Knee Pain After Cycling

author : AMSSM

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IT Band Friction Causing Knee Pain in Beginner

Member Question:
"I have just started in the past month trying to establish a base line of fitness to make my first attempt at a sprint and hopefully an Olympic triathlon in 2016. However, recently on my bike rides of about 10 - 14 miles, I experience pain the next day on the outside of my knee going down into my calf. It feels like it may be a tendon. Sometimes it is in both legs and sometimes just one. I'm not sure if this is just a sore muscle or if I am doing something incorrect that will lead to an injury. Any thoughts? Unfortunately I don't have clip in pedals, I just have pedals with cages on them. That may be the problem, but I'm trying my best to keep costs down at the moment."

Answer from Lee Kneer, MD
Member AMSSM

Pain in the lateral knee is common in those just beginning to ramp up their activity in sports that involve repetitive bending at the knee.  Given your description of symptoms and in the absence of any injury it sounds like you may be experiencing friction of the iliotibial (IT) band.

The IT band is a thick band of fascia originating in the pelvis. It travels along the outer thigh to attach on the lateral knee and acts as an important knee stabilizer.  Along its path, it courses over the lateral epicondyle of the femur, a small protrusion of bone just above the knee that can serve as a source of friction if the IT band is too tight. This can result in lateral knee pain that often radiates to the outside of the lower leg.  It predominantly affects runners but can present with any sport involving repetitive knee flexion and extension, including cycling, swimming, and even squatting.

Treatment of IT band friction syndrome involves a period of rest from activities that cause pain and a daily regimen of stretching and strengthening exercises aimed at increasing the functional length of the IT band and improving stability in the hip and knee. To treat successfully I typically recommend treatment with a physical therapist to obtain this home exercise program. The physical therapist will be able to evaluate your progress and adjust the stretching/strengthening regimen accordingly based on your sport-specific performance goals.

Treatment modalities such as ice, heat, and anti-inflammatories can augment your home program but should not be used alone.  I recommend a regimen of heating soft tissues before exercise (“warming up”) and icing afterward (“cooling down”) to facilitate recovery.  If pain persists despite adherence to the home exercise program, an ultrasound-guided corticosteroid injection may provide some relief though should never be the first line of treatment.  In rare cases a surgery to lengthen the IT band can be performed.

Prevention of IT band friction syndrome involves ensuring the strength of the lateral hip muscles, flexibility of the IT band, and elimination of other risk factors.  These include physical features such as a varus (“bowlegged”) knee alignment, overpronation of the foot, a foot arch that is either too high or low, and leg length discrepancies.  In addition, risk factors associated with training include an excessive “toe-in” cycling posture, running on cambered roads, and excessive hill work. In my clinic, however, the greatest training risk factor I see is an inappropriate increase in activity duration. In general, I recommend increasing weekly mileage by no more than ten percent.  In your case I would also suggest a formal gait analysis and bike fitting as well as investing in a clip-in pedal setup.

Iliotibial band friction is a common condition in beginning triathletes and can quickly derail your performance goals if untreated.  Fortunately, conservative treatment strategies and elimination of risk factors is usually successful in resolving symptoms and allowing for a return to full activity within several weeks.

Lee Kneer, MD
Emory Sports Medicine
Atlanta, GA

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date: January 30, 2016