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Treating Cycling Knee Pain - The Patellar Tendon


The Patellar Tendon runs from the kneecap (Patella) to the top of the shin-bone (Tibial Tuberosity) and transmits the contractile force of the front thigh muscle (Quadriceps) to straighten the knee.

Pain from the Patellar Tendon (Patellar Tendinopathy) affects many cyclists, which is not surprising given that the Quadriceps muscle creates much of the force of propulsion when riding a bike, and if you use cleats, the Quadriceps muscle is engaged for even more of each pedal stroke.

Tendon injuries are classified into 2 stages:

1/ Reactive:

Here the tendon swells due to water retention and tendon cells becoming more metabolically active. The tendon tissue is sensitized and pain is easily provoked from use. This stage normally occurs due to an impact injury, or sudden and sustained activity increase, such as when you start riding more frequently or start incorporating steep hills for the first time.

2/ Degenerative:

Here the tendon has a longstanding disorganization of its collagen fibres, resulting in a reduced ability to withstand and transmit load. This in turn leads to painful dysfunction of athletic movement. This is more likely in cyclists who have been riding for longer, but may also be apparent in people new to cycling, who have done other sports in the past.


The ideal treatment for tendon problems depends on which stage you are in and the severity of the pain. Fortunately it is only in the most severe cases that it is necessary to stay off your bike completely. In fact, complete rest is usually counter-productive for tendon problems.

In the reactive stage of Patellar Tendinopathy, a reduction in the activities contributing to the problem will usually be required. Generally this means less cycling, and particularly less cycling in harder gears, on uphill inclines or pushing higher watts. You may be able to continue with flat rides and spinning a higher cadence.

In later stages of degenerative tendon injury, when the problem is well advanced, the focus should be on restoring functional capacity to the muscle/ tendon unit, and the supporting muscles with appropriate strength exercises. This process will stimulate the tendon and help build enough healthy collagen tissue to bear the load of normal activity. These exercises should follow standard strengthening protocols, and will need to continue for 2-3 months. There are no shortcuts here!

Regardless of injury duration, if pain is particularly strong, heavy and sustained isometric Quadriceps holds are proven to provide significant pain relief, and these should be done several times per day. They also help the brain to "turn the muscle back on" by reducing the nerve impulses that inhibit the muscle, effectively increasing muscle strength (by almost 20%!). Typical isometric exercises might be sustained squats or sustained leg extensions held in a mid range position. 5 repetitions of 45 seconds with 2 minutes rest between each, is one well-documented protocol.

Other Considerations

A full investigation of the reasons for the tendon dysfunction is important, to work out if there are cycling technique faults, bike fit issues, biomechanical limitations, anatomical asymmetries or non-cycling activities that are contributing.The problem is unlikely to go away if these factors are not addressed.

Many therapies that were once in favour have now been disproven, or have little supporting research evidence. For example, we now know that you are unlikely to gain significant long-term benefit to an injured tendon from ultrasound treatments, friction massage or dry needling, although you may gain some short term relief. These "passive" treatments for tendon problems do not address the causes.

Stretching the Quadriceps may be included as part of a full rehabilitation plan, as this muscle often becomes tight and short in cyclists. However stretching can be counterproductive in tendon injuries, as the wringing out effect of passive tension reduces blood flow to the tendon.

Tendon problems are notoriously stubborn to treat, so for best results, work closely with your physiotherapist to ensure you are doing the correct exercises for your condition, and that you are doing each exercise with good technique. Remember that resolution of tendon injuries takes time and effort, so be patient and stick with your program!

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