Friday, 8 July 2016

Cycling Series: Knee Pain

The cycling season is in full flow in the alps and the Tour de France is well underway. Last Sunday, the Col d'Iseran was shut to motor vehicles while around 200 road cyclists climbed the Col.  Cycling is a wonderful way to exercise, whatever your level or age, with a host of health benefits. It’s also a great way for skiers to maintain their fitness throughout the summer season.

However, cycling is a highly repetitive sport, therefore niggles can soon develop into overuse injuries if the cause is not identified and corrected.  Overuse injuries most commonly occur to the knee, back, neck, hand / wrist, calf / achilles region and the foot.

Cyclists are also at risk of traumatic injuries, which most commonly result from falls and crashes. As well as bumps and bruises, fractures most commonly occur to the collar bone and scaphoid (small bone at the base of the thumb) often due to landing on a shoulder or outstretched hand.

The following extract was taken from

A review of studies on injuries in professional cycling was undertaken by Marc Silberman and published in Current Sports Medicine Reports in 2013. Silberman observed the following:
  • In a 4-year study of 51 top-level professionals, 43 cyclists experienced 103 injuries, with 50 (48.5%) traumatic injuries and 53 (51.5%) overuse injuries. Twenty-nine cyclists (67.4%) experienced more than one injury. Twenty-eight fractures occurred, with the clavicle having the most common fracture (11 cases). Only eight cyclists (15.6%) were injury free (De Bernardo, Barrios, Vera, Laíz, & Hadala, 2012).
  • In another study in elite professionals, 38% of injuries were traumatic and 62% overuse injuries (Barrios, Sala, Terrados, & Valenti, 1997).
  • More than two-thirds of traumatic injuries occur in the upper extremity, and two-thirds of overuse injuries occur in the lower extremity (De Bernardo, Barrios, Vera, Laíz, & Hadala, 2012).
  • Cyclists are exposed to high traumatic risk racing in a peloton, at high speeds, on various road and weather conditions. By stage 9 of the 2011 Tour de France, 14 fractures occurred and 16 riders retired from the race, with one in intensive care (Greve & Modabber, 2012).
  • Data from 2009-2010 looked at 93 cyclists. A total of 117 injuries (1.2 injury per cyclist per year) were reported, the most common types of which were abrasions (63%), contusions (23%), and strains (8%). Most injuries were located in the upper (47%) or lower extremities (47%) – with the knee (18%), wrist and palms (16%), shoulder and clavicle (16%), elbow (14%) and femur (14%) the most common sites (Bagherian and Rahnama, 2010).
I have not recited this data to put people off cycling. Cycling is a challenging sport and I feel that highlighting such data can only help to initiate appropriate injury prevention strategies. This data has been collated from professional cyclists and it clearly shows a high rate of injuries in this population. To my knowledge, there is very little up to date research on injuries in amateur cyclists, therefore a lot of my blog will be based on my professional experience treating cycling injuries. However, I did come across a study from 2014 (Van der Valt et al.) which collected injury data from 3300 amateur cyclists and found that non-traumatic injuries were reported by 88% of the respondents! The areas of pain were neck 34%, back 41%, hand/wrist 41%, buttock/perineum 41%, hip 7%, knee 33% and foot/ankle 24%.

Over the next few weeks, our blog will focus on different overuse injuries that can occur in cyclists. We will discuss why injuries occur, how to avoid them and what to do if you are suffering. Today, we will start with knee pain which Van der Valt (2014) cited was the injury that was most responsible for the need to stop training in the largest percentage of respondents.

Knee pain is often cited as the most common injury seen in cyclists and is usually due to the highly repetitive motion of the knee flexing as the pedal goes round. A knee normally moves directly above the line of the toes as the pedal goes around which helps to generate the power through the leg and into the pedal. Poor bicycle set up or excessive sideways motion of the knee can accentuate the forces going through the joint and lead to inflammation, overuse or wear and tear on the various structures around the joint.

In cyclists, knee pain commonly affects the following structures and / or causes the following conditions:
  • Iliotibial band syndrome. A seat that is too high or too far back may lead to excessive strain on the ilio-tibial band which a strong fibrous structure that runs down the side of the thigh from the hip to the outside of the knee. 
  • Patella-femoral pain. This can be caused by increased stress between patella (knee-cap) and the femur (thigh bone). A seat that is too low can cause pain under or around the knee cap due to prolonged time spent pushing whilst too bent. 
  • Tendinopathy: This can occur in both the quadriceps tendon (above the knee) and the patellar tendon (below the knee). This is usually as a result of overuse (too much too soon), lack of strength training to prepare for cycling and incorrect bike set up. Again, if the saddle is too low you put the patellar and quadriceps tendon under increased strain. 
  • Medial knee pain: Amongst other conditions, Pes Anserine Bursitis may occur through overuse and / or wrong cleat rotation. The pes anserinus is an area on the front and inside of the shin bone and a bursa provides cushioning. 
  • Posterior knee pain: This can affect a range of different structures behind the knee, such as the popliteus tendon and the hamstring tendons. Saddle height, fore-aft position and cleat rotation may all contribute.
Tips to avoid knee pain: 
  • If you are new to cycling, or have just returned to the sport after the winter make sure your training is gradually introduced and well paced. Knee pain often occurs when cyclists are too ambitious and do too much too soon. Like with any sport, the muscular system needs time to adapt to new demands placed on the body and you should gradually increase you milage over a series of weeks. 
  • Strength and flexibility training is important in conjunction with cycling. In the lower limbs the gluteal muscles, quadriceps, adductors, hamstrings and the calf muscles are ares that must be kept strong and flexible. Like with any sport, cross training and varying your exercise / fitness routine is important in helping to prevent overuse injuries. 
  • Ensure your bike is well 'set-up' by a professional fitter. Mal-alignement can cause undue stress. Points to consider include: 
    • Saddle height and fore-aft position. Having the correct saddle height is one of the most important ways of reducing stress through the knees. The saddle may also need to be moved forward or backwards to create a good knee position over the pedal. 
    • Handlebar position - consider both height and width. 
    • Cleat position and rotation. If incorrect, this will increase rotational forces on the knee. Ideal cleat position may be very different for men and woman. Women tend to have larger hips, therefore the cleats will need to be adjusted to help maintain their legs in a more 'natural' alignment to minimise stress through the knees. This will often be by moving the cleats to the middle or even inside of the shoe.
    • September 2012, Top of Col d'Iseran.
      Rapid weather change in a short space of time.
    • Length of crank arm.
  • Weather and Attire: Do your research before you set off. I have supported bike rides where the weather at the bottom of the Col has been warm and pleasant, however the top of the Col has been a different story. It can be very difficult to plan effectively, however getting cold as you climb is a big factor in muscle strains and increasing tension through the knee joint.

How can physiotherapy help?

If you have knee pain during or after cycling, it is important to identify the cause. A physiotherapist will take a thorough history and will carry out a detailed assessment in order to get to the root of the problem. From there, a treatment program is tailored to a persons individual need.

If you have knee pain, rest from cycling until the cause has been identified. However, this doesn't mean doing nothing. Stretching (as long as this doesn't reproduce your symptoms), foam rolling and alternative exericse that doesn't exacerbate your symptoms are usually fine to continue with.

Physiotherapy may involve soft tissue release, taping techniques and biomechanical correction through education and exercises. If in doubt, please call for advise. Physiotherapy treatment will usually speed up recovery and get you back on your bike a lot quicker than an untreated injury.


Non-traumatic injury profile of amateur cyclists. A van der Walt, 1 MB ChB; D C Janse van Rensburg, 1 MD; L Fletcher, 2 PhD; C C Grant, 1 PhD; A J van der Walt, 3 FCP (SA).  South African Sports Medicine Association · November 2014

The purpose of this blog, is to provide general information and educational material relating to physiotherapy and injury management. Bonne Santé physiotherapy has made every effort to provide you with correct, up-to-date information. In using this blog, you agree that information is provided 'as is, as available', without warranty and that you use the information at your own risk. We recommend that you seek advise from a fitness or healthcare professional if you require further advice relating to exercise or medical issues. 
We recommend seeking advise from a healthcare or fitness professional when starting new exercises. 

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