There is no doubt that the definition of an ‘average’ bike rider is changing. Bike riding is no longer the domain of wiry late-teen/early-twenties whippets, supplementing their 700km per week ‘habit’ with 20 hours working in a bike shop, and the rest of the time either on the massage table or asleep! While that rider still exists, lately cycling has become the go-to for those of more mature years, seeking improved health, a social outlet, some competitive opportunities, and access to nice pieces of trinketry and shiny widgets. Yes it seems a cliché nowadays, but I can confirm that the average demographic of the cyclists that we consult would have otherwise turned to golf had they not chosen to get out on their (expensive) bike. Which is impressive given a large proportion of these riders are notching up in excess of 300km per week on Strava.
What has also changed is the type of event that the average cyclist would participate in. Keen bike riders no longer rely purely on their local club to provide an outlet for their competitive whims, and mass-participation events such as the Spring Cycle or Sydney to Gong Ride, are no longer counted as a true test of a ‘real cyclist’s’ endurance. At the time of writing, a large portion of our daily work this week has been helping iron out kinks in bodies preparing for the 3 Peaks Challenge – 235km of mountainous terrain which must be completed in less than 13 hours. What adds a level of complication to this work is that many, if not the majority of the riders, have only gotten into regular cycling in the past two years.
With the change in rider demographic and event, so too comes a change in the type of injury we see in the clinic. This week has seen a handful of riders complaining of pain on the outside of their knee. These riders usually come armed with a Dr Google self-diagnosis of, ‘it’s my ITB’.
Given the repetitive nature of cycling (a two-hour ride at 90RPM requires 10,800 knee bends per knee), over-use injuries can occur due to a combination of biomechanical issues (inefficiencies in the body), external forces (how the bike is ‘positioned’), and training overload (‘too much, too soon’).
The ITB is a fibrous band running down the outside of the thigh, from the pelvis to the outside of the leg below the knee. The band essentially operates as the tendon of the tensor fascia lata and gluteus maximus muscles (the two most superficial buttock and outside-hip muscles), attaching these muscles to the outside of the tibia (shin) bone. In isolation, these structures are used to lift the leg out to the side when standing (or one leg off the other when lying); however when combined with the remainder of your leg muscles when standing, walking, running, jumping or pushing a pedal, the muscles and their tendon (the ITB) are used to assist in stabilising the pelvis and secondarily, to control the movement of the knee inwards and outwards.
The problem area for the tendon exists where it passes across the outside of the knee (the lateral femoral condyle). When the ITB is placed under load by the TFL and gluteus maximus muscle, there is a certain amount of friction where it passes across the bony prominence on the outside of the femur (thigh bone) just above the knee, even in a healthy, pain-free knee. Iliotibial Band Friction Syndrome (ITBFS) is significant inflammation eventually causing pain when this tension and load is too great, combined with the tendon passing across the lateral femoral condyle too often.
So what causes there to be too much tension and load in the ITB? It is a mistake to think of the ITB being a contractile structure – i.e. ‘my ITB is tight/short’ (causing pain), and when it is not painful it is ‘long/relaxed’. By definition, a tendon attaches muscle onto bone – it is in essence an inert structure at the mercy of the muscles pulling on it. Our experience in dealing with ITB issues multiple times per day suggests that overactivity of your TFL and gluteus maximus, especially at times of physical activity, tends to result from a rider under-using their deep gluteal muscles to stabilise the pelvis. The responsibility then falls upon the TFL and Glut Max to become the primary pelvis stabilisers, significantly increasing tension in the ITB.
What is the relevance of the change in our ‘average’ rider demographic? The reason that most of our clients find it difficult to engage the ‘correct’ muscle group at the right time to stabilise the pelvis is because they sit on them all day! The changing nature of (a) modern work practices, and (b) the advancing age of the ‘average’ cyclist means they have spent a fair amount of their life sitting on their gluteals, which makes them more inclined to overuse their hip flexors, quadriceps, and lateral hip muscles (ITB and gluteus maximus) to stabilise the pelvis – all putting their knees under duress. This means that a management program to address ITB issues is actually a process of reversing the demands of sedentary work postures.
Following is an example of a couple of simple at desk and pre-ride management exercises we implement for riders to prevent as well as attend to ITB issues. Our intention is to reduce tension in, and overactivity of the thigh and outside hip muscles as a consequence of sitting; and activate the deep gluteals (again as a consequence of sitting) before riding. This combination should reduce tension through the ITB whilst riding.
Another reason for the ITB being placed under excessive tension comes from outside of the body – how your bike is set up.
There are two common areas of concern we would look at when assessing the riding position of a rider with ITB issues: the cleat position and the saddle position.
One of the body’s primal functions is self preservation, meaning that subconsciously your body will find its preferred position when allowed. This will generate an abundance of debate in bike fitting and biomechanical circles, however our stance on foot position (and therefore knee position when viewed front-on), is that a ‘natural’ stance will be significantly safer than trying to establish a ‘neutral’ stance. Please contact me directly if you wish to discuss further. Cleat manufacturers are kind enough to provide models allowing for ‘float’ – movement of the heel in and out, allowing for your foot to find its preferred ‘natural’ stance. Whilst pedalling, it is ideal for your foot to settle somewhere inside this float without abutting either limit (figure below).
Tension through the ITB whilst riding occurs when the rider’s heel is pushing against the inside-limit of the cleat float, i.e. the heel is not able to travel closer to the crank arm/all of the cleat float is away from the crank arm.
A simple off-the-bike test is to view the leading edges of the cleat; if there is undue wear on the border of the cleat float on the little-toe side, it is likely that it needs to be adjusted on the shoe (figure below). If this is the case, loosen the cleat screws and rotate the front of the cleat towards the big toe; in Speedplay cleats, release the ‘heel in’ screw.
Note: wear and tear can occur on the big-toe edge of the ‘float’ leading-edge due to the action of clipping out of the pedal when stopping)
Given the highly repetitive nature of the demands of cycling, and the opportunity cost of time off the bike (both psychologically and physically) the guidance of an experienced, qualified bike fitter (ideally who hails from a health profession background) would be advised for this process.
If a rider has to reach excessively with the leg through the front of the pedal stroke (Figure 1), and/or the bottom of the pedal stroke (Figure 2), they will be placing additional tension through all of their leg muscles, including the TFL/Glut Max/ITB complex (indicated below in green and blue). Performed repetitively on a longer ride, this additional tension through the ITB will cause excessive inflammation and therefore pain across the outside of the knee. A rider will be able to feel this undue inflammation as a clicking across the outside bony prominence of the knee (femoral condyle) whilst pedalling.
The combination of a large reach to the front end of the bike (as in both figures, indicated in yellow) will also increase tension and load in the muscles described.
In these instances, we would suggest the rider bring the saddle forward to reduce reaching out and forwards through the pedal stroke, therefore unloading the hip and knee muscles. However care must be taken to ensure there is not too much resultant knee-bending through the front and top of the stroke, so again consulting a bike fitter would be advised. In addition, this will reduce reach and therefore effort to get to the front end of the bike; installation of a shorter stem for a period may also assist.
The final significant causative factor of any overuse injury is people’s tendency towards doing too much, too soon. We are expecting an influx of phone calls after this weekend from riders who have pulled up sore after their final big ride pre-3 Peaks. (With 200km being bandied around as being the standard!)
Society’s goalposts seem to be shifting – no longer do people take up running to complete the City to Surf, their goal is to run a Marathon within six months; triathletes are measured by how many ironman events they have completed; and it seems that office-dwelling professionals taking up cycling now measure their mettle by their 3 Peaks time after only six months of riding! I can tell you by personal as well as professional experience that ‘endurance’ comes through consistency, rather than through one ride, or one weekend of amazing mileage. Most issues we see arise through riding for too long and going too hard; frequency tends to never be a problem. If a rider can get themselves to the start line in one piece, with months of consistent, uninterrupted riding (even if their longest ride is 100km!), then they are well prepared and have the most chance of success. Not the rider who gets through their 300km weekend and has to battle an injury and time off the bike over the following weeks. Remember you can’t make yourself FIT in one ride, but you can make yourself VERY UNFIT!
What if I already experience pain on the outside of my knee whilst riding?
Hopefully the above will reduce your risk of experiencing this issue; however if you are currently having issues or if problems do arise, we recommend the following:
- Significantly reduce the duration and intensity (though ideally not the frequency) of your rides. Try to ride within your symptoms (don’t ride until you feel pain, ride short of feeling pain). If you do experience pain, stop. If you don’t experience pain, stop! (Don’t keep riding until you feel pain);
- Ice your knee (20 minutes, ice pack or peas, not gel pack) post ride, plus a couple more times per day;
- Stretch the TFL / ITB (as above);
- Foam roller? This treatment generates much debate even in our practice, however many get great relief from using the foam roller up and down the outside of the thigh. If you do roll, avoid the bony prominence on the outside of the hip, and never roll over the painful spot on the outside of the knee! (Remember though – the ITB is essentially a tendon, not a piece of dough – the best way to reduce tension in the band is to reduce demand on its inserting muscles, not to trying to make it longer!). It is also worth massaging/trigger pointing the gluteal and especially the TFL muscles prior to stretching them;
- Make a booking asap to see your bike fitter/physiotherapist/osteopath/chiropractor/soft tissue therapist, who must be familiar with cycling and cyclists even if they don’t ride themselves;
- Don’t lose your head! You are FIT from riding regularly, however continuing to push through symptoms will very quickly make you UNFIT!
If like most of our clientele, you are funding your cycling ‘career’ by sitting upwards of 40 hours per week, regular ‘maintenance’ work should keep your body attuned to the demands of bike riding. Coupled with a few position tweaks on the bike and a carefully graded training program focused on sustainable, consistent volumes of riding, chances are you will not have to endure lateral knee pain… nor need to explain, ‘I think it’s my ITB’.