You should consider getting tricycle or some such. They can help relieve some of the stress on your knees. May 8, 2023 at 22:12
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    I am also diagnosed with PFPS on my left knee, due to overuse, and the best thing for me was to take it very very slowly. Doing very short and easy rides, that didn't aggravate the pain, and progressing very slowly to slightly longer rides each month. A week every month would be a recovery week, when I barely ride at all, and instead do simple stretching and foam rolling.
    – Robert
    Jun 16, 2023 at 19:19

5 Answers 5

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I think you really have to see a professional (or several) for this. The first priority would be to make sure your seating position is not causing or aggravating the issue. A physiotherapist who’s specialized on cyclists or a bikefitter should be able to do that. A good physiotherapist will also be able to pinpoint the underlying problem and tell you what exercises you should be doing. Maybe a few abductor or abductor exercises are all you need. Or maybe you need shims under your shoes.

The next thing (and the only thing we can really help you with) is making sure you have enough easy gears. If you are “grinding” hard gears uphill at 60rpm it is really taxing for the quads and patella tendon and your stabilizer muscles will struggle much harder to keep the knee stable. If you lack those easy gears we can make suggestions on which parts to change.

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    the only thing we can really help you with Bike fit specifics matter, too, especially saddle height and pedal/foot orientation. IMO that can be covered here, too. May 8, 2023 at 15:40
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You may need to see three different specialists, and may even need to get them talking to each other.

  • A sports-medicine doctor
  • A physical therapist
  • A bike fitter

Depending on the particular practitioners you see, they may have some overlapping competencies so you might only need to see two. But I would make sure that a fitter is one of them. Even people with no musculoskeletal problems can benefit from seeing a bike fitter.

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Try not to hurry. This should reduce all forces acting on the knee, as well as the required cadence. Walking speed is 4 km/h or about, hence bicycle should make sense starting from 8 km/h. This is a half to one third of the speed most cyclists usually ride and well above the minimum at that it becomes difficult to drive. Experiment which gear fits you the most. Avoid uphills.

If you would get this working, an E bike set to max assist should return back big part of the speed while retaining effort and cadence you know is safe. Or, if the electricity is against your beliefs, simply stay slow: this puts you some limits (busy road, restricted commuting range) but not many.

You may also think about the "easy bicycle": light, high end, narrow racing tires, just more comfortable rider position configured for the slow riding. My electric beast is close to 27 kg. You can buy a 7 kg bicycle like this for the same price.

But before that, discuss with doctor how much is a bicycle advisable for your case. While a great machine, it may not be usable with some diseases. I hope the doctor, ideally specialist on your problem (not generic "family doctor") should be able to provide the necessary safety, and check if the knees are not getting worse.

How much a bicycle fitter would help, I am not sure. I was always convinced they job is to fit a bicycle for a more or less healthy cyclist. But who knows.

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More specifically than Adam, I would attempt to find, in this order:

  1. A bike fitter who knows biomechanical issues well. Simply having lasers in their studio doesn't cut it. You will need to find someone who knows the human body well.

  2. A physical therapist who has some specialization in sports.

I don't know how helpful it is to see a medical doctor. A primary care MD may just order X-rays to check your cartilage, prescribe you pain medication if needed, and maybe refer you to a physical therapist. A more specialist MD might be warranted if you are thinking of surgical treatments for your knee, but you want to address how you interact with the bike and any weaknesses in your muscles before you let things get to that point.

A good bike fitter should be able to help you work out your bike fit. One of the things that a good one will look for is how your knees track while pedaling. You don't want your knees to kick outward or inward during the pedal stroke. This video isn't a perfect illustration of that phenomenon, but it's the best I can find right now. Knees not tracking can indicate an issue with your bike fit - for example, I had my saddle up too high, and one of my knees was flaring out slightly, and I developed an overuse injury this way. In addition, a good fitter should assess for any physical asymmetries - for example structural or functional leg length differences, with the latter meaning that it's not your bones that are actually longer, but rather something about your musculature, maybe as a function of your posture, affects how you sit and stand, thus affecting your leg length.

A good bike fitter is also likely to know stretches and exercises that address muscular imbalances that can contribute to knee pain. Physical therapists should also know these exercises and be able to assess them. I suspect they won't have the knowledge to sort out your bike fit. You may benefit from seeing both types of professionals at the same time.

I am less sure how to reliably find a good bike fitter. I don't know that all bike fitters are good. For sure, there is a learning curve. The human body is complex, and the ways it can interface with the bike are complex. I'm going to bend the site's norm of not recommending specific products to show what I would try to look for. Steve Hogg appears to be one professional who's thought deeply about these types of issues, and he has trained bike fitters in a number of countries. Note that Hogg personally prefers a cleat position that is much aft of the norm and that may not work for all riders, but I don't think that's a symptom of maladaptive thinking. The bike fitters who sorted out my issues were not affiliated with Hogg et al, but they had extensive experience with professional athletes before becoming independent bike fitters. They're in Minneapolis, Minnesota in the US.

In the list above, I made a dig at fancy fit systems. I was thinking about Specialized's Retül system. My point is that merely possessing advanced equipment is unlikely to be enough. Possessing a Retül system is absolutely not a disqualifier, it's just that you need someone with hands on experience with athletes. Searching for a good one can be tricky. Thinking about the issue, I actually do not think I can think of disqualifying signs that are reliable enough that I'd state them here. If you have riding friends, see if you can get recommendations by word of mouth.

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Perhaps you could try a recumbent bicycle.

e.g.: https://duckduckgo.com/?t=ffab&q=greenspeed+recumbent+bicycles&iax=images&ia=images

The rider cycles in a non-upright position, so while they are still putting force through the knees, the rider is not able to put full body weight on a single knee - like you would say, standing on the pedals going up-hill.

Three-wheel recumbent bikes do not need to balance, so you can drop into really low gears and "crawl" up hills at very low speeds. Using very low gears should reduce the force needing to be applied through your legs.

You could also try a recumbent hand-cycle.

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    I’ve read that recumbents actually allow you to put more force through the legs because you can brace against the seat and are not limited by body weight.
    – Michael
    May 9, 2023 at 7:17
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    @Michael do ride one if you ever get the opportunity. If I tried that on my bent, it would push my torso up the seat. The bent is certainly good for back and arm, neck and shoulder aches in my experience, less so for legs, ankles, etc.
    – Criggie
    May 9, 2023 at 8:38
  • @Michael there's the intermediate category of "crank forward" bikes which are a bit of both and may suit this need as well.
    – Criggie
    May 9, 2023 at 8:38

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