Knee Pain & the Cyclist [How to Prevent & Solve Knee Pain on the Bike]

Many if not most cyclists develop painful knees at some time in their cycling careers. You may be experiencing sore knees currently when you ride. If you are, make a change before riding again! If you ride with the same set up, distance, cadence, lack of stretching or knee protection, etc., as the time your knee got sore, it likely will get sore again. When you irritate the same body part again and again, it eventually becomes damaged enough to need a long rest or medical help before it will heal completely, so don’t ride again without making some change that might fix it. 

Luckily, mild knee pain can usually be cleared up quickly by caring for your knees during rides (see below) and by using some simple home treatments (see second part of article). If you have any hint of sore knees or want to avoid them in the future, do what most experienced cyclists do and follow the advice below:

Eight Keys to Avoiding and Preventing Recurrence of Sore Knees

1. Keep Knees Warm
   Unless it is hot out, keep your knees covered when riding. A simple pair of knee warmers has saved many cycling careers. If the temperature is below 68º F (20º C) as you start, wear leg or knee warmers or tights. Take the coverings off as the temperature rises if you prefer. Put them back on if the mercury drops again. When racing, use protective warming gel. It works by drawing warm blood to the treated area.

2. Knee-Aware Bike Fit
   Get your bike properly fitted by an experienced coach or bike fitter who asks determines with you how each adjustment feels rather than using only computers or formulae to adjust your position. Most frontal knee pain is caused by the saddle too low or too far forward, though tight hamstrings can cause trouble in the same area. A saddle tilted down in front also challenges the front of the knee as you over-engage quadriceps to push yourself back with each pedal stroke. Pain in the back of the knee is often a result of the saddle too high or too far back. Pain to one side or the other of the front of the knee can be a cleat alignment problem or the need for arch support. A skilled fitter can get you correctly positioned before you have knee trouble or help you after it strikes. Once you get your bike fitted, mark the seat post with tape so you can return it to the correct position if it ever gets moved accidentally. Experienced and serious cyclists do not lend their bikes to friends or give their bikes to shops without marking the seat post. Do not remove the seat post or lower the seat to put your bike in the car without a marking you can’t absolutely identify after. It’s not worth the risk to the knees. Note: If your knees hurt only when you ride and you are already doing the other things on this list, you have a bike-fit problem no matter who did your fit or how much high-tech gadgetry they used.

3. Cleat Adjustment
   A good bike fit includes a check of cleat rotation and side-to-side cleat tilt, which is corrected with wedges. Don’t use the cleat to “hold your foot in the right position.” Rather, the cleat should allow your foot to take its natural position. If the cleat holds your foot in other than it’s natural position, it may cause sore knees. 
4. Correct Large Leg-Length Discrepancies
   Many riders have small, unimportant leg-length discrepancies, but if the difference is larger, perhaps over ¼ inch (6mm) it can be impossible to have the correct saddle height for both legs at the same time. In that case, a shim between the cleat and the shoe on the short-leg side can be the only way to keep both knees happy. 
5. Shoe Choice
   Use good quality, supportive, stiff-soled cycling shoes and clipless pedals. (MTB riders may wonder why clipless pedals are recommended here. With flat pedals, your feet can be in slightly different positions throughout a ride. Riders with sensitive knees often require the precise foot position achieved by clipping in to avoid problems.) Most riders do best with pedals that have some free rotation or “float” in the angle, though others benefit from the support of a floatless pedal. See more articles about foot pain and numbness and the foot/shoe/cleat/pedal connection.  
6. Arch Supports and/or Orthotics
   If you tend to pronate, get arch supports. That is, if you have flat feet or you tend to roll your foot inwards, a custom orthotic or even an inexpensive drug-store arch support – if it is the right shape –  will help keep your foot and knee aligned. If you are mechanically inclined, multiple, carefully-placed, half-width strips of duct tape on the underside of your factory-installed insole can turn it into a home-made custom orthotic.
7. Spin Versus Mashing
   Pushing hard against big gears can make knees sore. As you get stronger and fitter, you deliver more force to the pedals through your feet and knees. Low cadence or other habits that were okay when you were starting out may become injurious when you are well trained. Spinning means pedaling smoothly at a high cadence. A cadence of 90+ rpm is a good target for most riders. If your current comfortable cadence is much lower than that, aim for a few rpm above the most comfortable cadence and then boost the target cadence as your spin improves.
8. Consistency of Training
   Going for a hard ride once a week as your only training or taking a few weeks off and then doing full normal training the first day back on the bike is a common pathway to injury. If you are forced to take more than three days off the bike, take one or a few easy days when you first get back on. If you take time off to travel, aim for at least 30 minutes on an exercise bike every second day while you are away.

Six Treatments for Dealing with Sore Knees from Cycling

1. Correct the Riding Position NOW!
   Sore knees that are caused by position problems won’t improve with time, even with stretching, keeping warm and spinning light gears, but they will generally clear up within a few minutes to a few days once you get the position corrected. Correct position includes: seat height; seat set-back; seat tilt; bar height, reach and tilt; and cleat alignment, wedging and shimming; shoe fit, quality and arch support. If you let sore knees go for weeks or months, it may take much longer for the pain to clear even with a good position. You may even develop permanent problems. Bottom line: If you have sore knees, deal with them right away.
2. Ice the Problem Area Soon After Each Ride
   Use a cold pack/pad, bag of frozen vegetables or crushed ice wrapped in a thin towel. Press it gently to the painful area for about 10 minutes at a time. You can repeat this once an hour if you like.  The ice will reduce the inflammation and pain but will not correct the problem that caused the pain in the first place.
3. Aspirin/Tylenol/Ibuprofen/Etc.
   Use non-steroidal anti-inflammatory medicines (NSAIDs) only to help you sleep or allow you to do your normal daily non-cycling activities, and never to reduce pain during exercise. Ibuprofen and similar drugs will reduce the pain and swelling but not correct the underlying problem. Never use anti-inflammatory medication to make riding possible. Chronic NSAID use is linked to gastric ulcers. Researchers say that NSAID use during endurance athletic activities can cause permanent kidney damage, particularly if the athlete becomes dehydrated. Finally, since NSAIDs make riding many miles in a bad position or damaging way tolerable, they make it possible to do extreme damage to your body. 
   
4. Stretch
   Some sore knees respond well to stretching of the hamstrings, quadriceps or adductors. If they are going to help, they usually do so after one session of stretching, and the stretches need to be repeated before and possibly during each ride. 
5. Taping/Bracing
   Some riders claim that their sore knees have responded well to kinesiology tape or neoprene braces. A chiropractor or physical therapist can instruct you on proper application. 
6. Physical Therapy
   A very few riders will have sore knees or other injuries due to an inefficient or improper muscle recruitment pattern. For most riders the relative contributions from different muscles are well controlled by bike fit. A low saddle causes over-recruitment of the quadriceps and keeps the gluteus and hamstring muscles from contributing, for example. In rare instances, the muscle firing patterns cannot be corrected by bike fit. In those cases a physical therapist may be able to guide an athlete to correct the pattern and fix the injury. 

If you take good care of your knees, following all the guidelines above, it should be possible to enjoy a lifetime of cycling without knee pain. Good luck.

Head Coach Scott Saifer, M.S. has been doing bike fittings and helping people with bike-related pains and overuse injuries for over 30 years. He can do bike fits over video when necessary.  Contact him for a fit!