If you suffer from cycling knee pain, you know how debilitating this can be. With the warmer weather approaching it is time to start getting back on the bike and building up your fitness over summer. Whether you are training for a full day race or just interested in commuting more, this can be a potentially problematic period of time for the body. This is because the amount of time you spend on the bike increases. We’ve covered Bike fitting previously on this website and I have recently had another article of mine published in Flow Magazine, Bike Fitting Fundamentals: A Case Study with Dylan Cooper.
On this occasion I thought we could take a closer look at knees as a potential problem area for cyclists and some ways of preventing knee pain. At an elite level in one study, knee pain accounted 57% of injuries that required time off the bike. However, there are some steps you can take to help prevent you falling into this group.
What I’ll cover in this article:
- Anatomy of the knee
- Types of knee pain
- How to fix cycling knee pain
- How to prevent cycling knee pain
- Best 3 stretches for cycling knee pain
Anatomy of the knee
To understand knee pain it is helpful to have a basic idea of what lies beneath the skin. In simplistic terms, think of the knee joint as a hinge where the quadriceps muscles pull the knee straight and the hamstring muscles bend the knee. The quadriceps run from the front of the femur (thigh bone) to the patella (knee cap). The patella acts as a pulley to increase the force generated by quadriceps which creates a greater torque on the tibia (shin bone).
In the bad old days surgeons would often remove a patella if it was causing pain from arthritis. The knee would still function but couldn’t generate as much pushing force. I would certainly prefer mine where it is. Hamstrings on the other hand run from the lower point of your pelvic bone (the point that you hopefully sit on whilst riding) to deep behind the knee on the tibia.
To make matters more complicated, the ITB runs down the outside of the thigh and blends into the outside of the knee. ITB stands for iliotibial band and is a well known potential source of trouble for cyclists, runners and active people in general. The ITB is also attached to your gluteals (buttock muscles) and a hip flexors. Often when looking for the source of knee pain we have to pay close attention to hip flexibility and control.
Types of knee pain
Where can it all go wrong?
The most common type of knee pain in cyclists is often described as patello-femoral pain. This is referring to pain in region around the knee cap. Patello-femoral pain can be mild in nature or quite debilitating depending on its severity. It is often but not always a result of tight quadriceps, a tight ITB and poor quadriceps and gluteal strength. Bike setup can also play a part by causing an increased compressional force between the patella and the femur with the seat too low or too far forward.
The ITB can also create pain at the front or outside of the knee if it is too tight. If the hip stabilizing muscles are too weak this can also cause a greater pull on the ITB which lead to abnormally loading structures at the front of the knee. In less common cases the thick band of tendon that runs from the patella to the tibia known as the patella tendon can become unhealthy and degenerated.
In these cases, the predisposing factors are very similar to the ones found in patellofemoral pain. However training volume and changes in training types needs to be taken into account as tendons do not respond to change as quickly as some of the other structures in the body. Consequently, the patella tendon can become unhealthy and degenerated and cause pain at the front of the knee.
How to fix cycling knee pain
Obviously prevention is better than the cure, so read on to find out ways of keeping the knee happy whilst the volume and intensity of training increases. All of the conditions above are treatable. If caught quickly, the treatment time can be significantly reduced. Physiotherapy is usually effective in treating the types of knee pain described above so there is no need to be a hero and put up with pain. Treatment will be different for each person based on an assessment as to which muscles are tight and which areas are weak.
Massage, soft tissue release and foam rolling can all be effective in reducing muscle tightness in conjunction with a home stretching program. Often strength exercises need to be prescribed. These stretches will help to decrease load on painful structures, improve the health of degenerated structures, or alleviate biomechanical abnormalities. In severe enough cases, physiotherapy can be supplemented with a course of anti-inflammatories as recommended by your GP. Or in certain situations, even a cortisone injection may apply. It is important to remember that these last 2 remedies may take the pain away, but the predisposing factors still need to be treated to get an optimal outcome and prevent the pain from potentially re-occurring.
How to prevent cycling knee pain
Firstly, let’s get the bike right. Knees are most commonly affected by a seat being too low, too far forward or the wrong cleat position. If this seems to be a problem for you it may be time for a bike fit. To keep those achey muscles happy over the spring and summer months it might be time to start some stretching. Maintaining flexibility is important for injury prevention as tight muscles can lead to overuse injuries.
For cycling related anterior pain (front of the knee) the main muscles to pay attention to will be the quads, hip flexors and glutes. There are several ways to stretch these but I’ve just shown the simple versions below. For recovery purposes I tend to recommend stretching each muscle group for a minute after each training session. However, during rehab, stretches may need to be done 2-4 times daily.
Stretching for less than about 15 seconds is not overly effective as the muscle takes approximately 18 seconds to fully relax. Sometimes during periods of higher training load you will need to stretch more frequently if you start to notice your flexibility decreasing. While you’re at it stretching, don’t forget about the rest of the body… there are many other muscles that get tight from riding and they too need a bit of TLC.
Top 3 stretches for cycling knee pain
Here are some positions for stretching some of those tight leg muscles.
Bring your knee to your chest, place the same side hand on the outside of your knee. Place your other hand on top of your foot. Pull your foot towards your chest and push your knee across to your opposite shoulder.
Hip Flexor / ITB Stretch
Place a pillow on the floor in front of the chair. Place your toes on the chair and your knee on the pillow. Put your other foot out in front with your knee bent to 90° and in line with the knee on the pillow.
Stand with your back to the table and place your toes on the table. Place a rolled towel in the crease of your knee. Lean backwards and push your hip forwards.