Understanding Knee Pain in Cycling and chondromalacia patella

This article originally appeared in the Capital Bicycle Club Newsletter November, 2012

You would think I’d be tired of writing about knee pain by now, but the truth is, it continues to be one of the most common reasons people come to my office for consultation, especially among cyclists. In general, knee pain is the most common area of complaint for cyclists in the lower extremity. Narrowing it down a little further, the anterior/front part of the knee is the location of highest involvement. For the rest of this article, I would like to focus on pain in this area of the knee that is caused by a condition called chondromalacia patella.

Background/Symptoms: Also called patellofemoral syndrome, the term chondromalacia patella itself means “bad cartilage” and describes the condition of the cartilage on the underside of the knee and/or on the surface that the patella glides along in the groove of the femur. Some of the symptoms include pain in the front of the knee, especially going up and down stairs, and while kneeling or squatting. Specific to cycling, is the potential for pain while pedaling or after long hard rides, climbing, or using low cadence & heavy gearing. Often, the cyclist suffering from this syndrome may continue to feel soreness in the knees on days after such rides. Some patients I’ve encountered will often refer to their knees as feeling stiff and hot. Another common symptom that is often associated with this condition is the sound of crackling/popping in the knees when they are bent and straightened Usually the sound is just loud enough to make a squeamish observer cringe…

Evaluation: Evaluating the knees often involves checking alignment and range of motion of the knees, and palpating to observe swelling. Also, muscles are tested around the joint, along with other tests as needed. X rays may also be useful in helping to determine if there is any degeneration to the knee, cartilage that has worn away, or other potential causes for the pain. In my office, I’m also particularly mindful of checking out other areas besides the knee. I like to evaluate the hip and lower back, as well as the calf and ankle. One of the more common things that I find is that the hips are very tight and that the deep muscles of the hip area are extremely sensitive to pressure. In fact, with very little pressure, this is one of the easiest areas to have someone jump with surprise at how tender their muscles are.

Cycling Focus: Some of the things to keep in mind when dealing with this syndrome are riding habits, training load, and equipment. Because of the repetition of cycling, bad habits can quickly amplify and cause problems. If you are accustomed to the feel of heavy gearing, it may take outside monitoring like a cadence meter to help you change this habit. When your symptoms are worse, try to keep your cadence above 80 rpm and stay on flat terrain while riding. This should help ease your pain. Another issue is training load. If you are piling on miles and steep terrain faster than your body can recover/adapt, there is potential for breakdown of the cartilage. As the cartilage becomes inflamed, it can begin to soften and wear grooves and pits that lead to the crackling sound you may hear. Regarding equipment, the anterior knee is the site of focus for incredible stress when the saddle is too high or too far forward. Proper bend in the knee is vital for maintaining good healthy knees in this sport.

Treatment: Common treatment strategies include temporarily decreasing how much and how hard you ride in order to diminish the stress on the joint. You can do this by using higher cadence and choosing flat terrain for riding until symptoms diminish. Other ways of getting the area to calm down may include ice and anti-inflammatory medications, but check with your doctor about this before doing so. I have found more long term success in dealing with hip dysfunction/weakness directly with stretching and strengthening exercises as a way of taking stress off the knees. Of course, making sure your equipment fits you is also extremely important as poor fit can undermine all of your other efforts. Repeated issues with this condition may warrant further imaging and consultation with a specialist.

It’s my hope that most people reading this article won’t need all the details included here, and find that a few simple changes can help your knees. For those of you who do need more, however, you can see that there are a lot of potential avenues for correcting this particular problem so you can enjoy cycling for years to come.