Cyclist Hip Pain - Physio Bike Fit Case Study
- Jake Tay
- Nov 7
- 5 min read
Understanding how to manage traumatic hip pain in a 36-year-old cyclist
A 36-year-old cyclist, standing 5’9”, presents with a significant medical history. He is normally fit but has experienced issues following a road traffic accident (RTA) five years ago. This incident resulted in right hip pain and reduced mobility. Additionally, he has a long-standing history of lower back pain, which predates the accident. He attributes his right hip pain directly to the RTA, feeling that his right hip has become weaker as a result with reduced power through the pedal stroke.
Medical Background: Lower Back and Hip Pain
History of Lower Back Pain
The patient reports right side lower back pain that occasionally radiates into his right foot. He experiences numbness but notes no actual weakness or loss of sensation. He does not experience any bladder or bowel disturbances. Prior to his bike fit, his GP requested an MRI, which indicated a disc bulge between L5 and S1. He has been advised to manage his condition conservatively through physiotherapy unless his symptoms worsen.
Pain Triggers
Riding longer than 5 miles aggravates his lower back pain, regardless of hand position. Although the discomfort doesn’t completely stop him from cycling, it certainly leads to stiffness by the end of his rides.
History of Right Hip Pain
In addition to his lower back pain, the patient experiences pain in his right hip while cycling or squatting. Following the RTA, an X-ray revealed a bony spur in the hip joint. His surgeon recommended conservative management 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 1 cm. 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. The patient struggles to achieve a full squat or lunge with the right leg due to pain.
Physiotherapy Assessment and Tests
Lumbar Spine Assessment
The patient demonstrated full range of motion in lumbar spine flexion, extension, and lateral flexion. There was no pain upon applying overpressure. However, due to the reported numbness in his 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 he 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 a bony spur 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.
Treatment Plan
I prescribed a tailored strength and flexibility program targeting both his 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
Upon evaluating the bike fit, it became clear that the saddle was positioned too high by 1 cm and angled upward. This not only constricted 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 his core muscles.
Saddle Pressure Mapping Assessment
We also conducted a saddle pressure mapping assessment. This assessment revealed asymmetry in foot angular ranges, with the right foot plantar flexing more to compensate for the left leg's longer length.
Changes to Bike Setup
The saddle height was adjusted down by 1 cm to enhance hip mobility and facilitate proper hamstring engagement. The saddle angle was also modified to open up the hips. Additionally, we shortened and raised the handlebar stem to alleviate stress on the lower back while maintaining a low front end. Finally, 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.
Follow-up Appointment
During the follow-up, the patient reported significant improvement. The hip pain had resolved following the bike setup changes. He also felt increased power from his right leg, allowing him to effectively drive his heel through the pedal stroke. Notably, lower back pain was improving and appeared later in his rides. Furthermore, his right foot numbness had disappeared. He was able to utilize his core to maintain a neutral spine, reducing reliance on his leg muscles for stability.
Review of Exercise Program
Upon reviewing his exercise program, it was apparent that he made strides in maintaining a neutral spine. A core strength test and muscle flexibility assessments confirmed improvement in hip flexor flexibility. This supports the idea that the targeted exercises are achieving their intended effect. However, there is still room for growth in his strength and conditioning journey, which we plan to reassess in three months.
It will be interesting to see if he can avoid hip pain long term, particularly given the early signs of osteoarthritis. By managing the aggravating factors, he may be able to delay the predicted need for a total hip replacement.
Conclusion
The long-term strategy involves continued optimization of his 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 elevating his bike position, either on his current road bike or a new one with higher stack and more relaxed geometry.
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