If you have experienced cycling knee pain, you are not alone. Pain in the front of the knee is one of the most common overuse injuries in riding. A recent study found that 36% of all recreational cyclists have experienced knee pain in the past year; what a way to wreck your next Old La Honda PR Attempt.
The good news? Many times cycling knee pain is caused by easily modifiable factors. A few changes to your bike fit and training regime will help you remain pain-free for years to come. That means nothing to stop you from experiencing the freedom that you only get from being on your bike.
This article contains everything that you need to know about the common causes of cycling knee pain. It should not be used as a supplement to a knowledgeable, medical professional but rather a guide to determine your next steps.
Use this article as a roadmap to educate yourself on the common causes of knee pain.
- Find the area of your knee that is affected
- Read to understand the most common pathologies
- See bike fit adjustments that may help resolve your knee pain
Don’t forget to complete the “Check Your Understanding” Quiz at the end of this article!
Anterior (Front) Knee Pain
Anterior cycling knee pain is the most common location of knee pain in cyclists. There are many possible pathologies that may lead to pain at the front of the knee. The most common causes are:
- Patellofemoral pain syndrome
- Quadricep muscle strain or quadriceps muscle tendinopathy
What is Patellofemoral Pain Syndrome (PFPS)?
PFPS is a painful irritation of the front joint of the knee. In a healthy patellofemoral joint, the two bones glide seamlessly: the kneecap stays aligned in the groove in the femur (the large thigh bone). If the two joint surfaces move correctly, the risk of injury is low. However, muscle tightness, muscle weakness, altered biomechanics or training error can cause the kneecap to track improperly; increased force can then be placed on the joint surfaces causing pain and discomfort.
Due to the many variables that may contribute to this condition, it is important to be evaluated by a physical therapist.
What about the bike?
A seat that is too low or too far forward can also cause excess stress at the front of the knee. Cleat position and alignment should be considered as it affects the alignment of the entire limb while on the bike.
What is a quadriceps strain?
The quadriceps muscle group is a group of 4 muscles (hence “quad”) at the front of the thigh. While biking, their main role is to assist in straightening the knee during the downward portion of the pedal stroke.
Their job is tough, especially when you are climbing a big hill, sprinting to pass someone or cranking along in a high gear. When these muscles are stressed beyond their limit, acute tears can form in the muscle.
A physical therapist can help design a strengthening program to rehabilitate this injury and keep it from coming back, but if this injury is caused from riding your bike, it is likely that a change in your bike position will be beneficial.
Raising your seat slightly will decrease the load on the quadriceps muscle. You may also consider pedaling in a lower gear as increasing cadence will also decrease stress on the quadriceps muscle. Riding at a higher RPM also requires more effective biking mechanics and is a great way to improve your efficiency on the bike long term.
Remember that any change you make to one part of your bike will affect the relative fit of all other parts. Use the advice of a trained bike fit professional to ensure proper overall fit.
Lateral (Side) Knee Pain
The most common cause of cycling knee pain on the outside of the knee is ITB friction syndrome.
The ITB is a thick band of connective tissue on the outside of the thigh. It attaches from the hip region to the outer part of the knee.
This long piece of fascia has no attachments to bone all the way from the hip to the knee allowing some movement as the leg moves forward and backward.
By the knee, the ITB lies near a bony bump (lateral femoral epicondyle – for all you anatomy nerds out there). When the knee is straight, the ITB lies in front of this bump. When the knee is bent to 30 degrees or more, it lies behind the bony bump.
What does all this mean?
If the position of your bike allows your knee to bend more than 30 degrees, you run the risk of repetitively moving the ITB over this bony bump: this can cause pain and discomfort.
While there are soft tissue mobilization techniques and strengthening exercises that can decrease the likelihood of this condition, a simple bike fix of raising your seat slightly may be enough to decrease the stress on this region. Again, it is important to remember that one adjustment on your bike affects all others so it is helpful to make adjustments with the guidance of a trained professional.
Posterior Knee Pain
The most common cause of cycling knee pain at the back of the knee in cyclist is hamstring muscle strain.
The hamstrings are a group of muscles located at the back of the thigh. They work, with other muscles, bring your foot from the bottom of the pedal stroke to the top of the pedal stroke. Similar to the case with a quadriceps tendinopathy, when they are stressed some of the small muscle fibers that make up the hamstrings may rupture causing pain, discomfort and decreased force production of the muscle.
A physical therapist can help design a strengthening program to ready the hamstrings for the load they must endure during cycling, however bike fit should also be considered.
A seat that is too high or too far back can lead to excess stress on the hamstrings, while improper cleat position may also play a role. Changing this factors, combined with a well-designed strengthening program will help your hamstrings to work at their fullest capacity.
The most common causes of knee pain in cyclists are well understood, however, there are many other potential causes of knee pain in cyclists. If you are experiencing pain in the knee do not wait to have an examination by a medical professional.
In preparation for your appointment, think about the following questions. Your answers will help guide your physical therapist toward the proper treatment approach.
- Where is the pain located?
- How intense is the pain?
- What does it feel like (sharp, dull, achy, tingly)?
- What causes the pain?
- How long into your ride does it occur?
- Does the pain occur with flat cycling, climbing?
- Do you notice a change based on RPM? What (approximate) RPM do you ride at?
- What gear do you normally ride in?
- How long after your ride does the pain last?
- Why type of bike do you ride?
- Has your bike ever been fitted to you? Who performed the fit? Have you adjusted your bike?
- How has this changed your symptoms?
Educating yourself on the cause of your pain is the first step to ensuring that the pain does not continue to limit your ability to perform the activities that you love. Pain while biking is NOT normal. Respect your body and know that there are always options to improve your efficiency, comfort and performance on the bike.
COR Bike Fit
For the cyclist, the best treatment approach will involve not only standard physical therapy care but also an in-depth analysis of your bike fit position. Finding a physical therapist who has an understanding of all factors that contribute to your cycling knee pain will be crucial to you improving your performance, decreasing your pain and enhancing your riding.
For more information about the COR bike fit process, click here.
Check Your Understanding!
1. Raising your seat position may help decrease pain from all of the following positions except:
- ITB syndrome
- Hamstring strain
- Quadricep strain
2. The most common cause of knee pain on the outer (lateral) side of the knee is?
- ITB syndrome
- Hamstring strain
- Quadricep strain
3. Which of the following is least likely to help decrease pain from a quadricep strain?
- Increasing cadence (while maintaining the same average speed)
- Riding in a lower gear
- Limiting hill riding
- Decreasing cadence (while maintaining the same average speed)
4. Why is it important to have your bike fit by a physical therapist?
- They have a thorough understanding of biomechanics, anatomy and injury pathology (as well as bike fit)
- They will ensure a bike fit that is best for your body type, strengths/weaknesses, current/past injuries and goals as a cyclist
- They are wonderful people
- All of the above 🙂
Dr. Erin Cameron
DOCTOR OF PHYSICAL THERAPY
In 4th grade, when asked what she wanted to be when she grew up Dr. Erin Cameron, DPT replied “physical therapist,” a rather unconventional response for a child that age. She was a young swimmer with shoulder pain, desperate to return the to sport that she loved so dearly. The dedication of her physical therapist allowed her to pursue her passion and eventually go on to compete at the collegiate level. While swimming at the University of Michigan she studied to obtain a Bachelor of Science in Movement Science from the School of Kinesiology. During her collegiate swimming career, she earned the following accolades: two-time CSCAA Honorable Mention Scholar All-American, three-time Big Ten Distinguished Scholar, team captain and the Michigan Leadership Academy Leader of Distinction award.
Erin has dedicated much of her life to the sport of swimming. In addition to competing in the sport for 15 years, she has coached at various elite swim camps and clinics growing her expertise in stroke technique and video critique. She has also served as a volunteer staff member for Division I, II and III swim programs aiding in both coaching and developing exercise programs/educational sessions for upper extremity injury prevention.
Erin received her Doctorate in Physical Therapy from Northwestern University’s Feinberg School of Medicine. During her time in physical therapy school, she developed a special interest in treating patients with orthopedic injuries and promoting general health and wellness in people of all ages. She has since focused much of her continuing education on the treatment of runners and cyclists and has a special interest in maintaining the health and improving the performance of endurance athletes and is a Bronze Level Bike PT fit specialist.
- Moen E. BikePT – Bronze. Continuing Education Course Presented at Corpore Sano Physical Therapy and Sports Performance in Kenmore, WA. September 15 – 16.