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Cycling Knee Pain Causes, Symptoms and Treatment

Liam Hallam is a sports science graduate. He is also a keen cyclist and a lover of the Derbyshire Dales and Peak District.

A Guide To Knee Pain From Cycling

We all know that cycling is a great exercise due to it's low impact nature and the potential benefits for our health can be great for our mind, body and soul. However, a common complaint made by newcomers to the sport and regular riders is that it's repetitive nature can cause joint problems. Whether it's too much, too soon or incorrect cycling posture.

This guide will provide an insight into the causes, symptoms and treatment of knee pain for cyclists. You'll be able to establish whether you're experiencing anterior, posterior or lateral knee problems and preventative action for the future.

We will look at getting your anatomical posture sorted too for lots of trouble free riding.

Knee Pain Is A Common Complaint Amongst Cyclists

The repetitive nature of the pedal stroke can exacerbate cycling knee pain

The repetitive nature of the pedal stroke can exacerbate cycling knee pain

Sports Injury Prevention For Cyclists

There are three ways that way can prevent sports injuries. 1. you can aim to prevent a problem from occurring (primary).2. You can look at how the problem can be prevented from becoming a chronic issue once it has occurred (secondary) and 3. You can look at preventing the problem after it's occurrence (tertiary).

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General Causes Of Cycling Knee Pain

There are a number of factors which are responsible for causing knee pain

1. Incorrect On Bike Posture

Your position on the bike means everything to your pedalling action and it's subsequent effect on your knee joints. From the height of your saddle to the position of your pedal cleats, your on bike contact points can have a dramatic effect on your knees.

2. Cycling Pedal Technique Related Overuse Injuries

Your pedalling technique can make a huge impact on the pressures placed on your physiology. Issues with your pedal technique can lead to problems over time. Particularly relevant to overuse problems as the repetitive nature of cycling means that the effects of poor pedal technique over-and-over again can lead to long-term problems.

3. Training Errors

A common problem in many riders is to incorporate too many miles too soon out of panic or simple over-exuberance. Too much hill climbing, too much speed work or too much time in huge gears.

4. Body Type Issues / Anatomy

Your own anatomy can also have an effect in the form of leg length discrepancies and other musculo-skeletal problems. These can lead to problems such as the mal-tracking of the knee caps.

5. Off-Bike Related Issues

Your lifestyle off the bike can have an impact on your body. Whether you hit the gym or head out running- these activities have an impact on your knee health.

Protect Those Knees When Your Cycle!

Poor posture and technique can lead to cycling related knee problems such as Patellofemoral Pain Syndrome

Poor posture and technique can lead to cycling related knee problems such as Patellofemoral Pain Syndrome

Anatomical Issues That Can Cause Cycling Knee Pain

There are a number of personal anatomical issues which could impact on your potential occurrences of bicycling related knee problems. Everyone's body has it's own limitations and some of these factors will therefore be more influential than ofhers on your long term riding health.

Flat Feet And Cycling Knee Pain

If you're a cyclist with flat feet you're automatically at a heightened risk of experiencing knee problems in future. Flat feet often lead an athlete to encounter excessive pronation at the feet (Inward roll). For many riders with flat feet orthotic shoe inserts may be the only solution to prevent cycling knee pain caused by flat feet.

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Leg Length Discrepancies And Knee Problems

Bicycles are designed symmetrically. If you're not symmetrical you're going to struggle to fit correctly onto your bike. One of the most influential factors on this is a cyclists leg length. Leg length discrepancies can be categorised as of two distinct types which will potentially require different forms of corrective actiion. i) True leg-length discrepancies and ii) functional leg length discrepancies. The video below features techniques of diagnosis.

Leg Length Discrepancy Diagnosis

True Leg Length Discrepancy Testing

True Leg Length Discrepancies are as a result of slow bone growth. This can be as a result of a leg break during childhood stunting bone development or illness. The effects of this can be counteracted by the use of cleat shims to adjust to correct leg lengths.

Simple True Leg Length Discrepancy Test

Lie on your back with your knees flexed at a 90° angle and your feet flat on the floor

  • If one knee lifts higher= The tibia of that leg is longer.
  • If one knee projects further forward= The femur of the leg is longer on the further forward knee leg


Functional Leg Length Discrepancies

Functional legs length discrepancies develop as a result of the actions of our musculo-skeletal system. They're particularly related to rotation at the pelvis and abnormalities at the hips.

Types Of Knee Problems From Cycling

There are a number of knee problems commonly exhibited which can lead to pain from cycling. These can be broken down into Anterior Knee Pain, Posterior and Medial or Lateral Knee Pain

Common causes of anterior knee pain from cycling

  • Chondromalacia Patellae
  • Quadriceps Tendinosis
  • Patellar Tendinosis

Anterior Knee Pain- Patello-Femoral Pain Syndrome

One of the most common anterior (frontal) forms of knee pain from cycling is Patello-femoral pain syndrome which relates to the incorrect tracking of the kneecap (patella) along the lines of the femoral condyles.

Causes of Patellofemoral Pain Syndrome

It is believed that excessive forces can create stress and shearing forces by pushing the patellar against the surface of the femur. There are many potential causes of Patello-femoral Pain ranging from incorrect saddle height placing additional stress on the area. Excessively high gearing and large amounts of hill climbing can also lead to tenderness in the area of the patella. Weaknesses in the vastus mediallis muscle on the inside of the thighs have also been pin-pointed as a potential cause.

Future management of Patellofemoral Pain Syndrome

To avoid and protect against Patellofemoral pain syndrome from cycling and rider needs to look deeply at their position on the bicycle. Saddle height should be slightly higher than normal leading to a knee bend of less that 25 degrees when the foot is parallel to the ground at the base of the pedal stroke (6 on a clockface).

A consideration is to attempt to widen the distance between the feet to ensure reduced pressure on the patella tendon while riding. This can be achieved through using awider bottom bracket axle or using a spacer on the pedal axles to move them laterally outwards.

Sufferers should look at increasing their pedalling cadence to above 85 rpm to avoid excessive stresses.

Anterior Knee Problems: Chondromalacia Patellae

Causes of Chondromalacia

Characterised by pain to the back of the kneecap- Chondromalacia Patellae is believed to be due to the irritation of the cartilage on the lower surface of the patella which is often symbolised by mal-tracking of the kneecap.

Treatment of Chondromalacia Patellae

Treatment involves a healthy dose of rest to allow the repair of the cartilage on the underside of the patellae. After a period of inactivity, active recuperation is required to stimulate mobility and enhance healing with exercises that exercise the knee gently through it's range of motion. In the gym assisted body-weight squats (featured below) are an excellent exercise to consider if you do not experience any pain during the squat.

Assisted Bodyweight Squats For Chondromalacia Patellae Recovery

Quadriceps Tendinosis From Cycling

The degeneration of the quadriceps tendon can lead to pain above the knee cap at the point of it's insertion to the patella. The pain often manifests to the outside of the quadriceps tendon and can be excruciating as a result of inflammation of the affected area. It is more common in older athletes due to long term development of the condition.

Causes of Quadriceps Tendinosis

The main cause of quadriceps tendinosis is believed to be poor bike fitting combined with repetitive / prolonged activities placing additional stress upon the quadriceps tendon and contributory factors can include

  • Joint stiffness at the knee, hips, ankles or lower back
  • Increased muscle tightness (quadriceps, hamstrings or calf muscles)
  • Excessive training volume or load
  • Muscle weaknesses
  • Poor recovery post previous quadriceps injuries
  • Biomechanical issues of the foot and leg
  • Inappropriate on-bike position

Treatment of the condition

Initial rest and the standard RICE (Rest, Ice Compression, Elevation) technique is required. As the inflammation is not the cause of the pain- anti-inflammatory drugs will not assist in alleviating pain symptoms.

A suggestion is the performance of eccentric exercises however these must be discussed with a physiotherapist prior to further action. As with any cycling related health problems consult your doctor if rest does not help alleviate your symptoms.

Physiotherapy treatment can range from:

  • Soft tissue sports massage
  • Stretching programs
  • Joint mobilization regimes
  • Patella taping (Sports tape)
  • Gym related exercises for improved muscle strength and flexibility
  • Crutches to alleviate pressure on the area
  • Prescription of orthotics if required
  • On bike positional analysis

Patellar Tendinopathy Through Cycling

Patellar Tendinopathy pain manifests at the front of the knee in a more localized area than patellofemoral pain syndrome.

Patellar Tendinopathy pain manifests at the front of the knee in a more localized area than patellofemoral pain syndrome.

Visual Representation Of Patellar Tendinopathy

Patellar Tendinopathy And Cycling

Another anterior form of cycling related knee pain is patella tendinosis which features tenderness which resonates local to the lower end of the patella. If patellar tendinopathy becomes a chronic problem for the athlete it can lead to a longer period of recovery and therefore it is important to recognise the condition early.

Causes of Patellar Tendinosis

Patellar tendinopathy often results from a rapid, sudden increase in mileage. For many cyclists it can be most common at the end of the winter when spring and summer loom with a short period of good weather coaxing a rider to suddenly up their mileage. It can also result from excessive angular pull on your patellar tendon while pedalling which can result from worn pedal cleats.

Treatment and management of Patellar Tendinopathy

Due to any angular pull on the patellar tendon it may be a requirement for the cyclist to consider a pair of orthotic shoe inserts if the foot pronates dramatically. However in cases where heavily worn cleats are being used it can mean that simple replacement can help.

If the problem becomes chronic it can require periods of up to a year to put right with potential requirements for cortisone injections. Chronic tendinopathies are classed where symptoms have been present for a period inn excess of 3 months.

Effective Pedalling Technique Helps Prevent Injuries

Learn to pedal in circles for a better technique and guarding against future joint problems

Learn to pedal in circles for a better technique and guarding against future joint problems

Posterior Knee Pain and Biycling: Biceps Tendinosis

Posterior knee pain relates to pain felt at the back of the knee and the most likely cause of this is inflammation of the tendon of the biceps femoris

Potential causes of biceps tendinosis

  • Excessively high saddle position
  • Too much pedal float
  • Sitting too far back in the saddle
  • Weak hamstrings muscles and lack of flexibility
  • Riding too high gearing
  • Excessive heel drop at the base of the pedal stroke.

Management on and off the bike

A rider, coach or physiotherapist needs to look closely at on bike position and make adjustments to move the saddle forward while maintaining an adequate saddle height.

Limit pedal float. If you currently ride Look Keo red cleats a switch to their limited 4.5 degree float Look Keo grey cleats which may provide some relief as will looking at further development of the pedal stroke to ensure the heel does not pronouncedly drop towards the base of the action (Around 6 on a clockface)

Strengthening of the hamstrings is an important part of maintenance and alleviating symptoms of biceps tendinosis.

Lateral And Medial Knee Pain From Bicycling

Common causes of medial or lateral knee pain from cycling include

  • Iliotibial band syndrome
  • Pes Anserine Bursitis
  • Plica Syndrome

Lateral Knee problems- Iliotibial Band Tendinosis

Iliotibial Band Tendinosis from cycling often features tenderness laterally above and below the kneecap (pictured)

Iliotibial Band Tendinosis from cycling often features tenderness laterally above and below the kneecap (pictured)

Lateral Knee Pain: Iliotibial Band Syndrome

Lateral (outside) knee pain is usually characterized by an onset of localized pain while a cyclist is pedalling. Iliotibial band (ITB) syndrome often results from an excessive level of irritation to the ITB band as a result of repetitive friction over the lateral femoral condyle of the femur bone.

Causes of Iliotibial Band Syndrome

A key cause of ITB problems for cyclists is cleat positioning. Although other precursors can be a narrow bottom bracket axle or excessive levels of high climbing and/ or too high gearing choices over an extended period of time. A wide pelvis, bow-legs and tight glutes may be contributory factors.

Management And Treatment Of ITB Problems For Cyclists

  • Adjust cleat angle to angle feet away and toes slightly further outward
  • Increase distance between pedals by using a wider bottom bracket or spacers at the crank/ pedal axle interface.
  • Check for leg length discrepancies and us spacers to create equidistant levers
  • Avoid excessive gearing
  • Avoid excessive hill work- gradually phase into training
  • Iliotibial band stretching

Pes Anserine Bursitis And Plica Syndrome

Pes Anserine Bursitis results from stress where the insertion of the conjoined tendons of the sartorius, semitendinosus and gracilis muscles meet the tibia bone at an area at the front of the shin. It's often as a result of anatomic deformity although cycling can lead to inflammation as a result of overuse. This condition affects the medial section of the knee joint.

Common treatment and management options for pes anserine bursitis involve a detailed stretching regime, RICE treatment and potentially surgery in the long term.

Plica Syndrome refers to synovial plica syndrome. Plica are fetal remnants from birth which remain as sleeves of tissue which can be prone to irritation. Plica can impinge on the femoral condyle during knee flexion and lead to irritation and injury.

Symptoms of plica syndrome include the clicking or locking of the knee and pain can be aggravated by climbing on a bike.

Have Your Say On This Article

Lorraine Lam from Hong Kong on October 07, 2018:

loved this article and have saved it. we skiers also have knee problem so it's really useful. Thanks a lot ya!

Susan Sears on May 15, 2017:

Very interesting article. I deal with knee pain at times and have wondered about the size of my bike and my body. I have very long legs and often have trouble with a good fit on a bike.

Prisana Nuechterlein from Thailand and Colorado on May 20, 2016:

Excellent article!! I shared it on my FB and Pinterest My son and his wife are experiencing knee pain on their rides and this hub will be of great benefit to them! Thank you for your in-depth examination and explanations of what causes knee pain and how to prevent further pain.

Liam Hallam (author) from Nottingham UK on April 07, 2013:

Thanks all for the comments

@tirelesstraveler- it's amazing what we often attribute our pains to especially when we grow accustomed to a specific set-up. Our body adapts but sometimes those adaptations have a negative effect long term

@Tony (capon). Interesting point and i've had similar effects in the past too. Injuries which effect running or are gym exercise based sometimes have minimal effect on our cycling. Cycling's low impact format can help to enhance recovery by mobilising joints although I have to stress that it is only in some cases and not all.

@dannydydek- thanks for the feedback. I have placed a diagram for Patellar Tendinopathy I have located and will have a look at adding some simple, easy to visualise diagrams for the future

@INFJay. Thank you for your feedback- I hope all my work pays off with this article.

Thank You To All

Judy Specht from California on April 07, 2013:

Very good. Personal experience with incorrect fitting has me very picky about how my bike and cleats fit. My husband and I had a month long fight over whether or not our water bed was the cause of his back and knee pain. It was his new bike seat that was the problem. You cannot stress fit enough for keeping the knees healthy and happy while cycling.

Tony Capon from Upminster, Essex, United Kingdom on April 06, 2013:

About 4 years ago I injured my right knee when performing weighted step-ups in the Gym (it flares up from time to time). Although it was painful to walk and run, I found that I could ride "pain-free!" tony

Danny Dydek from Pittsburgh, PA on April 06, 2013:

Very thorough...though maybe some diagrams of the knee? I started losing track of which part you were talking about.

Jay Manriquez from Santa Rosa, California on April 05, 2013:

Very informative and thoroughly researched. Your expertise is quite evident!

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