I recently received an inquiry on my blog regarding knee pain and cycling.

The individual wanted to know if Iliotibial Band friction syndrome (ITB) could be caused by pelvic asymmetry, also known as pelvic malalignment? Since a common complaint among many cyclists is Iliotibial Band Friction Syndrome (ITB), I provided my fellow blogger with an article written by Physiotherapist Catherine McLean, i which she discusses the causes and prevalence of ITB Friction Syndrome. Dr. McLean posted her article on the Austrailan Physiotherapist Association Web site.

She wrote, "The knee is probably the second most injured part of the body, of which most injuries are sports-related. Due to the repetitive nature of cycling, cyclists are more likely to experience ITB friction syndrome. During one hour of cycling, a rider may average up to 5000 pedal revolutions. The smallest amount of malalignment, whether anatomical or equipment related, can lead to dysfunction, impaired performance and pain."

What is ITB Friction Syndrome?

"The ITB is a thick fibrous band that runs on the outside of the leg from the hip to below the knee. With ITB friction syndrome, you will feel the pain either just above the outside of the knee or where the tendon attaches to the bone, just below the knee joint.

Pain usually starts as an intermittent niggle, sharp in nature and very focal. If this pain is ignored, it can develop into a dull ache even when you are not cycling. You may also notice a decrease in pedal power. The pain is a result of the ITB running across the bony prominence every time you pedal, hence the name 'friction syndrome.'

If you notice ITB pain, immediately ice the knee and begin gentle hip and hamstring stretches. It is important to see your physiotherapist as soon as possible -- as it may be necessary to stop cycling -- seek appropriate treatment and determine the cause of the pain," said McLean.

How is it caused?

Mclean states, "There are two main causes of ITB friction syndrome which are inappropriate training and abnormal biomechanics, both of which cause extra stress on the ITB."

Saddle position:

McLean recommends, "Checking your bike setup to ensure a proper bike fit. It is very important to have the proper saddle height. Too high a saddle will increase knee extension and irritate the ITB. If the saddle is too far back, the cyclist will have to reach further for the pedal and this will also stretch the ITB and possibly lead to irritation."

Foot position:

"Foot position on the pedal is also important. Whether using cleats or toe straps, ensure the heel is neither rotating too far -- in or out -- which in turn varies the knee position. An ideal position is such that the heel is kept in line with the lower leg through a whole pedal stroke," McLean said.

Gear choice:

McLean also pointed out that one of the most frequently seen causes of overuse knee injuries on the bike, such as ITB friction syndrome, is riding in too high a gear. "The optimal cadence for cycling is about 85 revolutions per minute, on the flat with minimal wind resistance. You should adjust your gears accordingly to achieve this cadence. On hills, choose a gear that will get you to the top with the least effort to minimize stress on the knees," McLean said.

Anatomical factors:

"There are also anatomical factors which may contribute to ITB friction syndrome, such as leg length discrepancy, a wide pelvis, tibial rotation, and leg inflexibility. These factors would be identified by your physiotherapist on assessment," McLean said.

Footwear:

"Footwear can also affect your knees on a bicycle, especially if you have flat feet. An ideal bicycle shoe is more rigid than a running shoe and I would strongly advise a regular cyclist to invest in a good pair of cycle shoes. I know from experience that when I wore my running shoes cycling, having forgotten to bring my clip-in cycle shoes, I experienced pain in the arches of my feet when climbing and when using the higher gears. This could, in turn, lead to variations in the position of the knee during a pedal cycle and hence, ITB pain," McLean said.

"So, ensure you have a proper bike setup, check your footwear, stretch, stretch, stretch and see your physiotherapist if you experience ITB pain," McLean said.

Combs is a coach, cyclist and triathlete and expert in bicycling fitting/rider positioning. He takes a holistic approach to bike fitting to assess and correct repetitive strain injuries, pelvic asymmetry and muscle imbalances. He is also the Director of the Sport Management Program at Methodist University in Fayetteville, NC. For more information browse: www.velosmart.com or email him at gcombs@methodist.edu.