VMO pain, bike fit issue?

Training
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Hi guys and girls. I have been off training for a week due to VMO pain ( and the inserts along the medial part of the knee). It’s been brewing for 2-3 weeks but now I’ve had to concede and have some time off, but it’s not so bad as the kickr is being replaced at the same time!

Both VMO’s are tender and spasming at times, but left is more pronounced.

I have iced/heated/raised/massaged/bought a massage gun/tonic water/ electrolytes/stretched/NSAIDS etc and nothing has eased it so far. I have been to the docs, no input apart from rest (but I squeezed diazepam out of him).

I know il have to rest it up, but could it have all been caused by a bike fit issue and if it was, is it just down to saddle height? Cleats and shoes are the same across both bikes, I ride a hybrid and hard tail on flat pedals too. But 50-60% is on my trainer, minimum.

At which part of the pedal stroke is the VMO most active? I’ve read it’s the bottom 35deg, but unsure if that’s correct? My hips don’t rock (had a bike friend check), it doesn’t feel like I over extend or feel cramped up. I’m at a loss

Anyone had similar?

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I’d start w/ proper assessment of cleat positioning. If there is a Retul fitter in your area, they will do a cleat adjustment fitting for fairly cheap

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Ok cheers, there isn’t a Retul fitter anywhere close, but there is an Idcleat fitter. Il book in

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I was pretty embarrassed by how far off my positioning was on my cleats. “Eyeballing” it apparently does not work in my case

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Depends on what you are using to “eyeball”.

  1. The quick check is to sit on a bench,
  2. Hang your feet off and rotate at your ankles until your foot is roughly level with the floor,
  3. Look at the direction your feet point (toe in / straight / toe out) and
  4. Then roughly match that direction with your cleat orientation.

The idea being to find your natural foot rotation and mimic that with cleat/shoe direction. Too many people assume they point dead straight. Some do, but there is a notable amount of riders that are toe out to some degree with a few toe in. No matter the direction, this is a decent start for people who have never had clipless setups.

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that’s pretty much eyeballing it. You need a device like and Ergon to make sure the axis of the met heads is properly aligned with the cleat. I’ve had former pro cyclists/bike fitters who use the above method and were way off.`If you’re not having knee pain, they’re probably close enough; if you are having knee pain, start w/ cleat alignment. Even if you had it right to start with, dirt and grit can work into the bolts and repeated clipping in/out can cause slight misalignments. Just my opinion, but it’s based on 35 years of cycling experience and 20 years of physical therapy experience.

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Cheers, I’m booked in but I’m almost certain it isn’t the root cause. I’m starting to wonder if it’s saddle height/fore/aft. I’m (almost) sure it’s overuse! Last night I had 2xelectrolyte tabs and a Valium and it’s very much eased off today

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I have VMO pain from time to time. I had it several times in the summer(before trainer road) but it would usually go away 15 to 20 miles into a ride. I hadn’t had any issues with it recently until… I had a fit done on Saturday! If I stop my TR workout and do some strecthing it ususally goes away. Doing Eclipse Sunday I had to stop in the middle of 2 of the 20 minute sweet spots because my VMOs were hurting. By the third interval I had no issue. Come to think of it I had no pain in the VMO area last night at all.

Could my pain have resurface because I finally got a cleat re-adjustment with my fit because I am using those muscles differently now that I have been adjusted?

Nonetheless if it persists I will go back to the fitter.

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I ruptured my VMO thanks to a bad overuse injury a couple seasons back. It hit without any warning, but in hindsight the warning signs were there.

If the pain is very localised in the VMO, close to tendons, persisting and sharp (ie unlike the good kind of burn we get when riding at intensity) I would be very careful not to pedal too much or too hard for a while.

Bike fit may contribute to the problem, even cause it, and this surely varies case by case. But along with potential fit issues I would check if one has muscular / functional imbalances. IMHO the knee joint is a relatively simple hinge, and the soft tissues related to it are often victims of the bad company they keep, ie not very functional and/or weak hips and in some cases ankles, which are much more complex joints. Surely very badly positioned cleats and/or saddle may generate problems. However, per research (see for instance Rodrigo Bini’s or Phil Burt’s works about bike fit) the acceptable ‘fit window’ is often quite large for many if not most individuals, and we thus can absorb many kinds of suboptimal fits. My experience is the same.

So at a minimum, I would try to assess if there are weak / inhibited glutes (hip extension, abduction), weak and/or badly coordinated core, and tight / weak hip flexors (rectus femoris, tensor fascia latae, psoas) involved. There may be a ton of other issues, but I mention these just to paint a picture. Such an assesment is ideally done with a physiotherapist who is experienced with working with athletes and cyclists. If the problem lies in this area, the PT can hopefully teach one master movements that are effective for fixing the functional problems.

In my case the root cause were muscular imbalances typical to a roadie and a desk worker (quad dominance, tight hips, weak core, and especially underused glutes as well as badly controlled scapulae, and whatnot). This was exacerbated by several movement compensations developed to avoid the pain in the VMO, which both made the problem worse in an immediate sense (ie hurt, because wrong muscles were trying to stabilise the hip & knee in everything I did) and also prevented me to re-establish proper movement patterns.

So for me grasping and fixing the imbalances have been the key to recovery. Chasing pain in the VMO directly or attributing it mainly to bike fit were not very helpful. The recovery has been very frustrating and slow, but I am a better and more balanced rider these days.

Best of luck!

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If its down to muscle tightness in other places, id be a definite candidate then…

I do stretch, admittedly not enough (and more focussed around lumbar as previous surgery had me laid up for a long time) il take a visit to a physio next week… thank you

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great post!! you pretty much nailed all the things I typically find in the clinic. The only hard part is the chicken/egg question between fit and physiological causes. Which do you look at first? I like to rule out cleats simply because I’ve been a victim of misaligned cleats before (one had worked loose a bit and caused IT band issues), and they are a relatively easy, cheap fix

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Interesting topic. I have been out of the Physical Therapy game for a number of years now but I don’t think things would have changed too much.

VMO isn’t actually a muscle in itself but the inferior part of the Vastus Medialis, the fibres do run more obliquely and are said to have their own nerve supply.

To engage the muscle you work the last part of extension. If your seat is too high this could make the knee extend and work the VMO more than normal.

Obviously there could be other factors in play such as muscle imbalance or tightness so I would suggest maybe a bike fit and / or assessment by a professional.

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Thx. Indeed, the chicken/egg (fit / imbalances) problem is the difficult one to address from a practitioners POV. In my post I mostly wanted suggest that eggs are real and may have a big impact as well. :slight_smile:

FWIW, my bike fit and cleat position have both changed a bit to support a more neutral low back and facilitate using the hips while pedaling.

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Hi i think I have the same sort of vmo issue for some time , i was wondering if you’ve gotten the problem solved and if so how , cheers

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Hi. Only just resubbed and saw this topic!

My saddle was a bit too far forward and high, it was dropped and pushed back over 5cm. The cleats were taken almost fully back too (they were quite far back anyway from protecting an old Achilles injury). Almost immediately the glutes were able to contribute to the workload.

In the short term the stretch that was most useful was to do an very wide squat (almost sumo stance) and put my elbows inside my knee’s to push outwards. The immediate relief was awesome.

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Hi i have only seen your reply on this , im very happy you got back on this topic , it sounds like you are back on track :+1:, im still struggling a bit with the problem but nowhere near as bad as it was i have tried a few physiotherapist with mixed results , i have made very similar changes to the bike and cleats as you have decribed and am noticing some really positive results of late on the bike and the stretch you decribed makes perfect sence i will add it to my stretching routine , i would be curious to know if you have added in any specific vmo strengthening exercises to keep on top of the injury , thanks again for getting back on this.

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There’s no particular VMO strengthening exercise, I’m very quad dominant and my VMO is grossly out of proportion anyway!!

Good old fashioned squats and front squats hit me hard and I find good benefit from them