Recreational cycling has surged in popularity across Saudi Arabia, attracting individuals for its well-documented health benefits, social engagement and accessibility (Althunyan, Darwish & Wahab 2017). Regular cycling improves cardiovascular fitness, boosts muscular endurance and enhances psychological well-being (Nordengen et al. 2019). Studies demonstrate its role in reducing the risks of chronic diseases, such as obesity and diabetes, while promoting mental health through stress reduction (Götschi, Garrard & Giles-Corti 2016). In Saudi Arabia, this rise aligns with a growing interest in physical activity amid a historically sedentary culture, spurred by government initiatives such as Vision 2030, which promotes healthier lifestyles. However, as participation increases, so do challenges related to injury prevention, training optimisation and self-management practices.

Despite this growth, no evidence-based SMP exists for recreational cyclists in the region, leaving a significant gap in support for this burgeoning community.

Cycling’s demands extend beyond physical benefits. It fosters a sense of community and social belonging, particularly valuable in areas with limited structured sports opportunities (Götschi et al. 2016). In Saudi Arabia, where traditional sports infrastructure has been underdeveloped, cycling offers an accessible entry point for exercise, often requiring minimal equipment beyond a bicycle. While this democratisation of the sport is promising, it also amplifies risks for those unprepared for its physical demands. Despite its advantages, cycling carries inherent risks, particularly for recreational cyclists who lack self-management skills. Overuse injuries, such as patellofemoral pain syndrome (PFPS), improper bike fitting, hydration mismanagement and inadequate recovery are prevalent (Prieto-González et al. 2021). Patellofemoral pain syndrome, a common knee condition among cyclists, is often caused by repetitive stress and poor biomechanics, which can be exacerbated by suboptimal equipment or technique (Althunyan et al. 2017). In Saudi Arabia, these risks are compounded by environmental and infrastructural factors.

Extreme temperatures, frequently exceeding 40°C, challenge hydration and heat management, while limited cycling-friendly infrastructure, such as dedicated lanes or shaded routes, intensifies the potential for injury (Althunyan et al. 2017; Tarawneh & Chowdhury 2018). Urban areas, such as Riyadh and Jeddah, offer some facilities, but rural and desert regions often lack them, forcing cyclists to navigate uneven terrain or busy roads. These conditions underscore the urgent need for a structured SMP tailored to the region’s unique context.

Self-management programmes empower athletes to regulate training loads, mitigate injuries and optimise recovery, a principle well-established in endurance sports (Phillips & Hopkins 2020).

In cycling, where performance and injury risk are tightly linked to self-regulation, such frameworks enhance consistency and longevity (Phillips & Hopkins 2020). Effective programmes typically integrate nutrition planning, strength and conditioning, sleep optimisation and injury prevention strategies, customised to participants’ needs (Masoudi et al. 2025). For instance, strength exercises targeting the quadriceps and hips can reduce the incidence of PFPS, while hydration protocols can mitigate heat-related fatigue (Passigli, Capacci & Volpi 2017). However, without a standardised, culturally relevant programme, Saudi recreational cyclists struggle to adopt these practices, often relying on trial and error or anecdotal advice. This gap is particularly stark given the sport’s physical demands and the region’s environmental stressors, which amplify the consequences of poor preparation.

The efficacy of self-management is well-documented in other endurance disciplines. Studies in running and swimming show reduced injury rates and improved performance through structured self-regulation (Wu et al. 2021). For example, peer-led programmes in running have reduced overuse injuries by 30%, while swimming interventions enhance recovery by focusing on sleep and nutrition (Malachowski 2016). Professional cyclists benefit from sports science support, including coaches, physiotherapists and data-driven training plans. However, recreational cyclists rarely access such resources (Masoudi et al. 2025). Instead, they turn to informal sources, such as online forums or peers, which may lack scientific grounding. This disparity underscores the need for an accessible, evidence-based SMP tailored to Saudi Arabia’s recreational cycling community, thereby bridging the gap between elite and amateur support systems. With notable advancements in Africa and other regions, SMP in physiotherapy is gaining increasing popularity worldwide.

A national survey conducted in Ghana found that more than 60% of physiotherapists used multimodal techniques to treat chronic low back pain, which included massage, electrotherapy, exercises and home advice (Oppong-Yeboah & May 2014). Similar to this, a feasibility study conducted in Ghana demonstrated the potential of an exercise and biopsychosocial education programme guided by a physiotherapist for managing low back pain, highlighting the value of combining education with physical therapy (Motha et al. 2024). According to a study conducted in Ethiopia, many healthcare practitioners faced fragmented information and encountered obstacles, including systemic constraints and a lack of competency, when providing SMP for persistent low back pain (Chala et al. 2022).

Developing such a programme requires a consensus-driven approach to ensure relevance and applicability. The Delphi method, widely used in sports science and healthcare, offers a systematic framework for achieving expert agreement on programme components (Nasa, Jain & Juneja 2021). By synthesising diverse perspectives, including those of sports physiotherapists, specialist musculoskeletal physiotherapists and experienced cyclists, the Delphi method aimed to establish a robust, multidisciplinary foundation (Nasa et al. 2021). This method’s strength lies in its ability to complex, subjective inputs into an integrated strategy, making it ideal for addressing the multifaceted needs of Saudi Arabian cyclists. Previous Delphi studies have successfully shaped interventions in sports medicine, such as injury prevention protocols for runners, demonstrating their utility (Brady 2015). A key advantage of the Delphi method is its iterative nature, which allows for continuous refinement through multiple feedback rounds (Brady 2015). Our study leverages this process to create a comprehensive framework tackling injury prevention, training periodisation, psychological resilience and environmental adaptation. Injury prevention, for instance, might include bike-fitting guidelines to reduce PFPS, while periodisation could balance training intensity with Saudi Arabia’s seasonal heat peaks. Psychological resilience is crucial for maintaining motivation in a challenging environment and can incorporate mindfulness techniques, which have been shown to aid in pain management among endurance athletes (Passigli et al. 2017). Environmental adaptation is equally critical, given Saudi Arabia’s distinct conditions. Extreme heat necessitates hydration strategies that go beyond general recommendations, such as electrolyte supplementation, while desert terrain demands skills for navigating uneven surfaces (Tarawneh & Chowdhury 2018).

Cultural and contextual considerations are paramount. Saudi Arabia’s climate, with summer temperatures often exceeding 45°C, poses risks of dehydration and heatstroke, which is absent in temperate regions (Tarawneh & Chowdhury 2018). Its cycling culture, still emerging, differs from Western models, with religious practices (e.g. prayer times) and language preferences (Arabic) shaping participation (Bahari & Kerari 2024). An SMP must integrate these factors, offering Arabic resources, flexible scheduling and heat-specific protocols, to ensure adherence. General guidelines, often designed for milder climates or established cycling nations, fail to address these nuances (Bahari & Kerari 2024; Masoudi et al. 2025). For example, European cycling programmes emphasise rain preparedness, which is irrelevant to Saudi Arabia’s arid environment, while neglecting desert-specific challenges such as sand hazards.

Patellofemoral pain syndrome is one of the most widespread overuse injuries among recreational cyclists and other physically active populations; however, it remains under-recognised and poorly handled worldwide (Crossley et al. 2016; Lankhorst et al. 2016). Even while exercise, education and load management have been shown to be beneficial therapies, there are currently few structured SMPs created especially for PFPS, especially in culturally diverse settings such as Saudi Arabia. Many cyclists are at risk for chronic pain, functional difficulties and decreased physical activity because of this gap, which may have an effect on their long-term health and athletic performance (Collins et al. 2022; Rathleff et al. 2013). Through the development of a culturally sensitive SMP that integrates clinical best practices and strategies for engaging patients, this research addresses an important demand and has received approval from specialists. This document presents a scalable model that could lead to the development of PFPS-specific SMPs worldwide, thereby reducing the economic, social and individual burdens associated with this widespread condition. This method is applicable beyond Saudi Arabia.

Our study employs a modified Delphi approach to identify, refine and validate a SMP for Saudi recreational cyclists. Engaging a panel of regional and international experts ensures scientific rigour and cultural relevance. The resulting framework aims to empower cyclists to manage PFPS and other risks, enhancing participation safety and enjoyment. Addressing this gap is vital as cycling continues to grow in Saudi Arabia, supporting public health goals and fostering a sustainable recreational culture.

A modified Delphi technique was employed to gather consensus from a panel of expert physiotherapists specialising in musculoskeletal dysfunction and sports injuries to develop a SMP for recreational cyclists in Saudi Arabia experiencing PFPS. The modified Delphi approach is grounded in the principle that collective expert opinions surpass individual perspectives (Brady 2015). It enables a panel of experts to collaboratively address complex issues through an iterative process. In our study, the method facilitated consensus among specialists on an SMP for recreational cyclists with PFPS in Saudi Arabia.

A panel of multidisciplinary experts in the management of PFPS, including physiotherapists, sports medicine specialists, exercise physiologists and biokineticists, were recruited based on predefined eligibility criteria. To qualify, experts had to have either published at least one research article on PFPS or possess a minimum of 10 years of experience in managing musculoskeletal conditions. Initially, experts from 10 countries (two per continent) were invited, considering their interest in cycling and its cultural relevance to Saudi Arabia. However, because of a low response rate, the recruitment focus shifted to experts available worldwide who were from Saudi Arabia, Egypt, Ghana, Nigeria and South Africa, ensuring alignment with cultural and civic perspectives. While this adjustment strengthened the contextual and cultural relevance of the panel to the Saudi setting, it may also have reduced the diversity of perspectives and potentially limited the generalisability of findings to non-regional contexts. Ultimately, 25 experts participated in Round 1 of the Delphi. Table 1 summarises their demographic details, professional positions and academic qualifications.

A two-round modified Delphi survey was conducted to reach a consensus among experts on the components of a SMP for PFPS among recreational cyclists. Twenty-five experts completed the first round, while 19 completed the second round, resulting in a 76% retention rate. The process was iterative, allowing items with moderate support in Round 1 to be re-evaluated and refined in Round 2. Across both rounds, substantial agreement was observed, and by the end of Round 2, consensus (defined as ≥ 90% agreement) was achieved for most of the proposed items. Table 1 presents the demographic characteristics of the participating experts.

In the first round, 25 specialists participated, with a majority being male (84%) and most falling within the age range of 35–54 years. Nineteen specialists completed the second round, maintaining a comparable gender and age distribution. The panel was predominantly composed of physiotherapists, with contributions from other fields, including sports medicine, academia, exercise physiology and biokinetics. The clinical experience of the participants with cyclists varied, although nearly half indicated they had less than 5 years of experience. Detailed demographic information is outlined in Table 1.

This modified Delphi study identified expert consensus on the core components of SMP for PFPS in recreational cyclists in Saudi Arabia. The findings contribute significantly to the development of a culturally tailored, patient-centred and evidence-informed intervention framework for physiotherapists and health professionals managing PFPS. In the first round, 25 experts participated; however, six withdrew before the second round, resulting in a retention rate slightly above 75%, which is consistent with or slightly higher than rates typically reported in similar Delphi studies (Mokkink et al. 2010). This discussion expands on our study’s five major themes, which include (1) patient empowerment and education, (2) function and performance outcomes, (3) programme evaluation, (4) cultural considerations and (5) biopsychosocial pain management.

In conclusion, our study provides a consensus-driven framework for an SMP tailored to recreational cyclists with PFPS in Saudi Arabia. By integrating evidence-based pain relief, cultural sensitivity and cyclist-specific outcomes, the programme addresses a critical gap in regional sports medicine. Its key contributions include combining physical and psychological strategies, embedding cultural relevance and aligning with best practice in rehabilitation. Beyond the Saudi context, the framework has potential for regional and international adaptation, particularly in cycling communities with similar cultural and sporting needs. Future research should focus on piloting this SMP in diverse clinical and community settings to evaluate its feasibility, acceptability and impact on long-term outcomes.