Knee Pain While Cycling? Here’s what you need to know about Patellofemoral Pain

Patellofemoral (i.e. knee cap) pain is a common overuse knee injury in cycling and is one of the conditions we see in our Cycling Physiotherapy sessions. It is commonly called runners knee or chondromalacia, which are terms describing the same condition, and of course not all cyclists run! Patellofemoral pain presents as pain around and/or behind the knee cap with activities such as cycling, running, squatting and using the stairs. It affects active individuals of all ages, and in older individuals, may be a symptom of patellofemoral osteoarthritis (Crossley et al., 2016).

What are Contributing Factors to Patellofemoral Pain?

There is a lack of strong evidence about what factors related to the body, bike or training/racing load might lead to cycling-related knee pain (Visentini et al,. 2022). However, patellofemoral pain has been extensively researched in other sports such as running, with numerous contributing factors identified. Based on this, and other research, the following factors should be considered in people with cycling-related knee pain:

1. Quadriceps weakness

High quality research has found that quadriceps muscle weakness is a risk factor for patellofemoral pain (Neal et al., 2018) and patellofemoral osteoarthritis (Culvenor et al., 2018). Although this has not been exclusively researched in a cycling population, it is plausible that quadriceps weakness could be a risk factor given the muscles important role in the pedalling biomechanics.

2. Hip muscle weakness

Hip muscle weakness may not be a risk factor for the development of patellofemoral pain, however in those who have the condition show decreased hip strength (Rathleff et al., 2014). In cycling, the hip muscles are vital for controlling the tracking of the knee joint, and for producing power, particularly during the downstroke phase of the pedal cycle from the 12 o’clock to the 3 o’clock position.

3. Muscle tightness

Muscle tightness of the quadriceps may place additional compression on the patellofemoral joint during cycling.

4. Cycling biomechanics

In the cycling population, there is limited, and even conflicting evidence looking at the relationship between cycling biomechanics and the development of patellofemoral pain. Research has not found a consistent relationship between knee biomechanics and pain (Branco et al., 2023). However, these studies are often small, therefore difficult to draw conclusions from. In other research looking at walkers and runners, high quality research has found altered hip, knee and ankle biomechanics in those who have developed patellofemoral pain (Bazett?Jones et al., 2023). Therefore, cycling biomechanics may possibly contribute to patellofemoral pain and anecdotally changing them can help, however we need some better-quality research to explore this.

5. Bike set up

In cyclists, riding with a suboptimal saddle position or saddle height may contribute to patellofemoral pain, although like biomechanics, more research is needed to explore this (Visentini et al., 2022). Existing studies have not demonstrated significant differences in patellofemoral joint forces across various saddle heights (Bini & Hume, 2014) or saddle setback positions (Menard et al., 2018). However, similar to the research on other cycling biomechanics, these studies are small and more research is needed. Despite the current lack of high-quality evidence, it is possible that bike setup factors play a role in the onset and/or persistence of patellofemoral pain, and anecdotally changing them can help with pain.

6. Training factors

A sudden increase in cycling load, whether in distance, power, or hills, may contribute to the onset of patellofemoral. Moderate quality evidence from a systematic review suggests a link between training and racing variables, and the development of overuse injuries in cycling (Visentini et al., 2022). A biomechanical study has also reported increased patellofemoral joint forces with higher power outputs (Erickson & Nisell, 1987), indicating higher cycling intensity may increase the risk of

The development of patellofemoral pain is often multifactorial; while a sudden increase in training load may act as a trigger, factors such as insufficient tissue capacity, suboptimal cycling technique, and inadequate bike setup can collectively contribute to patellofemoral joint overload. These are all things we consider during a thorough assessment of someone with cycling-related knee pain

How is Patellofemoral Pain Managed?

Physiotherapy is recommended for the management of patellofemoral pain. This may include:

1. Knee targeted exercises

There is very high certainty evidence to support knee targeted exercises for improving pain and function in those with patellofemoral pain (Neal et al., 2024). Since quadriceps function is a key component of the pedal stroke, especially in generating force, it’s important that the muscle is strong.

2. Hip targeted exercises

There is lower certainty evidence to support hip targeted exercises for improving pain and function, however it is strongly recommended by experts particularly if knee targeted exercises are too painful (Neal et al., 2024). Furthermore, the hip muscles are important to target considering its importance for generating force and controlling the tracking of the knee joint during cycling.

3. Orthotics

High quality evidence has demonstrated strong clinical recommendation for the use of foot orthoses in those with patellofemoral pain for short term improvements (Neal et al., 2024). However, in the cycling population, research looking at foot orthoses is limited (Fitzgibbon et al., 2016). Despite this, orthotics may be appropriate for some people if foot function is related to knee pain.

4. Taping

There is high quality evidence to support the use of taping for patellofemoral pain (Neal et al., 2024). However, taping is only recommended for short term use and in combination with other treatments.

5. Manual therapy

There is moderate certainty evidence to support manual therapy for short term improvements in function in those with patellofemoral pain (Neal et al., 2024). However, manual therapy should only be used as part of a more holistic treatment plan.

6. Cycling technique

There is limited evidence looking at retraining cycling technique. However, in the running population, gait retraining is commonly recommended by experts, and is often implemented alongside rehabilitation for running-related injuries. Anecdotal evidence suggests that visual and verbal feedback aimed at reducing hip adduction and internal rotation can be beneficial for runners with patellofemoral pain (Barton et al., 2016). Given this, it is plausible that similar cueing approaches could be applied to cyclists experiencing patellofemoral pain.

7. Bike set up

Increasing the saddle height and the amount of float in your cleats may help reduce stress on the patellofemoral joint (Fitzgibbon et al., 2016). Chat to your Physiotherapist for simple tips on bike set up, or about referral to a professional bike fitter which in some instances can help a lot.

• Written by Josie Pepper

  Josie Pepper is a physiotherapist with a Bachelor of Physiotherapy from Newcastle University and extensive experience in musculoskeletal care. She has a special interest in cycling, triathlon, and foot and ankle injuries and is currently completing a Master of Sports Physiotherapy at La Trobe University. A trained Clinical Pilates instructor with expertise in strength and conditioning, Josie is dedicated to helping patients achieve their rehabilitation goals through tailored exercise programs. Outside of work, she is a competitive road cyclist, riding for a Melbourne-based team.