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  Latest update: 2/26/2022

Knee, Leg, and Hip Pain.

Cycling and Arthritis

Does cycling increase your arthritis risk?

Arthritis is used synonymously by many for joint pain, which from a medical perspective is a symptom in hundreds of diagnoses. The causes of joint pain can easily be divided into 2 distinct groupings.

Joint "wear and tear (trauma) from normal daily activities has been considered the reason for the most common arthritis seen with aging, osteoarthritis. The question at the moment is whether cycling increases the risk for osteoarthritis.

There is no evidence that moderate recreational or sports activities increase the risks of developing osteoarthritis of the knee or hip. The same is not the case for sports that would be expected to increase stress on the joints such as soccer, competitive weight lifting, and elite level running.

I could not find a single article commenting on cycling, which in itself marks it as a low risk activity.

On the contrary, cycling is often mentioned as an effective treatment for joint pain. I couldn't track down Dr. Mirkin's reference, but he states "...6500 women (followed) for 12 years showed that those who exercised regularly had far fewer complaints of joint pain than those who did not exercise or who exercised only a little bit."

This anecdotal comment from an orthopedic surgeon in Great Britain "..while professional cyclists regularly displayed signs of arthritis, it was only once they had retired from competition and reduced their levels of exercise that they tended to suffer the pain characteristic of the condition" emphasizes the point.

The take away is that there is no evidence to support the idea that you will be "wearing out" your joints by cycling. In fact cycling actually appears to be an overall health plus as it appears to protect us from the discomfort of the osteoarthritis 1 out of 10 of us will develop as we age.

What I found most interesting was current work indicating that it was a low level of ongoing inflammation of the joint lining that is the culprit in the development of osteoarthritis, a condition that has up to now been considered as purely the result of the wear and tear of aging. And the reason for that inflammation? Our diet may be the culprit. Here are a couple links for those that are interested.

Knee Pain

Knee pain is one of the most common overuse-type injuries in cyclists. In a survey of 109 professional cyclists, nearly a quarter (23%) reported having knee pain in the last 12 months. In recreational cyclists, the numbers are even worse. On a survey in California, 42% reported knee injuries, and a low level of cycling experience was associated with an increased prevalence.

It's the repetitive nature of pedaling that is the most common reason, especially when it is early in the season and you are pushing your training before the ligaments and tendons have had a chance to strengthen in response.

The most common cause of knee pain is patellofemoral pain syndrome or PFPS and hip pain is usually from iliotibial band (IT band) syndrome. However there is overlap and isolated knee pain can be from IT band syndrome as well. The IT band is a thick fibrous band of tissue, which runs on the outside of the leg from the hip to the knee. Pain is caused when the band becomes tight and rubs over the bony prominences of the hip (greater trochanter) and/or the knee (lateral epicondyle). Tight inflexible lower extremity muscles may worsen the condition.

As injury is generally a problem of overuse, it is often seen in the cyclist just beginning a training program or early in the training season when the temptation is to do too much too fast. In order to minimize knee and hip pain in the early season, take it easy for the first few weeks - pedal with low resistance and keep that cadence up at 80-90 rpm as you give your body time to adjust to your return to road riding.The same approach is recommended for any changes you might make in your position on the bike.

Minimize hard riding and hill work for the first few weeks of the season, and consider adding a stretching program for your lower extremities, especially for the gluteus and IT band as you make the early season to help transition.

Other common causes of knee pain are:

And finally don't forget about the low back as playing a role in leg pain - especially the back of the leg and hamstrings. All leg pain is not from problems "where it hurts".

Additional References

Q. I have a question about lower back and leg pain that I sometimes experience while riding. Sometimes when I am riding my legs will become so racked with pain that I can no longer pedal. I know I have lower back issues from years of heavy Olympic style weightlifting, but this is ridiculous. Sometimes I cannot climb even the smallest hills without stiffness and pain so bad that I almost black out. Any ideas? SG

A. A lot of leg pain is really back pain. So if you have a history of low back problems from the past, I'd start with a good massage therapist that deals with sports injuries combined with a program of back stretches.

Knee Pain - Location

One way to classify knee pain (and identify possible solutions) is to look at the location of the pain.

This is a nice summary article that provides additional thoughts on knee pain and its causes/treatments.

Saddle Adjustment

A simple seat height adjustment may ease the forces placed on the knee. If the seat is too low, stress is placed on the knee from the patellar and quadriceps tendons and is generally felt anteriorly below the patella where the tendon inserts on the tibia. If the seat is too high, pain may develop behind the knee.

There are several different ways to determine proper seat height. The easiest way is to allow one pedal to drop to the 6 o'clock position and observe the angle of the knee joint. There should be a 25-30 degree flexion in the knee when the pedal is at the bottom most point. Another is to measure your inseam (in centimeters) and multiply this measurement by 0.883. This should be your distance from the top of the seat to the center of the bottom bracket. If you place your heels on the pedals, have someone else hold the bike, and pedal backwards, your hips should not rock back and forth. Likewise if your hips rock when you are riding, lower your saddle until you achieve a smooth pedal stroke.

Seat fore/aft position and cleat position may also contribute to knee pain. Saddles that are too far back cause the cyclist to reach for the pedal and stretch the IT band with resultant knee pain. Saddle position can be evaluated with the "plumb bob technique". Seated with the pedal in the 3 o'clock position, a "plumb" hung from the most forward portion of the knee, should intersect the ball of the foot and the axle of the pedal.

Cleat Position

Thanks to Chad Asplund and Chris Carmichael ("The Ultimate Ride") for the following. These comments are meant for those using fixed cleats systems as the newer systems allowing internal and external rotation of the shoe,or "float" (such as the Speedplay system) have minimized cleats as the issue in knee pain.

Cleats that are too far internally rotated may cause increased stress to the IT band as it crosses the outside of the knee. This can be caused by a narrow stance width on the pedal (cleats too near the bottom bracket) and generally the toes will point in as you look down from above. The solution is to return the cleat to a more neutral position (let the toes point more fore/aft) and/or widen the stance on the pedal. Remember to make these adjustments in millimeters as a small movement on the cleat can translate into major changes at the knee and hip level. Rotational cleat position can also be evaluated by use of a commercial/bike shop "fit kit" or rotational adjustment device - this is more important for cleats with less than 5 degrees of float.

Medial knee pain can result from external rotation (toes pointing outward) and/or stance too wide on the pedals. As you might surmise, the remedy is to align cleat toward neutral with the toes more forward) and perhaps narrow the stance on the pedal (move the cleat towards to bottom bracket). Cleats should be positioned fore/aft so that the ball of your foot is directly over the axle of the pedal.

Relationship of Knees and Top Tube

Should My Knees Be Closer to the Top Tube? (excerpted from

Question: I recently rode with an experienced racer. He said my knees are too far out to the side as I pedal, and I would benefit from bringing them closer to the top tube. "Think of holding a ball between your knees," he said. I'm quite bowlegged (thanks Mom) so for me to make my knees touch the top tube is almost impossible. Should I work on keeping my knees closer to the frame? -- Randy S.

Answer: I see quite a few riders with knees splayed outward. This can be caused by anatomical characteristics or bad bike fit -- or a combination. Narrower knees are certainly better in terms of aerodynamics. Watching the Tour de France this summer, head-on camera shots made some riders look knock-kneed. But it's a common misconception that pedaling with knees nearly brushing the top tube increases power.

Knee position is determined by your anatomy. Ideally, your knees will be directly over the pedals. But if you're bowlegged, they will tend to be fairly far from the top tube. Trying to pull them in is likely to strain and ultimately injure ligaments and tendons. If you have had a professional bike fit , let your knees do what they want to do, naturally. That's the best way to avoid injury and produce the most power your body is capable of generating.


The knee joint is basically a ball-and-socket joint, with the ball at the bottom of the femur and the socket at the top of the shinbone or tibia (although a very shallow socket - unlike the hip joint for example). Protecting the front of the relatively unstable knee joint is a third bone, the patella, which is embedded in the quadriceps tendon and which slides in a shallow groove on the femur and tibia. A common cycling-related injury is called chondromalacia, and has to do with irritation of the cartilage behind the patella.

This is more commonly seen in women - perhaps because of the angling of the knee related to their wider pelvis. When asked "where does it hurt" the patient often cannot point with a single finger to a specific location but will classically move their palm over the entire anterior knee or patellar area. Another clue is that the knee will often hurt after prolonged flexion (the theater sign).

Chondromalacia is often blamed on lateral movement of the patella which may not "track" smoothly in the patellar groove as it moves. A common prescription to reduce discomfort is strengthening the quadriceps muscles which run along the front of the thigh and help to stabilize the kneecap and counteract or correct this mis-tracking which, with repeated knee bending causes irritation of the tissue behind the patella.

One exercise which will strengthen the quads and decrease this lateral movement is to sit in a chair holding one leg at a time out straight, unsupported. Sometimes it is suggested you place a pillow or other weight (such as a sock filled with pennies) on the extended foot. Making a conscious effort to avoid lateral knee movement during your pedal stroke (by watching your knees as you ride in a low-traffic setting)can help you retrain your pedal stroke. The knees should move up and down as you pedal, with no sidewards motion. Many cyclists have a sideways hitch in their pedaling motion, which may be a major contributor to chondromalacia. Two other suggestions:

Patellar Tendonitis

Tendonitis is inflammation of a tendon, usually from overuse. With repeated irritation and thus inflammation, scarring can occur. The tearing and resulting scarring increase friction as the tendon moves. As a result, the tendon might squeak like a rusty hinge or piece of dry leather when you bend your knee. This is called crepitus and reflects both the inflammation and the lack of normal lubrication of the tendon. The result is pain.

The patella is the kneecap. It's surrounded by the tendon structure itself, which connects the quadriceps muscle group to the tibia or lower leg. Your patella is a triangle. If you look down at it, the pain is usually centered on the lower tip (inferior pole) where it connects to the tendon. If the tendinitis is severe, you may get localized swelling. It might look like a little bump or nodule at the lower end of your patella.

You will feel pain in the front of the knee, below the patella, when you pedal or walk upstairs, and it will probably be even worse descending stairs. It also hurts when you palpate, or press, on the tendon itself. There may be some swelling.

Patellar tendonitis often appears after hard sprinting, big-gear climbing, or off-bike jumping activities. It also can flare up after hard leg presses or squats. Many times it is simply doing too much, too soon in your training program.

Treatment includes applying ice up to three times a day and a non-steroidal anti-inflammatory drug (NSAID) with food. Consider raising your saddle height if this is biking related, and pedal easily or stop riding for several days to allow the inflammation to quiet down.


If your cadence is too slow (less than 70 or so) you will put too much pressure on the knee with each revolution. And too fast (let's say > 110 ?), your biomechanics can get sloppy with poor knee cap tracking over the knee joint (a particlualr problem if you have chondromalacia). You can lessen the risk of pain from a high cadence with spinning practice at the gym, paying particular attention to developing a smooth, circular pedal rotation.

Individual Anatomy

(leg length discrepancies; flat feet)

Per Chad Asplund MD "individual cyclist anatomy may contribute to knee and hip pain. Cyclists with leg length discrepancies may develop knee pain as only one side is correctly fitted to the bicycle. This leads to increased stress inside the knee and hip joints on the improperly fitted side. Cyclists with flat feet may be more prone to excessive pronation (internal rotation) of the lower extremity causing greater stress on the IT band at the knee. Orthotics (anatomic shoe inserts crafted by podiatrists) may correct the alignment of the knee and decrease or prevent medial or lateral rotational stress on the connective tissue of the ankle, knee or hip, thus reducing the pain."

Almost everyone has a small leg-length inequality, but a difference of 1/8 inch (3 mm) or so shouldn't affect your cycling. When the difference is greater, however, it can open the door to a host of leg and back problems. The solution involves either cleat repositioning or, when the inequality is 6 mm or more, a shim under the cleat of the short leg.

Here's a quick way to get a ballpark idea as to whether you might have a problem.

Treatment of Knee Pain

Knee pain generally develops slowly over a number of days and is not an emergency. Immediate care is always available at a walk in clinics, but it is more productive to see your primary care physician or a sports medicine physician as the first step.

Dealing with yourself will be the biggest issue. Competitive athletes have a "fear of rest" - yet rest is probably the single most effective treatment. Peer pressure to continue to ride doesn't help when you are trying to do the right thing for yourself (and your knee).

For those interested, here here are additional articles on knee pain:

All questions and suggestions are appreciated and will be answered.

Cycling Performance Tips
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