Cycling is a highly repetitive sport, with a rider averaging about 5000 pedal strokes per hour.
The repetitive nature of the sport means that overuse injuries are common, with knee injuries probably being the most common of all.
Even the smallest amount of mal-alignment or incorrect distribution of load, whether anatomic or equipment related, can lead to dysfunction, impaired performance, and pain. ( learn about bike fits)
Overuse injuries occur when a tissue accumulates damage caused by repetitive sub-maximal loading. This damage is referred to as microtrauma.
Without adequate recovery, microtrauma stimulates an inflammatory response that can damage local tissue. Cumulative microtrauma from further repetitive activity (cycling again before you have fully recovered) eventually leads to clinical injury. In chronic cases, this continued process can result in degenerative changes that lead to weakness, loss of flexibility, and chronic pain. Thus, in overuse injuries, the problem is often not acute tissue inflammation, but chronic degeneration.
In our experience, Patellofemoral (kneecap) joint pain is the most common overuse injuries in cyclists. Injury may be related to improper bike fit or equipment, poor technique, biomechanical issues, or inappropriate training patterns. Patellofemoral pain is usually worse when the knee is loaded eg. when climbing or descending stairs, during prolonged sitting or squatting. On the bike it tends to happen when climbing hills or pushing hard gears.
8 Reasons Why Cyclists Get Knee Pain
Muscle tightness – most cyclists’ quadriceps and hamstrings will tighten with prolonged riding due to the repeated contraction and shortening of these muscle groups. Inflexibility of the quadriceps or hamstrings may restrict range of motion around the knee and are likely to increase the forces on the knee. (get the strength and stretching guide)
Weak leg muscles – may lead to fatigue-induced alterations in pedalling technique, which will also alter the forces on the knee. As muscles fatigue, their ability to take load decreases, increasing forces through the joint.
Muscle imbalance – poor activation of the inside quad muscle (VMO) and/or tightness/overactivity of the outside quad muscle (vastus lateralis) and ITB/Tensor Fascia Lata (TFL) can alter patella tracking, increasing load though one part of the knee.
Training errors – include heavy training loads and high mileage (beyond what the body is conditioned to do), or a rapid increase in training duration or intensity, especially hill work, or inadequate rest/recovery.
Gearing and cadence – pushing hard gears at low revolutions puts high load through the patella, whereas lower gears at a high cadence (85-90rpm) will put less load through the patellofemoral joint with each stroke.
Pedaling mechanics – inside drift (internal rotation and/or adduction) of the knee, especially during the push down phase, can be due to weakness or fatigue of the glutes or inside quads muscle (VMO). This increases the lateral forces on the patella.
Saddle position – may be too low, too far forward, or both, causing excessive patellofemoral loading throughout the pedal cycle. When the saddle is low, the knee functions in hyperflexion, increasing compression of the patella on the femur. Conversely, a saddle that is too high can destabilise the pelvis or foot, leading to poor mechanics.
Cleats – improper shoe cleat position or float may force the rider to pedal with poor biomechanics, increasing patellar forces. Cleats with excessive internal or external rotation may cause exaggerated tibial rotation, placing more stress on the patellofemoral joint. (learn about cleat set up)
How to prevent cycling-related knee injuries
To treat and prevent cycling knee pain, you need to alter the amount of load going through your patella and surrounding tissues.
Your Physiotherapist will be able to assess what is tight, weak, or simply not working properly, not only around your knee, but also around your foot/ankle, hip, pelvis and trunk, and design a program to address these issues. A cycling-savvy therapist will also be able to give you advice on training, technique and help you identify when you should rest or push on.
A comprehensive bike fit is essential, looking at the 5 points of contact – saddle, handlebars and foot/pedal.
- The saddle (height, fore/aft, tilt, type)
- Shoe (size, width, heel support, insoles, wedges,)
- cleat (position, float)
- crank length
- handlebars (reach, height, angle, levers)
All of these components need to be considered and addressed. Learn more about our bike fit service.
Finding the right balance between comfort, efficiency and injury with so many variables involved, takes the skill of an experienced bike fitter!
Book in for an expert bike fit service now and enjoy your cycling pain free.
This article was written by TBM Cycling Physio – Nicole Oh