How To Reduce Knee Pain Mountain Biking & Some Easy Fixes

Last week I was riding with a friend when he casually stated that his knee hurt. While knee pain is a common ailment of many mountain bikers, it should not be passively accepted as if it is a right of passage to ride a bike. This article explains some ways to reduce knee pain mountain biking plus a couple easy fixes for your next ride.

The best way to reduce knee pain is to first understand the cause of this pain. After nailing down the cause of the pain, the athlete can complete therapy, check the bike fit, and alter training strategies. Reducing knee pain on the mountain bike is primarily focused around maintaining proper body biomechanics and finding the correct bike fit.

• Causes of Knee Pain
• How to Treat General Knee Pain
• Is Knee Pain A Sign of Getting Stronger or of Injury?
• Some Knee Strengthening Exercises for Cycling

Causes of Knee Pain:

Knee pain is one of the most common injuries of cyclists. These injuries occur because cycling is a repetitive sport. In one hour of cycling, a cyclist’s knee will bend and straighten over 5,000 times. In a study of 500 recreational cyclists, 42% reported knee pain while riding.¹

Patellar Tendonitis:  The patellar tendon connects the bottom of the kneecap to the tibial tuberosity (or the bump toward the top of your shin bone).  The quadriceps muscles insert at the patellar tendon and allow the knee to straighten with each pedal stroke. This means that each pedal stroke places stress on this small rope-like tendon.

Mechanism of Injury: Patellar tendonitis generally occurs due to overuse. When repetitive stress is placed on the tendon, the tendon becomes inflamed and micro-tears occur which heal and result in micro-scars.²

Symptoms: Pain will occur at the bottom of the kneecap. The worst pain will occur when the knee is extended or when you are pushing down on the pedals. You will also experience pain when walking down stairs.² You may even be able to feel a thickening of the tendon or little tiny bumps forming throughout it.

Treatment: The best treatment for patellar tendonitis is rest. Unfortunately, endurance athletes are probably some of the hardest people on the planet to get to rest. Other treatments include ice and rehabilitation. The main stay of tendonitis treatment is eccentric exercise.

Another way to decrease tendon injury is through the use of cross-friction massage. Find the tendon that hurts and rub your fingers across the tendon (perpendicular to the direction they run) for anywhere from 1-15 minutes.³ This treatment may actually make the pain worse at first, but in the long run has been shown to enhance healing.²

For patellar tendonitis rehab, stand on a slight decline with your toes facing down the ramp. Stand on the injured leg and bend your leg a little bit, then place the other foot on the ground in order to assist you in standing back up to neutral.

Iliotibial Band Friction Syndrome:  The iliotibial (IT) band sits on the outside of the leg, beginning up toward the hip and ending just below the knee.  When the knee bends, the IT band must pass over a small bony prominence located on the femur (thigh bone). If the IT band is too tight, or it is forced to pass over the bony marker too many times, the IT band will become inflamed or worse, tear.

Mechanism of Injury: This injury occurs with repetitive bending and straightening of the knee which makes cycling the perfect storm for this injury. Excessive tightness of the IT band or weakness of the hips will predispose an individual for this condition.

Symptoms: Pain will be described on the outside of the knee when it is bent to or passed 30 degrees of flexion. It may also be described when touching or pressing on the IT band, especially as it passes by the knee.

Treatment:  Ice and rest will be important initial treatments of this condition. Hip strengthening such as glute bridges will help in the prevention of this condition, along with consistent stretching.

Patellofemoral Pain Syndrome:  Patellofemoral pain syndrome is a generalized term that is associated with knee pain and discomfort. This diagnosis can only be applied when other conditions have been ruled out.⁴

Mechanism of Injury: The mechanism for patellofemoral pain syndrome will vary across a long range of imbalances. The way in which is injury comes about is usually due to some sort of anatomical misalignment or muscular imbalance. These imbalances will need to be evaluated separately but can usually be adjusted with equipment or therapy.

Symptoms: The pain will be centered around the front of the knee. The pain will increase with sitting, climbing and descending stairs.⁴ You may experience some clicking when bending or straightening the leg.

Treatment: The treatment of this syndrome will need to be focused around muscular imbalances. One of the most common causes of this syndrome are weak abductors. Strengthening will involve completing more lateral movements such as side stepping with a band or completing the ‘clam shell’ exercise.

Get Some Help: While distinguishing the cause or diagnosis of your knee pain is a helpful element of determining how to treat your pain, not all of us are diagnosticians. There is a reason I went to school, got a degree in a health care profession, and had to pass a national board exam. It wasn’t so that people could Google the problem and come up with the same answer. If you are experiencing pain and it progresses or lasts longer than a week, I highly recommend seeking out a doctor, athletic trainer, or physiotherapist. Before that though, you can try these tips for treating general knee pain.

 How to Treat General Knee Pain:

Every knee condition is a little bit different, but the truth is, many chronic knee injuries will be treated similarly. Here are some ideas that will help (or at least not hurt) most chronic knee injuries that you come across.

Get Some Rest: When you first start having some knee pain, stop. Take a break. If you rest early and enough, you might just catch your injury before it becomes too serious.

Try taking three days off of the bike. I know that days off don’t sound fun, but your body will thank you and 3 days off at the beginning is less than 2 weeks that you might have to take off if your injury progresses.

If your injury starts to get better after 3 days off then try to slowly build back into riding. Don’t increase your ride time by more than 12% each week. If you don’t make any progress over those 3 days, then it might be time to seek some medical help for more advanced treatment.

Ice Your Injury: When you experience an injury, whether you see it or not, your body experiences some degree of inflammation. This inflammation impedes range of motion and can hinder your ability to restore normal activity.

The proper way to ice an injury is to ice for 15-20 minutes 3 times per day. Place ice cubes or crushed ice in a plastic zip lock bag. Then place a small washcloth over your knee and set the ice on top. Wrap the ice in place by using some sort of compression wrap.²

Another way to ice your injury is by freezing water in a paper cup. Once the water has frozen remove the cup from the freezer and tear back the cup until the ice is exposed.  Place the ice onto your skin and move the cup around the injured area. As the ice slowly melts away, you will be performing what is known as an ‘ice massage.’

Strengthening: Your knee is a modified hinge joint, meaning that it bends and extends as well as rotates. There are many muscles that cause these motions. In fact, more than 8 muscles cross the knee joint. It is important that all of these muscles (and more) are strong and work well in harmony. Keep reading for specific exercises.

Stretching:  When your muscles become overly tight, they can exert unnecessary force on their insertions and connections. Sometimes this tension can result in knee pain. For example, overly tight hamstrings or quadriceps muscles can pull at their insertions near the knee joint.

In addition to stretching, you can try foam rolling. When foam rolling, lay on the foam roller and breath in and then out. As you breath out sink a little bit deeper into the foam roller. Only move one or two inches at a time and pause when you find a particularly tender spot. Do not slide up and down on the foam roller. You are not kneading bread.

Heating: It is important to always ice an injury for the first 72 hours. After that, you can experiment with heat.  Heat allows for muscle relaxation, increases cell metabolism, and pulls blood to the heated area.  Try heating before a ride and icing after.

Is Knee Pain A Sign of Getting Stronger or of Injury?

 The knee is not a muscle. The knee itself does not grow stronger. The muscles surrounding it may become sore, but sore is not pain. You should not feel pain in your knees.

I hear people talk about living through and pushing through pain all of the time. I do not believe that life should be this way. Of course there is always an acceptation to the rule, however, generally speaking, pain should not be a part of life. If you are experiencing knee pain you should not train through it.

If you feel pain in your knees, seek professional medical help. Help certainly won’t hurt it more. Maybe the problem is simple and you can have relief with a quick fix, or maybe the problem is much more advanced and professional help is the only cure.

Some Knee Strengthening Exercises for Cycling

While the knee is not a muscle, the knee joint can be stabilized and supported by strengthening the muscles surrounding it and influencing it.

Clam Shell: The clam shell exercise helps to strengthen the gluteus medius muscle. This muscle is chronically weak in cyclists because cycling occurs only in one direction. The gluteus medius allows you to move from side to side.

When the gluteus medius is weak it will pull on your IT band for help, and the IT band will in turn pull on the insertion at the knee. If your knee collapses toward the frame while you ride, you most likely have a weak gluteus medius.

In order to complete the clam shell exercise, lay on your side and bend your knees to about 90 degrees with one leg on top of the other. Then with your feet still touching each other, pull your knees apart. For extra resistance add a Theraband around your legs. Complete about 3 sets of 8-12 repetitions.

Hamstring Curls on Swiss Ball: The hamstrings are three muscles on the back of the leg and all three cross the knee joint and influence the knee. It is important that the hamstrings and quadriceps work in harmony. Many people have strong quadriceps, but in comparison their hamstrings are weak.

Strengthen the hamstrings by laying on your back and placing your feet on a Swiss ball. Lift your glutes and back off of the ground so that your weight is on your shoulder blades. Curl your feet and the Swiss ball toward your glutes and then return back to the starting position. Complete 2-3 sets of 6-8 repetitions.

 Foam Roller Leg Extensions: The quadriceps are on the front of the legs, and all four muscles cross the knee joint. These muscles must work in unity with each other as well as with the other muscles on the legs. The quadriceps on the inside of the leg is called the vastus medius oblique. This muscle has been sighted to help assist with patellar tracking.

Place a foam roller on the ground and place your leg on top of the foam roller above the knee. Allow your heal to drop to the ground on the other side of the foam roller. Then use your quad muscles to lift your heal off of the ground while still keeping in contact with the foam roller. Hold this leg extended position for 2-3 seconds and compete about 2 sets of 10 repetitions.

 4 Easy Fixes to Try On Your Next Ride:

1.  Knee Warmers: Studies have shown that patients with osteoarthritis often perceive their pain as greater when the weather is colder.⁵ Osteoarthritis is the best documented condition that is influenced by weather, however, patients who have undergone various surgeries and with other conditions have also reported greater pain while exercising in cold conditions.

Your quick fix to try on your next ride is to simply wear knee warmers. See if a little bit of extra warmth can save you a little bit of pain, and if it does, that’s a pretty easy fix!

2.  Check Your Cleat Position: Flip over both of your shoes and see if your cleat position matches. Even the smallest difference can cause knee pain. If one cleat is different than the other and that is the knee that causes you pain, simply move the cleat to match the other shoe.

If you want a bonus on this tip, then seek out some shoe orthotics.  90% of people have a varus forefoot which complement pronation. In this position the foot collapses toward the pedal platform and the knee falls in toward the top tube.² Try shopping for a varus wedge which will place your knee in neutral by correcting your foot position.² 

3.  Increase Your Cadence: Too low of a cadence can increase the forces on the patellofemoral joint. You are relying heavily on your quadriceps muscles and are creating extra pull on your patellar tendon. Try to maintain a cadence around 90 RPMs throughout your ride and see if your knees thank you for it.

This quick fix is actually the reason that in road cycling, junior riders are forced to have “junior gearing.” Juniors are required to run easier gears. This isn’t to put juniors at a disadvantage; it is to protect developing knees. 

4.  Manage Your Seat Height: Before your next ride evaluate your seat height. A simple move with a multi-tool could make your knee pain disappear for good. Set your bike up on a stationary trainer and pedal for a couple of minutes to find your position on the bike. Then, pause with your foot at the bottom of the pedal stroke. Recruit someone else to measure the angle of your knee in this position. Your knee should be at 25-30 degrees in this position.¹

Too Low of a Saddle: Too low of a saddle causes extreme knee flexion at the top of your pedal stroke. This creates too much stress on the knee cap and can result in pain. Additionally, in this position the leg never straightens and there is a sensation that pressure builds up behind the kneecap.²

Too High of a Saddle:  Too high of a saddle not only makes your power output suffer but it also causes your leg to over straighten as if your leg is reaching for the pedal. In this position, the hamstrings stretch excessively. When the saddle is too high you will often feel pain in the back of your knee by your hamstrings.²

MTB Ride Pain Free

Knee pain is not a way of life and it is not a right of passage to being a mountain biker. If you are experiencing knee pain while trying to enjoy the pleasures of mountain biking, then try the treatments, exercises, and quick fixes described in this article. Give them a week or two to manifest in your body.

If you are still experiencing pain then employ one of the many people who have studied to help you. Doctors, physical therapists, athletic trainers, and professional bike fitters want to see you riding pain-free.

 References:

1. Asplund, Chat, and Patrick Pierre. “Knee Pain and Bicycling.” The Physician and

Sports Medicine, vol. 32, no. 4, Apr. 2004.

2. Pruitt, Andrew L., and Fred Matheny. Andy Pruitt’s Complete Medical Guide for

Cyclists. VeloPress, 2006.

3. Chamberlain, Gail J. “Cyriax’s Friction Massage: A Review.” Journal of Orthopaedic

& Sports Physical Therapy, vol. 4, no. 1, 1982, pp. 16–22., doi:10.2519/jospt.1982.4.1.16.

4. Starkey, Chad. Examination of Orthopedic and Athletic Injuries. F.A. Davis Co.,

2010.

5. Aikman, Helen. “The Association between Arthritis and the

Weather.” International Journal of Biometeorology, vol. 40, no. 4, 1997, pp. 192–199., doi:10.1007/s004840050041.