Knee Pain & Cycling – Why It Happens and How a Physio With Bike Fit Knowledge Can Help

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Knee pain is one of the most common reasons cyclists present to the clinic. Unlike acute crashes or traumatic injuries, knee issues on the bike usually creep in quietly, a niggle after longer rides, discomfort on hills, or pain that only appears once training volume increases. Left unchecked, these symptoms can quickly become ride-limiting.

The knee sits at the centre of the cycling movement, transferring force between the hip and the foot thousands of times per ride. Small changes in bike setup or movement patterns can significantly alter how load is distributed through the joint.

Common Knee Issues in Cyclists

Cycling-related knee pain can present in a few key ways, depending on how and where load is being absorbed:

  • Anterior knee pain (around or behind the kneecap), often linked to excessive compressive load

  • Patellofemoral irritation, commonly aggravated by higher gears, climbing, or sustained efforts

  • Medial or lateral knee pain, sometimes related to alignment or tracking issues

  • Tendon-related pain, particularly through the patellar or quadriceps tendon in higher-volume riders

These issues are rarely caused by one bad ride. More often, they develop gradually as training load increases or bike position no longer matches the rider’s current capacity.

Bike Fit Factors That Commonly Contribute

From a bike fitting perspective, knee pain is often influenced by how efficiently force is transferred through the pedal stroke. Common contributing factors include:

  • Saddle height too low, increasing compressive forces at the knee

  • Saddle height too high, leading to excessive knee extension and altered tracking

  • Cleat position too far forward or rotated, changing lever arms and knee alignment

  • Crank length mismatched to rider mobility, increasing joint stress at the top or bottom of the stroke

  • Stance width or foot position issues, subtly altering how the knee tracks under load

Because cycling is such a repetitive activity, even small setup changes can have a big cumulative effect over time.

How a Physio With Bike Fit Knowledge Can Help

A physio with bike fitting experience looks beyond angles and measurements alone. The focus is on how your body moves on the bike and how load is being managed through the knee across the entire pedal cycle.

This may involve:

  • Assessing knee tracking, hip control, and foot stability

  • Advice on adjusting saddle height, cleat position, or stance width to optimise load distribution

  • Identifying movement compensations of the bike that increase stress at the knee

  • Reviewing training load and recent changes that may have triggered symptoms

The aim isn’t just to reduce pain, but to create a setup that supports sustainable riding as volume or intensity increases.

Preventing Recurrence: Strength, Control & Load Management

As with lower back pain, bike fit is only part of the solution. The knee relies heavily on the capacity of the hip, trunk, and lower limb to control load efficiently.

A physio will focus on:

  • Improving hip and gluteal strength to support knee alignment

  • Addressing foot and ankle control where relevant

  • Building tolerance to sustained cycling loads

  • Modifying training progression to allow tissues time to adapt

When bike setup and physical capacity are addressed together, cyclists often find not only that knee pain settles, but that pedalling feels smoother, stronger, and more efficient.

Happy Riding!

Seb Hardy