Virtual Case Study: Pain in the Front of the Knee While Cycling

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.    

diagram of the muscles of the hip and thigh

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?


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.


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?

Tips for first aid for injuries
exercise program to address pain in the front of the knee when cycling

Referral: When is it Time to Ask For Help?

red avatar cycling

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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