What causes knee and body pain in the cyclist? How do you treat the knee non-surgically?

Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

People who contact us who happen to be cyclists or bikers typically contact us for many problems beyond the knee. This would include degenerative hip pain, degenerative shoulder pain, sciatica-like symptoms, calf and ankle pain, low back pain, and neck pain. Sometimes they have problems head to foot and tell us about their knee pain and inability to see behind them because they cannot turn their head all the way.

Many of these cyclist/bikers are also multi-sport, multi-athletes. They are tri-athletes, distance runners, swimmers, play tennis, play golf, martial artists, hikers, and basically are very competitive people. They also tell us about their medical history of multiple surgeries. They tell us about the multiple shoulders or hip surgeries to repair the labrum or other tears, decompression surgeries in the spine, surgeries on their knees. For some of these once super completive people, they are now limited to walking, when they can, and an understanding that they no longer can do what they once did and simply now want to cycle a bit. Worse for some is the weight gain.

For others, they continue to cycle using various remedies and self-help aids. The distances are shorter, the times are no longer measured, the goal is simply going as far as they can and getting back.

If you are reading this article you may see yourself in the above description. You want to stay on the bike or get back on the bike but after years of conservative care, knee braces, anti-inflammatories, rest (which you may have thought the toughest “remedy”), physical therapy, chiropractic care, and ultimately arthroscopy or minimally invasive surgery, you are now basically shut down or on your way to shutting down.

The many problems in the knee of the cyclist

This article will focus on knee pain in the cyclist with the understanding as pointed out above, knee pain in the cyclist is often one of many pain challenges the athlete’s faces and when treatments are concentrated on solely fixing one chronic problem you may not be solving the athlete’s multi-joint or whole-body problem.

This study is from June 2020 (1) and gives us a good overview of these diagnoses and the many problems the cyclist faces. What you will see in this study is that a simple chronic complaint of knee pain in the cyclist can be sub-divided into many different diagnoses.

The study begins with an understanding that the underlying cause of this type of knee pain is not well understood by doctors

The study begins with an understanding that the underlying cause of this type of knee pain is not well understood. It comes from knee instability but how does wear and tear cause knee instability in this group of patients? What is it that is breaking down first? Is it the tendons? The meniscus? The ligaments? What is it that is bringing the whole knee down? Here are the learning point observations. What we will suggest is that the knee is in a spontaneous breakdown, the whole knee is contributing to its own downfall.

• “Overuse injuries of the knee are a common cause of missed training and competition days in elite cyclists, however, the underlying conditions causing this knee pain are not well defined. (The researchers of this paper) conducted a diagnostic study, investigating a consecutive series of 53 high-level cyclists with non-traumatic knee pain over a 14 month period.
• The results of this study show seven different overuse injuries that can be identified. The seven are:
  • Prepatellar friction syndrome
  • Medial plica syndrome
  • Biceps femoris tendinopathy
  • Patellar tendinopathy
  • Infrapatellar plica friction syndrome
  • Infrapatellar fat pad impingement
  • Iliotibial band syndrome

Prepatellar friction syndrome

The researchers observed that: prepatellar friction syndrome accounted for the majority of these overuse injuries (46%).

• • Prepatellar friction syndrome is considered a knee pain that is unique to cyclists, particularly in long-distance cyclists. In 2015 it was discussed as a new clinical entity that may be overlooked. (2) In that study, the researchers wrote: “Although anterior (front of the knee) pain is extremely common in high-level road cyclists, the exact etiology (cause) still remains unclear.” Looking for an answer the researchers examined 28 professional male elite cyclists diagnosed with Prepatellar Friction Syndrome.
  • Ten of the 28 had a traumatic injury, 18 of the 28 cyclists had wear and tear degenerative conditions.
  • Conservative treatment delivered poor results and all cases were eventually treated surgically. Surgery confirmed macroscopic damage to at least one prepatellar fascial layer in all patients, after which partial fasciectomy was performed through a mini-incision.
  • For more information on patella disorders please see our article Treating Patellofemoral Pain Syndrome and chondromalacia patella.

Medial plica syndrome

Media plica syndrome is another form of anterior or front of the knee pain. While it may not a common diagnosis, it may be a more common problem than thought. In the research we are exploring, medial plica syndrome was seen in 15% of the elite cyclist group. Media plica syndrome is often seen in people who perform activities, like cycling, where the knee is bent and straighten frequently in creating the force of propulsion. Plica is a membrane that surrounds the knee and in simplest terms helps hold the synovial fluid in.

Biceps femoris tendinopathy

Your doctor may have discussed your knee issues in the context of a hamstring problem of a biceps femoris tendinopathy. This is tendinitis or inflammation of the biceps femoris tendon which is to the back and outside of your knee. Typically treatment would include rest, anti-inflammatories, and physical therapy recommendations. In the study, we are examining 7.5% of the elite cyclists who were diagnosed with biceps femoris tendinopathy.

Patellar tendinopathy

Patellar tendinopathy, like the other conditions we are discussing, can be a confusing issue. We do see many people who fall under the Patellar tendinopathy umbrella who are not quite sure what the diagnosis means.

• Patellar tendinitis is inflammation, pain, and swelling.
  • As discussed above this is one of the problems of knee swelling. Patellar tendinitis occurs, for instance, when a cyclist has knee pain after a ride.
• Patellar tendinosis is pain and weakness without inflammation.
  • This is a chronic degenerative condition.  If this cyclist has a history of cortisone shots in the patellar tendon or they take anti-inflammatories for a very long time, the tendinitis (pain and degenerative knee disease symptoms with inflammation) becomes tendinosis (pain and degenerative knee disease symptoms without inflammation).

In the study, we are examining 9.4% of the elite cyclists who were diagnosed with Patellar tendinopathy. We have a much more detailed discussion of this problem here in our article Patellar Tendinopathy surgery and treatment options.

Infrapatellar plica friction syndrome

Infrapatellar plica friction syndrome is another confusing diagnosis. It is a wear and tear syndrome that can impact the patella, the ligaments that hold the patella in place, and the bursa. As mentioned above, the plica is a thin membrane that surrounds the knee. Sometimes this condition is described as Synovial Plica Syndrome.

A paper in the Surgery Journal (3) helps us understand this diagnosis:

“Synovial plica syndrome occurs in the knee when an otherwise normal structure becomes a source of pain due to injury or overuse. Patients may present to general practitioners, physiotherapists, or surgeons with anterior knee pain with or without mechanical symptoms, and the diagnosis can sometimes be difficult. .  .Synovial Plica Syndrome of the knee is common . . . A diagnosis of Synovial Plica Syndrome should be suspected in patients with intermittent pain, swelling, and snapping sensation affecting the knees, which is associated with activity that involves increased loading of the patellofemoral joint. (Like cycling and the activities mentioned above). Nonoperative strategies are usually successful for early or mild disease, or where the advanced disease is associated with minimal symptoms. Conservative management requires good compliance from the patient but is often sufficient in reducing symptoms, which will not necessarily be recurrent. “

In the study, we are examining 7.5% of the elite cyclists who were diagnosed with infrapatellar plica friction syndrome.

Infrapatellar fat pad impingement 

Infrapatellar fat pad impingement or Hoffa’s syndrome is yet another confusing, misdiagnosed, or missed diagnosis that is causing pain in the front of the knee. The confusion is in the cause of knee inflammation which is often seen as synovitis. Sitting below and behind the knee cap is the Hoffa fat pad. It is often subjected to being squeezed and or impinged. The fat pad itself is very sensitive to pain because of the nerve endings within it.  As with any inflammation, first-line treatments would include anti-inflammatory medications and rest.

In the study, we are examining 5.7% of the elite cyclists who were diagnosed with infrapatellar fat pad impingement.

Iliotibial band syndrome

Iliotibial band syndrome was seen in 3.7% of the elite cyclists in this study. If you went to the doctor and told him/her that you did a lot of running, iliotibial band syndrome may be explained to you as “runner’s knee.” If you went to the doctor and told him/her that you did a lot of sports involving jumping, iliotibial band syndrome may be explained to you as “jumper’s knee.” For more information, we have a detailed article Iliotibial band friction syndrome – Sports-related knee pain that discusses treatment options and why some treatments did not help you.

So there is a common diagnosis. If you are like the patients we see at our center you will likely have a combination of these diagnoses and possibly problems related to the low back, hip, and ankle as well as shoulder and neck.

“Prevalence, clinical characteristics and severity of gradual onset injuries in cyclists are poorly documented”

Above is a quotation from a study in the journal Physical Therapy in Sport (4). To better understand overuse injuries in cyclists, the researchers examined data from almost 36,000 who entered the Cape Town Cycle Tour. What they found were areas that needed to be addressed in preventing and treating cycling wear and tear injuries.

More common anatomical regions affected by gradual onset injuries (wear and tear) were:

• lower limb (43.4%),
• knee (26.3%), The most common gradual onset injury was anterior knee pain (14.2%).
• upper limb (19.8%),
• shoulder (13%),
• lower back (11.5%).

Treatments

By this point, you have probably understood the prevailing message of this article. The problem with your knee is multi-factorial. It is typically not a single knee problem but a combination of knee problems leading to your knee pain. Your knee pain may be leading to problems in your hip or lower back, equally your hip and low back may be leading to problems in your knee. Your neck hurts possibly because of low back pain that is being generated by the knee.

Who are we seeing in this image?

Ross Hauser, MD an avid athlete who completed five Ironman triathlons – Ironman Coeur D’Alene in 2004, Ironman Canada in 2005, Ironman Florida in 2006, Ironman Arizona in 2007, and Lake Placid in 2008.

Chronic knee swelling, knee synovitis, and inflammation

We have a more detailed and extensive article titled: Treating chronic knee swelling, knee synovitis, and inflammation without anti-inflammatory medication. A summary of that article is presented here to address problems of chronic knee swelling.

A cyclist usually does not need to be examined by a medical professional to know that they have problems with knee inflammation. The cyclist will usually have a pre-and post-ride regiment to address the swelling before and after riding. Critical of course is pre-ride swelling because the knees have to bend. Compression is thought to be the key. The cyclist has many different types of knee braces, ace bandages, various tapes, and knee sleeves. They will also have various types of ice gel packs and plenty of ice for after the ride.

References:

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This article was updated April 26, 2021

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.