Will asks the Guru some in-depth questions about both his knee and achilles pain

July 29, 2014

Hi, I hope you don’t mind if I ask a couple of sports injury related questions:

  1. I did a long cycling event a month ago. The event went well, but the next day I woke and my left knee was very painful – particularly going up or down stairs. The pain has gone, but my knee still feels quite swollen, especially the area just below the knee cap. It doesn’t look swollen, but it feels that way. I’ve done a couple of gentle rides and the knee has felt ok, a little stiff and achy, but not painful. Would you recommend that I wait and see if the knee gets better on its own or should I see someone about it now, even though the initial pain has gone?
  2. I have had Achilles tendon problems in both heels for about seven years now. I can do slow runs maybe once or twice per week, but anything more and my heels flare up, so I have not been able to do any consistent running during this time. I’ve seen a few physios who diagnosed tendonitis, but doing eccentric heel drops and stretching hasn’t solved the problem. I was able to get referred to a consultant sports doctor, Dr Courtnay Kipps. He had an idea that I could have something called Haglund’s Deformity, but circumstances stopped me from getting a scan to check this at the time and now the Dr is no longer available. Would you think that getting some kind of scan done on my heels is a good idea, even if I have to pay for it privately? I’m not really sure what else I can try.

Thanks for taking the time to look at my questions.


July 29, 2014

Hi Will

Great questions. I’m taking it that you’re not a sporty 80 year old, who binge trains and lives like a teenager!

1. When was the cycle ride? How long is long and did you do enough training?

Where your pain and swelling are located thankfully nails it down to only 1 or 2 like things. Either an irritated infrapatella fat pad or a patella tendonopathy. I think likely to be the latter as up and down stairs are painful, rather than just the going down – and if it was fat pad locking your knee back is also sore.

This is why the time since ride is important with what to do next. If it was only a few ago, the rest through the reactive phase. If it was a month+ ago then it needs to be respectfully loaded. Certainly eccentric loading (as below) may be of benefit. If your patella tendon has been over loaded due to the ride then you’ll most likely need releasing elsewhere to help speed you along.

2. Courtney is a great doc [sports physiotherapists for sports injuries London] – and if he thinks you’re got a Haglunds deformity then that’s good for me at the moment. But (and there always is) insertional tendon issue don’t always like being loaded eccentrically – they prefer isometrically (just hold/hover in the air, heel of the ground, knee bent and straight) and they really don’t like being over stretched….

Haglunds always have a boney bump, and it’s over this boney bump you run into trouble with your achilles. Get your GP to refer you for a plain X-ray in the first instance, and then report back….

The Guru
Six Physio

Will replied to the Guru with some more information:

Hi Guru!

Thank you very much for taking the time to reply to my message. No, I’m not an 80 year old! I’m a 33 year old man, otherwise fit and healthy.

1. The cycle sportive was on 29th June. It was 70 miles and hilly in the Brecon Beacons, Wales. I’ve been cycling for a few years now, two or three times per week. My normal rides are 20-30 miles in Surrey or Richmond Park, but I’d done a couple of 40 and 50 mile rides leading up to the event. So my training was ok, but not brilliant. I have done rides of over 100 miles in the past, although nothing of that length since last summer. My knee has never caused me a problem before though.

Is patella tendonopathy the same thing as ‘runners knee’? I think I came across the term when googling knee injuries.

The injury is a month old now. You mentioned in your email about respectfully loading the knee, maybe eccentric exercises and about ‘releasing elsewhere to help speed you along’. Could you elaborate on these please, are there some exercises I could try at home? Or is this something that I should come to see someone in person about?

2. I was lucky that Dr Kipps had a clinic at my GP’s surgery. But unfortunately he no longer does the clinic and I’m not sure I could afford to see him privately. He thought that Haglund’s Deformity would be worth investigating as my Achilles tendon issues are so persistent and he did refer me for an X-ray. There was a bit of a debacle at the hospital though, as the consultant radiologist refused to do the x-ray saying that he didn’t think it worthwhile! I tried to go back to Dr Kipps to explain the situation, but he had moved on from the clinic by this time. Anyway, I think you’re right that I should try to see my GP again and try to get someone to do an x-ray – I’m sure it would help to get an idea of what’s going on under the skin there.

Thanks again, Will.

The Guru responded:

Thanks Will

…I’d have put you at 34 😉

I think it’s the hilly bit that’s the key. Richmond park is great for speed and distance but part from 2 short hills, it just doesn’t give the required wattage, cadence or grunt of the Beacons.

I think patella tendonosis sounds on the money, as long as the pain is centred under the patella. The mechanism fits, location fits and description fits.

Runners knee is much more patellofemoral (kneecap) in nature. It generally doesn’t swell, is felt under the patella or grossly around the knee and is made worse but the things that make you worse (downstairs is commonly worse) but also things like sitting down for 40 minutes or kneeling down or full squatting.

Because you’re now +1 month, you will have started to adapt your movement patterns to try to get around the pain. In doing so you will overuse some bits of tissue and disuse other bits. Things that generally need releasing (and not necessarily stretching – rolling, massage, deep tissue release etc) are quads, calfs, the front of your hip and your patella. Getting. Your gluts to do more is no bad thing either – small controlled, single knee dips.

Keep your wattage down on your bike and keep in higher gears. Ice is still good and sometimes patella straps can help (they can also hinder too!)

2. Great idea re your GP – keep badgering him. Or Ping Courtney an email. He’s super diligent and conscientious and I’m sure he’d pleased to help get you in the right direction.

The Guru
Six Physio

Guru Responded

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