We’re big fans of cycling here at Chris Bailey Orthopaedics. Not just for ourselves – though we like a weekend bike ride as much as the next person – but as a potential exercise option for patients.
The health benefits of cycling are pretty compelling. It gets you out of the house and into the open air and sunlight. It gets the heart pumping but doesn’t pound the joints. It works the muscles but without the sudden, high-impact injury risk of sports like, say, football or hockey.
There’s good evidence that cycling can protect our knees against injury over the long-term, too. A study last year concluded that people who cycled at any point in their lives were 17% less likely to develop knee pain and 21% less likely to develop arthritis with knee joint pain.
That’s why we often recommend cycling as a good alternative sport for people who are suffering from knee arthritis. In fact it’s not uncommon to find patients with advanced osteoarthritis who struggle to walk yet find they can cycle without pain. That’s a huge positive.
However…
When cycling does cause knee pain
Like any other sporting activity, cycling isn’t immune to injury issues. One scientific review, published in Australia a few years ago, found that up to a third of cyclists have struggled with knee pain at some point. Most cycle injuries, fortunately, tend to be short lived. But they’re not totally unusual. So where and why does cycling-related pain typically happen – and what can you do about it if you’re affected? First, let’s look at three key areas of the knee where niggles occur…
Pain at front of the knee
Front-of-knee (‘anterior’) pain usually relates to the patella – otherwise known as your kneecap. When cycling, your kneecap comes under most pressure at the top of the stroke, as you begin to push down on the pedal. At this point, the patella is pulled towards the femur (thighbone), and that’s where irritation can occur – particularly if you have strong quadriceps that exert serious force as you ride. Irritation here can trigger patellar tendonitis, where the kneecap gets inflamed, swollen or painful. Muscles that are stronger on the outside of the legs – quite common in cyclists – can also tug at the kneecap, pulling it out of kilter. A bad bike setup can make these pressures worse, too. If your saddle is too low, or your cranks are too long, you’ll put your kneecap under more pressure at the top of the stroke.
Pain at sides of the knee
If you’re getting pain on either side of your knee and you also wear cleats (pedals that attach to your shoes), the cleats could well be causing the issue. The problem area here is the Q angle (or Q-factor). That’s the distance between the outer sides of the crank arms. If your cleats are too close to the insides of your shoes, you increase the distance between your feet and potentially put too much strain on your inner knee ligaments. Another common issue for cyclists (and runners too) is iliotibial band syndrome. The IT band is a thick tendon that runs down the outside of the leg. It can become inflamed and irritated where it passes over the outer end of the thighbone, causing sharp pain on the outside of the knee. Again, cleats can be the culprit here: if you misalign them, or place them too far to the outer edge of your shoes, you can put excessive pressure on the IT band.
Pain at back of the knee
This kind of cycling-related knee pain – “posterior” pain in medical verbiage – is very often due to “overextension”. That’s when you have to stretch too far to push down on the pedal as you hit the bottom of the stroke. What causes overextension? Often it comes down to a badly positioned saddle. Set your saddle too high, and you invite strain at the back of the knee; likewise if you set your saddle too far back. If you’re getting swelling and pain at the back of a knee, it’s also possible that bursitis is to blame. Bursitis is when one of the protective sacs in the joint becomes inflamed, often after overuse. You can find out more about it in this article: What on earth is knee bursitis? (and how to get rid of it).
What to do about cycling knee pain
Rest up…
Boring but true! While it’s tempting to push through the pain, putting more pressure on a knee injury will only make it worse. Instead, prioritise rest for a week or two. You may want to add in the other parts of the RICE protocol as well. That’s applying Ice (to reduce swelling), Compression (lightly wrapping a bandage around your knee for support) and Elevation (raising your knee on a pillow, to reduce swelling).
Modify your programme
One of the biggest mistakes people make with a training programme – or when coming back after a break – is the too-hard-too-fast trap. Rushing your joints and muscles into action, especially with high-intensity workouts, risks an overuse injury as the tissues in your legs and knees struggle to recover. That’s why cycling experts will always encourage you to stage your programme over several weeks. Build up slowly and surely.
Strengthen supportive muscles
Many cycling knee injuries are ultimately caused by problems further up or down the body. Weak gluteal muscles, for instance, cause the knee to adduct (move towards the midline of the body). This can put excessive pressure on the inside of the knee, prompting inflammation and injury. That’s why it’s important to build up strength in the range of muscles that support your knee joint: especially the hamstrings, quads, calves and glutes.
Consider getting a Bike Fit
A Bike Fit is where an expert tailors your bike settings to your body and riding position. You book a one-to-one session, which usually involves some of these elements:
- An interview – to discuss the type of cycling you do (e.g. trail or road), your goals, and any problems or injuries you’ve had
- An assessment – to observe your riding position (often by videoing it) and check the strength and flexibility of your muscles
- Adjustments – to find the best fits for your saddle, cleats, cranks and other key contact points on the bike
- Testing – to see how you work with the adjustments, often using another video for comparison
A good bike fit will help your body to stay well aligned as you ride, knees over feet in the best positions for your height and body shape, increasing your comfort in the saddle and reducing the chances of picking up a knee injury. Some are provided by physiotherapists or sports science specialists who can advise on injuries too. There are quite a few bike fit providers here in Hampshire. You may find it worth googling in your own local area – search for “bike fit” or “bike fitting” to see what’s available.
Further reading
What causes a painful kneecap?
