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Cycling Knee Problems


Cycling is a great low-impact aerobic activity. Cyclists are usually more efficient on both hills and flat terrain when they pedal quickly (at about 80-85 rpm) rather than at slower cadences. Although cycling is considered a knee-sparing exercise because it does not require impact with the ground, the repetitive motion of pedalling can lead to a variety of overuse knee injuries. The majority of cycling injuries are indeed caused by overuse, which leads to cumulative tissue microtrauma and consequent symptoms. In overuse injuries the problem is often not acute tissue inflammation, but chronic degeneration.

Cycling is obviously very repetitive: during one hour of cycling a rider may average up to 5000 pedal revolutions. But which cyclists sustain overuse knee injuries? Basically, cyclists of every ability level are at risk: riding too hard, too soon and too far is the usual recipe for numerous knee problems. Touring cyclists often develop a knee overuse injury during or after one specific usually long ride. These sporadic high-mileage riders often do not train adequately. Patellar pain is the most frequent problem (for more information see our Patellofemoral problems page), followed by Iliotibial Band Syndrome (see Overuse Injuries page and scroll down to ITBS section for further information). Bicycle maladjustments are also frequent in this group and amongst recreational cyclists.

Gwydyr Forrest Cycling Trial

Cyclists vs. Runners

Cycling and Running are two very popular sports, but compared to cycling, running seems to be a better way do build up leg bone density, while cycling regularly will improve on upper limb bone density. This is very important when you consider that osteoporosis causes 310,000 fractures in the UK every year. Runners have a bit less developed arm muscles. Apart from that, it seems that cycling and running have similar effects on body composition: participants in both have approximately 10% more leg muscle than the exercise abstainers.

Cycling on Berneray

Knee Pain

The knee is the most common site of overuse injury in the cyclist, with an estimated 40% to 60% of riders experiencing knee pain. Like other cyclists, mountain bikers can suffer overuse injuries. Such injuries have been studied little in mountain bikers. In one study involving 265 off-road cyclists, 30% had recently experienced knee pain associated with mountain biking, and 37% reported low-back pain while riding; wrist pain and hand numbness were each reported by 19% (4).

Overuse injuries: in chronic cases, continued activity produces 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 (hence, for example, patella tendinosis instead of tendinitis). Pain in overuse injuries typically has insidious onset, but it may have an acute-on-chronic presentation. Overuse injuries most likely occur when an athlete changes the mode, intensity, or duration of training. Biomechanic (intrinsic) factors and equipment or training (extrinsic) issues are the main contributors to overuse injuries (3).

When evaluating knee pain it is very important to consider cyclists and bicycle anatomy, seasonal variations (early cycling season), training distance and intensity, and numerous human anatomical factors such as inflexibility, muscle imbalance, patellofemoral malalignment, leg-length discrepancy, etc. Do check the leg length: if the difference is up to 10 mm you can correct it by putting spacers under one cleat. If one leg is shorter by more than 10 mm you should try a shorter crank arm on the short leg side. Generally using shorter cranks keeps pedal speed up and knee stress down. Too long crank arms increase forces on the entire knee, but patellar and quadriceps tendons are most affected. For information on special bicycle adaptations see Chris Bell's website: Highpath Engineering Specialist Services.

Anterior Knee Pain

Anterior knee pain is very common in cyclists. The patellofemoral joint is subject to variable and extreme pressure and friction, which depend on rider's anatomy, muscle power and balance, distances, elevation but also on many other mechanical variations which are related to cysling shoes, cleats and general bike fit. Apart from the joint itself and the state of patellofemoral ariculating surfaces and subchondral bone riders with anterior knee pain often develop extra-articular manifestations. Female riders in particular often have weakness of the peri-articular hip musculature as well as that of the knee, the combination of which results in deficient dynamic postural stability. It has been show that quadriceps to hamstring strength ratio correlates well to functional outcomes in patients with anterior knee pain, further emphasising the importance of neuromuscular connection (and consequent rehabilitation and exercise strategies). Source: Oday Al-Dadah and Caroline Hing, Editorial, The Knee 23 (2016) 565.

Patella and Quadriceps Tendinosis (Extensor Tendinopathy)

Patella and quadriceps tendinosis are common and often stubborn cycling and running knee problems. Tendinosis vs. Tendinitis: the term tendinosis was first used in the 1940’s by a group of German researchers, however the term did not receive much attention until it was used again in the mid 1980’s to describe a non-inflammatory tendon condition. The more commonly used term of tendinitis has since been proven to be a misnomer for several reasons. The first of which is that there is a lack of inflammation in conditions that were typically called a tendonitis. Since inflammation is the key pathological process involved with that term, and the discovery that there in fact were no, or very few, inflammatory cells present in the condition, a new term tendinosis was adopted. This has a profound impact on how the condition is treated. 

Treatment Options: although the surgical treatment of patellar tendinopathy is a common procedure, there have been no randomized, controlled trials comparing this treatment with forms of non-operative treatment. The purpose of the study conducted by Roald Bahr and colaborators was to compare the outcome of open patellar tenotomy with that of eccentric strength training in patients with patellar tendinopathy. Although surgical treatment and eccentric strength training can produce significant improvement in terms of pain and function scores, it appears that only about half of all patients will be able to return to sport within one year after treatment with each option, and fewer still will have relief of all symptoms. In the absence of other validated treatment options, authors believe that eccentric training, a low-risk and low-cost option, should be tried before surgery is considered. Conslusion: No advantage was demonstrated for surgical treatment compared with eccentric strength training. Eccentric training should be tried for twelve weeks before open tenotomy is considered for the treatment of patellar tendinopathy (2).

Eccentric exercises: "the key to the rationale behind eccentric drills is that they are the best way of promoting tendon remodelling - the regrowth and reordering of fibrous tissue in place of the denser, degenerative tissue typical of tendinosis. The athlete needs to be taught eccentric exercises (see table below). A 45-degree slope is required and (at a later stage) a weights bar. Initially the athlete stands straight on the slope, then flexes his/her knees to 90 degrees, returning to a straight position again. The movement down must be done slowly (to a count of three) and the return can be done quickly (to a count of one). When away from home the slope can be replaced by the edge of a curb or step so that opportunities can be taken whenever possible to do the drills. The number of repetitions is determined by the amount of discomfort felt in the patellar tendon. I advise athletes to stop a sequence of repetitions when they perceive an ache in the patellar tendon of 3/10, using the scale described above. The rationale for this is to stimulate the patellar tendon eccentrically to a fixed (symptomatic) level each day, but without such a high score as to produce pain and further damage. I suggest to athletes that they can do these repetitions as often as possible every day and many achieve the repetitions 3 to 4 times a day. The exercise sequence can be progressed as shown in Table 1. For some athletes stage 1 is too easy and they cannot bring on any discomfort in the patellar tendon. For others, the rate-limiting factor is quadriceps fatigue and for this reason they can use two legs in returning to the standing position (see stages 2 to 4).





Two legs, 90 degree squat, no slope 


Two legs, 90 degree squat on 45 degree slope 


Single leg for squat phase (eccentric); two legs return phase (concentric), on slope 


10kg bar; single leg for squat phase, two legs return, on slope


Single leg only throughout, on slope 


As the stages progress the athlete will be able to increase the number of repetitions they can perform before the symptoms come on at a discomfort level of 3/10. There will be some days when the athlete can manage more repetitions than others, but normally they will be able to move on to the next stage after 2 to 4 weeks -- so improvement in this condition is usually measured in months, not weeks. The rate of progression will vary from athlete to athlete, dependent in large part on how often they perform the exercises. If more pain occurs in the tendon, the athlete should be advised to rest for 2 to 3 days and then drop back one stage in the rehab exercise progression." 

Shockwave Treatment: Extracorporeal Shock Wave Therapy (ESWT) is the application of Shock Waves in medicine. It is clinically proven that pressure waves, when applied to injured tissues, stimulate metabolic reactions: reduction of pain felt by nerve fibers, increase of blood circulation in surrounding soft tissues, beginning of healing process triggered by stem cells activation. Patients not responding to conservative treatment for six months should undergo radial shock wave therapy (RSWT), which usually requires three weekly sessions. Shockwave Therapy can be used to treat longstanding pain and discomfort. We use an EMS Swiss DolorClast Master shockwave machine. A hand-held device (EVO Blue RSWT Handpiece) is moved over a conductive gel on the skin to send waves of energy to patella or quadriceps tendons. These mechanical pressure pulses – known as shockwaves - work by reinjuring tendons and surrounding tissues, which in turn stimulates blood flow helping problem areas to heal (neoangiogenesis).  The results are not instant, the treatment may be uncomfortable and the results can be operator dependent. A Shockwave treatment applied to patella and quadriceps tendons, but without correcting the underlying adverse biomechanics (patella tracking, muscle power, etc.) will not work. Correcting causative factors in combination with Shockwave treatment create the best outcomes and the holistic, whole body approach, means you have much better chance of recovery. Addressing the immediate symptoms is an important step to recovery and can help uncover potential underlying issues that need to be resolved. Shockwave is a major advance in effective, safe non-surgical treatment. 



Further Information:

  1. Andrea Ferretti, et al.: Patellar Tendinosis. A Follow-up Study of Surgical Treatment. The Journal of Bone and Joint Surgery (American) 84:2179-2185 (2002).
  2. Roald Bahr, et al.: Surgical Treatment Compared with Eccentric Training for Patellar Tendinopathy. A Randomized, Controlled Trial. The Journal of Bone and Joint Surgery (American). 2006;88:1689-1698.
  3. Paul Morrissey: The Shockwave Solution. 2016

ITBS (IlioTibial Band Syndrome)

Iliotibial band syndrome (ITBS) is the most common cause of lateral knee pain in cyclists and runners. ITBS is believed to result from repetitive friction of the iliotibial band (ITB) sliding over the lateral femoral epicondyle. The ITB is a dense fibrous band of tissue that originates from the anterior superior iliac spine region and extends down the lateral portion of the thigh to the knee. The ITB has insertions on the lateral tibial condyle (the Gerdy tubercle) and the distal portion of the femur. When the knee is extended, the ITB is anterior to the lateral femoral condyle. When the knee is flexed more than 30°, the ITB is posterior to the lateral femoral condyle. Cyclists with iliotibial band syndrome often demonstrate tenderness on palpation of the lateral femoral condyle approximately 2 cm above the joint line. Tenderness is frequently worse when the patient is in a standing position and the knee is flexed to 30 degrees. At this angle, the iliotibial band slides over the femoral condyle and is at maximal stress, thus reproducing the patient's symptoms Clinically, increased or noticeable tightness of the ITB also may be noted upon examination and performing the Ober's test (the patient lies down on the unaffected side down with the unaffected hip and knee at a 90-degree angle. If the iliotibial band is tight, the patient will have difficulty adducting the affected leg beyond the midline and may experience pain at the lateral knee). A modified Thomas test (which is also called the rectus femoris contraction test or Kendall test) can be performed to assess flexibility of the hip flexors, hamstrings, and the ITB. This test is commonly used to assess rectus femoris muscle flexibility about the knee joint, but the reliability of this test is questioned by several researchers.This overuse injury occurs with repetitive flexion and extension of the knee. Inflammation and irritation of the iliotibial band also may occur because of a lack of flexibility of the ITB, which can result in an increase in tension on the ITB during the leg extension. Other causes or factors that are believed to predispose an athlete to ITBS include excessive internal tibial rotation, genu varum, and increased pronation of the foot.The main symptom of ITBS is sharp pain or burning on the lateral aspect of the knee. Cyclists often note that they start out cycling pain free but develop symptoms after a reproducible time or distance. Early on, symptoms subside shortly after a short ride, but return with the next one. If ITBS progresses, pain can persist even during walking, particularly when the patient ascends or descends stairs.

In patients with iliotibial band syndrome, MRI is very useful diagnostically and shows a thickened iliotibial band over the lateral femoral epicondyle. MRI often detects a fluid collection deep to the iliotibial band in the same region (iliotibial bursa).

Low mileage, recreational cyclists usually improve with a simple regimen of anti-inflammatory medication and appropriate stretches. However, higher mileage, competitive cyclist typically require a more comprehensive treatment approach. Treating this condition can be a challenge because underlying myofascial restrictions can significantly contribute to the patient's pain and disability. After acute symptoms are alleviated with activity restriction and modalities, problematic trigger points can be managed with massage therapy or other treatments. A stepwise stretching and strengthening program can expedite rider's return to cycling. The keys to success for the more resistant cases are myofascial therapy after acute inflammation has been addressed and progression to weight-bearing strengthening exercises, with particular attention to the gluteus medius muscle, before return to running. Corticosteroid injections (DMI) should be considered if visible swelling or pain with ambulation persists for more than three days after initiating treatment. A small number of patients will not respond to conservative treatment and may require surgical release of the iliotibial band.

Causes of Knee Pain in Bicycling


Possible Result


Leg-length discrepancy

ITB stretch on shorter leg, posterior knee stress

Wide pelvis

Lateral knee stress (increased Q angle)

Pes planus and/or pronation

Medial knee pain

Internal tibial rotation

Patellar malalignment

Muscle weakness of quadriceps, hamstrings,   
hip flexors, gluteus

Fatigue-induced alterations in pedaling technique that
transfer stress to other parts of the kinetic chain

Leg inflexibility

ITB syndrome

Bike Fit

Saddle too high

Knee extension that irritates the ITB, stress on biceps
tendon, patellofemoral loading, hips stressed by
rocking while pedaling, posterior knee pain

Saddle too low

Stress on patellar and quadriceps tendons

Saddle too far forward

Stress on anterior knee from pedaling in
hyperflexed position

Saddle too far back

ITB stretch from excessive forward reach for pedal,
stress on biceps tendon

Crank arms too long

Increased forces on the entire knee; patellar
tendon and quadriceps tendon are most affected

Internally rotated cleats

Patellar tendinosis, tibial rotation stress
on anterior knee

Externally rotated cleats

Medial knee stress


Rapid increase in distance or intensity

Muscle tightness, microtrauma

Excessive hill work (on bike)

Cartilaginous breakdown, chondromalacia

Pushing high gear ratio

Medial knee stress

Hill running (on foot)

Medial knee stress (uphill), tight quadriceps (downhill)

Deep leg squats

Increased stress on entire knee

ITB = iliotibial band


Further information on cycling knee problems:

  1. Tony Wanich, et al.: Cycling Injuries of the Lower Extremity. J Am Acad Orthop Surg, December 2007;15:748-756.
  2. Michael J Callaghan: Lower body problems and injury in cycling. Journal of Bodywork and Movement Therapies (2005) 9, 226–236.
  3. Chad Asplund and Patrick St Pierre: Knee Pain and Bicycling. The Physician and Sportsmedicine, April 2004. Please note that free access to this article is no longer available from the PSM. However, try this link:
  4. Robert L Kronisch: Mountain Biking Injuries: Fitting Treatment to the Causes. The Physician and Sportsmedicine, March 1998. Please note that free access to this article is no longer available.
  5. Emma Colson: Knee Pain - Anterior Anguish. PDF download. Topbike Physio, March - April 2006

Bike Fit

Proper bike fit is essential in reducing the incidence of knee and numerous other injuries. Frame size, seat height and position, handlebar height and position, crank length, and foot position are the primary fit-related adjustments that must be made for each cyclist. A comfortable, perfect-fitting bike means your skills will improve immeasurably as you go out and enjoy each ride. And it all starts with the frame. Handlebars, stems and saddles can be swapped out or adjusted to create a better-fitting bike. But getting the frame right is the important first step (2). And again, correct positioning and set-up of all components are extremely important in achieving optimum power output and avoiding overuse knee and other injuries.

Further information:

  1. Robert L Kronisch: How to Fit a Mountain Bike. The Physician and Sportsmedicine, March 1998. Please note that free access to this article is no longer available.
  2. REI staff: The Perfect Fit - Bike Fit Basics. REI Expert Advice.
  3. Guy Andrews: Andy Pruitt's Fit Tips. Gear News, 23 January 2007.
  4. Matt Russ: Correcting Knees-out Pedalling. Cycling.
  5. Rob Coppolillo: Love Thy Knees: Get the Right Fit. Cycling.
  6. Edmund R Burke: Knees Among Most Vulnerable Joints for Cycling Injuries. Cycling.
  7. Vladimir Bobic: Cycling Knee Problems and Injuries. Nuffield Health Educational Seminars. Chester, UK. SlideShare Presentation, 28 April 2018

Cycling Equipment

we are still working on this section ...

How to Choose Cycling Shoes

Indoor Cycle Trainers

The UK weather is not an excuse for giving up on cycling. If you have a bit of space at home, and a few pennies for a decent cycle trainer or a roller, or both, you can continue Cyclops Rollerto cycle, workout, build endurance, gain confidence, loose weight, etc. Indoor cycle training is not something reserved for winter months and bad weather. Rather, it is the most effective and rewarding exercise to do when conditions and circumstances will not allow you to get outside and ride a bike. Basically, if you want fitness training get a cycle trainer but if you want technical training get rollers. Rollers are less boring than cycle trainers, are nearly silent to operate and cause less tyre wear, but require a great deal more concentration than cycle trainers. Rollers are hands down the best way to maintain bike-handling skills and a fluid pedal stroke.

Cycling for Knee Rehabilitation

Exercise bikes, static bikes, stationary cycles, bicycle ergometers - these are all names for the bicycles that you find in virtually every physiotherapy clinic, gym or health club across the world. Many knee rehabilitation protocols include cycling so why is this exercise modality so popular for knee rehabilitation? In comparison with other exercises cycling is a relatively ‘knee friendly’ activity that can help to improve knee joint mobility and stability. Cycling is frequently used as a rehabilitation exercise modality after knee injury or surgery as well as part of the management of chronic degenerative conditions such as osteoarthritis. This article will give you an insight into the use of a cycle for knee rehabilitation:

Page updated on: 27 June 2018

Site last updated on: 28 March 2014

Disclaimer: This website is a source of information and education resource for health professionals and individuals with knee problems. Neither Chester Knee Clinic nor Vladimir Bobic make any warranties or guarantees that the information contained herein is accurate or complete, and are not responsible for any errors or omissions therein, or for the results obtained from the use of such information. Users of this information are encouraged to confirm the accuracy and applicability thereof with other sources. Not all knee conditions and treatment modalities are described on this website. The opinions and methods of diagnosis and treatment change inevitably and rapidly as new information becomes available, and therefore the information in this website does not necessarily represent the most current thoughts or methods. The content of this website is provided for information only and is not intended to be used for diagnosis or treatment or as a substitute for consultation with your own doctor or a specialist. Email addresses supplied are provided for basic enquiries and should not be used for urgent or emergency requests, treatment of any knee injuries or conditions or to transmit confidential or medical information. If you have sustained a knee injury or have a medical condition, you should promptly seek appropriate medical advice from your local doctor. Any opinions or information, unless otherwise stated, are those of Vladimir Bobic, and in no way claim to represent the views of any other medical professionals or institutions, including Nuffield Health and Spire Hospitals. Chester Knee Clinic will not be liable for any direct, indirect, consequential, special, exemplary, or other damages, loss or injury to persons which may occur by the user's reliance on any statements, information or advice contained in this website. Chester Knee Clinic is not responsible for the content of external websites.

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