Knee pain in cyclists

Knee pain in cyclists has been cited as the most common injury reported in the two wheeled lycra loving population.  It has also been noted as the primary reason for the need to stop training (Van der Valt, 2014). As cycling is a non-impact sport, this may surprise a lot of people. However as I mentioned in a previous blog on An Introduction to Common Cycling Injuries, a study from 2014 (Van der Valt et al.) found that non-traumatic injuries were reported by 88% of the respondents!.

The knee is a strong joint, but knee pain in cyclists often occurs due to the highly repetitive motion of the knee flexing as the pedal goes round. Poor bicycle set up or excessive sideways motion of the knee can accentuate the forces going through the joint.  In turn, this can lead to inflammation, overuse or wear and tear on the various structures around the joint.

Many a cyclist has felt pain in their knee at some point, the degree and location of which will vary. Knee pain in cyclists maybe an occasional twinge, a deep ache or a sharp pain that comes and goes.

If you are struggling with knee pain, note where you feel it.  Is it at the front, around the knee cap? Is it one side or is it at the back of the knee.  How far into your ride does it start?  Does it make a difference on hill climbs?

Then ask yourself if you have changed anything with your training?  Have you increased your miles or are you travelling over tougher terrain?  Are you riding more hills than usual?  Have you changed your position on the bike?

Below, I have listed some of the most common structures and conditions that occur in cyclists.  A thorough bike fit and physical assessment is needed to identify the cause as there may be more than one factor leading to knee pain occurring.

Potential Causes of Knee Pain in Cyclists

• Iliotibial band syndrome.  This is a strong fibrous structure that runs down the side of the thigh from the hip to the outside of the knee. Pain on the outside of the knee joint may be due to excessive strain on the ilio-tibial band. There are various reasons that this may occur, including but not limited to incorrect cleat position, wrong saddle height or a weakness in the hips and gluteal muscles.
• Patella-femoral pain. In this condition symptoms are felt underneath or around the knee cap.  Patella-femoral pain may be due to increased stress between patella (knee-cap) and the femur (thigh bone). This is often due to overactive quadriceps muscles.  A seat that is too low can also cause pain under or around the knee cap due to prolonged time spent pushing in a flexed position and therefore increasing the shearing forces around the joint.  Overactive hamstrings can also play a role in putting the knee cap under extra strain.
• Tendinopathy: This can occur in both the quadriceps tendon (above the knee) and the patellar tendon (below the knee). This is usually as a result of overuse (too much too soon), lack of strength training to prepare for cycling and incorrect bike set up.  A saddle which is is too low increases the flexion angle of the knee. This will put the patellar and quadriceps tendons under increased strain which they may not be able to tolerate over long distances.
• Medial knee pain: This is pain on the inside of the knee joint. Amongst other conditions, bursitis (inflammation of a bursa) may occur through overuse and / or wrong cleat rotation. On the front and inside of the shin bone is the pes anserinus bursa.  A bursa provides cushioning to a joint or body part and maybe become inflammed due to excess pressure or friction forces.  Inaccurate cleat position can also put strain on the collateral ligaments which run down the inside and outside of the knee joint.
• Posterior knee pain: This can affect a range of different structures behind the knee, such as the popliteus tendon and the hamstring tendons. Saddle height, fore-aft position and cleat rotation may all contribute.

Tips to avoid knee pain:

• • Consider overall load management. Knee pain is common when cyclists are too ambitious and try to ride for longer or harder than the body is conditioned to. Build up the distance, speed and duration of your rides gradually.  If you are new to cycling or have just returned to the sport after the winter make sure your training is progressive.  Like with any sport, the muscular system needs time to adapt to new demands placed on the body.  You should gradually increase you mileage over a series of weeks.
  • Pace yourself.  Hard sprinting can put undue stress on the knee joints. Give yourself time to adapt to the intensity of pedal pushing in order to reduce the risk of exceeding the capacity of the muscles and tendons.
  • Strength and flexibility training is important in conjunction with cycling. In the legs the gluteal muscles, quadriceps, adductors, hamstrings and the calf muscles are areas that must be kept strong and flexible. Like with any sport, cross training and varying your exercise / fitness routine is important in helping to prevent overuse injuries.
  • Be aware of the position of your knee when you are cycling.  If your thigh is dropping inwards as you draw the pedal up or your lower leg is moving outwards during the downward pedal stroke, this may be putting your knee under more strain.
  • Dress appropriately for the weather.  If muscles and joints get cold they are at more risk of injury.
  • Ensure you allow and implement good recovery plans into your training schedule to include adequate rest, nutrition, hydration and sleep!

Bike set up

• • Ensure your bike is well ‘set-up’ by a professional fitter. Mal-alignement can cause undue stress. Points to consider include:
    • Saddle height and fore-aft position. Having the correct saddle height is one of the most important ways of reducing stress through the knees. The saddle fore-aft position may also need to be adjusted to create a well-aligned knee position over the pedal.
    • Cleat position and rotation. If incorrect, this will increase rotational forces on the knee. Ideal cleat position may be very different for men and woman as women tend to have larger hips.  The cleats will need to be adjusted to allow for this and to help maintain their legs in a more ‘natural’ alignment.  This will help to minimise stress through the knees.
    • Length of crank arm.

If you have knee pain should you stop cycling?

Yes, no, maybe!

If you have knee pain, it is a good idea to rest from cycling until the cause has been identified. However, this doesn’t mean doing nothing. Stretching (as long as this doesn’t reproduce your symptoms), foam rolling and alternative exercises that don’t exacerbate your symptoms are usually fine to continue with. When managed correctly and early on, knee pain can be easy to get on top of, however with prolonged stress knee pain in cyclists becomes more difficult to treat.

Injuries are highly frustrating for athletes.  However, often they are a huge opportunity to learn more about your body and come back fitter, stronger and more focused.

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Disclaimer:

The purpose of this blog, is to provide general information and educational material relating to physiotherapy and injury management. We make every effort to provide you with correct, up-to-date information. In using this blog, you agree that information is provided ‘as is, as available’, without warranty and that you use the information at your own risk. We recommend that you seek advise from a fitness or healthcare professional if you require further advice relating to exercise or medical issues.