Knee pain is hands-down the most common complaint I see from cyclists. And it makes sense when you think about it, the knee is a simple hinge joint compared to other joints in your body. Hinge joints move in one plane: they flex and extend. That’s it.
“They don’t love being twisted and they don’t love being bent in a plane of motion that’s outside of their natural plane of motion,” explains Neill Stanbury, expert bike fitter and sports physiotherapist.
Here’s the problem: your bike’s cranks move in a perfectly symmetrical circle. But your knees? They don’t always track in that same clean plane. One knee might be moving outside the line of the pedal, or inside it, or on an angle. When that plane of motion drifts too far, soft tissues get overloaded, and pain starts.
The good news? Most cycling knee pain isn’t dangerous – it’s inflammation, not structural damage. But if you don’t fix what’s causing it, it keeps coming back. You train hard, it hurts, you back off, and you plateau.
The Four Types of Cycling Knee Pain
Most cycling knee pain falls into one of four categories. Neill breaks them down by location – front, back, outside, and inside because where it hurts tells you what’s going wrong.
1. Front of the Knee (Anterior Cycling Knee Pain)
What’s hurting:
- Patellofemoral joint (kneecap tracking in the groove on your femur)
- Patellar tendon (just below the kneecap)
This is the most common type of cycling knee pain. Your kneecap runs up and down in a notch on the femur. On both the kneecap and femur, there’s a few millimeters of cartilage that can wear with age.
“When you’re 18, it’s three or four millimeters thick, and when you’re 75 there’s not much of it left, it wears out over your life,” Neill explains.
If your kneecap tracks vertically, it’ll last a long time. But if it pulls off-center for thousands of pedal strokes, pressure focuses on one spot of cartilage, and inflammation sets in.
Common causes:
- Knee tracking outside/inside the pedal line
- Saddle height way too high or way too low
The tendon below your kneecap can also flare up from either extreme saddle height. Too low and it’s overstretched; too high and it’s overloaded.
2. Back of the Knee (Posterior Cycling Knee Pain)
Less common, but usually one of two causes:
Hamstring tendons: Saddle too high → overextension → overloaded tendons.
Popliteus muscle: Foot rotating on the pedal → rotational load → back-of-knee irritation.
“If your foot is squirreling on the pedal, that rotation transfers load to the back of the knee. The popliteus tries to control it, but it’s a small muscle it can’t do it for long,” says Neill.
These pains can feel similar but come from totally different sources.
3. Outside of the Knee (Lateral Cycling Knee Pain / ITB Pain)
A huge number of cyclists know this one as ITB pain.
The iliotibial band (ITB) is a big sheet of tissue connecting your glute max to the outside of your leg, attaching just below the knee.
“It tends to get overloaded for the same reasons as patellofemoral pain because it’s connected onto the outside of the kneecap,” says Neill.
Signs:
- Almost always one-sided
- Caused by pedaling asymmetry, knee chopping in toward the pedal
This can lead to ITB friction syndrome or bursitis, both driven by uneven motion.
4. Inside of the Knee (Medial Cycling Knee Pain)
Usually caused by inflammation of the pes anserinus the insertion of three muscles on the inner front of your tibia.
It happens when your knee whips in at the bottom of the pedal stroke.
Your sartorius muscle tries to hold it, but if that whip happens thousands of times, irritation builds.
One-Sided vs. Both Knees: A Big Clue for Cycling Knee Pain
Both knees hurting?
- Saddle catastrophically low → front knee pain
- Saddle too high → back-of-knee pain
- Q-factor (stance width) too narrow or wide → both knees affected
One knee hurting?
That’s far more common and points to asymmetry pelvis tilt, leg-length difference, or dominant-side bias.
Why Asymmetry Causes Cycling Knee Pain (and Why It’s Often the Left Knee)
Let’s say you’re right-leg dominant and that leg is slightly shorter.
You drop your right hip down and forward to favor it.
Now your pelvis sits oblique to the bike, and your left knee is forced out of alignment.
“Of a hundred riders, about 90 will have left knee pain because most people are right-leg dominant. The nervous system protects the strong side at the expense of the weaker one,” says Neill.
How to Fix Cycling Knee Pain: The Step-by-Step Process
The solution? Build symmetry so your knees move cleanly over the pedals.
Step 1: Saddle height
- Too high → posterior pain
- Too low → anterior pain
Step 2: Q-factor (stance width)
If you’re wide-hipped and your stance is too narrow, widen it slightly. Narrow if knees splay out.
Step 3: Knee tracking
Keep knees moving vertically over the pedal spindle.
Step 4: Cleat position
Ensure rotation matches your natural foot angle no “squirreling” on the pedal.
Step 5: Leg-length shim
For real or functional short legs. Neill himself uses a 6mm shim to square his pelvis.
Step 6: Fore-aft saddle
Center your weight so both legs share the load.
“The position needs to be symmetrical. Once it is, your nervous system stops favoring one side,” says Neill.
When to Get a Professional Bike Fit for Cycling Knee Pain
If you’ve tried the basic adjustments and knee pain still persists, it’s time for a full professional bike fit.
A professional fitter can accurately assess leg length differences, pelvic rotation, saddle position, stance width, and cleat alignment factors that are difficult to self-diagnose.
Before booking a fit, make sure your saddle height is set correctly: How to Set Saddle Height or follow a structured approach inside our Bike Fit Fundamentals program.
Related Issue: Lower Back Pain in Cyclists
Many riders who struggle with knee pain also experience lower back pain often caused by the same asymmetries and rotational patterns Neill explains.
If you want to understand how back pain develops and how to fix it, watch this breakdown from our expert panel:
FAQs: Cycling Knee Pain and Bike Fit
Is cycling knee pain dangerous?
Usually not—it’s inflammation, not damage. But persistent pain needs positional correction.
Which type is most common?
Front-of-knee (patellofemoral) pain.
How does saddle height affect pain?
Too low = front pain. Too high = back pain.
Why one knee?
Asymmetry – dominant leg protection or pelvis tilt.
Can stance width cause pain?
Yes. Too narrow crowds the hips and forces knees to twist.
Why my left knee?
Most cyclists are right-leg dominant, so the left takes the extra load.
Bottom Line: Preventing Cycling Knee Pain
Knee pain on the bike is common because the knee wants a clean, vertical path but setup errors twist it off course.
Find which type you have, make the right adjustments, and re-test.
Relief often comes within a few rides once your knee tracks naturally again.
Your Next Step: Strength Training for Cyclists
Fixing bike fit solves the positioning problem, but long-term knee health also depends on strength.
If you’re ready to build resilience that supports both performance and injury prevention, check out our Strength Training for Cyclists – Only $75 program.
It’s a structured, 16-week system designed to complement your on-bike training and reduce the risk of common overuse injuries including cycling knee pain.
Fueling Matters Too: Recover Faster & Reduce Inflammation
Proper fueling plays a major role in recovery, especially when you’re dealing with tissue irritation, fatigue, or recurring knee pain.
Increasing your carbohydrate intake at the right times helps:
- Reduce soft-tissue stress
- Support higher training loads
- Improve day-to-day recovery
This clear explanation from our Sports Dietitian breaks it down simply: