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Cycling Injuries

Cycling injuries are a common cause of incorrect riding position (Bikefit) and/or anatomical and biomechanical problems that are related with the rider. Using our 3-step integrated package and a evidence based practice with a scientific approach we identify the cause to help resolve the problem.

Common areas of injury

Common overuse cycling injuries include; the back, perineum, hand, foot and most commonly the knee which affects 40%-60% of all cyclists on and off the road (1,2,3).

A contributing cause to overuse injuries is an incorrect bike set-up (cyclist body position) (4,5,6) these can include:

  • The pedal systems (7)

  • Problems with either the shoe/pedal interface (8,9)

  • Saddle height (10)

  • Saddle tilt (11)

  • Saddle construction and trunk angle (12)

  • Position of handlebar (13)

  • Biomechanical factors associated to misalignment of foot or leg (14)

Pattello-femerol joint pain

This injury is often referred to as ‘cyclist’s knee’, most frequently reported overuse injury in cyclists.  Pain or irritation is often felt behind or around the kneecap (patella). Possible causes may include abnormal motion or tracking of the patella affecting transition and wear of the posterior (back) surface of the patella.

Other examples include;

  • Incorrect saddle height (saddle too low) (16)

  • Saddle position too far forward (17)

  • Problems with the shoe/pedal interface - incorrect foot position or pronation (inward rolling of foot) linked to mis-alignments of the leg or foot (8,14)


Typically cycling involves a piston like, symmetrical motion of the legs for power generation. Our aim is to assess and correct problem areas as required to provide smooth rolling transition between the contact points of the joint surfaces to optimise leg motion for power generation.

Iliotibial Band Syndrome (ITBS)

ITBS is an inflammatory condition and arguably the second most frequent reported problem seen in cyclists. The condition develops when the iliotibial band repeatedly rubs over the lateral condyle (outside) of the knee during repeated flexion and extension of the knee joint during pedalling.  Other possible causes in cycling may include;

  • Incorrect saddle height too high or too far back (18,19)

  • Incorrect cleat position (17)

  • Excessive foot pronation linked with leg and foot alignment problems (14)

Patients often feel pain on the outside of the knee represented by a sharp or stabbing pain (17).

Lower Back Pain (LBP)

LBP is a common problem seen in cycling however little scientific studies exist to identify the cause and risk factors. LBP has been reported as up to 50% in recreational cyclists and 22% in professional cyclists (20, 5).  Despite the lack of scientific studies reports have shown that other contributing factors may be linked to the development of LBP for example Increased training loads or Incorrect bike set-up such as:

  • low handlebars aggravating increased trunk flexion (20)

  • incorrect saddle level/tilt (21)

Usually the standard saddle (with nose) should be set horizontally ‘level’, or with a slight tilt (±3º), by means of a spirit level (18). Women generally favour for the front to be angled marginally downwards to help reduce the pressure on the perineal area and in particular instances of LBP (13)  Riders that implement the more traditional zero position with a highly flexed trunk generally favour for a more radical forward tilt (≤10º), or choose to use a ‘no-nose’ saddle (22).

Riders that implement an upright position for example mountain bikers or recreational riders generally favour a level saddle or marginally tilted backwards saddle (18). This position helps to redistribute the rider’s body weight thereby helping to reduce pressure on the ulnar nerve (1)


The saddle should be approximately horizontal.


According to research reports, cyclists are at greater risks of developing urogenital symptoms than their sedentary counterparts (23,24). Problems of perineum saddle pressure is both a common problem in both men and female cyclists and recently a study identified complaints in 50-91% of cyclists (13,14, 25,26). Reasons may include;

  • Prolonged saddle pressure (26)

  • Excessive body weight and saddle design (27)

  • Saddle level/tilt (21)

  • Incorrect handlebar position (12,13)

Roland York

...John O’Groats to Land’s End...
Nick was also able to set up the bike to exactly the right  parameters for my particular requirements.

Having observed my cycling action and the fact that my right knee troubled me after long rides, he recommended special inserts for my shoes which greatly reduced my discomfort.

Nick’s knowledge of treatment and exercises for cyclists is very impressive – thanks Nick

Neil Grahame

Nick's treatments have helped revive my energy levels and fluidity of movement. The advice and exercise recommendations Nick provided were always clear and achievable.


I have since recommended Nicks Pain Relief Clinic to a number of people for effective pain relief due to his knowledge and professionalism.

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The perineum is a vulnerable area between the genitals and the anus composed of soft tissue, nerves and blood vessels. Urogenital symptoms may arise when the cyclist sits on the saddle for prolonged periods at a time which compresses these delicate structures (nerves and blood vessels) which may lead to the following urogenital symptoms and conditions. For example males may suffer symptoms of provisional groin numbness, pain, tingling sensations, erectile dysfunction and the frequent need to urinate. Females may develop symptoms such as frequent bladder infections and painful irritable skin problems.

The advantage of bike-fit is that most of the above symptoms can be reduced or alleviated using the correct discipline of bike-fit.

Anatomically our sit bones are wide at the back and gradually become narrower towards the front. This anatomical structure has implications depending on the cyclists riding position as the contact point (sit bones) with the saddle moves (re: cycle discipline). For example cyclists that adopt the upright position often sit towards their back part of their sit bones therefore needing a broader saddle. Other riders that adopt a forward aero position such as the triathlete cyclist use the narrower part of their sit bones as the contact point therefore requiring a narrower saddle. It is estimated that on average the pelvic width in males is 118mm and 130mm for females.  

Today the design of the modern saddle has a fractional or complete cut-out intended to reduce the pressure on the perineum. Saddles vary as some are nose-less designed to leave the perineum completely unloaded. A study carried out on American police officers introduced the nose-less variety of saddles and found that the transition was generally straight forward despite some getting used too. Following a six month trial period improvements had shown in genital sensation as men reported the lack of genital numbness by 27% to 82% after using the nose-less saddle design. Following the study 97% of American officers continued to use the nose-less saddle (27).

In brief perineum pain and urogenital complaints are common in both male and female cyclists. Saddle design is down to individual choice. However with the correct bike-fit set up (position of cyclist), pelvic width and saddle tilt are findamental aspects to help reduce or alleviate urogenital complaints and to attain the cyclist comfort.


Chronic ulnar nerve compression is the most common hand injury usually referred to as ‘Cyclist Palsy’ (28) with the median nerve less often involved (1). Hand overuse injuries of the ulnar and median nerve are both common in both experienced and unexperienced cyclists (28), particularly in long distance riders (29) and mountain bikers (30). Riders may experience symptoms of ulna nerve compression often presented as numbness and/or paraesthesia in the fourth and fifth finger due to prolonged pressure on the hypothenar eminence (below little finger on the fatty area of the palm on hand).  

During the Bike-fit set-up the key to alleviate or reduce this problem would be to simply reduce the pressure on the hypothemar eminence. This can be attained by adjusting the handlebars, body position intended to unload hand pressure on the handlebars by making variable adjustments in hand position or by simply wearing padded cycling gloves (28). Furthermore a nose-down saddle (with a forward tilt) has a tendency to redistribute the rider’s body weight, moving it forwards can lead to increased pressure on the hands and hypothemar eminence.  Furthermore the cyclist’s hand pressures tends to increase if the handlebars are lower than the saddle (31).


‘Hot foot’ or the medical term ‘Metatarsalgia’ is arguably the most common problem affecting cyclists.   It is a condition where the nerves and tissues close to the ball of your foot are repeatedly squeezed and aggravated by the long metatarsal bones. The symptoms represent throbbing, burning pain and tenderness on the sole of the foot, usually over the 3rd and 4th metatarsophalangeal (toe) joints, with pain radiating along corresponding toes (32).

The cause can simply be shoes that are too tight leading to compression of the nerves (32), or more frequently the cause is related to either under-pronation (pes cavus) or over-pronation of the foot, which in turn, places extra loading on the forefoot (33). Although there are no robust research studies on cause and subsequent treatment of metatarsalgia in cycling, anecdotally the use of appropriate shoe inserts to support the relevant arch(s) and forefoot wedges appear to help.

Like other overuse injuries, successful treatment requires a thorough understanding of it(s) causes which can be multifactorial.

Read more about how we can help you understand and avoid your bike related pain.
For those of you who'd like to know more - here's the science...
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