Knee Pain in Cyclists
Kristin Wingfield, MD, CCFP
Medical Director, Center for Sports Medicine, Saint Francis Memorial Hospital, Corte Madera
Knee pain is one of the most common complaints in cycling. There are various forms and reasons, ranging from trauma to overuse. Let's take a look at some of the more common causes of knee pain, and what you can do to treat these various injuries.
Overuse Injuries
1) Anterior knee pain - Patello-femoral pain syndrome, also known as "cyclist's knee" or "runner's knee"
This vague achy pain under and around the knee cap results from mal-tracking or poor alignment of the knee cap as it moves over the groove it runs in on the femur, or thigh bone. The pain usually gets better as with warming up but can return with pushing big gears or steep hill climbing or by the end of a long ride. The knee may also get stiff and achy after sitting (off the bike) for a long time, doing things like driving or watching a movie. The knee may be painful going up and especially down stairs. Catching and popping and clicking may also be present.
This injury can linger despite usual treatments of ice and Advil, unless the underlying biomechanical problems are addressed. Contributing factors to patello-femoral knee pain include:
- Training errors such as pushing big gears too aggressively, climbing steep hills, inadequate rest, deep squats or heavy weights with knee extension in the gym.
- Biomechanical factors such as overly pronated feet, bowed legs or knock knees.
- Bike fit factors such as seat too low or too far forward, not enough float in the cleats, or cranks that are too long.
- One of these factors alone may not cause pain, but several in combination, especially heavy training in big gears or on hills, combined with one or more bike fit or biomechanical errors, may lead to pain.
The treatment of patello-femoral knee pain is correction of underlying training errors and strengthening of the inside quad muscle and stretching of the ilio-tibial band (ITB), which when too tight, pulls the kneecap laterally and contributes to the mal-tracking. Deep tissue massage of the ITB, hamstrings and butt muscles in combination with a stretching and strengthening program are helpful. Occasionally physical therapy may be necessary to help settle down inflammation of the cartilage under the kneecap, in combination with ice, anti-inflammatory medication and rest (modified activity.)
2) Lateral knee pain - Ilio-tibial band friction syndrome
Since fixed cleats were introduced in 1985, pain and tightness on the outside of the knee (ITB friction syndrome) has become one of the most common cycling injuries. This chronic injury can be tricky to treat and may be due to underlying biomechanical problems (as mentioned above) as well. Hyper-pronation and leg length discrepancies, or even subtle weakness of core stabilizing muscles, can contribute to tightening of the ITB on the outside of the leg and knee, which can then lead to bursitis - local inflammation as the band crosses the knee joint.
The pain is most pronounced at about 30 degrees of knee flexion. The area is tender to the touch and the knee may be swollen. Treatment involves a stretching program for ITB, gluts and hips, as well as deep tissue massage. Physical therapy may be helpful in acute cases, along with ice, massage and anti-inflammatories for pain control. Cross training and work on core strength and stretching programs are important for long-term relief and prevention of recurrence.
3) Posterior knee pain
Common causes of pain behind and on the sides of the knee are hamstring strains and tendonitis. These conditions will present themselves as sharp pain at the attachment of the hamstrings, on either side and the back of the knee. Pain will be present with activity, but usually improve after warming up and then reappear towards the end of a ride. Pain may be worse with (and caused by) aggressive work out of the saddle, or pulling up too much with the hamstrings. Bike fit problems (seat too high, pedals too far aft, not adjusting for leg length discrepancy, toes too far in) may also contribute. Treatment includes, ice, stretching and gradual strengthening for the hamstrings. Relative rest is also necessary to settle down the acute pain and inflammation.
Traumatic Injuries
1) Knee bursitis
After a fall onto the front of the knee, a cyclist can develop a big swollen knee, or "water on the knee". This happens when the bursa between the knee and the skin gets irritated and inflamed and produces fluid that accumulates within it. This condition in itself is not serious, but concurrent infection can be. The fluid will slowly resorb with time, ice, compression and anti-inflammatories, or can be drained by a doctor. If signs of infection (redness, heat, extreme tenderness, fever or chills) develop, a doctor should be seen immediately.
These are some of the common knee injuries in cyclists. I hope these tips will help prevent and treat any knee pain you get from riding!
Kristin Wingfield, MD, CCFP
Medical Director, Center for Sports Medicine, Saint Francis Memorial Hospital, Corte Madera
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