- September 2, 2021
- 3 Comments
Eliminate and prevent the pain on the outside of your knee when cycling by following these simple tips!
Patient Presentation: History, Background, and Complaints
Brodie B. presented to my office when the pain on the outside of his knee when cycling made it difficult to continue randonneuring through the sequoias, and caused a hitch in his step when he stopped to have his brevet stamped at the summit of the Titans Grove KOM.
It was obvious that Brodie was having a bad day when he could be overheard saying, “I forgot my cycling shoes on the way to the ‘control’ and had to borrow a pair.” He wondered if this had anything to do with it. It was 1,000K ago.
Brodie complained of the following symptoms:
- A dull ache along the outside of his knee when cycling that worsened to stabbing or stinging as the ride progressed.
- A clicking or snapping over his knee as it bent and straightened during the pedal stroke.
- Swelling and warmth near the outside of his knee.
- A feeling of tightness and pain on the outside of his thigh and hip.
- Lingering pain after riding, particularly with walking on uneven terrain, climbing up or down stairs, or when rising from a sitting to standing position.
- While pedaling the pain is most intense when his knee is in a slightly bent position, like right before or after the bottom of the stroke.
Physical Examination
While Brodie’s lower body strength appeared good, he did demonstrate weakness when attempting to rotate his hip outward. Most significant, however, was the extreme tightness he displayed on the outside of his hip and thigh, which when stretched while he bent his knee produced clicking and pain on the outer portion of his knee.
Diagnosis: What is it Called?
Iliotibial Band Friction Syndrome
Describes symptoms caused by inflammation of the iliotibial band (or IT band). The IT band is a connective tissue structure which travels along the outside of the thigh from the hip to the knee, whereupon it becomes thickened at its attachment. With tightness of the IT band, that fibrous attachment creates inflammation-causing friction as it rubs excessively against the bone or bursa resulting in swelling and discomfort.
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 abnormal stress to the outer portion of the knee.
Muscle Imbalance or Weakness
Stiffness or shortening of the IT band due to prolonged repetitive exercise while improperly positioned or if a congenital musculoskeletal predisposition exists. Or weakness of the external hip rotator muscles and glutes which when fatigued allow the leg to turn inward.
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 on the outside of the knee occurs when improper cleat position causes your foot to be excessively toed in or too close to the crank. It may also be due to a saddle which is too high.
- Focus upon a comfortable cadence and smooth pedal stroke.
- 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
Pain on the outside of the knee, often the result of excessive tightness of the musculoskeletal structures on the outer thigh, can be chronic and negatively affect cycling performance and enjoyment. The good news is that Iliotibial Band Friction Syndrome is effectively treated and even avoided by following the simple tips outlined above.
Brodie B., convinced that by following a consistent stretching and recovery plan he would be able to once again ride pain free, had this to say as he set off without a hitch, “Now off to collect my Brevet d’Audax.”
Next appointment
In the next instalment in this series, learn what may be causing the pain on the back of your knee and what you can do to keep riding without performance limiting discomfort.
What about you?
Have you suffered from IT Band syndrome? If yes, let your fellow virtual cyclists know what worked best for you.
Learn more about your cycling-related aches and pain by visiting the Virtual Case Study page of 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!
Should have read this six months ago… Started to have this problem since my vEveresting mid-March and made the error to ignore the pain and soldier on for two more months to win our ZRL S3 division. Been off cycling for three months since, countless sports physician and physiotherapist visits and still no significant improvement. A recent ultrasound showed the IT band is swollen and there’s a bursitis as well (after three months without any serious strain on the tendon). My sports physician switched to anti-inflammatory medication now. Hoping that helps and these exercises might put me on the right track afterwards!
Sorry to hear that Steven. Consistency in this program will help. Be sure to follow the recommendations of your health professionals. Great job on the vEveresting and ZRL.
[…] For a deeper dive into other possible causes, treatment, and prevention of lateral knee pain, check out the ZOM virtual case study entitled “Pain on the Outside of the Knee While Cycling.“ […]