- August 31, 2021
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Ride strong without that nagging pain in the front of your knee by following these tips to eliminate and prevent pain in the front of the knee when cycling!
Patient Presentation: History, Background, and Complaints
Amelia A. presented to my office, somewhat harried as if no time to spare, with a flushed look and complaining of pain in the front of the knee when cycling.
Amelia noted that her knee was fine for the first hour (significant and of ‘record’), but the strain of riding continually at a threshold pace on a hilly course eventually caused a dull ache above, behind, or below her kneecap.
Amelia also admitted that when offered a new bike by her team, she was enamored by the pink embrase’ one (not knowing what it actually did), and assumed that her soigneur had adjusted it to suit her.
Physical Examination
While Amelia displayed exceptional quad muscle strength, her hip, core, and hamstring muscles demonstrated relative weakness. In addition, the long hours spent in the saddle caused muscle imbalances due to excessive tightness of her hamstrings, hip, and calf muscles.
Amelia’s kneecap also seemed to move to the outside (improper lateral patellar tracking) when she flexed her thigh and her inner quad (VMO) muscle appeared smaller in proportion.
Diagnosis: What is it Called?
Patellofemoral Pain Syndrome
Pain which occurs around the patella (knee cap) or is felt as irritation, clicking, or grinding behind the patella.
Quadriceps Tendinosis
The quadriceps tendon is located above the patella and connects the quadricep (thigh) muscles to the top of the kneecap, which when irritated pain is felt in the front and just above the knee.
Patellar Tendinosis
The patellar tendon connects the patella to the tibia (shinbone) and if inflamed causes pain below the knee.
Etiology: What Causes It?
Overuse
Irritation due to the repetitive nature of the pedal stroke if performed improperly or if problematic, especially if improper positioning causes excessive bending of the knee.
Muscle Imbalance or Weakness
Stiffness and weakness of the muscles and structures attached to the patella can cause it to be positioned improperly resulting in pain during movement.
Core Weakness
Without strong back and abdominal muscles there is no foundation for strength production by the legs and an inconsistent and improper pedal stroke can result.
Injury
The residual effects of prior trauma or recent injury can cause significant and limiting knee pain.
Bike Fit
Improper positioning on the bike causes repetitive stress-causing inflammation and pain in the affected area.
Treatment: What Can You Do About It?
- If the pain is the result of a recent injury or is acute (sudden onset within ~24 hours) with swelling, control the symptoms by following the ‘PRICE principle’ (an acronym which stands for Protect, Rest, Ice, Compression, and Elevation) immediately for the next 2 to 3 days.
- Check your bike fit: Pain in the front of the knee is usually due to your saddle being too low or too far forward, excessive forward placement of your cleats, or if the crank is too long creating an improper and excessive flexion (bend) angle while pedaling.
- Focus upon a high-cadence smooth pedal stroke and avoid ‘mashing a heavy gear’ at a low cadence with excessive force on the downstroke.
- Follow a consistent and effective recovery strategy.
- Avoid ‘Spring Knee’, the pain and discomfort caused by a sudden increase in mileage and/or intensity in an attempt to make rapid fitness gains, by following a sound progressive training plan.
- Address muscle imbalances through a focused strengthening and stretching plan, making sure to only perform exercises which can be done pain free and without residual soreness.
Referral: When is it Time to Ask For Help?
- A proper bike fit performed by a certified professional is always a good idea, especially when the small incremental changes you have made to your setup don’t provide the results or eliminate the pain you are experiencing.
- A progressive periodized training and recovery plan is essential and when followed with the aid of a knowledgeable cycling coach there is a tendency to be more accountable and disciplined.
- If your knee pain is persistent, worsens, or significantly interferes with your cycling, seek the assistance of a Sports Medicine Physician or Physical Therapist for an expert biomechanical and musculoskeletal assessment and treatment.
The Expected Outcome: Conclusion
Anterior knee pain can be an annoyance which if left untreated can become a significant limiting factor requiring time spent off the bike. But it doesn’t have to!
By identifying the possible underlying causes, and implementing a solid training, strengthening, stretching, and recovery plan, knee pain can be eliminated and avoided. You will be pacing Amelia A. in no time! Speaking of Amelia…
After checking her UI and realizing that her 15 minute break was nearing an end, Amelia stood up and while duck walking out the office door could be heard cheering, “I am Mademoiselle Chrono again!”
Next Appointment
In the next instalment in this series, learn what may be causing the pain on the outside of your knee and what you can do to keep riding without the frustration of nagging pain.
What about you?
Do you have pain in the front of your knee like Amelia A? What is your experience and how do you deal with it? Your fellow virtual cyclist would like to know. Comment below.
For more helpful cycling-related injury tips check out the Virtual Case Study page on The ZOM.
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Semi-retired as owner and director of his private Orthopedic Physical Therapy practice after over 20 years, Chris is blessed with the freedom to pursue his passion for virtual cycling and writing. On a continual quest to give back to his bike for all the rewarding experiences and relationships it has provided him, he created a non-profit. Chris is committed to helping others with his bike through its work and the pages of his site.
In the summer of 2022, he rode 3,900 miles from San Francisco to New York to support the charity he founded, TheDIRTDadFund. His “Gain Cave” resides on the North Fork of Long Island, where he lives with his beautiful wife and is proud of his two independent children.
You will read him promoting his passion on the pages of Cycling Weekly, Cycling News, road.cc, Zwift Insider, Endurance.biz, and Bicycling. Chris is co-host of The Virtual Velo Podcast, too!
