Chondromalacia - exercise protocol?

[coreJack]

I'm a 35y/o male, and have had anterior knee pain (right knee worse than left) since my late-20s from running and squatting, both of which I did sparingly. A couple of years ago, I took up cycling, and while my knees would occasionally bother me, the pain was manageable. Last winter, I rode for the first time in a couple of months and simply went too hard too quickly, and experienced a lot of pain in my right knee - even walking hurt for a couple of weeks.

Since then, I've seen an ortho who wanted me to strengthen my VMO, but that didn't seem to help at all. I've since discovered that anterior knee pain is often the result of dysfunction elsewhere. And I've noticed quite a few issues:
- quad dominance and weak posterior chain
- anterior pelvic tilt
- right hip higher than left
- feet point out (have flat feet, left is worse; orthotics for both)
- when standing with feet pointed straight ahead, my kneecaps point inward (internally rotated femurs under load)
- tight calves/soleus
- tight hip flexors
- occasional knots in my lower back


I saw a chiro who is ART trained and works with a lot of cyclists and she performed a test for chondromalacia (leg extension while she pushes on my kneecap), which produced pain in my right, but not left, knee.

For the last several months, I've been focusing on core training and posterior chain strengthening, and my knee pain is reduced, but comes back if I get on the bike, run, or squat/lunge. My right knee will even act up if I swim freestyle (flutter kick).

Here's a list of the primary exercises I perform during a week:
- dynamic warmup using lots of movements from Robertson/Cressey’s Magnificent Mobility
- anterior/posterior and side-to-side leg swings
- side, front planks
- reverse crunches
- ankle mobility movements to increase dorsiflexion
- box squats, bodyweight; notice that knee feels better when I focus on keeping the inner thighs tense at the bottom of the squat and spreading the floor with my feet
- deadlifts (limited hamstring flexibility, so I don't get low)
- pull throughs
- x-band walks

I wasn’t doing much foam rolling or stretching, but I just started on that. Also started doing pigeon pose to help improve hip flexibility; this pose is quite difficult for me - no surprise there.

Is there anything else I should be doing or should not be doing? Thanks for any feedback.

[UConnJulie]

How is your quad and rectus femoris flexibility?
Hip flexor/TFL flexibility?

[coreJack]

Originally Posted by UConnJulie

How is your quad and rectus femoris flexibility?
Hip flexor/TFL flexibility?

Both were poor before my injury, but since then, I've worked to improve them, but I'm not sure if you would consider my flexibility there to be "good". Is there an objective/quantifiable way for me to measure this flexibility?

And how can I stretch the TFL specifically?

Generally speaking, flexibility around my hips is poor in that I cannot do pigeon pose properly yet. But I'm getting better at it.

[UConnJulie]

If you can lie prone and keep your knees together and get your heel to your butt and not feel much stretch in the quad, then your flexibility is fine. If you compensate by abducting your thigh or rotating your hip, then it's not, even if you can get your heel to your butt. If you can't get your heel to your butt ... not good.

The best way I've found to stretch TFL ... first foam roll it, a lot ... then do a sidelying quad stretch and use your bottom leg to pull your top leg down by putting the foot of the bottom leg on top of the top knee.

Keep working on that hip flexibility (including adductors, hip flexors, TFL, glutes and other rotators) and then the gluteal activation will get easier ... which in turn should help the patellofemoral issues.

[coreJack]

Originally Posted by UConnJulie

If you can lie prone and keep your knees together and get your heel to your butt and not feel much stretch in the quad, then your flexibility is fine. If you compensate by abducting your thigh or rotating your hip, then it's not, even if you can get your heel to your butt. If you can't get your heel to your butt ... not good.

Can't do that. Looks like I've got some work to do.

Originally Posted by UConnJulie

The best way I've found to stretch TFL ... first foam roll it, a lot ...

I was told that the way to foam roll the TFL is to position yourself as if you were foam rolling the quads (i.e., prone position) and move roller around the hip area and rotate foot inward at 45* angle to expose TFL. Does this sound right to you?

Originally Posted by UConnJulie

Keep working on that hip flexibility (including adductors, hip flexors, TFL, glutes and other rotators) and then the gluteal activation will get easier ... which in turn should help the patellofemoral issues.

Yeah, adductors are very tight; will have to work on those.

Thanks for the tips UCJ. It sounds like the activation/strengthening work I've done (in first post) is not sufficient to achieve proper biomechanics if flexibility is still poor.

[UConnJulie]

Yes.

Flexibility is a huge component that is often overlooked.

[coreJack]

I'm not currently doing any single leg work in my gym routine because I find lunging, even reverse lunging bothers my knee. But from what I've read, single leg work is great for rehab because it really gets the stabilizers working. Are there any easy-on-the-knee single leg exercises that I can do - especially stuff that works glutes/hams and not so much quads?

[UConnJulie]

Single leg RDLs
Single leg glute bridges (on a ball or not)
Regular deadlifts (ie not single leg)