Cycling / clicking / sitting and knee pain

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A question from an email:

“Hi Brian,

I just came across your excellent site with the post about ITB stretching. Thanks, I am just trying to digest all of the info now.

Could I ask a question – what is the primary reason for knee cap clicking?

I have two problems 1) ITB pain – very sharp, in the lateral insertion in both knees and 2) much more troubling, general knee pain on the clicking knee only, like when sitting down and walking down stairs.

I am only 28 but its hard to be active at all with it! Is clicking almost always a sign of maltracking? I notice it a lot when I cycle. It sort of feels there is no power in the knee and I can literally feel it not moving right until eventually it will pop and feel “better”. But feeling “better” does not improve the pain, its still there, it just feels like it is somehow working better.

I have had an MRI and it hasn’t shown anything and I literally cannot find a decent PT or even doctor anyway! So I am stuck trying to figure things out on my own!

Do you have any advice as to where I should start? Everything I try, like even starting ankle mobility, hurts cos it involves pressure on the knee.

Thanks so much,

Paul”

 Knee cap clicking

Any clicking in the knee is typically from one of two things,

1) A tear in the cartilage.

2) Maltracking issues affecting the patellar tendon and surrounding structures.

Because 1) seems to have been ruled out for you, 2) is likely the culprit. Now, clicking or popping in itself isn’t a problem. If there’s pain associated though, then obviously it is.

Knee pain and sitting

A great way to alleviate knee issues when sitting is to do two things,

1) Make sure your knees are not caved inward.

Rather, sit with the knees outside of the feet, nice and relaxed,

2) Make sure the knees aren’t too bent.

The knees don’t have to be completely straight, but the feet should be pretty far forward, and not turned out!

So,

It’s important to consider all scenarios where you sit, driving included. 

Which brings us to cycling

Getting more specific to some of the activities you mentioned, we want to bring all the principles of sitting into how you cycle. The biggest principle being your knee absolutely, positively cannot turn inward.

Looking at the right knee (left in the picture):

I haven’t seen you bike, but when it comes to knee pain while cycling, this movement issue is a damn near guarantee in my experience.

Biking in this manner -with the knee repetitively turning inward- is going to engage the tensor fascia latae / IT band and adductor magnus. Although I haven’t written much about the adductor magnus, I’ve written extensively about the TFL and IT Band, and as I’ve mentioned, when you have knee pain it’s another just about guarantee the last thing you need is more TFL work.

So, we want to cycle with the knees straight, if not turned out a little bit.

This goes for when you stand up as well!

Honestly, if you’re sitting quite a bit throughout the day I would get off the bike period, at least for a while. Rather than exercise where you’re seated you’d be much better off performing things where you’re standing or laying down.

Bringing us to exercise

A couple of good stretches would be the ones outlined in the Best damn IT band stretch ever with the Standing version too. 

The leg curls I talked about in My visit to the Washington University in St. Louis would be beneficial as well.

If it’s not obvious in the video the toes are together but the heels are apart. 

This kind of scratches the surface of what you could do, but I don’t want to overload you with things.

Your best course of action is likely to really focus on how you sit throughout the day, perform the above stretches / exercises (with obsession over doing them properly), and being cognizant of the position of your knees when cycling. If you do things properly and are on the right track, you should notice an immediate difference in how your knees feel. They may not feel completely better right away, but they should feel noticeably better quickly.

Hope this is helpful.