Virtual Case Study: Pain Behind the Knee When Cycling

Eliminate and prevent pain behind the knee when cycling by following these simple injury prevention and exercise tips!

Patient Presentation: History, Background, and Complaints

Coco C. presented to my office looking blue and when asked replied, “You would be sad too if 100’s of you friends were constantly trying to half-wheel you.”  It soon became clear that the real reason, the one she was attempting to deny, was the bothersome discomfort and pain behind the knee when cycling.

Ms. Cadence reported that she has always prided herself on the ability to pedal pleasant circles, but recently feels that she is reaching with her foot and constantly sliding to the nose of her saddle.

Physical Examination

An assessment of Ms. Cadence’s strength showed that her quads were much stronger than her hamstrings, causing a muscle imbalance and the tendency for her quad muscles to overpower her hamstrings, leaving them overworked.  Most notable, however, was the lack of flexibility in her hamstrings, glutes, and calf muscles.  Ms. Cadence also appeared to have swelling behind her knee and it was tender to the touch.

Diagnosis: What is it Called?

Hamstring Strain or Biceps Femoris Tendonitis

An irritation (inflammation) of the hamstring tendon where it attaches at the back of the knee, causing tenderness and swelling at the back of your knee which develops and worsens over time.

diagram of muscles behind the knee
Calf Strain or Gastrocnemius Tendinitis

An inflammation of the calf muscle tendon at the back of the knee producing pain of a gradual onset behind the knee, which can make going up on your tiptoes with your legs straight difficult or painful.

Baker’s Cyst or Popliteal Cyst

Swelling that occurs at the back of the knee, often about the size of a golf ball but can vary over time, causing pressure and difficulty bending 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 straightening of the knee.

Muscle Imbalance or Weakness

Stiffness or shortening of the hamstrings, calf muscles, and glutes due to prolonged repetitive exercise while improperly positioned or if you have a congenital musculoskeletal predisposition.  Or quads that are stronger than your hamstrings, which overpower them while pedaling causing overload.

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?

static stretching tips
exercise program for pain behind the knee when cycling

Referral: When is it Time to Ask For Help?

blue avatar cycling

The Expected Outcome: Conclusion

Pain felt at the back of a cyclist’s knee is frequently the result of improper bike fit and muscle tightness or imbalance. Once identified, take some recovery time to allow the inflammation to decrease while addressing the potential underlying causes of the issue.


Initiate a program of gentle stretching and progressive strengthening in a pain free manner when able. You will be pedaling perfect painfree circles with C. Cadence in no time!

Next appointment

In the next instalment in this series, learn what may be causing the pain in your hip and what you can do to keep riding without performance limiting discomfort.

What about you?

Have you suffered from pain in the back of your knee?  If yes, let your fellow virtual cyclists know what worked best for you. 

For more great injury prevention tips check out the Virtual Case Study page on The ZOM!

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