Background: Among competitive cyclists, anterior knee pain is a common overuse injury. Alignment of the rider on the bicycle and the loading pattern on the pedals are proposed as factors in this pain. The patient was a 23-year-old competitive female cyclist who was riding up to 200 miles weekly and had developed bilateral anterior knee pain within the 3 months preceding our examination. The purpose of this case report is to demonstrate the effectiveness of adjusting this patient’s static alignment (ie. position while seated on bicycle, but not actively pedaling) on the bike and modifying her habitual pedaling pattern. Methods: The patient was analyzed using both static and dynamic measures of alignment while on her bicycle. Her bicycle seat was raised and moved rearward, and her pedaling force output was analyzed using a Computrainer™. Over a 4-week period, she was taught to modify her pedaling force using video biofeedback. Outcomes: After adjustments and training, she could ride for over 3.5 hours without knee pain. Visual analog scale pain score improved from 6/10 to 0/10; Lower Extremity Functional Score improved from 65 to 79; and Knee Injury and Osteoarthritis Outcome Score improved from 81 to 98.5. Clinical Relevance: This case illustrates how application of biomechanical principles and training in pedaling movement patterns can be effective at eliminating knee pain in competitive cyclists. While rest, decreased training volume, and appropriate medication should be considered as treatment components, we believe the initial treatment for competitive cyclists should include biomechanical evaluation of alignment and pedaling pattern.

Author Bio(s)

Tim Evens, PT, DPT is a senior staff therapist at Agility Sport and Spine, Tucson, AZ. He is also a highly competitive bicycle racer and marathoner.

Jerome Danoff, PT, PhD is Professor Emeritus from the George Washington University Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health. He rides bicycles frequently, but slowly.



Fig 1.1.jpg (387 kB)
Figure 1

Fig 2.1.jpg (1855 kB)
Figure 2

Fig 3.1.jpg (812 kB)
Figure 3

Fig 4.1.jpg (2905 kB)
Figure 4

Fig 5.1.jpg (3251 kB)
Figure 5

Fig 6.1.jpg (5390 kB)
Figure 6

Fig 7.1.jpg (466 kB)
Figure 7

Bicycle Nomenclature.docx (81 kB)
Bicycle Nomenclature

Bicycle Captions.docx (63 kB)
Bicycle Captions

Responses to Reviewers Comments 1818.docx (174 kB)
Responses to Reviewers

ABSTRACT 1818.docx (75 kB)
Revised Abstract

Bicycle Seat REV1818.docx (62 kB)
Revised Manuscript


Submission Location


To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.