Cycling provides participants with one of the great pleasures in life: the ability to enjoy nature at its finest.  Yet, with an ever increasing population of cyclists enjoying the great outdoors and pushing their bodies to the limit, this increase in physical activity can come with a cost of wear and tear to both you and your bike.

Anyone who has cycled for any period of time will be in no doubt that the effects of long rides do have their influence on the cyclists’ body and these obviously vary from individual to individual. There are some classic injuries associated with cycling and a large body of research and development into injury prevention and management has occurred for both elite and novice riders alike.

Unlike a number of other sports, cycling has some unique features that influence the athletes involved.  Due to the mechanical nature of the sport and the high level of mileage that occurs for most keen riders, the cycle set up is integral to both the prevention of injury and the management of injuries. One of the most dominant traits of cyclists is that the more they ride the more they want to ride! This allows the smallest of biomechanical inefficiencies to become a strong influence on the rider’s body and can create significant long term issues and pain.

In the following article I will look at some of the issues that can affect cyclists and possible solutions. Each individual is different and while certain parameters are useful, all advice should be used in conjunction with a qualified health professional and certainly a professional bike fit is a must!


Chronic knee pain is a very common injury in cyclists. Although there may be many causes for chronic knee pain, only anterior and lateral knee pain will be discussed in this article, as they are reported most frequently.


Chronic Anterior Knee Pain:

The most common cause for chronic anterior knee pain in cyclists is patellofemoral pain syndrome (PFP).  This is a condition where repetitive flexion/extension of the knee results in peri-patellar pain. During cycling, the force generated by quadriceps muscle contraction during the downstroke (knee extension) is translated to the patellofemoral joint.  This patellofemoral joint reaction force is thought to injure the peri-patellar structures, resulting in injury.  Predisposing factors to PFP in cyclists include training errors (rapid increases in training volume, incorrect use of bicycle gearing, increased hill training), incorrect pedal/foot interface (type of cycling shoes and cleats used), incorrect bicycle set-up (incorrect frame size, saddle height to high or low, incorrect saddle position – usually too far forward), muscle imbalances (quadriceps and hip stabiliser muscles), and anatomical abnormalities in the cyclist (small mobile patella, hypoplasia of the lateral femoral condyle, patella alta).

In recent years, biomechanical studies using two-dimensional video analysis conducted at the Sports Medicine Unit of the University of Cape Town have shown that cyclists with PFP exhibit an abnormal nonlinear pattern of knee movement during the downstroke of cycling. Once this abnormal pattern is corrected (by using custom-made orthoses, altering the cleats, or by altering saddle height), PFP can be treated effectively.

The principles of management of PFP in cyclists are to treat the pain, followed by altering training and correcting other predisposing factors.  The bicycle set-up, as well as biomechanical analysis of the downstroke, may be required to reduce the loads on the patellofemoral joint.

Iliotibial Band Friction Syndrome

The most common cause of chronic lateral knee pain in cyclists is iliotibial band (ITB) friction syndrome. This injury is thought to occur as a result of repetitive mechanical friction between the iliotibial band and the lateral femoral condyle. The diagnosis is made by careful clinical examination. Pain can be reproduced by repetitive knee flexion and extension while applying pressure over the lateral femoral condyle.

Classically, pain is maximal at 30 degree knee flexion – the angle at which the ITB crosses over the femoral condyle (known as the ITB impingement angle). Specific predisposing factors for this injury in cyclists have not been well studied. In a recently published study, researchers showed that the minimum knee flexion angle during cycling (at the bottom of the downstroke) is close to the ITB impingement angle. Therefore, apart from correcting training errors and conditioning the hip stabiliser muscles, the adjustment of saddle height is probably the most effective management of ITB friction syndrome in cyclists.

One of the problems with most cyclists is the lack of lateral gluteal muscles (gluteus medius/minimus /lower posterior gluteus maximus).  These muscles help to maintain optimal hip angle and knee alignment in the downstroke.  We will be looking at some example core conditioning programmes to help manage these issues in my next article.

Tim Robinson

VIATim Robinson
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Tim is an experienced musculo skeletal physiotherapist who has extensive sports medicine experience and has worked with a large number of athletes and sports teams for over 25 years. He has worked with international teams like the All Blacks and Waikato Chiefs in professional rugby and the NZ Ski team and members of the New Zealand Triathlon team as well. Tim is a keen cyclist and is often found riding his mountain bike through the forests of Noosa. Tim rides a Giant TCR road bike.