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Cycling science: How to prevent cycling knee pain

Michael Donlevy
20 Apr 2020

It's a common complaint for cyclists, but there's a lot you can do to avoid or overcome knee pain

Knees are important. Without them we’d be like elephants – unable to jump or ride a bike – so it seems cruel that for so many of us they can be a source of pain when cycling. Yet it can be prevented, and cycling can be a way of warding off and even curing knee problems.

‘Knee pain generally stems from a muscular weakness or tightness, or both,’ says Paul Butler of PB Cycle Coaching. ‘If one muscle is tight it pulls the kneecap one way, but if the opposing muscle is weak it can’t pull the kneecap back the other way to keep it aligned.

'This leads to cartilage wear behind the kneecap – and pain. Other causes include infections, repeated impact from running and knocks from falling, plus degenerative cartilage wear brought on by ageing.’

‘In my experience, most cyclists with knee pain have come to cycling from running,’ says sports therapist Ian Holmes, formerly a soigneur for Madison Genesis.

He takes a slightly different view to Butler: ‘The knee is a complicated joint, but most knee problems are with the soft tissue and can be improved by cycling. The fixed position of the knee actually reduces knee pain for most.’

You can prevent – or ease – knee pain by refining your technique. ‘You can learn to use some muscles more than others,’ says Butler.

‘When pedalling, most of the work is done by the quadriceps [thighs] and gluteals [buttocks] on the down stroke and, if you pull up on the pedals, by the hamstrings on the upstroke.

‘The common imbalance among cyclists is being too quad-dominant’. The glutes don’t do enough of the pushing, so the quads pull excessively on the knee.’

If the bike fits

Your technique can be improved by coaching, but also by getting a proper bike fit. ‘I’ve suffered from knee pain,’ says Andrew Soppitt, a physician now aged 53 who took up cycling at 38 and represented at age-group triathlons before knee problems forced him to give up running.

‘My knees improved markedly following a proper bike fit. I had a proper analysis of my riding style, which was worth every penny. I also found having my saddle a little higher than “ideal” helps my knee pain.’

‘The first thing I ask a client with knee pain is, “What have you changed?”,’ says Holmes. ‘It’s usually shoes, pedals or a saddle. I always look for the underlying cause. In some cases one leg is longer than the other, which can be fixed through a bike fit.

‘Or your foot is in a fixed position in the cleat, with a limited amount of float, and the foot position might be wrong for your biomechanics – your feet might turn out and the cleats might be turning them in.

‘Your foot will adapt but you may develop knee pain before it does. But also, if it ain’t broke don’t fix it. I’ve seen riders whose knees stick out and been asked, “Can you fix it?” Well, no – there’s no need if they’ve cycled for years without pain. The body is adaptable.’

It comes back to knowing your body, and this is where sports therapists can help.

‘Anywhere in the body that affects your alignment, any imbalance that causes a muscle to work harder, can cause pain,’ says Butler.

You can, of course, address muscle weakness by exercising off the bike. Holmes has worked with young British sprinter Ryan Owens.

‘He has enormous quads, which place huge stress on the knee. The sort of brutal, explosive training he does builds the tendons in the knees. Lots of people say squats are bad for the knee but they’re not – it’s just that people do them wrong. He’s very different to a roadie, but all cyclists would benefit from extra strength and stability in the knees from exercises such as squats and lunges.’

‘Every knee condition is specific, so it’s important a physio diagnoses you and prescribes exercises specific to you,’ says Butler. 'From a preventative point of view, I’d suggest an assessment with a personal trainer or physio to spot any potential issues and work on strength and flexibility.’

Pain management

There is another way. ‘Cycling keeps my knee pain manageable,’ says Soppitt. ‘It’s worse if I have significant time off the bike.

‘I have grade four osteoarthritis of both knees and will need replacements. This is, according to my ortho surgeon, being delayed by being active and cycling regularly.’

‘I feel sorry for GPs,’ says Holmes. ‘They have to deal with 100% of the population, 90% of whom are sedentary, so if you go to them with a sports injury they always say to rest it.

‘But how long for? You don’t want to be off the bike if you’ve got a race coming up, so it may be that you just need to adjust your training.

‘If the pain is a dull ache it’s probably an overuse injury and will ease with time, and by scaling back. If it’s a sharp pain, see someone qualified. If the pain is so severe you can’t ride there’s an underlying problem.

‘Massage can help but it goes further than that – a good therapist can assess any underlying issues,’ he adds. ‘Massage can help eradicate or prevent pain. What it can’t do is help if the problem is with the meniscus or cartilage – that’s a structural issue with the knee.’

‘Massage allows a specialist to identify tight areas, and they’ll recommend stretches to keep the tightness from returning,’ Butler agrees. 'Stretching can be dangerous if you get it wrong, though, so learn to do it under guidance, with advice on how to do it safely.’

Food for thought

And what about diet? ‘A lot of foods and supplements are touted as effective for preventing or easing knee pain – fish oils, various vitamins, herbs and phytochemicals – but really their impact isn’t huge and evidence is mixed,’ says sport nutritionist Drew Price.

‘That’s also the case with glucosamine. The dose is large, and expensive, and you need to use it long-term to see if it works for you.

‘Inflammation is an issue, and a lot depends on your diet,’ he adds. 'Cleaning up your fat intake – consuming healthy fats from whole foods, not processed foods – and increasing micro and phytonutrient intake from fruit and veg may help long-term. But only may.'

'The fact is many riders are overweight, despite their time in the saddle,’ says Price. 'Getting weight down will take a load off the knees and reduce pain off the bike. I get a huge number of referrals from physios for just this reason.’

‘Exercise puts a stress on your muscles, which you adapt to and become stronger,’ says Butler. 'Cycling is great for this because it isn’t weight-bearing, it’s carried out smoothly, it’s performed through a very small range and it keeps you well aligned. There’s less to aggravate the knees.’

And that would explain why elephants cry.

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