Managing Anterior Knee Pain
Most cyclists have experienced knee pain at some point while riding. For some, this pain may be due to an existing injury or trauma, such as a fall or crash. However, anterior knee pain (pain in the front of the knee) often arises without any specific injury. Riders might describe pain above, below, or even beneath the kneecap, which can worsen during rides and sometimes lead to discomfort off the bike. So, what are the common causes of pain in this area, and how can we manage them? Let’s take a look!
The anterior aspect of the knee is dominated by the patella, or kneecap. The patella is embedded in the tendon that connects the quadriceps muscle to the tibia (shinbone) and acts as a fulcrum to improve the muscle's angle of pull over the knee joint. The patella is often the first area where pain can develop. As the knee flexes and extends, the patella needs to move up and down over the femur. Ideally, this patellofemoral joint glides smoothly due to the cartilage on the surfaces of both bones; however, problems can arise. Due to the position of the joint, age-related or genetic variations in the joint surface, or muscle strength and tightness, the patellofemoral joint can become painful when the two surfaces no longer glide smoothly over one another. Pain in the patellofemoral joint is often described as dull with intermittent sharp pain when extending or fully flexing the knee, as well as pain "under" or "deep" in the knee.
In addition to the patella itself, the quadriceps tendon attaches the quadriceps muscles to the top of the patella, and the patellar ligament attaches the patella to the tibia. These structures can also cause pain, which tends to be localized, sharp, and worsened with knee extension, especially under load. Quadriceps or patellar tendinitis is often most noticeable for cyclists during the initial part of a ride and can sometimes lessen while riding, only to worsen again when off the bike. In some cases, pain can also affect off-bike activities, such as squatting or managing stairs.
The other structures that cyclists might encounter causing issues are the knee bursae. The bursae around the knee are small, fluid-filled sacs that act as cushions between bones and soft tissues, reducing friction and facilitating smooth movement. Bursitis occurs when one or more of these bursae become inflamed, leading to pain, swelling, and reduced mobility. Bursitis pain is often described as a dull, aching discomfort that worsens with movement and pressure. This is different from tendinitis, which typically presents as sharp, localized pain. Bursitis can be caused by repetitive stress or excessive pressure on the knee, which is common in cycling due to pedaling at cadences of 60-120 rpm over multiple hours.
So, what can a cyclist do to manage these pains? Here are some starting points:
**Proper Bike Fit:** Anterior knee pain is often blamed on a saddle height that is too low, leading to a flexed knee that increases strain on the structures discussed above. Additionally, a seat that is too far forward can cause similar excess flexion, and improperly aligned cleats can also place strain on the anterior knee. Cleats, in particular, should be adjusted to the rider's unique lower extremity anatomy to avoid excessive rotation.
**Strengthening Exercises:** Tendinitis in the anterior knee is often caused in part by a mismatch between demand and strength or tissue resilience. Repetitive pedaling, especially at high efforts such as climbing or "big ring" riding, can irritate the tendons if they are not conditioned for such effort. Strength training is the best way to improve tissue resilience and minimize the risk of injury. Additional benefits of strengthening include better neuromotor control, which can aid in improving pedaling form.
**Stretching and Flexibility:** Maintaining flexibility around the knee, particularly in the quads, can reduce excess strain on structures at risk for overuse. Stretching can be done before or after cycling, or even as a standalone exercise. The most important aspect is consistency.
**When to Seek Professional Help**
If you adjust your bike fit and ramp up your stretching and strengthening routines but the knee pain persists, it might be time to consult a professional. When seeking out a provider, look for someone knowledgeable about not just the condition you are dealing with, but also the activity you want to return to. Physical therapists, orthopedists, physiatrists, or rehab-minded chiropractors can all be good first steps for managing knee pain.
Typical approaches include first-line conservative measures such as physical therapy, which often involves manual therapy and individualized exercise prescriptions. Be cautious of providers who recommend invasive or costly procedures right away. While sometimes necessary, most cases resolve with less invasive methods, and it’s beneficial to get second opinions before committing to treatments that may have adverse side effects.
In summary, if you’re dealing with anterior knee pain while cycling, there are several potential causes and solutions. With minor adjustments to bike fitting and exercise routines, most issues can be resolved. Persistent problems are best managed by health professionals familiar with cycling injuries.
If you or someone you know is experiencing anterior knee pain while riding, reach out to Cycle Life PT for a free virtual consult to start on the path to pain-free riding.
