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, 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%).
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.
The knee’s toxic, inflammatory environment and the inability of anti-inflammatories to help
A knee that is constantly swelled is a knee in degenerative knee disease. As pointed out, eventually the swelling of the knee becomes so toxic it will be difficult to manage without the strongest of anti-inflammatories. When this happens, your knee is in a corrosive state where it is breaking down faster than your body can repair it. The inflammatory process is corrosive. This is why there is an urgency to shut down the inflammation to stop joint erosion.
Research: Patients do not know how bad their inflammation is, or how destructive it is to their knees.
In March 2019, doctors at Brigham and Women’s Hospital, Harvard Medical School, Boston University School of Medicine, Weil Cornell Medicine, and the Mayo Clinic released their findings that basically said, patients, do not know how bad their inflammation is. When a patient reports to the doctor that they have problems with swelling, the doctor should consider the problem worse than the patient is suggesting.
Listen to the learning points of the research published in the journal Arthritis Care & Research. (5)
- Synovitis is a prevalent feature in patients with knee osteoarthritis and meniscal tear and is associated with pain and cartilage damage.
- The researchers analyzed data from patients with knee pain and swelling. When these patients had an MRI, the MRI found much more swelling than the patients reported. The conclusion of this study urged doctors to use caution against using patient-reported swelling as a proxy of inflammation manifesting as effusion-synovitis. In other words, the swelling is worse than the patients think it is. Simply, the knee is worse than they think it is.
What does 18 months of continued inflammation do to your knee when you have a meniscus tear?
Early in January 2019, the same research team published in the journal Arthritis & Rheumatology (6) a study of 221 patients with knee osteoarthritis and meniscal tear. They examined these patients over a time period of 18 months.
- effusion-synovitis (swelling) was persistently minimal in 45.3% and persistently extensive in 21.3% of the patients.
- The remaining 33.5% of the patients had minimal synovitis on one occasion and extensive synovitis on the other.
- Patients with extensive effusion-synovitis at baseline (a lot of swelling) persistently extensive effusion-synovitis (continued extensive swelling) had a significantly increased risk of progression of cartilage damage depth. (A bigger hole in the cartilage or commonly the greater the risk of progression to “bone on bone,” within the 18 month study period).
These problems are getting worse DESPITE YEARS of medications.
When we see a patient in our clinic with knee swelling, we ask, “what have you been taking for this?”
Typically the first line of treatment will include the use of anti-inflammatory drugs. The list includes many familiar names, medications you may already be on as well.
- Most common : aspirin, ibuprofen (Motrin, Advil), naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
- Prescriptions: celecoxib, diclofenac indomethacin, oxaprozin (Daypro), piroxicam (Feldene)
You are told to have a cortisone injection
In our article Alternatives to Cortisone, we discuss some of this research which suggests cortisone leads to the greater need for knee or hip replacement.
Corticosteroid damaged knee cartilage and provided no significant pain relief after two years.
- “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide (a synthetic corticosteroid medication) every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?” Writing in the Journal of the American Medical Association, (JAMA) (7) doctors published their answer:
- “Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”
- In the International Journal of Clinical Rheumatology, (8) researchers wrote: “Corticosteroid therapy, as well as NSAIDs, can lead to the destruction of cartilage, suggesting that a positive effect on joint pain may also be associated with accelerated joint destruction, which is an extremely important factor in a chronic, long-term condition such as osteoarthritis.”
If you have a lot of swelling hyaluronic acid is really not going to help.
You have a lot of swelling and pressure in your knee because you have too much “water on the knee” or in reality too much synovial fluid. That is a simple explanation. Many people find relief when this fluid is drained. So will people find relief if more fluid is added? It seems counterproductive for knee pain relief. This is why there is a debate over the long-term effectiveness of hyaluronic acid injections for knee osteoarthritis. We are only going to present one study here, please see our article: Research and reviews of Hyaluronic injections for Knee Osteoarthritis for more on this topic.
Getting back to the question above – does injecting hyaluronic acid, putting more synovial type fluid in your knee, work when you already have an overabundance of this fluid? For some, the answer is yes it helps. For others, it does not help.
A January 2021 study in the medical journal Rheumatology (9) explains it. What the researchers in this study set out to do was to determine whether ultrasound-detected synovitis affects the therapeutic efficacy of hyaluronic acid injection for treating knee osteoarthritis.
- The 137 patients in this study received hyaluronic acid injection two times at 2-week intervals.
- Initially, all the patients were helped. However, the patients who had ultrasound detected suprapatellar effusion (knee swelling) had greatly reduced benefits from the injections.
To understand your inflammation is to understand that your knee is or has become unstable. But in is your unstable knee causing inflammation or is it inflammation causing your unstable knee? Something needs to get fixed.
Research is busy asking the question, what comes first, the inflammation or the degenerative knee disease? On the surface that seems pretty straightforward, inflammation and degeneration cause knee erosion. But not so fast –
Doctors at the University of Calgary, publishing in the medical journal Osteoarthritis and Cartilage, (10) suggest that knee joint instability leads to destructive alterations in the synovial membranes and cartilage. So in this research, the knee instability came first, then inflammation, then osteoarthritis.
Therefore to treat synovial inflammation – you must treat knee instability
Their research conclusion was that knee joint instability may promote an inflammatory intra-articular milieu (a diseased joint environment), thereby contributing to the development of osteoarthritis.
Getting rid of swelling and inflammation and degeneration requires a health professional familiar with using inflammation as a healing tool.
Above we said that a joint that lives in constant inflammation is a joint in a state of unrelenting erosion. Your knee is in a place where it is breaking down faster than your body can repair it. We are not just talking about a piece of the knee like it’s just the cartilage, or it is just a tendon, or it is just a ligament, it is the whole knee spontaneously degenerating. This is why your whole knee is swelled up.
The focus of our treatment is the strengthening and repair of the knee ligaments. Why is this our focus?
If you want to get rid of chronic knee swelling you must have a treatment that repairs the entire knee. The ligaments are the structures that hold the entire knee together. This means to help repair a meniscus, you must strengthen the ligaments. To heal cartilage damage, you must treat the ligaments. To prevent the recurrence of a Baker’s Cyst, you must treat the ligaments. To prevent continued knee degeneration from the destructive forces of osteoarthritis, you must treat the ligaments with a treatment that correctly turns off the inflammation in such a way that beneficial inflammation, the inflammation process that repairs, is left behind to heal the damage.
Everything in the knee affects the ligaments and the ligaments affect everything in the knee. Undetected micro ligament damage causes swelling
Ligaments function primarily to maintain smooth joint motion, restrain excessive joint displacement, and provide stability across the knee joint. When the forces to which ligaments are subjected are too great (acute injury or degenerative failure caused by ligament laxity), failure occurs, resulting in drastic changes in the structure and physiology of the joint. In your knee, it is causing a lot of swelling and functional instability.
Above we discussed research that suggested that the patient did not realize how bad their knee was and that is why they had chronic swelling. Knee instability and swelling can be caused by microdamage which causes instability that is not easily seen on MRI and is difficult to determine in a knee examination? Why because when the whole knee is in failure, it is hard to see the little things. Like micro-tearing of the knee ligaments. One thing is easy to see however, that is the result of micro ligament damage also referred to as ligament laxity.
Comprehensive Prolotherapy for problems of knee instability and wear and tear and bone on bone
Repetitive inflammation as an anti-inflammatory
Comprehensive Prolotherapy is an injection technique that uses a simple sugar, dextrose, and in some cases, it is combined with Platelet Rich Plasma Therapy (blood platelets) to address damage and micro-tearing of the ligaments or soft tissue in the knee. A series of injections are placed at the tender and weakened areas of the affected structures of the knee. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction.
The localized inflammation causes healing cells to arrive at the injured area and lay down new tissue, creating stronger ligaments and rebuilding soft tissue. As the ligaments tighten and the soft tissues heal, the knee structures function normally rather than subluxing and moving out of place. When the knee functions normally, the pain and swelling go away.
In published research in the Journal of Prolotherapy, we investigated the outcomes of patients receiving Prolotherapy treatment for unresolved, difficult-to-treat knee pain at a charity clinic in Illinois. Here are the bullet points of our research:
- The results of this retrospective, uncontrolled, observational study, show that Prolotherapy helps decrease pain and improve the quality of life of patients with unresolved knee pain.
- Decreases in pain, stiffness and crunching levels reached statistical significance with Prolotherapy.
- The percentage of patients with less knee pain was 95%, and 99% reported long-term improvements in stiffness after Prolotherapy.
- Eighty-six percent of patients decreased their need for additional pain therapies, including medication usage by 90% or more, after Prolotherapy.
- Eighty-two percent showed an improvement in sleep.
- For those with depression and anxiety, 86% were less depressed and 82% were less anxious.
- In regard to activities of daily living, Prolotherapy improved walking ability in 84%, athletic ability in 76%, and dependency on another person in 75% of patients treated.
- Of the patients treated with the Hackett-Hemwall technique of dextrose Prolotherapy, 95% felt an overall improvement in their quality of life.
- Ninety-four percent of patients noted their improvement in an overall disability has mostly continued since their last treatment.
Synovial fluid accumulated in the bursae around the knee joint
Doctors in Taiwan publishing their study in the medical journal Experimental Gerontology (11) examined the effects of Platelet Rich Plasma on synovial fluid volumes, protein concentrations, and severity of pain in patients with knee osteoarthritis. Here is their research summary:
- Patients with knee osteoarthritis are often complicated with joint soreness, swelling, weakness, and pain. These complaints are often caused by the excessive amount of synovial fluid accumulated in the bursae around the knee joint.
- They examined the effectiveness of platelet-rich plasma in treating patients with minor to moderate knee osteoarthritis combined with supra-patellar bursitis.
- Twenty-four elderly patients with minor to moderate knee osteoarthritis combined with supra-patellar bursitis were recruited.
- Aspiration of the synovial fluid was performed under ultrasound followed by subsequent PRP injections.
- Three monthly PRP injections were performed to the affected knees for a total of 3 months.
- Approximately after the 2nd PRP injection, significant decreases in synovial fluid total protein concentrations and volumes (signifying a decrease in inflammation), and Lequesne index values (this is a value given to measure the severity of knee osteoarthritis) were observed.
- Therefore, at least two monthly PRP injections may be beneficial for treating patients with minor to moderate knee osteoarthritis combined with supra-patellar bursitis.
Questions about our treatments?
If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated April 26, 2021