Over the past few years, I've been getting recurring pain behind one or both kneecaps with increasing frequency. It seems to be correlated with a few things. Foremost is excessive volume plus intensity without enough recovery. I think mostly the bike is responsible. Running doesn't seem to exacerbate the problem, it just delays it going away. I can run with zero pain when riding hurts. Letting my knees get cold also aggravates the problem. Even when it is not cold out, sometimes if my knees are achy, I'll feel them, and they are cold. The other thing I noticed is there seems to be a direct correlation with dehydration and achy knees. Often, when I know I'm low on hydration, my knees will be tender going up or down stairs. This isn't all the time, just when two or three of the above are present simultaneously.
Back in March, I went down to North Carolina for an intensive week of mountains riding. On the first day, Arik and I went out for short, hard spin to Sassafras Mtn and back. It got wicked cold on the ride back as a winter weather front moved in late in the day. My knees got extremely cold. Whole body got cold in fact. Back at the house, I was pretty much an invalid when it came to the stairs. I needed to support most of my body weight with both hands on rails. The pain was excruciating. I was probably dehydrated, and we went awfully hard up Sassafras. I thought my trip was doomed, but a couple Aleve, rehydration, I was good to go the next day. I think I wore AmFib tights. Knees stayed warm. I did not have trouble with it the rest of the trip.
I was concerned though. Definitely as I get older, my body parts are breaking down. I started searching for remedies. Several people I know, including my dad and long-time riding partner Steve G., swear by glucosamine. Steve has been taking various preparations of it for many years, my dad the last couple years. My dad has had both knees worked on years ago and was having a lot of trouble in his 70's. Since he started taking Osteo-Biflex, he claims his knees feel the best in 25 years. That is a pretty bold statement.
So I picked up a bottle of glucosamine with MSM at Sam's Club and started taking it right after I got back from my trip in March. I took recommended dosage of 1500mg per day, a tablet in the morning and evening.
Fast forward to the week leading up to Memorial Day. I was increasingly feeling not well. It was a not quite put your finger on it, kind of a general malaise thing. My weight was mysteriously going up. I stayed below 160 lbs almost all winter, and my weight typically goes down in the spring when my total training volume goes up. Instead, my weight peaked above 165 lbs with a 10.5% body fat on the Tanita scale. I was even trimming calories as weight was going up. WTF!
That wasn't all of it. I'd wake up with a headache every morning. I rarely get headaches, and now I seemed to have a low-grade headache most of the time. I could hear my heartbeat go whoosh, whoosh, whoosh in my ears too, kind of like I had pressure in my head. I would have thought maybe a sinus infection, but I never got sick and had zero sinus symptoms. Then to top this all off, a couple times going out at lunch, I bonked immediately. One in particular was an easy run day. Two miles out I was in a hallucinogenic bonk state. I almost had to sit down, it was so bad. Something was very wrong. I started thinking Lyme disease? Pancreatitis? All kinds of scary things went through my mind.
Then on a whim, I Googled glucosamine and weight gain. I got 800,000 hits and started reading. Wow. Glucosamine, in dosages that people often take for osteoarthritis, can wreak havoc on your whole insulin response thing. Didn't understand the minutia of mechanisms behind it, but it appears that glucosamine causing Type 2 diabetes systems is far more supported in research than mending bad knees. In fact, the most thorough study concluded that glucosamine is statistically insignificant in helping joint pain.
So I checked the flip side, Googling glucosamine and weight loss. 2.5 Million hits! Oh man, it can't be both ways, can it? Well yeah, people have amazing ways to attribute effects to causes, aka placebo effect. But then I started reading. Pretty much every correlation with glucosamine and weight loss were cessation of weight loss. That is, people that were in weight loss programs stopped losing weight when they started taking glucosamine.
That pretty much clinched it for me. I couldn't think of anything else that changed in my diet or lifestyle to be causing the changes I was experiencing. I stopped taking glucosamine. That was about two weeks ago.
The first couple days, I didn't notice any change. But then on the third or fourth day, I woke up without feeling like I had pressure in my head and no nagging headache. Of course, my weight was still up.
Now, two weeks after stopping glucosamine, I feel 100% normal again, and a little weight has come off. Did glucosamine do this to me? I didn't have 100 of me to control this experiment. I'll never know. One thing is certain, I won't blindly jump into a supplement again.
So what about my knees? There's also chondroitin. Seems much less risky from what I read. Strangely, I think the glucosamine was working. Maybe a much smaller dose is all I need. Steve takes a Hammer product with glucosamine, 250mg I think. I was taking 6x that amount. Maybe I need to adjust my bike(s) fit. I have Pruit's book on bike fit and common cycling maladies. Pain behind kneecap is often over-use/over-training related and extended rest period can make it go away. I'm not doing anything atypical from seasons past, other than I'm 50 now. I'd be interested in any experience readers have had with this.
11 comments:
Hey Doug-Robert here from NYC.I'm a bodyworker(massage therapist) here in NYC and long time professional inline speedskater.I also ride ,rollerski and x-c ski in the winter.Waterville Valley is my home base for x-c skiing and I've seen you up there a few times.To comment on the issue with your knees as you have mentioned it's most likely an overuse syndrome.The human body is not designed well for repetitive stress.It will attempt to adapt to the stress placed on it by making itself stronger.To do so it needs sufficient recovery.Insufficient recovery and excessive external stress(intense workouts etc) result in dysfunction in the system.This shows up primarily in the soft tissues of the muscles,tendons,ligaments,joint capsules,and fascia.The brain's first response to stress is to create what's called a trigger point or taught knot or band within the affected muscle.This is an attempt to protect sn overstressed muscle by shortening it.This taught knot leaves the muscle in a partially shortened state.The bones to which the muscle attaches then are pulled out of alignment slightly.Obviously you can imagine how this affects a joint as you continue engage in the repetitive stress activity.If the mechanical dysfunction at the joint persists long enough pain will show up.At that point it's simply a signal that something is not moving properly.Trigger points can also cause pain directly through the phenomenon of what's called referred pain.Referred pain is pain that is referred to another area from the actual trigger point knot.Sometimes it's right in the area of the knot and sometimes it can be a great distance away.Trigger points have a common reproducible referred pain pattern.They will always occur in the same area and refer to the same area.And luckily they are easy to self treat.So the pain in your knees is most likely from a mechanical dysfunction regarding the weight bearing joints or referred pain form the trigger points themselves.Trigger points can cause both issues.Based on what you describe I would guess the quadriceps and calf muscles are involved.Proper function between those 2 muscle groups are critical for proper knee function.And the fact that you feel it primarily cycling rather than running points to the likelihood that the quads are the primary issue as they are the main propulsive force in cycling and in running it's the hamstrings.To self treat a trigger you simply have to compress it for a short period of time.You can use your hands,a foam roller,a lacrosse ball,a baseball or any other tool you wish.I would pick up a copy of a book called "The Trigger Point Therapy Workbook" by Clair Davies.It explains everything you need to know about treating trigger points.There are many web resources as well like triggerpoints.net.As for the muscles I woud focus on the quads-most importantly the big vastus laetralis on the side of the thigh,the vastus intermedius,the vastus medialis,and the rectus femoris.the Iliotibial band is an important factor in knee pain due to it's traction on the lateral part of the knee.For that treat the Gluteus Maximus and the tensor fascia latae.Additionally the gastrocnemius and especially the Soleus muscle in the calf are important for proper knee function.So try treating those points and see what happens.I've really simplified things here but it's a good place to start.I highly doubt supplements have any beneficial effect as this is most likely your body's response to repetitive stress.Fortunately it's treatable .However as long as you continue to subject the body to the same type of stress the trigger points will return.You just have to stay on top of them.On a side note dehydration certainly doesn't help either.Fascia tends to be very reactive to dehydration.Good luck and let me know how it goes or if you need any further assistance-Robert
Funny, I was going to mention bike fit round about the second paragraph..... of course, with the number of bikes you have, just getting them all identical is a problem. Are you sure you don't have one bike with a too-high saddle?
The two things that worked for me is (a) a professional bike fit, and (b) keeping the knees warm. I see a scary number of people out riding in shorts in the cold, leaving the knees completely unprotected. At anything below 60 degrees, I'll have my knees covered, especially on the road.
Cold affects both the fluid in the knee (the bursa) and the tendons. Yes, I know your tendency to overheating.... but you can get knee warmers and leave the rest of your leg uncovered.
Fatty, Have you tried, "chewing your food 32 times", program? I suspect, the frequency in which you inhale your food, combined with the massive quantities, is putting your large and small intestine into overload. Tilt! The intenstines compensenate by rejecting the bigger food morsels and deliver them to your knee joint area. This has been proven! I searched on the Internet for it. Anyhow, these food morsels lodge themselves up behind your kneecamp and in between ligaments and such. By chewing food 32 times, this gives your intestine the ability to handle your disgusting caloric intake. Give it a try! Let me know how it works out.
A few things I have learned:
1.) Supplements are crap - you just piss them out and stress your organs in the process. Why do you want to ingest anything made in a lab? It's all crap.
2.) Don't run on pavement, ever, if at all possible. Why do you want to jump up and down on a rock, mile after mile? I know many ex-pro runners who offer this advice btw...
3.) Listen to your body. If something hurts (over-use injury), use it less.
4.) Seated climbing at high power output puts a lot of stress on the knees. You can vary your position and alternate between seated and standing climbing.
5.) If none of that works, you're just friggen old. ;^)
How is the mobility of your patella?
Great feed back all!
Anonymous - I played with my patellas a bit and compared mobility with youtube videos. Pretty good I think, especially medially and laterally. Very loose and fluid. However, if I put any pressure on patella while moving it along length of my leg, I feel some catching.
Rob - ha, ha. There is one supplement I swear by - fish oil. Our meat supply in this country is screwed up, very little open range fed anymore, so no Omega 3 content. Too much oily fish gives you mercury poisoning. Then we get way too much Omega 6 in vegetable oil. Americans get 30:1 Omega 6 to 3. Healthy ratio is 2:1 or 1:1. Only way to reasonably get it is with supplementation. Since going on fish oil a few years ago, I've been asymptomatic of asthma, a lifelong affliction. Studies support role of Omega-3 alleviating asthma, particularly in athletes.
Robert - Sounds like I have some reading assignments here. I've always had flexibility issues. Even in kindergarten, I could not sit on the floor with my legs crossed because it made my hips hurt too bad. I can't even come close to touching my toes. Never have. I used to stretch my quads but abandoned it, instead working on my much more problematic hamstrings. Perhaps I should bring back quad stretches. Man, getting old sucks.
Doug, yes, agreed, I generalize for sure on the supplements, but there is a lot of truth in what I say. I take no supplements. You don't trust any of those labs. They are just pumping out crap and marketing to clueless consumers. Go to a GNC some day, step back, and look at what they are pedaling (no pun intended). It is all crap - extremely profitable crap.
Years ago (when I actually had some semblance of speed) I experimented with all sorts of diets. My first coach, Tom Masterson, had a very knowledgable wife at the time, Jen Mynter, who wrote a very interesting, small book on food. It is not published as far as I know. Maybe I can scan a copy. It is like nothing you have ever read, but it makes you think a lot about our food supply and how our bodies really turn food into fuel.
I could write a long blog post on what I tried. My Dad said I'd eat like a bird. I did, for awhile, but I learned a lot. The conclusion I came to was that my body worked best on normal, healthy, real food. A balance of lean meats, whole grain carbs, and fresh veggies works best for me.
So, what is normal, healthy, real food? Well, it is actually almost impossible to buy unaltered food in this country anymore unless you are a farmer. My only advice is to stay as close to the original, unprocessed food source as you can. Anything that comes in a box or a sealed bag is crap.
I am not a fan of the vegetarian diet nor am I a big fan of organic food. I know some people do it and if it works for them, great. Again, if I lived in VT and could grow my own food, I would. Maybe someday...
Now look, I am also a realist. I won't think anything of grabbing a burger at McDonalds now and then and that stuff is truly garbage. One burger won't kill you, but making a habit of it will. It's just like your Mountain Dew. One of them after a hard ride is actually beneficial, but you wouldn't want to drink them everyday.
I was thinking about knee pain again on my run last night. For me, I get two types of knee pain. The first is that 'behind the knee' pain and it is definitely from over-doing the seated power climbing. If I try to push my personal limit too much, I get this. I also think it has a lot to do with age. I could go crazy things in my 20's and never had any issues. Your knees actually do wear as you get older and a lot of it has to do with genetics and what you have done with your body over the years.
You could have your knees scanned to see what they look like and how much they have worn.
The second type of pain I get is more of an ache and it comes from too many running miles. Running on pavement exacerbates this for me. Over the years I have learned my limits and how my body works. I will run on pavement on occasion and even do a race here and there, but ask anyone who knows me and they will tell you I avoid tar like the plague. I do much better when I run on dirt.
I also know that my breaking point is about 18 miles. If I keep my runs in the 6-8 mile range I have no issues. I can throw in a longer run of 10-12, but I have to be careful not to do too many. If I try running 15 miles at one time, my legs suffer too much damage. I can do it and even perform quite well in a trail race, but I don't like how long it takes me to recover. So you have to listen to your body. Everyone is different.
Doug,
Two more things I thought of: cadence and knee tracking.
What cadence are you riding at? You could try bumping up your cadence. It'll put less stress on your legs and more on your cardio engine, but you have a good engine!
The other thing is have you ever had anyone look at your pedaling from the front to see how your knees track? You can do this with fancy video capture equipment, but even a good fitter can see it while you pedal. Shims may help. I really like the 1.5 degree ones made by Specialized.
Rob - good questions. My cadence has been coming down over the years. I always used to be a spinner, 90+ RPM even climbing. Not sure why I'm finding lower cadences more efficient these days. I've probably dropped 10rpm in the last 5yrs. Certainly not knee friendly. I find I stand a lot more climbing too, and I suspect that might have something to do with bringing running into the mix.
I've never had my fit or knee tracking professionally analyzed. People I ride with have commented on how inline everything tracks though. Best I can tell, my knees follow arc in a plane. I do know that the super wide Q-factor of the Fat Bike I sold bothered the outside of my knee joints.
Okay here is another one to look at: the fore/aft position of your saddle and well as the height. I know you put in a bazillion miles so you probably know what works for you, but different positions affect the knees in different ways. Another is to look at the amount of float you have in your pedals.
I know every year my bike position and cleat setup seems to become more important. I used to be able to get away with a lot more in the 20's. In my 40's I seem to be much more susceptible to 'things that are slightly off'.
I think a seated position is fine for climbing, provided your seat is not too high, nor too low. Tour riders tend to ride slightly lower saddles. TT and Tri guys tend to run as high of a position as they can get away with to eek out every last bit of poer. There is no 'perfect position'.
You need to be in that sweet spot (for you) so you are not torquing the hell out of your knees, particularly while climbing. I know for me I have to watch this and I can only sit and push on the pedals so hard, for so many miles, before I know I will feel it the next day. This never happened to me when I was younger.
...I should add that, yes, I find that I am more comfortable with standing on the pedals, when I have been logging more running miles. This makes sense as you are effectively 'running on your pedals'.
Also, the lighter you are, the more efficient you can be when you stand. If you look at all of the lightweight ProTour climbers, they can stand and pedal away forever. Larger, more powerful riders can do this in short bursts, but ala Ullrich, they can also diesel away at low cadences while seated and climb just as fast.
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