- August 26, 2021
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Hip pain when cycling, the result of long periods of time slumped over the handlebars or seated at work, can be prevented by following these simple steps.
Patient Presentation: History, Background, and Complaints
Dan D. presented to my office with complaints of hip pain when cycling stating, “My legs are like pistons that can fire all day, but now all I can muster is exhaust.” Dan admits that he isn’t highly competitive and doesn’t like to push hard, but he loves to ride his bike and does so often and for long periods.
Although Dan fancies the bike he was given by the team, it forces him to remain in a bent over (flexed) position all of the time, never allowing him to sit up and enjoy the draft. Dan elaborates on that thought,
“My hips never have a chance to open up and always feel stiff and achy...in the front, in my buttocks, and in my back as well.”
Dan also reports that when his hip is sore he has difficulty raising his knee and it often ‘clicks or pops’ while pedaling. It is during this time that Dan also is unable to produce power when pushing down on the pedals.
Physical Examination
Dan D. demonstrates good overall leg muscle strength, although on further examination significant weakness of his glutes and piriformis (the muscle which rotates the hip outward) were revealed.
Most significant is the extreme flexibility limitation (shortening) found in the muscles of the front of his hips (the hip flexor muscles), which at times makes it difficult to stand upright and also causes pressure in his low back.
In addition, Dan D. displays tenderness and a feeling of muscle spasm when pressure is applied to the deep muscles of his buttock, which when irritated sometimes causes pain to travel down his leg.
Diagnosis: What is it Called?
Hip Flexor Tendinitis
When repetitive motion causes the structures of the front of the hip (iliopsoas muscle, tendons, and bursa) to become irritated (inflammation), it becomes painful to use it and may create a ‘snapping or clicking’ sensation felt during motion.
Hip (Trochanteric) Bursitis
A condition where the hip’s bursae (fluid-filled sac in joint meant to decrease friction) becomes inflamed and pain is typically felt on the outside of the hip and travels down into the thigh.
Gluteus Medius Tendinopathy (Dead Butt Syndrome)
A painful condition caused by inflammation in the tendons of the gluteus medius muscle, one of the smaller buttocks muscles, which provides stability to the hip and pelvis during weight-bearing activity. When irritated pain travels from the buttock into the hamstring and weakness occurs when attempting to push downward.
Femoroacetabular Impingement Syndrome
A condition in which abnormal bone growth occurs in the hip joint giving it an irregular shape causing the bones to rub against each other during movement. Repetitive motion of the hip creates friction which can damage the joint, causing pain and limiting activity.
Piriformis Syndrome
A deep rotator muscle of the hip which runs over the sciatic nerve, when the piriformis is inflamed or overused, it can apply pressure to the nerve, causing extreme pain which often travels down the back of the thigh.
Hip Osteoarthritis
A degeneration of the bones of the hip joint due to progressive usage that characteristically produces pain which is referred to the groin.
Etiology: What Causes It?
Overuse
Irritation due to the repetitive nature of the pedal stroke if performed improperly or if problematic, especially if improper positioning causes excessive bending of the hip and trunk and the inability for the hip to extend or open up (straighten).
Muscle Imbalance or Weakness
Stiffness or shortening of the hip flexors and rotators due to prolonged repetitive exercise while improperly positioned, or seated posture while off the bike. In addition, the glutes develop weakness due to being maintained in a stretched position causing them to become overworked.
Core Weakness
Without strong back and abdominal muscles there is no foundation for strength production by the legs and an inconsistent and improper pedal stroke can result.
Injury
The residual effects of prior trauma or recent injury can cause significant and limiting knee pain.
Bike Fit
Improper positioning on the bike causes repetitive stress-causing inflammation and pain in the affected area.
Treatment: What Can You Do About It?
- If the pain is the result of a recent injury or is acute (sudden onset within ~24 hours) with swelling, control the symptoms by following the ‘PRICE principle’ (an acronym which stands for Protect, Rest, Ice, Compression and Elevation) immediately for the next 2 to 3 days.
- Check your bike fit: Pain in the hip is due to positioning which causes the rider to be excessively bent at the trunk or which causes the hip to bend excessively. This can be corrected by adjusting crank length, handlebar size and position, saddle height, and fore-aft position to avoid exceeding the athlete’s range of hip motion at the top of the pedal stroke.
- Focus upon a comfortable cadence and smooth pedal stroke and avoid pushing too hard during the downstroke.
- Follow a consistent and effective recovery strategy.
- Address muscle imbalances through a focused strengthening and stretching plan, making sure to only perform exercises which can be done pain free and without residual soreness.
Referral: When is it Time to Ask For Help?
- A proper bike fit performed by a certified professional is always a good idea, especially when the small incremental changes you have made to your setup don’t provide the results or eliminate the pain you are experiencing.
- A progressive periodized training and recovery plan is essential and when followed with the aid of a knowledgeable cycling coach there is a tendency to be more accountable and disciplined.
- If your hip pain is persistent, worsens, or significantly interferes with your cycling, seek the assistance of a Sports Medicine Physician, Physical Therapist, or Athletic Trainer for an expert biomechanical and musculoskeletal assessment and treatment.
The Expected Outcome: Conclusion
Hip tightness is a huge problem for cyclists, on the bike and off, as prolonged seated postures during work and off time contributes to the issue. If not addressed, the rider is at risk for pain which progresses to severe and debilitating, and to include the hip, thigh, and back.
Thankfully, by paying attention to proper bike fit, performing a consistent and effective stretching program, and through focal strengthening, ride limiting hip pain can be eliminated and avoided.
You will be firing on all cylinders like Dan D., with locomotive power but more of a spark, in no time.
Next appointment
In the next instalment in this series, learn what may be causing the pain in your back during a long day in the saddle and what you can do to prevent it from taking the fun out of your ride.
For other virtual cases studies like this one, and other helpful tips check out our Strength & Conditioning page.
What about you?
Have you suffered from hip pain that prevented you from enjoying your ride? If yes, let your fellow virtual cyclists know what worked best for you.
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Semi-retired as owner and director of his private Orthopedic Physical Therapy practice after over 20 years, Chris is blessed with the freedom to pursue his passion for virtual cycling and writing. On a continual quest to give back to his bike for all the rewarding experiences and relationships it has provided him, he created a non-profit. Chris is committed to helping others with his bike through its work and the pages of his site.
In the summer of 2022, he rode 3,900 miles from San Francisco to New York to support the charity he founded, TheDIRTDadFund. His “Gain Cave” resides on the North Fork of Long Island, where he lives with his beautiful wife and is proud of his two independent children.
You will read him promoting his passion on the pages of Cycling Weekly, Cycling News, road.cc, Zwift Insider, Endurance.biz, and Bicycling. Chris is co-host of The Virtual Velo Podcast, too!
