Cycling: Foot and Ankle Injuries

We live in a community where cycling is an integral part of the culture. Consequently, I treat a lot of injuries related to cycling – both mountain biking and road biking.

Ensuring proper bike fit is a good place to start in terms of treating and preventing chronic cycling injuries. When standing over the top tube of a road bike, there should be 1-2 inches of space between the rider’s crotch and the top tube. Mountain bikes will have quite a bit more space to accommodate for different riding styles and frame geometries. Saddle position is also of significant importance. On a road bike: Place the crank arms at the 6 and 12 o’clock position, the bottom of the 6 o’clock foot should be parallel to the floor and the knee just flexed when sitting on the seat. On a mountain bike, this would be an appropriate position for a fully extended dropper seat post. Regarding fore and aft seat position: With the crank arms placed in the 3 and 9 o’clock position, a plumb line off the patella should pass through the center of the pedal axle for the forward foot. Mountain bikers should slide the seat back about an inch to improve traction on steep climbs and confidence on steeper descents.

Clipless pedals that allow some degree of float are much preferred as opposed to rigid/fixed pedal systems. Cleat position is something that I will modify frequently to address certain types of pathologies. A good place to start is with the cleat centered under the widest part of the foot. I will often post the cleat at an angle to accommodate for various lower extremity deformities such as excessive pronation or supination.

Cycling shoes, especially road cycling shoes, tend to be quite snug and rigid. It is the rigidity and tightness that allows for efficient transfer of power from the lower extremity to the crank arms. Unfortunately, this can have the unintended consequence of lower extremity and foot pain. Pain under the ball of the foot or metatarsalgia and neuromas are frequently exacerbated under these conditions. Shoe modifications such as wedging, padding, and orthotics are usually quite effective at treating these conditions with cycling shoes, as long as there is adequate width.

Below is an algorithm that a lot of cyclists may find as a useful starting point for addressing different types of lower extremity injuries and pain:

  • Achilles tendinitis – move the cleat back on the shoe so that the ball of the foot is more forward on the pedal, raise saddle height, address a limb length discrepancy with appropriate shim, decrease resistance and increase cadence.
  • Patellar/quadriceps/patellofemoral tendinitis – raise saddle height and slide saddle back, decrease resistance and increase cadence.
  • Plantar fasciitis – raise saddle height, remove the cleat back towards the heel, address a limb length discrepancy with appropriate shim.
  • Tight hamstrings – ensure appropriate cleat position, move saddle forward, lower the saddle.
  • IT band syndrome – position cleat with slight external rotation, move saddle forward, lower saddle.


-Dr. Douglas Goforth