Knee ache is without doubt one of the most typical accidents skilled by cyclists, and it’s normally attributable to overuse, or, overload. The prevalence is comprehensible contemplating our sport entails a repetitive motion carried out over lengthy hours within the saddle.
A UK research in 2023 reported that 48% of cyclists had skilled knee ache in some unspecified time in the future, with 26.1% experiencing it prior to now month. Different research have proven yearly prevalence of 25.8% in a gaggle of aggressive and non-competitive cyclists, and 23% in a gaggle {of professional} cyclists.
Overuse accidents happen following repetitive loading, which – with out correct restoration – result in a power cycle of improperly healed inflammation. Because the knee is a hinge joint, which doesn’t function exterior of a single airplane, it may be topic to rotational stresses and torsion when caught between a foot, mounted to the pedal, and hip, mounted to the saddle.
Nicole
Nicole Oh is a Sydney born and skilled physiotherapist. Nicole’s curiosity has at all times been within the remedy of sports activities accidents, in addition to biomechanical assessments and sports activities harm rehabilitation. She has additionally accomplished coaching in acupuncture and medical pilates. As a aggressive highway racer herself, within the UK Nicole competed at nationwide degree.
Kinds of knee ache
There are 4 principal areas of knee ache:
- Anterior knee ache – ache on the entrance of the knee
- Posterior knee ache – ache in the back of the knee
- Medial knee ache – ache on the within of the knee
- Lateral knee ache – ache on the skin of the knee
To clarify all these knee ache, we’re going to have to make use of some extra medical phrases, which you’ll hear in case you go to a physiotherapist or skilled. Bear with me, we’ll get to options and proposals, quickly.
Ache on the entrance of the knee
Ache on the entrance of the knee could also be right down to incorrect monitoring
Anterior knee ache is by far the most typical, and the most typical reason for this ache is from the Patellofemoral joint. Different much less widespread sources of anterior knee ache are from the patella (or quads) tendon, fats pad or bursas over the knee.
Patellofemoral ache is commonly described as a obscure ache below or across the patella, which is felt throughout or after loading. There are few definitive medical checks, and scans will usually present minimal structural modifications.
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Throughout knee motion, the patella (knee cap) tracks alongside the femur (thigh bone) in what we name the ‘trochlea groove’. Patellofemoral ache happens when there’s a focus of strain on one space of the joint, which ends up in irritation and irritation of the comfortable tissues round it. That is usually because of – in layman’s phrases – incorrect monitoring of the patella and imbalanced forces appearing on the joint.
What causes incorrect monitoring? It’s normally weak point or poor activation of the VMO muscle – situated on the within of the quad – which serves to tug the patella medically and stabalise it within the trochlear groove; ache or swelling within the knee can even inhibit the VMO.
The knee dropping inwards below load – known as Dynamic knee valgus – can even trigger incorrect monitoring, by altering the alignment of the groove. This is because of a scarcity of rotation management at both the foot, or hip, or each.
Ache in the back of the knee
A saddle that’s too excessive is commonly the reason for ache behind the knee
(Picture credit score: Anna Marie Hughes)
Posterior knee ache is mostly the results of overload of the hamstring (or much less generally, calf) tendons the place they connect in the back of the knee, and the perpetrator may be very usually a saddle that’s too excessive, or set too far again, leading to overextension of the knee on the backside of the pedal stroke. The popliteus – a muscle operating behind the knee – can be a supply of posterior knee ache whether it is working too exhausting to manage rotation of the foot on the pedal.
Ache on the skin or within the knee
Lateral knee ache – on the skin of the knee – is mostly because of compression on the ITB insertion on the skin of the knee. It may be attributable to muscle imbalances across the hip, poor management of knee rotation, or inappropriate stance width and saddle place.
The principle perpetrator in medial knee ache – on the within of the knee – is bursitis or tendinopathy of the realm on the within of the knee the place the sartorius, gracilis and semimembranosus tendons connect, known as the pes anseurinus. That is additionally possible because of poor management of knee rotation and inappropriate stance width, ensuing within the knee dropping and rotating inwards excessively.
Causes of knee ache
Most cycling-related knee ache could be attributed to a mix of the next:
- Particular person anatomical or biomechanics elements
- Bike arrange
- Coaching load errors
We’ll have a look at every of those, independently.
Causes to do with the physique
Let’s begin with the bike owner themselves. Muscle imbalance, weak point and tightness are major elements.
Stretching, foam rolling and therapeutic massage may also help to relive tightness
(Picture credit score: Future)
As talked about beforehand, poor VMO activation and/or tightness or overactivity of the skin quad muscle and ITB can alter patella monitoring, rising load although one a part of the knee joint. If the glutes are usually not offering their justifiable share of energy manufacturing – both because of weak point or poor recruitment – this can improve demand on the quads and therefore stress on the patella which they connect to.
Muscle imbalance additionally has a job in ITB-related ache. Recruitment of TFL – a a lot smaller muscle alongside the outer thigh – over glute med to stabilise the hip can lead to extreme stress on the ITB, leading to ache on the exterior of the knee, or contributing to incorrect monitoring of the patella.
Workouts to assist recruit the glute muscular tissues could also be wanted
Weak spot in any of the muscle teams across the hip or knee can result in alterations in pedalling method when below excessive load or when fatigued. That is notably vital regarding the glutes and lateral stabilisers of the hip which management rotation of the knee. The identical could be stated for the muscle that stabilise the core and pelvis, which offer a secure base for environment friendly switch of energy to the pedals.
Muscle tightness can be problematic. Most cyclists’ quadriceps, hamstrings, glutes and hip flexors will tighten with extended driving as a result of repeated contraction and shortening of those muscle teams, which may improve forces on the knee.
Causes to do with the bike
Addressing your bike match will be the reply to knee ache when biking
(Picture credit score: Nicole Oh)
Nearly all points of motorcycle match can affect knee ache, nevertheless, widespread culprits are points with saddle top, cleat and foot alignment and stability, and crank size.
An inappropriate saddle top and setback will end in under-extension or over-extension of the knee on the backside of the pedal stroke. While an excessively low saddle can actually improve the load by means of the patellofemoral joint a saddle that’s too excessive is simply as more likely to trigger points on the knee joint. Any improve in seat top above optimum will create some type of instability of the foot on the pedal or pelvis on the saddle, difficult the rotation management of the knee.
A saddle that’s too excessive can create a toe down pedalling fashion with a battle to achieve the underside of the pedal stroke, which is a extra unstable place for the ankle joint and foot. Cleats which can be set too far ahead can even create this difficulty. The pelvis may additionally tilt (normally to at least one aspect) on the saddle whether it is too excessive. The leg will are inclined to fall into inner rotation on the downstroke.
Moreover, a saddle that’s too excessive will have an effect on the perform of the hamstrings. The hamstrings are required to manage knee extension on the backside of pedal stroke. A excessive saddle can improve pressure on the hamstrings as it’s pressured to work past its optimum vary leading to ache or harm. Alternatively, the hamstrings might disengage on the backside of the pedal stroke, shedding management of extension and loading the quads and patella.
Stability of the foot and alignment of the knee could be addressed by way of cleats and/or pedals. Ideally, we would like the hip, knee and foot to function in a straight line to scale back torsion forces on the knee. Because the foot is mounted, we have to align the foot with the knee, not the opposite means round, which is completed by putting the cleats to the within or exterior of the shoe to widen or slim stance width. Stance width can be elevated through the use of pedal spacers or becoming pedals with longer spindles.
Cleat arrange could make all of the distinction to biking knee ache
(Picture credit score: Future)
Cleats with some quantity of float will enable the toes and knees to work exterior of a set airplane of motion, versus mounted float cleats. The angle the cleat is about additionally must be thought-about. The foot doesn’t need to be working towards the sting of the cleat float in both route, and therefore the cleat might have to be angled barely heel in or heel out accordingly. Getting the precise cleat angle on a shoe will imply there’s much less reliance on float to maintain the foot, and knee, throughout the accessible vary, taking load off the popliteus.
Using wedges within the shoe or below the cleat could also be wanted to change the alignment of the foot, and therefore the knee, and optimise monitoring. Cleat shims can be utilized to appropriate leg size discrepancies if required, which may trigger asymmetrical loading on the bike.
A crank that’s too lengthy will improve the closed angle of the hip and knee joints on the high of the pedal stroke, with elevated compression of those joints presumably leading to ache. It might additionally trigger compensation methods resembling pelvic rocking and knee out-flaring. This difficulty is additional exacerbated if the rider additionally has restricted hip or knee flexion vary of movement.
Coaching load errors
Merely doing an excessive amount of, too quickly, can lead to knee ache
(Picture credit score: Future)
Inappropriate coaching load or coaching errors are a think about many overuse and overload accidents, not simply of the knee. It may be described as a coaching load that’s past the person’s capability, and might happen in a spread of conditions. Coaching load error can lead to ache and harm in itself, with none intrinsic (physique) and extrinsic (bike) contributing elements.
Overload is commonly related to a fast improve in quantity, depth, or frequency, particularly if elevated all of sudden; in different phrases, doing “an excessive amount of, too quickly”. This may very well be early on after adopting a brand new interest, or it might comply with a interval of lowered coaching or day without work coaching (eg. following an harm or sickness, or low season break), through which the physique has de-conditioned and might now not adapt to earlier coaching hundreds. Including an excessive amount of excessive depth coaching with a scarcity of base conditioning can be an element.
Making vital positional or gear modifications can improve stress on tissues, particularly if completed throughout a interval of excessive coaching load, when the physique is near its restrict of load tolerance already.
An extreme improve in muscular load, resembling pushing exhausting gears at low revolutions, for instance throughout lengthy climbs, can lead to patellofemoral ache. Any such driving can also be extra more likely to end in fatigue-induced modifications in pedalling method, resembling heel dropping and knee valgus, placing added stress on constructions on the again and sides of the knee.
Lastly, if the physique will not be allowed ample restoration, it could result in poor tissue restore and harm. This contains insufficient vitamin and sleep.
The best way to repair your knee ache
The very first thing to do is to find out what the injured construction is and the severity of the harm. A Physiotherapist with a data of biking will probably be in a position that will help you with this, in addition to information your rehab to make a full return to biking.
Foam rolling areas that are tight will assist get you on the highway to restoration
(Picture credit score: Future)
Relying on the issue, motion will have to be taken to alleviate ache, restore regular motion, and retrain muscle perform. This may occasionally contain releasing or stretching tight constructions such because the quads, TFL/hip flexors, hamstrings or glutes. Delicate tissue work, stretching, or dry needling are some methods used to do that, in addition to at dwelling stretches, foam rolling or set off level ball self-releases.
You’ll possible must retrain some muscle teams. For instance, the VMO (inside thigh muscle) and gluteus medius (aspect backside/hip muscle) are sometimes dysfunctional in individuals with knee ache. You might have to be taught tips on how to activate these muscular tissues, after which strengthen them. However it’s usually not simply the muscular tissues across the knee that have to be addressed; a number of the muscular tissues across the pelvis/hip, foot and trunk may have consideration as nicely.
Workouts that will help you recruit the glute muscular tissues will probably be on the menu
Unloading and relative relaxation is vital to forestall the harm from progressing, however this normally doesn’t imply it’s essential, or ought to, cease biking fully. Shorter distances, fewer hills, decrease gears, and relaxation days in between rides might allow you to keep up a level of conditioning with out aggravating your knee ache. Likelihood is, additionally, you will want to switch your coaching load, build up steadily and monitoring the response.
Changes to your bike match could also be wanted if it has not been arrange optimally within the first place. The bike can be adjusted to both quickly unload a construction or to accommodate a present weak point, resembling poor flexibility or motion management, then reviewed as the problem resolves. A complete bike match will deal with these points.
Lastly, it’s at all times useful to determine doable causes that might have contributed to the problem. This may embrace modifications to your bike, coaching, and even on a regular basis actions. Usually an consciousness of potential overload and early intervention can cease a niggle turning into an harm that retains you off your bike.
Knee ache rehab success story
Adjustments to the bike, coaching load and power and conditioning work all helped get Matt again on the bike, ache free
(Picture credit score: Nicole Oh)
A bike owner with an extended historical past of patellofemoral ache got here and noticed me in clinic, initially for a motorcycle match. We’ll name him Matt. Matthad skilled each left and proper knee ache since 2014, with the left just lately giving him extra hassle. MRI’s prior to now confirmed no structural abnormalities. He had had 3 earlier bike suits, the final being in 2021 when he bought his most up-to-date bike.
Throughout the bodily screening, I discovered that Matt had tight TFL, glute med weak point, decreased eccentric quads management, and decreased hip flexion ROM. On the bike, his saddle was toohigh and set again, the attain was too lengthy, the handlebars have been too excessive, creating inadequate drop, and he had asymmetrical knee monitoring. There was a suspicion that the bike might have really been too large for him.
We moved the saddle down by 20mm and ahead to the accessible restrict. We shortened the stem by 20mm and lowered it by 25mm. These modifications created much more stability of his toes and pelvis, and eradicated over-extension of the knee on the backside of the saddle stroke. We titled the saddle nostril down barely to permit for extra pelvis rotation and saddle consolation and facilitate hip hinge, then placedarus forefoot wedges in each sneakers to additional stabilise the toes. Ultimately, Matt ended up selecting to purchase a brand new (smaller) bike, at which level he shortened the crank size from 172.5 to 165mm, permitting extra room at high useless centre for his knees and stiff hips.
In addition to the bike match modifications, Matt additionally undertook a strengthening program, focussed primarily on progressively strengthening the VMO and quads muscular tissues. He had completed some earlier rehab work with a Physio final 12 months, which focussed primarily on gluts and core. He was additionally given some stretches and releases to do at dwelling for this TFL, glute med and lateral quads.
Coaching initially consisted of zone 2 work solely (monitored by an influence meter), build up quantity first. He then added threshold interval work 1-2 instances per week.
Matt has been in a position to construct again as much as 10 hours of coaching per week, together with lengthy rides and hill work, though he does often have a flare up of his patellofemoral ache, which is managed by means of load modification. Moreover, he’s feeling higher activation of his glute muscular tissues when driving.
