Most cyclists – from beginners to the pros – will experience knee pain when cycling at some point during their riding career.
In fact, a study of 116 professional cyclists found that 94 percent experienced some sort of overuse injury over the period of a year, and 23 percent of those riders reported knee pain.
Whilst professional riders do of course expose themselves to a much greater training load, they’ve also got physiotherapists and osteopaths at their disposal on a regular basis – so if almost a quarter of them are struggling with a pain in the knee, you can bet that it’ll be an issue for a high number of amateurs.
We caught up with ex-pro rider turned osteopath to the cycling stars, Alice Monger-Godfrey of AMG Osteo, plus ex-pro, bike fitter and coach, Jimmy George of V02 cycling in Kent to get some answers.
In this article, we’ve covered:
- Anterior knee pain – pain at the front of the knee
- Posterior knee pain – pain at the back of the knee
- Lateral and medial knee pain – pain at the side of the knee
- Knee pain as a result of weakness in the core
- ‘Spring knee’ pain
The knee is a complicated joint
It’s important to remember that the knee is effectively a hinge between the hip and the ankle. It’s very rare that the problem is actually with the knee itself.
Monger-Godfrey explains: “There are so many structures involved that means the pain is localized to the knee – but you need to look at the ankle, hip, and lower back. Because it’s so complicated, it’s great to treat because you often get a really good response rate.”
Anterior knee pain: pain at the front of the knee
Pain at the front of the knee is very common, and its proper name is ‘anterior knee pain’. Usually, it’s caused by tightness in the quads or the fibrous tissue that runs alongside the outer leg – the Iliotibial band – pulling on the patella (knee cap). This can be down to bike fit, or tightness as a result of a lack of maintenance or overuse.
Monger-Godfrey explains: “The main thing to look at is the patella [knee cap]. Everyone talks about patella tracking, or malfunction of the patella, basically the way the knee cap glides over the joint. Often people will say the patella gets ‘stuck’, feels like it clicks or gives way.”
The patella doesn’t get itself into trouble on its own – Monger-Godfrey says: “If you took the quadriceps away from the knee… it would basically fall off…if one side is tight, it pulls the patella in the wrong way, so it doesn’t track smoothly and can cause pain. Cyclists use the quads most in the downward stroke, so that’s a lot of pressure on the knee.”
Tight quads affect the pedaling action, and can be seen visually in advanced cases in a pattern we could refer to as ‘Kermit the Frog Syndrome’.
Jimmy George at V02 Cycling says: “Some cyclists have quads and IT bands that seem to be made of steel. I often see people pedaling with their knees going out during bike fits. Even though their cleats are straight. The quads are so overused that the muscle is short and the only way they can get the leg to pedal right is to pull them out.”
Treated early, pain can be reduced very quickly. However, if left alone, it can cause longer-term damage – Monger-Godfrey explains: “Pain at the front of the knee can come from damage to the meniscus or cartilage – often that comes from trauma, but can also be from repetitive movement. If the knee is held in the wrong position for a long time it can really irritate the tendons where the quads attach at the front, just below the knee cap – you can get quite severe pain there where the tendon gets inflamed, and this can spread around the knee.”
How to fix anterior knee pain
So what can we do about pain at the front of the knee? First – it’s a good idea to check your bike fit. Monger-Godfrey says: “[Pain at the front of the knee] often arises from the saddle being too low and too far forward. Often racers feel they get more power down that way, with their teeth on the bars – but that means they’re sitting on top of the knee and pushing a lot of force through it.”
Cranks that are loo long can also create a similar incorrect angle, and overly tight cleats can cause strain from repeated unclipping.
When it comes to treating the tightness – be it a result of improper bike fit or simply originating from heavy mileage – it’s all about foam rolling and stretching. Monger-Godfrey comments: “Stretch the muscle that is the issue, loosen off the buttocks with massage and that will release some of the tension, then foam roll – gently.”
George adds his tips, saying: “Foam roll the quads, the inside of the thigh and IT band. All rolling needs to be done slowly. Sometimes people go up and down like it’s a rolling pin – but that just flushes over the fibers, and doesn’t get into it – this needs to be one long smooth and progressive push through the fibers to add a bit of length into the muscle.”
Kinesio tape – frequently used to increase blood flow to an injured area – can also be used to push the patella into the correct position. However, George says: “You can have it taped – but that’s a classic case of putting a plaster on the problem. The tape puts the knee back into the right position – what you need is for the tight muscles to relax so that it naturally goes into the right position. Taping is a really quick fix, but doesn’t work long term.”
Posterior knee pain: pain at the back of the knee
Whilst pain at the front of the knee often involves the quadriceps, pain at the back – called posterior knee pain – often has a lot to do with the hamstrings.
George explains: “The saying in bike fitting is ‘pain at front of knee [anterior], the saddle is too low, pain at the back of knee [posterior], the saddle is too high’. From a bike fit point of view, that’s the easiest thing to look at first.”
He added: “Posterior pain can be from overextension – if the saddle is too high the muscles get very tight and the knee cant copes with that degree of flexion. It’s basically overload. The hamstrings are being pulled and you’ll get pain in the hamstring and where the muscle inserts around the knee.”
A saddle that’s too high can cause the lower back to work too hard, Monger-Godfrey says: “A lot of people think you don’t really use the hamstrings in cycling, but you do in the pull-up stroke. That tends to shorten the hamstrings. If they’re put under too much pressure, they can pull on the pelvis. Then the quads try to counterbalance that, which can cause a hip movement that results in a leg length discrepancy – which can also put pressure on the knee.”
There are other causes, as well. Monger-Godfrey pulls out one particular muscle – the popliteus –which sits across the back of the knee. She says: “If you don’t optimize the round pedal stroke, you can put it under stress and cause irritation.”
Fixing posterior knee pain
In the case of posterior knee pain, the first thing you should do is check your saddle height and fore/aft – being too high and too far back could be the cause.
When it comes to treatment, Monger-Godfrey recommends icing and more foam rolling – saying: “Icing for five minutes every hour can really help. Then foam roll and stretch the posterior chain – the hamstrings, calves and glutes. And stretch – hanging your heel off the back of a step helps, or you can shift forwards on the bike and stretch your calves and hamstrings by hanging your heel off the pedal, for about ten seconds.”
Medial and lateral knee pain
Lateral knee pain refers to pain on the outside of the knee, whilst medial knee pain is felt on the inside. Again, a tight IT band and quads can be to blame – but more often than not, Monger-Godfrey says pain here is simply referral from the causes mentioned above.
Cleat positioning is an exception to this rule and is a common cause of medial and lateral knee pain. Unless you’re correcting a specific issue, your cleats should be set up straight. If they’re tilted inwards, your knee will be forced to follow the ankle and track inwards –and vice versa.
There are many intricate alterations a professional bike fitter can make to find the optimum cleat position. But for a basic, neutral position, George says: “people try to do all sorts of clever things [with their cleats] – but really they should be under the ball of the foot – imagine standing on tiptoes – they should be right there, that places the cleat directly below the ball of the foot so you shouldn’t have problems.”
Other bike fit causes of knee pain
Though saddle height, offset, and cleat setup are all common culprits of knee pain, there are some other factors worth considering. Saddle discomfort – or a saddle sore – can cause a rider to sit off-center, again resulting in incorrect tracking as the pelvis shifts and gives the impression of a leg length discrepancy. Even overly low handlebars could be a cause – if the lower back becomes fatigued, changing the natural movement pattern.
Tinkering with your set up may help – but if your problems become chromic there’s little replacement for a physio led bike fit.
Weakness in the glute and core causing knee pain
Cyclists have a tendency to focus on strengthening the quads and calves – the areas that present themselves in rippling superiority when we look at pro cyclists. But we forget that the legs work from the core – the lower back, abs, glutes, and hip flexors are all involved.
A cyclist’s core needs to be strong, or smaller and less efficient muscles will be forced to work too hard, often resulting in pain.
George explains: “Weakness in the glute is a common cause of knee pain – it makes the hamstring and quads work too much. If you’re getting knee collapse [your knees tracking inwards towards the top tube], it’s a sign that the glute isn’t stabilizing the whole leg enough. The knee will track inwards and therefore become sore.”
He adds: “The glutes, abs, and core all work together – if they’re not working it will cause pain, and you need exercises to get them firing up.”
In particular, he suggests a single leg touch down – adding “over time, you can do this loaded with a bar – but you need to get a proper form with the knee tracking straight – and not inwards – first.”
- Single leg touches down: Start standing, with your legs hip-width apart. Raise your left arm and left leg, and reach down, touching the floor where the foot would be. Do not let your standing leg collapse at the knee. Repeat 8 times each side.
Monger-Godfrey agrees that a focus on core strength is hugely important – saying: “The core is paramount for everything- a strong core gives you a stable base, so anything that life throws at you – on or off the bike – you can cope with change – which is where bodies often start falling apart. Cyclists are often poor at maintaining core strength. It’s a shame, as the glutes should be the powerhouse.”
She adds: “I like pilates type core exercises – like tabletops [a form of which is pictured below] – not using extra weight but thinking more about engaging the pelvic floor and core. Getting the glutes working is not about doing loads of squats with dumbells, it’s making sure you’re activating them and switching them on.”
- Swiss ball bridge: Place your feet on a Swiss ball, engage your core and pelvic floor, raise your hips (without over-extending), go back to the floor and repeat.
- Leg extensions: Lie on your back, legs hip-width apart at a 90-degree angle – engage your core and pelvic floor. Slowly push your legs away from you – until you feel your back begin to arch. Return to starting position and repeat.
- Lunges: Start with your legs together. Engage your core and pelvic floor. Place one leg in front, making sure it’s not crossing over in front of the other (use a broom handle if it helps), dip down without letting your knee collapse.
Overload and spring knee
Finally – there are cases where a cyclist suffers from knee pain simply because they’ve done too much, too soon. Commonly called ‘spring knee’ it’s frequently a result of a sudden increase in mileage in an attempt at last-minute fitness gains.
George says: “You can get tendinitis in there – often riders have a break over winter – then they go out and carry on riding like they were – they’ll get tendinitis because the muscle just isn’t ready. From that point of view, they need load – strength work in the hamstring if they’re getting a dull aching pain. It’s important to stretch the hamstring then too.”
He adds: “From a coaching perspective – only ever add 10% of duration – if someone suddenly goes from nothing to 4 hours, they’re going to get pain. Same for intensity – if you increase intensity you need to back down on volume and ensure you’re getting rest.”
Spring knee is also sometimes associated with over-gearing, so it’s often a good idea to use smaller gears and higher cadence until the problem subsides.
When to see a bike fitter or physiotherapist
There is only so much you can learn from the internet – and it’s important to understand that lack of strength, flexibility and bike fit are all very intertwined. If you’re struggling from long term, persistent, or ride stopping pain – it’s a good idea to check yourself in with a physiotherapist, osteopath or medical professional. You should also aim to book in for a bike fit carried out by someone who will look at your own flexibility and weaknesses, as well as riding style and volume.