Cyclist Hip Pain - Physio Bike Fit Case Study

Understanding How to Manage Hip and Lower Back Pain in a 43-Year-Old Cyclist

A 36-year-old cyclist, presents with a significant medical history. She is normally fit but has experienced issues following a cycling accident eight years ago. This incident resulted in fracture of the pelvis and femur, resulting in a long period of immobility. Additionally, she has a long-standing history of lower back pain, which predates the accident. She attributes her right hip pain directly to the accident, feeling that her muscles in gluts and right leg have become weaker as a result, leading to reduced power through the pedal stroke.

Jake assessing hip range of movement to see what the client can achieve on the bike.

Medical Background: Lower Back and Hip Pain

History of Lower Back Pain

The client reports right-side lower back pain that occasionally radiates into her right foot. She experiences numbness but notes no actual weakness or loss of sensation. She doesn't experience any bladder or bowel disturbances. Prior to her bike fit, her GP requested an MRI, which indicated a disc bulge between L5 and S1. She has been advised to manage this condition conservatively through physiotherapy unless her symptoms worsen.

Pain Triggers

Riding longer than 15 miles triggers pain in her lower back. Although the discomfort doesn’t completely stop her from cycling, it certainly leads to stiffness by the end of her bike ride.

History of Right Hip Pain

In addition to her lower back pain, the patient experiences pain in her right hip while cycling or squatting. Following the cycling accident, an X-ray revealed moderate arthritis the right hip joint. Her surgeon recommended strength and conditioning through physiotherapy but indicated the potential necessity for a total hip replacement in the future. To delay this, the patient was advised to cease running.

Hip Pain Triggers

Pains are exacerbated by deep squats and cycling in a dropped position, where the hip undergoes extreme flexion. Dynamic movements such as hip adduction also provoke pain. Furthermore, loading the hip during activities like running causes discomfort. These movements contribute to right IT band pain and groin pain, which radiates from the hip bone (Greater Trochanter).

Physiotherapy Observations

Upon examination, it was noted that the left leg is longer than the right by 10mm. This discrepancy results in a standing posture where the left iliac crest appears higher than the right. Consequently, this alignment issue closes down the right lumbar area.

Movement Analysis

During squatting, significant over-pronation of the left foot is observed compared to the right. This imbalance is exacerbated during lunges and single-leg squats. She struggles to achieve a full squat or lunge with the right leg due to pain.

Physiotherapy Assessment and Tests

Lumbar Spine Assessment

She demonstrated limited range of motion into lumbar spine flexion, but extension, and side flexion was full. There was no pain upon applying overpressure. However, due to the reported numbness in her right foot, a neurological assessment was conducted, confirming intact myotomes, dermatomes, and reflexes for L1 through S1.

Muscle Strength and Flexibility Tests

Muscle strength evaluations revealed that the right quadratus lumborum was tighter than the left. The deep abdominal strength test indicated weakness, as she struggled to maintain posture for more than one minute. Both his hip flexors and quadriceps showed tightness bilaterally.

Hip Special Tests

The quadrant test of the right hip elicited pain in the hip joint. Similarly, the FADDIR’s test indicated joint pain as well as groin discomfort. These findings correlate with the X-ray observations of arthritis in the hip. Despite pain during hip flexion and adduction, the hip performed smoothly in other movements, indicating tolerance to a position on the bike that did not exceed 120 degrees of hip flexion.

Image showing a pelvis positioned on a saddle and at the angle of a typical upright riding position.

Treatment Plan

I prescribed a tailored strength and flexibility program targeting both her muscle function and pain management in the lower back and right hip. We plan to review progress in six weeks to assess effectiveness. Additionally, I provided advice on avoiding aggravating positions off the bike. While certain hip flexion scenarios cannot be completely avoided, they can be managed with better awareness of movement and targeted muscle use.

Adjusting the Bike Fit

Assessing her on the bike fit, it became clear that the saddle was positioned too high by 10mm and angled upward. This not only restricted the hip joint but also exacerbated right hip pain when reaching for the handlebars. The analysis further confirmed excessive lumbar rotation as a consequence of an improper saddle height, which also highlighted the weaknesses in her core muscles.

Saddle Pressure Mapping Assessment

We also conducted a saddle pressure mapping assessment. This assessment revealed asymmetry in her sit bones with the right loading more than the left due to the leg length difference. This was also confirmed with the left knee tracking out at the top of the pedal stroke and the right knee over extending.

Changes to Bike Setup

The saddle height was adjusted down by 10mm to enhance hip mobility and facilitate proper hamstring engagement. The saddle angle and for/aft position was also modified to open up the hips. Additionally, I extended and raised the handlebar stem to alleviate stress on the lower back. Finally. I then shortened the cranks from 172.5 to 165mm stopped her hip impingement at the top of the pedal stroke. A shim was placed under the right cleat to improve symmetry between the left and right sit bones, as evidenced by the saddle pressure mapping retest.

Saddle pressure mapping showing difference in sit bone loading before and after the bike fit. The red area is where the load should be not into the groin area.

Follow-up Appointment

During the follow-up, the patient reported significant improvement. The hip pain had resolved following the bike setup changes. She also felt increased power from his right leg, allowing her to effectively drive his heel through the pedal stroke. Notably, lower back pain was improving and appeared later in his rides. Furthermore, her right foot numbness had disappeared. She was able to utilize her core to maintain a neutral spine, reducing reliance on his leg muscles for stability.

Review of Exercise Program

After reviewing her position on the bike it was great to see she was now able to hold relaxed and efficient riding posture.

A core strength test and muscle flexibility assessments confirmed her under active right leg strength and abdominal strength had improved. This supports the idea that the targeted exercises are achieving their intended effect. However, there is still room for improvement in her strength and conditioning , which we plan to reassess in three months time

It will be interesting to see if she can avoid hip pain long term, particularly given the signs of developing arthritis. By managing the aggravating factors, she may be able to delay the predicted need for a total hip replacement.

Conclusion

The long-term strategy involves continued optimization of her bike fit alongside ongoing physiotherapy. As the osteoarthritis potentially worsens, his hip's range of motion may become restricted. In such scenarios, we may need to consider shorter cranks and a more up right riding position, either on her current road bike or a new one with higher stack and more relaxed geometry.

Additional Considerations for Cyclists

Cyclists often face unique challenges, especially when it comes to managing pain and discomfort. Understanding how to adjust your bike fit can significantly impact your riding experience. It's essential to regularly assess your setup and make necessary changes to avoid long-term issues.

Importance of Regular Physiotherapy

Regular physiotherapy sessions can help maintain your body's health and performance. Engaging in a tailored exercise program can strengthen your muscles and improve flexibility. This proactive approach can prevent injuries and enhance your cycling experience.

Staying Informed

As a cyclist, staying informed about your body and its needs is crucial. Knowledge about pain management, injury prevention, and bike fitting can empower you to make better decisions. Remember, addressing issues early can lead to a more enjoyable and pain-free riding experience.

By focusing on these aspects, you can enhance your performance and enjoy cycling to the fullest.

Contact Jake at Physio Fit Bristol to find out how I can help you ride pain free with a comprehensive bike fit.