Medically reviewed by 
As a cyclist, you probably know that you should always listen to your knees and the messages they send when they’re not so happy. These messages show up as aches and pains, and if you experience them as a rider, you are far from alone. Knee pain affects about 15 to 33 percent of cyclists, according to a 2018 systematic review published in Open Access Journal of Sports Medicine.
Fortunately, the culprit is often an easy fix, but the first step is to identify what may be causing your knee pain in the first place. For example, you may be overtraining and pushing your body harder than it’s used to, straining your connective tissues and causing inflammation and pain.
Any spontaneous twinges of crank-stopping knee pain may feel like they come out of no where, when actually they’re just the first noticeable symptoms of a long-brewing problem. This generally stems from equipment and/or bike position issues, says bike-fit specialist Michael Veal of BikeDynamics in Warwickshire, England.
“Many cyclists are forever tinkering with their position, looking for that elusive perfect position,” he says. But what feels just right for a few pedal strokes around the block can end up feeling pretty wrong after 70 miles of roads. A good bike fit is essential for preventing most causes of knee pain.
If you’re looking to figure out what pain in different parts of the knee means, and for specific strategies to address your cycling knee pain, read on for all you need to know about aches in your knees.
Cycling Knee Pain Symptoms and Remedies
To help you figure out where to start, here are the most common types of cycling knee pain and the ways in which your bike fit may contribute to each symptom.
Pain in the Front of the Knee
If your knee hurts right on the cap (or patella), it’s typically because of your quads. The four quadricep muscles attach to the shin via the patella, and when you’re putting force into your pedal stroke, these muscles deliver force across the knee joint.
Very strong quads deliver a lot of force, but your bike set-up can help with this problem. Determine whether adjusting your saddle height, saddle fore and aft, and/or crank length could alleviate the issue. Working with a professional bike fitter can be extremely helpful in addressing this type of knee pain.
“A saddle that is too low will keep your knee angle too tight at the top of the stroke, which increases the shear forces pulling the patella against the femur, which in turn increases the likelihood of tendonitis and harmful stresses in the cartilage behind the kneecap,” Veal says. “Likewise when the cranks are too long for your leg length, the knee joint is also too tight at the top of the stroke.”
How low is too low for a saddle? “For a quick reference to check if your saddle is the right height, have a seat and rest your heel on the pedal with the pedal in the 6 o’clock position,” says fit specialist and physical therapist Sara Bresnick, founder of Pedal Power Training Solutions in Medford, Massachusetts. “The knee of that leg should be straight. That equates to a 20- to 25-degree knee bend when clipped in.”
Riding with your saddle too far forward also can cause knee pain in the front, says Veal. “Your saddle should be positioned so the tibial tuberosity—or the bony bit below the kneecap—is directly above the ball of the foot, which in turn should be above the pedal spindle,” she says.
Also, be mindful of your form. Big-gear mashing, climbing in monster gears, and hard sprinting (especially if you’re not conditioned for it) can put undue stress on the knee and cause this type of pain.
If you do achieve a solid bike fit and avoid these common mistakes, and pain still persists, focus on stretching the quads to find relief.
Pain in the Back of the Knee
Pain behind the knee is less common than pain in the front, and is generally easier to trace back to a culprit: over-extending the knee, says Bresnick. Your saddle is too high or too far back. “Try lowering the saddle a bit or moving it forward a bit in relation to the handlebars,” she says.
This pain is also more common among cyclists who spend a lot of time on fixed-gear bikes; When you ride fixed, you use your hamstrings to decelerate your pedal stroke, which can put the biceps femoris tendon (a hamstring muscle that runs down the back of your leg toward the outside of your knee) under too much load and irritate it. Giving your legs a break with some freewheeling now and then can also help.
If pain sticks around after making bike adjustments, try stretching the hamstrings regularly and avoid frequent out-of-saddle riding.
Pain on the Inside of the Knee
When you feel pain on the inner (or medial sides) of your knees, look down at your feet: Improper cleat placement is often a culprit, says Veal. Your cleat position affects your Q-factor, which dictates how far apart your feet are laterally when pedaling.
Ideally, the spacing should be that the loads from your knees to your pedals are traveling vertically without pushing the knee inward or outward, which stresses the ligaments on either side of your knee and can lead to pain.
Cleats positioned too close to the insides of your cycling shoes increase the distance between your feet, which can stress the inside collateral ligaments and cause pain in the inner (or medial) sides of your knees.
Too much float in your pedals also can cause medial knee pain. A little float—about 4.5 degrees—is all you need to be comfortable and keep your knees from getting stressed.
While a professional can help you adjust cleat positioning, you can also have someone take a slow-motion video you riding on a trainer, recording movement from the front of the bike. Look for asymmetry between your left and right side.
If you still feel pain on the inside of your knee after aligning your cleats, especially if it is a burning pain at rest or sharp pain when you start to walk or step up or down, you may have a type of bursitis. This pain typically improves with a warmup and stretching of the hip flexors and adductors (inner thighs).
Pain on the Outside of the Knee
Pain on the outer (or lateral) sides of the knees is often caused by iliotibial (IT) band syndrome—a stabbing pain that happens when the IT band (a fibrous connective tissue band that runs from the hip along the thigh to the tibia) becomes stressed and inflamed.
IT band issues can appear to come out of nowhere, and hurt most when the knee is at 20- to 30-degrees of flexion, like when you approach the 6 o’clock position and start to come back up.
“Misaligned cleats that cause the foot to be excessively toed in can cause this,” says Veal. So can cleats that are placed too far to the outsides of the shoes, causing too narrow of a stance on the bike.
If you think the cleats on your bike are misaligned, take your bike in for an adjustment. (A slow-mo video of you riding from the front can also help you see if your cleat positioning is to blame!)
How to Prevent Cycling Knee Pain
Of course, what you do on your bike will also go a long way to promoting or alleviating knee pain. Here are some tips to assure it’s the latter.
Warm Up
Just as with most sports, a little warmup to get blood flowing and muscles primed is a good idea—so don’t skip it! As a general rule, aim for at least 15 minutes of moderate spinning before you attack the local climb or go hard on the flats.
Focus on Pedal Stroke
Look at video of the pros in action, and you’ll notice their rapid and fluid pedal strokes. Try this drill to improve your pedal stroke: The next time you are going up your favorite climb, use a gear at least two teeth lower (thus easier) than usual. This higher cadence is easier on your joints. Think about making round circles as you pedal, not ovals.
Build Mileage Gradually
Your first ride back after any extended amount of time off shouldn’t be five hours long. Instead, start with a lower mileage and build slowly.
Beware of Change
Your body likes consistency, so when you alter equipment, your knees often protest. Whether you get a new bike, new shoes, new pedals, or change stem length, go easy at first to give yourself time to adapt.
Stay Warm
Riding in 40-degree weather with red, chapped knees is a recipe for trouble. Pros routinely cover their legs in training when the temperature is below 60 degrees—that’s why knee warmers exist!
While each individual’s tolerance will differ, there’s certainly no harm in keeping muscles and joints warm. By using warmers, you can easily slip them off mid-ride if you start to warm up.
Take note of what gear works best in certain weather conditions, so you can repeat on future rides.
Get a Bike Fit
If knee pain persists, consider getting a professional bike fit. And no, we’re not talking about when a salesperson sets your seat height at purchase.
A professional bike fit should be an in-depth experience with a professionally trained fitter that includes an interview process, off-bike flexibility testing, and on-bike measurements and adjustments. Yes, it’s an investment (usually at least $200), but it’s worth it to ride pain-free. It could end up being the best money you ever spent on your cycling habit.
Fix Muscle Imbalances
If you’re still experiencing cycling knee pain after doing everything mentioned above, including a professional bike fit, it may be caused by muscle imbalances instead—like weak glutes, hips, or core. It’s best to consult with a sports medicine physician and/or physical therapist to find the right course of treatment for you.
John Vasudevan, M.D. is an associate professor at the University of Pennsylvania. He is board-certified in Physical Medicine & Rehabilitation and Sports Medicine. He is a Team Physician for UPenn Athletics and medical director of the Broad Street Run and Philadelphia Distance Run, and previously for the Rock 'n' Roll Half-Marathon and Tri-Rock Triathlon in Philadelphia. He is a director of the running and endurance Sports Medicine Program at Penn Medicine. Dr. Vasudevan provides non-operative management of musculoskeletal conditions affecting athletes and active individuals of all levels, and combines injury rehabilitation with injury prevention. He utilizes a variety of ultrasound-guided procedures and regenerative approaches such as platelet-rich plasma and percutaneous ultrasonic tenotomy. He sees patients at the Penn Medicine and the Philadelphia Veterans Administration hospital. Dr. Vasudevan attended medical school at the University of Wisconsin School of Medicine and Public Health in Madison. After his Transitional Year in Tucson, Arizona, he went to residency in PM&R at Thomas Jefferson University in Philadelphia and onwards to Stanford University for his fellowship in Sports Medicine. He has been in practice at the University of Pennsylvania since 2012.
