Knee recovery

It's been a while since 100km felt like such a great achievement, but the endorphin reward was no less for it! We managed a full 100k loop yesterday afternoon, out over the North Downs, and felt much better than I did doing a half-lap of Richmond Park as recently as Wednesday. My weekly Physio sessions had been progressing well enough, but Friday was something of a watershed; I'd been a bit disappointed by how, despite the noticeable improvement in patella tracking (less "clunking"), I was still not comfortable riding and so had't done as much as I'd hoped in the previous week. My physio however is now more fixated by the looming PBP qualifiers than I am -- I think the prospect of 600km ride is more daunting to her than me! -- but she did instill in me an appreciation of the need to build up some miles in the legs before diving in with my next big ride.

My two concerns going out for anything longer than my usual commute were that the knee discomfort would increase with distance to become distinct pain - and doing unknown damage, and that I would be frustrated in any goal to put out greater power output through a reward of more knee pain. Indeed this is what I'd found on the way to Wales a full month ago when the problem started, and which had been putting me off ever since: the further and harder I pedalled, the worse it got.

A small revelation had come on Saturday, when we'd made a short trip out to the pub for a friend's birthday. On the ride back home - slightly affected by the celebration beverages - I was more relaxed in position and less gingerly with the power, and I found that my knee was none the worse for it. Over the last fortnight I'd been spending much of my concentration on the relative position of knee and foot - as instructed by the physio - but not so much time considering the exact balance of muscle in use when putting out higher power. So on our longer ride yesterday I set out to thinking foremost about using my quads to the max, and about leg alignment as a secondary goal, and this appears to have made all the difference.

If at any point I found the twinge coming back to my knee, rather than ease back on the forces going through my knee I instead consciously pushed harder on the top of the pedal stroke, using my quads to their full, and the edge of pain would reliably recede. What a glorious discovery!

Certainly it is only though the physiotherapy that I've built up the correct balance in my quads, and can now at will choose to use the VMO to greater effect, that this surprise remedy of pushing harder to reduce pain is now available. What I believe is happening is whilst no longer clunking, when relatively relaxed the patella is still not tracking quite true, however when I squeeze on the VMO it pulls it fully into the channel in which it should move and run more freely. This led to a rather unusual situation that contrary to all received wisdom on the subject of knee care, we increasingly sought to push the biggest gear we could on flats and climbs; to give sufficient resistance to push against; rather than spinning in low gears.

Now I'll just have to see how this theory works on a longer ride.

Knee round 2: rehab

The Physiotherapy practice I am seeing, sixphysio.com, have a slightly unusual setup in that their staff either specialise in remedial & manipulation, or in exercise & rehab. So today I had my second physio appointment today, this time with a rehab specialist.

After another short consultation, with a bit more time spent talking about bike setup and possible theories of what might have triggered my pain a fortnight ago, I did a bit of balancing on one foot and so forth, and immediately all sorts of ingrained problems in my posture, balance, and general being became very apparent. It turns out to stand on my right leg I twist my pelvis, throw my left foot across behind me, twist on my knee and all sorts. As soon as she mentioned all this it triggered other recollections: when skiing I have more difficulty carving to the left - where more weight is on the right foot - and I can never sustain one-footed skiing on my right foot whereas I have a tolerable ability for this on the left foot.

Having determined how my right leg is generally disagreeable in performance, all quite explainable by the lazy Vastus Medialis muscle (VMO) as identified on Friday, I was started on the road to correcting it. First step was a round of electric-shock therapy. I had had the misfortune of doing some google searches for lazy VMO prior to the consultation, and come across some youtube videos of a chap putting himself through this - using some sort of homebrew kit, crocodile clips and all! Fortunately my treatment was considerably more clinical, but still a rather curious experience.

Once it was activated, I was put through various other exercises to help train this muscle into responding to normal activity. The most difficult bit of this was overpowering my subconcious tendency to twist feet and hips in strange ways, as much as anything because I'm trying to avoid making knees click -- a destructive feedback loop between symptom and cause that has no doubt deepened this issue over the years. I now have a routine of daily exercise to go along side the post-exercise stretches I was issued on Friday.

Cycling home I made a very conscious effort to keep my knees aligned over my pedals, rather than letting them bow inward toward the frame as I now see they do (the Physio had already guessed so much just by seeing the way I sat in the chair with my feet splayed toes outwards). What I had considered as my knees knocking outward at the top of the pedal stroke is infact them knocking inward throughout the entirety of the rest of the revolution.
On the way into work this morning I'd worn a knee compression bandage; this had seemed to prevent the worst of the clunking, but I still arrived with some mild tenderness. (A bad sign as this is only an 8 mile ride so easy to see how it would be worse scaled up to say 400km!)
Coming home, I had no knee bandage but the joint effect of keeping my legs better aligned and trying to clench my quads, and in particular my newly activated VMO, appeared to have a very noticeable result: not only was there no knee-clunking, but no knee pain either.
So now all I need to do is get my own portable electric shock machine to take on my next randonee.

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More practically, I'm also going to look into change the pedals on my commuting bike from SPDs to something with more lateral rotational float. I don't believe I need more float per-se, but I do think a freer pedal (such as the speedplays I use on my road bike) would give my more ongoing reminders keep these factors in mind. A lot of people recommend Time ATACs as a good MTB-style pedal with increased float, but I think I'm as much interested to have free float without the spring return that they have; without trying some it's hard to know. So I may just go for Speedplay's "frog" pedal - which frustratingly they've been previewing a replacement for called the SYZR for several years, but has never actually made it to retail. Feels wrong to be spending more on a pair of pedals than many people spend on an entire bike (or BSO), when you know it's already obsolete!

Thing1 knee 1

This week I finally got myself organised and saw a Physiotherapist on Friday, to have a look at my knee.

It's a fortnight now since the pain first started in it, on the way to Wales, and which caused us to pack the Brevet Cymru 400km just 30km in on the following day. I had thought it was improving so we drove to Ilminster last weekend to ride the Old Roads 300km, but overnight the pain returned and so we didn't even start. Something had to be done.

The Physio was a little confused by the long story I had to tell about my knee. It's been a bit "clunky" for about 10 years, but rarely painful so I never put much thought to it. I found that within half a minute of starting cycling, if it was clunking, I would unclip my right leg and kick it out a couple of times, and the knee would click the tension be released and this would stop the clunking for many hours or even days.
In short, the problem of the last fortnight is I can no longer click out my leg and so it is continuously clunking.

At the moment, it is looking hopeful the problem is one of patella tracking disorder, rather than more serious meniscus / cartilage damage.

One observation that seems to support this was quite late in the consultation my Physio asked me to clench my quads on either leg, and noticed that the Vastus Medialis muscle on my right leg was "lazy"; slow to contract only doing so in the final stages of squeezing the Vastus Lateralis muscle. In contrast on my left leg these fire about the same time as is desirable.

She made the observation that my quads and ITB are extremely tight, and I need to take up exercises and stretches to address this. She was quite surprised when I replied in the affirmative to a question of whether I own a foam roller! This is particularly good for loosing these areas, it turns out. I'm used to being made aware about how tight my hamstrings are, first time I'd really been made aware of this problem elsewhere.

The one thing she could explain is why, when walking up stairs, my knee clunk is far more pronounced when I make tall ankle extensions with each step. Most likely theory is extending the ankle through calve muscle contraction causes some other quad muscle activity to stablise the leg, having this side effect.

The final experiment of the session was to try taping my knee cap for a day. At first I found this to be rather uncomfortable, partly just from the stickiness pulling on skin and the lack of motion it allows. Cycling on to work it was initially giving a very disconcerting clunk, but eventually it settled and over the 24 hours it became much smoother feeling. Eventually I was surprised how I'd carefully stand up from sitting for a while, moving carefully in anticipation of a knee clunk that never occurred. This more than anything has given me hope that surgery is not going to be required, and I just need to sort out the kneecap stabilising muscles to cure the issue.

The time line for this is hard to predict though. Exercises to rebalance muscles could take a while to get full effect. Hopefully binding it will prove reliable enough to keep it in check in the interim, I will need to test this out on the daily commute and build up to longer distances with it.
The remaining pain and inflammation feeling needs to be given chance to recover as fully as possible before I take on any more long distances, and then I should also be prepared with a regime of ice packs to ward of any final niggles.

With these sorts of issues it seems often recommended runners take up cycling, cyclists take up swimming, for another source of exercise. I never learnt to swim with any real ability, maybe now is the chance? I started investiging some adult swimming lessons in London, and found the Art of Swimming which looks interesting. Would be interested to hear if anyone else has recommendations on this.