Saturday, September 1, 2012

Cycling Knee Pain

Walking, running and swimming are utterly inefficient when it comes to energy expenditure in relation to distance travelled. Numerous animals are better suited for long-distance travel, but we have something special too: our ingenuity. If we add a bicycle, humans are right up there with birds, at least in terms of energy efficiency.

Cycling knee pain can be dealt with in many ways - Picture by Nicki Varkevisser

There’s no denying that the bicycle is an insanely useful invention, yes, even called “most popular vehicle in world” and I whole-heartily agree, but like with everything else, bicycling has its flaws. This article deals with cycling knee pain, its causes and solutions.

Knee Pain and Bicycling
Surprisingly, knee pain is one of the most often voiced complaints among avid bicyclists. Bicycling is a low-impact sport and often recommended as a way to recover after injuries or even surgeries, so what gives? It turns out there are two major causes for cycling knee pain.

The first reason some bicyclists have knee pain is because they’re too ambitious with their training and do too much too soon. The second cause for cycling knee pain lies in the nature of the bicycle itself: the man-machine-interaction. The bicycle turns into an extension of the human body and as you exert force on your bike your bike also exerts force on you. Any misalignment will put undue stress on either system, but only you will develop pain. Therefore we need to check the setup of the bike and the “setup” of your body, to determine any additional causes for cycling knee pain.

The following article will address these causes for cycling knee pain in more detail and offer a number of treatment suggestions.

Common causes for cycling knee pain

There are several common and a few uncommon causes for cycling knee pain. To have at least some degree of order, the cycling knee pain causes related to the human will be listed first and only then will problems with the bike itself be dealt with.

Cycling Knee Pain: poster child for overuse?
A very short, but to the point, definition of over training is “doing too much too soon”. As an athlete I can relate to that. You love your sport and if the world was coming to an end, many of us would just go out and train one more time, dead-set on putting up one more personal record. But you know what? The world isn't ending and only a chosen few are professional athletes, with first class medical staff on hand and money in the bank for putting their body on the line.

If you don’t let your body recover properly, you can suffer chronic pain, debilitating injuries and hefty medical bills. It’s that serious. Many seasoned athletes will have stories about their regrets in that concern on hand. Be smarter and address your cycling knee pain today.

Preventing Overuse Injuries
If you suffer cycling knee pain, the first and most important step to kick off the healing process is to stop the activity that is causing the pain. Take a break from cycling at least for a week or two. See how your body feels. During these two weeks you won’t be sitting around though. The following steps will put you on your way towards fixing your cycling knee pain.

Fixing posture and tissue quality

The first task on your list is to check your posture. Do you have postural problems like anterior pelvic tilt orinternally rotated femurs? You will also need to determine whether there are muscle-imbalances and if biking is your only sport, I can guarantee that you have some degree of muscle-imbalance that need to be fixed. Here is a short checklist to get you started:

Flexibility and or tissue quality of:


Hip Flexors

Tensor Fascia Latae

Iliotibial band

Strength of:


Hip Flexors



You can address tissue quality yourself by getting a foam roller like the Rumble Roller or another cheaper foam roller, although I find the Rumble Roller to be a lot more effective. Mike Robertson published an excellent introductory article on this subject on T-Nation: Feel better for 10 bucks. Foam rolling and stretching helped me to fix my knee pain.

If you have a bigger budget or just want the highest quality treatment you can get, I suggest you seek out an ART-massage practitioner. These guys will not only find tissue problems, but they will also efficiently fix them. ART-professionals can help you fix your cycling knee pain quicker and more permanently.

You can also outsource the task of checking your posture. To do this, you could find someone who is FMS-certified and if you happen to find a practitioner of ART who is also FMS-certified, you have won the fixing cycling knee pain lottery. Of course you can also do everything yourself, but that will take much longer and require a bigger effort on your side. So why not just play it safe, go talk to a pro and be back on the bike earlier? That’s what I would do.

Easing back into training
Once you have fixed your posture and ironed out any tissue quality issues, you need to slowly ease yourself back into training to prevent your cycling knee pain from returning. It’s a good idea to take a month or even 6 weeks to slowly get back into shape. In the first three weeks you will just do easy rides, without fatigue and pain. After that you transition to endurance pace work, but don’t exceed around 75 % of your max effort. For the three weeks doing this you will push yourself, but not too hard. Now you can start doing some moderate-intensity work to reach the full distance you rode before your break to fix cycling knee pain. This rehabilitation stage will last another two to three weeks and once this is done you can start doing some high-intensity work at your full competition distance. At this point you should take another week or two of training, but can then start competing again.

One important point to remember is that to prevent your cycling knee pain from returning you need to keep addressing your tissue quality and muscle balance throughout the season. This way you can make sure that you don’t run into the knee pain problem again. Let me also give another piece of advice from my personal experience: if the knee pain isn’t gone before you start your training again, stretching and foam rolling won’t help you. Giving the body ample time to recover from knee pain is imperative.

Now let’s look at some specific anatomical issues that can cause cycling knee pain.
Anatomical causes for cycling knee pain 

There are certain individual factors in each person’s anatomy that may contribute to cycling knee pain.

Leg length discrepancies
If you have a leg length discrepancy, only one of your legs will be correctly fitted to the bike. This will put the ill-fitted leg under more stress, potentially causing hip and knee pain. However, you have to distinguish between a true leg length discrepancy and a functional leg length discrepancy.

True Leg Length Discrepancy
A true leg length discrepancy can be caused by a broken bone during childhood, which subsequently caused the respective bone to grow slower. However, there are other potential causes for leg length discrepancy like infections, asymmetric paralysis, juvenile rheumatoid arthritis and even tumors. Here are two tests you can use to determine whether you have a true leg length discrepancy:

Test 1 

Lie on your back with your legs in a neutral position. Have a friend measure the distance between your anterior superior iliac spine and your medial malleolus on each side. Compare the measurements of each side. The difference shouldn’t be greater than a few millimeters (< 1/8 inch). 

Test 2
Lie on your back with your knees flexed at a 90° angle and your feet flat on the surface. If one knee his higher than the other the tibia in that leg is longer. If one knee projects further forward the femur of the respective leg is longer.

Functional Leg Length Discrepancy
A functional Leg Length Discrepancy can be caused by a pelvic tilt or rotation, as well as abnormalities in the hip or sacroiliac joint. To test for muscular imbalances around the hip which cause the hip to tilt laterally you can do the following.

1) stand normally with your feet hip-width apart and then

 watch whether one hip is higher than the other (i.e. your belt isn’t horizontal, which of course requires your belt to sit symmetrically on your hip)

2) assume a widened foot stance 

 if the pelvis is level now, you have shortened hip abductors on the side that was low in part
1) A similar test will have you compare your leg lengths while lying on your back and after sitting up from that position (i.e. sitting on the floor with legs extended in front of you). If there’s an inequality of one leg on sitting up, you have a functional leg length discrepancy. 

What to do next

If you discover that you have a leg length discrepancy you need to a more precise exam from an orthopedist, a sports medicine practitioner or another qualified professional. To compensate for different leg lengths in cycling and thereby remove this potential cause of cycling knee pain, you can either change your cleat positioning or, if the difference is greater than 2/8 inch, put a shim under the cleat of the shorter leg.

flat feet – Pes Planus
If you have flat fleet you are at a higher risk of developing cycling knee pain. People with flat feet are likely to pronate excessively and in doing so they put stress on the IT band at the knee. Getting orthotics usually is the first suggestion when it comes to fixing flat feet, but I would also urge you to see whether you have bad posture. You won’t do yourself any favors if you don’t check for more underlying causes for your flat feet, as orthotics will not address those. However, if there are unchangeable anatomical issues, orthotics may be the only solution to remedy cycling knee pain caused by flat feet.

Muscle length restrictions and soft tissue quality

Whatever anatomical positions you put yourself in, your body will slowly adapt. This is bad news if you sit at a desk all week and want to train like Lance Armstrong on the weekend. Your central nervous system will prevent certain muscles from extending enough and on top of that the prolonged sitting has lowered your tissue quality and thereby reduced your flexibility even further. This will leave you more prone for injury and more likely to develop cycling knee pain. Jump back to “Fixing posture and tissue quality” and read up on how to solve this problem.

Check your bicycle: bike fit
Riding an ill-fitted bicycle will dramatically increase your chances of developing cycling knee pain, since as a cyclist you not only spend a lot of time on your bike, but you also repeat the pedaling motion several thousand times per hour. Even a small alignment error can cause pain with these repetition numbers. Making sure your bike fits your individual anatomy will therefore go a long way in ensuring a pain-free adventure on the road.

Saddle height / position
Problems with saddle height and position are very common causes for cycling knee pain. If your saddle is too low, you put the patellar and quadriceps tendon under increased stress. If the saddle is too high, you will not only irritate the connective tissue around your knee, but your hip will also take a beating, since you’re more likely to rock from side to side.

Putting the saddle too far forward or too far backward will also negatively affect your connective tissues because you’re either pedaling in an overly flexed position or you have to reach forward too far, which will irritate your iliotibial band and biceps tendon.

Crank arm length

If the crank arm is too long, it will expose the knee to higher forces. You’re likely to notice this first in the area of your patellar and quadriceps tendon.

Cleat rotation
Wrong cleat rotation will increase rotational forces on the knee. You are likely to develop pain on the medial side of your knee from having externally rotated cleats, whereas internally rotated cleats will likely cause conditions such as patellar tendinosis.

Finding the proper bike fit  
Properly fitting a bike includes finding the right saddle, adjusting it in height, moving it forward or backward to create a good knee position over the pedal spindle, changing the handlebar positioning (height and width) to remove undue stress from wrists and elbows, determining cleat position and rotation, putting shims under your feet to account for leg length discrepancies, using wedged shims to remove stress caused by an angled forefoot and, finally, checking every single aspect several times to make sure you get as close to perfect as possible.

As much as I’d like to give you the complete rundown on how to fit your bike properly, it is something that would add another 10 pages to this document, because it’s a science in its right, as the previous paragraph has probably shown. That being the case, I recommend you get your bike fitted by a professional. It’s certainly worth the money. An ill-fitted bike will not only cause cycling knee pain, but all sorts of other maladies. And what’s even worse: it will prevent you from achieving your full athletic potential.

Common cycling knee pain complaints and injuries
A quick way to identify potential culprits for knee pain and their respective remedies relies on using the site of pain as an identifier.

Anterior Knee Pain
Pain on the front of the knee can be the symptom of patellofemoral pain syndrome, quadriceps tendinosis, patellar tendinosis, as well as chondromalacia (among others, the diseases listed being the most common). 

Patellofemoral Pain Syndrome
Patellofemoral pain syndrome is an early warning sign and if left ignored can lead to cartilage damage. It is caused by increased stress between patella and femur, which slowly wears out the cartilage on the patella. This increased stress is usually the result of abnormal movement of the patella, which can be caused by soft-tissue problems or muscular dysfunction.

In cyclists the pain usually occurs after exercise and is often perceived to originate from the center of the knee cap. To deal with soft-tissue problems you would foam-roll your IT band, tensor fascia latae and quads (while you’re at it, why not roll the rest of the leg as well?) and then stretch your quads, as well as your TFL (read up on how to do that: anterior pelvic tilt: causes, effects and fixes). Do this every day and cut your biking down to a minimum, to let your body heal.

When you return to biking, ride at a higher cadence of around 70 to 90 rpm, check whether you can reduce cycling knee pain by increasing saddle height by small increments and determine if moving the cleat forward by a few millimeters helps reduce the pain. If you have a leg length discrepancy set the saddle height for the longer leg and use a shim on the shorter leg.

Quadriceps Tendinosis
If your bike is poorly fitted, quadriceps tendinosis can result when accumulating a lot of training volume. This kind of cycling knee pain is a degeneration of the quadriceps tendon or in other words: there is damage at the cellular level that is not inflammation but chronic! The pain will reside above the knee cap, where the quadriceps tendon inserts into the patella. In bicyclists the painful area is most commonly described to be on the outer side of the quadriceps tendon.

In cases of cycling knee pain where the pain resides in the area of the quadriceps tendon stopping the activity is absolutely imperative. According to Wilsen et al. only 80 % of tendinosis patients will recover fully and if you address the issue in its initial phase, you’re looking at a recovery time of two to three months. If you let the injury progress into more serious stages the recovery time will be three to six months.

Treatment suggestions range from just resting, over performing eccentric exercises right down to surgery if conservative therapy has failed. Since inflammation is not the (primary) cause for pain in tendons with tendinosis, anti-inflammatory drugs will not help fix the problem. The tissue has been weakened over a longer period of time and for this to take place you need to supply the tissue with nutrients and the proper stimulus (e.g. through controlled eccentric loading). A soft-tissue professional like an ART-practitionercan help you.

Patellar Tendinosis
Patellar tendinosis is very similar to quadriceps tendinosis, but in this case the patellar tendon is painful. The patellar tendon connects the patella with the tibia and usually gets irritated by angular loading. This can be caused by soft-tissue restrictions of the legs and hips, as well as wrong cleat position.

Just like quadriceps tendinosis, patellar tendinosis needs to be dealt with as soon as possible. You can follow the same treatment protocol as with patellofemoral pain syndrome, but be sure to allow ample rest for the tissue to regenerate. Stretching your quadriceps muscles will “feed some slack” to the patellar tendon and thereby take load off the tissue.

Chondromalacia patellae
Chondromalacia is pain in the area behind the knee cap and if usually gets aggravated through activities that require knee-bending like climbing, squatting and even sitting. The current consensus is that chondromalacia is caused by irritation to the cartilage on the undersurface of the patella, due to wrong tracking of the knee cap.

Conventional treatment for chondromalacia entails ample rest for the cartilage to recover. This step can take several weeks and during this time painful activities should be avoided. As with all the other cycling knee pain maladies, soft-tissue work needs to be done and since cartilage requires movement for nutrition, joint mobility should be performed to accelerate healing. Pick exercises that put low load on the knee, but it through the full range of motion (this is important). Such exercises are the bear squat and the assisted bodyweight squat.

For the assisted bodyweight squat you just hold on to something, like a door, table or other sturdy piece of furniture, and sit back rather than squat down. Your feet should be hip-width apart and pointing straight ahead. Your knees need to be tracking over your toes and must not collapse inward (valgus). Keep sitting back until your thighs touch your calves, maintaining vertical shins by holding on to the support. Here is a demonstration of the assisted bodyweight squat, although this guy could drop down even deeper. If the exercise is painful, don’t do it, but go get professional help.

Medial and Lateral Knee Pain
Medial and lateral knee pain (pain on the inner side and the outer side of the knee) can be traced back to improper bike fit and anatomical problems. In cases of medial knee pain the height of the saddle and its fore-aft position needs to be checked. Cleat position and rotation is also important. Two common ailments with medial knee pain symptoms are pes anserine bursitis and mediopatellar plica syndrome. If your pain is on the outside of the knee (lateral knee pain) you could have iliotibial band syndrome. 

Pes Anserine Bursitis
The pes anserinus is an area on the front and inside of the shin bone. The tendons of three conjoined muscles insert on the tibia and if this area becomes inflamed, which mostly happens through overuse, pain, swelling and tenderness can result.

Treatment options include hamstring stretches, icing of the pes anserinus, placing a cushion between the knees when sleeping and sometimes surgery.

Plica Syndrome
Plicae are remnants of certain embryonic development stages. Inflammation and swelling on the medial side of the knee can be caused by the plica impinging on the femoral condyle during knee flexion. The plica can also be pinched between the thigh bone and the knee cap. Symptoms of plica syndrome include clicking, snapping, locking of the knee or the feeling as if something in the knee caught on to some other part. The pain is usually aggravated by climbing, standing, squatting and sitting. 

Chad Asplund, MD, suggests that an orthopedist be consulted if symptoms persist for longer than 6 months. This is a difficult condition to deal with and sometimes hard to distinguish from other knee injuries.

Iliotibial band syndrome
The IT band is a thick layer of connective tissue on the outside of the leg that runs from your hip to your knee. Iliotibial band syndrome occurs when the fascia of the ITB gets inflamed, which mostly happens due to repeated rubbing on the lateral epicondyle of the femur (the lower part of the thigh bone, where it bulges out right above the knee joint). Symptoms for iliotibial band syndrome include a tight (and sometimes painful) outer thigh and a snapping sensation on the outside of your knee. 

IT band syndrome is linked to inflexible leg musculature, leg length discrepancy, a saddle that is too high or too far back, varus alignment of the legs (bow-legged) and excessive pronation. As with the other cycling knee pain maladies, iliotibial band syndrome can be remedied by fitting the bike properly (e.g. using shims for a shorter leg, adjusting the saddle height etc.). Foam-rolling and stretching the IT band and the tensor fascia latae are also on the to-do list if you want to remedy iliotibial band syndrome.

Posterior Knee Pain
According to Chad Asplund, MD, posterior knee pain is rare in cyclists. If the saddle is set too high or too far back, the biceps tendon can be aggravated. Too much internal rotation of the cleats, a bow-legged alignment of the legs and leg length discrepancy may also contribute to posterior knee pain. In case of leg length discrepancies the shorter leg will be symptomatic. Biceps tendinosis occurs more frequently than medial hamstring tendinosis.

To deal with posterior cycling knee pain you have to limit your pedal float and find the correct saddle height. The saddle height has to be set for the longer leg and the shorter leg will have to be accommodated by using shims.

10 step action plan against cycling knee pain 

The following steps will help you reduce your cycling knee pain and put you on track for recovery.

Cease the activity
The most important step when dealing with pain is to stop the activity that is causing the pain. Of course in the end it’s not the activity per se that is causing pain, but rather a combination of circumstances like improper bike fit, tight leg muscles and overtraining. To get a “clean slate” again, so to speak, you have to give your body time to repair the damage.

Of course this doesn’t mean doing nothing. You will work on flexibility, tissue quality, fixing muscular imbalances, fitting your bike properly and even your nutrition. Just don’t think you can end your cycling knee pain by sticking a couple of stretches into a demanding training routine (been there, tried that – didn’t work btw).

Check your bike fit or have it looked at by a pro
If you pedal at 90 rpm you will perform 5400 repetitions per hour. Having your bike fitted properly is an absolute must for your body to be able to endure that kind of work. Either use the information provided in this article to get clues about what to change or just go get your bike fitted by a professional. Considering the medical costs you’ll be avoiding it’s absolutely worth it.

Check your leg length and posture
Leg length and posture are two important factors, not only as potential causes for cycling knee pain, but for pain in general. Improving your posture can “magically” cure many other small nagging injuries and let’s face it: it’s a cheap and easy way to look a lot better.

Improve your tissue quality
Fascia matters. Soft-tissue restrictions will decrease your flexibility and prevent you from expressing yourself freely in motion. Take care of your soft-tissue by using a RumbleRoller and your body will thank you.

Improve your tissue length
The central nervous system gets new information through every movement you make and if the majority of your body positions put a certain muscle in a shortened state, your CNS will try to keep it that way even if you want that muscle to relax. Retrain your CNS to allow muscle relaxation, which is particularly important in your hip and leg musculature, at least when it comes to fixing cycling knee pain.

For more information on how the nervous system determines how flexible you are, go to this article: The central nervous system, muscle length and the lie of stretching.

Adapt a more anti-inflammatory diet
Some of the ailments listed in this article are caused by inflammation and others are the result of tissue breakdown. Changing your nutrition to be more anti-inflammatory will help your body heal in either case. Here are a few bullet points to get you started:

Add wild-caught cold water fish or another good source of omega 3 fatty acids

Completely avoid trans fats

Avoid Alcohol

Avoid excessive caffeine consumption

Avoid excessive refined carb consumption

Eat grass-fed and grass-finished meat

Lower your body fat percentage if you’re overweight

Use spices like curcumin (turmeric), ginger and oregano

Eat more vegetables and fruits

Drink only water

Consider adding anti-inflammatory supplements
There are many anti-inflammatory supplements out there that can help you deal with your cycling knee pain. Fish oil capsules that supply you with EPA and DHA (important omega 3 fatty acids) should be on the top of your list, but be sure to do good market research before buying. Many fish oil supplements contain ridiculously low amounts of EPA/DHA and still cost a fortune.

If you are in the US you could get “Flamout” (manufactured by “Biotest”). Outside of the US you will have to find another omega 3 supplement that contains around 500 mg of DHA and 200 mg of EPA per capsule (many contain only 1/10 of that). I use “EPA/DHA essentials” by a company called “Pure encapsulations”. You will have to do some digging to find out which omega 3 supplements are available in your region.

There are some other supplements that boast anti-inflammatory properties (like concentrated curcumin supplements), but if you make improving your diet your highest priority and take omega 3 supplements I don’t see the need to add anything else, unless you’re a competitive athlete. 

Don’t rush back into training
Your body needs time to properly adapt to the training stimulus. If you rush back into training you might have temporary success, but you also risk the return of cycling knee pain. Just go easy for a few weeks and maybe even consider ditching the cleats for some time. Becoming a top-level athlete takes years, decades even, and there is no magic shortcut to success. Enjoy the journey.

Listen to your body
Our bodies are smart and highly adaptable, but unfortunately our minds are racing and impatient. In the first few months of training results will come quickly, but after that it will require smart work and a dedicated effort. The longer you stay injury-free, the more you can train, but if you crash and burn every couple of months your progress is guaranteed to stall forever, while more and more injuries are piling up.

Listen to your body and learn to walk the fine line between overtraining and not training enough. Since every one of us is different, with a distinct recovery ability at the cellular level, blindly sticking to someone else’s program will never deliver the best results. Get a help from a qualified cycling coach or read up on the subject matter. That will not only provide knowledge, but also motivation.

Go see a professional to help you deal with your pain


A number of things have to be considered when addressing cycling knee pain, but the most important question will always be whether the athlete is exceeding his ability to recover. With continued over-training, adverse symptoms are bound to set in and it will only be a question of time until small nagging pains turn into serious chronic problems. Be smarter and listen to your body sooner.

On top of that the individual anatomy of the cyclist and the bicycle fit also play a crucial role. Only when the bike is adapted to the body of the rider can cycling knee pain be prevented and performance maximized.

“Common Overuse Tendon Problems: A Review and Recommendations for Treatment”, JOHN J. WILSON, M.D., and THOMAS M. BEST, M.D., PH.D., University of Wisconsin Medical School, Madison, Wisconsin
“Knee Pain and Bicycling – Fitting Concepts for Clinicians”, CPT Chad Asplund, MD; COL Patrick St Pierre, MD
“Pes Anserinus Bursitis”, P Mark Glencross, MD, MPH, FACOEM, FAAPMR
“Plica Syndrome”, Tracy Lee Bigelow, DO
“Science of Cycling: Human Power”,
“Scientific Analysis of the Efficiency of Bird Flight”,
“Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis”, N. Mafi, R. Lorentzon und H. Alfredson

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