Knee pain from cycling, the same as for instance lower back pain, is, unfortunately, a common discomfort or injury for cyclists. It can be a limiting factor in the joy of cycling at the least. In some cases, cycling isn’t even possible because of the pain. You are probably reading this article because you are somewhere in the above-mentioned spectrum and want to know or do something about the knee pain from cycling. I hope this article will answer your questions and you’ll know where to start with your recovery.

In this article, I will explain what knee pain from bicycle touring is, moreover what the definition is, how knee pain behaves, what the signs & symptoms are and what you yourself can do about it. If you know what the risk factors and causes are, you’re halfway of your recovery. It is the starting point for treatment and recovery.

Knee pain from cycling defined

Knee pain is the generic term for, no surprise, pain in or around your knee. There are many causes for knee pain of which the main part has nothing to do with cycling. So the term is too broad and doesn’t do justice to knee pain from cycling.

I’ll narrow it down for you, without (hopefully) being too technical. This way, you’ll understand a bit more about what knee pain from cycling is in contrast to knee pain in general. knee pain from cycling

Specific vs nonspecific knee injuries

Knee pain is a so-called musculoskeletal disorder. This means a disorder of muscles and/or bones. These kinds of disorders are divided into two categories, specific and nonspecific.

Specific meaning a disorder diagnosed by for instance x-ray. A broken kneecap, for instance, is diagnosed with an x-ray. These disorders are categorized as a disease.



Nonspecific meaning a functional disorder like an overuse injury. These nonspecific disorders cannot be diagnosed by any medical instruments like for instance x-ray, MRI, CT scan, blood test and so on. They are not a ‘disease’, but as mentioned before, a functional disorder.

Specific knee pain from cycling

There are some specific disorders of the knee which can be caused by cycling. Well known are iliotibial band syndrome, tendinitis of the patella tendon or chondromalacia. However, all of these disorders, or ‘diseases’, are rare among cyclists. On top of that, in my humble opinion, knee pain is often unjustifiably diagnosed as one of the above.

To diagnose it for instance as tendinitis, there has to be inflammation. This is important so pay attention! Inflammation is clearly visible, easy to diagnose and most importantly a normal reaction to tissue damage. The signs of inflammation are swollen tissue, often red-colored skin, it hurts, it feels warm and you can’t use the affected area properly (resp. tumor, rubor, dolor, calor and function laesa).

If there is only knee pain, there’s a very good chance it is not inflamed. Which means, it is a perfectly healthy knee that hurts.

Nonspecific knee pain from cycling

The reason why I am explaining all this, again this is important, non-specific disorders have nothing to do with damage or disease to the muscles, tendons or bones. They are simply a fact of life. Athlete or couch tiger, nonspecific disorders will occur from time to time and in 95% of the cases will go away with time.

The lesson we take from this is that knee pain can be without disease. It hurts, it gnaws, it keeps you awake, it’s frustrating, it can take the joy out of cycling, however, the knee is not ill nor is it broken or damaged.

This type of knee pain is by far the most common knee pain from cycling. It is a nonspecific disorder known as patellofemoral pain syndrome (PFPS). Patello meaning kneecap, femoral meaning thigh bone and pain syndrome meaning you’re in pain.

PFPS is just a fancy word for knee pain without disease or damage around the kneecap. Most often it has to do with overuse of the soft – and connective tissue. More fancy words for something as simple as muscles, tendons, and ligaments. So everything that is not bone.

PFPS – a very common knee injury

PFPS is common among the normal population with an annual prevalence (amount of people with PFPS in one year) of 22.7% and more common among cyclists. The natural course, how long it takes before the pain goes away without any therapeutic intervention, can range from several weeks to months, sometimes even years.

Signs and symptoms

PFPS is characterized by a number of signs and symptoms:

Absence of clear inflammatory signs (swelling, red-colored skin, heat, pain, loss of function), with pain being the clear exception



A dull or diffuse ache at the front of the knee, the sides of the kneecap or under the kneecap



Absence of knee trauma (accident) as a cause for the knee pain



Walking stairs, squatting, getting out of a chair, sitting for a prolonged time and of course, cycling are typical activities that aggravate the pain to a sharper sensation



The sides of the patella are painful when you press on them



The pain is directly related to cycling. It can be felt when starting the ride, during the ride, after the ride or a combination of these



The knee pain can last up to several days after the ride.

knee pain from cycling: a big load

Causes of knee pain from cycling

Unfortunately, it is still unknown what the exact (physiological) cause for PFPS is. It is an overuse injury, that much is clear. This means that in some way a form of tissue (muscle, tendon, ligament, cartilage or bone) is exposed to forces it cannot process correctly. Pain is a result of this, which is like a protest of the brain saying ‘STOP!’. And so finally, here it is. The known causes of knee pain from cycling for the brain to say ‘stop!’.

Too fast too soon. By going too fast or too far too soon, you’re likely to start feeling protest somewhere. The knees being one of the likely areas to protest.



Not fit enough. This is probably the most logical cause, though, in my opinion, the most overlooked cause. With ‘fit’ I mean an adjusted body and brain to specific stimuli. For instance, you can easily cover hundred kilometers a day several times a week on a road bike.



This doesn’t mean you can cover the same distance several times a week on a fully loaded touring bicycle. You need time to adjust. Without time to adjust, protest will be a result and chances are that it will be in the form of pain or hypersensitivity of soft tissue.



Grinding the pedals. The optimum cadence for cycling is between 80-110 rotations per minute. By constantly pedaling under 80 rpm, the forces on the kneecap and its soft tissue are too great. Knee pain can be a result.



A big load. If your touring bike is very heavily loaded, it takes more strength and power output to keep your speed. Overuse and pain in the end are likely to occur.



Bend the knee! If the saddle height is too low, the knee angle at the upright position, twelve o’clock, of the pedals (twelve o’clock) is to tight. in other words, your knee has to bend too much just before you push the pedal downward. This creates greater forces on the soft tissue of the kneecap with pain as a possible result.



Saddle is put too far forward If your saddle is put too far forward, the center of the knee will surpass the ball of your foot in the three o’clock position. As a result, the knee angle will again be too tight. And, it’s getting a bit boring, with knee pain as a possible result. At the tip of the saddle.



Long crank. If you are a small humanoid and your crank is too long, your knee angle at twelve o’clock position of the cranks is too tight. And…. Well you can guess what happens next.



Wrong position of the feet. Toe in and toe out. If you are using clipless pedals, SPD, Look or any other system where your feet are fixed there is a chance your feet are positioned wrong. The result is a misalignment of ankle, knee, and hip with greater forces on the soft tissue surrounding the kneecap.



Who knows….!? Sometimes, for no apparent reason, without a clear cause, your knee or knees start to hurt. Maybe it was the weather, the food, sleep pattern, stress, anything is possible.



Treatment and things you can do yourself

knee pain from cycling: relative rest

Knowing what can cause knee pain from cycling is half the work of solving it. With the following steps, there is a good chance you can solve your knee pain.

Make sure there is no inflammation. For more information see ‘specific knee pain’. If in doubt, go see a doctor or physical therapist. If inflammation is diagnosed, a different treatment is necessary than the one I’m advising in the following steps.

Give it time and relative rest. In most cases, knee pain from cycling, and many other ‘nonspecific’ disorders or overuse injuries will go away with time. It is wise though, to adjust the load your putting on your body and brain. Shorten your rides, ride with a higher cadence (80-110rpm is advised), try to avoid climbing, do some alternative sports and build in some extra rest. Passive rest is NOT advised! Your body and brain need stimuli to adjust. When three weeks have passed and nothing has changed, continue with step 3.

Don’t worry and especially don’t panic. Pain is a normal thing and part of life. Your knee is not damaged and you will not destroy your knees if you keep cycling with a bit of pain or discomfort. They are most likely perfectly healthy and strong, they just hurt. Usually, your knee pain will go away within weeks and all this will be forgotten.

Start stretching and exercising the muscles, tendons and joints which deal with cycling.These are ankles, knees, hips and lower back. The quadriceps (or quads), hamstrings, calves and glutes are the main focus. On Google and YouTube you’ll find many examples how to stretch these.



As an exercise try and incorporate mild squats, lunges and calf raises. Any discomfort while exercising is ok, but never exceed a pain score of 4 on a scale of 0-10 with 0 being no pain and 10 intolerable pain. Try to exercise multiple times per day with sets of around 10-20 repetitions. Keep this up for several weeks.



By doing this, the tissues will get adjusted to a higher load, you’ll gain some strength, muscles will tolerate a greater range of motion and the load capacity of the affected region will increase. Thus, the pain will alleviate or go away entirely.

Identify causes from the last few weeks that have disturbed your normal routine. Think about stress, lack of sleep, poor nutrition, a cold or the flu you had several weeks prior to the onset of knee pain. These factors, and many more, can disturb your load tolerance. If there is anything you think you can help yourself with in relation to the above mentioned, don’t hesitate to do so.



Go to bed early, skip that glass of wine, eat healthy and varied, meditate, do yoga, anything that would make you feel better can help. And yes I know, cycling like crazy would normally make you feel better, but that’s just not wise to do in this situation.

Recent changes in position on the bike. While going through the steps, simultaneously go through your position on the bike and any changes the last weeks that could have affected your position. You’ve probably ridden many years without knee pain on the same bike in the same position on it so immediate changes to your position are not advised.



Should any changes have occurred in your position lately, it is probably worthwhile to start with that. Maybe you got new shoes and your foot position is different than before. Or you’ve changed saddles and the height or fore-aft position is not correct yet. Might this be the case, start with improving on this.



I can’t stress this enough, but you need a good position on your bicycle! It is the base for recovery and prevention of knee pain and many other overuse injuries from cycling.

knee pain from cycling: poor bike fit

Basic rules for bike fitting in relation to knee pain

Kneecap The kneecap must never pass the ball of the foot when the crank is in 3 o’clock position.



The saddle has to be set at the right height. There is a simple trick to determine the right saddle height. Press your heels into the pedal which is positioned at six o’clock. Your knee should be almost completely extended. If the knee is flexed or hyper-extended with the heel on the pedal, adjust the saddle height and repeat the process. Once you think you have the right height you can perform an extra check. When you put the ball of the foot on the pedal, or clipped in if you ride clipless, the angle of your knee should be around 25 degrees. You need someone to measure this for you whilst sitting on the saddle.



Proper position of the saddle in relation to the handlebar (fore-aft position) To determine a proper fore-aft position of the saddle, your kneecap should be directly above the ball of your foot. The ball of your foot should be at the center point of the pedal. Place yourself in the most comfortable position on the saddle and estimate if the above mentioned is true. If not, correct the fore-aft position according to your judgment and repeat the process.



handlebar (fore-aft position) Correct foot position This is a difficult one, especially if you ride clipless. Everyone’s anatomy is different, therefore foot position is a personal matter. I would advise riding flat pedals if you are unsure of your natural foot position. You can then copy this natural position to your clipless pedals.



Try to align your foot, ankle, knee, and hip. Knee pain could derive from the misalignment of these joints. This does not account for everyone so it’s a bit of trial and error. If it works for you, hallelujah! If not, go back to your natural foot position.



If all of this doesn’t work and you have a suspicion that the knee pain is still caused by a poor bike fit? Go see a specialist and get a professional bike fitting.

Conclusion

Knee pain from cycling is a b*tch but not the end of the world. In most cases, it’s nothing more than an overuse injury. It has nothing to do with damage and cycling with knee pain won’t destroy your knees. Very likely that the pain will go away in a few weeks’ time. If the pain persists after a few weeks, there are several steps to go through which could help in the recovery.

A poor position on the bicycle (bike fitting), a lack of specific cycling fitness and too far/fast/heavy are likely causes of knee pain from cycling. Adjust or alter these factors accordingly and recovery will follow in 95% of the cases. Furthermore do not panic, trust your body, keep moving and have faith in a quick recovery!

Keep the shiny side up and the rubber side down! Happy cycling!

Me and Nienke at Chimborazo volcano

Disclaimer

This article should be read as expert advice and not medical advice. I am a licensed physical therapist, however, this is written on a personal note as a touring cyclist, an experienced expert in knee pain from cycling and a physical therapy enthusiast. If the reader is seeking professional advice or care, he or she should visit a doctor or physical therapist.