Knee Pain in Cyclists: Causes, Treatment and How to Get Back on the Bike

By Robert Brown, APA Sports and Exercise Physiotherapist | Salty Sports Physiotherapy, Kingscliff

There's an old joke in endurance sport circles: "What do you call a runner with knee pain? A cyclist." The idea being that cyclists escape the brutal impact forces that plague runners. And while that's partly true, so what happens when a cyclist gets knee pain?

Having spent several years as Head Physiotherapist for the ORICA GreenEdge Pro Cycling Team, riding alongside some of the world's best cyclists through Grand Tours and World Championships, I can tell you that knee pain in cyclists is extremely common. And when it does strike, it can be surprisingly stubborn to shift if you don't understand what's driving it.

Here's everything you need to know.

How Common is Knee Pain in Cyclists?

Very. Anterior knee pain (pain at the front of the knee) is by far the most common reason cyclists seek medical care, accounting for between 32% and 60% of overuse injuries in professional cyclists. Whether you're riding the Tour de France or commuting along the Tweed Coast, your knees are working hard.

Why Does Cycling Cause Knee Pain?

Here's what surprises most people: the force going through your foot during cycling is only about 17 to 19% of the vertical force experienced during running. So it's not the load that's the problem, it's the repetition.

Every pedal stroke involves a flexion and extension of the knee. Multiply that by thousands of revolutions per ride, week after week, and you've got the perfect recipe for irritating the soft tissues around the knee, particularly a structure called the medial plica.

What is the Medial Plica?

The plica is a fold of the synovial membrane, the lining of the knee joint. Most people have one and never know it. But with the repetitive cycling motion, this tissue can become irritated and thickened as it slides repeatedly over the medial aspect of the femur (thighbone), causing what's known as medial plica syndrome.

It can also flare up following a direct trauma to the knee, such as a crash.

What Does it Feel Like?

Medial plica syndrome typically presents with a dull, superficial ache on the inner front aspect of the knee, a snapping or clicking sensation over the inner side of the thighbone, tenderness when pressing over the inner knee while bending and straightening the leg, mild swelling or puffiness around the area, and symptoms that worsen with longer rides or after periods of sitting with the knee bent.

How is it Diagnosed?

A thorough clinical assessment by a sports physiotherapist is the most important step. Imaging such as MRI or ultrasound usually doesn't show anything significant with plica syndrome, but it can be useful to rule out other causes of knee pain such as meniscal tears, patellofemoral syndrome, or tendinopathy.

This is why getting an accurate diagnosis matters. Treating the wrong thing wastes time and keeps you off the bike longer than necessary.

What Are the Main Causes in Cyclists?

In my experience working with cyclists at both elite and recreational level, the two biggest contributors to anterior knee pain are bike fit and movement control.

A seat that's set too low or too far forward forces the quadriceps to work harder and increases tension on the soft tissues at the front of the knee. Getting a professional bike fit is one of the single best investments a serious cyclist can make, both for performance and injury prevention.

When the muscles around the hip and knee aren't working well together, the thigh tends to drop inward during the pedal stroke, with the knee tracking towards the frame rather than straight ahead. This places excessive tension on the medial structures of the knee and is a very common finding in cyclists with anterior knee pain.

How is it Treated?

The good news is that most cases of anterior knee pain in cyclists respond very well to physiotherapy. Here's a general guide to what treatment looks like.

The first priority is reducing pain and inflammation. This involves a temporary reduction in cycling load, anti-inflammatory medication if appropriate (discuss with your GP or doctor), and hands-on physiotherapy to reduce tissue irritability. In some cases, a cortisone injection may be recommended after medical consultation. This acute phase usually settles within 2 to 3 days with the right management.

Once the pain is under control, we get to work on the underlying drivers. This includes improving knee flexion range of movement, improving tissue extensibility of the quadriceps, ITB, and surrounding structures, correcting muscle activation patterns and lower limb control during the pedal stroke, and a bike fit review. Sometimes a small adjustment makes an enormous difference.

The final phase is a structured, progressive return to riding that ensures the problem doesn't simply come back when you increase your training load again.

A Note for Runners Considering Switching to Cycling

If you're a runner with knee pain who has been advised to try cycling as a lower-impact alternative, that's often great advice. But do be aware that cycling has its own set of overuse injuries, and anterior knee pain is the most prevalent among them. Getting set up on the bike correctly from the start goes a long way towards preventing problems down the track.

When to See a Physio

Don't wait for knee pain to become severe before seeking help. Early assessment and treatment nearly always leads to faster recovery and less time off the bike. If you're experiencing any of the symptoms described above, particularly if they've been hanging around for more than a week or two, come and see us.

At Salty Sports Physiotherapy in Kingscliff, we understand cycling inside and out. Whether you're a weekend rider, a triathlete, or a competitive road cyclist, we'll get to the bottom of what's causing your knee pain and get you back on the bike as quickly and safely as possible.

Book online at saltysportsphysio.com.au or call 0470 434 340. We're located inside Salt Movement and Recovery, Basement, 2 Bells Blvd, Salt Village, Kingscliff.

References

Barrios C, Sala D, Terrados N, Valenti JR. (1997) Traumatic and overuse injuries in elite professional cyclists. Sports Exerc. Inj. 3;176-9.

Dettori, N. J. & Norvell, D. C. (2006). Non-Traumatic Bicycle Injuries: A Review of the Literature. Sports Med. 36(1), 7-18.

Farell, C. K., Reisinger, K. D., & Tillman, M. D. (2003). Force and repetition in cycling: possible implications for iliotibial band friction syndrome. The Knee. 10;103-109.

Salty Sports Physiotherapy is located at Basement, 2 Bells Blvd, Salt Village, Kingscliff NSW 2487. Robert Brown is an APA Sports and Exercise Physiotherapist with over 20 years of elite sport experience including as Head Physiotherapist for the ORICA GreenEdge Pro Cycling Team. Online bookings available at saltysportsphysio.com.au