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  • Dr. Lee Brotherston

Cycling and knee pain - The role of the foot/ankle complex

Part 3 of a multipart series on cycling and staying healthy.

cycling knee pain

Last time we talked about cycling and knee pain we discussed how the hip could be the cause of the problem. In this post, we’ll talk about the foot/ankle complex and the role it may play in knee pain. Excessive pronation, or rotation of the foot can cause internal rotation of the tibia, which in turn, alters the way the patella (kneecap) tracks, leading to knee pain and a condition called PFPS (patella femoral pain syndrome).

Pain on the inside of the knee (medial) is common in this situation. There are a couple of things you can do to help correct, or prevent this. Firstly, and most importantly, if you are using clipless pedals, you need to ensure your cleats are aligned in a way that will evenly disperse the forces up the kinetic chain. Most people do well with a relatively neutral positioning – what I mean by this is when you are clipped in, your toes should be pointing almost straight forward, with perhaps a very slight external rotation. This photo from Pedal PT shows what I mean by this:

This will allow for optimal power transfer as well as prevent any excessive rotation of the tibia, uniformly dispersing the forces up the chain, and reducing stress on any individual structure. The cleat/pedal interface is a seemingly simple contact point, but it is absolutely critical for performance and injury prevention that you get it right. Watch out for a future post specifically addressing pedal/cleat positioning, or come on in to the clinic to learn more.

Overpronation is another dysfunctional movement that can lead to knee pain. It’s important to note that pronation is a normal movement that occurs during the gait cycle. With every step we take (or pedal stroke), the ground (or pedal) exerts an opposing force equal to the power we exert. These are called ground reaction forces. Pronation allows us to control the speed at which we decelerate as we come into contact with the ground, thereby reducing ground reaction forces. If you ran without shoes, on your heels (so your forefoot is unable to help absorb the impact), it would hurt – and the ground reaction forces would be very high. All this is to say that pronation is normal, and necessary. However, overpronation is not. This is when there is an excess amount of pronation, causing the foot to be very flexible, but unstable, putting more stress on the ligaments and muscles and altering the way the rest of the kinetic chain works. The foot is extremely complex, and there are textbooks dealing solely (pun intended) with the way the foot functions, but to put it simply: pronation is normal, but too much pronation, or the inability to supinate (the opposite of pronation) before toe off will result in impaired performance, and very likely, injury. This picture helps to show what I’m talking about:

So how to we fix overpronation? Well much like we talked about with hip internal rotation, it helps to be aware of the aberrant movement you are trying to avoid. Have a chiropractor, chiropodist, podiatrist, or physiotherapist watch your gait and film it in slow motion to help you understand what is happening. We can also work on strengthening the muscles involved in controlling the amount of pronation and supination you have.

It’s very important you make your feet, and the muscles in your leg that control your feet, work. Our feet get locked up inside our shoes and they aren’t made to do much, which results in deconditioning and abnormal movement patterns. While maybe not completely analogous, I like to point out that you wouldn’t dream of putting someone in a cervical collar for no reason, make them wear it every day while they went about their activities, and then wonder why they had neck pain when you removed it. So do yourself a favour, take your shoes off and make your feet do something for a change. Walk in the sand, and go for a hike without your boots – you’ll be amazed at how good it feels. It should go without saying, but work up to this slowly. Years of deconditioning cannot be fixed in a day. Also, when I say hike without shoes, use your judgment. Don’t carry a heavy pack and try to go unshod, and be very careful on pointy things, like rocks.

Another thing you can try using is an orthotic shoe insert. Here at ORHG, we can make a plaster mold of your foot, which we send to an orthotics lab in Toronto, who will make a footbed specifically for your foot and the type of shoes you wear (cycling shoes require a low profile footbed). Alternatively, you can try an over-the-counter orthotic insole. For patients wanting to go that route, we always recommend Superfeet brand, as they have a wide variety of insoles to fit different shoes, are of high quality, and quite inexpensive. Whether you use custom, or over-the-counter insoles, they work in the same manner – they make your body more aware of what the foot is doing, and help to increase the muscular control of the foot. How and why orthotics work will be a future topic of discussion.

So there you have it, a few things to look into if you are suffering from knee pain while cycling. A couple of blog posts isn’t nearly enough to cover every potential source of knee pain, but these are some of the more common problems. Feel free to give us a call, or book an appointment to discuss your case, and watch for more posts that well delve into more detail.


Dr. Lee Brotherston

Partner, Chiropractor

Oak Ridges Health Group

Uxbridge, ON



Asplund, C., & St Pierre, P. (2004). Knee pain and bicycling: fitting concepts for clinicians. The Physician and sportsmedicine, 32(4), 23-30.

Hannaford, D. R., Moran, G. T., & Hlavec, H. F. (2008, April). Video analysis and treatment of overuse knee injury in cycling: a limited clinical study. In ISBS-Conference Proceedings Archive (Vol. 1, No. 1).

Liebenson, C. (2014). Functional training handbook (1st ed.). Philadelphia: Wolters Kluwer Health.

Planet Mountainbike (2017). Retrieved 13 February 2017, from

PT, P. (2017). Pedal PT. Retrieved 9 February 2017, from

Team Doctors Blog. (2017). Retrieved 9 February 2017, from

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