Training & Nutrition

How to: Fix Knee Pain from Cycling

Cycling can be many things, but it certainly doesn't need to be painful

Cycling can be beautiful, exhilarating and exhausting in equal measures. One thing it doesn’t need to be is painful.  We’ve worked with Scott Holz – the expert who trains Specialized dealers in their Body Geometry Fit fit system (using advanced Retül bike fit tools) to bring you a series of guides on common problems and their equally common solutions. Holz has been helping riders discover their optimum fit for over 30 years, providing expertise for amateur everyday cyclists right through to World Champion Lizzie Armitstead. He’s well qualified, we assure you. 

To kick off the proceedings, we’re starting with the number one cycling gripe: knee pain. In future articles we’ll look at neck pain, shoulder pain, back pain and issues arising from desk work and sitting. 

Holz fitting Lizzie Armitstead. Image: Specialized 

Cyclists commonly struggle with sore knees. Be it a niggle, a vague irritation or a wincing pain with every pedal stroke, it’s not something to be ignored or endured. More often than not, proper bike fit can resolve the problem.

There are a few cases when the solution needs to be sought off the bike, and we do have to point out that though there are patterns and prevalent causes – every body is different. These are generalisations to give you an idea what could be causing your problems and how you can take steps to reduce your discomfort. To get the ideal diagnosis and set-up, your best bet is to get a bike fit with a trained professional.

There are important facts to note before we go on:

  • Firstly – you’re not alone, almost all cyclists have suffered from knee pain at some point.
  • Secondly – it’s very likely that it’s not actually your knee that’s the problem, but a symptom of an issue elsewhere.

Covering off both of these important statements, Holz tells us: “The number one source of problem for cyclists, pretty typically, is the knee. The knee is the victim between the hip and the foot. It’s not the knees fault, it’s trying to do its job. If it’s not tracking properly you get problems.”

To discover the cause of the pain, you probably need to start by looking at the symptoms.

Pain at the front of the knee

Photo: Iri Greco / BrakeThrough Media

If you’re experiencing pain right in the knee cap, or just below it, it’s likely you need to raise your saddle. Holz explains: “Low saddle height is probably the number one cause of patella pain. If somebody tells me ‘I’ve got pain in the front of my knee’ or the underside [he points just below knee] the first thing I’ll look at is saddle height. The lower the saddle the more pressure you’re putting through the knee joint.”

Low saddle height is common in beginner cyclists who feel they need to be able to put their feet square on the floor when they stop. Ideally, the average person is actually at optimal saddle height when they can only just touch their toes on to the floor when stopped. Of course the sweetspot in terms of saddle height will vary for each individual, and a professional bike fitter will help you find the optimum, but we’ve got more info on setting correct saddle height at home here.

Low saddle height is not the only cause – Holz adds: “Sometimes people are just pushing gears that are too big, or riding over long or steep climbs that they’re not used too – tendonitis around the patella becomes an issue.”

The answer for overuse? Rest, ice, compression, elevation, and avoid increasing mileage or climbing dramatically – try to build up slowly. The answer for pushing big gears? Work on dropping down to smaller gears and spinning the pedals more – either via drills or consciously not riding in the big ring. 

Pain at the back of the knee

Pain behind the knee and in the hamstrings is opposite to pain at the front of the knee – so it’s not too surprising that the cause can also be the reverse. Holz says: “Pain at the back of the knee, in the hamstring attachments – is often caused by the saddle being too high [as the leg is having to over extend].”

The alternative is that the hamstrings may be being forced to work too hard as a result of a lack of stability in the foot. This occurs when the rider has too much float in the cleat to shoe interface, when riding clipped in.

Holz explains: “Your hamstrings act as stabilisers – kind of like the reigns of the horse. If the foot is flopping around, they have to work really hard trying to hold it straight.”

Ideally, in cycling pedals and cleats you should be able to move your foot a couple of millimeters if you give it a wobble in the pedal, but no more. If you’re riding too lose, you can fix this by opting for a cleat that offers less float, or tightening the adjustment on your pedal system. 

Pain at the side of the knee: hip or foot causes

Photo: Iri Greco / BrakeThrough Media

Some people get pain at the side of the knees – medial being pain on the inside and lateral being pain on the outside. There are several potential causes for this.

Before we go on – it’s worth checking that your cleats are in good nic. That means they’re not worn, and that they’re pointing straight and set up to sit below the ball of your foot unless you’ve been directed otherwise by a professional who has examined your foot and pedaling technique. If your cleats aren’t straight, and they’re not correcting an existing issue, they’ll be forcing your knee at an odd angle with every single stroke.

If you know the issue isn’t cleat alignment, we can look at hip and foot issues.

Holz tells us: “Medial pain is almost always caused by a tracking where the knee is driving towards the top tube. There could be several reasons why that’s happening. It could be something going on in the hip.” In this case, it’s often a weakness in the hip and glutes that needs to be worked on off the bike, or a tightness that needs to be addressed via stretching, massage and foam rolling. 

If the issue is not in the hip, it could be a problem in the foot. The feet might not seem to be doing much in the cycling motion, but they were never designed to pedal – they’re made to walk and run. When they try to continue with their natural movement on the bike, we end up with problems: “Very commonly it can be arches that are collapsing [causing medial knee pain]. As the arch collapses the knee has to follow. When you heel strike as you’re walking, the outside edge [of the foot] comes down, the arch acts as a shock absorber, and the forefoot collapses so you can adjust to the terrain. Then you spring forward, you build energy and push off. All of that doesn’t need to be happening in cycling – but if your arch is collapsing before you get to the pedal stroke, your knee typically follows it – so that’s all just [unnecessary] medial movement.”

How can we fix this? Via support via insoles that creates a natural position and prevents the foot from trying to act as it might during a walking motion. Holz says: “We’re not trying to correct anything, we’re just trying to support the natural, neutral shape of the foot – so when you apply power you’re applying power faster and we’re preventing that collapse.”

You may already have insoles for walking and running, but you’ll want something very different on the bike: “Support for cycling isn’t good for walking [you’d be walking around with flat feet]. On a bike we want that foot to be a nice rigid lever. If you support all of that, your knee tracking improves a lot.”

Specialized create all of their cycling shoes with Body Geometry Fit sole construction and footbed, designed to optimise hip, knee, and foot alignment. However, at they also offer wedges for those that need extra support, and these are best prescribed as part of a bike fit to ensure you walk away with the right pair.

Pain at the side of the knee: sitting wonky

Holz working on team riders

Another cause of pain on the inside or outside of the knee could be a discrepancy in leg length – either due to the dimensions of your body or due to sitting in an awkward position on the bike that’s causing your legs to be different lengths, artificially.

Sitting Wonky? The Relationship Between Saddle Discomfort and Lower Back Pain

Scott tells us: “The other cause of medial pain, or a combination, so medial on one side and lateral on the other – the rider very well could be sitting crooked on the saddle, either due to a leg length discrepancy, saddle discomfort, or due to a pelvic rotation causing one leg to be shortened and the other to be lengthened.  We need to ask ‘do they have a leg length discrepancy or do they have a rotated pelvis’?”

Leg discrepancies can be solved using a wedge in the shoe. However, it’s important to check the issue is not actually a rotated pelvis caused by anything from sitting awkwardly at a desk or simply an ingrained stance off the bike.

The rotated pelvis makes the knees work differently – Holz says: “When your pelvis rotates, your sit bones aren’t aligned, your body really wants them aligned, so your knees move.”

If this is the case, work needs to happen off the bike. Fixing it on the bike won’t help, as the degree of rotation will shift depending on how carefully you’re monitoring it – a visit to a physiotherapist will straighten you up, as will sitting at a desk more squarely, and stretching more often. In this case, core work, regular stretching and trying to address the cause with a physiotherapist at hand is the best solution.

Pain on the outside of the knee and IT band pain

Holz fitting Lizzie Armitstead. Image: Specialized 

Scott opens on this issue saying: “You know the guy you see riding down the road like a V8 engine?” I’m not very into engines, so  I ask if he means the rider pedalling like Kermit the frog, and he confirms – then goes on to say:  “Most of those guys have IT band pain.”

The IT band runs along the outside of the thigh and Holz expains: “Their IT bands are literally having to stretch around their knees. We fix that by getting them on wider pedals or via cleat adjustment if it’s a small amount. Speedplay pedals have different length spindles which is awesome and means you have much more adjustment available to you. You’re probably never going to bring their knees in, so you move their feet so they’re below their knees. That takes the tension of the IT band.”

We do hope that helps clear up a few questions around knee pain and cycling, helping any reader’s suffering to overcome issues that are easy to solve. If you’re experiencing ongoing problems, check in for a bike fit.

The average fit can cost around £100, which might seem a lot to be leaving an identical bike, just altered a bit here and there. However, being comfortable on your bike is a performance aid greater than any upgrade, so we’d recommend it. 

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