Knee and hip pain are the most common cycling injuries. The most common cause of knee (and hip pain) in cyclists is iliotibial band (IT band) syndrome. The IT band is a thick fibrous band of tissue, which runs on the outside of the leg from the hip to the knee. Pain is caused when the band becomes tight and rubs over the bony prominences of the hip (greater trochanter) and/or the knee (lateral epicondyle). Tight inflexible lower extremity muscles may worsen the condition.

As injury is generally a problem of overuse, it is often seen in the cyclist just beginning a training program or early in the training season when the temptation is to do too much too fast. In order to minimize knee and hip pain in the early season, take it easy for the first few weeks – pedal with low resistance and keep that cadence up to at least 80-90 rpm allowing your body to adjust again to road riding. (Likewise with any change that leads to a slightly new bike position.) Minimize hard riding or hill work for the first few weeks. Add in a stretching program for your lower extremities, especially for the gluteus and IT band to help transition you into your riding season.

The most common causes are:

  • Faulty saddle height or position
  • Crank too long – especially if you have chondromalacia
  • Pushing excessively high gears (slow cadence in cold weather)
  • Too much leg work in the gym
  • Cleat alignment
  • Individual cyclist anatomy

And finally don’t forget about the low back as playing a role in leg pain – especially the back of the leg and hamstrings. All leg pain is not from problems “where it hurts”.

Q. I have a question about lower back and leg pain that I sometimes experience while riding. Sometimes when I am riding my legs will become so racked with pain that I can no longer pedal. I know I have lower back issues from years of heavy Olympic style weightlifting, but this is ridiculous. Sometimes I cannot climb even the smallest hills without stiffness and pain so bad that I almost black out. Any ideas? SG

A. A lot of leg pain is really back pain. So if you have a history of low back problems from the past, I’d start with a good massage therapist that deals with sports injuries combined with a program of back stretches.

Knee Pain

Knee Pain Location

One way to classify knee pain (and identify possible solutions) is to look at the location of the pain.

  • Anterior (see chondromalacia below)
    • Reasons
      • patellar tendonitis
      • patellofemoral syndrome
    • Causes
      • pushing BIG gears – cadence too low
      • saddle too low or too far forward
      • foot too far forward on the pedal
      • crank arms too long
      • leg length discrepancy with seat set for shorter leg
    • Possible solutions
      • ride at 75 rpm or higher
      • raise seat (in small increments of less than 5mm) or move seat back
      • move cleat forward 1 to 2 mm
      • shorten crank arms by 2.5 cm
      • set seat for longer, not shorter, leg with correction for the shorter leg
  • Posterior
    • Reasons
      • hamstring/gastrocnemius
      • neurovacular bundle
    • Causes
      • saddle too high or too far back
      • too much pedal float
      • leg length discrepancy with no correction for shorter leg
    • Possible solutions
      • lower seat (in small increments) or move seat forward
      • limit float to 6 – 8 degrees
      • set seat for longer, not shorter, leg with correction for the shorter leg
  • Medial (inner side)
    • Reasons
      • medial collateral ligament
      • pes anserenus
    • Causes
      • cleat position too wide – foot held externally rotated (toes point out)
      • excessive knee frontal plane motion
      • too little pedal float
    • Possible solutions
      • narrow foot position by moving cleat towards the outside of the foot (thus your foot moves nearer the bottom bracket)
      • orthotic or wedge to correct foot alignment
      • pedal float should be 6 – 8 degrees
  • Lateral
    • Reasons
      • iliotibial band
      • degenerative lateral meniscus
    • Causes
      • cleat position too narrow – foot held internally rotated (toes pointed in)
      • too little pedal float
      • excessive knee frontal plane motion
    • Possible solutions
      • widen foot position by moving cleat away from the bike
      • pedal float should be 6 – 8 degrees
      • orthotic or wedge to correct foot alignment

Saddle Adjustment

A simple seat height adjustment may ease the forces placed on the knee. If the seat is too low, stress is placed on the knee from the patellar and quadriceps tendons and is generally felt anteriorly below the patella where the tension inserts on the tibia. If the seat is too high, pain may develop behind the knee.

There are several different ways to determine proper seat height. The easiest way is to allow one pedal to drop to the 6 o’clock position and observe the angle of the knee joint. There should be a 25-30 degree flexion in the knee when the pedal is at the bottom most point. Another is to measure your inseam (in centimeters) and multiply this measurement by 0.883. This should be your distance from the top of the seat to the center of the bottom bracket. If you place your heels on the pedals, have someone else hold the bike, and pedal backwards, your hips should not rock back and forth. Likewise if your hips rock when you are riding lower your saddle until you achieve a smooth pedal stroke.

Seat fore/aft position and cleat position may also contribute to knee pain. Saddles that are too far back cause the cyclist to reach for the pedal and stretch the IT band with resultant knee pain. Saddle position can be evaluated with the “plumb bob technique”. Seated with the pedal in the 3 o’clock position, a “plumb” hung from the most forward portion of the knee, should intersect the ball of the foot and the axle of the pedal.

Cleat Position

Thanks to Chad Asplund and Chris Carmichael (“The Ultimate Ride”) for the following. These comments are meant for those using fixed cleats systems as the newer systems allowing internal and external rotation of the shoe, or “float” (such as the Speedplay system) have minimized cleats as the issue in knee pain.

Cleats that are too far internally rotated may cause increased stress to the IT band as it crosses the outside of the knee. This can be caused by a narrow stance width on the pedal (cleats too near the bottom bracket) and generally the toes will point in as you look down from above. The solution is to return the cleat to a more neutral position (let the toes point more fore/aft) and/or widen the stance on the pedal. Remember to make these adjustments in millimeters as a small movement on the cleat can translate into major changes at the knee and hip level. Rotational cleat position can also be evaluated by use of a commercial/bike shop “fit kit” or rotational adjustment device – this is more important for cleats with less than 5 degrees of float.

Medial knee pain can result from external rotation (toes pointing outward) and/or stance too wide on the pedals. As you might surmise, the remedy is to align cleat toward neutral with the toes more forward) and perhaps narrow the stance on the pedal (move the cleat towards to bottom bracket). Cleats should be positioned fore/aft so that the ball of your foot is directly over the axle of the pedal.

Relationship of Knees and Top Tube

Should My Knees Be Closer to the Top Tube? (excerpted from

Question: I recently rode with an experienced racer. He said my knees are too far out to the side as I pedal, and I would benefit from bringing them closer to the top tube. “Think of holding a ball between your knees,” he said. I’m quite bowlegged (thanks Mom) so for me to make my knees touch the top tube is almost impossible. Should I work on keeping my knees closer to the frame? — Randy S.

Answer: I see quite a few riders with knees splayed outward. This can be caused by anatomical characteristics or bad bike fit — or a combination. Narrower knees are certainly better in terms of aerodynamics. Watching the Tour de France this summer, head-on camera shots made some riders look knock-kneed. But it’s a common misconception that pedaling with knees nearly brushing the top tube increases power.

Knee position is determined by your anatomy. Ideally, your knees will be directly over the pedals. But if you’re bowlegged, they will tend to be fairly far from the top tube. Trying to pull them in is likely to strain and ultimately injure ligaments and tendons. If you have had a professional bike fit, let your knees do what they want to do, naturally. That’s the best way to avoid injury and produce the most power your body is capable of generating.


The knee joint is basically a ball-and-socket joint, with the ball at the bottom of the femur and the socket at the top of the shinbone or tibia (although a very shallow socket – unlike the hip joint for example). Protecting the front of the relatively unstable knee joint is a third bone, the patella, which is embedded in the quadriceps tendon and which slides in a shallow groove on the femur and tibia. A common cycling-related injury is called chondromalacia, and has to do with irritation of the cartilage behind the patella.

This is more commonly seen in women – perhaps because of the angling of the knee related to their wider pelvis. When asked “where does it hurt” the patient often cannot point with a single finger to a specific location but will classically move their palm over the entire anterior knee or patellar area. Another clue is that the knee will often hurt after prolonged flexion (the theatre sign).

Chondromalacia is often blamed on lateral movement of the patella which may not “track” smoothly in the patellar groove as it moves. A common prescription to reduce discomfort is strengthening the quadriceps muscles which run along the front of the thigh and help to stabilize the kneecap and counteract or correct this mis-tracking which, with repeated knee bending causes irritation of the tissue behind the patella.

One exercise which will strengthen the quads and decrease this lateral movement is to sit in a chair holding one leg at a time out straight, unsupported. Sometimes it is suggested you place a pillow or other weight (such as a sock filled with pennies) on the extended foot. Making a conscious effort to avoid lateral knee movement during your pedal stroke (by watching your knees as you ride in a low-traffic setting) can help you retrain your pedal stroke. The knees should move up and down as you pedal, with no sideward motion. Many cyclists have a sideways hitch in their pedaling motion, which may be a major contributor to chondromalacia. Two other suggestions:

  • Shortening your crank length. Women, in particular, often have a crank that is too long for them, which then places an increased load on the patella when the pedal is at the front of its stroke.
  • Spin at a higher RPM. Pushing big gears at a low RPM puts a tremendous load on the knee.

Patellar Tendonitis

Tendonitis is inflammation of a tendon, usually from overuse. With repeated irritation and thus inflammation, scarring can occur. The tearing and resulting scarring increase friction as the tendon moves. As a result, the tendon might squeak like a rusty hinge or piece of dry leather when you bend your knee. This is called crepitus and reflects both the inflammation and the lack of normal lubrication of the tendon. The result is pain.

The patella is the kneecap. It’s surrounded by the tendon structure itself, which connects the quadriceps muscle group to the tibia or lower leg. Your patella is a triangle. If you look down at it, the pain is usually centered on the lower tip (inferior pole) where it connects to the tendon. If the tendinitis is severe, you may get localized swelling. It might look like a little bump or nodule at the lower end of your patella.

You will feel pain in the front of the knee, below the patella, when you pedal or walk upstairs, and it will probably be even worse descending stairs. It also hurts when you palpate, or press, on the tendon itself. There may be some swelling.

Patellar tendonitis often appears after hard sprinting, big-gear climbing, or off-bike jumping activities. It also can flare up after hard leg presses or squats. Many times it is simply doing too much, too soon in your training program.

Treatment includes applying ice up to three times a day and a non-steroidal anti-inflammatory drug (NSAID) with food. Consider raising your saddle height if this is biking related, and pedal easily or stop riding for several days to allow the inflammation to quiet down.

Individual Anatomy

(Leg length discrepancies; flat feet)

Per Chad Asplund MD “individual cyclist anatomy may contribute to knee and hip pain. Cyclists with leg length discrepancies may develop knee pain as only one side is correctly fitted to the bicycle. This leads to increased stress inside the knee and hip joints on the improperly fitted side. Cyclists with flat feet may be more prone to excessive pronation (internal rotation) of the lower extremity causing greater stress on the IT band at the knee. Orthotics (anatomic shoe inserts crafted by podiatrists) may correct the alignment of the knee and decrease or prevent medial or lateral rotational stress on the connective tissue of the ankle, knee or hip, thus reducing the pain.”

Almost everyone has a small leg-length inequality, but a difference of 1/8 inch (3 mm) or so shouldn’t affect your cycling. When the difference is greater, however, it can open the door to a host of leg and back problems. The solution involves either cleat repositioning or, when the inequality is 6 mm or more, a shim under the cleat of the short leg.

Here’s a quick way to get a ballpark idea as to whether you might have a problem.

  • Remove your socks and lie on your back on a firm surface. Straighten your spine as much as possible.
  • Have a friend pick up both legs by the heels, shake them gently, stretch them forward and set them down with anklebones (malleoli) touching.
  • Have your friend can see how your ankles match. If the bones are offset (AND you’re experiencing leg or knee problems) it may be worth getting a more precise exam from an orthopedist or sports medicine practitioner.


Treatment of Knee Pain

Knee pain generally develops slowly over a number of days and is not an emergency. Immediate care is always available at a walk in clinics, but it is more productive to see your primary care physician or a sports medicine physician as the first step.

Dealing with yourself will be the biggest issue. Competitive athletes have a “fear of rest” – yet rest is probably the single most effective treatment. Peer pressure to continue to ride doesn’t help when you are trying to do the right thing for yourself (and your knee).

  • First Aid

As in any musculoskeletal injury, ice, elevation, and resting the knee are all helpful.

  • Rehabilitation

Take a few days off and then begin a limited riding program – cut back mileage by 20 – 30 % and spin at a high rpm and in a low gear for a week or two. And the same goes for leg work in the gym. Remember, if you push too hard, you just get to start over again. Mild stretching before and after the ride keep the muscles loose, and icing the knee after the ride may be beneficial as well.

  • Drugs

Tylenol or NSAIDs such as Motrin are a good start. Motrin can be taken up to 800 mg 3 times a day for a few days, but then drop back to the recommended dose on the bottle. If you have a history of ulcer problems or develop GI side effects, either switch to Tylenol (it helps pain but is not as good an anti-inflammatory) or see your physician for one of the newer medications.

  • Prevention

And finally, don’t forget about prevention. Why did the pain develop in the first place? Overuse is the big one, but also consider these possibilities:

    • Correct biomechanics – follow suggestions above
    • Consider a complete bike fit
    • Choose gears that allow a cadence of at least 75 – 80 RPM
    • Don’t make big changes in your training program – increasing mileage by more than 10% a week is a risk factor for injury as is over zealous interval training.
    • Keep your legs covered in cold temperatures – there is no scientific proof, but plenty of individual experience that suggests this will decrease injuries. (And the hassles of knee or leg warmers are reasonable insurance if you are prone to knee pain or leg strain.)

For those interested, here is another excellent article on knee pain reprinted from the The Physician and Sports Medicine

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